bid_id	contract_year	version	cs_b0056	cs_b0057	cs_b0058	cs_b0059	cs_b0060	cs_b0061	cs_b0062	cs_b0063	cs_b0064	cs_b0065	cs_c0056	cs_c0057	cs_c0058	cs_c0059	cs_c0060	cs_c0061	cs_c0062	cs_c0063	cs_c0064	cs_c0065	cs_d0012	cs_d0056	cs_d0057	cs_d0058	cs_d0059	cs_d0060	cs_d0061	cs_d0062	cs_d0063	cs_d0064	cs_d0065	cs_e0025	cs_e0026	cs_e0027	cs_e0028	cs_e0029	cs_e0030	cs_e0031	cs_e0032	cs_e0033	cs_e0034	cs_e0035	cs_e0036	cs_e0037	cs_e0038	cs_e0039	cs_e0040	cs_e0041	cs_e0042	cs_e0043	cs_e0044	cs_e0045	cs_e0046	cs_e0047	cs_e0048	cs_e0049	cs_e0050	cs_e0051	cs_e0052	cs_e0053	cs_e0054	cs_e0055	cs_e0056	cs_e0057	cs_e0058	cs_e0059	cs_e0060	cs_e0061	cs_e0062	cs_e0063	cs_e0064	cs_e0065	cs_f0025	cs_f0026	cs_f0027	cs_f0028	cs_f0029	cs_f0030	cs_f0031	cs_f0032	cs_f0033	cs_f0034	cs_f0035	cs_f0036	cs_f0037	cs_f0038	cs_f0039	cs_f0040	cs_f0041	cs_f0042	cs_f0043	cs_f0044	cs_f0045	cs_f0046	cs_f0047	cs_f0048	cs_f0049	cs_f0050	cs_f0051	cs_f0052	cs_f0053	cs_f0054	cs_f0055	cs_f0056	cs_f0057	cs_f0058	cs_f0059	cs_f0060	cs_f0061	cs_f0062	cs_f0063	cs_f0064	cs_f0065	cs_f0066	cs_g0012	cs_g0025	cs_g0026	cs_g0027	cs_g0028	cs_g0029	cs_g0030	cs_g0031	cs_g0032	cs_g0033	cs_g0034	cs_g0035	cs_g0036	cs_g0037	cs_g0038	cs_g0039	cs_g0040	cs_g0041	cs_g0042	cs_g0043	cs_g0044	cs_g0045	cs_g0046	cs_g0047	cs_g0048	cs_g0049	cs_g0050	cs_g0051	cs_g0052	cs_g0053	cs_g0054	cs_g0055	cs_g0056	cs_g0057	cs_g0058	cs_g0059	cs_g0060	cs_g0061	cs_g0062	cs_g0063	cs_g0064	cs_g0065	cs_h0025	cs_h0026	cs_h0027	cs_h0028	cs_h0029	cs_h0030	cs_h0031	cs_h0032	cs_h0033	cs_h0034	cs_h0035	cs_h0036	cs_h0037	cs_h0038	cs_h0039	cs_h0040	cs_h0041	cs_h0042	cs_h0043	cs_h0044	cs_h0045	cs_h0046	cs_h0047	cs_h0048	cs_h0049	cs_h0050	cs_h0051	cs_h0052	cs_h0053	cs_h0054	cs_h0055	cs_h0056	cs_h0057	cs_h0058	cs_h0059	cs_h0060	cs_h0061	cs_h0062	cs_h0063	cs_h0064	cs_h0065	cs_i0025	cs_i0026	cs_i0027	cs_i0028	cs_i0029	cs_i0030	cs_i0031	cs_i0032	cs_i0033	cs_i0034	cs_i0035	cs_i0036	cs_i0037	cs_i0038	cs_i0039	cs_i0040	cs_i0041	cs_i0042	cs_i0043	cs_i0044	cs_i0045	cs_i0046	cs_i0047	cs_i0048	cs_i0049	cs_i0050	cs_i0051	cs_i0052	cs_i0053	cs_i0054	cs_i0055	cs_i0056	cs_i0057	cs_i0058	cs_i0059	cs_i0060	cs_i0061	cs_i0062	cs_i0063	cs_i0064	cs_i0065	cs_j0025	cs_j0026	cs_j0027	cs_j0028	cs_j0029	cs_j0030	cs_j0031	cs_j0032	cs_j0033	cs_j0034	cs_j0035	cs_j0036	cs_j0037	cs_j0038	cs_j0039	cs_j0040	cs_j0041	cs_j0042	cs_j0043	cs_j0044	cs_j0045	cs_j0046	cs_j0047	cs_j0048	cs_j0049	cs_j0050	cs_j0051	cs_j0052	cs_j0053	cs_j0054	cs_j0055	cs_j0056	cs_j0057	cs_j0058	cs_j0059	cs_j0060	cs_j0061	cs_j0062	cs_j0063	cs_j0064	cs_j0065	cs_j0066	cs_j0067	cs_j0068	cs_k0025	cs_k0026	cs_k0027	cs_k0028	cs_k0029	cs_k0030	cs_k0031	cs_k0032	cs_k0033	cs_k0034	cs_k0035	cs_k0036	cs_k0037	cs_k0038	cs_k0039	cs_k0040	cs_k0041	cs_k0042	cs_k0043	cs_k0044	cs_k0045	cs_k0046	cs_k0047	cs_k0048	cs_k0049	cs_k0050	cs_k0051	cs_k0052	cs_k0053	cs_k0054	cs_k0055	cs_k0056	cs_k0057	cs_k0058	cs_k0059	cs_k0060	cs_k0061	cs_k0062	cs_k0063	cs_k0064	cs_k0065	cs_k0066	cs_l0012	cs_l0025	cs_l0026	cs_l0027	cs_l0028	cs_l0029	cs_l0030	cs_l0031	cs_l0032	cs_l0033	cs_l0034	cs_l0035	cs_l0036	cs_l0037	cs_l0038	cs_l0039	cs_l0040	cs_l0041	cs_l0042	cs_l0043	cs_l0044	cs_l0045	cs_l0046	cs_l0047	cs_l0048	cs_l0049	cs_l0050	cs_l0051	cs_l0052	cs_l0053	cs_l0054	cs_l0055	cs_l0056	cs_l0057	cs_l0058	cs_l0059	cs_l0060	cs_l0061	cs_l0062	cs_l0063	cs_l0064	cs_l0065	cs_m0025	cs_m0026	cs_m0027	cs_m0028	cs_m0029	cs_m0030	cs_m0031	cs_m0032	cs_m0033	cs_m0034	cs_m0035	cs_m0036	cs_m0037	cs_m0038	cs_m0039	cs_m0040	cs_m0041	cs_m0042	cs_m0043	cs_m0044	cs_m0045	cs_m0046	cs_m0047	cs_m0048	cs_m0049	cs_m0050	cs_m0051	cs_m0052	cs_m0053	cs_m0054	cs_m0055	cs_m0056	cs_m0057	cs_m0058	cs_m0059	cs_m0060	cs_m0061	cs_m0062	cs_m0063	cs_m0064	cs_m0065	cs_m0066	cs_m0067	cs_m0068	cs_n0025	cs_n0026	cs_n0027	cs_n0028	cs_n0029	cs_n0030	cs_n0031	cs_n0032	cs_n0033	cs_n0034	cs_n0035	cs_n0036	cs_n0037	cs_n0038	cs_n0039	cs_n0040	cs_n0041	cs_n0042	cs_n0043	cs_n0044	cs_n0045	cs_n0046	cs_n0047	cs_n0048	cs_n0049	cs_n0050	cs_n0051	cs_n0052	cs_n0053	cs_n0054	cs_n0055	cs_n0056	cs_n0057	cs_n0058	cs_n0059	cs_n0060	cs_n0061	cs_n0062	cs_n0063	cs_n0064	cs_n0065	cs_n0066
E5088_801_0	2007	3	e.3.	h.6.	h.7.	i.7.							DME/Prosthetics/Supplies	OP Facility - Other	OP Facility - Other	Professional							2000	Diabetic Mon Supplies	Urgent Care	PT/OT/ST/CORF/Cardiac Rehab/Pain Clinic	Chemotherapy and IV therapy							A		D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin		V	V	V	V		V	Coin				V		V					Coin	V	V	Coin																																																-		206		805	621	97	15.48	7.29	288	377		632				3210	2899	92	883		576	16.38	19			601							3.87	79	155	9.51							300/admit + 100/admit if fail to pre-notify (PBP #1A/1B)		0/day for 1st 20 days; 75/day for days 21 - 100 (#2)	10/visit + 5/visit if fail to pre-notify (#6)	25 copay (#10A)	10 coinsurance if under 750 or preauthorized; 20 otherwise (#11A)	Prosthetics: 10 coinsurance if under 750 or preauthorized; 20 otherwise; Medical Supplies: 0 coinsurance; Diabetes Monitoring Supplies: see below (e.3.) (#11B)	50/visit (#4A)	75/visit (#9B)	0 coinsurance (#8A)	25 copay/day for MRIs; all other diagnostic radiology 0 copay; therapeutic radiology 15 copay (#8A/B)	0 coinsurance	0 coinsurance (#12)		5/visit (#7A)	15/visit (#7D/7F/7G/14C)	15/visit (#7E/7H)	15/visit (#7C/7I)		Chiropractic Services: 15/visit (#7B)	10 coinsurance (#15)	eyewear after cataract surgery: 15 copay (#17B)			15/visit (#17A)		0 copay (#18A)					Glucose monitors: 0 coinsurance for Bayer glucometer 50 for all others; Test strips: 10 coinsurance for Bayer test strips 50 for all others; 10 coinsurance for lancets and all other supplies (#11C)	25 copay (#4B)	15 copay (#3/9D)	10 coinsurance (#8A)							307.83		38.88	10.58	24.05	0.1	0.02	48.1	72.15		3.48				4.81	14.43	14.43	14.43		14.43	0.1	14.43			14.43							0.17	24.05	14.43	0.1							5.28	-	2.61	0.55	0.19	1.53	0.13	1.15	2.27	-	0.18	-	-	-	1.29	3.49	0.11	1.06	-	0.69	1.58	0.02	-	-	0.72	-	-	-	-	-	-	0.66	0.16	0.19	0.91	-	-	-	-	-	-	24.78	0	0.98	5.28	-	2.61	0.55	0.19	1.53	0.13	1.15	2.27	-	0.18	-	-	-	1.29	3.49	0.11	1.06	-	0.69	1.58	0.02	-	-	0.72	-	-	-	-	-	-	0.66	0.16	0.19	0.91	-	-	-	-	-	-	24.78																																																																																				-			5.28	-	2.61	0.55	0.19	1.53	0.13	1.15	2.27	-	0.18	-	-	-	1.29	3.49	0.11	1.06	-	0.69	1.58	0.02	-	-	0.72	-	-	-	-	-	-	0.66	0.16	0.19	0.91	-	-	-	-	-	-	24.78
H0104_002_0	2007	3																					3500											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	317.5	3.18	785.16	0	290.77	28.15	1.31	292.78	291.44	0	0	0	0.2	19.64	3595.24	4580.32	129.15	418	0	219.73	5.97	602.07	0	0	366.45	0	148.99	0	0	0	0											600 Per Admit	600 Per Admit	100 Per Day:  1-35		150 Per Run	20	20	50 ER/30 UC	200 Per Visit	0	0		0	30 OP SA / 0 Cardiac Rehab	30 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20	30 Vision/0 Blood		0	30		30				0											499.14	499.14	76.72	0	124.76	0.17	0.17	35.97	166.37	0	0	0	0.2	0.1	24.92	24.94	24.95	23.59	0	8.35	0.17	24.47	0	0	24.95	0	24.95	0	0	0	0											13.21	0.13	5.02	-	3.02	4.68	0.22	0.88	4.04	-	-	-	0.04	1.9	7.47	9.52	0.27	0.82	-	0.15	1.01	1.23	-	-	0.76	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.68	0	11.06	13.21	0.13	5.02	-	3.02	4.68	0.22	0.88	4.04	-	-	-	0.04	1.9	7.47	9.52	0.27	0.82	-	0.15	1.01	1.23	-	-	0.76	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.68	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											11.6	0.09	1.07	1.51	0.37	1.33	0.02	0.17	0.89	0.35	0.95	0	0.01	0.92	1.76	5.04	0.05	0.15	1.12	0.85	0.28	0.2	0	0	0	0	0	0	0	0	0											28.74	2000	0	24.81	0.22	6.09	1.51	3.4	6.01	0.24	1.04	4.93	0.35	0.95	-	0.05	2.82	9.23	14.56	0.31	0.97	1.12	1	1.3	1.43	-	-	0.76	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.42
H0104_004_0	2007	3																					2500											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.17	3.07	801.53	0	298.54	27.38	1.3	299.23	288.88	0	0	0	0.2	19.68	3808.08	4811.08	136.19	438.89	0	233.43	5.99	637.63	0	0	364.08	0	148.36	0	0	0	0											300 Per Admit	300 Per Admit	50 Per Day:  1-50		150 Per Run	20	20	50 ER/15 UC	100 Per Visit	0	0		0	15 OP SA / 0 Cardiac Rehab	15 PCP	15 SCP / 15 Chiro / 15 Podiatrist	15 MH	15 Therapy		15 Hearing / 0 Preventive	20	15 Vision/0 Blood		0	15		15				0											255.67	255.67	41.28	0	128.06	0.17	0.17	32.56	85.24	0	0	0	0.2	0.06	12.76	12.8	12.79	12.79	0	4.17	0.17	12.55	0	0	12.79	0	12.79	0	0	0	0											6.61	0.07	2.76	-	3.19	4.67	0.22	0.81	2.05	-	-	-	0.04	1.11	4.05	5.13	0.15	0.47	-	0.08	1.04	0.67	-	-	0.39	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.66	0	5.82	6.61	0.07	2.76	-	3.19	4.67	0.22	0.81	2.05	-	-	-	0.04	1.11	4.05	5.13	0.15	0.47	-	0.08	1.04	0.67	-	-	0.39	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.66	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											11.6	0.09	1.07	1.51	0.37	1.33	0.02	0.17	0.89	0.35	0.95	0	0.01	0.92	1.76	5.04	0.05	0.15	1.12	0.85	0.28	0.2	0	0	0	0	0	0	0	0	0											28.74	2000	0	18.21	0.15	3.82	1.51	3.56	6	0.24	0.98	2.95	0.35	0.95	-	0.05	2.03	5.81	10.18	0.19	0.62	1.12	0.93	1.33	0.87	-	-	0.39	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4
H0104_006_0	2007	4																					none											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	369.87	3.51	0	0	313.31	30.63	1.53	326.65	23.03	0	0	0	0.25	949.89	4747.39	5861.69	168.38	536.64	0	291.28	0	784.43	0	0	0	0	0	0	0	0	0											000 Per Admit	000 Per Admit	0		050 Per Run	0	0	50 ER/50 UC	000 Per Visit	0	0		0	10 OP SA / 0 Cardiac Rehab	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	10 MH	10 Therapy		10 Hearing / 0 Preventive	0	10 Vision/0 Blood		0	10		10				0											0	0	0	0	50	0	0	50	0	0	0	0	0.2	10	9.97	10.02	10	10	0	3.58	0	10	0	0	0	0	0	0	0	0	0											0	-	-	-	1.31	-	-	1.36	-	-	-	-	0.05	0.79	3.94	4.89	0.14	0.45	-	0.09	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.67	0	0	0	-	-	-	1.31	-	-	1.36	-	-	-	-	0.05	0.79	3.94	4.89	0.14	0.45	-	0.09	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.67	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											14.01	0.11	1.29	1.83	0.45	1.61	0.02	0.2	1.08	0.42	1.15	0	0.01	0.95	2.13	6.09	0.05	0.18	1.35	1.02	0.34	0.15	0	0	0	0	0	0	0	0	0											34.44	2000	0	14.01	0.11	1.29	1.83	1.76	1.61	0.02	1.56	1.08	0.42	1.15	-	0.06	1.74	6.07	10.98	0.19	0.63	1.35	1.11	0.34	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.11
H0104_007_0	2007	4																					3500											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	873.15	10.53	768.3	2126.1	287.01	26.99	1.27	280.75	282.55	0	0	0	0.2	19.29	3499.68	4445.3	125.84	406.66	0	204.62	5.85	588.81	0	0	343.17	0	138.79	0	0	0	0											315 Per Day: 1 to 4	315 Per Day: 1 to 4	100 Per Day:  1-35		150 Per Run	30	30	50 ER/35 UC	350 Per Visit	0	0		0	35 OP SA / 0 Cardiac Rehab	35 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MH	35 Therapy		35 Hearing / 0 Preventive	20	35 Vision/0 Blood		0	35		35				0											247.16	247.12	72.33	27.45	117.51	0.24	0.24	35.23	274.2	0	0	0	0.2	0.11	27.36	27.35	27.43	22.33	0	7.84	0.16	26.89	0	0	27.43	0	27.39	0	0	0	0											17.98	0.22	4.63	4.86	2.81	6.35	0.3	0.82	6.46	-	-	-	0.04	2.13	7.98	10.13	0.29	0.76	-	0.13	0.94	1.32	-	-	0.78	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.25	0	19.1	17.98	0.22	4.63	4.86	2.81	6.35	0.3	0.82	6.46	-	-	-	0.04	2.13	7.98	10.13	0.29	0.76	-	0.13	0.94	1.32	-	-	0.78	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.25	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											8.04	0.06	1.07	1.18	0.37	1.34	0.02	0.17	0.9	0.35	0.95	0	0.01	0.92	1.77	5.06	0.05	0.15	1.12	0.85	0.28	0.2	0	0	0	0	0	0	0	0	0											24.87	2000	0	26.03	0.28	5.7	6.05	3.18	7.68	0.32	0.99	7.35	0.35	0.95	-	0.05	3.06	9.75	15.19	0.33	0.91	1.12	0.98	1.22	1.52	-	-	0.78	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.12
H0104_008_0	2007	3																					2500											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	coin	coin	coin	coin	coin	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	331.38	3.26	0	0	0	28.25	1.34	314.56	19.44	0	0	0	0.21	20.13	43.77	117.03	1.21	3.71	2620.29	5322.68	6.15	654.26	0	0	377.37	0	162.26	0	0	0	0											000 Per Admit	000 Per Admit	0		000 Per Run	20	20	50 ER/00 UC	000 Per Visit	0	0		0	0 OP SA / 0 Cardiac Rehab	0 PCP	0 SCP / 0 Chiro / 0 Podiatrist	0 MH	0 Therapy		15 Hearing / 0 Preventive	20	15 Vision/0 Blood		0	15		15				0											0	0	0	0	0	0.2	0.2	32.78	0	0	0	0	0.2	0.02	0	0	0	0	0.01	0.25	0.2	14.58	0	0	14.85	0	14.85	0	0	0	0											0	-	-	-	-	5.59	0.26	0.86	-	-	-	-	0.04	0.33	-0.01	0.02	0	0	0	0.11	1.24	0.79	-	-	0.47	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.91	0	0.1	0	-	-	-	-	5.59	0.26	0.86	-	-	-	-	0.04	0.33	-0.01	0.02	0	0	0	0.11	1.24	0.79	-	-	0.47	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.91	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											11.61	0.09	0.37	1.51	0.37	1.33	0.02	0.15	0.89	0.35	0.95	0	0.01	0.92	1.77	5.05	0.05	0.15	1.12	0.85	0.28	0.2	0	0	0	0	0	0	0	0	0											28.05	2000	0	11.61	0.09	0.37	1.51	0.37	6.93	0.29	1.01	0.89	0.35	0.95	-	0.05	1.25	1.76	5.07	0.05	0.15	1.12	0.96	1.53	1	-	-	0.47	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.96
H0104_801_0	2007	3																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	317.12	3.18	809.53	0	292.74	27.61	1.3	288.94	289.17	0	0	0	0.19	19.64	3473.83	4466.18	126.89	409.63	0	215.18	5.96	588.41	0	0	0	0	0	0	0	0	0											400 Per Admit	400 Per Admit	50 Per Day		100 Per Run	20	20	50 ER/30 UC	200 Per Visit	0	0		0	30 OP SA / 0 Cardiac Rehab	30 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20	30 Vision/0 Blood		0	30		30				0											400	400	50	0	100	0.2	0.2	43.22	200	0	0	0	0.2	0.12	29.96	29.97	30	27.79	0	10.69	0.2	29.4	0	0	0	0	0	0	0	0	0											10.57	0.11	3.37	-	2.44	5.52	0.26	1.04	4.82	-	-	-	0.04	2.28	8.67	11.16	0.32	0.95	-	0.19	1.22	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.39	0	0	10.57	0.11	3.37	-	2.44	5.52	0.26	1.04	4.82	-	-	-	0.04	2.28	8.67	11.16	0.32	0.95	-	0.19	1.22	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.39	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											10.73	0.08	1.01	1.42	0.35	1.27	0.06	0.16	0.85	0.33	0.9	0	0.01	0.87	1.59	4.64	0.04	0.14	1.04	0.77	0.27	0.18	0	0	0	0	0	0	0	0	0											26.72	1500	0	21.3	0.19	4.38	1.42	2.79	6.79	0.32	1.2	5.67	0.33	0.9	-	0.05	3.16	10.26	15.8	0.36	1.09	1.04	0.97	1.49	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.12
H0104_802_0	2007	5																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	317.12	3.18	809.53	0	292.74	27.61	1.3	288.94	289.17	0	0	0	0.19	19.64	3473.83	4466.18	126.89	409.63	0	215.18	5.96	588.41	0	0	0	0	0	0	0	0	0											400 Per Admit	400 Per Admit	50 Per Day		100 Per Run	20	20	50 ER/30 UC	200 Per Visit	0	0		0	30 OP SA / 0 Cardiac Rehab	30 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20	30 Vision/0 Blood		0	30		30				0											400	400	50	0	100	0.2	0.2	43.22	200	0	0	0	0.2	0.12	29.96	29.97	30	27.79	0	10.69	0.2	29.4	0	0	0	0	0	0	0	0	0											10.57	0.11	3.37	-	2.44	5.52	0.26	1.04	4.82	-	-	-	0.04	2.28	8.67	11.16	0.32	0.95	-	0.19	1.22	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.39	0	0	10.57	0.11	3.37	-	2.44	5.52	0.26	1.04	4.82	-	-	-	0.04	2.28	8.67	11.16	0.32	0.95	-	0.19	1.22	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.39	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											10.73	0.08	1.01	1.42	0.35	1.27	0.06	0.16	0.85	0.33	0.9	0	0.01	0.87	1.59	4.64	0.04	0.14	1.04	0.77	0.27	0.18	0	0	0	0	0	0	0	0	0											26.72	1500	0	21.3	0.19	4.38	1.42	2.79	6.79	0.32	1.2	5.67	0.33	0.9	-	0.05	3.16	10.26	15.8	0.36	1.09	1.04	0.97	1.49	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.12
H0104_804_0	2007	5																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	317.12	3.18	809.53	0	292.74	27.61	1.3	288.94	289.17	0	0	0	0.19	19.64	3473.83	4466.18	126.89	409.63	0	215.18	5.96	588.41	0	0	0	0	0	0	0	0	0											400 Per Admit	400 Per Admit	50 Per Day		100 Per Run	20	20	50 ER/30 UC	200 Per Visit	0	0		0	30 OP SA / 0 Cardiac Rehab	30 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20	30 Vision/0 Blood		0	30		30				0											400	400	50	0	100	0.2	0.2	43.22	200	0	0	0	0.2	0.12	29.96	29.97	30	27.79	0	10.69	0.2	29.4	0	0	0	0	0	0	0	0	0											10.57	0.11	3.37	-	2.44	5.52	0.26	1.04	4.82	-	-	-	0.04	2.28	8.67	11.16	0.32	0.95	-	0.19	1.22	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.39	0	0	10.57	0.11	3.37	-	2.44	5.52	0.26	1.04	4.82	-	-	-	0.04	2.28	8.67	11.16	0.32	0.95	-	0.19	1.22	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.39	none	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30	30											10.73	0.08	1.01	1.42	0.35	1.27	0.06	0.16	0.85	0.33	0.9	0	0.01	0.87	1.59	4.64	0.04	0.14	1.04	0.77	0.27	0.18	0	0	0	0	0	0	0	0	0											26.72	1500	0	21.3	0.19	4.38	1.42	2.79	6.79	0.32	1.2	5.67	0.33	0.9	-	0.05	3.16	10.26	15.8	0.36	1.09	1.04	0.97	1.49	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.12
H0150_001_0	2007	9																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1200.47	37.72	348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																150 per day for 1st 10 days	170 per day for 1st 10 days	95 for days 1 to 100		160 per trip	20 coinsurance		50 per visit	265 per visit						5 per visit	15 per visit	15 per visit		15 per visit		10 per Script					100 limit on eyewear																150	170	95		160	0.2		50	265						5	15	15		15		0.1					100																15.01	0.53	2.76	-	0.92	1.47	-	1.18	4.22	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.48	0	0	15.01	0.53	2.76	-	0.92	1.47	-	1.18	4.22	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.48	2000																																																																																			-	0	0	15.01	0.53	2.76	-	0.92	1.47	-	1.18	4.22	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.48
H0150_006_0	2007	5																					2000											D	D	D	V	T	COIN	COIN	P	P	P	P	P	P	P	V	V	V	V	V	V	COIN	COIN	T	V	V	V				O	V																																																				-		1238.2		348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																170 per day for 1st 10 days		150 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	300 per visit						10 per visit	30 per visit	30 per visit		30 per visit		10 per Script					100 limit on eyewear																170		150		150	0.2		50	300						10	30	30		30		0.1					100																17.54	-	4.36	-	0.86	1.47	-	1.18	4.78	-	-	-	-	-	3.11	7.96	0.25	-	0.24	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.36	0	0	17.54	-	4.36	-	0.86	1.47	-	1.18	4.78	-	-	-	-	-	3.11	7.96	0.25	-	0.24	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.36	2000																																																																																			-			17.54	-	4.36	-	0.86	1.47	-	1.18	4.78	-	-	-	-	-	3.11	7.96	0.25	-	0.24	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.36
H0150_007_0	2007	8																					0											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		0		0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0	0					0											0 copay	0 copay	0 copay		0 per trip	0 coins	0 coins	0 copay	0 copay		0 copay		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0	0	0 copay		0 copay	100 limit on eyewear					0 copay											0	0	0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0						0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H0150_010_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	P	P	O	V	O	V	O	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1238.2		348.99		68.82	7.35		273.52	184.71						3737.2	3184.18	98.35		95.46		15.33					369.22																225 per day for 1st 10 days		150 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	315 per visit						10 per visit	30 per visit	30 per visit		30 per visit		10 per Script					100 limit on eyewear																225		150		150	0.2		50	315						10	30	30		30		0.1					100																23.22	-	4.36	-	0.86	1.47	-	1.14	4.85	-	-	-	-	-	3.11	7.96	0.25	-	0.24	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.07	0	0	23.22	-	4.36	-	0.86	1.47	-	1.14	4.85	-	-	-	-	-	3.11	7.96	0.25	-	0.24	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.07	2000																																																																																			-	0	0	23.22	-	4.36	-	0.86	1.47	-	1.14	4.85	-	-	-	-	-	3.11	7.96	0.25	-	0.24	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.07
H0150_012_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1200.47	37.72	348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																150 per day for 1st 10 days	125 per day for 1st 10 days	95 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	200 per visit				15 per visit		5 per visit	15 per visit	15 per visit		15 per visit		10 per Script				15   1 visit per year	100 limit on eyewear	15   1 visit per year															150	125	95		150	0.2		50	200				15		5	15	15		15		0.1				15	100	15															15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	2000																																																																																			-	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25
H0150_015_0	2007	7																					2000											D	D	D	V	T	Coin	Coin	V	P	O	V	O	V	O	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		0		0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0	0		0			0											0 copay	0 copay	0 copay		0 per trip	0 coins	0 coins	0 copay	0 copay		0 copay		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0	0	0 copay		0 copay	100 limit on eyewear		500 / once every 3 years			0 copay											0	0	0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0			0			0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2000																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H0150_017_0	2007	7																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1200.47	37.72	348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																150 per day for 1st 10 days	125 per day for 1st 10 days	95 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	200 per visit						5 per visit	15 per visit	15 per visit		15 per visit		10 per Script					100 limit on eyewear																150	125	95		150	0.2		50	200						5	15	15		15		0.1					100																15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	2000																																																																																			-	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25
H0150_018_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	P	P	O	V	O	V	O	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1671.57		471.14		92.9	9.93		363.79	245.67						5045.23	4298.64	132.77		128.87		20.69					498.45																250 per day for 1st 10 days		150 for days 1 to 100		160 per trip	20 coinsurance		50 per visit	350 per visit						15 per visit	30 per visit	30 per visit		30 per visit		10 per Script					100 limit on eyewear																250		150		160	0.2		50	350						15	30	30		30		0.1					100																34.82	-	5.89	-	1.24	1.99	-	1.52	7.17	-	-	-	-	-	6.31	10.75	0.33	-	0.32	-	2.07	-	-	-	-	4.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.55	0	0	34.82	-	5.89	-	1.24	1.99	-	1.52	7.17	-	-	-	-	-	6.31	10.75	0.33	-	0.32	-	2.07	-	-	-	-	4.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.55	2000																																																																																			-	0	0	34.82	-	5.89	-	1.24	1.99	-	1.52	7.17	-	-	-	-	-	6.31	10.75	0.33	-	0.32	-	2.07	-	-	-	-	4.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.55
H0150_802_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1200.47	37.72	348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																150 per day for 1st 10 days	125 per day for 1st 10 days	95 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	200 per visit						5 per visit	15 per visit	15 per visit		15 per visit		10 per Script					100 limit on eyewear																150	125	95		150	0.2		50	200						5	15	15		15		0.1					100																15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	2000																																																																																			-	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25
H0150_804_0	2007	8																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1200.47	37.72	348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																150 per day for 1st 10 days	125 per day for 1st 10 days	95 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	200 per visit						5 per visit	15 per visit	15 per visit		15 per visit		10 per Script					100 limit on eyewear																150	125	95		150	0.2		50	200						5	15	15		15		0.1					100																15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	2000																																																																																			-	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25
H0150_805_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1200.47	37.72	348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																150 per day for 1st 10 days	125 per day for 1st 10 days	95 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	200 per visit						5 per visit	15 per visit	15 per visit		15 per visit		10 per Script					100 limit on eyewear																150	125	95		150	0.2		50	200						5	15	15		15		0.1					100																15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	2000																																																																																			-	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25
H0150_806_0	2007	8																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		1200.47	37.72	348.99		68.82	7.35		282.95	191.08						3737.2	3184.18	98.35		95.46		15.33					369.22																150 per day for 1st 10 days	125 per day for 1st 10 days	95 for days 1 to 100		150 per trip	20 coinsurance		50 per visit	200 per visit						5 per visit	15 per visit	15 per visit		15 per visit		10 per Script					100 limit on eyewear																150	125	95		150	0.2		50	200						5	15	15		15		0.1					100																15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25	2000																																																																																			-	0	0	15.01	0.39	2.76	-	0.86	1.47	-	1.18	3.18	-	-	-	-	-	1.56	3.98	0.12	-	0.12	-	1.53	-	-	-	-	3.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.25
H0151_001_0	2007	5																					3700											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1038.86	49.2	395.13	0	138.87	19.47	11.43	307.12	28.64	4391.88	40.09	0	0.52	16.93	2241.12	1804.71	192.02	2.11	0	0	34.36	380.3	0	0	85.1	0	99.27	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											207	207	105.25	0	122.8	0.21	0.22	35.08	0.18	4.21	0.14	0	0.21	0.18	10	25	37.5	0.18	0	0	0.21	25	0	0	25	0	25	0	0	0	0											17.92	0.85	3.47	-	1.42	4.1	2.5	0.9	5.02	1.54	5.51	-	0.11	2.97	1.87	3.76	0.6	0.37	-	-	7.23	0.79	-	-	0.18	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.32		22.78	17.92	0.85	3.47	-	1.42	4.1	2.5	0.9	5.02	1.54	5.51	-	0.11	2.97	1.87	3.76	0.6	0.37	-	-	7.23	0.79	-	-	0.18	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.32																																																																																				-			17.92	0.85	3.47	-	1.42	4.1	2.5	0.9	5.02	1.54	5.51	-	0.11	2.97	1.87	3.76	0.6	0.37	-	-	7.23	0.79	-	-	0.18	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.32
H0151_013_0	2007	6																					2800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		369.34	18.66	150.23	0	36.09	16.3	11.45	102.35	18.45	1637.71	42.26	0	0.14	11.54	677.77	523.82	70.13	2.31	0	0	48.8	167.17	0	0	13.33	0	36.37	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 (16a 16b1-16b5)	30 (17a)	0 (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											209.72	209.72	106.64	0	124.41	0.21	0.22	35.55	0.21	4.27	0.17	0	0.21	0.21	15	30	37.5	0.21	0	0	0.21	30	0	0	30	0	30	0	0	0	0											6.45	0.33	1.34	-	0.37	3.48	2.51	0.3	3.94	0.58	7.07	-	0.03	2.46	0.85	1.31	0.22	0.49	-	-	10.41	0.42	-	-	0.03	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.67		16.07	6.45	0.33	1.34	-	0.37	3.48	2.51	0.3	3.94	0.58	7.07	-	0.03	2.46	0.85	1.31	0.22	0.49	-	-	10.41	0.42	-	-	0.03	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.67																																																																																				-			6.45	0.33	1.34	-	0.37	3.48	2.51	0.3	3.94	0.58	7.07	-	0.03	2.46	0.85	1.31	0.22	0.49	-	-	10.41	0.42	-	-	0.03	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.67
H0151_015_0	2007	6	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					NA	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-																																											(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 0/0 Coinsurance	(4a/4b) 0/0 per Visit	(9b) 0 per Visit	(8a) 0 per Visit	(8b) 0 per Visit	(9a) 0 per Visit	(12) 0 Coinsurance	(9a) 0 per Visit	(7a) 0 per Visit	(7d) 0 per Visit	(7h) 0 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	0 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit		(7b) 0 per Visit	(7f) 0 per Visit																																																-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H0151_017_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2070.11	192.76	8962.4	175.04	656.96	22.5	7.06	188.94	125.44	3902.67	173.5	34.31	4.49	291.71	127.88	1309.08	1700.55	20.09		273.34	263.11	1336.65	1200		140.2	166		54.6				111.41	0.28	0.07	300	295.2						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						132	132			66	18	18	44	22			22		22		9				9		9										31		22								22.8	2.12	-	-	3.62	3.96	1.24	0.69	0.23	-	-	0.06	-	0.54	-	0.96	-	-	-	0.2	-	0.98	-	-	-	-	-	-	-	-	-	0.29	-	0	-	-	-	-	-	-	-	37.7		5.09	22.8	2.12	-	-	3.62	3.96	1.24	0.69	0.23	-	-	0.06	-	0.54	-	0.96	-	-	-	0.2	-	0.98	-	-	-	-	-	-	-	-	-	0.29	-	0	-	-	-	-	-	-	-	37.7																																																																																				-		0	22.8	2.12	-	-	3.62	3.96	1.24	0.69	0.23	-	-	0.06	-	0.54	-	0.96	-	-	-	0.2	-	0.98	-	-	-	-	-	-	-	-	-	0.29	-	0	-	-	-	-	-	-	-	37.7
H0151_019_0	2007	4																					3100											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1040.88	49.3	395.9	0	139.14	19.47	11.43	307.71	28.64	4400.41	40.09	0	0.52	16.93	2245.47	1808.21	192.39	2.11	0	0	34.36	381.04	0	0	85.26	0	99.46	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											194.14	194.14	98.72	0	115.17	0.2	0.21	32.91	0.16	3.95	0.13	0	0.2	0.16	10	25	37.5	0.16	0	0	0.2	25	0	0	25	0	25	0	0	0	0											16.84	0.8	3.26	-	1.34	3.84	2.37	0.84	4.71	1.45	5.17	-	0.1	2.78	1.87	3.77	0.6	0.35	-	-	6.78	0.79	-	-	0.18	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.06		26.13	16.84	0.8	3.26	-	1.34	3.84	2.37	0.84	4.71	1.45	5.17	-	0.1	2.78	1.87	3.77	0.6	0.35	-	-	6.78	0.79	-	-	0.18	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.06																																																																																				-			16.84	0.8	3.26	-	1.34	3.84	2.37	0.84	4.71	1.45	5.17	-	0.1	2.78	1.87	3.77	0.6	0.35	-	-	6.78	0.79	-	-	0.18	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.06
H0151_020_0	2007	4																					2250											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		385.45	19.48	156.78	0	37.66	16.3	11.45	106.81	18.45	1709.16	42.26	0	0.14	11.54	707.35	546.68	73.19	2.31	0	0	48.8	174.46	0	0	13.91	0	37.96	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 (16a 16b1-16b5)	30 (17a)	0 (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											193.22	193.22	98.25	0	114.62	0.2	0.2	32.75	0.2	3.93	0.15	0	0.2	0.2	15	30	37.5	0.2	0	0	0.2	30	0	0	30	0	30	0	0	0	0											6.21	0.31	1.28	-	0.36	3.2	2.33	0.29	3.63	0.56	6.5	-	0.03	2.26	0.88	1.37	0.23	0.45	-	-	9.59	0.44	-	-	0.03	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.05		19.38	6.21	0.31	1.28	-	0.36	3.2	2.33	0.29	3.63	0.56	6.5	-	0.03	2.26	0.88	1.37	0.23	0.45	-	-	9.59	0.44	-	-	0.03	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.05																																																																																				-			6.21	0.31	1.28	-	0.36	3.2	2.33	0.29	3.63	0.56	6.5	-	0.03	2.26	0.88	1.37	0.23	0.45	-	-	9.59	0.44	-	-	0.03	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.05
H0151_023_0	2007	5																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		946.28	44.82	359.92	0	126.5	18.95	11.13	279.75	27.88	4000.48	39.03	0	0.51	16.48	2041.4	1643.87	174.91	2.06	0	0	33.45	346.41	0	0	77.52	0	90.42	0	0	0	0											170 (1a)	170 (1b)	95 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											114.15	114.15	63.79	0	117.51	0.2	0.21	33.57	0.13	4.03	0.11	0	0.2	0.13	10	20	37.5	0.13	0	0	0.2	20	0	0	20	0	20	0	0	0	0											9	0.43	1.91	-	1.24	3.82	2.35	0.78	3.74	1.34	4.11	-	0.1	2.21	1.7	2.74	0.55	0.28	-	-	6.74	0.58	-	-	0.13	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.9		18.46	9	0.43	1.91	-	1.24	3.82	2.35	0.78	3.74	1.34	4.11	-	0.1	2.21	1.7	2.74	0.55	0.28	-	-	6.74	0.58	-	-	0.13	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.9																																																																																				-			9	0.43	1.91	-	1.24	3.82	2.35	0.78	3.74	1.34	4.11	-	0.1	2.21	1.7	2.74	0.55	0.28	-	-	6.74	0.58	-	-	0.13	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.9
H0151_024_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		940.31	44.54	357.65	0	125.7	18.95	11.13	277.98	27.88	3975.24	39.03	0	0.51	16.48	2028.52	1633.5	173.8	2.06	0	0	33.45	344.23	0	0	77.03	0	89.85	0	0	0	0											170 (1a)	170 (1b)	95 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											106.58	106.58	59.56	0	109.72	0.19	0.2	31.35	0.13	3.76	0.1	0	0.19	0.13	10	20	37.5	0.13	0	0	0.19	20	0	0	20	0	20	0	0	0	0											8.35	0.4	1.78	-	1.15	3.57	2.21	0.73	3.5	1.25	3.84	-	0.1	2.06	1.69	2.72	0.54	0.26	-	-	6.29	0.57	-	-	0.13	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.27		20.91	8.35	0.4	1.78	-	1.15	3.57	2.21	0.73	3.5	1.25	3.84	-	0.1	2.06	1.69	2.72	0.54	0.26	-	-	6.29	0.57	-	-	0.13	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.27																																																																																				-			8.35	0.4	1.78	-	1.15	3.57	2.21	0.73	3.5	1.25	3.84	-	0.1	2.06	1.69	2.72	0.54	0.26	-	-	6.29	0.57	-	-	0.13	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.27
H0151_801_0	2007	4																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2371.87	98.83	859.02	0	304.17	18.11	10.27	575.8	29.44	9692.35	39.53	0	0.75	17.81	4399.7	3816.13	389.01	1.84	0	0	38.51	921.28	0	0	157.91	0	200.57	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											220.34	220.34	94.43	0	110.17	0.16	0.17	31.48	0.16	3.78	0.12	0	0.19	0.16	20	30	37.5	0.16	0	0	0.19	30	0	0	30	0	30	0	0	0	0											43.55	1.81	6.76	-	2.79	2.85	1.75	1.51	4.63	3.05	4.88	-	0.14	2.8	7.33	9.54	1.22	0.29	-	-	7.27	2.3	-	-	0.39	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38		49.28	43.55	1.81	6.76	-	2.79	2.85	1.75	1.51	4.63	3.05	4.88	-	0.14	2.8	7.33	9.54	1.22	0.29	-	-	7.27	2.3	-	-	0.39	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38																																																																																				-			43.55	1.81	6.76	-	2.79	2.85	1.75	1.51	4.63	3.05	4.88	-	0.14	2.8	7.33	9.54	1.22	0.29	-	-	7.27	2.3	-	-	0.39	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38
H0154_001_0	2007	4																																A	A	D	V	T	Coin	Coin	V	V	P	P	O	V	V	V	V	V	V	P	V	Coin	P		P	V	P	V																																																								-		214.32	1.78	839.03	0	187.49	7.68	7.68	611.15	372.2	0	75.26	3.95	15.18	297.97	5551.68	7971.26	143.56	309.77	0	1205.28	10.98	0		0	72.58	0	43.56															Avg copay per admit of 3000 for transplants and 200 for other IP admissions	200 per admit	95/day for days 8-28 with 1995 annual out-of-pocket max (est. as avg 46.83 per day copay)	No member cost sharing	125 copay per one-way trip	20 coinsurance	20 coinsurance	50 emergency room copay and 50 urgent care facility copay	175 per visit 1050 out-of-pocket maximum	No member cost sharing	40 radiation therapy copay	30 per day	50 per visit	25 rehab. services (CORF) copay and 30 outpatient substance abuse svcs copay	10 per visit	15 per visit	30 per visit	25 per visit	No member cost sharing	15 chiropractic copay 15 podiatry copay and 30 other health care services copay	20 coinsurance and 2500 OOP max on Medicare covered chemotherapy drugs	No member cost sharing		0	15 per visit	0	Avg copay of 13 assumes 2/3 of svcs delivered by contracted specialist at 15 copay and 1/3 by PCP at 10 copay															210.19	200	46.83	0	125	0.2	0.2	50	175	0	40	30	50	25.25	10	15	30	25	0	15.05	0.17	0		0	15	0	13.33															3.75	0.03	3.27	-	1.95	1.54	1.54	2.55	5.43	-	0.25	0.01	0.06	0.63	4.63	9.96	0.36	0.65	-	1.51	1.89	-	-	-	0.09	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.14			3.75	0.03	3.27	-	1.95	1.54	1.54	2.55	5.43	-	0.25	0.01	0.06	0.63	4.63	9.96	0.36	0.65	-	1.51	1.89	-	-	-	0.09	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.14																																																																																				-			3.75	0.03	3.27	-	1.95	1.54	1.54	2.55	5.43	-	0.25	0.01	0.06	0.63	4.63	9.96	0.36	0.65	-	1.51	1.89	-	-	-	0.09	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.14
H0154_008_0	2007	2																																A	A	D	V	T	Coin	Coin	V	V	P	P	O	V	V	V	V	V	V	P	V	Coin	P		P	V	P	V																																																								-		213.93	1.77	837.47	0	187.14	7.67	7.67	610.02	371.51	0	75.12	3.95	15.15	297.42	5541.41	7956.51	143.29	309.2	0	1203.05	10.96	0		0	72.44	0	43.48															Avg copay per admit of 3000 for transplants and 150 for other IP admissions	150 per admit	95/day for days 8-28 with 1995 annual out-of-pocket max (est. as avg 46.83 per day copay)	No member cost sharing	125 copay per one-way trip	20 coinsurance	20 coinsurance	50 emergency room copay and 20 urgent care facility copay	125 per visit 1000 out-of-pocket maximum	No member cost sharing	40 radiation therapy copay	25 per day	50 per visit	25 per visit	5 per visit	10 per visit	25 per visit	25 per visit	No member cost sharing	10 chiropractic copay 10 podiatry copay and 25 other health care services copay	20 coinsurance and 2500 OOP max on Medicare covered chemotherapy drugs	No member cost sharing		No member cost sharing	10 per visit	0	Avg copay of 8.33 assumes 2/3 of svcs delivered by contracted specialist at 10 copay and 1/3 by PCP at 5 copay															160.37	150	46.83	0	125	0.2	0.2	40	125	0	40	25	50	25	5	10	25	25	0	10.06	0.17	0		0	10	0	8.33															2.86	0.02	3.27	-	1.95	1.53	1.53	2.03	3.87	-	0.25	0.01	0.06	0.62	2.31	6.63	0.3	0.64	-	1.01	1.88	-	-	-	0.06	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.88			2.86	0.02	3.27	-	1.95	1.53	1.53	2.03	3.87	-	0.25	0.01	0.06	0.62	2.31	6.63	0.3	0.64	-	1.01	1.88	-	-	-	0.06	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.88																																																																																				-			2.86	0.02	3.27	-	1.95	1.53	1.53	2.03	3.87	-	0.25	0.01	0.06	0.62	2.31	6.63	0.3	0.64	-	1.01	1.88	-	-	-	0.06	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.88
H0154_009_0	2007	3																																A	A	D	V	T	Coin	Coin	V	V	P	P	O	V	V	V	V	V	V	P	V	Coin	P		P	V	P	V																																																								-		235.76	1.95	922.93	0	206.24	8.45	8.45	672.27	409.42	0	82.79	4.35	16.7	327.77	6106.85	8768.39	157.91	340.75	0	1325.81	12.08	0		0	79.84	0	47.92															Avg copay per admit of 3000 for transplants and 200 for other IP admissions	200 per admit	95/day for days 8-28 with 1995 annual out-of-pocket max (est. as avg 46.83 per day copay)	No member cost sharing	125 copay per one-way trip	20 coinsurance	20 coinsurance	50 emergency room copay and 50 urgent care facility copay	175 per visit 1050 out-of-pocket maximum	No member cost sharing	40 radiation therapy copay	30 per day	50 per visit	25 rehab. services (CORF) copay and 30 outpatient substance abuse svcs copay	10 per visit	15 per visit	30 per visit	25 per visit	No member cost sharing	15 chiropractic copay 15 podiatry copay and 30 other health care services copay	20 coinsurance and 2500 OOP max on Medicare covered chemotherapy drugs	No member cost sharing		0	15 per visit	0	Avg copay of 13 assumes 2/3 of svcs delivered by contracted specialist at 15 copay and 1/3 by PCP at 10 copay															210.19	200	46.83	0	125	0.2	0.2	50	175	0	40	30	50	25.25	10	15	30	25	0	15.05	0.17	0		0	15	0	13.33															4.13	0.03	3.6	-	2.15	1.69	1.69	2.8	5.97	-	0.28	0.01	0.07	0.69	5.09	10.96	0.39	0.71	-	1.66	2.08	-	-	-	0.1	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.16			4.13	0.03	3.6	-	2.15	1.69	1.69	2.8	5.97	-	0.28	0.01	0.07	0.69	5.09	10.96	0.39	0.71	-	1.66	2.08	-	-	-	0.1	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.16																																																																																				-			4.13	0.03	3.6	-	2.15	1.69	1.69	2.8	5.97	-	0.28	0.01	0.07	0.69	5.09	10.96	0.39	0.71	-	1.66	2.08	-	-	-	0.1	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.16
H0154_801_0	2007	1																																A	A	D	V	T	Coin	Coin	V	V	P	P	O	V	V	V	V	V	V	P	V	Coin	P		0	0	0	0																																																								-		192.88	1.6	755.06	0	168.73	6.92	6.92	549.99	334.95	0	67.73	3.56	13.66	268.15	4996.1	7173.54	129.19	278.77	0	1084.66	9.88	0		0	0	0	0															250 per admit	250 per admit	75 per day	No member cost sharing	125 copay per one-way trip	20 coinsurance	20 coinsurance	50 per visit	175 per visit 1050 out-of-pocket maximum	No member cost sharing	40 radiation therapy copay	30 per day	50 per visit	30 rehab. services (CORF) copay and 30 outpatient substance abuse svcs copay	25 per visit	25 per visit	30 per visit	25 per visit	No member cost sharing	25 chiropractic copay 25 podiatry copay and 30 other health care services copay	20 coinsurance and 2500 OOP max on Medicare covered chemotherapy drugs	No member cost sharing		0	0	0	0															250	250	75	0	125	0.2	0.2	50	175	0	40	30	50	30	25	25	30	25	0	25.02	0.17	0		0	0	0	0															4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65																																																																																				-			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65
H0154_802_0	2007	1																																A	A	D	V	T	Coin	Coin	V	V	P	P	O	V	V	V	V	V	V	P	V	Coin	P		0	0	0	0																																																								-		192.88	1.6	755.06	0	168.73	6.92	6.92	549.99	334.95	0	67.73	3.56	13.66	268.15	4996.1	7173.54	129.19	278.77	0	1084.66	9.88	0		0	0	0	0															250 per admit	250 per admit	75 per day	No member cost sharing	125 copay per one-way trip	20 coinsurance	20 coinsurance	50 per visit	175 per visit 1050 out-of-pocket maximum	No member cost sharing	40 radiation therapy copay	30 per day	50 per visit	30 rehab. services (CORF) copay and 30 outpatient substance abuse svcs copay	25 per visit	25 per visit	30 per visit	25 per visit	No member cost sharing	25 chiropractic copay 25 podiatry copay and 30 other health care services copay	20 coinsurance and 2500 OOP max on Medicare covered chemotherapy drugs	No member cost sharing		0	0	0	0															250	250	75	0	125	0.2	0.2	50	175	0	40	30	50	30	25	25	30	25	0	25.02	0.17	0		0	0	0	0															4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65																																																																																				-			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65
H0154_803_0	2007	1																																A	A	D	V	T	Coin	Coin	V	V	P	P	O	V	V	V	V	V	V	P	V	Coin	P		0	0	0	0																																																								-		192.88	1.6	755.06	0	168.73	6.92	6.92	549.99	334.95	0	67.73	3.56	13.66	268.15	4996.1	7173.54	129.19	278.77	0	1084.66	9.88	0		0	0	0	0															250 per admit	250 per admit	75 per day	No member cost sharing	125 copay per one-way trip	20 coinsurance	20 coinsurance	50 per visit	175 per visit 1050 out-of-pocket maximum	No member cost sharing	40 radiation therapy copay	30 per day	50 per visit	30 rehab. services (CORF) copay and 30 outpatient substance abuse svcs copay	25 per visit	25 per visit	30 per visit	25 per visit	No member cost sharing	25 chiropractic copay 25 podiatry copay and 30 other health care services copay	20 coinsurance and 2500 OOP max on Medicare covered chemotherapy drugs	No member cost sharing		0	0	0	0															250	250	75	0	125	0.2	0.2	50	175	0	40	30	50	30	25	25	30	25	0	25.02	0.17	0		0	0	0	0															4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65																																																																																				-			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65
H0154_804_0	2007	1																																A	A	D	V	T	Coin	Coin	V	V	P	P	O	V	V	V	V	V	V	P	V	Coin	P		0	0	0	0																																																								-		192.88	1.6	755.06	0	168.73	6.92	6.92	549.99	334.95	0	67.73	3.56	13.66	268.15	4996.1	7173.54	129.19	278.77	0	1084.66	9.88	0		0	0	0	0															250 per admit	250 per admit	75 per day	No member cost sharing	125 copay per one-way trip	20 coinsurance	20 coinsurance	50 per visit	175 per visit 1050 out-of-pocket maximum	No member cost sharing	40 radiation therapy copay	30 per day	50 per visit	30 rehab. services (CORF) copay and 30 outpatient substance abuse svcs copay	25 per visit	25 per visit	30 per visit	25 per visit	No member cost sharing	25 chiropractic copay 25 podiatry copay and 30 other health care services copay	20 coinsurance and 2500 OOP max on Medicare covered chemotherapy drugs	No member cost sharing		0	0	0	0															250	250	75	0	125	0.2	0.2	50	175	0	40	30	50	30	25	25	30	25	0	25.02	0.17	0		0	0	0	0															4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65																																																																																				-			4.02	0.03	4.72	-	1.76	1.38	1.38	2.29	4.88	-	0.23	0.01	0.06	0.67	10.41	14.94	0.32	0.58	-	2.26	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.65
H0251_001_0	2007	6																																D	D	D	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	P	V	P	V	P	O	O	O																																																				-		2301.41	493.96	1114.97		11.42	25.85	28.11	1025.46	36.22	21.48	22.17	1.58	1.88	25.69	0	33.62	7.13	1.79	23.36	108.7	23.33	0.08																				50 (1a)	50 (1b)	50 (2a)	0 (6a)	23.6 (FFS) (10a)	23.6 (FFS) (11a)	23.6 (FFS) (11b 11c)	50 (ER 4a)  23.6 (UC 4b)	23.6 (FFS) (9b)	23.6 (FFS) (8a 8b)	23.6 (FFS) (8a 8b)	23.6 (FFS) (incl in h.5)	23.6 (FFS) (12)	23.6 (FFS) (3 5 9a 9c 9d)	0 (7a 14)	23.6 (FFS) (7b 7d 7f 7g)	23.6 (FFS) (7e 7h)	23.6 (FFS) (7c 7i)	23.6 (FFS) (incl in h.2)	23.6 (FFS) (14i)	23.6 (FFS) (15)	23.6 (FFS) (13a 16b 17b 17a 18a)	0 n/c (10b)	0 (16a 16b)	0 (17a)	0 (17b)	0 n/c (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 (13b)											50	50	50		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				9.59	2.06	4.65	-	2.69	6.1	6.63	4.27	8.55	5.07	5.23	0.37	0.44	6.06	0	7.93	1.68	0.42	5.51	25.65	5.51	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.46		0	9.59	2.06	4.65	-	2.69	6.1	6.63	4.27	8.55	5.07	5.23	0.37	0.44	6.06	0	7.93	1.68	0.42	5.51	25.65	5.51	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.46																																																																																				-		0	9.59	2.06	4.65	-	2.69	6.1	6.63	4.27	8.55	5.07	5.23	0.37	0.44	6.06	0	7.93	1.68	0.42	5.51	25.65	5.51	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.46
H0302_001_0	2007	14																																D	D	D	V	T	Coin	Coin	V	V	O	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	P	V	P																																																							-		1342.47	83.07	993.89		169	18.37	3.02	282.55	134.06		638.23		11.26	408.15	4921.88	6981.25	193.8			2.03	13.88	145.95			130.93		242				6.2											1a: 125 days 1-4	1b: 125 days 1-8 175 days 31+	2: 0 days 1-20 50 days 21-100	6:00	10a: 100/15	11a: 0-20	11b: 0-20 11c: 0-12	4a: 50 4b: 25	9b: 150	8a: 0	8b: 0-300 20	9a: 0	12: 10/30	3 5 9c: 0 9a: 10	7a 14c: 20 14b 14d 14e 14f 14h:  0; 14g: 25	7b 17a 18a:  20; 7d: 20/30; 7f: 30; 16b: 20	7e 7h: 20	7b: 20 7c 7i: 0	0 (incl in i.2.)	7g: 20	15:20	13a: 0 17b: 20	10b: 0	16a: 0	17a: 20		18a: 20	18b: 0		14a:  0	13c:  15											89.64	96.12	14.17		100.14	0.09	0.04	47.87	150		49.23		11.54	8.63	12.59	19.28	16			6	0.2	20			20		20				5.5											10.03	0.67	1.17	-	1.41	1.6	0.11	1.13	1.68	-	2.62	-	0.01	0.29	5.16	11.22	0.26	-	-	0	2.78	0.24	-	-	0.22	-	0.4	-	-	-	0	-	-	-	-	-	-	-	-	-	-	41		0	10.03	0.67	1.17	-	1.41	1.6	0.11	1.13	1.68	-	2.62	-	0.01	0.29	5.16	11.22	0.26	-	-	0	2.78	0.24	-	-	0.22	-	0.4	-	-	-	0	-	-	-	-	-	-	-	-	-	-	41																																																																																				-		0	10.03	0.67	1.17	-	1.41	1.6	0.11	1.13	1.68	-	2.62	-	0.01	0.29	5.16	11.22	0.26	-	-	0	2.78	0.24	-	-	0.22	-	0.4	-	-	-	0	-	-	-	-	-	-	-	-	-	-	41
H0302_004_0	2007	13																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	Coin	V	V	V	V	V																																																				-		2489.03	60.97	1091.69		350.13	23.7	33.17	592.34	654.52		633.23		2.55	1117.42	6571.66	12138.51	307.65	1174.23		6154.08	52.22	33.95			129.91		232.59	38.94														1a: 125 days 1-4	1b: 125 days 1-8 175 days 31+	2: 0 days 1-20 50 days 21-100	6:00	10a: 100/15	11a: 0-20	11b: 0-20 11c: 0-12	4a: 50 4b: 25	9b: 150	8a:  0	8a: 0-75; 8b: 0-300 20	9a: 0	12: 10/30	3 9d: 10; 5 9c: 20; 9a: 25-150	7a: 10; 14c: 20; 14f: 0-150; 14g: 25; 14b: 0-25; 14i: 0-10; 14d 14e 14h:  0	7b 7f: 40; 16b:  20; 18a: 20 7d: 10/40; 17a: 20/30	7e: 20; 7h: 40	7b: 40 7c 7i: 10	0 (incl in i.2.)	7g: 10-50; 16b: 20	15:20	13a: 0 17b: 20	10b: 0	16a: 0	17a: 20		18a: 20	18b: 0		14a:  0												102.67	96.74	14.17		100.13	0.09	0.05	47.87	150		53.07		11.54	10.35	11.52	28.58	20	10		9.13	0.2	20			20		20	20														21.3	0.49	1.29	-	2.92	2.07	1.53	2.36	8.18	-	2.8	-	0	0.96	6.31	28.91	0.51	0.98	-	4.68	10.44	0.06	-	-	0.22	-	0.39	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	96.46		0	21.3	0.49	1.29	-	2.92	2.07	1.53	2.36	8.18	-	2.8	-	0	0.96	6.31	28.91	0.51	0.98	-	4.68	10.44	0.06	-	-	0.22	-	0.39	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	96.46																																																																																				-		0	21.3	0.49	1.29	-	2.92	2.07	1.53	2.36	8.18	-	2.8	-	0	0.96	6.31	28.91	0.51	0.98	-	4.68	10.44	0.06	-	-	0.22	-	0.39	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	96.46
H0303_013_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.71	36.21	1040.24	1976.07	176.53	14.89	1.04	385.74	384.27	684.43	28.51	29.71	4.24	616	5402.62	4315.85	253.71	462.8	29.4	22288.23	12.37	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	69	0	100	0.2	0.2	46.73	200	0	0.15	0	0	135.61	10	30	30	30	0.27	0.01	0.2	0	0	0	30	30	0	0	0	0	0											14.54	0.33	5.98	-	1.47	2.92	0.21	1.5	6.4	-	4.39	-	-	6.96	4.5	10.79	0.63	1.16	7.99	0.01	2.47	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.21	0	0	14.54	0.33	5.98	-	1.47	2.92	0.21	1.5	6.4	-	4.39	-	-	6.96	4.5	10.79	0.63	1.16	7.99	0.01	2.47	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.21	None																																																																																			-	0	0	14.54	0.33	5.98	-	1.47	2.92	0.21	1.5	6.4	-	4.39	-	-	6.96	4.5	10.79	0.63	1.16	7.99	0.01	2.47	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.21
H0303_015_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1296.76	35.13	1439.02	1692.4	261.69	16.24	1.13	417.34	387.65	818.31	37.26	29.97	4.64	621.42	5901.9	4128.56	250.28	350.26	38.42	23756.11	12.37	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	69	0	100	0.2	0.2	46.73	150	0	0.15	0	0	102.6	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											10.58	0.32	8.27	-	2.18	3.19	0.23	1.63	4.85	-	5.74	-	-	5.31	7.38	10.32	0.63	0.88	9.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.79	0	0	10.58	0.32	8.27	-	2.18	3.19	0.23	1.63	4.85	-	5.74	-	-	5.31	7.38	10.32	0.63	0.88	9.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.79	None																																																																																			-	0	0	10.58	0.32	8.27	-	2.18	3.19	0.23	1.63	4.85	-	5.74	-	-	5.31	7.38	10.32	0.63	0.88	9.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.79
H0303_034_0	2007	4																					700											D	D	D	V	T	Coin	Coin	V	P	P	P	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	700	1588.53	43.03	1762.8	2073.19	320.57	8.76	0.61	511.25	474.87	1002.43	1261.09	36.72	2.5	761.24	7229.83	5057.49	250.28	429.07	20.73	29101.25	6.06	0	0	1538.5	113.87	257.37	203.52	36.51	0	0	652.33											75 [day(s) 1- 10];0 [day(s) 11-90]	75 [day(s) 1- 10];0 [day(s) 11-90]	0 [Day(s) 1-20]; 120 [Day(s) 21-26];0 [Day(s) 27-100]	0	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10	Ambulatory Surgical Center Copay: 25; Outpatient Hospital Copay: 25	0	Radiation Therapy: 10; Compex Radiology (MRIMRACTPETSpec): 10	0	20 Coinsurance	Cardiac Rehabilitation: 25; Pulmonary Rehabilitation: 25; Ambulatory Surgical Center Copay: 25; Outpatient Hospital Copay: 25	0	10	0	Occupational Therapy: 10; PT and Speech/Language Therapy: 10	Routine Outpatient X-Ray: 10; Radiation Therapy: 10; Compex Radiology (MRIMRACTPETSpec): 10	10	Inhalation Solutions: 0; Oral Chemo: 0; Anti-Emetics: 0; Outpatient Injectables  -Self Administered: 0	0	0/24 one-way trips/year	5 Office Visit2 teeth cleanings/year and preventative care	5 1/12 mths	Materials copay 5/12 months	5 /12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											31.4	37.42	5.49	0	37.46	0.2	0.2	11.26	12.49	0	1.77	0	0.2	10.65	0	4.99	0	4.99	0.13	2.44	0	0	0	1.77	5	5	5	0	0	0	0											4.16	0.13	0.81	-	1	1.72	0.12	0.48	0.49	-	0.19	-	0.5	0.68	-	2.1	-	0.18	2.68	5.91	-	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.62	0	21.2	4.16	0.13	0.81	-	1	1.72	0.12	0.48	0.49	-	0.19	-	0.5	0.68	-	2.1	-	0.18	2.68	5.91	-	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.62	700																																																																																			-	0	0	4.16	0.13	0.81	-	1	1.72	0.12	0.48	0.49	-	0.19	-	0.5	0.68	-	2.1	-	0.18	2.68	5.91	-	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.62
H0303_035_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1391.92	37.71	869.07	1692.4	198.88	15.47	1.08	385.74	435.64	708.7	37.5	33.68	5.17	698.36	5402.62	4027.73	250.28	350.26	38.67	22498.77	12.37	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	69	0	100	0.2	0.2	46.73	150	0	0.15	0	0	102.6	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											11.35	0.34	5	-	1.66	3.04	0.22	1.5	5.45	-	5.77	-	-	5.97	6.75	10.07	0.63	0.88	10.01	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.05	0	0	11.35	0.34	5	-	1.66	3.04	0.22	1.5	5.45	-	5.77	-	-	5.97	6.75	10.07	0.63	0.88	10.01	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.05	None																																																																																			-	0	0	11.35	0.34	5	-	1.66	3.04	0.22	1.5	5.45	-	5.77	-	-	5.97	6.75	10.07	0.63	0.88	10.01	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.05
H0303_036_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1694.47	45.9	1880.36	2211.46	341.95	21.09	1.47	545.34	506.54	1069.29	48.39	39.17	6.02	812.01	7712.02	5394.8	250.28	457.69	49.89	31042.14	12.37	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	0 1/yr	500/3 yrs	Not Covered	0	Acupuncture: 10 / 12 visits yr; Routine Chiropractic: 10 / 12 visits yr											97.89	109.69	69	0	100	0.2	0.2	46.73	150	0	0.15	0	0	102.6	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	8.95											13.82	0.42	10.81	-	2.85	4.14	0.29	2.12	6.33	-	7.45	-	-	6.94	9.64	13.49	0.63	1.14	12.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	96.88	0	0	13.82	0.42	10.81	-	2.85	4.14	0.29	2.12	6.33	-	7.45	-	-	6.94	9.64	13.49	0.63	1.14	12.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	96.88	None																																																																																			-	0	0	13.82	0.42	10.81	-	2.85	4.14	0.29	2.12	6.33	-	7.45	-	-	6.94	9.64	13.49	0.63	1.14	12.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	96.88
H0303_037_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1569.4	42.51	1199.99	2311.94	206.53	17.05	1.19	451.3	454.7	800.76	32.64	35.16	4.91	728.9	6320.89	5049.4	253.71	541.46	33.65	26120.91	12.37	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	0 1/yr	500/3 yrs	Not Covered	0	Acupuncture: 10 / 12 visits yr; Routine Chiropractic: 10 / 12 visits yr											130.52	109.69	69	0	100	0.2	0.2	46.73	200	0	0.15	0	0	135.61	10	30	30	30	0.28	0.01	0.2	0	0	0	30	30	0	0	0	0	8.96											17.07	0.39	6.9	-	1.72	3.35	0.24	1.76	7.58	-	5.03	-	-	8.24	5.27	12.62	0.63	1.35	9.28	0.01	2.47	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	85.34	0	0	17.07	0.39	6.9	-	1.72	3.35	0.24	1.76	7.58	-	5.03	-	-	8.24	5.27	12.62	0.63	1.35	9.28	0.01	2.47	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	85.34	None																																																																																			-	0	0	17.07	0.39	6.9	-	1.72	3.35	0.24	1.76	7.58	-	5.03	-	-	8.24	5.27	12.62	0.63	1.35	9.28	0.01	2.47	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	85.34
H0303_038_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1796.99	48.68	1374.01	2611.46	233.29	19.39	1.35	516.75	520.63	906.32	37.27	40.26	5.66	834.61	7139.8	5703.59	250.28	611.61	38.43	29628.33	12.37	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	0 1/yr	500/3 yrs	Not Covered	0	Acupuncture: 10 / 12 visits yr; Routine Chiropractic: 10 / 12 visits yr											97.89	109.69	69	0	100	0.2	0.2	46.73	150	0	0.15	0	0	102.6	15	30	30	30	0.27	0.01	0.2	0	0	0	30	30	0	0	0	0	8.95											14.66	0.44	7.9	-	1.94	3.81	0.27	2.01	6.51	-	5.74	-	-	7.14	8.92	14.26	0.63	1.53	10.55	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	90.21	0	0	14.66	0.44	7.9	-	1.94	3.81	0.27	2.01	6.51	-	5.74	-	-	7.14	8.92	14.26	0.63	1.53	10.55	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	90.21	None																																																																																			-	0	0	14.66	0.44	7.9	-	1.94	3.81	0.27	2.01	6.51	-	5.74	-	-	7.14	8.92	14.26	0.63	1.53	10.55	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	90.21
H0303_039_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1296.76	35.13	1439.02	1692.4	261.69	17.42	1.22	417.34	387.65	818.31	39.95	29.97	4.97	621.42	5901.9	4128.56	250.28	350.26	41.19	23756.11	12.37	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 [Day(s) 1-10]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	35	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											167.66	109.69	69	0	100	0.2	0.2	46.73	200	0	0.15	0	0	135.61	15	35	30	35	0.25	0.01	0.2	0	0	0	30	30	0	0	0	0	0											18.12	0.32	8.27	-	2.18	3.42	0.24	1.63	6.46	-	6.15	-	-	7.02	7.38	12.04	0.63	1.02	10.13	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.42	0	0	18.12	0.32	8.27	-	2.18	3.42	0.24	1.63	6.46	-	6.15	-	-	7.02	7.38	12.04	0.63	1.02	10.13	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.42	None																																																																																			-	0	0	18.12	0.32	8.27	-	2.18	3.42	0.24	1.63	6.46	-	6.15	-	-	7.02	7.38	12.04	0.63	1.02	10.13	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.42
H0303_040_0	2007	2																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1296.76	35.13	1439.02	1692.4	261.69	15.8	1.1	417.34	387.65	818.31	36.24	29.97	4.51	621.42	5901.9	4128.56	250.28	350.26	37.37	23756.11	12.37	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	62	0	100	0.2	0.2	46.73	150	0	0.15	0	0	102.6	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											10.58	0.32	7.43	-	2.18	3.1	0.22	1.63	4.85	-	5.58	-	-	5.31	7.38	10.32	0.63	0.88	9.8	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.61	0	0	10.58	0.32	7.43	-	2.18	3.1	0.22	1.63	4.85	-	5.58	-	-	5.31	7.38	10.32	0.63	0.88	9.8	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.61	None																																																																																			-	0	0	10.58	0.32	7.43	-	2.18	3.1	0.22	1.63	4.85	-	5.58	-	-	5.31	7.38	10.32	0.63	0.88	9.8	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.61
H0303_041_0	2007	1																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1391.92	37.71	869.07	1692.4	198.88	14.95	1.04	385.74	435.64	708.7	36.23	33.68	4.99	698.36	5402.62	4027.73	250.28	350.26	37.36	22498.77	12.37	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	62	0	100	0.2	0.2	46.73	150	0	0.15	0	0	102.6	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											11.35	0.34	4.49	-	1.66	2.94	0.21	1.5	5.45	-	5.58	-	-	5.97	6.75	10.07	0.63	0.88	9.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.12	0	0	11.35	0.34	4.49	-	1.66	2.94	0.21	1.5	5.45	-	5.58	-	-	5.97	6.75	10.07	0.63	0.88	9.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.12	None																																																																																			-	0	0	11.35	0.34	4.49	-	1.66	2.94	0.21	1.5	5.45	-	5.58	-	-	5.97	6.75	10.07	0.63	0.88	9.89	0.01	2.47	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.12
H0303_801_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1337.11	36.22	1383.15	1812.89	236.05	10.11	0.71	439.11	412.43	824.79	22.32	31.89	2.94	661.14	6004.05	4390.23	263.34	406.71	22.59	24359.53	15.49	0	0	0	114.4	258.56	204.46	36.68	0	0	655.03											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											224.01	223.96	102.38	0	111.98	0.3	0.3	11.92	254.29	0	0.23	0	0.3	58.5	31.31	41.59	25.6	41.59	0.31	4.52	0.3	0	0	0	0	0	0	0	0	0	0											24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	0	64.76	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	5000																																																																																			-	0	0	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08
H0303_803_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1337.11	36.22	1383.15	1812.89	236.05	10.11	0.71	439.11	412.43	824.79	22.32	31.89	2.94	661.14	6004.05	4390.23	263.34	406.71	22.59	24359.53	15.49	0	0	0	114.4	258.56	204.46	36.68	0	0	655.03											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											224.01	223.96	102.38	0	111.98	0.3	0.3	11.92	254.29	0	0.23	0	0.3	58.5	31.31	41.59	25.6	41.59	0.31	4.52	0.3	0	0	0	0	0	0	0	0	0	0											24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	0	64.76	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	5000																																																																																			-	0	0	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08
H0303_804_0	2007	5																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1337.11	36.22	1383.15	1812.89	236.05	10.11	0.71	439.11	412.43	824.79	22.32	31.89	2.94	661.14	6004.05	4390.23	263.34	406.71	22.59	24359.53	15.49	0	0	0	114.4	258.56	204.46	36.68	0	0	655.03											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											224.01	223.96	102.38	0	111.98	0.3	0.3	11.92	254.29	0	0.23	0	0.3	58.5	31.31	41.59	25.6	41.59	0.31	4.52	0.3	0	0	0	0	0	0	0	0	0	0											24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	0	64.76	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	5000																																																																																			-	0	0	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08
H0303_805_0	2007	5																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1337.11	36.22	1383.15	1812.89	236.05	10.11	0.71	439.11	412.43	824.79	22.32	31.89	2.94	661.14	6004.05	4390.23	263.34	406.71	22.59	24359.53	15.49	0	0	0	114.4	258.56	204.46	36.68	0	0	655.03											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											224.01	223.96	102.38	0	111.98	0.3	0.3	11.92	254.29	0	0.23	0	0.3	58.5	31.31	41.59	25.6	41.59	0.31	4.52	0.3	0	0	0	0	0	0	0	0	0	0											24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	0	64.76	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08	5000																																																																																			-	0	0	24.96	0.68	11.8	-	2.2	3.03	0.21	0.44	8.74	-	5.16	-	0.88	3.22	15.66	15.22	0.56	1.41	7.07	9.18	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08
H0307_008_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1558.52	11.89	1533.84	2334.45	225.6	0.82	0.06	341.4	261.13	216.13	147.36	9.82	77.15	83.5	5474.85	4543.23			200.44		7.13											82.03	0.63	9.74								285/day (1-5)	285/day (1-5)	0/day (1-6) 150/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200-295/ Visit	10-295/ Visit	25-295/ Visit	295/ Visit	0/ Procedure	15-250/ Visit	15/ Visit	40/ Visit			150/ Visit		20 Coins											285/day (1-5)	285/day (1-5)	20 Coins								193.86	193.86	43.64	0	100	0.2	0.2	47	231.35	230.23	68.33	295	0	40.88	15	40			150		0.2											193.86	193.86	0.2								25.18	0.19	5.58	-	1.88	0.16	0.01	1.34	5.03	4.15	0.84	0.24	-	0.28	6.84	15.14	-	-	2.51	-	1.43	-	-	-	-	-	-	-	-	-	-	1.33	0.01	1.95	-	-	-	-	-	-	-	74.09	0	0	25.18	0.19	5.58	-	1.88	0.16	0.01	1.34	5.03	4.15	0.84	0.24	-	0.28	6.84	15.14	-	-	2.51	-	1.43	-	-	-	-	-	-	-	-	-	-	1.33	0.01	1.95	-	-	-	-	-	-	-	74.09																																																																																				-			25.18	0.19	5.58	-	1.88	0.16	0.01	1.34	5.03	4.15	0.84	0.24	-	0.28	6.84	15.14	-	-	2.51	-	1.43	-	-	-	-	-	-	-	-	-	-	1.33	0.01	1.95	-	-	-	-	-	-	-	74.09
H0307_801_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									8.8	0.07	0.47	0	0.62	0.06	0	0.44	1.45	0.51	0.08	0.03	0	0.11	3.03	4.4			0.83		0.49			0	0		0					0.46	0									21.85		1652.44	12.61	1626.27	2475.13	239.19	0.9	0.07	354.74	276.86	229.15	36.46	10.42	81.8	88.53	5804.78	4817.01			212.52		7.86			0	0		0					86.97	0.66									300/day (1-5)	300/day (1-5)	0/day (1-6) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									28.1	0.21	1.49	-	1.99	0.18	0.01	1.4	4.61	1.63	0.25	0.09	-	0.34	9.67	14.05	-	-	2.66	-	1.57	-	-	-	-	-	-	-	-	-	-	1.48	0.01	-	-	-	-	-	-	-	-	69.75	300	0	36.9	0.28	1.96	-	2.62	0.24	0.02	1.83	6.06	2.14	0.32	0.11	-	0.45	12.7	18.45	-	-	3.49	-	2.06	-	-	-	-	-	-	-	-	-	-	1.94	0.01	-	-	-	-	-	-	-	-	91.6																																																																																				-			36.9	0.28	1.96	-	2.62	0.24	0.02	1.83	6.06	2.14	0.32	0.11	-	0.45	12.7	18.45	-	-	3.49	-	2.06	-	-	-	-	-	-	-	-	-	-	1.94	0.01	-	-	-	-	-	-	-	-	91.6
H0307_802_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									8.31	0.03	0.39	0	0.82	0.04	0	0.35	1.23	0.63	0.1	0.03	0	0.13	3.55	4.35			0.9		0.4											0.44	0									21.72		1831.49	7.05	1607.29	2485.12	368.62	0.82	0.06	334.67	276.36	331.4	52.72	15.06	33.13	128.04	7968.71	5583.78			271.16		7.55											96.39	0.37									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									197.88	197.88	10.67	0	96.97	0.19	0.19	45.81	193.94	82.65	78.96	96.97	0	45.06	19.39	33.94			145.46		0.19											197.88	197.88									30.2	0.12	1.43	-	2.98	0.16	0.01	1.28	4.47	2.28	0.35	0.12	-	0.48	12.88	15.79	-	-	3.29	-	1.46	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.89	300	2.46	38.52	0.15	1.82	-	3.8	0.2	0.02	1.63	5.7	2.91	0.44	0.16	-	0.61	16.42	20.14	-	-	4.19	-	1.87	-	-	-	-	-	-	-	-	-	-	2.03	0.01	-	-	-	-	-	-	-	-	100.61																																																																																				-			38.52	0.15	1.82	-	3.8	0.2	0.02	1.63	5.7	2.91	0.44	0.16	-	0.61	16.42	20.14	-	-	4.19	-	1.87	-	-	-	-	-	-	-	-	-	-	2.03	0.01	-	-	-	-	-	-	-	-	100.61
H0307_803_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									8.8	0.07	0.47	0	0.62	0.06	0	0.44	1.45	0.51	0.08	0.03	0	0.11	3.03	4.4			0.83		0.49			0	0		0					0.46	0									21.85		1652.44	12.61	1626.27	2475.13	239.19	0.9	0.07	354.74	276.86	229.15	36.46	10.42	81.8	88.53	5804.78	4817.01			212.52		7.86			0	0		0					86.97	0.66									300/day (1-5)	300/day (1-5)	0/day (1-6) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									28.1	0.21	1.49	-	1.99	0.18	0.01	1.4	4.61	1.63	0.25	0.09	-	0.34	9.67	14.05	-	-	2.66	-	1.57	-	-	-	-	-	-	-	-	-	-	1.48	0.01	-	-	-	-	-	-	-	-	69.75	300	0	36.9	0.28	1.96	-	2.62	0.24	0.02	1.83	6.06	2.14	0.32	0.11	-	0.45	12.7	18.45	-	-	3.49	-	2.06	-	-	-	-	-	-	-	-	-	-	1.94	0.01	-	-	-	-	-	-	-	-	91.6																																																																																				-			36.9	0.28	1.96	-	2.62	0.24	0.02	1.83	6.06	2.14	0.32	0.11	-	0.45	12.7	18.45	-	-	3.49	-	2.06	-	-	-	-	-	-	-	-	-	-	1.94	0.01	-	-	-	-	-	-	-	-	91.6
H0307_804_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									8.31	0.03	0.39	0	0.82	0.04	0	0.35	1.23	0.63	0.1	0.03	0	0.13	3.55	4.35			0.9		0.4											0.44	0									21.72		1831.49	7.05	1607.29	2485.12	368.62	0.82	0.06	334.67	276.36	331.4	52.72	15.06	33.13	128.04	7968.71	5583.78			271.16		7.55											96.39	0.37									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									197.88	197.88	10.67	0	96.97	0.19	0.19	45.81	193.94	82.65	78.96	96.97	0	45.06	19.39	33.94			145.46		0.19											197.88	197.88									30.2	0.12	1.43	-	2.98	0.16	0.01	1.28	4.47	2.28	0.35	0.12	-	0.48	12.88	15.79	-	-	3.29	-	1.46	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.89	300	2.46	38.52	0.15	1.82	-	3.8	0.2	0.02	1.63	5.7	2.91	0.44	0.16	-	0.61	16.42	20.14	-	-	4.19	-	1.87	-	-	-	-	-	-	-	-	-	-	2.03	0.01	-	-	-	-	-	-	-	-	100.61																																																																																				-			38.52	0.15	1.82	-	3.8	0.2	0.02	1.63	5.7	2.91	0.44	0.16	-	0.61	16.42	20.14	-	-	4.19	-	1.87	-	-	-	-	-	-	-	-	-	-	2.03	0.01	-	-	-	-	-	-	-	-	100.61
H0316_002_0	2007	5																					3600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1696.93	133.27	590.42	0	252.54	13.52	8.43	459.91	38.95	10797.95	50.26	0	-0.02	16.72	4406.77	4408.67	571.97	1.33	0	0	50.52	1087.91	0	0	70.25	0	224.28	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											179.46	179.46	91.25	0	106.46	0.18	0.21	30.42	0.15	3.65	0.11	0	0.18	0.15	5	25	37.5	0.15	0	0	0.18	25	0	0	25	0	25	0	0	0	0											25.38	1.99	4.49	-	2.24	2.47	1.75	1.17	5.92	3.28	5.73	-	0	2.54	1.84	9.18	1.79	0.2	-	-	9.22	2.27	-	-	0.15	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.07		42.39	25.38	1.99	4.49	-	2.24	2.47	1.75	1.17	5.92	3.28	5.73	-	0	2.54	1.84	9.18	1.79	0.2	-	-	9.22	2.27	-	-	0.15	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.07																																																																																				-			25.38	1.99	4.49	-	2.24	2.47	1.75	1.17	5.92	3.28	5.73	-	0	2.54	1.84	9.18	1.79	0.2	-	-	9.22	2.27	-	-	0.15	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.07
H0316_005_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1622.59	146.07	642.17	0	246.98	12.93	6.76	470.76	27.86	6722.17	40.17	0	0.16	19.92	3764.64	3569.55	624.21	1.73	0	0	18.75	721.56	0	0	119.05	0	216.09	0	0	0	0											350 (1a)	350 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											201.64	201.64	103.7	0	100.82	0.17	0.2	28.81	0.17	1.15	0.13	0	0.17	0.17	10	30	37.5	0.17	0	0	0.17	30	0	0	30	0	30	0	0	0	0											27.26	2.45	5.55	-	2.08	2.24	1.38	1.13	4.82	0.65	5.13	-	0.03	3.44	3.14	8.92	1.95	0.3	-	-	3.24	1.8	-	-	0.3	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.34		43.55	27.26	2.45	5.55	-	2.08	2.24	1.38	1.13	4.82	0.65	5.13	-	0.03	3.44	3.14	8.92	1.95	0.3	-	-	3.24	1.8	-	-	0.3	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.34																																																																																				-			27.26	2.45	5.55	-	2.08	2.24	1.38	1.13	4.82	0.65	5.13	-	0.03	3.44	3.14	8.92	1.95	0.3	-	-	3.24	1.8	-	-	0.3	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.34
H0316_010_0	2007	2																					3200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1696.93	133.27	590.42	0	252.54	13.52	8.43	459.91	38.95	10797.95	50.26	0	-0.02	16.72	4406.77	4408.67	571.97	1.33	0	0	50.52	1087.91	0	0	70.25	0	224.28	0	0	0	0											250 (1a)	250 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	15 (9b)	15 (8a 8b)	15/15 (8a 8b)	15 (incl in h5)	30 (12)	15 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	15 (7b 7d 7f 7g)	40/30 (7e 7h)	15 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 15 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	15 (17a)	0 n/c (17b1-17b5)	15 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											155.84	155.84	77.92	0	109.09	0.19	0.21	31.17	0.09	3.74	0.07	0	0.19	0.09	5	15	37.5	0.09	0	0	0.19	15	0	0	15	0	15	0	0	0	0											22.04	1.73	3.83	-	2.3	2.53	1.78	1.19	3.64	3.37	3.75	-	0	1.56	1.84	5.51	1.79	0.12	-	-	9.45	1.36	-	-	0.09	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.15		34.28	22.04	1.73	3.83	-	2.3	2.53	1.78	1.19	3.64	3.37	3.75	-	0	1.56	1.84	5.51	1.79	0.12	-	-	9.45	1.36	-	-	0.09	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.15																																																																																				-			22.04	1.73	3.83	-	2.3	2.53	1.78	1.19	3.64	3.37	3.75	-	0	1.56	1.84	5.51	1.79	0.12	-	-	9.45	1.36	-	-	0.09	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.15
H0316_011_0	2007	2																					2600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1622.59	146.07	642.17	0	246.98	12.93	6.76	470.76	27.86	6722.17	40.17	0	0.16	19.92	3764.64	3569.55	624.21	1.73	0	0	18.75	721.56	0	0	119.05	0	216.09	0	0	0	0											295 (1a)	295 (1b)	155 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											171.06	171.06	89.88	0	101.48	0.17	0.2	28.99	0.12	3.48	0.09	0	0.17	0.12	10	25	37.5	0.12	0	0	0.17	25	0	0	25	0	25	0	0	0	0											23.13	2.08	4.81	-	2.09	2.25	1.38	1.14	3.23	1.95	3.44	-	0.03	2.31	3.14	7.44	1.95	0.2	-	-	3.26	1.5	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.03		36.81	23.13	2.08	4.81	-	2.09	2.25	1.38	1.14	3.23	1.95	3.44	-	0.03	2.31	3.14	7.44	1.95	0.2	-	-	3.26	1.5	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.03																																																																																				-			23.13	2.08	4.81	-	2.09	2.25	1.38	1.14	3.23	1.95	3.44	-	0.03	2.31	3.14	7.44	1.95	0.2	-	-	3.26	1.5	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.03
H0316_012_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					730	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V		V	V																																																-		2311.38	331.81	1561.83		286.64	22.81	19.03	825.44	335.06	1976.5	822.83	58.84	2.52	1825.52		3290.62		471.34		758.38												289.96		134.93	229.12							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							37	37	18		37	10	10	18	12	5	5	12	10	12		5		5		5												5		5	5							7.17	1.03	2.32	-	0.89	2.26	1.89	1.23	0.35	0.82	0.34	0.06	0.25	1.89	-	1.36	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.63		22.98	7.17	1.03	2.32	-	0.89	2.26	1.89	1.23	0.35	0.82	0.34	0.06	0.25	1.89	-	1.36	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.63																																																																																				-		0	7.17	1.03	2.32	-	0.89	2.26	1.89	1.23	0.35	0.82	0.34	0.06	0.25	1.89	-	1.36	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.63
H0316_801_0	2007	3																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1773.6	139.22	616.04	0	263.93	14.06	8.79	480.62	40.6	11304.91	52.36	0	-0.03	17.33	4612	4611.4	597.53	1.38	0	0	52.84	1139.22	0	0	73.07	0	234.53	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											228.56	228.56	97.95	0	114.28	0.16	0.18	32.65	0.16	3.92	0.12	0	0.2	0.16	10	35	37.5	0.16	0	0	0.2	35	0	0	35	0	35	0	0	0	0											33.78	2.65	5.03	-	2.51	2.3	1.6	1.31	6.63	3.69	6.41	-	-0.01	2.83	3.84	13.45	1.87	0.23	-	-	10.35	3.32	-	-	0.21	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.69		41.89	33.78	2.65	5.03	-	2.51	2.3	1.6	1.31	6.63	3.69	6.41	-	-0.01	2.83	3.84	13.45	1.87	0.23	-	-	10.35	3.32	-	-	0.21	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.69																																																																																				-			33.78	2.65	5.03	-	2.51	2.3	1.6	1.31	6.63	3.69	6.41	-	-0.01	2.83	3.84	13.45	1.87	0.23	-	-	10.35	3.32	-	-	0.21	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.69
H0317_001_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1249.55	9.12	448.28	2138.81	124.72	0.7	0.05	202.37	441.13	813.52	554.67	36.98	379.2	314.32	7149.49	8480.59			312.73		9.76											13.27	0.1	15.88								300/admit	300/admit	0/day (1-6) 125/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	25-50/ Visit	150/ Visit	0-150/ Visit	25-150/ Visit	100/ Visit	25/ Procedure	15-150/ Visit	5/ Visit	25/ Visit			150/ Visit		20 Coins											300/admit	300/admit	20 Coins								60.56	62.56	36.36	0	100	0.2	0.2	49.39	150	115.91	45	100	25	37.94	5	25			150		0.2											300	300	0.2								6.31	0.05	1.36	-	1.04	0.14	0.01	0.83	5.51	7.86	2.08	0.31	0.79	0.99	2.98	17.67	-	-	3.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.33	0	3.18	-	-	-	-	-	-	-	57.3	0	0	6.31	0.05	1.36	-	1.04	0.14	0.01	0.83	5.51	7.86	2.08	0.31	0.79	0.99	2.98	17.67	-	-	3.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.33	0	3.18	-	-	-	-	-	-	-	57.3		600/admit	600/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	15 Coins	15 Coins			0/Procedure		20 Coins	20 Coins					20 Coins													20 Coins								1.47	0.01	0.37	0.5	0.26	0.04		0.26	1.72	2.03			0		1.71	2.06					0.55													0.59								11.57	0	0	7.78	0.06	1.73	0.5	1.3	0.18	0.01	1.09	7.23	9.88	2.08	0.31	0.79	0.99	4.69	19.73	-	-	3.91	-	2.51	-	-	-	-	-	-	-	-	-	-	0.33	0	3.76	-	-	-	-	-	-	-	68.87
H0317_002_0	2007	7	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1249.92	9.12	448.41	2139.43	124.75	0.7	0.05	202.43	441.26	813.76	554.84	36.99	379.31	314.41	7151.58	8483.07			312.82		9.77											13.28	0.1	15.89								550/admit	550/admit	0/day (1-6) 135/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	25-50/ Visit	150/ Visit	0-150/ Visit	25-150/ Visit	150/ Visit	0/ Procedure	15-150/ Visit	10/ Visit	35/ Visit			150/ Visit		20 Coins											550/admit	550/admit	20 Coins								111.02	114.7	39.27	0	100	0.2	0.2	49.39	150	115.91	46.67	150	0	40.88	10	35			150		0.2											550	550	0.2								11.56	0.09	1.47	-	1.04	0.14	0.01	0.83	5.52	7.86	2.16	0.46	-	1.07	5.96	24.74	-	-	3.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.61	0	3.18	-	-	-	-	-	-	-	72.57	0	0	11.56	0.09	1.47	-	1.04	0.14	0.01	0.83	5.52	7.86	2.16	0.46	-	1.07	5.96	24.74	-	-	3.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.61	0	3.18	-	-	-	-	-	-	-	72.57		950/admit	950/admit	20 Coins	20 Coins	100/Trip	50 Coins		50/Visit	20 Coins	20 Coins			25/Procedure		20 Coins	20 Coins					20 Coins													20 Coins								2.92	0.02	0.23	0.31	0.33	0.06		0.32	2.87	3.38			0.25		2.15	2.58					0.69													0.74								16.85	500	0.64	14.49	0.11	1.7	0.31	1.37	0.2	0.01	1.16	8.38	11.24	2.16	0.46	0.25	1.07	8.11	27.32	-	-	3.91	-	2.65	-	-	-	-	-	-	-	-	-	-	0.61	0	3.91	-	-	-	-	-	-	-	89.41
H0317_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		255.89	1.93	454.78	2169.86	126.53	0.72	0.05	250.38	447.54	825.33	562.73	37.52	384.71	318.88	7253.3	8603.73			317.27		10.05											13.47	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.79	0.1	0.33	1.81	1.05	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.11	25.09	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.37	0	0	12.79	0.1	0.33	1.81	1.05	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.11	25.09	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.37		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.27	0.02	0.38	0.52	0.26	0.05		0.26	4.71	5.56			0		1.76	4.24					0.57																					20.6	0	0	15.07	0.11	0.71	2.33	1.32	0.23	0.01	1.2	12.17	7.97	2.15	0.31	-	1	16.87	29.33	-	-	0.93	-	2.58	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.97
H0317_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.57	1.92	452.45	2158.7	125.88	0.72	0.05	249.09	445.24	821.09	559.83	37.32	382.73	317.24	7215.98	8559.46			315.64		9.94											13.4	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.73	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.42	2.39	2.14	0.31	-	1	15.03	24.97	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.98	0	0	12.73	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.42	2.39	2.14	0.31	-	1	15.03	24.97	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.98		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.66	5.5			0		1.75	4.2					0.56																					20.4	0	0	14.99	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.08	7.9	2.14	0.31	-	1	16.78	29.16	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.38
H0317_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		255.89	1.93	454.78	2169.86	126.53	0.72	0.05	250.38	447.54	825.33	562.73	37.52	384.71	318.88	7253.3	8603.73			317.27		10.05											13.47	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.79	0.1	0.33	1.81	1.05	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.11	25.09	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.37	0	0	12.79	0.1	0.33	1.81	1.05	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.11	25.09	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.37		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.27	0.02	0.38	0.52	0.26	0.05		0.26	4.71	5.56			0		1.76	4.24					0.57																					20.6	0	0	15.07	0.11	0.71	2.33	1.32	0.23	0.01	1.2	12.17	7.97	2.15	0.31	-	1	16.87	29.33	-	-	0.93	-	2.58	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.97
H0317_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.57	1.92	452.45	2158.7	125.88	0.72	0.05	249.09	445.24	821.09	559.83	37.32	382.73	317.24	7215.98	8559.46			315.64		9.94											13.4	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.73	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.42	2.39	2.14	0.31	-	1	15.03	24.97	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.98	0	0	12.73	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.42	2.39	2.14	0.31	-	1	15.03	24.97	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.98		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.66	5.5			0		1.75	4.2					0.56																					20.4	0	0	14.99	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.08	7.9	2.14	0.31	-	1	16.78	29.16	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.38
H0318_001_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	P	P	V	P	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	18.07	0	0	0	0	317.28	0	22.16														100/day 1-5	100/day 1-5	0/day 1-20100/day 21-100	0	100	20	20	50  ER 35 UC	200	0	0 100 Complex	30	30	30	10	30	30	30	30	30	20	0	Not Covered	Not Covered	30	Not Covered	30	500 Every 3 years														60.67	60.67	40.15	0	100	0.2	0.2	48.05	200	0	34.2	30	30	30	10	30	30	30	30	30	0.2	0	0	0	30	0	30	0	0	0	0											7.87	0.15	4.25	-	1.92	3.14	0.2	1.67	5.74	-	3.2	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.87			7.87	0.15	4.25	-	1.92	3.14	0.2	1.67	5.74	-	3.2	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.87																																																																																				-			7.87	0.15	4.25	-	1.92	3.14	0.2	1.67	5.74	-	3.2	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.87
H0318_002_0	2007	6																																D	D	D	V	T	Coin	Coin	V	P	V	P	V	V	V	V	V	V	V	V	V	Coin	O			V		V	P																																																							-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	18.07	0	0	0	0	317.28	0	22.16														200/day 1-5	200/day 1-5	0/day 1-20100/day 21-100	0	100	20	20	50 40 UC	250	0	0 Routine 100 Complex	35	30	35	20	30	35	35	30	35	20	0	Not Covered	Not Covered	35	Not Covered	35	500 Every 3 years														121.34	121.34	40.15	0	50	0.2	0.2	48.7	250	0	34.2	35	30	35	20	34.45	35	35	35	35	0.2	0	0	0	35	0	35	0	0	0	0											15.74	0.31	4.25	-	0.96	3.14	0.2	1.7	7.17	-	3.2	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.7			15.74	0.31	4.25	-	0.96	3.14	0.2	1.7	7.17	-	3.2	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.7																																																																																				-			15.74	0.31	4.25	-	0.96	3.14	0.2	1.7	7.17	-	3.2	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.7
H0318_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5319.24	6747.88	193.76	1121.23	1532.39	2779.34	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98
H0318_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5319.24	6747.88	193.76	1121.23	1532.39	2779.34	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98
H0319_001_0	2007	6	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						800	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T	P	V	P	V	P				V	V	V	V	V																																															-		1331.62	17.27	7662.21	24.88	453.12	395.89	2080.39	105.71	87.23	604.03	145.03	19.79	2.8	101.76	30133.76	1162.38	233.38	3.67		456.76	1364.68	836.53	2309.18	1042.82	24.77	157.7		51.87				105.86	1.28	0	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip	(16a) 0/proc	(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						70	70			70			46	23			23		23																		9										7.73	0.1	-	-	2.63	-	-	0.41	0.17	-	-	0.04	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	11.36		0.87	7.73	0.1	-	-	2.63	-	-	0.41	0.17	-	-	0.04	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	11.36		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						1.84	0.01	0.71	0.01	0.19	0.14	0.04	0.02	0.17	0.37	0.56	0.01	-0.02	0.08	0.01	1.58	0.03	0		0.12		0.17	0.09		0							0	0	0	0.02	0.02						6.2		0	9.58	0.11	0.71	0.01	2.82	0.14	0.04	0.43	0.34	0.37	0.56	0.05	-0.02	0.28	0.01	1.58	0.03	0	-	0.12	-	0.17	0.09	-	0	-	-	-	-	-	-	0.09	0	0	0.02	0.02	-	-	-	-	-	17.56
H0319_002_0	2007	6	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					730	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V		V	V																																																-		2428.79	348.66	1635.37		311.83	27.55	22.99	913.6	370.84	2187.6	910.71	65.12	3.09	2020.49		3445.57		500.92		794.09												320.93		141.28	239.91							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							7.14	1.03	2.31	-	0.92	2.59	2.16	1.29	0.36	0.86	0.36	0.06	0.29	1.98	-	1.35	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.09	-	-	-	-	-	-	23.48		26.43	7.14	1.03	2.31	-	0.92	2.59	2.16	1.29	0.36	0.86	0.36	0.06	0.29	1.98	-	1.35	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.09	-	-	-	-	-	-	23.48		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 per Visit	30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.33	0.15	0.42	0.43	0.08	0.17	0.14	0.05	0.18	0.14	0.12	0.02	0.02	0.23	0.35	0.21	0.04	0.03	0.14	0.73	0.14	0																				6.12		0	9.47	1.18	2.73	0.43	0.99	2.76	2.3	1.34	0.54	0.99	0.48	0.08	0.31	2.21	0.35	1.56	0.04	0.23	0.14	1.04	0.14	0	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.09	-	-	-	-	-	-	29.6
H0319_004_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		2391.23	216.96	960.77		213.24	23.15	26.73	591.3	459.65	2307.07	976.34	73.62	1.23	1387.74		5045.84		476.49		934.02												269.47		260.37	264.02							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						42	42	20		42	8	11	20	14	3	6	14	11	14		6		6		6												6		6	6							8.44	0.77	1.63	-	0.75	1.96	3.02	1	0.54	0.54	0.46	0.09	0.14	1.63	-	2.38	-	0.22	-	0.44	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.12	-	-	-	-	-	-	24.39		18.79	8.44	0.77	1.63	-	0.75	1.96	3.02	1	0.54	0.54	0.46	0.09	0.14	1.63	-	2.38	-	0.22	-	0.44	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.12	-	-	-	-	-	-	24.39		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	(16a/16b) 0 per Visit	30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.61	0.1	0.26	0.32	0.06	0.14	0.16	0.04	0.28	0.18	0.18	0.02	0.01	0.19	0.36	0.3	0.03	0.03	0.2	0.88	0.18	0	0.04		0.01		0.01															6.59		0	11.05	0.86	1.89	0.32	0.81	2.1	3.18	1.04	0.82	0.72	0.64	0.11	0.15	1.83	0.36	2.68	0.03	0.26	0.2	1.32	0.18	0	0.04	-	0.01	-	0.01	-	-	-	-	0.13	-	0.12	0.12	-	-	-	-	-	-	30.98
H0320_001_0	2007	9																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1291.11	102.73	578.91	1155.26	168.48	6	7.78	277.68	35.16		12.85	1.94	0.08	13.84	3819.21	5672.96	306.63	961.93	21.45	6.86	25.54				126.92		113.62															#1A: 185 days 1-5	#1B: 200 days 1-5	#2: 45 days 11-100	#6: 13	#10A: 125	#11A: 20	#11B Pros: 35; #11B Supplies: 20; #11C: 20	#4: 50	#9A OP Hosp: 15 NTE 440; #9B ASC: 15 NTE 240	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 25; #5: 50; #9A OP Hosp 15 / Chemo 20; #9C: 50; #9D: 25	#7A: 20; #14C: 25	#7B : 12; #7D/7F/7G #16B #17A #18A: 35	#7E/#7H: 50	#7C/#7I: 25	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance	#18A: 30	#18B: 400 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	113.39	122.59	24.2	13	125	0.2	0.24	50	0.12		0.16	0.15	0.2	0.15	20.1	32.58	50	25	0.15	0.15	0.2				25		30															12.2	1.05	1.17	1.25	1.75	1.2	1.86	1.16	4.11	-	2.03	0.29	0.02	2.07	6.4	15.4	1.28	2	3.22	1.03	5.11	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.13		0	12.2	1.05	1.17	1.25	1.75	1.2	1.86	1.16	4.11	-	2.03	0.29	0.02	2.07	6.4	15.4	1.28	2	3.22	1.03	5.11	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.13																																																																																				-		0	12.2	1.05	1.17	1.25	1.75	1.2	1.86	1.16	4.11	-	2.03	0.29	0.02	2.07	6.4	15.4	1.28	2	3.22	1.03	5.11	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.13
H0320_002_0	2007	6																					7000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1314.95	85.03	583.07	1184.44	164	5.92	7.9	265.57	37.36		13.5	2.07	0.08	13.1	3986.63	6029.06	282.85	1035.24	22.78	7.3	26.43				126.9		113.6															#1A: 75 days 1-5	#1B: 200 days 1-5	#2: 30 days 11-100	#6: 5	#10A: 100	#11A: 20	#11B/11C: 20	#4: 50	#9A OP Hosp: 15 NTE 300; #9B ASC: 15 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 12	#9A: 15	#12: 20	#3: 15; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 35; #9D: 15	#7A: 10; #14C: 10	#7B : 8; #7D/7F/7G #16B #17A #18A: 30	#7E/#7H: 40	#7C/#7I: 15	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance	#18A: 20	#18B: 400 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	43.01	114.7	15.1	4.68	93.57	0.19	0.19	46.79	0.1		0.12	0.14	0.19	0.14	9.37	25.88	37.43	14.03	0.09	0.09	0.19				25		20															4.71	0.81	0.73	0.46	1.28	1.11	1.48	1.04	3.8	-	1.69	0.29	0.02	1.85	3.11	13	0.88	1.21	2.13	0.69	4.95	-	-	-	0.26	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.69		3.11	4.71	0.81	0.73	0.46	1.28	1.11	1.48	1.04	3.8	-	1.69	0.29	0.02	1.85	3.11	13	0.88	1.21	2.13	0.69	4.95	-	-	-	0.26	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.69																																																																																				-		0	4.71	0.81	0.73	0.46	1.28	1.11	1.48	1.04	3.8	-	1.69	0.29	0.02	1.85	3.11	13	0.88	1.21	2.13	0.69	4.95	-	-	-	0.26	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.69
H0321_002_0	2007	2																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		336.19	23.42	26.09		15.95	21.15	23.1	865.22	29.51	20.49	15.18	1.75	1.32	46.97		33.39		3.39	27.42	99.49	27.85	0.03			88.39																	#1A 0/day days 1-60 250/day days 61-90	#1B 0/day days 1-60 250/day days 61-90	#2 0/day days 1-20 125/day days 21-100	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8B 20	#9A 20	#12 20	#3 20 #5 20 #9C 20 #9D 20	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0 #18A 0	#7B 20 #7D 20 #7F 20 #7G 20 #16B 20 #17A 20	#7E 0 #7H 0	#7C 20 #7I 20	20 (incl in h2)	#14I 20	#15 20	#13A 20	#10B 0 n/c	#16A 0	#17A 5	#17B 0	0 n/c	0 n/c	0 n/c	#14A 0	#13B 0 n/c											0.07	0.07	0.16		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24		0.24		0.24	0.24	0.24	0.24	0.24			5																	23.42	1.63	4.18	-	3.76	4.99	5.45	3.6	6.96	4.84	3.58	0.41	0.31	11.09	-	7.88	-	0.8	6.47	23.48	6.57	0.01	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.48	138	0	23.42	1.63	4.18	-	3.76	4.99	5.45	3.6	6.96	4.84	3.58	0.41	0.31	11.09	0	7.88	0	0.8	6.47	23.48	6.57	0.01	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.48																																																																																				-		0	23.42	1.63	4.18	-	3.76	4.99	5.45	3.6	6.96	4.84	3.58	0.41	0.31	11.09	0	7.88	0	0.8	6.47	23.48	6.57	0.01	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.48
H0322_001_0	2007	6																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-	3000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5														200/day 1-5	200/day 1-5	0/day 1-20100/day 21-100	0	100	0	0	50  35 UC	250	0	0 100	30	30	35	20	35	35	35	30	35	20	0	Not Covered	Not Covered	35	Not Covered	35	300 Every 3 Years														121.34	121.34	40.15	0	100	0.2	0.2	48.05	250	0	34.2	35	35	35	20	35	35	35	35	35	0.2	0	0	0	35	0	35	0	0	0	0											13.85	0.27	3.74	-	1.69	2.77	0.18	1.47	6.31	-	2.82	-	-	-	7.96	17.22	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.29			13.85	0.27	3.74	-	1.69	2.77	0.18	1.47	6.31	-	2.82	-	-	-	7.96	17.22	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.29		20	20	20	20	100	20	20	50  35 UC	20	20	20	20	20	20	20	20	20	20	20	20	20	20	Not Covered	Not Covered	20	Not Covered	20	0	0	Not Covered	0											3.66	0	0.59	0.53	0.16	0.3	0	0.14	0.38	0.13	0.37	0	0.12	0.4	0.48	0.59	0.02	0.06	0.44	1.6	0.35	0	0	0	0.06	0	0.02	0	0	0	0											10.42	500	9.2	17.51	0.27	4.34	0.53	1.85	3.07	0.18	1.61	6.68	0.13	3.19	-	0.12	0.4	8.44	17.81	0.53	1.53	2.85	5.24	0.35	-	-	-	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.71
H0322_002_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-	3000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5														100/day 1-5	100/day 1-5	0/day 1-20100/day 21-100	0	100	20	20	50 30 UC	200	0	0 Routine 100 Complex	30	30	30	10	30	30	30	30	30	20	0	Not Covered	Not Covered	30	Not Covered	30	300 Every 3 Years														60.67	60.67	40.15	0	100	0.2	0.2	47.4	200	0	34.2	30	30	30	10	30	30	30	30	30	0.2	0	0	0	30	0	30	0	0	0	0											6.92	0.13	3.74	-	1.69	2.77	0.18	1.45	5.05	-	2.82	-	-	-	3.98	14.76	0.43	1.26	2.06	3.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.37			6.92	0.13	3.74	-	1.69	2.77	0.18	1.45	5.05	-	2.82	-	-	-	3.98	14.76	0.43	1.26	2.06	3.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.37		20	20	20	20	100	20	20	50 30 UC	20	20	20	20	20	20	20	20	20	20	20	20	0.2	0	Not Covered	Not Covered	20	Not Covered	20	0	0	Not Covered	0											3.66	0	0.59	0.53	0.16	0.3	0	0.14	0.38	0.13	0.37	0	0.12	0.4	0.48	0.59	0.02	0.06	0.44	1.6	0.35	0	0	0	0	0	0	0	0	0	0											10.34	500	9.2	10.59	0.13	4.34	0.53	1.85	3.07	0.18	1.59	5.42	0.13	3.19	-	0.12	0.4	4.46	15.35	0.46	1.32	2.51	4.72	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.7
H0322_006_0	2007	7																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-	3000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5														200/day 105	200/day 105	0/day 1-20100/day 21-100	0	100	0	0	50   (Waived if Admitted; Worldwide) 35	250	0	0 100	30	30	35	20	35	35	35	30	35	20	0	Not Covered	Not Covered	35	Not Covered	35	300 Every 3 Years														121.34	121.34	40.15	0	100	0.2	0.2	48.05	250	0	34.2	35	35	35	20	35	35	35	35	35	0.2	0	0	0	35	0	35	0	0	0	0											13.85	0.27	3.74	-	1.69	2.77	0.18	1.47	6.31	-	2.82	-	-	-	7.96	17.22	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.29			13.85	0.27	3.74	-	1.69	2.77	0.18	1.47	6.31	-	2.82	-	-	-	7.96	17.22	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.29		20	20	20	20	100	20	20	50   (Waived if Admitted; Worldwide) 35	20	20	20	20	20	20	20	20	20	20	20	20	0.2	0	Not Covered	Not Covered	20	Not Covered	20	300 Allowance/Every 3 Years	N/A	Not Covered	0											3.66	0	0.59	0.53	0.16	0.3	0	0.14	0.38	0.13	0.37	0	0.12	0.4	0.48	0.59	0.02	0.06	0.44	1.6	0.35	0	0	0	0.06	0	0.02	0	0	0	0											10.42	500	9.2	17.51	0.27	4.34	0.53	1.85	3.07	0.18	1.61	6.68	0.13	3.19	-	0.12	0.4	8.44	17.81	0.53	1.53	2.85	5.24	0.35	-	-	-	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.71
H0322_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4680.93	5938.14	170.51	986.68	1348.5	2445.82	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.78			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.78		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.68	18.61	0.55	3.01	4.89	10.6	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.05
H0322_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4680.93	5938.14	170.51	986.68	1348.5	2445.82	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.78			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.78		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.68	18.61	0.55	3.01	4.89	10.6	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.05
H0351_014_0	2007	6																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	353.86	3.52	947.34	0	323.5	3.65	1.43	381.42	367.76	0	2040.54	0	0.19	763.88	3420.22	4120.87	194.15	112.64	0	211.78	16.76	706.32	0	0	0	0	0	0	0	10400	0											200/admit	950 deductible 225/day for days 61-90 450/day for days 91-190	100/day days 21-100	0 copay	100 copay	30 DME / 0 Diabetes Monitoring Supplies	30 coinsurance	50 ER / 35 UC	150 ASC / 150 OP	0 copay	25 - 200 per	0 copay	20 coinsurance	35 OP SA / 35 Cardiac Rehab	0 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MH	35 Therapy	0 copay	35 Hearing / 0 Preventive	30 coinsurance	35 Vision					0				0 copay											200	950	17.47	0	100	0.24	0.3	43.85	150	0	74.22	0	0.2	35	0	34.86	35	23.66	0	12.84	0.3	35	0	0	0	0	0	0	0	0	0											5.9	0.28	1.38	-	2.7	0.89	0.43	1.39	4.6	-	12.62	-	0.04	2.23	-	11.97	0.57	0.22	-	0.23	5.03	2.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.52	0	0	5.9	0.28	1.38	-	2.7	0.89	0.43	1.39	4.6	-	12.62	-	0.04	2.23	-	11.97	0.57	0.22	-	0.23	5.03	2.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.52	none																																																																																			-	0	0	5.9	0.28	1.38	-	2.7	0.89	0.43	1.39	4.6	-	12.62	-	0.04	2.23	-	11.97	0.57	0.22	-	0.23	5.03	2.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.52
H0351_029_0	2007	6																					none											D	D	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1927.98	28.81	1097.27	0	359.73	3.99	1.56	452.18	44.06	0	2247.04	0	0.22	25.12	0	0	239.26	0	0	12.51	18.35	0	1320	16.39	507.7	315	0	0	0	10400	0											0/day	203/day for days 9-190	50/day days 21-100	0 copay	25 copay	25 DME / 15 Diabetes Monitoring Supplies	25 coinsurance	50 ER / 0 UC	0 ASC / 0 OP	0 copay	0 - 100 per	0 copay	20 coinsurance	10 OP SA / 0 Cardiac Rehab	0 PCP	0 SCP / 0 Chiro / 0 Podiatrist	10 MH	0 Therapy	0 copay	0 Hearing / 0 Preventive	30 coinsurance	0 Vision	0 copay	Prev/Diag/Restor 100 IN / 80 OON; Other Major 80 IN / 50 OON	10 copay	0 copay	0				0 copay											0	68.33	8.73	0	25	0.23	0.25	29.51	0	0	29.77	0	0.2	10	0	0	10	0	0	0	0.3	0	0	0.1	10	0	0	0	0	0	0											-	0.16	0.8	-	0.75	0.92	0.39	1.11	-	-	5.57	-	0.04	0.02	-	-	0.2	-	-	-	5.5	-	-	1.68	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.58	0	0	-	0.16	0.8	-	0.75	0.92	0.39	1.11	-	-	5.57	-	0.04	0.02	-	-	0.2	-	-	-	5.5	-	-	1.68	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.58	none																																																																																			-	0	0	-	0.16	0.8	-	0.75	0.92	0.39	1.11	-	-	5.57	-	0.04	0.02	-	-	0.2	-	-	-	5.5	-	-	1.68	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.58
H0351_030_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	337.59	3.36	907.45	0	305.95	3.49	1.36	369.15	348.31	0	1932.61	0	0.18	723.79	3359.79	4027.92	186.8	108.37	0	206.29	15.77	679.55	0	0	0	0	0	0	0	10400	0											100/admit	950 deductible 225/day for days 61-90 450/day for days 91-190	100/day days 21-100	0 copay	100 copay	30 DME / 0 Diabetes Monitoring Supplies	30 coinsurance	50 ER / 25 UC	100 ASC / 100 OP	0 copay	25 - 200 per	0 copay	20 coinsurance	25 OP SA / 25 Cardiac Rehab	0 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MH	25 Therapy	0 copay	25 Hearing / 0 Preventive	30 coinsurance	25 Vision					0				0 copay											100	950	17.47	0	100	0.24	0.3	39.76	100	0	74.08	0	0.2	25	0	24.9	25	23.59	0	9.06	0.3	25	0	0	0	0	0	0	0	0	0											2.81	0.27	1.32	-	2.55	0.85	0.41	1.22	2.9	-	11.93	-	0.04	1.51	-	8.36	0.39	0.21	-	0.16	4.73	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.08	0	0	2.81	0.27	1.32	-	2.55	0.85	0.41	1.22	2.9	-	11.93	-	0.04	1.51	-	8.36	0.39	0.21	-	0.16	4.73	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.08	none																																																																																			-	0	0	2.81	0.27	1.32	-	2.55	0.85	0.41	1.22	2.9	-	11.93	-	0.04	1.51	-	8.36	0.39	0.21	-	0.16	4.73	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.08
H0351_032_0	2007	6																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	355.82	3.54	956.36	0	322.44	3.68	1.44	380.75	367.12	0	2036.95	0	0.19	762.87	3469.03	4179.68	196.92	114.25	0	214.8	16.61	716.4	0	0	0	0	0	0	0	10400	0											200/admit	950 deductible 225/day for days 61-90 450/day for days 91-190	100/day days 21-100	0 copay	100 copay	30 DME / 0 Diabetes Monitoring Supplies	30 coinsurance	50 ER / 35 UC	150 ASC / 150 OP	0 copay	25 - 200 per	0 copay	20 coinsurance	35 OP SA / 35 Cardiac Rehab	0 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MH	35 Therapy	0 copay	35 Hearing / 0 Preventive	30 coinsurance	35 Vision					0				0 copay											200	950	17.47	0	100	0.24	0.3	43.85	150	0	74.08	0	0.2	35	0	34.86	35	23.59	0	12.84	0.3	35	0	0	0	0	0	0	0	0	0											5.93	0.28	1.39	-	2.69	0.9	0.43	1.39	4.59	-	12.57	-	0.04	2.23	-	12.14	0.57	0.22	-	0.23	4.98	2.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.68	0	0	5.93	0.28	1.39	-	2.69	0.9	0.43	1.39	4.59	-	12.57	-	0.04	2.23	-	12.14	0.57	0.22	-	0.23	4.98	2.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.68	none																																																																																			-	0	0	5.93	0.28	1.39	-	2.69	0.9	0.43	1.39	4.59	-	12.57	-	0.04	2.23	-	12.14	0.57	0.22	-	0.23	4.98	2.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.68
H0351_801_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	296.19	3.02	824.7	0	273.16	3.06	1.2	307.89	308.36	0	1710.95	0	0.16	641.02	2803.19	3432.95	167.76	97.33	0	177.28	13.92	610.31	0	0	0	0	0	0	0	0	0											1000 deductible 250/day for days 61-90 500/day for days 91-190	1000 deductible 250/day for days 61-90 500/day for days 91-190	125/day days 21-100	0 copay	100 copay	30 DME / 20 Diabetes Monitoring Supplies	30 coinsurance	50 ER / 50 UC	200 ASC / 200 OP	0 copay	25 - 200 per	0 copay	20 coinsurance	40 OP SA / 40 Cardiac Rehab	15 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	30 coinsurance	40 Vision					0															1000	1000	21.83	0	100	0.28	0.3	50	200	0	76.58	0	0.2	40	14.99	39.83	40	23.59	0	15.15	0.3	40	0	0	0	0	0	0	0	0	0											24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	none																																																																																			-	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52
H0351_803_0	2007	1																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	296.19	3.02	824.7	0	273.16	3.06	1.2	307.89	308.36	0	1710.95	0	0.16	641.02	2803.19	3432.95	167.76	97.33	0	177.28	13.92	610.31	0	0	0	0	0	0	0	0	0											1000 deductible 250/day for days 61-90 500/day for days 91-190	1000 deductible 250/day for days 61-90 500/day for days 91-190	125/day days 21-100	0 copay	100 copay	30 DME / 20 Diabetes Monitoring Supplies	30 coinsurance	50 ER / 50 UC	200 ASC / 200 OP	0 copay	25 - 200 per	0 copay	20 coinsurance	40 OP SA / 40 Cardiac Rehab	15 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	30 coinsurance	40 Vision					0															1000	1000	21.83	0	100	0.28	0.3	50	200	0	76.58	0	0.2	40	14.99	39.83	40	23.59	0	15.15	0.3	40	0	0	0	0	0	0	0	0	0											24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	none																																																																																			-	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52
H0351_804_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	296.19	3.02	824.7	0	273.16	3.06	1.2	307.89	308.36	0	1710.95	0	0.16	641.02	2803.19	3432.95	167.76	97.33	0	177.28	13.92	610.31	0	0	0	0	0	0	0	0	0											1000 deductible 250/day for days 61-90 500/day for days 91-190	1000 deductible 250/day for days 61-90 500/day for days 91-190	125/day days 21-100	0 copay	100 copay	30 DME / 20 Diabetes Monitoring Supplies	30 coinsurance	50 ER / 50 UC	200 ASC / 200 OP	0 copay	25 - 200 per	0 copay	20 coinsurance	40 OP SA / 40 Cardiac Rehab	15 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	30 coinsurance	40 Vision					0															1000	1000	21.83	0	100	0.28	0.3	50	200	0	76.58	0	0.2	40	14.99	39.83	40	23.59	0	15.15	0.3	40	0	0	0	0	0	0	0	0	0											24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	none																																																																																			-	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52
H0351_806_0	2007	1																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	coin	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	296.19	3.02	824.7	0	273.16	3.06	1.2	307.89	308.36	0	1710.95	0	0.16	641.02	2803.19	3432.95	167.76	97.33	0	177.28	13.92	610.31	0	0	0	0	0	0	0	0	0											1000 deductible 250/day for days 61-90 500/day for days 91-190	1000 deductible 250/day for days 61-90 500/day for days 91-190	125/day days 21-100	0 copay	100 copay	30 DME / 20 Diabetes Monitoring Supplies	30 coinsurance	50 ER / 50 UC	200 ASC / 200 OP	0 copay	25 - 200 per	0 copay	20 coinsurance	40 OP SA / 40 Cardiac Rehab	15 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	30 coinsurance	40 Vision					0															1000	1000	21.83	0	100	0.28	0.3	50	200	0	76.58	0	0.2	40	14.99	39.83	40	23.59	0	15.15	0.3	40	0	0	0	0	0	0	0	0	0											24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52	none																																																																																			-	0	0	24.68	0.25	1.5	-	2.28	0.86	0.36	1.28	5.14	-	10.92	-	0.03	2.14	3.5	11.39	0.56	0.19	-	0.22	4.18	2.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.52
H0354_001_0	2007	6																					none											A	A	D	P	T	P	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	O		V	V		V			O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	309.43	4.48	661.2	0	259.36	5.27	0	733.56	120.69	5108.06	3297.63	0	93.45	359.38	0	0	34.1	37.69	0	13727.85	6.87	0	0	0	299.79	0	27.58	0	0	0	154.93											Contracted - 200/admit; Gastic Bypass - 20 coin.	MHSA - 876/admit	Contracted - 100/day; days 21-100; Non-contracted - 100/day	0	100/trip	20 for high cost DME	0	CMG Urgent Care - 5/visit; Non-CMG Urgent Care - 25/visit; Emergency Room - 50/visit	125/visit	CMG Specialist - 20/visit; Non-CMG Specialist - 30/visit	High Tech - 150/visit; Low Tech  - 30/visit; Mammography - 0/visit	0	25/visit	30/visit	0	0	30/visit	CMG Specialist - 20/visit; Non-CMG Specialist - 30/visit	0	Primary Care - 5/visit; CMG Specialist - 20/visit; Non-CMG Specialist - 30/visitGastric Bypass - 20 coin.	10 coinsurance	0	0	0	CMG Routine Exam - 5/visit	0	Hearing Aid Fitting - 0/visit; CMG Routine Exam - 5/visit	0	0	0	CMG Podiatrist - 20/visit; CMG Nail Technician - 5/visit; Non-CMG Nail Technician - 30/visitNon-CMG Podiatrist - 30/visit											200.29	876	100	0	100	347.4	0	29.06	125	21.42	50.47	0	25.2	30	0	0	30	30	0	16.05	0.1	0	0	0	10.2	0	2.5	0	0	0	12.71											5.16	0.33	5.51	-	2.16	0.15	-	1.78	1.26	9.12	13.87	-	0.2	0.9	-	-	0.09	0.09	-	18.36	0.69	-	-	-	0.25	-	0.01	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	60.09		0	5.16	0.33	5.51	-	2.16	0.15	-	1.78	1.26	9.12	13.87	-	0.2	0.9	-	-	0.09	0.09	-	18.36	0.69	-	-	-	0.25	-	0.01	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	60.09	none																																																																																			-		0	5.16	0.33	5.51	-	2.16	0.15	-	1.78	1.26	9.12	13.87	-	0.2	0.9	-	-	0.09	0.09	-	18.36	0.69	-	-	-	0.25	-	0.01	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	60.09
H0354_012_0	2007	3																					none											A	A	D	P	T	P	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	O		V	V		V			O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	371.99	5.39	1424.1	0	388.42	11.07	0	1084.56	115.52	4350.06	3167.86	0	74.49	209.12	0	0	47.68	53.93	0	14986.84	9.77	0	0	3221	485.4	0	45.13	0	0	0	220.43											Contracted - 0/admit; Gastic Bypass - 20 coin.	MHSA - 0/admit	Contracted - 0/day; days 21-100; Non-contracted - 50/day	0	50/trip	20 for high cost DME	0	CMG Urgent Care - 0/visit; Non-CMG Urgent Care - 25/visit; Emergency Room - 50/visit	5/visit	CMG Specialist - 0/visit; Non-CMG Specialist - 10/visit	High Tech - 10/visit; Low Tech  - 5/visit; Mammography - 0/visit	0	5/visit	5/visit	0	0	10/visit	CMG Specialist - 0/visit; Non-CMG Specialist - 10/visit	0	Primary Care - 0/visit; CMG Specialist - 0/visit; Non-CMG Specialist - 10/visitGastric Bypass - 20 coin.	10 coinsurance	0	0	0	CMG Routine Exam - 0/visit	0	Hearing Aid Fitting - 0/visit; CMG Routine Exam - 0/visit	0	0	0	CMG Podiatrist - 0/visit; CMG Nail Technician - 0/visit; Non-CMG Nail Technician - 10/visitNon-CMG Podiatrist - 10/visit											2.2	0	0.66	0	50	360.51	0	28.59	5	5	4.67	0	5	5	0	0	10	5	0	3.54	0.1	0	0	47.9	2.05	0	0	0	0	0	0.12											0.07	-	0.08	-	1.62	0.33	-	2.58	0.05	1.81	1.23	-	0.03	0.09	-	-	0.04	0.02	-	4.42	0.98	-	-	12.86	0.08	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	26.3		0	0.07	-	0.08	-	1.62	0.33	-	2.58	0.05	1.81	1.23	-	0.03	0.09	-	-	0.04	0.02	-	4.42	0.98	-	-	12.86	0.08	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	26.3	none																																																																																			-		0	0.07	-	0.08	-	1.62	0.33	-	2.58	0.05	1.81	1.23	-	0.03	0.09	-	-	0.04	0.02	-	4.42	0.98	-	-	12.86	0.08	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	26.3
H0354_801_0	2007	2																					none											A	A	D	P	T	P	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	O			V		V			O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	287.39	4.16	460.01	0	212.05	6.32	0	675.82	148.83	5369.71	3328.51	0	119.87	778.11	0	0	31.91	35.07	0	13588.5	6.4	0	0	0	0	0	0	0	0	0	0											Contracted - 250/admit; Gastic Bypass - 20 coin.	MHSA - 876/admit	Contracted - 150/day; days 21-100; Non-contracted - 150/day	0	100/trip	20 for high cost DME	0	CMG Urgent Care - 30/visit; Non-CMG Urgent Care - 50/visit; Emergency Room - 50/visit	150/visit	CMG Specialist - 30/visit; Non-CMG Specialist - 30/visit	High Tech - 150/visit; Low Tech  - 30/visit; Mammography - 0/visit	0	30/visit	30/visit	0	0	30/visit	CMG Specialist - 30/visit; Non-CMG Specialist - 30/visit	0	Primary Care - 30/visit; CMG Specialist - 30/visit; Non-CMG Specialist - 30/visitGastric Bypass - 20 coin.	10 coinsurance	0	0	0	0	0	0	0	0	0	0											250.47	876	150	0	100	380.52	0	40.91	150	22.5	50.47	0	30	30	0	0	30	30	0	30	0.1	0	0	0	0	0	0	0	0	0	0											6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28		0	6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28	none																																																																																			-		0	6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28
H0354_804_0	2007	2																					none											A	A	D	P	T	P	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	O			V		V			O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	287.39	4.16	460.01	0	212.05	6.32	0	675.82	148.83	5369.71	3328.51	0	119.87	778.11	0	0	31.91	35.07	0	13588.5	6.4	0	0	0	0	0	0	0	0	0	0											Contracted - 250/admit; Gastic Bypass - 20 coin.	MHSA - 876/admit	Contracted - 150/day; days 21-100; Non-contracted - 150/day	0	100/trip	20 for high cost DME	0	CMG Urgent Care - 30/visit; Non-CMG Urgent Care - 50/visit; Emergency Room - 50/visit	150/visit	CMG Specialist - 30/visit; Non-CMG Specialist - 30/visit	High Tech - 150/visit; Low Tech  - 30/visit; Mammography - 0/visit	0	30/visit	30/visit	0	0	30/visit	CMG Specialist - 30/visit; Non-CMG Specialist - 30/visit	0	Primary Care - 30/visit; CMG Specialist - 30/visit; Non-CMG Specialist - 30/visitGastric Bypass - 20 coin.	10 coinsurance	0	0	0	0	0	0	0	0	0	0											250.47	876	150	0	100	380.52	0	40.91	150	22.5	50.47	0	30	30	0	0	30	30	0	30	0.1	0	0	0	0	0	0	0	0	0	0											6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28		0	6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28	none																																																																																			-		0	6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28
H0354_805_0	2007	2																					none											A	A	D	P	T	P	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	O			V		V			O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	287.39	4.16	460.01	0	212.05	6.32	0	675.82	148.83	5369.71	3328.51	0	119.87	778.11	0	0	31.91	35.07	0	13588.5	6.4	0	0	0	0	0	0	0	0	0	0											Contracted - 250/admit; Gastic Bypass - 20 coin.	MHSA - 876/admit	Contracted - 150/day; days 21-100; Non-contracted - 150/day	0	100/trip	20 for high cost DME	0	CMG Urgent Care - 30/visit; Non-CMG Urgent Care - 50/visit; Emergency Room - 50/visit	150/visit	CMG Specialist - 30/visit; Non-CMG Specialist - 30/visit	High Tech - 150/visit; Low Tech  - 30/visit; Mammography - 0/visit	0	30/visit	30/visit	0	0	30/visit	CMG Specialist - 30/visit; Non-CMG Specialist - 30/visit	0	Primary Care - 30/visit; CMG Specialist - 30/visit; Non-CMG Specialist - 30/visitGastric Bypass - 20 coin.	10 coinsurance	0	0	0	0	0	0	0	0	0	0											250.47	876	150	0	100	380.52	0	40.91	150	22.5	50.47	0	30	30	0	0	30	30	0	30	0.1	0	0	0	0	0	0	0	0	0	0											6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28		0	6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28	none																																																																																			-		0	6	0.3	5.75	-	1.77	0.2	-	2.3	1.86	10.07	14	-	0.3	1.95	-	-	0.08	0.09	-	33.98	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.28
H0401_002_0	2007	9																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1756.14	152.98	835.84	0	236.38	12.31	5.31	437.24	27.28	6303.2	37.96	0	0.19	20.76	2890.64	3387.23	581.41	1.59	0	0	19.04	589.03	0	0	132.65	0	183.81	0	0	0	0											275 (1a)	275 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											165.63	165.63	81.31	0	105.4	0.18	0.2	30.11	0.12	1.2	0.1	0	0.18	0.12	15	30	37.5	0.12	0	0	0.18	30	0	0	30	0	30	0	0	0	0											24.24	2.11	5.66	-	2.08	2.22	1.08	1.1	3.29	0.63	3.68	-	0.03	2.5	3.61	8.47	1.82	0.19	-	-	3.44	1.47	-	-	0.33	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.42		34.31	24.24	2.11	5.66	-	2.08	2.22	1.08	1.1	3.29	0.63	3.68	-	0.03	2.5	3.61	8.47	1.82	0.19	-	-	3.44	1.47	-	-	0.33	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.42	3400	375 (1a)	375 (1b)	185 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	28 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	38 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 38 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	38 (17a)	0 n/c (17b1-17b5)	38 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.87	0.25	0.67	0.68	0.46	0.49	0.24	0.24	1.44	0.56	1.58	0	0.01	1.1	1.86	2.35	0.45	0.08	0	0	0.76	0.41	0	0	0.09	0	0.13	0	0	0	0											16.72		7.05	27.11	2.36	6.34	0.68	2.53	2.71	1.31	1.34	4.73	1.19	5.26	-	0.04	3.6	5.48	10.82	2.27	0.28	-	-	4.2	1.88	-	-	0.42	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.14
H0401_003_0	2007	8																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1756.14	152.98	835.84	0	236.38	12.31	5.31	437.24	27.28	6303.2	37.96	0	0.19	20.76	2890.64	3387.23	581.41	1.59	0	0	19.04	589.03	0	0	132.65	0	183.81	0	0	0	0											275 (1a)	275 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											155.49	155.49	76.33	0	98.95	0.17	0.19	28.27	0.11	3.39	0.09	0	0.17	0.11	15	30	37.5	0.11	0	0	0.17	30	0	0	30	0	30	0	0	0	0											22.75	1.98	5.32	-	1.95	2.09	1.03	1.03	3.09	1.78	3.46	-	0.03	2.35	3.61	8.47	1.82	0.18	-	-	3.23	1.47	-	-	0.33	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.43		38.41	22.75	1.98	5.32	-	1.95	2.09	1.03	1.03	3.09	1.78	3.46	-	0.03	2.35	3.61	8.47	1.82	0.18	-	-	3.23	1.47	-	-	0.33	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.43	3000	375 (1a)	375 (1b)	185 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	28 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	38 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 38 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	38 (17a)	0 n/c (17b1-17b5)	38 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.7	0.24	0.63	0.38	0.43	0.46	0.2	0.23	1.35	0.52	1.48	0	0.01	1.03	1.05	1.33	0.26	0.08	0	0	0.71	0.23	0	0	0.05	0	0.07	0	0	0	0											13.44		10.33	25.45	2.22	5.95	0.38	2.38	2.55	1.23	1.26	4.44	2.3	4.94	-	0.04	3.38	4.67	9.8	2.07	0.26	-	-	3.94	1.7	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.87
H0401_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2176.59	344.4	1112.72		249.61	24.14	20.92	840.77	364.55	1912.65	897.33	62.1	2.9	1888.11		3444.54		515.25		801.76												269.15		153.15	227.84							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							37	37	18		37	10	10	18	12	5	5	12	10	12		5		5		5												5		5	5							6.63	1.05	1.63	-	0.76	2.35	2.04	1.23	0.37	0.78	0.36	0.06	0.28	1.92	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.67		22.77	6.63	1.05	1.63	-	0.76	2.35	2.04	1.23	0.37	0.78	0.36	0.06	0.28	1.92	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.67		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							1.96	0.13	0.25	0.33	0.06	0.15	0.13	0.04	0.17	0.12	0.12	0.01	0.02	0.19	0.32	0.19	0.04	0.03	0.13	0.61	0.12	0																				5.14		0	8.59	1.18	1.88	0.33	0.82	2.5	2.17	1.27	0.54	0.9	0.48	0.08	0.3	2.11	0.32	1.59	0.04	0.24	0.13	0.94	0.12	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	26.81
H0401_801_0	2007	6																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2004.29	174.6	953.95	0	302.69	15.76	6.8	559.88	34.94	8071.17	48.61	0	0.24	26.59	3701.42	4337.31	744.49	2.03	0	0	24.39	754.24	0	0	169.86	0	235.37	0	0	0	0											350 (1a)	350 (1b)	140 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											230.07	230.07	92.03	0	115.03	0.16	0.18	32.87	0.13	3.94	0.11	0	0.2	0.13	35	35	37.5	0.13	0	0	0.2	35	0	0	35	0	35	0	0	0	0											38.43	3.35	7.32	-	2.9	2.59	1.23	1.53	4.59	2.65	5.15	-	0.05	3.5	10.8	12.65	2.33	0.27	-	-	4.81	2.2	-	-	0.5	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.51		40.68	38.43	3.35	7.32	-	2.9	2.59	1.23	1.53	4.59	2.65	5.15	-	0.05	3.5	10.8	12.65	2.33	0.27	-	-	4.81	2.2	-	-	0.5	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.51																																																																																				-			38.43	3.35	7.32	-	2.9	2.59	1.23	1.53	4.59	2.65	5.15	-	0.05	3.5	10.8	12.65	2.33	0.27	-	-	4.81	2.2	-	-	0.5	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.51
H0408_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2279.38	212.24	8807.58	165.07	619.52	21.06	6.6	178.17	118.29	3680.3	163.61	32.35	4.23	275.09	123.26	1234.49	1603.66	18.94		257.76	261.17	1260.48	1140		133.19	157.7		51.87				105.06	0.26	0.07	285	280.44						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						131	131			65	17	17	44	22			22		22		9				9		9										31		22								24.87	2.32	-	-	3.38	3.68	1.15	0.65	0.22	-	-	0.06	-	0.5	-	0.9	-	-	-	0.19	-	0.92	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	39.09		5.69	24.87	2.32	-	-	3.38	3.68	1.15	0.65	0.22	-	-	0.06	-	0.5	-	0.9	-	-	-	0.19	-	0.92	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	39.09		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						3.07	0.09	0.87	0.09	0.39	0.33	0.1	0.04	0.21	0.63	0.7	0.04	0.01	0.12	0.01	1.83	0.17	0		0.18		0.13	0.06		0.02							0.02	0	0	0.02	0.02						9.12		0	27.94	2.4	0.87	0.09	3.77	4.01	1.26	0.69	0.42	0.63	0.7	0.1	0.01	0.62	0.01	2.72	0.17	0	-	0.37	-	1.04	0.06	-	0.02	-	-	-	-	-	-	0.28	0	0	0.02	0.02	-	-	-	-	-	48.21
H0408_002_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2176.45	202.66	8409.87	157.62	591.55	19.2	6.02	170.12	112.95	3514.11	156.23	30.89	4.04	262.67	117.7	1178.74	1531.24	18.09		246.12	249.38	1203.57	1140		133.19	157.7		51.87				100.32	0.25	0.06	285	280.44						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						132	132			66	18	18	44	22			22		22		9				9		9										31		22								24	2.23	-	-	3.26	3.39	1.06	0.63	0.21	-	-	0.06	-	0.48	-	0.87	-	-	-	0.18	-	0.88	-	-	-	-	-	-	-	-	-	0.26	-	0	-	-	-	-	-	-	-	37.51		5.01	24	2.23	-	-	3.26	3.39	1.06	0.63	0.21	-	-	0.06	-	0.48	-	0.87	-	-	-	0.18	-	0.88	-	-	-	-	-	-	-	-	-	0.26	-	0	-	-	-	-	-	-	-	37.51		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						2.8	0.08	0.79	0.08	0.35	0.3	0.1	0.04	0.19	0.57	0.64	0.04	0.01	0.11	0.01	1.67	0.15	0		0.17		0.11	0.06		0.02							0.02	0	0	0.02	0.02						8.33		0	26.8	2.31	0.79	0.08	3.61	3.69	1.16	0.66	0.4	0.57	0.64	0.09	0.01	0.59	0.01	2.53	0.15	0	-	0.35	-	1	0.06	-	0.02	-	-	-	-	-	-	0.27	0	0	0.02	0.02	-	-	-	-	-	45.84
H0410_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							14.22	14.2	440.51	405.88		271.05	58.72		1060.98		6167.76	135.73			968.05					137.43		289.34						11.93	350.7		101.7	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.52	2.51	1.33	1.5	-	0.4	0.22	-	3.91	-	9.1	0.2	-	-	1.43	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.52	-	0.15	0.23	-	-	-	-	24.73		3.09	-	-	-	-	-	2.52	2.51	1.33	1.5	-	0.4	0.22	-	3.91	-	9.1	0.2	-	-	1.43	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.52	-	0.15	0.23	-	-	-	-	24.73		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.3	0.04	0.41	0.37	0.06	0.09	0.09	0.03	0.25	0.15	0.14	0.02	0	0.15		0.29	0.01	0.03	0.17	0.67	0.15	0			0.01		0.01															5.43		0	2.3	0.04	0.41	0.37	0.06	2.6	2.6	1.36	1.74	0.15	0.54	0.23	0	4.07	-	9.39	0.21	0.03	0.17	2.1	0.15	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.52	-	0.15	0.23	-	-	-	-	30.17
H0410_002_0	2007	2	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							14.22	14.2	440.51	405.88		271.05	58.72		1060.98		6167.75	135.73			968.05					137.43		289.34						11.93	350.7		101.7	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.52	2.51	1.33	1.5	-	0.4	0.22	-	3.91	-	9.1	0.2	-	-	1.43	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.52	-	0.15	0.23	-	-	-	-	24.73		3.09	-	-	-	-	-	2.52	2.51	1.33	1.5	-	0.4	0.22	-	3.91	-	9.1	0.2	-	-	1.43	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.52	-	0.15	0.23	-	-	-	-	24.73		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.3	0.04	0.41	0.37	0.06	0.09	0.09	0.03	0.25	0.15	0.14	0.02	0	0.15		0.29	0.01	0.03	0.17	0.67	0.15	0			0.01		0.01															5.43		0	2.3	0.04	0.41	0.37	0.06	2.6	2.6	1.36	1.74	0.15	0.54	0.23	0	4.07	-	9.39	0.21	0.03	0.17	2.1	0.15	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.52	-	0.15	0.23	-	-	-	-	30.17
H0410_003_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								31.15	734.08	570.65		433.31	91.4		1722.85		6899.82	442.57			1472.02							289.34						67.78	356.04		287.04	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit											17	34	42		17	42		42		17	17			17							20						17	17		17	20					-	-	-	-	-	-	5.21	2.1	1.99	-	0.6	0.32	-	6.01	-	9.62	0.62	-	-	2.11	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.5	-	0.4	0.23	-	-	-	-	30.28		5.7	-	-	-	-	-	-	5.21	2.1	1.99	-	0.6	0.32	-	6.01	-	9.62	0.62	-	-	2.11	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.5	-	0.4	0.23	-	-	-	-	30.28		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						3.03	0.12	0.3	0.38	0.07	0.17	0.19	0.04	0.33	0.2	0.21	0.03	0.01	0.23		0.35	0.03	0.03	0.22	0.83	0.19	0			0.01		0.01															6.96		0	3.03	0.12	0.3	0.38	0.07	0.17	5.4	2.14	2.32	0.2	0.81	0.35	0.01	6.23	-	9.97	0.65	0.03	0.22	2.94	0.19	0	-	-	0.01	-	0.49	-	-	-	-	-	0.09	0.5	-	0.4	0.23	-	-	-	-	37.24
H0410_004_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2416.84	225.04	9338.73	175.02	656.89	1477.5	7180.78	188.91	125.43	3902.24	173.48	34.3	4.49	291.68	134.6	1377.83	1789.86	21.14		287.69	276.92	1406.84	2250		140.2	166		54.6				111.4	0.28	0.07	300	295.2						(1a) 25/day	(1b) 25/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 20/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						23	23			45			45																								18										4.55	0.42	-	-	2.48	-	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	8.33		0.88	4.55	0.42	-	-	2.48	-	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	8.33		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							20	30	30	30	30						3.45	0.1	0.98	0.1	0.44	0.37	0.12	0.04	0.23	0.71	0.79	0.05	0.01	0.13																		0.01	0	0								7.52		0	8	0.52	0.98	0.1	2.91	0.37	0.12	0.75	0.23	0.71	0.79	0.05	0.01	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.18	0	0	-	-	-	-	-	-	-	15.85
H0504_015_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	P	P	V	O	P	P	P	V	P	P	P	Coin		T		P	P	P	P																																																							-		1062.57	47.13	556.96	73.42	391.95	3.15	0.81	185.73	107.71	1018.91	209.46	21.92	25.02	419.84	1690.63	7875.44	140.56	1526.35	6077.27	1364.64	0.49	0	0	0	199.5	153.56	85.5	10.73	0	0	0											55.00 for Days 1-10	55.00 for Days 1-10	65 for Days 21-100	0.00 Copay	100 Copay per trip (1-way)	20 Coinsurance of medicare-allowable	20 Coinsurance of medicare-allowable	50 Copay - waived if admited to hospital	50 Copay per visit	0.00 Copay	0.00 Copay	0.00 Copay	10 Coinsurance of medicare allowable + applicable drug copays	10.00 Copay per visit	5.00 Copay per visit	10.00 Copay per visit	30 Copay per visit	10 Copay per visit	0.00 Copay	10 Copay per visit	20 Coinsurance of BSC Contracted Rate	10 Copay	0.00 Copay	0.00 Copay	10 Copay per Exam	20 Copay for Frames & Lenses	0.00 Copay	0.00 Copay		0.00 Copay	0.00 Copay											55	55	65	0	100	0.2	0.2	38.65	50	0	0	0	17.1	10	5	10	30	10	0	10	0.2	10	0	0	10	20	0	0	0	0	0											4.87	0.22	3.02	-	3.27	0.63	0.16	0.6	0.45	-	-	-	0.04	0.35	0.7	6.56	0.35	1.27	-	1.14	0.1	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.14			4.87	0.22	3.02	-	3.27	0.63	0.16	0.6	0.45	-	-	-	0.04	0.35	0.7	6.56	0.35	1.27	-	1.14	0.1	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.14																																																																																				-			4.87	0.22	3.02	-	3.27	0.63	0.16	0.6	0.45	-	-	-	0.04	0.35	0.7	6.56	0.35	1.27	-	1.14	0.1	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.14
H0504_017_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	P	P	V	O	P	P	P	V	P	P	P	Coin		T		P	P	P	P																																																							-		1066.76	47.32	559.68	73.64	393.5	2.51	0.64	188	109.03	1031.33	212.01	22.18	24.34	424.96	1690.63	7875.44	140.56	1526.35	6077.27	1364.64	0.65	0	0	0	199.5	153.56	85.5	10.73	0	0	0											125.00 for Days 1-10	125.00 for Days 1-10	75 for Days 21-100	0.00 Copay	100 Copay per trip (1-way)	20 Coinsurance of medicare-allowable	20 Coinsurance of medicare-allowable	50 Copay - waived if admited to hospital	100 Copay per visit	0.00 Copay	0.00 Copay	0.00 Copay	10 Coinsurance of medicare allowable + applicable drug copays	10.00 Copay per visit	5.00 Copay per visit	10.00 Copay per visit	30 Copay per visit	10 Copay per visit	0.00 Copay	10 Copay per visit	20 Coinsurance of BSC Contracted Rate	10 Copay	0.00 Copay	0.00 Copay	10 Copay per Exam	20 Copay for Frames & Lenses	0.00 Copay	0.00 Copay		0.00 Copay	0.00 Copay											125	125	75	0	100	0.2	0.02	39.67	100	0	0	0	14.95	10	5	10	30	10	0	10	0.2	10	0	0	10	20	0	0	0	0	0											11.11	0.49	3.5	-	3.28	0.5	0.01	0.62	0.91	-	-	-	0.03	0.35	0.7	6.56	0.35	1.27	-	1.14	0.13	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.39			11.11	0.49	3.5	-	3.28	0.5	0.01	0.62	0.91	-	-	-	0.03	0.35	0.7	6.56	0.35	1.27	-	1.14	0.13	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.39																																																																																				-			11.11	0.49	3.5	-	3.28	0.5	0.01	0.62	0.91	-	-	-	0.03	0.35	0.7	6.56	0.35	1.27	-	1.14	0.13	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.39
H0504_019_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	P	P	V	O	P	P	P	V	P	P	P	Coin		T		P	P	P	P																																																							-		1062.57	47.13	556.96	73.42	391.95	3.15	0.81	185.73	107.71	1018.91	209.46	21.92	0.94	419.84	1690.63	7875.44	140.56	1526.35	6077.27	1364.64	0.49	0	0	0	199.5	153.56	85.5	10.73	0	0	0											55.00 for Days 1-10	55.00 for Days 1-10	65 for Days 21-100	0.00 Copay	100 Copay per trip (1-way)	20 Coinsurance of medicare-allowable	20 Coinsurance of medicare-allowable	50 Copay - waived if admited to hospital	50 Copay per visit	0.00 Copay	0.00 Copay	0.00 Copay	10 Coinsurance of medicare allowable + applicable drug copays	10.00 Copay per visit	5.00 Copay per visit	10.00 Copay per visit	30 Copay per visit	10 Copay per visit	0.00 Copay	10 Copay per visit	20 Coinsurance of BSC Contracted Rate	10 Copay	0.00 Copay	0.00 Copay	10 Copay per Exam	20 Copay for Frames & Lenses	0.00 Copay	0.00 Copay		0.00 Copay	0.00 Copay											55	55	65	0	100	0.2	0.2	38.65	50	0	0	0	17.1	10	5	10	30	10	0	10	0.2	10	0	0	10	20	0	0	0	0	0											4.87	0.22	3.02	-	3.27	0.63	0.16	0.6	0.45	-	-	-	0	0.35	0.7	6.56	0.35	1.27	-	1.14	0.1	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.11			4.87	0.22	3.02	-	3.27	0.63	0.16	0.6	0.45	-	-	-	0	0.35	0.7	6.56	0.35	1.27	-	1.14	0.1	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.11																																																																																				-			4.87	0.22	3.02	-	3.27	0.63	0.16	0.6	0.45	-	-	-	0	0.35	0.7	6.56	0.35	1.27	-	1.14	0.1	-	-	-	0.17	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.11
H0504_021_0	2007	4																																				T	Coin		V					O				V				Coin		T		V	P																																																									-		1062.57	47.13	556.96	73.42	391.95	3.15	0.81	185.73	107.71	1018.91	209.46	21.92	23.09	419.84	1690.63	7875.44	140.56	1526.35	6077.27	1364.64	0.49	0	0	0	199.5	153.56	85.5	10.73	0	0	0											0.00 for Days 1-10	0.00 for Days 1-10	20.00 Copay Days 21-100	0.00 Copay	60 Copay per trip (1-way)	20 Coinsurance of medicare-allowable	20 Coinsurance of medicare-allowable	50 Copay - waived if admited to hospital	0.00 Copay	0.00 Copay	0.00 Copay	0.00 Copay	25.00 Copay Days 1-100	0.00 Copay	0.00 Copay	0.00 Copay	30.00 Copay per visit	0.00 Copay	0.00 Copay	0.00 Copay	20 Coinsurance of BSC Contracted Rate	0.00 Copay	0.00 Copay	0.00 Copay	10.00 Copay	0 Copay for frames and 15 copay for lenses	0.00 Copay	0.00 Copay		0.00 Copay	0.00 Copay											0	0	20	0	60	0.2	0	26.67	0	0	0	0	25	0	0	0	30	0	0	0	0.2	0	0	0	10	15	0	0	0	0	0											-	-	0.93	-	1.96	0.63	-	0.41	-	-	-	-	0.05	-	-	-	0.35	-	-	-	0.1	-	-	-	0.17	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79			-	-	0.93	-	1.96	0.63	-	0.41	-	-	-	-	0.05	-	-	-	0.35	-	-	-	0.1	-	-	-	0.17	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79																																																																																				-			-	-	0.93	-	1.96	0.63	-	0.41	-	-	-	-	0.05	-	-	-	0.35	-	-	-	0.1	-	-	-	0.17	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79
H0504_023_0	2007	4																																				T	Coin		V					O				V				Coin		T		V	P																																																									-		1062.57	47.13	556.96	73.42	391.95	3.15	0.81	185.73	107.71	1018.91	209.46	21.92	23.09	419.84	1690.63	7875.44	140.56	1526.35	6077.27	1364.64	0.49	0	0	0	199.5	153.56	85.5	10.73	0	0	0											0.00 for Days 1-10	0.00 for Days 1-10	20.00 Copay Days 21-100	0.00 Copay	60 Copay per trip (1-way)	20 Coinsurance of medicare-allowable	20 Coinsurance of medicare-allowable	50 Copay - waived if admited to hospital	0.00 Copay	0.00 Copay	0.00 Copay	0.00 Copay	25.00 Copay Days 1-100	0.00 Copay	0.00 Copay	0.00 Copay	30.00 Copay per visit	0.00 Copay	0.00 Copay	0.00 Copay	20 Coinsurance of BSC Contracted Rate	0.00 Copay	0.00 Copay	0.00 Copay	10.00 Copay	0 Copay for frames and 15 copay for lenses	0.00 Copay	0.00 Copay		0.00 Copay	0.00 Copay											0	0	20	0	60	0.2	0	26.67	0	0	0	0	25	0	0	0	30	0	0	0	0.2	0	0	0	10	15	0	0	0	0	0											-	-	0.93	-	1.96	0.63	-	0.41	-	-	-	-	0.05	-	-	-	0.35	-	-	-	0.1	-	-	-	0.17	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79			-	-	0.93	-	1.96	0.63	-	0.41	-	-	-	-	0.05	-	-	-	0.35	-	-	-	0.1	-	-	-	0.17	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79																																																																																				-			-	-	0.93	-	1.96	0.63	-	0.41	-	-	-	-	0.05	-	-	-	0.35	-	-	-	0.1	-	-	-	0.17	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79
H0504_025_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	P	P	V	O	P	P	P	V	P	P	P	Coin		T		P	P	P	P																																																							-		1062.57	47.13	556.96	73.42	391.95	3.15	0.81	185.73	107.71	1018.91	209.46	21.92	25.02	419.84	1690.63	7875.44	140.56	1526.35	6077.27	1364.64	0.49	0	0	0	199.5	153.56	85.5	10.73	0	0	0											200.00 for Days 1-10	200.00 for Days 1-10	75 for Days 21-100	0.00 Copay	125 Copay per trip (1-way)	20 Coinsurance of medicare-allowable	20 Coinsurance of medicare-allowable	50 Copay - waived if admited to hospital	150 Copay per visit	0.00 Copay	0.00 Copay	0.00 Copay	10 Coinsurance of medicare allowable + applicable drug copays	10.00 Copay per visit	10.00 Copay per visit	15.00 Copay per visit	30 Copay per visit	15.00 Copay per visit	0.00 Copay	10 Copay per visit	20 Coinsurance of BSC Contracted Rate	10 Copay	0.00 Copay	20.00 Copay	20.00 Copay per Exam	20 Copay for Frames & Lenses	0.00 Copay	0.00 Copay		0.00 Copay	0.00 Copay											200	200	75	0	125	0.2	0.2	50	150	0	0	0	17.1	10	10	15	30	15	0	10	0.2	10	0	20	20	0	0	0	0	0	0											17.71	0.79	3.48	-	4.08	0.63	0.16	0.77	1.35	-	-	-	0.04	0.35	1.41	9.84	0.35	1.91	-	1.14	0.1	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.44			17.71	0.79	3.48	-	4.08	0.63	0.16	0.77	1.35	-	-	-	0.04	0.35	1.41	9.84	0.35	1.91	-	1.14	0.1	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.44																																																																																				-			17.71	0.79	3.48	-	4.08	0.63	0.16	0.77	1.35	-	-	-	0.04	0.35	1.41	9.84	0.35	1.91	-	1.14	0.1	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.44
H0523_002_0	2007	5																																D		D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1423.19	0	1126.53	37.74	62.94	26.98	0	516.82	279.7	2222.71	1236.96	0	0	528.31	3806.12	4407.23	0	448.15	0	0	272	0	0	0	65.78	0	0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/Day 1-20 20/Day 21-100	0	75	20	20	50 25 UC	70	0	0 Routine 75 Complex	10	10	10	5	10	25	10	10	10	45				10		10	500 Every 3 years		Not Covered												45.5	0	8.03	0	75	0.2	0.2	46.75	70	0	34.2	10	10	10	5	10	25	10	10	10	45	0	0	0	10	0	10	0	0	0	0											5.4	-	0.75	-	0.39	5.4	-	2.01	1.63	-	3.53	-	-	0.44	1.59	3.67	-	0.37	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.26			5.4	-	0.75	-	0.39	5.4	-	2.01	1.63	-	3.53	-	-	0.44	1.59	3.67	-	0.37	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.26																																																																																				-			5.4	-	0.75	-	0.39	5.4	-	2.01	1.63	-	3.53	-	-	0.44	1.59	3.67	-	0.37	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.26
H0523_022_0	2007	5																																D		D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1768.93	0	1893.82	1892.66	149.18	22.72	0	704.56	218.83	1944.76	1249.66	0	0	413.34	3860.6	4187.81	0	235.36	0	0	272	0	0	0	160.02	0	0	0	0	0	0											50/Day 1-5	50/Day 1-5	0/Day 1-20 20/Day 21-100	0	100	15	15	50 25 UC	100	0	0 Routine 100 Complex	10	10	10	5	10	25	5	5	5	45				5		5	500 Every 3 years														30.34	0	8.03	0	100	0.15	0.15	46.75	100	0	34.2	10	10	10	5	10	25	5	5	5	45	0	0	0	5	0	5	0	0	0	0											4.47	-	1.27	-	1.24	3.41	-	2.74	1.82	-	3.56	-	-	0.34	1.61	3.49	-	0.1	-	-	1.02	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.15			4.47	-	1.27	-	1.24	3.41	-	2.74	1.82	-	3.56	-	-	0.34	1.61	3.49	-	0.1	-	-	1.02	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.15																																																																																				-			4.47	-	1.27	-	1.24	3.41	-	2.74	1.82	-	3.56	-	-	0.34	1.61	3.49	-	0.1	-	-	1.02	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.15
H0523_025_0	2007	5																																D		D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1116.95	0	1412.76	973.66	101.51	22.84	0	396.41	223.76	1789.94	1278.81	0	0	422.65	2906.48	2447.75	0	240.5	0	0	272	0	0	0	62.46	0	0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/Day 1-20 20/Day 21-100	0	75	20	20	50 25 UC	70	0	0 Routine 100 Complex	10	10	10	5	10	25	10	10	10	45				10		10	500 Every 3 years														45.5	0	8.03	0	75	0.2	0.2	46.75	70	0	34.2	10	10	10	5	10	25	10	10	10	45	0	0	0	10	0	10	0	0	0	0											4.24	-	0.95	-	0.63	4.57	-	1.54	1.31	-	3.64	-	-	0.35	1.21	2.04	-	0.2	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.75			4.24	-	0.95	-	0.63	4.57	-	1.54	1.31	-	3.64	-	-	0.35	1.21	2.04	-	0.2	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.75																																																																																				-			4.24	-	0.95	-	0.63	4.57	-	1.54	1.31	-	3.64	-	-	0.35	1.21	2.04	-	0.2	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.75
H0523_026_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1492.92	0	352.94	452.9	46.98	21.63	0	649.55	753.34	1902.52	1236.85	0	0	1422.98	4253.25	3936.65	0	348.07	0	0	272	0	0	0	122.72	0	0.12	0	0	0	0											50/Day 1-5	50/Day 1-5	0/Day 1-20 20/Day 21-100	0	100	15	15	50 25 UC	100	0	0 Routine 100 Complex	10	10	10	5	10	25	10	10	10	45				10		10	500 Every 3 years														30.34	0	8.03	0	100	0.15	0.15	46.75	100	0	34.2	10	10	10	5	10	25	10	10	10	45	0	0	0	10	0	10	0	0	0	0											3.77	-	0.24	-	0.39	3.24	-	2.53	6.28	-	3.53	-	-	1.19	1.77	3.28	-	0.29	-	-	1.02	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.63			3.77	-	0.24	-	0.39	3.24	-	2.53	6.28	-	3.53	-	-	1.19	1.77	3.28	-	0.29	-	-	1.02	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.63																																																																																				-			3.77	-	0.24	-	0.39	3.24	-	2.53	6.28	-	3.53	-	-	1.19	1.77	3.28	-	0.29	-	-	1.02	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.63
H0523_031_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1768.93	0	1893.82	1892.66	149.18	19.91	0	704.56	218.83	1944.76	1249.66	0	0	413.34	3860.6	4187.81	0	235.36	0	0	272	0	0	0	160.02	0	0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/day 1-20 50/day 21-100	0	75	20	20	50 25 UC	60	0	0 Routine 100 Complex	0	0	0	0	0	0	0	0	0	45				0		0	500 Every 3 years														45.5	0	20.07	0	75	0.2	0.2	46.75	60	0	34.2	0	0	0	0	0	0	0	0	0	45	0	0	0	0	0	0	0	0	0	0											6.71	-	3.17	-	0.93	3.98	-	2.74	1.09	-	3.56	-	-	-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.21			6.71	-	3.17	-	0.93	3.98	-	2.74	1.09	-	3.56	-	-	-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.21																																																																																				-			6.71	-	3.17	-	0.93	3.98	-	2.74	1.09	-	3.56	-	-	-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.21
H0523_032_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1857.38	0	1988.51	1987.29	149.18	21.82	0	739.79	229.77	2042	1312.15	0	0	434.01	4053.63	4397.2	0	247.13	0	0	8.38	0	0	0	160.02	0	0	0	0	0	0											150/day 1-5	150/day 1-5	0/day 1-20 25/day 21-100	0	50	20	20	50 25 UC	50	0	0 Routine 50 Complex	15	15	15	10	15	15	15	15	15	20				15		15	500 Every 3 years														91.01	0	10.04	0	50	0.2	0.2	46.75	50	0	17.1	15	15	15	10	15	15	15	15	15	0.2	0	0	0	15	0	15	0	0	0	0											14.09	-	1.66	-	0.62	4.36	-	2.88	0.96	-	1.87	-	-	0.54	3.38	5.5	-	0.31	-	-	1.68	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.04			14.09	-	1.66	-	0.62	4.36	-	2.88	0.96	-	1.87	-	-	0.54	3.38	5.5	-	0.31	-	-	1.68	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.04																																																																																				-			14.09	-	1.66	-	0.62	4.36	-	2.88	0.96	-	1.87	-	-	0.54	3.38	5.5	-	0.31	-	-	1.68	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.04
H0523_034_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1857.38	0	1988.51	1987.29	149.18	21.82	0	739.79	229.77	2042	1312.15	0	0	434.01	4053.63	4397.2	0	247.13	0	0	8.38	0	0	0	160.02	0	0	0	0	0	0											150/day 1-5	150/day 1-5	0/day 1-20 25/day 21-100	0	50	20	20	50 25 UC	50	0	0 Routine 50 Complex	15	15	15	10	15	15	15	15	15	20				15		15	500 Every 3 years		Fitness												91.01	0	10.04	0	50	0.2	0.2	46.75	50	0	17.1	15	15	15	10	15	15	15	15	15	0.2	0	0	0	15	0	15	0	0	0	0											14.09	-	1.66	-	0.62	4.36	-	2.88	0.96	-	1.87	-	-	0.54	3.38	5.5	-	0.31	-	-	0	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.37			14.09	-	1.66	-	0.62	4.36	-	2.88	0.96	-	1.87	-	-	0.54	3.38	5.5	-	0.31	-	-	0	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.37																																																																																				-			14.09	-	1.66	-	0.62	4.36	-	2.88	0.96	-	1.87	-	-	0.54	3.38	5.5	-	0.31	-	-	0	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.37
H0523_045_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1857.38	0	1988.51	1987.29	156.64	22.79	0	739.79	229.77	2042	1312.15	0	0	434.01	4053.63	4397.2	0	247.13	0	0	0	0	0	0	168.02	0	0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/Day 1-20 20/Day 21-100	0	75	20	20	50 25 UC	65	0	0 Routine 50 Complex	10	10	10	5	10	10	10	10	10	20				10		10	500 Every 3 years														45.5	0	8.03	0	75	0.2	0.2	46.75	65	0	17.1	10	10	10	5	10	10	10	10	10	0.2	0	0	0	10	0	10	0	0	0	0											7.04	-	1.33	-	0.98	4.56	-	2.88	1.24	-	1.87	-	-	0.36	1.69	3.66	-	0.21	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.97			7.04	-	1.33	-	0.98	4.56	-	2.88	1.24	-	1.87	-	-	0.36	1.69	3.66	-	0.21	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.97																																																																																				-			7.04	-	1.33	-	0.98	4.56	-	2.88	1.24	-	1.87	-	-	0.36	1.69	3.66	-	0.21	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.97
H0523_046_0	2007	3																																D		D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1857.38	0	1988.51	1987.29	156.64	22.79	0	739.79	229.77	2042	1312.15	0	0	434.01	4053.63	4397.2	0	247.13	0	0	0	0	0	0	168.02	0	0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/Day 1-20 20/Day 21-100	0	75	20	20	50 25 UC	65	0	0 Routine 50 Complex	10	10	10	5	10	10	10	10	10	20				10		10	500 Every 3 years		Fitness												45.5	0	8.03	0	75	0.2	0.2	46.75	65	0	17.1	10	10	10	5	10	10	10	10	10	0.2	0	0	0	10	0	10	0	0	0	0											7.04	-	1.33	-	0.98	4.56	-	2.88	1.24	-	1.87	-	-	0.36	1.69	3.66	-	0.21	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.97			7.04	-	1.33	-	0.98	4.56	-	2.88	1.24	-	1.87	-	-	0.36	1.69	3.66	-	0.21	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.97																																																																																				-			7.04	-	1.33	-	0.98	4.56	-	2.88	1.24	-	1.87	-	-	0.36	1.69	3.66	-	0.21	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.97
H0523_047_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1768.93	0	1893.82	1892.66	149.18	22.72	0	704.56	218.83	1944.76	1249.66	0	0	413.34	3860.6	4187.81	0	235.36	0	0	272	0	0	0	160.02	0	0	0	0	0	0											50/Day 1-5	50/Day 1-5	0/Day 1-20 20/Day 21-100	0	100	20	20	50 25 UC	100	0	0 Routine 100 Complex	10	10	10	5	10	25	10	10	10	45				10		10	500 Every 3 years		Fitness												30.34	0	8.03	0	100	0.15	0.15	46.75	100	0	34.2	10	10	10	5	10	25	5	5	5	45	0	0	0	5	0	5	0	0	0	0											4.47	-	1.27	-	1.24	3.41	-	2.74	1.82	-	3.56	-	-	0.34	1.61	3.49	-	0.1	-	-	1.02	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.15			4.47	-	1.27	-	1.24	3.41	-	2.74	1.82	-	3.56	-	-	0.34	1.61	3.49	-	0.1	-	-	1.02	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.15																																																																																				-			4.47	-	1.27	-	1.24	3.41	-	2.74	1.82	-	3.56	-	-	0.34	1.61	3.49	-	0.1	-	-	1.02	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.15
H0523_048_0	2007	4																																D		D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1423.19	0	1126.53	37.74	62.94	26.98	0	516.82	279.7	2222.71	1236.96	0	0	528.31	3806.12	4407.23	0	448.15	0	0	272	0	0	0	65.78		0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/Day 1-20 20/Day 21-100	0	75	20	20	50 25 UC	70	0	0 Routine 100 Complex	10	10	10	5	10	25	10	10	10	45				10		10	500 Every 3 years		Fitness												45.5	45.5	8.03	0	75	0.2	0.2	46.75	70	0	34.2	10	10	10	5	10	25	10	10	10	45	0	0	0	10	0	10	0	0	0	0											5.4	-	0.75	-	0.39	5.4	-	2.01	1.63	-	3.53	-	-	0.44	1.59	3.67	-	0.37	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.26			5.4	-	0.75	-	0.39	5.4	-	2.01	1.63	-	3.53	-	-	0.44	1.59	3.67	-	0.37	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.26																																																																																				-			5.4	-	0.75	-	0.39	5.4	-	2.01	1.63	-	3.53	-	-	0.44	1.59	3.67	-	0.37	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.26
H0523_049_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1492.92	0	352.94	452.9	46.98	21.63	0	649.55	753.34	1902.52	1236.85	0	0	1422.98	4253.25	3936.65	0	348.07	0	0	272	0	0	0	122.72	0	0.12	0	0	0	0											50/Day 1-5	50/Day 1-5	0/Day 1-20 20/Day 21-100	0	100	15	15	50 25 UC	100	0	0 Routine 100 Complex	10	10	10	5	10	25	10	10	10	45				10		10	500 Every 3 years		Fitness												30.34	0	8.03	0	100	0.15	0.15	46.75	100	0	34.2	10	10	10	5	10	25	10	10	10	45	0	0	0	10	0	10	0	0	0	0											3.77	-	0.24	-	0.39	3.24	-	2.53	6.28	-	3.53	-	-	1.19	1.77	3.28	-	0.29	-	-	1.02	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.63			3.77	-	0.24	-	0.39	3.24	-	2.53	6.28	-	3.53	-	-	1.19	1.77	3.28	-	0.29	-	-	1.02	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.63																																																																																				-			3.77	-	0.24	-	0.39	3.24	-	2.53	6.28	-	3.53	-	-	1.19	1.77	3.28	-	0.29	-	-	1.02	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.63
H0523_050_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1116.95	0	1412.76	973.66	101.51	22.84	0	396.41	223.76	1789.94	1278.81	0	0	422.65	2906.48	2447.75	0	240.5	0	0	272	0	0	0	62.46	0	0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/Day 1-20 20/Day 21-100	0	75	20	20	50 25 UC	70	0	0 Routine 100 Complex	10	10	10	5	10	25	10	10	10	45				10	200 every 2 years	10	500 Every 3 years		Fitness												45.5	0	8.03	0	75	0.2	0.2	46.75	70	0	34.2	10	10	10	5	10	25	10	10	10	45	0	0	0	10	0	10	0	0	0	0											4.24	-	0.95	-	0.63	4.57	-	1.54	1.31	-	3.64	-	-	0.35	1.21	2.04	-	0.2	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.75			4.24	-	0.95	-	0.63	4.57	-	1.54	1.31	-	3.64	-	-	0.35	1.21	2.04	-	0.2	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.75																																																																																				-			4.24	-	0.95	-	0.63	4.57	-	1.54	1.31	-	3.64	-	-	0.35	1.21	2.04	-	0.2	-	-	1.02	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.75
H0523_051_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1768.93	0	1893.82	1892.66	149.18	19.91	0	704.56	218.83	1944.76	1249.66	0	0	413.34	3860.6	4187.81	0	235.36	0	0	272	0	0	0	160.02	0	0	0	0	0	0											75/Day 1-5	75/Day 1-5	0/day 1-20 50/day 21-100	0	75	20	20	50 25 UC	60	0	0 Routine 100 Complex	0	0	0	0	0	0	0	0	0	45				0		0	500 Every 3 years		Fitness												45.5	0	20.07	0	75	0.2	0.2	46.75	60	0	34.2	0	0	0	0	0	0	0	0	0	45	0	0	0	0	0	0	0	0	0	0											6.71	-	3.17	-	0.93	3.98	-	2.74	1.09	-	3.56	-	-	-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.21			6.71	-	3.17	-	0.93	3.98	-	2.74	1.09	-	3.56	-	-	-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.21																																																																																				-			6.71	-	3.17	-	0.93	3.98	-	2.74	1.09	-	3.56	-	-	-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.21
H0523_801_0	2007	2																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5319.24	6747.88	193.76	1121.23	1532.39	2779.34	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98
H0523_805_0	2007	2																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5319.24	6747.88	193.76	1121.23	1532.39	2779.34	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.98
H0524_002_0	2007	12																					4000											D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		993	57	548		258	10		670	45	3541	1306			51	9476	3	260	882			261				239					109												300/days 1-10	300/days 1-10	100/days 21-100		300/trip	twenty percent		50/ER visit 15/UR visit	250/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			15/visit	15/visit	15/visit	15/visit	15/visit			11/generic 40/brand				15/visit					15/visit												219	219	18		267	0.2		36.71	222.5	17.8	21.81			13.35	13.35	13.35	13.35	13.35			24.31				13.35					13.35												18.12	1.04	0.82	-	5.73	1.98	-	2.05	0.83	5.25	2.37	-	-	0.06	10.54	0	0.29	0.98	-	-	0.53	-	-	-	0.27	-	-	-	-	0.12	-	-	-	-	-	-	-	-	-	-	-	50.98		13.32	18.12	1.04	0.82	-	5.73	1.98	-	2.05	0.83	5.25	2.37	-	-	0.06	10.54	0	0.29	0.98	-	-	0.53	-	-	-	0.27	-	-	-	-	0.12	-	-	-	-	-	-	-	-	-	-	-	50.98																																																																																				-			18.12	1.04	0.82	-	5.73	1.98	-	2.05	0.83	5.25	2.37	-	-	0.06	10.54	0	0.29	0.98	-	-	0.53	-	-	-	0.27	-	-	-	-	0.12	-	-	-	-	-	-	-	-	-	-	-	50.98
H0524_003_0	2007	5																					4000											D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		882.39	50.85	432.26		223.37	8.45		532.8	50.17	3532.95	1302.9			50.64	9878.39	3.02	271.33	919.1			261.02				239.04					134.29												300/days 1-10	300/days 1-10	100/days 21-100		300/trip	twenty percent		50/ER visit 15/UR visit	250/procedure	25/routine lab	25/x-ray 50/MRIPET CAT Scans			20/visit	20/visit	20/visit	20/visit	20/visit			11/generic 40/brand				20/visit					20/visit												219	219	18		270	0.2		37.13	225	22.5	27			18	18	18	18	18			24.31				18					18												16.1	0.93	0.65	-	5.03	1.69	-	1.65	0.94	6.62	2.93	-	-	0.08	14.82	0	0.41	1.38	-	-	0.53	-	-	-	0.36	-	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	54.31		12.16	16.1	0.93	0.65	-	5.03	1.69	-	1.65	0.94	6.62	2.93	-	-	0.08	14.82	0	0.41	1.38	-	-	0.53	-	-	-	0.36	-	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	54.31																																																																																				-			16.1	0.93	0.65	-	5.03	1.69	-	1.65	0.94	6.62	2.93	-	-	0.08	14.82	0	0.41	1.38	-	-	0.53	-	-	-	0.36	-	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	54.31
H0524_008_0	2007	5																					4000											D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1118	52	551		258	10		582	76	2012	709			26	9313	2	290	834			224				233					201												275/days 1-10	275/days 1-10	100/days 21-100		300/trip	twenty percent		50/ER visit 25/UR visit	225/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			30/visit	30/visit	30/visit	30/visit	30/visit			11/generic 40/brand				30/visit					30/visit												209	209	18		270	0.2		39.38	202.5	18	22.05			27	27	27	27	27			17.41				27					27												19.47	0.9	0.83	-	5.81	1.97	-	1.91	1.29	3.02	1.3	-	-	0.06	20.95	0	0.65	1.88	-	-	0.32	-	-	-	0.52	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	61.34		14.4	19.47	0.9	0.83	-	5.81	1.97	-	1.91	1.29	3.02	1.3	-	-	0.06	20.95	0	0.65	1.88	-	-	0.32	-	-	-	0.52	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	61.34																																																																																				-			19.47	0.9	0.83	-	5.81	1.97	-	1.91	1.29	3.02	1.3	-	-	0.06	20.95	0	0.65	1.88	-	-	0.32	-	-	-	0.52	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	61.34
H0524_010_0	2007	7																					4000											D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1335.98	61.58	570.58		279.41	11.3		587.81	98.67	1999.57	704.86			25.96	9416.64	2.24	293.7	843.52			223.59				232.94					168.75												300/days 1-10	300/days 1-10	100/days 21-100		300/trip	twenty percent		50/ER visit 25/UR visit	250/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			25/visit	25/visit	25/visit	25/visit	25/visit			11/generic 40/brand				25/visit					25/visit												222	222	18		267	0.2		38.94	222.5	17.8	21.81			22.25	22.25	22.25	22.25	22.25			17.41				22.25					22.25												24.72	1.14	0.86	-	6.22	2.26	-	1.91	1.83	2.97	1.28	-	-	0.05	17.46	0	0.54	1.56	-	-	0.32	-	-	-	0.43	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	63.86		16.18	24.72	1.14	0.86	-	6.22	2.26	-	1.91	1.83	2.97	1.28	-	-	0.05	17.46	0	0.54	1.56	-	-	0.32	-	-	-	0.43	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	63.86																																																																																				-			24.72	1.14	0.86	-	6.22	2.26	-	1.91	1.83	2.97	1.28	-	-	0.05	17.46	0	0.54	1.56	-	-	0.32	-	-	-	0.43	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	63.86
H0524_013_0	2007	5																					4000											D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		949.84	43.78	567.48		245.33	10.05		521.15	96.99	2034.6	717.21			26.41	9739.48	2.31	303.77	872.44			223.59				232.94					247.49												275/days 1-10	275/days 1-10	100/days 21-100		300/trip	twenty percent		50/ER visit 25/UR visit	225/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			30/visit	30/visit	30/visit	30/visit	30/visit			11/generic 40/brand				30/visit					30/visit												209	209	18		270	0.2		39.38	202.5	18	22.05			27	27	27	27	27			17.41				27					27												16.54	0.76	0.85	-	5.52	2.01	-	1.71	1.64	3.05	1.32	-	-	0.06	21.91	0.01	0.68	1.96	-	-	0.32	-	-	-	0.52	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	59.43		13.67	16.54	0.76	0.85	-	5.52	2.01	-	1.71	1.64	3.05	1.32	-	-	0.06	21.91	0.01	0.68	1.96	-	-	0.32	-	-	-	0.52	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	59.43																																																																																				-			16.54	0.76	0.85	-	5.52	2.01	-	1.71	1.64	3.05	1.32	-	-	0.06	21.91	0.01	0.68	1.96	-	-	0.32	-	-	-	0.52	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	59.43
H0524_015_0	2007	13																					4000											D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		924.85	53.29	471.68		234.05	9.55		561.47	53.74	3540.49	1305.68			50.75	9475.21	2.89	260.26	881.59			261.02				239.04					99.87												300/days 1-10	300/days 1-10	100/days 21-100		300/trip	twenty percent		50/ER visit 25/UR visit	250/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			30/visit	30/visit	30/visit	30/visit	30/visit			11/generic 40/brand				30/visit					30/visit												219	219	18		270	0.2		39.38	225	18	22.05			27	27	27	27	27			24.31				27					27												16.88	0.97	0.71	-	5.27	1.91	-	1.84	1.01	5.31	2.4	-	-	0.11	21.32	0.01	0.59	1.98	-	-	0.53	-	-	-	0.54	-	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	61.6		13.37	16.88	0.97	0.71	-	5.27	1.91	-	1.84	1.01	5.31	2.4	-	-	0.11	21.32	0.01	0.59	1.98	-	-	0.53	-	-	-	0.54	-	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	61.6																																																																																				-			16.88	0.97	0.71	-	5.27	1.91	-	1.84	1.01	5.31	2.4	-	-	0.11	21.32	0.01	0.59	1.98	-	-	0.53	-	-	-	0.54	-	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	61.6
H0524_029_0	2007	10																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1418.91	81.76	760.93		447.83	22.91		942.41	46.45	3624.47	1336.65			51.95	9322.83	2.85	256.07	867.41			261.02				239.04					118.79												300/day	300/day	125/days 21-100		290/trip	twenty five percent		50/ER visit 45 UR visit	250/procedure	35/routine lab	35/x-ray 50/MRIPET CAT Scans			45/visit	45/visit	45/visit	45/visit	45/visit			11/generic 40/brand				45/visit					45/visit												300	300	47.5		290	0.25		48.75	250	35	37.25			45	45	45	45	45			24.31				45					45												35.47	2.04	3.01	-	10.82	5.73	-	3.83	0.97	10.57	4.15	-	-	0.19	34.96	0.01	0.96	3.25	-	-	0.53	-	-	-	0.9	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	117.85			35.47	2.04	3.01	-	10.82	5.73	-	3.83	0.97	10.57	4.15	-	-	0.19	34.96	0.01	0.96	3.25	-	-	0.53	-	-	-	0.9	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	117.85																																																																																				-			35.47	2.04	3.01	-	10.82	5.73	-	3.83	0.97	10.57	4.15	-	-	0.19	34.96	0.01	0.96	3.25	-	-	0.53	-	-	-	0.9	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	117.85
H0524_030_0	2007	6																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		2102.2	96.9	1335.39		634.08	27.42		1073.18	75.91	2371.83	836.08			30.79	11040.39	2.62	344.35	988.97			223.59				232.94					273.91												300/days	300/days	125/days 21-100		290/trip	twenty five percent		50/ER visit 45/UR visit	250/procedure	35/routine lab	35/x-ray 50/MRIPET CAT Scans			45/visit	45/visit	45/visit	45/visit	45/visit			11/generic 40/brand				45/visit					45/visit												300	300	47.5		290	0.25		48.75	250	35	37.25			45	45	45	45	45			17.41				45					45												52.55	2.42	5.29	-	15.32	6.86	-	4.36	1.58	6.92	2.6	-	-	0.12	41.4	0.01	1.29	3.71	-	-	0.32	-	-	-	0.87	-	-	-	-	1.03	-	-	-	-	-	-	-	-	-	-	-	146.65			52.55	2.42	5.29	-	15.32	6.86	-	4.36	1.58	6.92	2.6	-	-	0.12	41.4	0.01	1.29	3.71	-	-	0.32	-	-	-	0.87	-	-	-	-	1.03	-	-	-	-	-	-	-	-	-	-	-	146.65																																																																																				-			52.55	2.42	5.29	-	15.32	6.86	-	4.36	1.58	6.92	2.6	-	-	0.12	41.4	0.01	1.29	3.71	-	-	0.32	-	-	-	0.87	-	-	-	-	1.03	-	-	-	-	-	-	-	-	-	-	-	146.65
H0524_801_0	2007	11																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1379.31	79.48	778.08		362.2	13.43		830.44	79.01	5531.32	2039.87			79.28	14749.53	4.5	405.13	1372.32			277.49				239.04					210.88												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/ER visit 30/UR visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			30/visit	30/visit	30/visit	30/visit	30/visit			11/generic 40/brand				30/visit					30/visit												175	175	47.5		250	0.2		45	125	20	21.5			30	30	30	30	30			26.05				30					30												20.11	1.16	3.08	-	7.55	2.69	-	3.11	0.82	9.22	3.65	-	-	0.2	36.87	0.01	1.01	3.43	-	-	0.6	-	-	-	0.6	-	-	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	94.65			20.11	1.16	3.08	-	7.55	2.69	-	3.11	0.82	9.22	3.65	-	-	0.2	36.87	0.01	1.01	3.43	-	-	0.6	-	-	-	0.6	-	-	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	94.65																																																																																				-			20.11	1.16	3.08	-	7.55	2.69	-	3.11	0.82	9.22	3.65	-	-	0.2	36.87	0.01	1.01	3.43	-	-	0.6	-	-	-	0.6	-	-	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	94.65
H0524_802_0	2007	3																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1650.47	76.08	806.43		368.06	15.27		811	119.65	2921.57	1029.87			37.93	14281.46	3.39	445.43	1279.3			211.15				232.94					370.83												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			35/visit	35/visit	35/visit	35/visit	35/visit			11/generic 40/brand				35/visit					35/visit												175	175	47.5		250	0.2		50	125	20	24.5			35	35	35	35	35			17.41				35					35												24.07	1.11	3.19	-	7.67	3.05	-	3.38	1.25	4.87	2.1	-	-	0.11	41.65	0.01	1.3	3.73	-	-	0.31	-	-	-	0.68	-	-	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	99.56			24.07	1.11	3.19	-	7.67	3.05	-	3.38	1.25	4.87	2.1	-	-	0.11	41.65	0.01	1.3	3.73	-	-	0.31	-	-	-	0.68	-	-	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	99.56																																																																																				-			24.07	1.11	3.19	-	7.67	3.05	-	3.38	1.25	4.87	2.1	-	-	0.11	41.65	0.01	1.3	3.73	-	-	0.31	-	-	-	0.68	-	-	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	99.56
H0524_803_0	2007	10																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1625.29	93.65	840.11		408.34	11.29		803.45	61.09	4462.73	1645.79			63.97	12057.2	3.68	331.18	1121.82			265.79				239.04					227.79												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/ER visit 30/UR visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			30/visit	30/visit	30/visit	30/visit	30/visit			11/generic 40/brand	0			30/visit					0												175	175	47.5		250	0.2		45	125	20	24.5			30	30	30	30	30			26.05				30					30												23.7	1.37	3.33	-	8.51	2.26	-	3.01	0.64	7.44	3.36	-	-	0.16	30.14	0.01	0.83	2.8	-	-	0.58	-	-	-	0.6	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	89.29			23.7	1.37	3.33	-	8.51	2.26	-	3.01	0.64	7.44	3.36	-	-	0.16	30.14	0.01	0.83	2.8	-	-	0.58	-	-	-	0.6	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	89.29																																																																																				-			23.7	1.37	3.33	-	8.51	2.26	-	3.01	0.64	7.44	3.36	-	-	0.16	30.14	0.01	0.83	2.8	-	-	0.58	-	-	-	0.6	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	89.29
H0524_804_0	2007	4																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1812.96	83.57	851.67		435.6	16.16		899.29	122.46	2810.26	990.63			36.48	13570.03	3.23	423.24	1215.57			211.15				232.94					268.65												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			35/visit	35/visit	35/visit	35/visit	35/visit			11/generic 40/brand				35/visit					35/visit												175	175	47.5		250	0.2		50	125	20	24.5			35	35	35	35	35			17.41				35					35												26.44	1.22	3.37	-	9.08	3.23	-	3.75	1.28	4.68	2.02	-	-	0.11	39.58	0.01	1.23	3.55	-	-	0.31	-	-	-	0.68	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	101.31			26.44	1.22	3.37	-	9.08	3.23	-	3.75	1.28	4.68	2.02	-	-	0.11	39.58	0.01	1.23	3.55	-	-	0.31	-	-	-	0.68	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	101.31																																																																																				-			26.44	1.22	3.37	-	9.08	3.23	-	3.75	1.28	4.68	2.02	-	-	0.11	39.58	0.01	1.23	3.55	-	-	0.31	-	-	-	0.68	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	101.31
H0524_805_0	2007	13																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1379.31	79.48	778.08		362.2	13.43		830.44	79.01	5531.32	2039.87			79.28	14749.53	4.5	405.13	1372.32			277.49				239.04					210.88												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/ER visit 30/UR visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			30/visit	30/visit	30/visit	30/visit	30/visit			11/generic 40/brand				30/visit					30/visit												175	175	47.5		250	0.2		45	125	20	21.5			30	30	30	30	30			26.05				30					30												20.11	1.16	3.08	-	7.55	2.69	-	3.11	0.82	9.22	3.65	-	-	0.2	36.87	0.01	1.01	3.43	-	-	0.6	-	-	-	0.6	-	-	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	94.65			20.11	1.16	3.08	-	7.55	2.69	-	3.11	0.82	9.22	3.65	-	-	0.2	36.87	0.01	1.01	3.43	-	-	0.6	-	-	-	0.6	-	-	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	94.65																																																																																				-			20.11	1.16	3.08	-	7.55	2.69	-	3.11	0.82	9.22	3.65	-	-	0.2	36.87	0.01	1.01	3.43	-	-	0.6	-	-	-	0.6	-	-	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	94.65
H0524_806_0	2007	6																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1650.47	76.08	806.43		368.06	15.27		811	119.65	2921.57	1029.87			37.93	14281.46	3.39	445.43	1279.3			211.15				232.94					370.83												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			35/visit	35/visit	35/visit	35/visit	35/visit			11/generic 40/brand				35/visit					35/visit												175	175	47.5		250	0.2		50	125	20	24.5			35	35	35	35	35			17.41				35					35												24.07	1.11	3.19	-	7.67	3.05	-	3.38	1.25	4.87	2.1	-	-	0.11	41.65	0.01	1.3	3.73	-	-	0.31	-	-	-	0.68	-	-	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	99.56			24.07	1.11	3.19	-	7.67	3.05	-	3.38	1.25	4.87	2.1	-	-	0.11	41.65	0.01	1.3	3.73	-	-	0.31	-	-	-	0.68	-	-	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	99.56																																																																																				-			24.07	1.11	3.19	-	7.67	3.05	-	3.38	1.25	4.87	2.1	-	-	0.11	41.65	0.01	1.3	3.73	-	-	0.31	-	-	-	0.68	-	-	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	99.56
H0524_807_0	2007	13																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1625.29	93.65	840.11		408.34	11.29		803.45	61.09	4462.73	1645.79			63.97	12057.2	3.68	331.18	1121.82			265.79				239.04					227.79												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/ER visit 30/UR visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			30/visit	30/visit	30/visit	30/visit	30/visit			11/generic 40/brand				30/visit					30/visit												175	175	47.5		250	0.2		45	125	20	24.5			30	30	30	30	30			26.05				30					30												23.7	1.37	3.33	-	8.51	2.26	-	3.01	0.64	7.44	3.36	-	-	0.16	30.14	0.01	0.83	2.8	-	-	0.58	-	-	-	0.6	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	89.29			23.7	1.37	3.33	-	8.51	2.26	-	3.01	0.64	7.44	3.36	-	-	0.16	30.14	0.01	0.83	2.8	-	-	0.58	-	-	-	0.6	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	89.29																																																																																				-			23.7	1.37	3.33	-	8.51	2.26	-	3.01	0.64	7.44	3.36	-	-	0.16	30.14	0.01	0.83	2.8	-	-	0.58	-	-	-	0.6	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	89.29
H0524_808_0	2007	7																																D	D	D		T	Coin		V	P	V	V			V	V	V	V	V			S				V					V																																																					-		1812.96	83.57	851.67		435.6	16.16		899.29	122.46	2810.26	990.63			36.48	13570.03	3.23	423.24	1215.57			211.15				232.94					268.65												175/day	175/day	125/days 21-100		250/trip	twenty percent		50/visit	125/procedure	20/routine lab	20/x-ray 50/MRIPET CAT Scans			35/visit	35/visit	35/visit	35/visit	35/visit			11/generic 40/brand				35/visit					35/visit												175	175	47.5		250	0.2		50	125	20	24.5			35	35	35	35	35			17.41				35					35												26.44	1.22	3.37	-	9.08	3.23	-	3.75	1.28	4.68	2.02	-	-	0.11	39.58	0.01	1.23	3.55	-	-	0.31	-	-	-	0.68	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	101.31			26.44	1.22	3.37	-	9.08	3.23	-	3.75	1.28	4.68	2.02	-	-	0.11	39.58	0.01	1.23	3.55	-	-	0.31	-	-	-	0.68	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	101.31																																																																																				-			26.44	1.22	3.37	-	9.08	3.23	-	3.75	1.28	4.68	2.02	-	-	0.11	39.58	0.01	1.23	3.55	-	-	0.31	-	-	-	0.68	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	101.31
H0532_001_0	2007	2																					3500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	Coin	V	Coin	V	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	228.11	2.43	0	0	183.25	10.22	6.69	288.39	273.6	0	0	40.57	0	503.95	6237.58	6578.58	163.72	410.24	0	847.43	503.22	749.02	0	0	448.2	0	192.09	0	0	0	0											PBP: 1A IP Acute: 450 per admit	1B IP Psych: 450 per admit	2 SNF: 0	6 Home Health: 0	10A Ambulance: 100	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 20	4A ER: 50 4B Urgent Care: 40	9B ASC Services: 100	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 100	12 Renal Dialysis: 0	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 15 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 20 7D Physician Specialist: 20 7F Podiatry: 20	7E Mental Health: 20 7H Psychiatric: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	Included in i.2.	7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0-20	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non Medicare Covered Comprehensive Dental: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											438.63	438.63	0	0	97.47	0.19	0.19	48.17	97.47	0	0	97.47	0	19.49	14.62	19.49	19.49	19.49	0	19.49	16.67	19.08	0	0	19.49	0	19.49	0	0	0	0											8.34	0.09	-	-	1.49	1.99	1.3	1.16	2.22	-	-	0.33	-	0.82	7.6	10.69	0.27	0.67	-	1.38	0.7	1.19	-	-	0.73	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.27	0	1.07	8.34	0.09	-	-	1.49	1.99	1.3	1.16	2.22	-	-	0.33	-	0.82	7.6	10.69	0.27	0.67	-	1.38	0.7	1.19	-	-	0.73	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.27	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.34	0.09	-	-	1.49	1.99	1.3	1.16	2.22	-	-	0.33	-	0.82	7.6	10.69	0.27	0.67	-	1.38	0.7	1.19	-	-	0.73	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.27
H0532_006_0	2007	5																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	420.19	34.71	76.23	0	11.7	27.6	17.77	622.47	15.79	11.06	22.13	0.72	0.83	30.53	54.79	105.92	8.22	4.27	28.47	35.67	7.14	3.65	0	0	0	0	0	0	0	0	0											6.6 FFS Medicare Actuarially Equivlent Cost Sharing with 925 deductible	6.6 FFS Medicare Actuarially Equivlent Cost Sharing with 925 deductible	14 FFS Medicare Actuarially Equivlent Cost Sharing	0 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	PBP 4A: Emergency Care 50 Copay; 4B Urgent Care: 23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	22.8 FFS Medicare Actuarially Equivlent Cost Sharing	22.7 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	23.6 FFS Medicare Actuarially Equivlent Cost Sharing	10B Transportation: 0	16A Preventive Dental: Not Covered 16B Non-Medicare Covered Comprehensive Dental: Not Covered	17A Routine Vision Exams: 0	17B Eye Wear: Not Covered	18A Routine Hearing Exams: 0	18B Hearing Aids: 500 maximum plan benefit coverage amoutn	N/A	14A Health Education/Wellness: Not Covered	13C1 Personal Emergency Response Device: 0 7F Routine Podiatry: 0											0.07	0.07	0.14	0	0.24	0.24	0.24	48.77	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											27.67	2.29	10.64	-	2.76	6.51	4.19	2.53	3.73	2.61	5.22	0.17	0.2	7.2	12.49	24.03	1.94	1.01	6.72	8.42	1.69	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.88	0	0	27.67	2.29	10.64	-	2.76	6.51	4.19	2.53	3.73	2.61	5.22	0.17	0.2	7.2	12.49	24.03	1.94	1.01	6.72	8.42	1.69	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.88	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	27.67	2.29	10.64	-	2.76	6.51	4.19	2.53	3.73	2.61	5.22	0.17	0.2	7.2	12.49	24.03	1.94	1.01	6.72	8.42	1.69	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.88
H0532_801_0	2007	2																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	248.98	1.42	37.65	44.43	5.02	10.22	6.69	301.68	20.17	6.65	19.26	0.61	0.08	21.47	39.35	96.21	1.22	3.14	30.27	34.9	5.2	5.91	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 6.6 FFS Medicare Actuarially Equivlent Cost Sharing	1B IP Psych: 6.6 FFS Medicare Actuarially Equivlent Cost Sharing	2 SNF: 0 days 1-20 118.70 days 21-100 yields 14.0 actuarially equivalent cost sharing	6 Home Health: 0 FFS Medicare Actuarially Equivlent Cost Sharing	10A Ambulance: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	11A DME: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	11B Prosthetic Medical Supplies 11C Diabetes Monitoring Supplies: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	PBP 4A: Emergency Care 50 Copay; 4B Urgent Care: 23.6 FFS Medicare Actuarially Equivalent Cost Sharing	9B ASC Services: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	8A OP C/D/T: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	8B OP X-Ray: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	9A OP Hospital: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	12 Renal Dialysis: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	3 CORF 5 Partial Hosp 9C OP Substance Abuse 9D Cardiac Rehab: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7A PCP 14B Immunizations 14C Routine Physical Exams 14D Pap Smears 14D Pelvic Exams 14E Prostate Screening 14F Colorectal Screening 14G Bone Mass Measurement 14H Mammography 14I Diabetes Monitoring: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7B Chiropractic 7D Physician Specialist 7F Podiatry: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7E Mental Health 7H Psychiatric: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7C Occupational Therapy 7I Physical and Speech Therapy: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7D Specialist: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7G Other Health Care 18A Medicare Covered Hearing Exams: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	15 Part B Drugs: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	13A Blood 16B Medicare Covered Comprehensive Dental Services 17A Medicare Covered Eye Exams: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non Medicare Covered Comprehensive Dental: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0.07	0.07	0.14	0	0.24	0.24	0.24	49.43	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.32	0.09	5.26	-	1.18	2.41	1.58	1.24	4.76	1.57	4.55	0.14	0.02	5.07	9.29	22.71	0.29	0.74	7.14	8.24	1.23	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.22	0	0	16.32	0.09	5.26	-	1.18	2.41	1.58	1.24	4.76	1.57	4.55	0.14	0.02	5.07	9.29	22.71	0.29	0.74	7.14	8.24	1.23	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.22	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	16.32	0.09	5.26	-	1.18	2.41	1.58	1.24	4.76	1.57	4.55	0.14	0.02	5.07	9.29	22.71	0.29	0.74	7.14	8.24	1.23	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.22
H0532_802_0	2007	2																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	248.98	1.42	37.65	44.43	5.02	10.22	6.69	301.68	20.17	6.65	19.26	0.61	0.08	21.47	39.35	96.21	1.22	3.14	30.27	34.9	5.2	5.91	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 6.6 FFS Medicare Actuarially Equivlent Cost Sharing	1B IP Psych: 6.6 FFS Medicare Actuarially Equivlent Cost Sharing	2 SNF: 0 days 1-20 118.70 days 21-100 yields 14.0 actuarially equivalent cost sharing	6 Home Health: 0 FFS Medicare Actuarially Equivlent Cost Sharing	10A Ambulance: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	11A DME: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	11B Prosthetic Medical Supplies 11C Diabetes Monitoring Supplies: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	PBP 4A: Emergency Care 50 Copay; 4B Urgent Care: 23.6 FFS Medicare Actuarially Equivalent Cost Sharing	9B ASC Services: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	8A OP C/D/T: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	8B OP X-Ray: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	9A OP Hospital: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	12 Renal Dialysis: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	3 CORF 5 Partial Hosp 9C OP Substance Abuse 9D Cardiac Rehab: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7A PCP 14B Immunizations 14C Routine Physical Exams 14D Pap Smears 14D Pelvic Exams 14E Prostate Screening 14F Colorectal Screening 14G Bone Mass Measurement 14H Mammography 14I Diabetes Monitoring: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7B Chiropractic 7D Physician Specialist 7F Podiatry: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7E Mental Health 7H Psychiatric: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7C Occupational Therapy 7I Physical and Speech Therapy: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7D Specialist: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	7G Other Health Care 18A Medicare Covered Hearing Exams: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	15 Part B Drugs: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	13A Blood 16B Medicare Covered Comprehensive Dental Services 17A Medicare Covered Eye Exams: 23.6 FFS Medicare Actuarially Equivlent Cost Sharing	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non Medicare Covered Comprehensive Dental: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0.07	0.07	0.14	0	0.24	0.24	0.24	49.43	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.32	0.09	5.26	-	1.18	2.41	1.58	1.24	4.76	1.57	4.55	0.14	0.02	5.07	9.29	22.71	0.29	0.74	7.14	8.24	1.23	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.22	0	0	16.32	0.09	5.26	-	1.18	2.41	1.58	1.24	4.76	1.57	4.55	0.14	0.02	5.07	9.29	22.71	0.29	0.74	7.14	8.24	1.23	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.22	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	16.32	0.09	5.26	-	1.18	2.41	1.58	1.24	4.76	1.57	4.55	0.14	0.02	5.07	9.29	22.71	0.29	0.74	7.14	8.24	1.23	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.22
H0540_001_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	735.07	9.31	989.2	14.54	191.83	14.32	0.72	359.61	347.28	0	1179.36	0	0.18	682.09	3330.5	4313.13	0.84	440.71	0	205.95	0	572.54	0	0	1.93	0	113.38	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											9.19	0.05	0.49	2.18	1.6	4.3	0.21	1.09	2.89	-	0.73	-	0.03	0.57	2.77	3.59	0.42	0.37	-	0.06	-	0.48	-	-	0.97	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.08	0	0	9.19	0.05	0.49	2.18	1.6	4.3	0.21	1.09	2.89	-	0.73	-	0.03	0.57	2.77	3.59	0.42	0.37	-	0.06	-	0.48	-	-	0.97	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.08	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.19	0.05	0.49	2.18	1.6	4.3	0.21	1.09	2.89	-	0.73	-	0.03	0.57	2.77	3.59	0.42	0.37	-	0.06	-	0.48	-	-	0.97	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.08
H0540_010_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	259.31	2.52	0	0	195.31	14.64	0.71	394.28	357.14	0	1216.76	0	0.18	698.2	3321.75	4360.23	0.86	449.16	0	205.22	0	571.76	0	0	2.11	0	123.68	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.17	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											1.08	0.01	-	-	0.41	2.93	0.14	0.65	0.74	-	0.75	-	0.01	1	2.77	3.63	0.43	0.37	-	0.06	-	0.48	-	-	1.05	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.62	0	0	1.08	0.01	-	-	0.41	2.93	0.14	0.65	0.74	-	0.75	-	0.01	1	2.77	3.63	0.43	0.37	-	0.06	-	0.48	-	-	1.05	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.62	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.08	0.01	-	-	0.41	2.93	0.14	0.65	0.74	-	0.75	-	0.01	1	2.77	3.63	0.43	0.37	-	0.06	-	0.48	-	-	1.05	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.62
H0540_012_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	732.56	8.82	1045.47	24.78	187.78	16.6	0.91	335.62	327.1	0	1075.15	0	0.21	640.15	3647.16	4612.41	0.96	473.85	0	226.63	0	609.6	0	0	1.61	0	93.08	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											9.16	0.04	0.52	3.72	1.56	4.98	0.27	1.02	2.73	-	0.66	-	0.04	0.53	3.04	3.84	0.48	0.39	-	0.07	-	0.51	-	-	0.8	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.44	0	0	9.16	0.04	0.52	3.72	1.56	4.98	0.27	1.02	2.73	-	0.66	-	0.04	0.53	3.04	3.84	0.48	0.39	-	0.07	-	0.51	-	-	0.8	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.44	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.16	0.04	0.52	3.72	1.56	4.98	0.27	1.02	2.73	-	0.66	-	0.04	0.53	3.04	3.84	0.48	0.39	-	0.07	-	0.51	-	-	0.8	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.44
H0540_015_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	829.11	10.72	773.21	24.6	239.95	22.83	1.1	302.77	290.96	0	968.98	0	0.21	561.63	4056.46	5066.65	0.98	453.07	0	247.91	0	680.29	0	0	3.18	0	150.16	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.59	0	10	0	0	0.5	0	10	0	0	0	0											10.36	0.05	0.38	3.69	2	6.85	0.33	0.92	2.42	-	0.6	-	0.04	0.47	3.38	4.22	0.49	0.38	-	0.07	-	0.57	-	-	1.59	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.93	0	0	10.36	0.05	0.38	3.69	2	6.85	0.33	0.92	2.42	-	0.6	-	0.04	0.47	3.38	4.22	0.49	0.38	-	0.07	-	0.57	-	-	1.59	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.93	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.36	0.05	0.38	3.69	2	6.85	0.33	0.92	2.42	-	0.6	-	0.04	0.47	3.38	4.22	0.49	0.38	-	0.07	-	0.57	-	-	1.59	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.93
H0540_016_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	825.01	10.6	764.65	24.62	233.63	21.77	1.05	313.88	301.93	0	1010.23	0	0.21	585.83	4051.74	5093.44	0.98	465.86	0	248.01	0	683.38	0	0	3.13	0	149.36	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											10.31	0.05	0.38	3.69	1.95	6.53	0.32	0.95	2.52	-	0.62	-	0.04	0.49	3.38	4.24	0.49	0.39	-	0.07	-	0.57	-	-	1.57	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.68	0	0	10.31	0.05	0.38	3.69	1.95	6.53	0.32	0.95	2.52	-	0.62	-	0.04	0.49	3.38	4.24	0.49	0.39	-	0.07	-	0.57	-	-	1.57	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.68	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.31	0.05	0.38	3.69	1.95	6.53	0.32	0.95	2.52	-	0.62	-	0.04	0.49	3.38	4.24	0.49	0.39	-	0.07	-	0.57	-	-	1.57	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.68
H0540_017_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	732.28	9.85	1108.82	8.97	189.75	12.71	0.58	361.02	346.01	0	1187.96	0	0.16	673.33	3044.47	4206.84	0.84	466.16	0	188.69	0	532.3	0	0	2.47	0	134.79	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.53	0	10	0	0	0.5	0	10	0	0	0	0											9.15	0.05	0.55	1.35	1.58	3.81	0.17	1.1	2.88	-	0.73	-	0.03	0.56	2.54	3.5	0.42	0.39	-	0.06	-	0.44	-	-	1.23	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66	0	0	9.15	0.05	0.55	1.35	1.58	3.81	0.17	1.1	2.88	-	0.73	-	0.03	0.56	2.54	3.5	0.42	0.39	-	0.06	-	0.44	-	-	1.23	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.15	0.05	0.55	1.35	1.58	3.81	0.17	1.1	2.88	-	0.73	-	0.03	0.56	2.54	3.5	0.42	0.39	-	0.06	-	0.44	-	-	1.23	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66
H0540_020_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	748.4	9.48	998.58	14.39	194.96	14.61	0.71	360.99	356.24	0	1213.12	0	0.18	696.62	3201.54	4145.54	0.86	412.77	0	195.06	10.17	524.11	0	0	1.92	0	112.45	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.71	10	24.95	0.5	25	0	8.6	0.2	25	0	0	0.5	0	25	0	0	0	0											12.47	0.14	1.98	2.16	2.44	4.38	0.21	1.25	2.97	-	0.75	-	0.03	1.43	2.67	8.62	0.43	0.86	-	0.14	2.07	1.09	-	-	0.96	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.29	0	0	12.47	0.14	1.98	2.16	2.44	4.38	0.21	1.25	2.97	-	0.75	-	0.03	1.43	2.67	8.62	0.43	0.86	-	0.14	2.07	1.09	-	-	0.96	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.29	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.47	0.14	1.98	2.16	2.44	4.38	0.21	1.25	2.97	-	0.75	-	0.03	1.43	2.67	8.62	0.43	0.86	-	0.14	2.07	1.09	-	-	0.96	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.29
H0540_021_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	744.09	8.96	1046.06	24.94	190.01	16.86	0.91	333.04	333.33	0	1098.01	0	0.21	650.22	3506.92	4421.01	0.97	441.77	0	214.88	10.09	559.25	0	0	1.57	0	90.95	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.66	10	24.95	0.5	25	0	8.59	0.2	25	0	0	0.5	0	25	0	0	0	0											12.4	0.13	2.08	3.74	2.38	5.06	0.27	1.15	2.78	-	0.68	-	0.04	1.34	2.92	9.19	0.49	0.92	-	0.15	2.06	1.17	-	-	0.79	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.91	0	0	12.4	0.13	2.08	3.74	2.38	5.06	0.27	1.15	2.78	-	0.68	-	0.04	1.34	2.92	9.19	0.49	0.92	-	0.15	2.06	1.17	-	-	0.79	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.91	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.4	0.13	2.08	3.74	2.38	5.06	0.27	1.15	2.78	-	0.68	-	0.04	1.34	2.92	9.19	0.49	0.92	-	0.15	2.06	1.17	-	-	0.79	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.91
H0540_023_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	747.44	10.32	1129.7	8.35	193.11	12.99	0.57	363.89	355.84	0	1226.16	0	0.16	688.85	2906.01	4035.63	0.86	444.42	0	177.5	10.66	483.58	0	0	2.47	0	134.8	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.7	10	24.95	0.5	23.07	0	8.52	0.2	25	0	0	0.5	0	25	0	0	0	0											12.46	0.15	2.24	1.25	2.41	3.9	0.17	1.26	2.97	-	0.75	-	0.03	1.42	2.42	8.39	0.43	0.85	-	0.13	2.18	1.01	-	-	1.23	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.93	0	0	12.46	0.15	2.24	1.25	2.41	3.9	0.17	1.26	2.97	-	0.75	-	0.03	1.42	2.42	8.39	0.43	0.85	-	0.13	2.18	1.01	-	-	1.23	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.93	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.46	0.15	2.24	1.25	2.41	3.9	0.17	1.26	2.97	-	0.75	-	0.03	1.42	2.42	8.39	0.43	0.85	-	0.13	2.18	1.01	-	-	1.23	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.93
H0540_024_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	848.78	10.88	763.42	24.72	245.94	23.5	1.11	299.52	295.34	0	986.92	0	0.21	567.91	3935.77	4894.68	0.99	422.25	0	236.78	8.27	629.69	0	0	3.1	0	146.56	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.63	10	24.96	0.5	25	0	8.71	0.2	25	0	0	0.5	0	25	0	0	0	0											14.15	0.16	1.52	3.71	3.07	7.05	0.33	1.04	2.46	-	0.61	-	0.04	1.17	3.28	10.18	0.49	0.88	-	0.17	1.69	1.31	-	-	1.55	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.16	0	0	14.15	0.16	1.52	3.71	3.07	7.05	0.33	1.04	2.46	-	0.61	-	0.04	1.17	3.28	10.18	0.49	0.88	-	0.17	1.69	1.31	-	-	1.55	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.16	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.15	0.16	1.52	3.71	3.07	7.05	0.33	1.04	2.46	-	0.61	-	0.04	1.17	3.28	10.18	0.49	0.88	-	0.17	1.69	1.31	-	-	1.55	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.16
H0540_025_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	845.52	10.79	755.23	24.78	239.68	22.44	1.06	311.71	307.28	0	1031.57	0	0.21	593.52	3934.39	4928.96	1	435.51	0	237.01	9.13	633.06	0	0	3.08	0	146.91	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.63	10	24.96	0.5	25	0	8.68	0.2	25	0	0	0.5	0	25	0	0	0	0											14.09	0.16	1.5	3.72	3	6.73	0.32	1.08	2.56	-	0.63	-	0.04	1.22	3.28	10.25	0.5	0.91	-	0.17	1.86	1.32	-	-	1.54	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.18	0	0	14.09	0.16	1.5	3.72	3	6.73	0.32	1.08	2.56	-	0.63	-	0.04	1.22	3.28	10.25	0.5	0.91	-	0.17	1.86	1.32	-	-	1.54	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.18	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.09	0.16	1.5	3.72	3	6.73	0.32	1.08	2.56	-	0.63	-	0.04	1.22	3.28	10.25	0.5	0.91	-	0.17	1.86	1.32	-	-	1.54	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.18
H0540_028_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	813.15	10.57	1513.4	29.42	204.03	19.33	0.88	476.37	468.25	0	1552.45	0	0.2	876.76	3599.94	4672.72	0.99	444.16	0	217.67	9.31	565.49	0	0	2.64	0	142.55	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.75	10	24.96	0.5	25	0	8.64	0.2	25	0	0	0.5	0	25	0	0	0	0											13.55	0.16	3.01	4.41	2.55	5.8	0.26	1.65	3.9	-	0.95	-	0.03	1.81	3	9.72	0.5	0.93	-	0.16	1.9	1.18	-	-	1.32	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.08	0	0	13.55	0.16	3.01	4.41	2.55	5.8	0.26	1.65	3.9	-	0.95	-	0.03	1.81	3	9.72	0.5	0.93	-	0.16	1.9	1.18	-	-	1.32	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.08	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	13.55	0.16	3.01	4.41	2.55	5.8	0.26	1.65	3.9	-	0.95	-	0.03	1.81	3	9.72	0.5	0.93	-	0.16	1.9	1.18	-	-	1.32	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.08
H0540_029_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	255.21	2.36	0	0	187.95	16.62	0.91	361.81	327.52	0	1076.7	0	0.21	640.92	3647.14	4615	0.96	474.35	0	226.62	0	609.6	0	0	1.61	0	93.5	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.03	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											1.06	0.01	-	-	0.39	3.32	0.18	0.6	0.68	-	0.66	-	0.01	0.91	3.04	3.84	0.48	0.4	-	0.07	-	0.51	-	-	0.81	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.05	0	0	1.06	0.01	-	-	0.39	3.32	0.18	0.6	0.68	-	0.66	-	0.01	0.91	3.04	3.84	0.48	0.4	-	0.07	-	0.51	-	-	0.81	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.05	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.06	0.01	-	-	0.39	3.32	0.18	0.6	0.68	-	0.66	-	0.01	0.91	3.04	3.84	0.48	0.4	-	0.07	-	0.51	-	-	0.81	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.05
H0540_032_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	262.07	2.6	0	0	197.39	14.84	0.71	401.54	363.14	0	1239.3	0	0.18	707.94	3316.87	4389.15	0.86	454.31	0	204.76	0	571.17	0	0	2.21	0	129.92	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.19	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											1.09	0.01	-	-	0.41	2.97	0.14	0.67	0.76	-	0.76	-	0.01	1.01	2.76	3.65	0.43	0.38	-	0.06	-	0.48	-	-	1.11	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.81	0	0	1.09	0.01	-	-	0.41	2.97	0.14	0.67	0.76	-	0.76	-	0.01	1.01	2.76	3.65	0.43	0.38	-	0.06	-	0.48	-	-	1.11	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.81	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.09	0.01	-	-	0.41	2.97	0.14	0.67	0.76	-	0.76	-	0.01	1.01	2.76	3.65	0.43	0.38	-	0.06	-	0.48	-	-	1.11	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.81
H0540_033_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	257.25	2.35	0	0	189.23	16.77	0.91	366.41	331.19	0	1090.19	0	0.21	646.84	3649.16	4640.21	0.97	478.7	0	226.74	0	609.89	0	0	1.68	0	97.13	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.04	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											1.07	0.01	-	-	0.39	3.35	0.18	0.61	0.69	-	0.67	-	0.01	0.92	3.04	3.86	0.48	0.4	-	0.07	-	0.51	-	-	0.84	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.19	0	0	1.07	0.01	-	-	0.39	3.35	0.18	0.61	0.69	-	0.67	-	0.01	0.92	3.04	3.86	0.48	0.4	-	0.07	-	0.51	-	-	0.84	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.19	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.07	0.01	-	-	0.39	3.35	0.18	0.61	0.69	-	0.67	-	0.01	0.92	3.04	3.86	0.48	0.4	-	0.07	-	0.51	-	-	0.84	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.19
H0540_036_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	858.06	11	1075.95	24.89	243.67	19.61	0.95	318.33	307.02	0	1035.13	0	0.18	600.68	3618.69	4611.05	0.84	443.9	0	222.55	0	617.42	0	0	2.25	0	129.69	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.57	0	10	0	0	0.5	0	10	0	0	0	0											10.73	0.05	0.53	3.73	2.03	5.88	0.29	0.97	2.56	-	0.64	-	0.03	0.5	3.02	3.84	0.42	0.37	-	0.07	-	0.51	-	-	1.12	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.4	0	0	10.73	0.05	0.53	3.73	2.03	5.88	0.29	0.97	2.56	-	0.64	-	0.03	0.5	3.02	3.84	0.42	0.37	-	0.07	-	0.51	-	-	1.12	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.4	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.73	0.05	0.53	3.73	2.03	5.88	0.29	0.97	2.56	-	0.64	-	0.03	0.5	3.02	3.84	0.42	0.37	-	0.07	-	0.51	-	-	1.12	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.4
H0540_040_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	873.19	10.97	1076.48	25.2	248.16	20.04	0.96	314.75	310.85	0	1050.26	0	0.18	606.48	3493.75	4427.45	0.85	412.74	0	211.7	8.96	568.17	0	0	2.16	0	124.7	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.65	10	24.96	0.5	25	0	8.65	0.2	25	0	0	0.5	0	25	0	0	0	0											14.55	0.16	2.14	3.78	3.1	6.01	0.29	1.09	2.59	-	0.65	-	0.03	1.25	2.91	9.21	0.42	0.86	-	0.15	1.83	1.18	-	-	1.08	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.55	0	0	14.55	0.16	2.14	3.78	3.1	6.01	0.29	1.09	2.59	-	0.65	-	0.03	1.25	2.91	9.21	0.42	0.86	-	0.15	1.83	1.18	-	-	1.08	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.55	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.55	0.16	2.14	3.78	3.1	6.01	0.29	1.09	2.59	-	0.65	-	0.03	1.25	2.91	9.21	0.42	0.86	-	0.15	1.83	1.18	-	-	1.08	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.55
H0540_044_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	788.87	10.66	1217.37	11.79	215.15	15.93	0.71	371.56	355.33	0	1222.45	0	0.17	687.37	3610.66	4640.5	0.83	420.33	0	219.89	0	614.52	0	0	3.29	0	163.05	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.59	0	10	0	0	0.5	0	10	0	0	0	0											9.86	0.05	0.6	1.77	1.79	4.78	0.21	1.13	2.96	-	0.75	-	0.03	0.57	3.01	3.86	0.41	0.35	-	0.07	-	0.51	-	-	1.64	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.51	0	0	9.86	0.05	0.6	1.77	1.79	4.78	0.21	1.13	2.96	-	0.75	-	0.03	0.57	3.01	3.86	0.41	0.35	-	0.07	-	0.51	-	-	1.64	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.51	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.86	0.05	0.6	1.77	1.79	4.78	0.21	1.13	2.96	-	0.75	-	0.03	0.57	3.01	3.86	0.41	0.35	-	0.07	-	0.51	-	-	1.64	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.51
H0540_045_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	858.64	10.78	1327.9	21.6	219.24	19.59	0.97	391.02	376.2	0	1241.39	0	0.21	718.18	4041.07	5094.7	1	479.5	0	248.19	0	670.91	0	0	2.77	0	137.98	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											10.73	0.05	0.66	3.24	1.83	5.88	0.29	1.19	3.14	-	0.76	-	0.04	0.6	3.37	4.24	0.5	0.4	-	0.07	-	0.56	-	-	1.39	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.04	0	0	10.73	0.05	0.66	3.24	1.83	5.88	0.29	1.19	3.14	-	0.76	-	0.04	0.6	3.37	4.24	0.5	0.4	-	0.07	-	0.56	-	-	1.39	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.04	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.73	0.05	0.66	3.24	1.83	5.88	0.29	1.19	3.14	-	0.76	-	0.04	0.6	3.37	4.24	0.5	0.4	-	0.07	-	0.56	-	-	1.39	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.04
H0540_048_0	2007	8																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	809.16	10.97	1246.18	11.41	220.72	16.41	0.71	375.19	366.14	0	1264.23	0	0.17	704.35	3498.28	4498.09	0.84	393.63	0	209.37	9.92	566.29	0	0	3.3	0	163.48	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.74	10	24.96	0.5	25	0	8.7	0.2	25	0	0	0.5	0	25	0	0	0	0											13.49	0.16	2.48	1.71	2.76	4.92	0.21	1.3	3.05	-	0.78	-	0.03	1.45	2.91	9.36	0.42	0.82	-	0.15	2.03	1.18	-	-	1.65	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.2	0	0	13.49	0.16	2.48	1.71	2.76	4.92	0.21	1.3	3.05	-	0.78	-	0.03	1.45	2.91	9.36	0.42	0.82	-	0.15	2.03	1.18	-	-	1.65	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.2	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	13.49	0.16	2.48	1.71	2.76	4.92	0.21	1.3	3.05	-	0.78	-	0.03	1.45	2.91	9.36	0.42	0.82	-	0.15	2.03	1.18	-	-	1.65	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.2
H0540_049_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	860.46	10.69	1305.13	21.6	219.61	19.63	0.97	380.1	377.02	0	1244.48	0	0.21	719.64	3882.06	4844.37	1	440.46	0	235.05	8.53	615.37	0	0	2.56	0	127.19	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.7	10	24.96	0.5	25	0	8.67	0.2	25	0	0	0.5	0	25	0	0	0	0											14.34	0.16	2.59	3.24	2.75	5.89	0.29	1.32	3.14	-	0.77	-	0.04	1.48	3.23	10.08	0.5	0.92	-	0.17	1.74	1.28	-	-	1.28	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.46	0	0	14.34	0.16	2.59	3.24	2.75	5.89	0.29	1.32	3.14	-	0.77	-	0.04	1.48	3.23	10.08	0.5	0.92	-	0.17	1.74	1.28	-	-	1.28	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.46	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.34	0.16	2.59	3.24	2.75	5.89	0.29	1.32	3.14	-	0.77	-	0.04	1.48	3.23	10.08	0.5	0.92	-	0.17	1.74	1.28	-	-	1.28	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.46
H0540_054_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	264.65	2.81	0	0	195.58	13.2	0.56	403.94	362.96	0	1253.72	0	0.16	700.12	2993.19	4279.76	0.86	485.23	0	185.21	0	524.04	0	0	2.85	0	156.01	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.27	10	9.99	0.5	10	0	3.52	0	10	0	0	0.5	0	10	0	0	0	0											1.1	0.01	-	-	0.41	2.64	0.11	0.67	0.76	-	0.77	-	0.01	1.01	2.49	3.56	0.43	0.4	-	0.05	-	0.44	-	-	1.43	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.43	0	0	1.1	0.01	-	-	0.41	2.64	0.11	0.67	0.76	-	0.77	-	0.01	1.01	2.49	3.56	0.43	0.4	-	0.05	-	0.44	-	-	1.43	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.43	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.1	0.01	-	-	0.41	2.64	0.11	0.67	0.76	-	0.77	-	0.01	1.01	2.49	3.56	0.43	0.4	-	0.05	-	0.44	-	-	1.43	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.43
H0540_056_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	268.17	2.87	0	0	198.18	13.42	0.56	413.27	370.57	0	1282.99	0	0.16	712.06	2970.45	4312.83	0.88	493.86	0	183.7	0	520.35	0	0	3.03	0	165.61	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.29	10	9.99	0.5	10	0	3.51	0	10	0	0	0.5	0	10	0	0	0	0											1.12	0.01	-	-	0.41	2.68	0.11	0.69	0.77	-	0.79	-	0.01	1.03	2.47	3.59	0.44	0.41	-	0.05	-	0.43	-	-	1.51	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.68	0	0	1.12	0.01	-	-	0.41	2.68	0.11	0.69	0.77	-	0.79	-	0.01	1.03	2.47	3.59	0.44	0.41	-	0.05	-	0.43	-	-	1.51	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.68	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.12	0.01	-	-	0.41	2.68	0.11	0.69	0.77	-	0.79	-	0.01	1.03	2.47	3.59	0.44	0.41	-	0.05	-	0.43	-	-	1.51	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.68
H0540_060_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	274.86	2.74	0	0	242.18	23.07	1.1	328.07	292.51	0	975.57	0	0.21	563.88	4070.87	5096.37	0.98	455.57	0	248.63	0	682.71	0	0	3.25	0	153.71	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.13	10	9.99	0.5	10	0	3.59	0	10	0	0	0.5	0	10	0	0	0	0											1.15	0.01	-	-	0.5	4.61	0.22	0.54	0.61	-	0.6	-	0.01	0.8	3.39	4.24	0.49	0.38	-	0.07	-	0.57	-	-	1.63	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.97	0	0	1.15	0.01	-	-	0.5	4.61	0.22	0.54	0.61	-	0.6	-	0.01	0.8	3.39	4.24	0.49	0.38	-	0.07	-	0.57	-	-	1.63	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.97	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.15	0.01	-	-	0.5	4.61	0.22	0.54	0.61	-	0.6	-	0.01	0.8	3.39	4.24	0.49	0.38	-	0.07	-	0.57	-	-	1.63	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.97
H0540_061_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	272.12	2.75	0	0	238.92	22.72	1.1	324.85	290.19	0	965.95	0	0.21	560.54	4049.4	5052.21	0.97	451.86	0	247.5	0	679.18	0	0	3.14	0	148.51	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.11	10	9.99	0.5	10	0	3.59	0	10	0	0	0.5	0	10	0	0	0	0											1.13	0.01	-	-	0.5	4.54	0.22	0.54	0.6	-	0.59	-	0.01	0.8	3.37	4.21	0.49	0.38	-	0.07	-	0.57	-	-	1.57	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.74	0	0	1.13	0.01	-	-	0.5	4.54	0.22	0.54	0.6	-	0.59	-	0.01	0.8	3.37	4.21	0.49	0.38	-	0.07	-	0.57	-	-	1.57	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.74	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.13	0.01	-	-	0.5	4.54	0.22	0.54	0.6	-	0.59	-	0.01	0.8	3.37	4.21	0.49	0.38	-	0.07	-	0.57	-	-	1.57	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.74
H0540_062_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	275	2.74	0	0	232.89	21.69	1.05	336.11	301.36	0	1007.72	0	0.21	585.06	4046.58	5082.5	0.98	464.84	0	247.76	0	682.48	0	0	3.11	0	148.08	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.11	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											1.15	0.01	-	-	0.49	4.34	0.21	0.56	0.63	-	0.62	-	0.01	0.83	3.37	4.23	0.49	0.39	-	0.07	-	0.57	-	-	1.55	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.64	0	0	1.15	0.01	-	-	0.49	4.34	0.21	0.56	0.63	-	0.62	-	0.01	0.83	3.37	4.23	0.49	0.39	-	0.07	-	0.57	-	-	1.55	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.64	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.15	0.01	-	-	0.49	4.34	0.21	0.56	0.63	-	0.62	-	0.01	0.83	3.37	4.23	0.49	0.39	-	0.07	-	0.57	-	-	1.55	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.64
H0540_064_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	277.83	2.73	0	0	235.84	22.02	1.05	339.64	303.91	0	1018.15	0	0.21	588.68	4066.58	5126.45	0.99	468.9	0	248.81	0	686.09	0	0	3.22	0	153.41	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.13	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											1.16	0.01	-	-	0.49	4.4	0.21	0.56	0.63	-	0.63	-	0.01	0.84	3.39	4.27	0.49	0.39	-	0.07	-	0.57	-	-	1.61	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.87	0	0	1.16	0.01	-	-	0.49	4.4	0.21	0.56	0.63	-	0.63	-	0.01	0.84	3.39	4.27	0.49	0.39	-	0.07	-	0.57	-	-	1.61	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.87	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.16	0.01	-	-	0.49	4.4	0.21	0.56	0.63	-	0.63	-	0.01	0.84	3.39	4.27	0.49	0.39	-	0.07	-	0.57	-	-	1.61	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.87
H0540_066_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	722.09	9.32	769.8	24.73	309.87	31.85	1.51	351.99	336.99	0	1110.38	0	0.2	636.91	3295.05	4224.52	0.95	407.28	0	202.48	0	543.3	0	0	2.61	0	119.66	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.57	0	10	0	0	0.5	0	10	0	0	0	0											9.03	0.05	0.38	3.71	2.58	9.56	0.45	1.07	2.81	-	0.68	-	0.03	0.53	2.75	3.52	0.48	0.34	-	0.06	-	0.45	-	-	1.3	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.88	0	0	9.03	0.05	0.38	3.71	2.58	9.56	0.45	1.07	2.81	-	0.68	-	0.03	0.53	2.75	3.52	0.48	0.34	-	0.06	-	0.45	-	-	1.3	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.88	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.03	0.05	0.38	3.71	2.58	9.56	0.45	1.07	2.81	-	0.68	-	0.03	0.53	2.75	3.52	0.48	0.34	-	0.06	-	0.45	-	-	1.3	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.88
H0540_067_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	712.33	8.56	717.69	27.23	228.69	23.72	1.18	216.38	209.98	0	681.91	0	0.21	408.66	3372.43	4408.04	1	466.49	0	209.42	0	557.63	0	0	2.05	0	105.36	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.54	0	10	0	0	0.5	0	10	0	0	0	0											8.9	0.04	0.36	4.08	1.91	7.12	0.36	0.66	1.75	-	0.42	-	0.04	0.34	2.81	3.67	0.5	0.39	-	0.06	-	0.46	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.97	0	0	8.9	0.04	0.36	4.08	1.91	7.12	0.36	0.66	1.75	-	0.42	-	0.04	0.34	2.81	3.67	0.5	0.39	-	0.06	-	0.46	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.97	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.9	0.04	0.36	4.08	1.91	7.12	0.36	0.66	1.75	-	0.42	-	0.04	0.34	2.81	3.67	0.5	0.39	-	0.06	-	0.46	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.97
H0540_069_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	739.82	9.72	759.38	24.7	323	33.29	1.55	351.99	346.63	0	1146.29	0	0.2	652.41	3155.18	4042.57	0.96	378.12	0	190.83	6.6	496.25	0	0	2.58	0	118.14	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.72	10	24.96	0.5	25	0	8.65	0.2	25	0	0	0.5	0	25	0	0	0	0											12.33	0.15	1.51	3.71	4.04	9.99	0.46	1.22	2.89	-	0.7	-	0.03	1.34	2.63	8.41	0.48	0.79	-	0.14	1.35	1.03	-	-	1.29	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.73	0	0	12.33	0.15	1.51	3.71	4.04	9.99	0.46	1.22	2.89	-	0.7	-	0.03	1.34	2.63	8.41	0.48	0.79	-	0.14	1.35	1.03	-	-	1.29	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.73	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.33	0.15	1.51	3.71	4.04	9.99	0.46	1.22	2.89	-	0.7	-	0.03	1.34	2.63	8.41	0.48	0.79	-	0.14	1.35	1.03	-	-	1.29	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.73
H0540_070_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	724.37	8.73	704.39	27.31	233.51	24.28	1.19	210.37	209.88	0	684.27	0	0.22	407.51	3236.55	4212.41	1.01	433.97	0	198.2	5.85	510.88	0	0	1.98	0	101.72	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.48	10	24.95	0.5	25	0	8.58	0.2	25	0	0	0.5	0	25	0	0	0	0											12.07	0.13	1.4	4.1	2.92	7.28	0.36	0.73	1.75	-	0.42	-	0.04	0.83	2.7	8.76	0.51	0.9	-	0.14	1.19	1.06	-	-	0.99	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.49	0	0	12.07	0.13	1.4	4.1	2.92	7.28	0.36	0.73	1.75	-	0.42	-	0.04	0.83	2.7	8.76	0.51	0.9	-	0.14	1.19	1.06	-	-	0.99	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.49	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.07	0.13	1.4	4.1	2.92	7.28	0.36	0.73	1.75	-	0.42	-	0.04	0.83	2.7	8.76	0.51	0.9	-	0.14	1.19	1.06	-	-	0.99	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.49
H0540_072_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	239.85	2.34	0	0	306.84	31.53	1.5	378.84	334.91	0	1102.25	0	0.2	633.39	3296.57	4215.89	0.95	406.11	0	202.67	0	543.81	0	0	2.56	0	117.58	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.17	10	9.99	0.5	10	0	3.57	0	10	0	0	0.5	0	10	0	0	0	0											1	0.01	-	-	0.64	6.31	0.3	0.63	0.7	-	0.68	-	0.01	0.91	2.75	3.51	0.48	0.34	-	0.06	-	0.45	-	-	1.28	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.14	0	0	1	0.01	-	-	0.64	6.31	0.3	0.63	0.7	-	0.68	-	0.01	0.91	2.75	3.51	0.48	0.34	-	0.06	-	0.45	-	-	1.28	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.14	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1	0.01	-	-	0.64	6.31	0.3	0.63	0.7	-	0.68	-	0.01	0.91	2.75	3.51	0.48	0.34	-	0.06	-	0.45	-	-	1.28	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.14
H0540_073_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	226.85	2.16	0	0	228.6	23.72	1.18	234.54	209.98	0	681.91	0	0.21	408.66	3372.41	4407.88	1	466.46	0	209.41	0	557.63	0	0	2.05	0	105.33	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	16.97	10	9.99	0.5	10	0	3.54	0	10	0	0	0.5	0	10	0	0	0	0											0.95	0.01	-	-	0.48	4.74	0.24	0.39	0.44	-	0.42	-	0.01	0.58	2.81	3.67	0.5	0.39	-	0.06	-	0.46	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.26	0	0	0.95	0.01	-	-	0.48	4.74	0.24	0.39	0.44	-	0.42	-	0.01	0.58	2.81	3.67	0.5	0.39	-	0.06	-	0.46	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.26	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0.95	0.01	-	-	0.48	4.74	0.24	0.39	0.44	-	0.42	-	0.01	0.58	2.81	3.67	0.5	0.39	-	0.06	-	0.46	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.26
H0540_075_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	243.46	2.43	0	0	317.05	32.65	1.53	388.42	342.37	0	1130.13	0	0.2	645.47	3291.41	4245.95	0.96	410.15	0	202.14	0	542.28	0	0	2.72	0	124.74	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.19	10	9.99	0.5	10	0	3.57	0	10	0	0	0.5	0	10	0	0	0	0											1.01	0.01	-	-	0.66	6.53	0.31	0.64	0.71	-	0.69	-	0.01	0.92	2.74	3.54	0.48	0.34	-	0.06	-	0.45	-	-	1.36	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.59	0	0	1.01	0.01	-	-	0.66	6.53	0.31	0.64	0.71	-	0.69	-	0.01	0.92	2.74	3.54	0.48	0.34	-	0.06	-	0.45	-	-	1.36	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.59	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.01	0.01	-	-	0.66	6.53	0.31	0.64	0.71	-	0.69	-	0.01	0.92	2.74	3.54	0.48	0.34	-	0.06	-	0.45	-	-	1.36	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.59
H0540_076_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	229.01	2.25	0	0	232.94	24.22	1.19	235.22	209.88	0	683.99	0	0.22	407.59	3373.54	4442.29	1.01	472.66	0	209.44	0	557.32	0	0	2.14	0	110.36	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	16.98	10	9.99	0.5	10	0	3.54	0	10	0	0	0.5	0	10	0	0	0	0											0.95	0.01	-	-	0.49	4.84	0.24	0.39	0.44	-	0.42	-	0.01	0.58	2.81	3.7	0.51	0.39	-	0.06	-	0.46	-	-	1.07	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.47	0	0	0.95	0.01	-	-	0.49	4.84	0.24	0.39	0.44	-	0.42	-	0.01	0.58	2.81	3.7	0.51	0.39	-	0.06	-	0.46	-	-	1.07	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.47	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0.95	0.01	-	-	0.49	4.84	0.24	0.39	0.44	-	0.42	-	0.01	0.58	2.81	3.7	0.51	0.39	-	0.06	-	0.46	-	-	1.07	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.47
H0540_078_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	659.01	8.54	878.7	19.97	283.12	25.34	1.22	452.47	433.66	0	1428.37	0	0.14	815.08	3097.25	3886.23	0.67	359.67	0	189.91	0	511.29	0	0	1.77	0	106.22	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.45	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											8.24	0.04	0.44	2.99	2.36	7.6	0.36	1.37	3.61	-	0.88	-	0.02	0.68	2.58	3.24	0.34	0.3	-	0.06	-	0.43	-	-	0.89	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.52	0	0	8.24	0.04	0.44	2.99	2.36	7.6	0.36	1.37	3.61	-	0.88	-	0.02	0.68	2.58	3.24	0.34	0.3	-	0.06	-	0.43	-	-	0.89	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.52	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.24	0.04	0.44	2.99	2.36	7.6	0.36	1.37	3.61	-	0.88	-	0.02	0.68	2.58	3.24	0.34	0.3	-	0.06	-	0.43	-	-	0.89	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.52
H0540_079_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	751.51	9.53	1054.27	27.04	266.86	27.09	1.32	349.31	335.74	0	1103.95	0	0.22	640.06	3804.16	4903.97	1.04	487.46	0	234.49	0	628.71	0	0	2.59	0	131.54	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.56	0	10	0	0	0.5	0	10	0	0	0	0											9.39	0.05	0.52	4.06	2.22	8.13	0.39	1.06	2.8	-	0.68	-	0.04	0.53	3.17	4.08	0.52	0.41	-	0.07	-	0.52	-	-	1.29	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.05	0	0	9.39	0.05	0.52	4.06	2.22	8.13	0.39	1.06	2.8	-	0.68	-	0.04	0.53	3.17	4.08	0.52	0.41	-	0.07	-	0.52	-	-	1.29	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.05	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.39	0.05	0.52	4.06	2.22	8.13	0.39	1.06	2.8	-	0.68	-	0.04	0.53	3.17	4.08	0.52	0.41	-	0.07	-	0.52	-	-	1.29	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.05
H0540_080_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	676.15	8.9	879.87	19.94	296.35	26.6	1.25	460.09	453.98	0	1499.62	0	0.14	850.29	2966.61	3721.33	0.67	333.06	0	179.01	8.1	467.14	0	0	1.77	0	105.76	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.81	10	24.96	0.5	24.8	0	8.68	0.2	25	0	0	0.5	0	25	0	0	0	0											11.27	0.13	1.75	2.99	3.7	7.98	0.38	1.59	3.78	-	0.92	-	0.02	1.76	2.47	7.74	0.34	0.69	-	0.13	1.65	0.97	-	-	0.88	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.38	0	0	11.27	0.13	1.75	2.99	3.7	7.98	0.38	1.59	3.78	-	0.92	-	0.02	1.76	2.47	7.74	0.34	0.69	-	0.13	1.65	0.97	-	-	0.88	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.38	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.27	0.13	1.75	2.99	3.7	7.98	0.38	1.59	3.78	-	0.92	-	0.02	1.76	2.47	7.74	0.34	0.69	-	0.13	1.65	0.97	-	-	0.88	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.38
H0540_081_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	772.32	9.77	1061.43	27.1	277.34	28.25	1.34	349.91	345.75	0	1141.29	0	0.22	656.39	3680.71	4739.01	1.07	457.9	0	223.43	8.07	580.38	0	0	2.57	0	130.67	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.66	10	24.96	0.5	25	0	8.62	0.2	25	0	0	0.5	0	25	0	0	0	0											12.87	0.15	2.11	4.07	3.47	8.48	0.4	1.21	2.88	-	0.7	-	0.04	1.35	3.07	9.86	0.53	0.95	-	0.16	1.65	1.21	-	-	1.28	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.7	0	0	12.87	0.15	2.11	4.07	3.47	8.48	0.4	1.21	2.88	-	0.7	-	0.04	1.35	3.07	9.86	0.53	0.95	-	0.16	1.65	1.21	-	-	1.28	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.7	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.87	0.15	2.11	4.07	3.47	8.48	0.4	1.21	2.88	-	0.7	-	0.04	1.35	3.07	9.86	0.53	0.95	-	0.16	1.65	1.21	-	-	1.28	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.7
H0540_082_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	234.52	2.34	0	0	284.45	25.46	1.22	492.79	435.65	0	1435.17	0	0.14	818.39	3096.73	3889.64	0.67	360.04	0	189.86	0	511.09	0	0	1.79	0	107.1	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.22	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											0.98	0.01	-	-	0.59	5.09	0.24	0.82	0.91	-	0.88	-	0.01	1.17	2.58	3.24	0.34	0.3	-	0.06	-	0.43	-	-	0.89	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.63	0	0	0.98	0.01	-	-	0.59	5.09	0.24	0.82	0.91	-	0.88	-	0.01	1.17	2.58	3.24	0.34	0.3	-	0.06	-	0.43	-	-	0.89	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.63	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0.98	0.01	-	-	0.59	5.09	0.24	0.82	0.91	-	0.88	-	0.01	1.17	2.58	3.24	0.34	0.3	-	0.06	-	0.43	-	-	0.89	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.63
H0540_083_0	2007	4																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	260.94	2.52	0	0	264.34	26.82	1.31	375.29	333.31	0	1095.06	0	0.22	636.07	3796.58	4881.32	1.04	484.61	0	234.13	0	627.6	0	0	2.54	0	128.92	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.12	10	9.99	0.5	10	0	3.56	0	10	0	0	0.5	0	10	0	0	0	0											1.09	0.01	-	-	0.55	5.36	0.26	0.62	0.69	-	0.67	-	0.01	0.91	3.16	4.06	0.52	0.4	-	0.07	-	0.52	-	-	1.27	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.3	0	0	1.09	0.01	-	-	0.55	5.36	0.26	0.62	0.69	-	0.67	-	0.01	0.91	3.16	4.06	0.52	0.4	-	0.07	-	0.52	-	-	1.27	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.3	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.09	0.01	-	-	0.55	5.36	0.26	0.62	0.69	-	0.67	-	0.01	0.91	3.16	4.06	0.52	0.4	-	0.07	-	0.52	-	-	1.27	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.3
H0540_084_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	239.85	2.43	0	0	296.82	26.65	1.25	515.9	454.73	0	1502.27	0	0.14	851.61	3091.82	3922.81	0.67	363.49	0	189.27	0	509.51	0	0	1.93	0	115.72	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.24	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											1	0.01	-	-	0.62	5.33	0.25	0.86	0.95	-	0.92	-	0.01	1.22	2.58	3.27	0.34	0.3	-	0.06	-	0.42	-	-	0.97	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.19	0	0	1	0.01	-	-	0.62	5.33	0.25	0.86	0.95	-	0.92	-	0.01	1.22	2.58	3.27	0.34	0.3	-	0.06	-	0.42	-	-	0.97	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.19	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1	0.01	-	-	0.62	5.33	0.25	0.86	0.95	-	0.92	-	0.01	1.22	2.58	3.27	0.34	0.3	-	0.06	-	0.42	-	-	0.97	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.19
H0540_085_0	2007	7																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	265.3	2.61	0	0	271.45	27.6	1.33	383.94	340.14	0	1120.23	0	0.22	647.28	3817.97	4945.36	1.05	492.71	0	235.25	0	630.63	0	0	2.68	0	136.36	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.14	10	9.99	0.5	10	0	3.56	0	10	0	0	0.5	0	10	0	0	0	0											1.11	0.01	-	-	0.57	5.52	0.27	0.64	0.71	-	0.69	-	0.01	0.92	3.18	4.12	0.53	0.41	-	0.07	-	0.53	-	-	1.34	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.73	0	0	1.11	0.01	-	-	0.57	5.52	0.27	0.64	0.71	-	0.69	-	0.01	0.92	3.18	4.12	0.53	0.41	-	0.07	-	0.53	-	-	1.34	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.73	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	1.11	0.01	-	-	0.57	5.52	0.27	0.64	0.71	-	0.69	-	0.01	0.92	3.18	4.12	0.53	0.41	-	0.07	-	0.53	-	-	1.34	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.73
H0540_086_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	871.45	11.62	1056.95	16.53	226.02	17.66	0.76	338.13	321.29	0	1105.13	0	0.2	618.11	3946.28	5196.07	0.95	489.75	0	240.58	0	696.94	0	0	3.51	0	198.45	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.58	0	10	0	0	0.5	0	10	0	0	0	0											10.89	0.06	0.52	2.48	1.88	5.3	0.23	1.03	2.68	-	0.68	-	0.03	0.52	3.29	4.33	0.48	0.41	-	0.07	-	0.58	-	-	1.76	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.37	0	0	10.89	0.06	0.52	2.48	1.88	5.3	0.23	1.03	2.68	-	0.68	-	0.03	0.52	3.29	4.33	0.48	0.41	-	0.07	-	0.58	-	-	1.76	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.37	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.89	0.06	0.52	2.48	1.88	5.3	0.23	1.03	2.68	-	0.68	-	0.03	0.52	3.29	4.33	0.48	0.41	-	0.07	-	0.58	-	-	1.76	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.37
H0540_087_0	2007	5																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	902.18	12.09	1076.1	16.52	233.16	18.34	0.76	340.4	330.09	0	1140.58	0	0.2	630.67	3854.18	5074.68	0.98	463.65	0	231.02	9.37	649.53	0	0	3.54	0	199.71	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.63	10	24.96	0.5	25	0	8.67	0.2	25	0	0	0.5	0	25	0	0	0	0											15.04	0.18	2.14	2.48	2.91	5.5	0.23	1.18	2.75	-	0.7	-	0.03	1.29	3.21	10.55	0.49	0.97	-	0.17	1.91	1.35	-	-	1.77	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.27	0	0	15.04	0.18	2.14	2.48	2.91	5.5	0.23	1.18	2.75	-	0.7	-	0.03	1.29	3.21	10.55	0.49	0.97	-	0.17	1.91	1.35	-	-	1.77	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.27	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	15.04	0.18	2.14	2.48	2.91	5.5	0.23	1.18	2.75	-	0.7	-	0.03	1.29	3.21	10.55	0.49	0.97	-	0.17	1.91	1.35	-	-	1.77	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.27
H0540_807_0	2007	7																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H0540_808_0	2007	6																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H0540_813_0	2007	6																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H0543_001_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1217.58	32.98	1089.07	1710.54	244.69	22.64	1.58	357.73	291.8	1163.09	31.89	22.56	4.16	467.77	6865.2	4619.15	249.44	1087.76	32.3	28234.67	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											43.55	109.69	74	0	100	0.2	0.2	49.18	150	0	0.15	0	0	102.6	13.13	12.97	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.42	0.3	6.72	-	2.04	4.45	0.32	1.47	3.65	-	4.91	-	-	4	7.51	4.99	0.62	0.91	2.79	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.75	0	0	4.42	0.3	6.72	-	2.04	4.45	0.32	1.47	3.65	-	4.91	-	-	4	7.51	4.99	0.62	0.91	2.79	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.75	None																																																																																			-	0	0	4.42	0.3	6.72	-	2.04	4.45	0.32	1.47	3.65	-	4.91	-	-	4	7.51	4.99	0.62	0.91	2.79	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.75
H0543_004_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1323.26	35.85	1198.45	1738.07	144.47	17.88	1.25	357.73	282.45	888.17	29.11	21.84	3.8	452.78	5781.39	4089.05	252.94	546.64	29.48	23755.56	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	74	0	100	0.2	0.2	49.18	100	0	0.15	0	0	69.59	13.04	12.97	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											10.79	0.33	7.39	-	1.2	3.51	0.25	1.47	2.35	-	4.48	-	-	2.63	6.28	4.42	0.63	0.46	2.54	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.42	0	0	10.79	0.33	7.39	-	1.2	3.51	0.25	1.47	2.35	-	4.48	-	-	2.63	6.28	4.42	0.63	0.46	2.54	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.42	None																																																																																			-	0	0	10.79	0.33	7.39	-	1.2	3.51	0.25	1.47	2.35	-	4.48	-	-	2.63	6.28	4.42	0.63	0.46	2.54	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.42
H0543_007_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1162.79	31.5	1054.89	1710.54	142.76	18.86	1.32	357.73	293.79	809.22	29.16	22.72	4.01	470.97	5821.05	4206.68	249.44	708.94	29.53	22574.62	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											43.55	109.69	47	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	13.16	12.97	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.22	0.29	4.13	-	0.89	3.7	0.26	1.47	2.45	-	4.49	-	-	2.73	6.38	4.55	0.62	0.59	2.55	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.99	0	0	4.22	0.29	4.13	-	0.89	3.7	0.26	1.47	2.45	-	4.49	-	-	2.73	6.38	4.55	0.62	0.59	2.55	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.99	None																																																																																			-	0	0	4.22	0.29	4.13	-	0.89	3.7	0.26	1.47	2.45	-	4.49	-	-	2.73	6.38	4.55	0.62	0.59	2.55	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.99
H0543_013_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	17.14	1.2	357.73	282.08	985.74	28.34	21.81	3.69	452.2	5740.11	4026.02	249.44	661.92	28.7	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	74	0	100	0.2	0.2	49.18	200	0	0.15	0	0	140.29	15	30	30	30	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											13.65	0.31	7.66	-	1.19	3.37	0.24	1.47	4.7	-	4.36	-	-	5.29	7.18	10.07	0.62	1.65	2.48	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.89	0	0	13.65	0.31	7.66	-	1.19	3.37	0.24	1.47	4.7	-	4.36	-	-	5.29	7.18	10.07	0.62	1.65	2.48	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.89	None																																																																																			-	0	0	13.65	0.31	7.66	-	1.19	3.37	0.24	1.47	4.7	-	4.36	-	-	5.29	7.18	10.07	0.62	1.65	2.48	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.89
H0543_019_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1199.38	32.49	1282.64	1684.06	141.11	18.53	1.29	370.23	293.72	985.74	30.64	22.71	4.15	470.85	5740.11	4026.02	246.07	661.92	31.03	24823.2	23.58	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											400 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											69.69	109.69	47	0	75	0.2	0.2	49.18	175	0	0.15	0	0	119.11	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											6.97	0.3	5.02	-	0.88	3.64	0.26	1.52	4.28	-	4.72	-	-	4.67	4.78	6.71	0.62	1.1	2.68	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.8	0	0	6.97	0.3	5.02	-	0.88	3.64	0.26	1.52	4.28	-	4.72	-	-	4.67	4.78	6.71	0.62	1.1	2.68	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.8	None																																																																																			-	0	0	6.97	0.3	5.02	-	0.88	3.64	0.26	1.52	4.28	-	4.72	-	-	4.67	4.78	6.71	0.62	1.1	2.68	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.8
H0543_022_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1484.44	40.21	1648.05	1738.07	144.47	18.08	1.26	357.73	286.01	985.74	29.89	22.11	3.95	458.5	5740.11	4026.02	252.94	661.92	30.27	25279.72	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	68	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											16.15	0.37	9.34	-	1.2	3.55	0.25	1.47	4.77	-	4.6	-	-	5.18	4.78	6.71	0.63	1.1	2.61	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.39	0	0	16.15	0.37	9.34	-	1.2	3.55	0.25	1.47	4.77	-	4.6	-	-	5.18	4.78	6.71	0.63	1.1	2.61	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.39	None																																																																																			-	0	0	16.15	0.37	9.34	-	1.2	3.55	0.25	1.47	4.77	-	4.6	-	-	5.18	4.78	6.71	0.63	1.1	2.61	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.39
H0543_026_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1290.88	34.97	1219.14	1724.81	206.49	19.8	1.38	361.06	285.93	1206.23	31.34	22.11	4.06	458.37	6077.16	4184.51	251.25	711.54	31.74	28329.68	23.58	0	0	0	116.27	262.79	207.8	37.28	0	0	664.62											952 per admit	952 per admit	0 days 1-10;100 days 11-100	Covered in Full	100	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 20 PCP; 30 in-area in-network 50 other	Ambulatory Surgical Center Copay: 275; Outpatient Hospital Copay: 275	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 275; Outpatient Hospital Copay: 275	20	30	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not covered	Not covered	Not covered	Not covered	Not covered	Not covered	Not Covered	0	Acupuncture: Not covered; Routine Chiropractic: Not covered											123.69	85.4	62	0	100	0.2	0.2	49.18	275	0	0.15	0	0	189.8	28.8	30	30	30	0.09	0	0.2	0	0	0	0	0	0	0	0	0	0											13.31	0.25	6.3	-	1.72	3.89	0.28	1.48	6.55	-	4.83	-	-	7.25	14.58	10.46	0.63	1.78	2.74	0.01	4.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.76	0	0	13.31	0.25	6.3	-	1.72	3.89	0.28	1.48	6.55	-	4.83	-	-	7.25	14.58	10.46	0.63	1.78	2.74	0.01	4.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.76	None																																																																																			-	0	0	13.31	0.25	6.3	-	1.72	3.89	0.28	1.48	6.55	-	4.83	-	-	7.25	14.58	10.46	0.63	1.78	2.74	0.01	4.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.76
H0543_028_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1738.07	306.37	18.84	1.31	375.99	308.51	1235.06	29.68	23.85	4.16	494.56	6041.69	4154.59	252.94	589.61	30.06	28892.6	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 per admit	200 per admit	0 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	25 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 40; Urgent Care: 10 PCP Copay;20 In Area/In Network;40 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	10	10	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											34.84	24.06	0	0	25	0.2	0.2	39.18	0	0	0.15	0	0	0	10	10	10	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.88	0.07	-	-	0.64	3.7	0.26	1.23	-	-	4.57	-	-	-	5.03	3.46	0.21	0.49	2.59	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.82	0	0	3.88	0.07	-	-	0.64	3.7	0.26	1.23	-	-	4.57	-	-	-	5.03	3.46	0.21	0.49	2.59	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.82	None																																																																																			-	0	0	3.88	0.07	-	-	0.64	3.7	0.26	1.23	-	-	4.57	-	-	-	5.03	3.46	0.21	0.49	2.59	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.82
H0543_029_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1340.66	36.32	1286.75	1771.87	328.01	19.96	1.39	370.23	291.98	2502.1	33.03	22.58	4.06	468.07	6365	4051.23	257.24	357.69	33.46	46728.75	23.58	0	0	0	119.04	269.05	212.75	38.17	0	0	678.81											400 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											69.69	109.69	39	0	75	0.2	0.2	49.18	175	0	0.15	0	0	119.11	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											7.79	0.33	4.18	-	2.05	3.92	0.28	1.52	4.26	-	5.09	-	-	4.65	5.3	6.75	0.64	0.6	2.89	0.01	4.72	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.93	0	0	7.79	0.33	4.18	-	2.05	3.92	0.28	1.52	4.26	-	5.09	-	-	4.65	5.3	6.75	0.64	0.6	2.89	0.01	4.72	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.93	None																																																																																			-	0	0	7.79	0.33	4.18	-	2.05	3.92	0.28	1.52	4.26	-	5.09	-	-	4.65	5.3	6.75	0.64	0.6	2.89	0.01	4.72	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.93
H0543_032_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1159.13	31.4	1138.22	1738.07	253.13	19.91	1.39	357.73	258.87	1208.55	30.59	20.02	3.66	414.98	5970.33	4366.63	252.94	972.79	30.98	28103.62	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											12.61	0.29	5.88	-	2.11	3.91	0.28	1.47	4.31	-	4.71	-	-	4.69	4.98	7.28	0.63	1.62	2.67	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.11	0	0	12.61	0.29	5.88	-	2.11	3.91	0.28	1.47	4.31	-	4.71	-	-	4.69	4.98	7.28	0.63	1.62	2.67	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.11	None																																																																																			-	0	0	12.61	0.29	5.88	-	2.11	3.91	0.28	1.47	4.31	-	4.71	-	-	4.69	4.98	7.28	0.63	1.62	2.67	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.11
H0543_035_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1364.72	36.97	1407.52	1684.06	306.37	18.63	1.3	379.45	371.24	1235.06	29.35	28.7	4.95	595.12	6041.69	4154.59	246.07	589.61	29.72	29335.48	23.58	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 [Day(s) 1-5] Select;300 [Day(s) 1-5 Standard	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											143.38	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	13.1	12.97	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											16.31	0.34	7.27	-	2.55	3.66	0.26	1.56	6.19	-	4.52	-	-	6.73	6.6	4.49	0.62	0.49	2.56	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.78	0	0	16.31	0.34	7.27	-	2.55	3.66	0.26	1.56	6.19	-	4.52	-	-	6.73	6.6	4.49	0.62	0.49	2.56	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.78	None																																																																																			-	0	0	16.31	0.34	7.27	-	2.55	3.66	0.26	1.56	6.19	-	4.52	-	-	6.73	6.6	4.49	0.62	0.49	2.56	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.78
H0543_036_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1334.88	36.16	1220.02	1684.06	306.37	20.51	1.43	375.99	308.51	1235.06	32.31	23.85	4.53	494.56	6041.69	4154.59	246.07	589.61	32.72	28859.24	23.58	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 Select/800 Standard per admit	200 per admit	0 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	25 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 40; Urgent Care: 10 PCP Copay;20 In Area/In Network;40 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	10	10	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											44.25	24.06	0	0	25	0.2	0.2	39.18	0	0	0.15	0	0	0	10	10	10	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.92	0.07	-	-	0.64	4.03	0.29	1.23	-	-	4.98	-	-	-	5.03	3.46	0.21	0.49	2.82	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.81	0	0	4.92	0.07	-	-	0.64	4.03	0.29	1.23	-	-	4.98	-	-	-	5.03	3.46	0.21	0.49	2.82	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.81	None																																																																																			-	0	0	4.92	0.07	-	-	0.64	4.03	0.29	1.23	-	-	4.98	-	-	-	5.03	3.46	0.21	0.49	2.82	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.81
H0543_046_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1396.04	37.82	1138.4	1738.07	306.37	19.21	1.34	357.73	336.8	1235.06	30.26	26.04	4.63	539.91	6041.69	4154.59	252.94	589.61	30.65	29163.95	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	15	30	30	30	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											15.18	0.35	5.88	-	2.55	3.77	0.27	1.47	5.61	-	4.66	-	-	6.1	7.55	10.39	0.63	1.47	2.64	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.22	0	0	15.18	0.35	5.88	-	2.55	3.77	0.27	1.47	5.61	-	4.66	-	-	6.1	7.55	10.39	0.63	1.47	2.64	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.22	None																																																																																			-	0	0	15.18	0.35	5.88	-	2.55	3.77	0.27	1.47	5.61	-	4.66	-	-	6.1	7.55	10.39	0.63	1.47	2.64	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.22
H0543_049_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1186.98	32.15	964.86	1738.07	306.37	16.58	1.16	379.45	317.08	1235.06	26.12	24.52	3.76	508.29	6041.69	4154.59	252.94	589.61	26.45	28696.04	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	20	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	140.29	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											12.91	0.29	4.99	-	2.55	3.26	0.23	1.56	5.28	-	4.02	-	-	5.94	5.03	6.92	0.63	0.98	2.28	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.57	0	0	12.91	0.29	4.99	-	2.55	3.26	0.23	1.56	5.28	-	4.02	-	-	5.94	5.03	6.92	0.63	0.98	2.28	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.57	None																																																																																			-	0	0	12.91	0.29	4.99	-	2.55	3.26	0.23	1.56	5.28	-	4.02	-	-	5.94	5.03	6.92	0.63	0.98	2.28	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.57
H0543_050_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1284.3	34.79	1055.82	1710.54	142.76	17.92	1.25	357.73	248.63	908.18	29.2	19.22	3.4	398.58	5797.35	4018.93	249.44	541.14	29.58	23882.03	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											43.55	109.69	47	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	13	12.97	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.66	0.32	4.14	-	0.89	3.52	0.25	1.47	2.07	-	4.5	-	-	2.31	6.28	4.34	0.62	0.45	2.55	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.03	0	0	4.66	0.32	4.14	-	0.89	3.52	0.25	1.47	2.07	-	4.5	-	-	2.31	6.28	4.34	0.62	0.45	2.55	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.03	None																																																																																			-	0	0	4.66	0.32	4.14	-	0.89	3.52	0.25	1.47	2.07	-	4.5	-	-	2.31	6.28	4.34	0.62	0.45	2.55	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.03
H0543_060_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	19.23	1.34	357.73	282.08	1177.47	46.22	21.81	3.96	452.2	5973.01	4355.51	249.44	418.34	46.82	28316.95	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											0 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	25	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	109.69	39	0	75	0.2	0.2	49.18	200	0	0.15	0	0	140.29	10	25	30	25	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											-	0.31	4.04	-	0.89	3.78	0.27	1.47	4.7	-	7.12	-	-	5.29	4.98	9.07	0.62	0.87	4.04	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.11	0	0	-	0.31	4.04	-	0.89	3.78	0.27	1.47	4.7	-	7.12	-	-	5.29	4.98	9.07	0.62	0.87	4.04	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.11	None																																																																																			-	0	0	-	0.31	4.04	-	0.89	3.78	0.27	1.47	4.7	-	7.12	-	-	5.29	4.98	9.07	0.62	0.87	4.04	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.11
H0543_065_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1258.25	34.08	1311.81	1710.54	142.76	21.38	1.49	357.73	250.2	985.74	35.35	19.35	4.08	401.09	5740.11	4026.02	249.44	661.92	35.81	24633.46	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											400 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											69.69	109.69	74	0	100	0.2	0.2	49.18	175	0	0.15	0	0	119.11	13.02	21.49	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											7.31	0.31	8.09	-	1.19	4.2	0.3	1.47	3.65	-	5.44	-	-	3.98	6.23	7.21	0.62	1.1	3.09	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.85	0	0	7.31	0.31	8.09	-	1.19	4.2	0.3	1.47	3.65	-	5.44	-	-	3.98	6.23	7.21	0.62	1.1	3.09	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.85	None																																																																																			-	0	0	7.31	0.31	8.09	-	1.19	4.2	0.3	1.47	3.65	-	5.44	-	-	3.98	6.23	7.21	0.62	1.1	3.09	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.85
H0543_070_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1642.71	44.5	1409.78	1738.07	317.36	20.19	1.41	375.99	311.39	769.12	32.65	24.08	4.7	499.18	5716.63	4090.6	252.94	818.21	33.07	22830.82	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											400 Select/800 Standard per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											78.05	109.69	39	0	75	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	15	30	15	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											10.68	0.41	4.58	-	1.98	3.97	0.28	1.54	5.19	-	5.03	-	-	5.64	4.76	5.11	0.63	1.02	2.85	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.36	0	0	10.68	0.41	4.58	-	1.98	3.97	0.28	1.54	5.19	-	5.03	-	-	5.64	4.76	5.11	0.63	1.02	2.85	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.36	None																																																																																			-	0	0	10.68	0.41	4.58	-	1.98	3.97	0.28	1.54	5.19	-	5.03	-	-	5.64	4.76	5.11	0.63	1.02	2.85	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.36
H0543_071_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1637.13	44.35	1178.13	1738.07	514.22	33.31	2.32	375.99	311.52	1090.37	48.17	24.09	6.83	499.39	6523.07	4592.69	252.94	515.4	48.79	28017.04	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											400 Select/800 Standard per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											78.05	109.69	39	0	75	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	15	30	15	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											10.65	0.41	3.83	-	3.21	6.54	0.46	1.54	5.19	-	7.42	-	-	5.64	5.44	5.74	0.63	0.64	4.21	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.24	0	0	10.65	0.41	3.83	-	3.21	6.54	0.46	1.54	5.19	-	7.42	-	-	5.64	5.44	5.74	0.63	0.64	4.21	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.24	None																																																																																			-	0	0	10.65	0.41	3.83	-	3.21	6.54	0.46	1.54	5.19	-	7.42	-	-	5.64	5.44	5.74	0.63	0.64	4.21	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.24
H0543_072_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1531.32	41.48	1431.76	1738.07	340.75	23.05	1.61	375.99	311.43	1194.04	34.54	24.08	4.94	499.24	6253.9	4236.9	252.94	498.55	34.98	28827.7	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											400 Select/800 Standard per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											78.75	109.69	39	0	75	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	15	30	15	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											10.05	0.38	4.65	-	2.13	4.53	0.32	1.54	5.19	-	5.32	-	-	5.64	5.21	5.3	0.63	0.62	3.02	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.21	0	0	10.05	0.38	4.65	-	2.13	4.53	0.32	1.54	5.19	-	5.32	-	-	5.64	5.21	5.3	0.63	0.62	3.02	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.21	None																																																																																			-	0	0	10.05	0.38	4.65	-	2.13	4.53	0.32	1.54	5.19	-	5.32	-	-	5.64	5.21	5.3	0.63	0.62	3.02	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.21
H0543_077_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1314.09	35.6	1094.5	1675.59	139.84	18.52	1.29	350.42	246.88	534.06	38.1	19.09	3.64	395.76	5484.05	3829.73	249.44	440.07	38.59	18129.22	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											150 Select/250 Standard per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	25 1/yr	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											28.57	109.69	74	0	100	0.2	0.2	49.18	100	0	0.15	0	0	69.59	13.04	12.97	30	10	0.09	0	0.2	0	0	0	30	30	25	0	0	0	0											3.13	0.33	6.75	-	1.17	3.64	0.26	1.44	2.06	-	5.87	-	-	2.3	5.96	4.14	0.62	0.37	3.33	0	4.72	-	-	-	0.29	0.65	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.43	0	0	3.13	0.33	6.75	-	1.17	3.64	0.26	1.44	2.06	-	5.87	-	-	2.3	5.96	4.14	0.62	0.37	3.33	0	4.72	-	-	-	0.29	0.65	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.43	None																																																																																			-	0	0	3.13	0.33	6.75	-	1.17	3.64	0.26	1.44	2.06	-	5.87	-	-	2.3	5.96	4.14	0.62	0.37	3.33	0	4.72	-	-	-	0.29	0.65	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.43
H0543_078_0	2007	8																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1546.2	41.88	1531.08	2108.24	175.95	23.3	1.63	440.9	347.67	1214.92	38.53	26.88	5.01	557.33	7074.69	4962.08	249.44	815.82	39.02	30616.36	29.07	0	0	503.47	115.43	260.89	206.3	37.01	0	0	660.31											0 per admit	812 Copay Per Stay	No copay Day(s) 1-20; 120 [Day(s) 21-100]	Covered in Full	50 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0.2	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Oral Exam (4/yr)15 Cleaning (1/6 mths)	Exam 5/12 months	materials copay 5/12 months	5 Exam/12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	97.67	58	0	50	0.2	0.2	23.98	0	0	0.15	0	0.2	0	0	0	10	0	0.09	0	0.2	0	0	57.54	5	5	5	0	0	0	0											-	0.34	7.4	-	0.73	4.58	0.33	0.88	-	-	5.93	-	1	-	-	-	0.21	-	3.37	-	5.81	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.24	0	0	-	0.34	7.4	-	0.73	4.58	0.33	0.88	-	-	5.93	-	1	-	-	-	0.21	-	3.37	-	5.81	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.24	None																																																																																			-	0	0	-	0.34	7.4	-	0.73	4.58	0.33	0.88	-	-	5.93	-	1	-	-	-	0.21	-	3.37	-	5.81	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.24
H0543_079_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1691.3	45.82	1674.75	2343.2	194.77	23.38	1.63	482.27	380.29	1328.93	38.67	29.4	5.03	609.63	7738.6	5427.73	252.94	892.38	39.16	33510.51	31.79	0	0	503.47	117.05	264.55	209.2	37.53	0	0	668.62											0 per admit	812 Copay Per Stay	No copay Day(s) 1-20; 120 [Day(s) 21-100]	Covered in Full	50 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0.2	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Oral Exam (4/yr)15 Cleaning (1/6 mths)	Exam 5/12 months	materials copay 5/12 months	5 Exam/12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	97.67	47	0	50	0.2	0.2	23.98	0	0	0.15	0	0.2	0	0	0	10	0	0.09	0	0.2	0	0	57.54	5	5	5	0	0	0	0											-	0.37	6.56	-	0.81	4.59	0.33	0.96	-	-	5.95	-	1.01	-	-	-	0.21	-	3.38	-	6.36	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.19	0	0	-	0.37	6.56	-	0.81	4.59	0.33	0.96	-	-	5.95	-	1.01	-	-	-	0.21	-	3.38	-	6.36	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.19	None																																																																																			-	0	0	-	0.37	6.56	-	0.81	4.59	0.33	0.96	-	-	5.95	-	1.01	-	-	-	0.21	-	3.38	-	6.36	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.19
H0543_081_0	2007	8																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1605.9	43.5	1590.19	2189.65	182.75	22.26	1.55	457.92	361.09	1261.83	36.81	27.92	4.79	578.85	7347.87	5153.68	249.44	847.32	37.28	31798.54	30.19	0	0	503.47	115.43	260.89	206.3	37.01	0	0	660.31											0 per admit	812 Copay Per Stay	No copay Day(s) 1-20; 120 [Day(s) 21-100]	Covered in Full	50 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0.2	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Oral Exam (4/yr)15 Cleaning (1/6 mths)	Exam 5/12 months	materials copay 5/12 months	5 Exam/12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	97.67	58	0	50	0.2	0.2	23.98	0	0	0.15	0	0.2	0	0	0	10	0	0.09	0	0.2	0	0	57.54	5	5	5	0	0	0	0											-	0.35	7.69	-	0.76	4.37	0.31	0.92	-	-	5.67	-	0.96	-	-	-	0.21	-	3.22	-	6.04	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.14	0	0	-	0.35	7.69	-	0.76	4.37	0.31	0.92	-	-	5.67	-	0.96	-	-	-	0.21	-	3.22	-	6.04	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.14	None																																																																																			-	0	0	-	0.35	7.69	-	0.76	4.37	0.31	0.92	-	-	5.67	-	0.96	-	-	-	0.21	-	3.22	-	6.04	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.14
H0543_082_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1333.26	36.12	994.36	1710.54	306.37	16.86	1.18	385.1	341.21	1235.06	26.57	26.38	4.12	546.97	6041.69	4154.59	249.44	589.61	26.91	29101.35	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	15	30	30	30	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											14.5	0.33	5.14	-	2.55	3.31	0.24	1.58	5.69	-	4.09	-	-	6.18	7.55	10.39	0.62	1.47	2.32	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.63	0	0	14.5	0.33	5.14	-	2.55	3.31	0.24	1.58	5.69	-	4.09	-	-	6.18	7.55	10.39	0.62	1.47	2.32	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.63	None																																																																																			-	0	0	14.5	0.33	5.14	-	2.55	3.31	0.24	1.58	5.69	-	4.09	-	-	6.18	7.55	10.39	0.62	1.47	2.32	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.63
H0543_083_0	2007	6																					4000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	4000	1299.72	35.21	1287.01	1772.17	147.91	14.37	1	370.61	292.25	1561.6	25.22	22.6	3.33	468.49	5641.86	3877.47	249.44	1068.74	25.54	32912.3	19.52	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											125/day [Day(s) 1-8]	800 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	15 Coinsurance	Prosthetic Devices: 15 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 125; Outpatient Hospital Copay: 125	0	Radiation Therapy: 15 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 15 Coinsurance	0	0	Cardiac Rehabilitation: 10; Pulmonary Rehabilitation: 10; Ambulatory Surgical Center Copay: 125; Outpatient Hospital Copay: 125	10	20	10	Occupational Therapy: 10; PT and Speech/Language Therapy: 10	Routine Outpatient X-Ray: 10; Radiation Therapy: 15 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 15 Coinsurance	0	Inhalation Solutions: 15 Coinsurance; Oral Chemo: 15 Coinsurance; Anti-Emetics: 15 Coinsurance; Outpatient Injectables  -Self Administered: 15 Coinsurance	0	Not Covered	No	30 2/yrs	30	25 1/yr	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											86.46	84.62	54.52	0	87.94	0.15	0.15	43.25	109.92	0	0.12	0	0	74.99	11.39	18.89	8.79	17.59	0.17	0	0.15	0	0	0	30	30	25	0	0	0	0											9.36	0.25	5.85	-	1.08	2.12	0.15	1.34	2.68	-	2.91	-	-	2.93	5.36	6.11	0.18	1.57	4.34	0.01	2.93	-	-	-	0.29	0.65	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.52	0	6.74	9.36	0.25	5.85	-	1.08	2.12	0.15	1.34	2.68	-	2.91	-	-	2.93	5.36	6.11	0.18	1.57	4.34	0.01	2.93	-	-	-	0.29	0.65	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.52	4000																																																																																			-	0	0	9.36	0.25	5.85	-	1.08	2.12	0.15	1.34	2.68	-	2.91	-	-	2.93	5.36	6.11	0.18	1.57	4.34	0.01	2.93	-	-	-	0.29	0.65	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.52
H0543_084_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1738.07	144.47	17.09	1.19	357.73	282.08	985.74	28.26	21.81	3.68	452.2	5740.11	4026.02	252.94	661.92	28.62	24856.45	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	5	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	74	0	100	0.2	0.2	49.18	100	0	0.15	0	0	69.59	5	10	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											10.23	0.31	7.66	-	1.2	3.36	0.24	1.47	2.35	-	4.35	-	-	2.62	2.39	3.36	0.63	0.55	2.47	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.87	0	0	10.23	0.31	7.66	-	1.2	3.36	0.24	1.47	2.35	-	4.35	-	-	2.62	2.39	3.36	0.63	0.55	2.47	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.87	None																																																																																			-	0	0	10.23	0.31	7.66	-	1.2	3.36	0.24	1.47	2.35	-	4.35	-	-	2.62	2.39	3.36	0.63	0.55	2.47	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.87
H0543_085_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1738.07	306.37	19.96	1.39	375.99	308.51	1235.06	31.45	23.85	4.41	494.56	6041.69	4154.59	252.94	589.61	31.86	28892.6	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 [Day(s) 1-5] Select;300 [Day(s) 1-5] Std	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											138.36	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	15	30	15	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											15.41	0.33	6.3	-	2.55	3.92	0.28	1.54	5.14	-	4.84	-	-	5.59	5.03	5.19	0.63	0.74	2.75	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.93	0	0	15.41	0.33	6.3	-	2.55	3.92	0.28	1.54	5.14	-	4.84	-	-	5.59	5.03	5.19	0.63	0.74	2.75	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.93	None																																																																																			-	0	0	15.41	0.33	6.3	-	2.55	3.92	0.28	1.54	5.14	-	4.84	-	-	5.59	5.03	5.19	0.63	0.74	2.75	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.93
H0543_086_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1220.12	33.05	989.2	1738.07	288.8	22.85	1.59	357.73	297.88	1131.79	34.95	23.03	4.81	477.52	6102.8	4213.96	252.94	550.25	35.39	27246.92	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											400 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											69.69	109.69	39	0	75	0.2	0.2	49.18	175	0	0.15	0	0	119.11	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											7.09	0.3	3.21	-	1.81	4.49	0.32	1.47	4.34	-	5.38	-	-	4.74	5.09	7.02	0.63	0.92	3.05	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.53	0	0	7.09	0.3	3.21	-	1.81	4.49	0.32	1.47	4.34	-	5.38	-	-	4.74	5.09	7.02	0.63	0.92	3.05	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.53	None																																																																																			-	0	0	7.09	0.3	3.21	-	1.81	4.49	0.32	1.47	4.34	-	5.38	-	-	4.74	5.09	7.02	0.63	0.92	3.05	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.53
H0543_089_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1710.54	226.57	19.85	1.39	357.73	308.51	931.36	32.89	23.85	4.49	494.56	5932.33	4055.03	249.44	534.19	33.31	24491.58	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 per admit	200 per admit	0 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	25 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 40; Urgent Care: 10 PCP Copay;20 In Area/In Network;40 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	10	10	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											34.84	24.06	0	0	25	0.2	0.2	39.18	0	0	0.15	0	0	0	10	10	10	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.88	0.07	-	-	0.47	3.9	0.28	1.17	-	-	5.06	-	-	-	4.94	3.38	0.21	0.45	2.87	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.34	0	0	3.88	0.07	-	-	0.47	3.9	0.28	1.17	-	-	5.06	-	-	-	4.94	3.38	0.21	0.45	2.87	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.34	None																																																																																			-	0	0	3.88	0.07	-	-	0.47	3.9	0.28	1.17	-	-	5.06	-	-	-	4.94	3.38	0.21	0.45	2.87	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.34
H0543_091_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1710.54	306.37	19.23	1.34	357.73	308.51	1235.06	30.29	23.85	4.25	494.56	6041.69	4154.59	249.44	589.61	30.68	28855.74	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 per admit	200 per admit	0 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	25 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 40; Urgent Care: 10 PCP Copay;20 In Area/In Network;40 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	10	10	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											34.84	24.06	0	0	25	0.2	0.2	39.18	0	0	0.15	0	0	0	10	10	10	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.88	0.07	-	-	0.64	3.78	0.27	1.17	-	-	4.66	-	-	-	5.03	3.46	0.21	0.49	2.65	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.97	0	0	3.88	0.07	-	-	0.64	3.78	0.27	1.17	-	-	4.66	-	-	-	5.03	3.46	0.21	0.49	2.65	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.97	None																																																																																			-	0	0	3.88	0.07	-	-	0.64	3.78	0.27	1.17	-	-	4.66	-	-	-	5.03	3.46	0.21	0.49	2.65	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.97
H0543_093_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1710.54	358.26	15.18	1.06	357.73	308.51	1204.13	24.08	23.85	3.36	494.56	6057.68	4160.68	249.44	550.42	24.39	28429.05	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 per admit	200 per admit	0 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	25 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 40; Urgent Care: 10 PCP Copay;20 In Area/In Network;40 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	10	10	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											34.84	24.06	0	0	25	0.2	0.2	39.18	0	0	0.15	0	0	0	10	10	10	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.88	0.07	-	-	0.75	2.98	0.21	1.17	-	-	3.71	-	-	-	5.05	3.47	0.21	0.46	2.1	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.71	0	0	3.88	0.07	-	-	0.75	2.98	0.21	1.17	-	-	3.71	-	-	-	5.05	3.47	0.21	0.46	2.1	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.71	None																																																																																			-	0	0	3.88	0.07	-	-	0.75	2.98	0.21	1.17	-	-	3.71	-	-	-	5.05	3.47	0.21	0.46	2.1	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.71
H0543_095_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1738.07	144.47	17.19	1.2	357.73	282.08	985.74	28.43	21.81	3.7	452.2	5740.11	4026.02	252.94	661.92	28.79	24856.45	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	5	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: 5/6 visits; Routine Chiropractic: Not Covered											34.84	109.69	47	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	0	5	30	5	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0.78											3.64	0.31	4.87	-	0.9	3.38	0.24	1.47	2.35	-	4.38	-	-	2.62	-	1.68	0.63	0.28	2.48	0	4.72	-	-	-	0.29	0.66	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	34.94	0	0	3.64	0.31	4.87	-	0.9	3.38	0.24	1.47	2.35	-	4.38	-	-	2.62	-	1.68	0.63	0.28	2.48	0	4.72	-	-	-	0.29	0.66	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	34.94	None																																																																																			-	0	0	3.64	0.31	4.87	-	0.9	3.38	0.24	1.47	2.35	-	4.38	-	-	2.62	-	1.68	0.63	0.28	2.48	0	4.72	-	-	-	0.29	0.66	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	34.94
H0543_097_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	18.94	1.32	357.73	282.08	985.74	31.33	21.81	4.08	452.2	5740.11	4026.02	249.44	661.92	31.73	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											50 [Day(s) 1-5]	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											32.63	109.69	39	0	75	0.2	0.2	49.18	50	0	0.15	0	0	36.59	0	0	30	0	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.41	0.31	4.04	-	0.89	3.72	0.26	1.47	1.18	-	4.82	-	-	1.38	-	-	0.62	-	2.74	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.5	0	0	3.41	0.31	4.04	-	0.89	3.72	0.26	1.47	1.18	-	4.82	-	-	1.38	-	-	0.62	-	2.74	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.5	None																																																																																			-	0	0	3.41	0.31	4.04	-	0.89	3.72	0.26	1.47	1.18	-	4.82	-	-	1.38	-	-	0.62	-	2.74	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.5
H0543_098_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1738.07	306.37	22.5	1.57	375.99	308.51	1235.06	35.44	23.85	4.97	494.56	6041.69	4154.59	252.94	589.61	35.89	28892.6	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											400 Select/800 Standard per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											78.05	109.69	39	0	75	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	15	30	15	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											8.69	0.33	3.97	-	1.91	4.42	0.31	1.54	5.14	-	5.46	-	-	5.59	5.03	5.19	0.63	0.74	3.1	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.73	0	0	8.69	0.33	3.97	-	1.91	4.42	0.31	1.54	5.14	-	5.46	-	-	5.59	5.03	5.19	0.63	0.74	3.1	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.73	None																																																																																			-	0	0	8.69	0.33	3.97	-	1.91	4.42	0.31	1.54	5.14	-	5.46	-	-	5.59	5.03	5.19	0.63	0.74	3.1	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.73
H0543_099_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1738.07	306.37	23.6	1.65	375.99	308.51	1235.06	37.17	23.85	5.21	494.56	6041.69	4154.59	252.94	589.61	37.65	28892.6	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											400 Select/800 Standard per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											78.75	109.69	39	0	75	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	15	30	15	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											8.77	0.33	3.97	-	1.91	4.63	0.33	1.54	5.14	-	5.72	-	-	5.59	5.03	5.19	0.63	0.74	3.25	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.46	0	0	8.77	0.33	3.97	-	1.91	4.63	0.33	1.54	5.14	-	5.72	-	-	5.59	5.03	5.19	0.63	0.74	3.25	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.46	None																																																																																			-	0	0	8.77	0.33	3.97	-	1.91	4.63	0.33	1.54	5.14	-	5.72	-	-	5.59	5.03	5.19	0.63	0.74	3.25	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.46
H0543_105_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1738.07	144.47	17.59	1.23	357.73	282.08	985.74	29.09	21.81	3.79	452.2	5740.11	4026.02	252.94	661.92	29.46	24856.45	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	5	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											34.84	109.69	39	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	0	5	30	5	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.64	0.31	4.04	-	0.9	3.46	0.25	1.47	2.35	-	4.48	-	-	2.62	-	1.68	0.63	0.28	2.54	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.31	0	0	3.64	0.31	4.04	-	0.9	3.46	0.25	1.47	2.35	-	4.48	-	-	2.62	-	1.68	0.63	0.28	2.54	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.31	None																																																																																			-	0	0	3.64	0.31	4.04	-	0.9	3.46	0.25	1.47	2.35	-	4.48	-	-	2.62	-	1.68	0.63	0.28	2.54	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.31
H0543_106_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1684.06	141.11	18.34	1.28	370.23	282.08	985.74	30.33	21.81	3.95	452.2	5740.11	4026.02	246.07	661.92	30.72	24840.33	23.58	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											400 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											69.69	109.69	39	0	75	0.2	0.2	49.18	175	0	0.15	0	0	119.11	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											7.29	0.31	4.04	-	0.88	3.6	0.26	1.52	4.11	-	4.67	-	-	4.49	4.78	6.71	0.62	1.1	2.65	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.67	0	0	7.29	0.31	4.04	-	0.88	3.6	0.26	1.52	4.11	-	4.67	-	-	4.49	4.78	6.71	0.62	1.1	2.65	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.67	None																																																																																			-	0	0	7.29	0.31	4.04	-	0.88	3.6	0.26	1.52	4.11	-	4.67	-	-	4.49	4.78	6.71	0.62	1.1	2.65	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.67
H0543_108_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1738.07	306.37	15.58	1.09	379.45	308.51	1235.06	24.55	23.85	3.44	494.56	6041.69	4154.59	252.94	589.61	24.86	28896.62	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	20	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	140.29	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											14.54	0.33	6.3	-	2.55	3.06	0.22	1.56	5.14	-	3.78	-	-	5.78	5.03	6.92	0.63	0.98	2.14	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.66	0	0	14.54	0.33	6.3	-	2.55	3.06	0.22	1.56	5.14	-	3.78	-	-	5.78	5.03	6.92	0.63	0.98	2.14	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.66	None																																																																																			-	0	0	14.54	0.33	6.3	-	2.55	3.06	0.22	1.56	5.14	-	3.78	-	-	5.78	5.03	6.92	0.63	0.98	2.14	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.66
H0543_110_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1738.07	306.37	18.72	1.31	375.99	308.51	1235.06	29.48	23.85	4.14	494.56	6041.69	4154.59	252.94	589.61	29.86	28892.6	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 per admit	200 per admit	0 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	25 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 40; Urgent Care: 10 PCP Copay;20 In Area/In Network;40 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	10	10	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											34.84	24.06	0	0	25	0.2	0.2	39.18	0	0	0.15	0	0	0	10	10	10	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.88	0.07	-	-	0.64	3.68	0.26	1.23	-	-	4.54	-	-	-	5.03	3.46	0.21	0.49	2.58	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.74	0	0	3.88	0.07	-	-	0.64	3.68	0.26	1.23	-	-	4.54	-	-	-	5.03	3.46	0.21	0.49	2.58	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.74	None																																																																																			-	0	0	3.88	0.07	-	-	0.64	3.68	0.26	1.23	-	-	4.54	-	-	-	5.03	3.46	0.21	0.49	2.58	0	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.74
H0543_114_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1684.06	306.37	20.38	1.42	375.99	308.51	1235.06	32.11	23.85	4.5	494.56	6041.69	4154.59	246.07	589.61	32.52	28861.95	23.58	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 Select/800 Standard per admit	200 per admit	0 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	25 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 40; Urgent Care: 10 PCP Copay;20 In Area/In Network;40 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	10	10	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											44.25	24.06	0	0	25	0.2	0.2	39.18	0	0	0.15	0	0	0	10	10	10	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.93	0.07	-	-	0.64	4	0.28	1.23	-	-	4.94	-	-	-	5.03	3.46	0.21	0.49	2.81	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.75	0	0	4.93	0.07	-	-	0.64	4	0.28	1.23	-	-	4.94	-	-	-	5.03	3.46	0.21	0.49	2.81	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.75	None																																																																																			-	0	0	4.93	0.07	-	-	0.64	4	0.28	1.23	-	-	4.94	-	-	-	5.03	3.46	0.21	0.49	2.81	0	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.75
H0543_115_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1738.07	144.47	19.74	1.38	357.73	282.08	985.74	32.64	21.81	4.25	452.2	5740.11	4026.02	252.94	661.92	33.06	24856.45	23.58	0	0	0	117.05	264.55	209.2	37.53	0	0	668.62											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	10	20	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											13.65	0.31	6.42	-	1.2	3.88	0.28	1.47	4.7	-	5.03	-	-	5.11	4.78	6.71	0.63	1.1	2.85	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.79	0	0	13.65	0.31	6.42	-	1.2	3.88	0.28	1.47	4.7	-	5.03	-	-	5.11	4.78	6.71	0.63	1.1	2.85	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.79	None																																																																																			-	0	0	13.65	0.31	6.42	-	1.2	3.88	0.28	1.47	4.7	-	5.03	-	-	5.11	4.78	6.71	0.63	1.1	2.85	0.01	4.72	-	-	-	0.29	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.79
H0543_116_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1391.17	37.69	1377.56	1896.86	158.31	19.8	1.38	396.69	312.81	1093.11	32.73	24.19	4.26	501.45	6365.36	4464.56	249.44	734.02	33.15	27546.64	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	0	500/3 yrs	Not Covered	0	Acupuncture: 10 12 visits/yr; Routine Chiropractic: 10 12 visits/yr											43.55	109.69	68	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	13.02	12.97	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	8.96											5.05	0.34	7.81	-	0.99	3.89	0.28	1.63	2.61	-	5.04	-	-	2.91	6.91	4.83	0.62	0.61	2.86	0	4.72	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	52.52	0	0	5.05	0.34	7.81	-	0.99	3.89	0.28	1.63	2.61	-	5.04	-	-	2.91	6.91	4.83	0.62	0.61	2.86	0	4.72	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	52.52	None																																																																																			-	0	0	5.05	0.34	7.81	-	0.99	3.89	0.28	1.63	2.61	-	5.04	-	-	2.91	6.91	4.83	0.62	0.61	2.86	0	4.72	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	52.52
H0543_117_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	17.15	1.2	357.73	282.08	985.74	28.36	21.81	3.69	452.2	5740.11	4026.02	249.44	661.92	28.72	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											43.55	109.69	39	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	10	10	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.55	0.31	4.04	-	0.89	3.37	0.24	1.47	2.35	-	4.37	-	-	2.62	4.78	3.36	0.62	0.55	2.48	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.66	0	0	4.55	0.31	4.04	-	0.89	3.37	0.24	1.47	2.35	-	4.37	-	-	2.62	4.78	3.36	0.62	0.55	2.48	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.66	None																																																																																			-	0	0	4.55	0.31	4.04	-	0.89	3.37	0.24	1.47	2.35	-	4.37	-	-	2.62	4.78	3.36	0.62	0.55	2.48	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.66
H0543_118_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1487.96	40.31	1473.41	2028.84	169.33	21.66	1.51	424.29	334.58	1169.16	35.81	25.87	4.66	536.34	6808.25	4775.2	249.44	785.1	36.27	29463.29	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	0	500/3 yrs	Not Covered	0	Acupuncture: 10 12 visits/yr; Routine Chiropractic: 10 12 visits/yr											43.55	109.69	68	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	13.02	12.97	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	8.96											5.4	0.37	8.35	-	1.06	4.25	0.3	1.74	2.79	-	5.51	-	-	3.11	7.39	5.16	0.62	0.65	3.13	0	4.72	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	55.99	0	0	5.4	0.37	8.35	-	1.06	4.25	0.3	1.74	2.79	-	5.51	-	-	3.11	7.39	5.16	0.62	0.65	3.13	0	4.72	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	55.99	None																																																																																			-	0	0	5.4	0.37	8.35	-	1.06	4.25	0.3	1.74	2.79	-	5.51	-	-	3.11	7.39	5.16	0.62	0.65	3.13	0	4.72	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	55.99
H0543_119_0	2007	2																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	17.54	1.22	357.73	282.08	985.74	29	21.81	3.77	452.2	5740.11	4026.02	249.44	661.92	29.37	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											43.55	109.69	39	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	10	10	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.55	0.31	4.04	-	0.89	3.44	0.24	1.47	2.35	-	4.47	-	-	2.62	4.78	3.36	0.62	0.55	2.53	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.89	0	0	4.55	0.31	4.04	-	0.89	3.44	0.24	1.47	2.35	-	4.47	-	-	2.62	4.78	3.36	0.62	0.55	2.53	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.89	None																																																																																			-	0	0	4.55	0.31	4.04	-	0.89	3.44	0.24	1.47	2.35	-	4.47	-	-	2.62	4.78	3.36	0.62	0.55	2.53	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.89
H0543_120_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1465.53	39.7	1451.2	1998.26	166.77	21.26	1.48	417.9	329.53	1151.54	35.15	25.48	4.58	528.26	6705.6	4703.2	249.44	773.26	35.6	29019.08	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											50 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	5	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											8.71	109.69	62	0	100	0.2	0.2	49.18	50	0	0.15	0	0	36.59	5	10	30	10	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											1.06	0.36	7.5	-	1.39	4.18	0.3	1.71	1.37	-	5.41	-	-	1.61	2.79	3.92	0.62	0.64	3.07	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.61	0	0	1.06	0.36	7.5	-	1.39	4.18	0.3	1.71	1.37	-	5.41	-	-	1.61	2.79	3.92	0.62	0.64	3.07	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.61	None																																																																																			-	0	0	1.06	0.36	7.5	-	1.39	4.18	0.3	1.71	1.37	-	5.41	-	-	1.61	2.79	3.92	0.62	0.64	3.07	0	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.61
H0543_121_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	16.17	1.13	357.73	282.08	985.74	26.74	21.81	3.48	452.2	5740.11	4026.02	249.44	661.92	27.08	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											0 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	20 2 exams/yr	0 1/yr	0	0 1/yr	800 3/yrs	Not Covered	0	Acupuncture: 10 12 visits/yr; Routine Chiropractic: 10 12 visits/yr											0	109.69	62	0	100	0.2	0.2	49.18	0	0	0.15	0	0	3.58	4.53	4.46	30	0	0.09	0	0.2	0	0	0	0	0	0	0	0	0	8.96											-	0.31	6.42	-	1.19	3.18	0.23	1.47	-	-	4.12	-	-	0.13	2.17	1.5	0.62	-	2.34	-	4.72	-	-	-	-	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	28.87	0	0	-	0.31	6.42	-	1.19	3.18	0.23	1.47	-	-	4.12	-	-	0.13	2.17	1.5	0.62	-	2.34	-	4.72	-	-	-	-	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	28.87	None																																																																																			-	0	0	-	0.31	6.42	-	1.19	3.18	0.23	1.47	-	-	4.12	-	-	0.13	2.17	1.5	0.62	-	2.34	-	4.72	-	-	-	-	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	28.87
H0543_122_0	2007	5																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1023.9	27.74	1013.89	1396.1	116.52	11.83	0.83	291.97	230.23	804.53	19.56	17.8	2.55	369.07	4684.92	3285.93	249.44	540.24	19.81	20274.4	21.27	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200/day [Day(s) 1-8]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 10; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											141.88	98.94	66.75	0	90.2	0.2	0.2	44.36	180.39	0	0.15	0	0	126.53	13.53	27.06	27.06	27.06	0.2	0	0.2	0	0	0	30	30	0	0	0	0	0											12.11	0.23	5.64	-	0.88	2.32	0.17	1.08	3.46	-	3.01	-	-	3.89	5.28	7.41	0.56	1.22	3.91	0.01	4.25	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.37	0	6.03	12.11	0.23	5.64	-	0.88	2.32	0.17	1.08	3.46	-	3.01	-	-	3.89	5.28	7.41	0.56	1.22	3.91	0.01	4.25	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.37	5000																																																																																			-	0	0	12.11	0.23	5.64	-	0.88	2.32	0.17	1.08	3.46	-	3.01	-	-	3.89	5.28	7.41	0.56	1.22	3.91	0.01	4.25	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.37
H0543_123_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1710.54	306.37	16.79	1.17	385.1	308.51	1235.06	26.45	23.85	3.71	494.56	6041.69	4154.59	249.44	589.61	26.79	28887.57	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.18	200	0	0.15	0	0	135.61	15	30	30	30	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											14.54	0.33	6.3	-	2.55	3.3	0.23	1.58	5.14	-	4.07	-	-	5.59	7.55	10.39	0.62	1.47	2.31	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.65	0	0	14.54	0.33	6.3	-	2.55	3.3	0.23	1.58	5.14	-	4.07	-	-	5.59	7.55	10.39	0.62	1.47	2.31	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.65	None																																																																																			-	0	0	14.54	0.33	6.3	-	2.55	3.3	0.23	1.58	5.14	-	4.07	-	-	5.59	7.55	10.39	0.62	1.47	2.31	0.01	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.65
H0543_125_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1684.06	306.37	18.77	1.31	379.45	308.51	1235.06	29.57	23.85	4.15	494.56	6041.69	4154.59	246.07	589.61	29.95	28865.96	23.58	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	74	0	100	0.2	0.2	49.18	150	0	0.15	0	0	102.6	15	30	30	30	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											10.9	0.33	7.52	-	2.55	3.69	0.26	1.56	3.86	-	4.55	-	-	4.23	7.55	10.39	0.62	1.47	2.58	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.72	0	0	10.9	0.33	7.52	-	2.55	3.69	0.26	1.56	3.86	-	4.55	-	-	4.23	7.55	10.39	0.62	1.47	2.58	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.72	None																																																																																			-	0	0	10.9	0.33	7.52	-	2.55	3.69	0.26	1.56	3.86	-	4.55	-	-	4.23	7.55	10.39	0.62	1.47	2.58	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.72
H0543_126_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1336.44	36.2	1220.02	1684.06	306.37	17.75	1.24	375.99	308.51	1235.06	27.95	23.85	3.92	494.56	6041.69	4154.59	246.07	589.61	28.31	28861.95	23.58	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											100 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											65.26	109.69	74	0	100	0.2	0.2	49.18	100	0	0.15	0	0	69.59	13.1	21.49	30	20	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											7.27	0.33	7.52	-	2.55	3.49	0.25	1.54	2.57	-	4.3	-	-	2.87	6.6	7.44	0.62	0.98	2.44	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.42	0	0	7.27	0.33	7.52	-	2.55	3.49	0.25	1.54	2.57	-	4.3	-	-	2.87	6.6	7.44	0.62	0.98	2.44	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.42	None																																																																																			-	0	0	7.27	0.33	7.52	-	2.55	3.49	0.25	1.54	2.57	-	4.3	-	-	2.87	6.6	7.44	0.62	0.98	2.44	0.01	4.72	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.42
H0543_127_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	17.06	1.19	357.73	282.08	985.74	28.21	21.81	3.67	452.2	5740.11	4026.02	249.44	661.92	28.57	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											43.55	109.69	47	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	0	0	30	0	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.55	0.31	4.87	-	0.89	3.35	0.24	1.47	2.35	-	4.34	-	-	2.62	-	-	0.62	-	2.46	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.74	0	0	4.55	0.31	4.87	-	0.89	3.35	0.24	1.47	2.35	-	4.34	-	-	2.62	-	-	0.62	-	2.46	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.74	None																																																																																			-	0	0	4.55	0.31	4.87	-	0.89	3.35	0.24	1.47	2.35	-	4.34	-	-	2.62	-	-	0.62	-	2.46	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.74
H0543_128_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	17.44	1.22	357.73	282.08	985.74	28.85	21.81	3.75	452.2	5740.11	4026.02	249.44	661.92	29.22	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											250 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	No	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											43.55	109.69	47	0	75	0.2	0.2	49.18	100	0	0.15	0	0	69.59	0	0	30	0	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											4.55	0.31	4.87	-	0.89	3.43	0.24	1.47	2.35	-	4.44	-	-	2.62	-	-	0.62	-	2.52	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.97	0	0	4.55	0.31	4.87	-	0.89	3.43	0.24	1.47	2.35	-	4.44	-	-	2.62	-	-	0.62	-	2.52	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.97	None																																																																																			-	0	0	4.55	0.31	4.87	-	0.89	3.43	0.24	1.47	2.35	-	4.44	-	-	2.62	-	-	0.62	-	2.52	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.97
H0543_129_0	2007	8																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1254.52	33.98	1242.25	1710.54	142.76	18.9	1.32	357.73	282.08	985.74	31.25	21.81	4.07	452.2	5740.11	4026.02	249.44	661.92	31.66	24840.82	23.58	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											50 [Day(s) 1-5]	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	75 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	No	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											32.63	109.69	47	0	75	0.2	0.2	49.18	50	0	0.15	0	0	36.59	0	0	30	0	0.09	0	0.2	0	0	0	30	30	0	0	0	0	0											3.41	0.31	4.87	-	0.89	3.71	0.26	1.47	1.18	-	4.81	-	-	1.38	-	-	0.62	-	2.73	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3	0	0	3.41	0.31	4.87	-	0.89	3.71	0.26	1.47	1.18	-	4.81	-	-	1.38	-	-	0.62	-	2.73	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3	None																																																																																			-	0	0	3.41	0.31	4.87	-	0.89	3.71	0.26	1.47	1.18	-	4.81	-	-	1.38	-	-	0.62	-	2.73	-	4.72	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3
H0543_130_0	2007	8																					2900											D	D	D	V	T	Coin	Coin	V	P	P	P	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2900	1700.62	46.07	1552.47	2211.7	389.86	15.46	1.08	478.45	392.58	1571.62	925.19	30.35	3.41	629.33	7688.06	5286.73	252.94	750.28	24.66	36765.91	18.07	0	0	503.47	117.05	264.55	209.2	37.53	0	0	668.62											200 [day(s) 1-14]0 [day(s)15-90]	200 [day(s) 1-14]0 [day(s)15-90]	0 Copay [Day(s) 1-20]; 120 [Day(s) 21-44];0[Day(s)45 -100]	0	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 35 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 35; Outpatient Hospital Copay: 35	0	Radiation Therapy: 25; Compex Radiology (MRIMRACTPETSpec): 25	0	0.2	Cardiac Rehabilitation: 35; Pulmonary Rehabilitation: 35; Ambulatory Surgical Center Copay: 35; Outpatient Hospital Copay: 35	0	25	35/25	Occupational Therapy: 25; PT and Speech/Language Therapy: 25	Routine Outpatient X-Ray: 25; Radiation Therapy: 25; Compex Radiology (MRIMRACTPETSpec): 25	25	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Oral Exam (4/yr)15 Cleaning (1/6 mths)	5 1/12 mths	materials copay 5/12 months	5 /12 months	400/ 3 years	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											108.28	120.28	19.27	0	60.21	0.2	0.2	15.3	21.07	0	5.35	0	0.2	18.88	0	15.05	21.07	15.05	0.24	8.95	0.2	0	0	57.54	5	5	5	0	0	0	0											15.35	0.46	2.49	-	1.96	3.04	0.22	0.61	0.69	-	0.41	-	0.68	0.99	-	6.63	0.44	0.94	5.82	27.43	3.61	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.43	0	47.44	15.35	0.46	2.49	-	1.96	3.04	0.22	0.61	0.69	-	0.41	-	0.68	0.99	-	6.63	0.44	0.94	5.82	27.43	3.61	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.43	2900																																																																																			-	0	0	15.35	0.46	2.49	-	1.96	3.04	0.22	0.61	0.69	-	0.41	-	0.68	0.99	-	6.63	0.44	0.94	5.82	27.43	3.61	-	-	2.41	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.43
H0543_131_0	2007	5																					2800											D	D	D	V	T	Coin	Coin	V	P	P	P	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2800	3584.39	132.12	15556.89	3114.7	2105.64	10.36	1.48	574.43	188.45	3656.83	612.16	23.35	6.34	628.93	1637.65	3719.58	1033.34	308.96	29.35	60552.03	22.72	0	0	503.47	56.69	128.13	82.49	14.8	0	0	125.66											200	20000	0	0	75	0	Prosthetic Devices: 0.2; Diabetes Monitoring Supplies: 0.2	ER Copay (per visit): 50; Urgent Care: 35	Ambulatory Surgical Center Copay: 35; Outpatient Hospital Copay: 35	0	Radiation Therapy: 0; Compex Radiology (MRIMRACTPETSpec): 0	0	0	Cardiac Rehabilitation: 35; Pulmonary Rehabilitation: 35; Ambulatory Surgical Center Copay: 35; Outpatient Hospital Copay: 35	0	15	35/25	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 0; Compex Radiology (MRIMRACTPETSpec): 0	0	Inhalation Solutions: 0; Oral Chemo: 0; Anti-Emetics: 0; Outpatient Injectables  -Self Administered: 0	0	24 OW	N	0	0	Not Covered	Not Covered	Not Covered	0	Acupuncture: N; Routine Chiropractic: N											123.55	137.25	0	0	51.52	0.2	0.2	33.93	24.04	0	0	0	0	20.55	0	10.3	24.04	10.3	0	0	0	0	0	0	0	0	0	0	0	0	0											36.9	1.51	-	-	9.04	2.07	0.3	1.62	0.38	-	-	-	-	1.08	-	3.19	2.07	0.27	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.43	0	26.62	36.9	1.51	-	-	9.04	2.07	0.3	1.62	0.38	-	-	-	-	1.08	-	3.19	2.07	0.27	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.43	2800																																																																																			-	0	0	36.9	1.51	-	-	9.04	2.07	0.3	1.62	0.38	-	-	-	-	1.08	-	3.19	2.07	0.27	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.43
H0543_802_0	2007	5																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1288.64	34.91	1197.65	1728.26	188.01	10.57	0.74	366.18	289.47	1128.13	17.66	22.38	2.22	464.03	6005.61	4164.74	252.62	740.22	17.74	27102.2	29.85	0	0	0	115.86	261.87	207.07	37.15	0	0	662.53											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.23	209.19	95.63	0	104.59	0.3	0.3	8.38	273.65	0	0.23	0	0.3	62.96	47.47	56.78	23.91	56.78	0.29	5.16	0.3	0	0	0	0	0	0	0	0	0	0											22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	0	84.06	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	5000																																																																																			-	0	0	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88
H0543_804_0	2007	5																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1288.64	34.91	1197.65	1728.26	188.01	10.57	0.74	366.18	289.47	1128.13	17.66	22.38	2.22	464.03	6005.61	4164.74	252.62	740.22	17.74	27102.2	29.85	0	0	0	115.86	261.87	207.07	37.15	0	0	662.53											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.23	209.19	95.63	0	104.59	0.3	0.3	8.38	273.65	0	0.23	0	0.3	62.96	47.47	56.78	23.91	56.78	0.29	5.16	0.3	0	0	0	0	0	0	0	0	0	0											22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	0	84.06	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	5000																																																																																			-	0	0	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88
H0543_805_0	2007	6																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1288.64	34.91	1197.65	1728.26	188.01	10.57	0.74	366.18	289.47	1128.13	17.66	22.38	2.22	464.03	6005.61	4164.74	252.62	740.22	17.74	27102.2	29.85	0	0	0	115.86	261.87	207.07	37.15	0	0	662.53											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.23	209.19	95.63	0	104.59	0.3	0.3	8.38	273.65	0	0.23	0	0.3	62.96	47.47	56.78	23.91	56.78	0.29	5.16	0.3	0	0	0	0	0	0	0	0	0	0											22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	0	84.06	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	5000																																																																																			-	0	0	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88
H0543_806_0	2007	6																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1288.64	34.91	1197.65	1728.26	188.01	10.57	0.74	366.18	289.47	1128.13	17.66	22.38	2.22	464.03	6005.61	4164.74	252.62	740.22	17.74	27102.2	29.85	0	0	0	115.86	261.87	207.07	37.15	0	0	662.53											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.23	209.19	95.63	0	104.59	0.3	0.3	8.38	273.65	0	0.23	0	0.3	62.96	47.47	56.78	23.91	56.78	0.29	5.16	0.3	0	0	0	0	0	0	0	0	0	0											22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	0	84.06	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88	5000																																																																																			-	0	0	22.47	0.61	9.54	-	1.64	3.17	0.22	0.26	6.6	-	4.08	-	0.67	2.43	23.76	19.71	0.5	3.5	5.12	11.64	8.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.88
H0544_001_0	2007	9	H.8	I.7									OP Facility - Other	Professional										Urgent Care	Lab/Path									D	D	D	V	T	Coin	Coin	V	V	O	O	V	O	O	V	V	V	V	P	P	Coin	O	T	V	V	P	V	P	P	P	P	V	O																																																		-			144.45			884.29	8.83		402.09									509.45				5.78			1947.75		141.31																	1B: 150 deductible			10A: 50 waived if admitted	11A: 20 if > 500		4A: 50 waived if admitted									9C: 15				20 for drugs over 200 max 550			16A: 15/oral exam 20/cleaning 10/fluoride  5/xray; 16B: 5-50/emergency services 5-15/diagnostic 19-430/restorative 25-373/edodontics/periodontics/extractions 28-525/prosthodontics other oral/maxillofacial surgery/other		25/frames																	17.53			5	0.04		25									1.5				0.17			6.78		25																-	0.21	-	-	0.37	0.32	-	0.84	-	-	-	-	-	-	-	-	0.06	-	-	-	0.98	-	-	1.1	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18			-	0.21	-	-	0.37	0.32	-	0.84	-	-	-	-	-	-	-	-	0.06	-	-	-	0.98	-	-	1.1	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18																																																																																				-			-	0.21	-	-	0.37	0.32	-	0.84	-	-	-	-	-	-	-	-	0.06	-	-	-	0.98	-	-	1.1	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18
H0544_002_0	2007	8	H.8	I.7									OP Facility - Other	Professional										Urgent Care	Lab/Path									D	D	D	V	T	Coin	Coin	V	V	O	O	V	O	O	V	V	V	V	P	P	Coin	O	T	V	V	P	V	P	P	P	P	V	O																																																		-			144.45			884.29	8.83		402.09									509.45				5.78			1947.75		141.31																	1B: 150 deductible			10A: 50 waived if admitted	11A: 20 if > 500		4A: 50 waived if admitted									9C: 15				20 for drugs over 200 max 550			16A: 15/oral exam 20/cleaning 10/fluoride  5/xray; 16B: 5-50/emergency services 5-15/diagnostic 19-430/restorative 25-373/edodontics/periodontics/extractions 28-525/prosthodontics other oral/maxillofacial surgery/other		25/frames																	17.53			5	0.04		25									1.5				0.17			6.78		25																-	0.21	-	-	0.37	0.32	-	0.84	-	-	-	-	-	-	-	-	0.06	-	-	-	0.98	-	-	1.1	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18			-	0.21	-	-	0.37	0.32	-	0.84	-	-	-	-	-	-	-	-	0.06	-	-	-	0.98	-	-	1.1	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18																																																																																				-			-	0.21	-	-	0.37	0.32	-	0.84	-	-	-	-	-	-	-	-	0.06	-	-	-	0.98	-	-	1.1	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18
H0544_003_0	2007	10																																D	D	D	V	Coin	P	P	Coin	V	V	V	V	V	V	P	P	P	P	P	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-						15.26			10.17													28.5																					No Copay	No Copay	No Copay	No Copay	20 Coins waived if admitted	No Copay	No Copay	20 Coins waived if admitted	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	20 Coins on drugs over 200 max 550	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay															0.02			0.1													0.17																					-	-	-	-	0.31	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	4.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.17			-	-	-	-	0.31	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	4.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.17																																																																																				-			-	-	-	-	0.31	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	4.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.17
H0544_004_0	2007	8																																D	D	D	V	T	Coin	P	V	V	V	V	V	V	V	P	P	P	P	P	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-			69.27			260.86	8.58		353.52						12.41							34.31			1947.75		124																	150/admit deductible 0 days 91-150			50 Copay waived if admitted	20 Coins on amts over 500		50 Copay waived if admitted						30 SA Copay							20 Coins on drugs over 200 max 550			up to 20 depending on svc		25 Copay																	14.24			5	0.05		25.02						1.5							0.17			6.78		25																-	0.08	-	-	0.11	0.43	-	0.74	-	-	-	-	-	0	-	-	-	-	-	-	5.83	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.55			-	0.08	-	-	0.11	0.43	-	0.74	-	-	-	-	-	0	-	-	-	-	-	-	5.83	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.55																																																																																				-			-	0.08	-	-	0.11	0.43	-	0.74	-	-	-	-	-	0	-	-	-	-	-	-	5.83	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.55
H0544_005_0	2007	8																																D	D	D	V	Coin	P	P	Coin	V	V	V	V	V	V	P	P	P	P	P	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-						47.83			8.57													29.59			1947.75		124																				20 Coins waived if admitted			20 Coins waived if admitted													20 Coins on drugs over 200 max 550			up to 20 Copay depending on svcs		25 Copay																				0.02			0.1													0.17			6.78		25																-	-	-	-	0.96	-	-	0.86	-	-	-	-	-	-	-	-	-	-	-	-	5.03	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.2			-	-	-	-	0.96	-	-	0.86	-	-	-	-	-	-	-	-	-	-	-	-	5.03	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.2																																																																																				-			-	-	-	-	0.96	-	-	0.86	-	-	-	-	-	-	-	-	-	-	-	-	5.03	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.2
H0544_007_0	2007	9																																D	D	D	V	T	Coin	P	V	V	V	V	V	V	V	V	P	P	P	P	P	Coin	P	P	P	P	P	P	P		P	P																																																				-		951.26	53.44			116.89	6.07		178.32						8.85	3045.51	4635.37					25.23			1947.75		123.96																100/day up to 400 max 800	150/admit deductible 0 days 91-150			50 Copay waived if admitted	20 Coin on amts over 500		50 Copay waived if admitted						15 SA Copay	5 Copay	10 Copay					20 Coins on drugs over 200 max 550			up to 20 depending on svc		25 Copay																46.15	18.31			5	0.05		25.03						0.75	5	10					0.17			6.78		25																3.66	0.08	-	-	0.05	0.3	-	0.37	-	-	-	-	-	0	1.27	3.86	-	-	-	-	4.29	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.24			3.66	0.08	-	-	0.05	0.3	-	0.37	-	-	-	-	-	0	1.27	3.86	-	-	-	-	4.29	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.24																																																																																				-			3.66	0.08	-	-	0.05	0.3	-	0.37	-	-	-	-	-	0	1.27	3.86	-	-	-	-	4.29	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.24
H0545_001_0	2007	2																					0											D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-	0	1353.04	60.57	1175.33		180.76	773.36	703.24	277.35	346.25		196.32	29.35		629.71	4505.97	6280.49	287.44	1088.72		825.21	22.07				113.91	268.15																1a: 75 days 1-6	1b: 75 days 1-6	2: 25 days 21-100	6:00	10a: 85	11a: 20	11b: 20 11c: 0	4a: 50 4b: 5/30	9b: 100	8a: 0	8a: 0/15 8b: 50	9a: 100	12:00	3 5 9c: 10; 9d: 0	7a 14c: 5 14b 14d 14e 14f 14g 14h 14i:  0	7b 7c 7d 7f 7i 16b 17a 18a:  10	7e 7h: 10	7b: 15 7c 7i: 10	0 (incl in i.2.)	7g: 10	15:10	13a 17b: 0	10b: 0	16a 16b: 0	17a: 15	17b: 25	18a: 0	18b: 0		14a:  0												61.2	61.2	3.13		85	21.07	20.6	49.97	100		44.55	100		98.44	5	10	10	10		10	0.1				15	25																6.9	0.31	0.31	-	1.28	1.36	1.21	1.15	2.89	-	0.73	0.24	-	5.17	1.88	5.23	0.24	0.91	-	0.69	2.21	-	-	-	0.14	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.39		0	6.9	0.31	0.31	-	1.28	1.36	1.21	1.15	2.89	-	0.73	0.24	-	5.17	1.88	5.23	0.24	0.91	-	0.69	2.21	-	-	-	0.14	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.39																																																																																				-		0	6.9	0.31	0.31	-	1.28	1.36	1.21	1.15	2.89	-	0.73	0.24	-	5.17	1.88	5.23	0.24	0.91	-	0.69	2.21	-	-	-	0.14	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.39
H0562_002_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		319.42	6.64	72.56	202.52	344.13	13.55	0.53	273.94	244.32	2.1	4.42	0.88	123.91	42.5	6385.76	5657	267.31	3381.39	1183.28	325.09	41.83	0	0	0	587.3	0	58.13	0	0	0	0											100 per day days 1-4	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	100 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	7 per office visit	10 per office visit	25 per office visit	0 per office visit	0 per office visit	10 per office visit	20 of Contracted Rate				10 per office visit		10 per office visit															291.51	900	287.14	0	125	0.2	0.2	50	100	0	275	0	25	0	7	10	25	0	0	10	0.2	0	0	0	10	0	10	0	0	0	0											7.76	0.5	1.74	-	3.58	2.71	0.11	1.14	2.04	-	0.1	-	0.26	-	3.73	4.71	0.56	-	-	0.27	8.37	-	-	-	0.49	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.1			7.76	0.5	1.74	-	3.58	2.71	0.11	1.14	2.04	-	0.1	-	0.26	-	3.73	4.71	0.56	-	-	0.27	8.37	-	-	-	0.49	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.1																									0																																									0																		-			7.76	0.5	1.74	-	3.58	2.71	0.11	1.14	2.04	-	0.1	-	0.26	-	3.73	4.71	0.56	-	-	0.27	8.37	-	-	-	0.49	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.1
H0562_009_0	2007	5																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		305.86	4.86	34.34	242.01	275.58	13.5	0.55	262.09	334.5	2.85	39.66	1.54	115.19	109.71	6597.82	6368.15	195.85	2478.22	1839.41	335.89	66.56	0	0	1000	1058.42	0	142.82	0	0	0	0											200 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	200 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	10 per office visit	25 per office visit	0 per office visit	0 per office visit	10 per office visit	20 of Contracted Rate	0		35 deductible	10 per office visit		10 per office visit															653.92	900	287.14	0	125	0.2	0.2	50	200	0	275	0	25	0	10	10	25	0	0	10	0.2	0	0	35	10	0	10	0	0	0	0											16.67	0.36	0.82	-	2.87	2.7	0.11	1.09	5.57	-	0.91	-	0.24	-	5.5	5.31	0.41	-	-	0.28	13.31	-	-	2.92	0.88	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.07			16.67	0.36	0.82	-	2.87	2.7	0.11	1.09	5.57	-	0.91	-	0.24	-	5.5	5.31	0.41	-	-	0.28	13.31	-	-	2.92	0.88	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.07																									0																																									0																		-			16.67	0.36	0.82	-	2.87	2.7	0.11	1.09	5.57	-	0.91	-	0.24	-	5.5	5.31	0.41	-	-	0.28	13.31	-	-	2.92	0.88	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.07
H0562_010_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		287.28	4.61	65.25	256.21	309.99	23.61	1.47	320.74	303.3	126.67	51.61	1.2	252.87	61.18	5839.83	5364.11	185.73	2858.33	1135	297.3	37.14	0	0	0	813.78	0	74.63	0	0	0	0											100 per day days 1-4	900 per admission	No charge	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	100 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	15 per office visit	25 per office visit	0 per office visit	0 per office visit	15 per office visit	20 of Contracted Rate				15 per office visit		15 per office visit															291.51	900	0	0	125	0.2	0.2	50	100	0	275	0	25	0	10	15	25	0	0	15	0.2	0	0	0	15	0	15	0	0	0	0											6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01																									0																																									0																		-			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01
H0562_011_0	2007	6																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		360.8	5.81	69.57	266.39	402.82	14.74	0.85	330.24	323.76	46.38	46.61	57.98	57.37	82.22	7874.52	7448.1	234.21	2928.61	2353.92	400.88	58.58	0	0	1000	669.19	0	75.61	0	0	0	0											175 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate	0		35 deductible	20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	10	20	25	0	0	20	0.2	0	0	35	20	0	20	0	0	0	0											17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	2.92	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.91			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	2.92	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.91																									0																																									0																		-			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	2.92	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.91
H0562_012_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		279.75	6.64	67.99	161.12	304.89	13.69	0.92	287.19	250	3.19	9.69	0.71	69.76	28.68	5898.65	5312.7	267.31	3293.31	1802.77	300.3	20.31	0	0	0	866.63	0	63.85	0	0	0	0											200 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	200 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	12 per office visit	25 per office visit	25 per office visit	0 per office visit	0 per office visit	10 per office visit	20 of Contracted Rate				25 per office visit		25 per office visit															653.92	900	287.14	0	125	0.2	0.2	50	200	0	275	0	25	0	12	25	25	0	0	10	0.2	0	0	0	25	0	25	0	0	0	0											15.24	0.5	1.63	-	3.18	2.74	0.18	1.2	4.17	-	0.22	-	0.15	-	5.9	11.07	0.56	-	-	0.25	4.06	-	-	-	1.81	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.97			15.24	0.5	1.63	-	3.18	2.74	0.18	1.2	4.17	-	0.22	-	0.15	-	5.9	11.07	0.56	-	-	0.25	4.06	-	-	-	1.81	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.97																									0																																									0																		-			15.24	0.5	1.63	-	3.18	2.74	0.18	1.2	4.17	-	0.22	-	0.15	-	5.9	11.07	0.56	-	-	0.25	4.06	-	-	-	1.81	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.97
H0562_017_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		295.89	6.64	95.55	342.68	251.08	14.1	0.84	286.66	175.95	43.49	0	0.66	27.02	18.45	5066.19	4753.7	267.31	2685.04	101.73	257.92	44.73	0	0	0	817.61	0	92.76	0	0	0	0											200 per day days 1-5	900 per admission	100 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	15 per office visit	25 per office visit	0 per office visit	0 per office visit	15 per office visit	20 of Contracted Rate				15 per office visit		15 per office visit															653.92	900	382.85	0	125	0.2	0.2	50	175	0	275	0	25	0	10	15	25	0	0	15	0.2	0	0	0	15	0	15	0	0	0	0											16.12	0.5	3.05	-	2.62	2.82	0.17	1.19	2.57	-	-	-	0.06	-	4.22	5.94	0.56	-	-	0.32	8.95	-	-	-	1.02	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22			16.12	0.5	3.05	-	2.62	2.82	0.17	1.19	2.57	-	-	-	0.06	-	4.22	5.94	0.56	-	-	0.32	8.95	-	-	-	1.02	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22																									0																																									0																		-			16.12	0.5	3.05	-	2.62	2.82	0.17	1.19	2.57	-	-	-	0.06	-	4.22	5.94	0.56	-	-	0.32	8.95	-	-	-	1.02	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22
H0562_036_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		305.86	4.86	34.34	242.01	275.58	13.5	0.55	262.09	334.5	2.85	39.66	1.54	115.19	109.71	6597.82	6368.15	195.85	2478.22	1839.41	335.89	66.56	0	0	0	1058.42	0	142.82	0	0	0	0											175 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	10	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	5.5	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.97			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	5.5	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.97																									0																																									0																		-			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	5.5	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.97
H0562_037_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		305.86	4.86	34.34	242.01	275.58	13.5	0.55	262.09	334.5	2.85	39.66	1.54	115.19	109.71	6597.82	6368.15	195.85	2478.22	1839.41	335.89	66.56	0	0	0	1058.42	0	142.82	0	0	0	0											Tier 1 200 Tier 2 175 days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	15 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	15	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	8.25	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	8.25	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71																									0																																									0																		-			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	8.25	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71
H0562_039_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		287.28	4.61	65.25	256.21	309.99	23.61	1.47	320.74	303.3	126.67	51.61	1.2	252.87	61.18	5839.83	5364.11	185.73	2858.33	1135	297.3	37.14	0	0	0	813.78	0	74.63	0	0	0	0											150 per day days 1-4	900 per admission	No charge	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	150 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	15 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															437.27	900	0	0	125	0.2	0.2	50	150	0	275	0	25	0	15	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											10.47	0.35	-	-	3.23	4.72	0.29	1.34	3.79	-	1.18	-	0.53	-	7.3	8.94	0.39	-	-	0.5	7.43	-	-	-	1.36	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.93			10.47	0.35	-	-	3.23	4.72	0.29	1.34	3.79	-	1.18	-	0.53	-	7.3	8.94	0.39	-	-	0.5	7.43	-	-	-	1.36	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.93																									0																																									0																		-			10.47	0.35	-	-	3.23	4.72	0.29	1.34	3.79	-	1.18	-	0.53	-	7.3	8.94	0.39	-	-	0.5	7.43	-	-	-	1.36	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.93
H0562_040_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		259.08	6.64	57.85	228.94	247.68	14.87	0.27	363.37	495.36	3.26	61.76	1.63	13.04	61.92	7604.18	6843.94	267.31	5585.86	895.36	387.12	54.38	0	0	0	823.61	0	147.34	0	0	0	0											200 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	200 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	15 per office visit	25 per office visit	25 per office visit	0 per office visit	0 per office visit	25 per office visit	20 of Contracted Rate				25 per office visit		25 per office visit															653.92	900	287.14	0	125	0.2	0.2	50	200	0	275	0	25	0	15	25	25	0	0	25	0.2	0	0	0	25	0	25	0	0	0	0											14.12	0.5	1.38	-	2.58	2.97	0.05	1.51	8.26	-	1.42	-	0.03	-	9.51	14.26	0.56	-	-	0.81	10.88	-	-	-	1.72	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.85			14.12	0.5	1.38	-	2.58	2.97	0.05	1.51	8.26	-	1.42	-	0.03	-	9.51	14.26	0.56	-	-	0.81	10.88	-	-	-	1.72	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.85																									0																																									0																		-			14.12	0.5	1.38	-	2.58	2.97	0.05	1.51	8.26	-	1.42	-	0.03	-	9.51	14.26	0.56	-	-	0.81	10.88	-	-	-	1.72	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.85
H0562_044_0	2007	7																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		319.42	6.64	72.56	202.52	344.13	13.55	0.53	273.94	244.32	2.1	4.42	0.88	123.91	42.5	6301.24	5657	267.31	3381.39	1183.28	325.09	41.83	0	0	1000	587.3	246	58.13	0	0	912	1261.42											100 per day days 1-4	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	100 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	7 per office visit	10 per office visit	25 per office visit	0 per office visit	0 per office visit	10 per office visit	20 of Contracted Rate	0		35 deductible	10 per office visit	0 per office visit	10 per office visit			0 per office visit	10 per office visit											291.51	900	287.14	0	125	0.2	0.2	50	100	0	275	0	25	0	7	10	25	0	0	10	0.2	0	0	35	10	0	10	0	0	0	10											7.76	0.5	1.74	-	3.58	2.71	0.11	1.14	2.04	-	0.1	-	0.26	-	3.68	4.71	0.56	-	-	0.27	8.37	-	-	2.92	0.49	-	0.05	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	42.02			7.76	0.5	1.74	-	3.58	2.71	0.11	1.14	2.04	-	0.1	-	0.26	-	3.68	4.71	0.56	-	-	0.27	8.37	-	-	2.92	0.49	-	0.05	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	42.02																									0																																									0																		-			7.76	0.5	1.74	-	3.58	2.71	0.11	1.14	2.04	-	0.1	-	0.26	-	3.68	4.71	0.56	-	-	0.27	8.37	-	-	2.92	0.49	-	0.05	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	42.02
H0562_045_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		287.28	4.61	65.25	256.21	309.99	23.61	1.47	320.74	303.3	126.67	51.61	1.2	252.87	61.18	5839.83	5364.11	185.73	2858.33	1135	297.3	37.14	0	0	0	813.78	0	74.63	0	0	0	0											100 per day days 1-4	900 per admission	No charge	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	100 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	15 per office visit	25 per office visit	0 per office visit	0 per office visit	15 per office visit	20 of Contracted Rate				15 per office visit		15 per office visit															291.51	900	0	0	125	0.2	0.2	50	100	0	275	0	25	0	10	15	25	0	0	15	0.2	0	0	0	15	0	15	0	0	0	0											6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01																																																																																				-			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01
H0562_046_0	2007	5																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		360.8	5.81	69.57	266.39	402.82	14.74	0.85	330.24	323.76	46.38	46.61	57.98	57.37	82.22	7770.29	7448.1	234.21	2928.61	2353.92	400.88	58.58	0	0	1000	669.19	0	75.61	0	0	0	0											175 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	12 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate	0		35 deductible	20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	12	20	25	0	0	20	0.2	0	0	35	20	0	20	0	0	0	0											17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	7.77	12.41	0.49	-	-	0.67	11.72	-	-	2.92	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.12			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	7.77	12.41	0.49	-	-	0.67	11.72	-	-	2.92	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.12																									0																																									0																		-			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	7.77	12.41	0.49	-	-	0.67	11.72	-	-	2.92	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.12
H0562_047_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		259.08	6.64	57.85	228.94	247.68	14.87	0.27	363.37	495.36	3.26	61.76	1.63	13.04	61.92	7604.18	6843.94	267.31	5585.86	895.36	387.12	54.38	0	0	0	823.61	0	147.34	0	0	0	0											200 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	200 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	15 per office visit	25 per office visit	25 per office visit	0 per office visit	0 per office visit	25 per office visit	20 of Contracted Rate				25 per office visit		25 per office visit															653.92	900	287.14	0	125	0.2	0.2	50	200	0	275	0	25	0	15	25	25	0	0	25	0.2	0	0	0	25	0	25	0	0	0	0											14.12	0.5	1.38	-	2.58	2.97	0.05	1.51	8.26	-	1.42	-	0.03	-	9.51	14.26	0.56	-	-	0.81	10.88	-	-	-	1.72	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.85			14.12	0.5	1.38	-	2.58	2.97	0.05	1.51	8.26	-	1.42	-	0.03	-	9.51	14.26	0.56	-	-	0.81	10.88	-	-	-	1.72	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.85																																																																																				-			14.12	0.5	1.38	-	2.58	2.97	0.05	1.51	8.26	-	1.42	-	0.03	-	9.51	14.26	0.56	-	-	0.81	10.88	-	-	-	1.72	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.85
H0562_048_0	2007	5																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		279.75	6.64	67.99	161.12	304.89	13.69	0.92	287.19	250	3.19	9.69	0.71	69.76	28.68	5820.58	5312.7	267.31	3293.31	1802.77	300.3	20.31	0	0	1000	866.63	246	63.85	0	0	912	1261.42											200 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	200 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	12 per office visit	25 per office visit	25 per office visit	0 per office visit	0 per office visit	10 per office visit	20 of Contracted Rate	0		35 deductible	25 per office visit	0 per office visit	25 per office visit			0 per office visit	10 per office visit											653.92	900	287.14	0	125	0.2	0.2	50	200	0	275	0	25	0	12	25	25	0	0	10	0.2	0	0	35	25	0	25	0	0	0	10											15.24	0.5	1.63	-	3.18	2.74	0.18	1.2	4.17	-	0.22	-	0.15	-	5.82	11.07	0.56	-	-	0.25	4.06	-	-	2.92	1.81	-	0.13	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	56.86			15.24	0.5	1.63	-	3.18	2.74	0.18	1.2	4.17	-	0.22	-	0.15	-	5.82	11.07	0.56	-	-	0.25	4.06	-	-	2.92	1.81	-	0.13	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	56.86																									0																																									0																		-			15.24	0.5	1.63	-	3.18	2.74	0.18	1.2	4.17	-	0.22	-	0.15	-	5.82	11.07	0.56	-	-	0.25	4.06	-	-	2.92	1.81	-	0.13	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	56.86
H0562_049_0	2007	4																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		305.86	4.86	34.34	242.01	275.58	13.5	0.55	262.09	334.5	2.85	39.66	1.54	115.19	109.71	6597.82	6368.15	195.85	2478.22	1839.41	335.89	66.56	0	0	1000	1058.42	0	142.82	0	0	0	0											200 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	200 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	10 per office visit	25 per office visit	0 per office visit	0 per office visit	10 per office visit	20 of Contracted Rate	0		35 deductible	10 per office visit		10 per office visit															653.92	900	287.14	0	125	0.2	0.2	50	200	0	275	0	25	0	10	10	25	0	0	10	0.2	0	0	35	10	0	10	0	0	0	0											16.67	0.36	0.82	-	2.87	2.7	0.11	1.09	5.57	-	0.91	-	0.24	-	5.5	5.31	0.41	-	-	0.28	13.31	-	-	2.92	0.88	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.07			16.67	0.36	0.82	-	2.87	2.7	0.11	1.09	5.57	-	0.91	-	0.24	-	5.5	5.31	0.41	-	-	0.28	13.31	-	-	2.92	0.88	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.07																									0																																									0																		-			16.67	0.36	0.82	-	2.87	2.7	0.11	1.09	5.57	-	0.91	-	0.24	-	5.5	5.31	0.41	-	-	0.28	13.31	-	-	2.92	0.88	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.07
H0562_050_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		305.86	4.86	34.34	242.01	275.58	13.5	0.55	262.09	334.5	2.85	39.66	1.54	115.19	109.71	6597.82	6368.15	195.85	2478.22	1839.41	335.89	66.56	0	0	0	1058.42	0	142.82	0	0	0	0											175 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	10	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	5.5	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.97			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	5.5	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.97																																																																																				-			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	5.5	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.97
H0562_051_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		305.86	4.86	34.34	242.01	275.58	13.5	0.55	262.09	334.5	2.85	39.66	1.54	115.19	109.71	6597.82	6368.15	195.85	2478.22	1839.41	335.89	66.56	0	0	0	1058.42	0	142.82	0	0	0	0											Tier 1 200 Tier 2 175 days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	15 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	15	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	8.25	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	8.25	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71																																																																																				-			14.58	0.36	0.82	-	2.87	2.7	0.11	1.09	4.88	-	0.91	-	0.24	-	8.25	10.61	0.41	-	-	0.56	13.31	-	-	-	1.76	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71
H0562_052_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		287.28	4.61	65.25	256.21	309.99	23.61	1.47	320.74	303.3	126.67	51.61	1.2	252.87	61.18	5839.83	5364.11	185.73	2858.33	1135	297.3	37.14	0	0	0	813.78	0	74.63	0	0	0	0											150 per day days 1-4	900 per admission	No charge	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	150 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	15 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															437.27	900	0	0	125	0.2	0.2	50	150	0	275	0	25	0	15	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											10.47	0.35	-	-	3.23	4.72	0.29	1.34	3.79	-	1.18	-	0.53	-	7.3	8.94	0.39	-	-	0.5	7.43	-	-	-	1.36	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.93			10.47	0.35	-	-	3.23	4.72	0.29	1.34	3.79	-	1.18	-	0.53	-	7.3	8.94	0.39	-	-	0.5	7.43	-	-	-	1.36	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.93																																																																																				-			10.47	0.35	-	-	3.23	4.72	0.29	1.34	3.79	-	1.18	-	0.53	-	7.3	8.94	0.39	-	-	0.5	7.43	-	-	-	1.36	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.93
H0562_053_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	238.73	2.42	0	0	223.28	23.76	1.1	371.3	362.04	0	1199.3	0	0.36	20.25	4898.6	6915.71	192.94	0	0	298.4	6.91	852.19	0	0	449.23	0	192.36	0	0	1000	0											Per Day: 150 (1-4)	Per Admit: 900	No Charge 100 Days Limit		125 per Ambulance Service	20 Based on Medicare Allowable Cost	20 Based on Medicare Allowable Cost	50 ER/ 20 UC	150 ASC / 150 OP		0-275 Based on Medicare Allowable Cost		25 RD	25 OP SA	10 PCP	20 SCP/ 10 Chiro	25 MH	No Charge	No Charge	20 per Visit	20 of Contracted Rate	20 Mdcr Cov Vision/Hearing			20 per Visit		20 per Visit															437.27	900	0	0	125	0.16	0.2	39.83	150	0	22.86	0	0.11	25	10	18.7	25	0	0	6.94	0.2	18.29	0	0	20	0	20	0	0	0	0											8.7	0.18	-	-	2.33	3.88	0.22	1.23	4.53	-	2.29	-	0.04	0.04	4.08	10.78	0.4	-	-	0.17	1.38	1.3	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.61	0	0	8.7	0.18	-	-	2.33	3.88	0.22	1.23	4.53	-	2.29	-	0.04	0.04	4.08	10.78	0.4	-	-	0.17	1.38	1.3	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.61	none																																																																																			-	0	0	8.7	0.18	-	-	2.33	3.88	0.22	1.23	4.53	-	2.29	-	0.04	0.04	4.08	10.78	0.4	-	-	0.17	1.38	1.3	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.61
H0562_054_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	238.73	2.42	0	0	223.28	23.76	1.1	371.3	362.04	0	1199.3	0	0.36	20.25	4898.6	6915.71	192.94	0	0	298.4	6.91	852.19	0	0	449.23	0	192.36	0	0	1000	0											Per Day: 150 (1-4)	Per Admit: 900	No Charge 100 Days Limit		125 per Ambulance Service	20 Based on Medicare Allowable Cost	20 Based on Medicare Allowable Cost	50 ER/ 20 UC	150 ASC / 150 OP		0-275 Based on Medicare Allowable Cost		25 RD	25 OP SA	10 PCP	20 SCP/ 10 Chiro	25 MH	No Charge	No Charge	20 per Visit	20 of Contracted Rate	20 Mdcr Cov Vision/Hearing			20 per Visit		20 per Visit															437.27	900	0	0	125	0.16	0.2	39.83	150	0	22.86	0	0.11	25	10	18.7	25	0	0	6.94	0.2	18.29	0	0	20	0	20	0	0	0	0											8.7	0.18	-	-	2.33	3.88	0.22	1.23	4.53	-	2.29	-	0.04	0.04	4.08	10.78	0.4	-	-	0.17	1.38	1.3	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.61	0	0	8.7	0.18	-	-	2.33	3.88	0.22	1.23	4.53	-	2.29	-	0.04	0.04	4.08	10.78	0.4	-	-	0.17	1.38	1.3	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.61	none																																																																																			-	0	0	8.7	0.18	-	-	2.33	3.88	0.22	1.23	4.53	-	2.29	-	0.04	0.04	4.08	10.78	0.4	-	-	0.17	1.38	1.3	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.61
H0562_055_0	2007	4																					none											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	316.69	2.61	1223.56	0	238.4	24.12	1.46	416.62	33.4	0	0	0	0.5	31.72	0	0	302.18	0	0	27.98	9.71	73.56	6000	0	0	0	0	0	0	1000	0											No Charge	Per Admit: 900	0 Day 1-20 / 50 Day 21-100		50 per Ambulance Service	15 of Contracted Rate	15 Coin/ 0 Diabetic Supplies	20 ER/ 0 UC	0 ASC / 0 OP	No Charge	No Charge		25 RD	10 OP SA	No Charge	0 SCP/ 10 (Routine) Chiro	10 MH	No Charge	No Charge	0 per Visit	20 of Contracted Rate																					0	900	11.8	0	50	0.12	0.15	13.22	0	0	0	0	0.12	10	0	0	10	0	0	0	0.2	0	0	0	0	0	0	0	0	0	0											-	0.2	1.2	-	0.99	2.95	0.22	0.46	-	-	-	-	0.06	0.03	-	-	0.25	-	-	-	1.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.3	0	0	-	0.2	1.2	-	0.99	2.95	0.22	0.46	-	-	-	-	0.06	0.03	-	-	0.25	-	-	-	1.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.3	none																																																																																			-	0	0	-	0.2	1.2	-	0.99	2.95	0.22	0.46	-	-	-	-	0.06	0.03	-	-	0.25	-	-	-	1.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.3
H0562_056_0	2007	5																					none											A	A	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	317.34	2.76	1232.34	0	247.2	27.03	1.62	396.28	398.39	0	32.81	0	0.41	413.66	6178.39	7233.98	235.81	822.06	44.55	246.95	9.21	1103.57	6000	2000	446.39	0	0	0	0	1000	1261											Per Day: 50 (1-8)	Per Admit: 900	0 Day 1-20 / 20 Day 21-100		75 per Ambulance Service	10 of Contracted Rate	10 Coin/ 0 Oxygen	50 ER/ 25 UC	25 ASC / 25 OP		10 Coin Contracted Rate		25 RD	25 OP SA	10 PCP	10 SCP/ 10 Chiro	25 MH	10 per Visit	10 Coin (OP Only)	10 per Visit	10 of Contracted Rate	10 Mdcr Cov Vision		35 Ded	10 per Visit						10 Chiro/Accu											191.43	900	4.72	0	75	0.06	0.1	41.53	25	0	0.08	0	0.12	10.9	10	9.99	25	10	0.01	0	0.1	9.26	0	17.5	10	0	0	0	0	0	10											5.06	0.21	0.48	-	1.54	1.65	0.16	1.37	0.83	-	2.46	-	0.05	0.38	5.15	6.02	0.49	0.69	0.26	-	0.92	0.85	-	2.92	0.37	-	-	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	32.92	0	0	5.06	0.21	0.48	-	1.54	1.65	0.16	1.37	0.83	-	2.46	-	0.05	0.38	5.15	6.02	0.49	0.69	0.26	-	0.92	0.85	-	2.92	0.37	-	-	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	32.92	none																																																																																			-	0	0	5.06	0.21	0.48	-	1.54	1.65	0.16	1.37	0.83	-	2.46	-	0.05	0.38	5.15	6.02	0.49	0.69	0.26	-	0.92	0.85	-	2.92	0.37	-	-	-	-	-	1.05	-	-	-	-	-	-	-	-	-	-	32.92
H0562_057_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		295.89	6.64	95.55	342.68	251.08	14.1	0.84	286.66	175.95	43.49	0	0.66	27.02	18.45	5066.19	4753.7	267.31	2685.04	101.73	257.92	44.73	0	0	0	817.61	0	92.76	0	0	0	0											200 per day days 1-5	900 per admission	100 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	15 per office visit	25 per office visit	0 per office visit	0 per office visit	15 per office visit	20 of Contracted Rate				15 per office visit		15 per office visit															653.92	900	382.85	0	125	0.2	0.2	50	175	0	275	0	25	0	10	15	25	0	0	15	0.2	0	0	0	15	0	15	0	0	0	0											16.12	0.5	3.05	-	2.62	2.82	0.17	1.19	2.57	-	-	-	0.06	-	4.22	5.94	0.56	-	-	0.32	8.95	-	-	-	1.02	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22			16.12	0.5	3.05	-	2.62	2.82	0.17	1.19	2.57	-	-	-	0.06	-	4.22	5.94	0.56	-	-	0.32	8.95	-	-	-	1.02	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22																																																																																				-			16.12	0.5	3.05	-	2.62	2.82	0.17	1.19	2.57	-	-	-	0.06	-	4.22	5.94	0.56	-	-	0.32	8.95	-	-	-	1.02	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22
H0562_058_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		287.28	4.61	65.25	256.21	309.99	23.61	1.47	320.74	303.3	126.67	51.61	1.2	252.87	61.18	5839.83	5364.11	185.73	2858.33	1135	297.3	37.14	0	0	0	813.78	0	74.63	0	0	0	0											100 per day days 1-4	900 per admission	No charge	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	100 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	15 per office visit	25 per office visit	0 per office visit	0 per office visit	15 per office visit	20 of Contracted Rate				15 per office visit		15 per office visit															291.51	900	0	0	125	0.2	0.2	50	100	0	275	0	25	0	10	15	25	0	0	15	0.2	0	0	0	15	0	15	0	0	0	0											6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01																									0																																									0																		-			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01
H0562_059_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	229.36	2.32	0	0	268.64	31.04	1.43	254.24	247.95	0	821.29	0	0.33	16.28	3739.22	5370.35	155.07	0	0	228.55	7.03	644.7	0	0	342.9	0	146.83	0	0	1000	0											Per Day: 150 (1-4)	Per Admit: 900	No Charge 100 Days Limit		125 per Ambulance Service	20 Based on Medicare Allowable Cost	20 Based on Medicare Allowable Cost	50 ER/ 20 UC	150 ASC / 150 OP		0-275 Based on Medicare Allowable Cost		25 RD	25 OP SA	10 PCP	20 SCP/ 10 Chiro	25 MH	No Charge	No Charge	20 per Visit	20 of Contracted Rate	20 Mdcr Cov Vision/Hearing			20 per Visit		20 per Visit															437.27	900	0	0	125	0.16	0.2	39.83	150	0	22.86	0	0.1	25	10	18.66	25	0	0	6.92	0.2	18.45	0	0	20	0	20	0	0	0	0											8.36	0.17	-	-	2.8	5.07	0.29	0.84	3.1	-	1.56	-	0.03	0.03	3.12	8.35	0.32	-	-	0.13	1.41	0.99	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39	0	0	8.36	0.17	-	-	2.8	5.07	0.29	0.84	3.1	-	1.56	-	0.03	0.03	3.12	8.35	0.32	-	-	0.13	1.41	0.99	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39	none																																																																																			-	0	0	8.36	0.17	-	-	2.8	5.07	0.29	0.84	3.1	-	1.56	-	0.03	0.03	3.12	8.35	0.32	-	-	0.13	1.41	0.99	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39
H0562_060_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	244.67	2.47	0	0	258.91	25.07	1.15	205.03	199.9	0	662.18	0	0.25	17.64	4496.94	6242.22	168.06	0	0	273.05	7.57	755.65	0	0	412.41	0	176.59	0	0	1000	0											Per Day: 150 (1-4)	Per Admit: 900	No Charge 100 Days Limit		125 per Ambulance Service	20 Based on Medicare Allowable Cost	20 Based on Medicare Allowable Cost	50 ER/ 20 UC	150 ASC / 150 OP		0-275 Based on Medicare Allowable Cost		25 RD	25 OP SA	10 PCP	20 SCP/ 10 Chiro	25 MH	No Charge	No Charge	20 per Visit	20 of Contracted Rate	20 Mdcr Cov Vision/Hearing			20 per Visit		20 per Visit															437.27	900	0	0	125	0.16	0.2	39.83	150	0	22.86	0	0.14	25	10	18.74	25	0	0	6.97	0.2	18.93	0	0	20	0	20	0	0	0	0											8.92	0.19	-	-	2.7	4.09	0.23	0.68	2.5	-	1.26	-	0.03	0.04	3.75	9.75	0.35	-	-	0.16	1.51	1.19	-	-	0.69	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.33	0	0	8.92	0.19	-	-	2.7	4.09	0.23	0.68	2.5	-	1.26	-	0.03	0.04	3.75	9.75	0.35	-	-	0.16	1.51	1.19	-	-	0.69	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.33	none																																																																																			-	0	0	8.92	0.19	-	-	2.7	4.09	0.23	0.68	2.5	-	1.26	-	0.03	0.04	3.75	9.75	0.35	-	-	0.16	1.51	1.19	-	-	0.69	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.33
H0562_061_0	2007	3																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	258.19	2.59	0	0	167.64	18.09	0.83	238.73	232.82	0	771.28	0	0.34	19.51	5298.5	7212.19	185.85	0	0	320.54	6.48	889.75	0	0	485.92	0	208.07	0	0	1000	0											Per Day: 150 (1-4)	Per Admit: 900	No Charge		125 per Ambulance Service	20 Based on Medicare Allowable Cost	20 Based on Medicare Allowable Cost	50 ER/ 20 UC	150 ASC / 150 OP		0-275 Based on Medicare Allowable Cost		25 RD	25 OP SA	10 PCP	20 SCP/ 10 Chiro	25 MH	No Charge	No Charge	20 per Visit	20 of Contracted Rate	20 Mdcr Cov Vision/Hearing			20 per Visit		20 per Visit															437.27	900	0	0	125	0.16	0.2	39.83	150	0	22.86	0	0.11	25	10	18.8	25	0	0	6.99	0.2	18.95	0	0	20	0	20	0	0	0	0											9.41	0.19	-	-	1.75	2.95	0.17	0.79	2.91	-	1.47	-	0.04	0.04	4.41	11.3	0.39	-	-	0.19	1.3	1.4	-	-	0.81	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.87	0	0	9.41	0.19	-	-	1.75	2.95	0.17	0.79	2.91	-	1.47	-	0.04	0.04	4.41	11.3	0.39	-	-	0.19	1.3	1.4	-	-	0.81	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.87	none																																																																																			-	0	0	9.41	0.19	-	-	1.75	2.95	0.17	0.79	2.91	-	1.47	-	0.04	0.04	4.41	11.3	0.39	-	-	0.19	1.3	1.4	-	-	0.81	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.87
H0562_062_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	262.54	2.66	0	0	214.82	32.32	1.49	443.27	432.25	0	1431.89	0	0.31	18.01	4526.64	6311.52	171.6	0	0	275.15	6.4	807.1	0	0	415.12	0	177.75	0	0	1000	0											Per Day: 150 (1-4)	Per Admit: 900	No Charge 100 Days Limit		125 per Ambulance Service	20 Based on Medicare Allowable Cost	20 Based on Medicare Allowable Cost	50 ER/ 20 UC	150 ASC / 150 OP		0-275 Based on Medicare Allowable Cost		25 RD	25 OP SA	10 PCP	20 SCP/ 10 Chiro	25 MH	No Charge	No Charge	20 per Visit	20 of Contracted Rate	20 Mdcr Cov Vision/Hearing			20 per Visit		20 per Visit															437.27	900	0	0	125	0.16	0.2	39.83	150	0	22.86	0	0.11	25	10	18.74	25	0	0	6.96	0.2	17.84	0	0	20	0	20	0	0	0	0											9.57	0.2	-	-	2.24	5.28	0.3	1.47	5.4	-	2.73	-	0.04	0.04	3.77	9.85	0.36	-	-	0.16	1.28	1.2	-	-	0.69	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.87	0	0	9.57	0.2	-	-	2.24	5.28	0.3	1.47	5.4	-	2.73	-	0.04	0.04	3.77	9.85	0.36	-	-	0.16	1.28	1.2	-	-	0.69	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.87	none																																																																																			-	0	0	9.57	0.2	-	-	2.24	5.28	0.3	1.47	5.4	-	2.73	-	0.04	0.04	3.77	9.85	0.36	-	-	0.16	1.28	1.2	-	-	0.69	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.87
H0562_063_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		287.28	4.61	65.25	256.21	309.99	23.61	1.47	320.74	303.3	126.67	51.61	1.2	252.87	61.18	5839.83	5364.11	185.73	2858.33	1135	297.3	37.14	0	0	0	813.78	0	74.63	0	0	0	0											100 per day days 1-4	900 per admission	No charge	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	100 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	15 per office visit	25 per office visit	0 per office visit	0 per office visit	15 per office visit	20 of Contracted Rate				15 per office visit		15 per office visit															291.51	900	0	0	125	0.2	0.2	50	100	0	275	0	25	0	10	15	25	0	0	15	0.2	0	0	0	15	0	15	0	0	0	0											6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01																																																																																				-			6.98	0.35	-	-	3.23	4.72	0.29	1.34	2.53	-	1.18	-	0.53	-	4.87	6.71	0.39	-	-	0.37	7.43	-	-	-	1.02	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.01
H0562_064_0	2007	2																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	229.36	2.32	0	0	268.64	31.04	1.43	254.24	247.95	0	821.29	0	0.33	16.28	3739.22	5370.35	155.07	0	0	228.55	7.03	644.7	0	0	342.9	0	146.83	0	0	1000	0											Per Day: 150 (1-4)	Per Admit: 900	No Charge 100 Days Limit		125 per Ambulance Service	20 Based on Medicare Allowable Cost	20 Based on Medicare Allowable Cost	50 ER/ 20 UC	150 ASC / 150 OP		0-275 Based on Medicare Allowable Cost		25 RD	25 OP SA	10 PCP	20 SCP/ 10 Chiro	25 MH	No Charge	No Charge	20 per Visit	20 of Contracted Rate	20 Mdcr Cov Vision/Hearing			20 per Visit		20 per Visit															437.27	900	0	0	125	0.16	0.2	39.83	150	0	22.86	0	0.1	25	10	18.66	25	0	0	6.92	0.2	18.45	0	0	20	0	20	0	0	0	0											8.36	0.17	-	-	2.8	5.07	0.29	0.84	3.1	-	1.56	-	0.03	0.03	3.12	8.35	0.32	-	-	0.13	1.41	0.99	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39	0	0	8.36	0.17	-	-	2.8	5.07	0.29	0.84	3.1	-	1.56	-	0.03	0.03	3.12	8.35	0.32	-	-	0.13	1.41	0.99	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39	none																																																																																			-	0	0	8.36	0.17	-	-	2.8	5.07	0.29	0.84	3.1	-	1.56	-	0.03	0.03	3.12	8.35	0.32	-	-	0.13	1.41	0.99	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39
H0562_068_0	2007	4																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		360.8	5.81	69.57	266.39	402.82	14.74	0.85	330.24	323.76	46.38	46.61	57.98	57.37	82.22	7874.52	7448.1	234.21	2928.61	2353.92	400.88	58.58	0	0	0	669.19	0	75.61	0	0	0	0											175 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	10	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	-	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.99			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	-	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.99																									0																																									0																		-			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	-	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.99
H0562_069_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		360.8	5.81	69.57	266.39	402.82	14.74	0.85	330.24	323.76	46.38	46.61	57.98	57.37	82.22	7874.52	7448.1	234.21	2928.61	2353.92	400.88	58.58	0	0	0	669.19	0	75.61	0	0	0	0											175 per day days 1-5	900 per admission	75 per day days 21-100	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	175 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	10 per office visit	20 per office visit	25 per office visit	0 per office visit	0 per office visit	20 per office visit	20 of Contracted Rate				20 per office visit		20 per office visit															572.18	900	287.14	0	125	0.2	0.2	50	175	0	275	0	25	0	10	20	25	0	0	20	0.2	0	0	0	20	0	20	0	0	0	0											17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	-	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.99			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	-	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.99																																																																																				-			17.2	0.44	1.66	-	4.2	2.95	0.17	1.38	4.72	-	1.07	-	0.12	-	6.56	12.41	0.49	-	-	0.67	11.72	-	-	-	1.12	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.99
H0562_070_0	2007	4																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	420.3	2.52	59.59	0	9.54	32.62	1.98	7.58	45.16	16.85	46.6	0	0.61	47.35	90.53	273.83	3.13	10.82	61.2	60.98	13.13	12.49	6000	0	0	0	0	0	0	1000	0											Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits	Medicare Level Benefits			No Charge		No Charge															0.06	0.06	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.21	0	0	0	0	0	0	0	0	0											25.61	0.15	10.07	-	2.25	7.7	0.47	1.79	10.66	3.98	11	-	0.14	11.17	21.36	64.62	0.74	2.55	14.44	14.39	3.44	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	209.15	0	0	25.61	0.15	10.07	-	2.25	7.7	0.47	1.79	10.66	3.98	11	-	0.14	11.17	21.36	64.62	0.74	2.55	14.44	14.39	3.44	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	209.15	none																																																																																			-	0	0	25.61	0.15	10.07	-	2.25	7.7	0.47	1.79	10.66	3.98	11	-	0.14	11.17	21.36	64.62	0.74	2.55	14.44	14.39	3.44	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	209.15
H0562_801_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		261.26	3.83	44.33	172.54	240.21	12.27	0.79	244.95	301.7	32.66	0.71	11.24	6.93	61.7	7258.48	6892.56	285.78	3584.34	1380.24	369.52	47.66	0	0	0	893.07	0	130.6	0	0	0	0											700 per admission	900 per admission	900 per admission	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	350 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	50 per office visit	50 per office visit	50 per office visit	0 per office visit	0 per office visit	50 per office visit	20 of Contracted Rate				50 per office visit		50 per office visit															700	900	900	0	125	0.2	0.2	50	350	0	275	0	25	0	50	50	50	0	0	50	0.2	0	0	0	50	0	50	0	0	0	0											15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31																																																																																				-			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31
H0562_803_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		261.26	3.83	44.33	172.54	240.21	12.27	0.79	244.95	301.7	32.66	0.71	11.24	6.93	61.7	7258.48	6892.56	285.78	3584.34	1380.24	369.52	47.66	0	0	0	893.07	0	130.6	0	0	0	0											700 per admission	900 per admission	900 per admission	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	350 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	50 per office visit	50 per office visit	50 per office visit	0 per office visit	0 per office visit	50 per office visit	20 of Contracted Rate				50 per office visit		50 per office visit															700	900	900	0	125	0.2	0.2	50	350	0	275	0	25	0	50	50	50	0	0	50	0.2	0	0	0	50	0	50	0	0	0	0											15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31																																																																																				-			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31
H0562_804_0	2007	3																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		261.26	3.83	44.33	172.54	240.21	12.27	0.79	244.95	301.7	32.66	0.71	11.24	6.93	61.7	7258.48	6892.56	285.78	3584.34	1380.24	369.52	47.66	0	0	0	893.07	0	130.6	0	0	0	0											700 per admission	900 per admission	900 per admission	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	350 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	50 per office visit	50 per office visit	50 per office visit	0 per office visit	0 per office visit	50 per office visit	20 of Contracted Rate				50 per office visit		50 per office visit															700	900	900	0	125	0.2	0.2	50	350	0	275	0	25	0	50	50	50	0	0	50	0.2	0	0	0	50	0	50	0	0	0	0											15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31																																																																																				-			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31
H0562_806_0	2007	2																																A	BP	A	V	T	Coin	Coin	V	V	V	V	O	V	O	V	V	V	V	P	V	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		261.26	3.83	44.33	172.54	240.21	12.27	0.79	244.95	301.7	32.66	0.71	11.24	6.93	61.7	7258.48	6892.56	285.78	3584.34	1380.24	369.52	47.66	0	0	0	893.07	0	130.6	0	0	0	0											700 per admission	900 per admission	900 per admission	No charge upon plan approval	125 for ambulance services	20 of contracted rate	20 of contracted rate	50 per ER visit	350 per surgical visit	0 per office visit	Adv Rad and Rad Thrpy above 1000	0 per office visit	25 per office visit	0 per office visit	50 per office visit	50 per office visit	50 per office visit	0 per office visit	0 per office visit	50 per office visit	20 of Contracted Rate				50 per office visit		50 per office visit															700	900	900	0	125	0.2	0.2	50	350	0	275	0	25	0	50	50	50	0	0	50	0.2	0	0	0	50	0	50	0	0	0	0											15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31																																																																																				-			15.24	0.29	3.32	-	2.5	2.45	0.16	1.02	8.8	-	0.02	-	0.01	-	30.24	28.72	1.19	-	-	1.54	9.53	-	-	-	3.72	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.31
H0564_003_0	2007	6																																Ded		Ded	V	Ded	Ded		V	Ded	Coin					P	P	P	P	P	P	Coin	O	V	P	V	V	V		V	O	O											54.65		5.69		1.29	2.12			5.18																																	68.92					868.32				231.37		114.28					8776.41	1835.17	137.02	1753.96	2438.2	28347.65	6.91	0	0	18.52	466.22	358.86	180.09		0	0	825.08														0				50		20 coin on complex pcdr					30	30	30	30	0	0	20 coinsurance	0		0/30/40 for cleaning x-rays	20/30	75 glasses/95 contacts	30				30											0	0	0	0	0	0	0	50	0	0.09	0	0	0	0	30	30	30	30	0	0	0.2	0	0	17.5	20	0	30	0	0	0	30											-	-	-	-	-	-	-	0.96	-	10.28	-	-	-	-	21.94	4.59	0.34	4.38	-	-	1.38	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	47.21	1900		54.65	-	5.69	-	1.29	2.12	-	0.96	5.18	10.28	-	-	-	-	21.94	4.59	0.34	4.38	-	-	1.38	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	116.13	0																																																																																			-			54.65	-	5.69	-	1.29	2.12	-	0.96	5.18	10.28	-	-	-	-	21.94	4.59	0.34	4.38	-	-	1.38	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	116.13
H0564_004_0	2007	7																					500											D		D	V	T	Coin		V	V	Coin					P	P	P	P	P	P	Coin			P	V	V	V				O											0		0	0	0	0		0	0	0					0	0	0	0	0	0	0			0	0	0	0				0											-		1437.04		1030.26	1629.73	216.54	19.94		240.78	216.17	84.17					10825.59	2263.66	169.01	2163.49	3007.49	34966.46	7.9			18.52	466.22	358.86	180.09				825.08											100/day for day 1-5		95/day for days 21-100	0	100	20 coinsurance		50	100	20 coin - complex					5	10	20	20	0	0	20 coinsurance			0/30/40 for cleaning x-rays	20	75 glasses/95 contacts	20				20											53.89		28.12	0	82.19	0.2		29.91	100	0.09					5	10	20	20	0	0	0.2			17.5	20	0	20				20											6.45	-	2.41	-	1.48	3.99	-	0.6	1.8	7.58	-	-	-	-	4.51	1.89	0.28	3.61	-	-	1.58	-	-	0.03	0.78	-	0.3	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	38.66		6.96	6.45	-	2.41	-	1.48	3.99	-	0.6	1.8	7.58	-	-	-	-	4.51	1.89	0.28	3.61	-	-	1.58	-	-	0.03	0.78	-	0.3	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	38.66	500																																																																																			-			6.45	-	2.41	-	1.48	3.99	-	0.6	1.8	7.58	-	-	-	-	4.51	1.89	0.28	3.61	-	-	1.58	-	-	0.03	0.78	-	0.3	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	38.66
H0564_005_0	2007	7																					375											D		D	V	T	Coin		V	V	Coin					P	P	P	P	P	P	Coin			P	V	V	V				O											0		0	0	0	0		0	0	0					0	0	0	0	0	0	0			0	0	0	0				0											-		1242.66		1077.69	1665.26	247.84	19.95		251.14	225.47	67.65					9174.3	1918.37	143.23	1833.48	2548.74	29632.8	7.96			18.52	405.44	312.08	180.09				825.08											75/day for first 5 days		100/day for days 21-100	0	100	20 coinsurance		50	100	20 coin - complex					5	10	10	10	0	0	20 coinsurance			0/30/40 for cleaning x-rays	20-Oct	75 glasses/95 contacts	10				20											41.37		29.6	0	80.01	0.2		25.25	100	0.09					5	10	10	10	0	0	0.2			17.5	20	0	10				20											4.28	-	2.66	-	1.65	3.99	-	0.53	1.88	6.09	-	-	-	-	3.82	1.6	0.12	1.53	-	-	1.59	-	-	0.03	0.68	-	0.15	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	31.97		4.41	4.28	-	2.66	-	1.65	3.99	-	0.53	1.88	6.09	-	-	-	-	3.82	1.6	0.12	1.53	-	-	1.59	-	-	0.03	0.68	-	0.15	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	31.97	375																																																																																			-			4.28	-	2.66	-	1.65	3.99	-	0.53	1.88	6.09	-	-	-	-	3.82	1.6	0.12	1.53	-	-	1.59	-	-	0.03	0.68	-	0.15	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	31.97
H0564_006_0	2007	8																					375											D		D	V	T	Coin		V	V	Coin					P	P	P	P	P	P	Coin			P	V	V	V				O											0		0	0	0	0		0	0	0					0	0	0	0	0	0	0			0	0	0	0				0											-		1219.11		899.11	1727.95	212.65	19.25		294.69	264.56	67.78					8588.31	1795.84	134.08	1716.37	2385.94	27740.07	7.64			18.52	466.22	358.86	180.09				825.08											75/day for first 5 days		65/day for days 21-100	0	100	20 coinsurance		50	75	20 coin - complex					5	10	20	20	0	0	20 coinsurance			0/30/40 for cleaning x-rays	20	75 glasses/95 contacts	20				20											41.37		19.24	0	79.74	0.2		31.66	75	0.09					5	10	20	20	0	0	0.2			17.5	20	0	20				20											4.2	-	1.44	-	1.41	3.85	-	0.78	1.65	6.1	-	-	-	-	3.58	1.5	0.22	2.86	-	-	1.53	-	-	0.03	0.78	-	0.3	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	31.61		4.87	4.2	-	1.44	-	1.41	3.85	-	0.78	1.65	6.1	-	-	-	-	3.58	1.5	0.22	2.86	-	-	1.53	-	-	0.03	0.78	-	0.3	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	31.61	375																																																																																			-			4.2	-	1.44	-	1.41	3.85	-	0.78	1.65	6.1	-	-	-	-	3.58	1.5	0.22	2.86	-	-	1.53	-	-	0.03	0.78	-	0.3	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	31.61
H0564_007_0	2007	7																					2100											D		D	V	T	Coin		V	V	Coin					P	P	P	P	P	P	Coin			P	V	V	V				O											0		0	0	0	0		0	0	0					0	0	0	0	0	0	0			0	0	0	0				0											-		1346.51		1127.89	772.42	244.82	22.36		184.01	165.2	67.7					9129	1908.9	142.53	1824.43	2536.15	29486.5	8.97			18.52	466.22	358.86	180.09				825.08											75/day for first 28 days		80/day for days 21-100	0	100	20 coinsurance		50	100	20 coin - complex					5	10	10	10	0	0	20 coinsurance			0/30/40 for cleaning x-rays	20-Oct	75 glasses/95 contacts	10				20											75.3		23.68	0	98.98	0.2		48.29	100	0.09					5	10	10	10	0	0	0.2			17.5	20	0	10				20											8.45	-	2.23	-	2.02	4.47	-	0.74	1.38	6.09	-	-	-	-	3.8	1.59	0.12	1.52	-	-	1.79	-	-	0.03	0.78	-	0.15	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	36.53		0.73	8.45	-	2.23	-	2.02	4.47	-	0.74	1.38	6.09	-	-	-	-	3.8	1.59	0.12	1.52	-	-	1.79	-	-	0.03	0.78	-	0.15	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	36.53	2100																																																																																			-			8.45	-	2.23	-	2.02	4.47	-	0.74	1.38	6.09	-	-	-	-	3.8	1.59	0.12	1.52	-	-	1.79	-	-	0.03	0.78	-	0.15	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	36.53
H0564_009_0	2007	5																																Ded		Ded	V	Ded	Ded		V	Ded	Coin					P	P	P	P	P	P	Coin	O	V	P	V	V	V		V	O	O											43.77		6.97		3.03	3.16			6.67																																	63.6					1177.49				227.47		98.85					8616.01	1801.63	134.52	1721.9	2393.64	27829.55	6.93	0	0	18.52	466.22	358.86	180.09		0	0	825.08														0				50		20 coin - complex					10	25	25	25	0	0	20 coinsurance	0		0/30/40 for cleaning x-rays	20/25	75 glasses/95 contacts	25				25											0	0	0	0	0	0	0	50	0	0.09	0	0	0	0	10	25	25	25	0	0	0.2	0	0	17.5	20	0	25	0	0	0	25											-	-	-	-	-	-	-	0.95	-	8.9	-	-	-	-	7.18	3.75	0.28	3.59	-	-	1.39	-	-	0.03	0.78	-	0.38	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	28.93	2000		43.77	-	6.97	-	3.03	3.16	-	0.95	6.67	8.9	-	-	-	-	7.18	3.75	0.28	3.59	-	-	1.39	-	-	0.03	0.78	-	0.38	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	92.53																																																																																				-			43.77	-	6.97	-	3.03	3.16	-	0.95	6.67	8.9	-	-	-	-	7.18	3.75	0.28	3.59	-	-	1.39	-	-	0.03	0.78	-	0.38	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	92.53
H0564_040_0	2007	8																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		410.24	35.7	60.03	75.15	16.32	59.82	3.7	11.13	13.99	9.73	20	0	23.78	20.87	30.37	46.88	9.88	7.22	30.14	144.15	24.76	3.25	5	0	0	0	0	0	0	2.5	15											FFS Medicare: PBP 1a	FFS Medicare: PBP 1b	FFS Medicare: PBP 2	FFS Medicare: PBP 6	FFS Medicare: PBP 10a	FFS Medicare: PBP 11a	FFS Medicare: PBP 11b 11c	FFS Medicare: PBP 4a 4b	FFS Medicare: PBP 9a 9b	FFS Medicare: PBP 8a	FFS Medicare: PBP 8b	FFS Medicare:	FFS Medicare: PBP 12	FFS Medicare: PBP 3 5 9a 9c 9d 13a 13b	FFS Medicare: PBP 4b 7a 14b-i	FFS Medicare: PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	FFS Medicare: PBP 7e 7h	FFS Medicare: PBP 7c 7i	FFS Medicare: PBP 7d	FFS Medicare: PBP 7d 7g	FFS Medicare: PBP 15	FFS Medicare: PBP 7g																				0.06	0.06	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				25.76	2.24	9.52	-	3.85	14.12	0.87	2.63	3.3	2.3	4.72	-	5.61	4.93	7.17	11.06	2.33	1.7	7.11	34.02	5.84	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.86	138	0	25.76	2.24	9.52	-	3.85	14.12	0.87	2.63	3.3	2.3	4.72	-	5.61	4.93	7.17	11.06	2.33	1.7	7.11	34.02	5.84	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.86																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	25.76	2.24	9.52	-	3.85	14.12	0.87	2.63	3.3	2.3	4.72	-	5.61	4.93	7.17	11.06	2.33	1.7	7.11	34.02	5.84	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.86
H0564_044_0	2007	6																					2000											D		D	V	T	Coin		V	V	Coin					P	P	P	P	P	P	Coin			P	V	V	V				O											0		0	0	0	0		0	0	0					0	0	0	0	0	0	0			0	0	0	0				0											-		1437.04		1030.26	1629.73	216.54	17.62		240.78	216.17	89.66					10825.59	2263.66	169.01	2163.49	3007.49	34966.46	6.95			18.52	466.22	358.86	180.09				825.08											200/day		25/day for days 21-100	0	100	20 coinsurance		50	200	20 coin - complex					30	30	30	30	0	0	20 coinsurance			0/30/40 for cleaning x-rays	20/30	75 glasses/95 contacts	30				30											144.2		7.4	0	92.08	0.2		41.07	200	0.09					30	30	30	30	0	0	0.2			17.5	20	0	30				30											17.27	-	0.64	-	1.66	3.52	-	0.82	3.6	8.07	-	-	-	-	27.06	5.66	0.42	5.41	-	-	1.39	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	78.85		7.54	17.27	-	0.64	-	1.66	3.52	-	0.82	3.6	8.07	-	-	-	-	27.06	5.66	0.42	5.41	-	-	1.39	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	78.85	2000																																																																																			-			17.27	-	0.64	-	1.66	3.52	-	0.82	3.6	8.07	-	-	-	-	27.06	5.66	0.42	5.41	-	-	1.39	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	78.85
H0564_045_0	2007	4																																Ded		Ded	V	Ded	Ded		V	Ded	Coin					P	P	P	P	P	P	Coin	O	V	P	V	V	V		V	O	O											49.81		5.82		1.28	2.74			5.58																																	65.24					1665.26				251.14		89.15					10549.5	2205.93	164.7	2108.31	2930.79	34074.69	6.44	0	0	18.52	466.22	358.86	180.09		0	0	825.08														0				50		20 coin - complex					25	25	25	25	0	0	20 coinsurance	0		0/30/40 for cleaning x-rays	20/25	75 glasses/95 contacts	25				25											0	0	0	0	0	0	0	50	0	0.09	0	0	0	0	25	25	25	25	0	0	0.2	0	0	17.5	20	0	25	0	0	0	25											-	-	-	-	-	-	-	1.05	-	8.02	-	-	-	-	21.98	4.6	0.34	4.39	-	-	1.29	-	-	0.03	0.78	-	0.38	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	44.57	2000		49.81	-	5.82	-	1.28	2.74	-	1.05	5.58	8.02	-	-	-	-	21.98	4.6	0.34	4.39	-	-	1.29	-	-	0.03	0.78	-	0.38	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	109.81																																																																																				-			49.81	-	5.82	-	1.28	2.74	-	1.05	5.58	8.02	-	-	-	-	21.98	4.6	0.34	4.39	-	-	1.29	-	-	0.03	0.78	-	0.38	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	109.81
H0564_046_0	2007	4																																Ded		Ded	V	Ded	Ded		V	Ded	Coin					P	P	P	P	P	P	Coin	O	V	P	V	V	V		V	O	O											50.56		5.19		1.49	2.95			7.31																																	67.49					1177.49				227.47		126.79					8616.01	1801.63	134.52	1721.9	2393.64	27829.55	7.57	0	0	18.52	466.22	358.86	180.09		0	0	825.08														0				50		20 coinsurance					25	30	30	30	0	0	20 coinsurance	0		0/30/40 for cleaning x-rays	20/30	75 glasses/95 contacts	30				30											0	0	0	0	0	0	0	50	0	0.09	0	0	0	0	25	30	30	30	0	0	0.2	0	0	17.5	20	0	30	0	0	0	30											-	-	-	-	-	-	-	0.95	-	11.41	-	-	-	-	17.95	4.5	0.34	4.3	-	-	1.51	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	44.28	2000		50.56	-	5.19	-	1.49	2.95	-	0.95	7.31	11.41	-	-	-	-	17.95	4.5	0.34	4.3	-	-	1.51	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	111.77																																																																																				-			50.56	-	5.19	-	1.49	2.95	-	0.95	7.31	11.41	-	-	-	-	17.95	4.5	0.34	4.3	-	-	1.51	-	-	0.03	0.78	-	0.45	-	-	-	2.06	-	-	-	-	-	-	-	-	-	-	111.77
H0564_801_0	2007	3																																Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0																																									-		282.86		34.85	22.01	10.06	7.59		15.54	27.31					67.98	104.9	131.12	16.39	16.39	26.22	32.78	10.83																					Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.06		0.17		0.24	0.24		0.24	0.24					0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					17.24	-	5.81	-	2.37	1.79	-	3.67	6.44	-	-	-	-	16.04	24.76	30.94	3.87	3.87	6.19	7.74	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.29			17.24	-	5.81	-	2.37	1.79	-	3.67	6.44	-	-	-	-	16.04	24.76	30.94	3.87	3.87	6.19	7.74	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.29																																																																																				-			17.24	-	5.81	-	2.37	1.79	-	3.67	6.44	-	-	-	-	16.04	24.76	30.94	3.87	3.87	6.19	7.74	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.29
H0564_810_0	2007	2																																Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0																																									-		282.86		34.85	22.01	10.06	7.59		15.54	27.31					67.98	104.9	131.12	16.39	16.39	26.22	32.78	10.83																					Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.06		0.17		0.24	0.24		0.24	0.24					0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					17.24	-	5.81	-	2.37	1.79	-	3.67	6.44	-	-	-	-	16.04	24.76	30.94	3.87	3.87	6.19	7.74	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.29			17.24	-	5.81	-	2.37	1.79	-	3.67	6.44	-	-	-	-	16.04	24.76	30.94	3.87	3.87	6.19	7.74	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.29																																																																																				-			17.24	-	5.81	-	2.37	1.79	-	3.67	6.44	-	-	-	-	16.04	24.76	30.94	3.87	3.87	6.19	7.74	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.29
H0571_001_0	2007	2																					3000											D	D	D	V	T	Coin	Coin	V	V					V	V	V	V	V		V		V			V		V				V																																																				-		486.1	8.7	343.1	0	121.5	8.42	5.25	325.6	250.1					247.6	3265.2	3033.3	125.5	1031.8		960.2		519.7			300.3		128.7				178.4											225/day for days 1-5	225/day for days 1-5	100/day for days 1-20		100/run	20 coinsurance	20 prosth/supplies 0 diab supplies	50 ER 15 urgent care	175/visit					25 CORF visit	15/visit	15/visit	15/visit	25/visit		15/visit for chiro pod hearing		15/visit for MC vision exams dental			15/visit		15/visit				15/visit for acupuncture											225	225	100	0	100	0.2	0.18	41.42	175					25	15	15	15	25		15		15			15		15				15											9.11	0.16	2.86	-	1.01	1.68	0.96	1.12	3.65	-	-	-	-	0.52	4.08	3.79	0.16	2.15	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	33.86		0	9.11	0.16	2.86	-	1.01	1.68	0.96	1.12	3.65	-	-	-	-	0.52	4.08	3.79	0.16	2.15	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	33.86																																																																																				-			9.11	0.16	2.86	-	1.01	1.68	0.96	1.12	3.65	-	-	-	-	0.52	4.08	3.79	0.16	2.15	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	33.86
H0571_002_0	2007	3																																D	D	D		T	Coin	Coin	V	V					V	V	V	V	V		V		V			V		V				V																																																				-		486.1	8.7	343.1		121.5	8.42	5.25	325.6	250.1					247.6	3265.2	3033.3	125.5	1031.8		960.2		519.7			300.3		128.7				178.4											225/day for days 1-5	225/day for days 1-5	100/day for days 1-20		100/run	20 coinsurance	20 prosth/supplies 0 diab supplies	50 ER 15 urgent care	175/visit					25 CORF visit	15/visit	15/visit	15/visit	25/visit		15/visit for chiro pod hearing		15/visit for MC vision exams dental			15/visit		15/visit				15/visit for acupuncture											225	225	100		100	0.2	0.18	41.42	175					25	15	15	15	25		15		15			15		15				15											9.11	0.16	2.86	-	1.01	1.68	0.96	1.12	3.65	-	-	-	-	0.52	4.08	3.79	0.16	2.15	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	33.86			9.11	0.16	2.86	-	1.01	1.68	0.96	1.12	3.65	-	-	-	-	0.52	4.08	3.79	0.16	2.15	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	33.86																																																																																				-			9.11	0.16	2.86	-	1.01	1.68	0.96	1.12	3.65	-	-	-	-	0.52	4.08	3.79	0.16	2.15	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	33.86
H0571_005_0	2007	3																					3000											D	D	D	V	T	Coin	Coin	V	V					V	V	V	V	V		V		V			V		V				V																																																				-		615.2	9.9	444.7	0	165	11.24	7.11	414.3	310.1					315.8	4558.9	4075.1	167.2	1356.3		1179.9		710.4			414.9		177.8				198											225/day for days 1-5	225/day for days 1-5	75/day for days 1-20		100/run	20 coinsurance	20 prosth/supplies 0 diab supplies	50 ER 15 urgent care	100/visit					20 CORF visit	5/visit PCP 10 phys. exam	10/visit	10/visit	20/visit		10/visit for chiro pod hearing		10/visit for MC vision exams dental			10/visit		10/visit				10/visit for acupuncture											225	225	75	0	100	0.2	0.18	39.47	100					20	5.06	10	10	20		10		10			10		10				10											11.54	0.19	2.78	-	1.38	2.25	1.3	1.36	2.58	-	-	-	-	0.53	1.92	3.4	0.14	2.26	-	0.98	-	0.59	-	-	0.35	-	0.15	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	33.85		0	11.54	0.19	2.78	-	1.38	2.25	1.3	1.36	2.58	-	-	-	-	0.53	1.92	3.4	0.14	2.26	-	0.98	-	0.59	-	-	0.35	-	0.15	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	33.85																																																																																				-			11.54	0.19	2.78	-	1.38	2.25	1.3	1.36	2.58	-	-	-	-	0.53	1.92	3.4	0.14	2.26	-	0.98	-	0.59	-	-	0.35	-	0.15	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	33.85
H0571_801_0	2007	1																					3000											D	D	D		T	Coin	Coin	V	V					V	V	V	V	V		V		V			V		V				V																																																				-		487.2	8.7	343.1		121.5	8.42	5.25	325.6	250.1					247.6	3265.2	3033.3	125.5	1049.3		960.2		519.7			300.3		128.7				178.4											200/day for days 1-5	200/day for days 1-5	100/day for days 1-20		100/run	20 coinsurance	20 prosth/supplies 0 diab supplies	50 ER 15 urgent care	150/visit					20 CORF visit	15/visit	15/visit	15/visit	20/visit		15/visit for chiro pod hearing		15/visit for MC vision exams dental			15/visit		15/visit				15/visit for acupuncture											200	200	100		100	0.2	0.18	41.42	150					20	15	15	15	20		15		15			15		15				15											8.12	0.15	2.86	-	1.01	1.68	0.96	1.12	3.13	-	-	-	-	0.41	4.08	3.79	0.16	1.75	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	31.83		0	8.12	0.15	2.86	-	1.01	1.68	0.96	1.12	3.13	-	-	-	-	0.41	4.08	3.79	0.16	1.75	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	31.83																																																																																				-			8.12	0.15	2.86	-	1.01	1.68	0.96	1.12	3.13	-	-	-	-	0.41	4.08	3.79	0.16	1.75	-	1.2	-	0.65	-	-	0.38	-	0.16	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	31.83
H0609_002_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1469.68	39.81	2198.65	1712.3	282.11	15.85	1.11	422	501.95	951.36	28.5	38.81	5.6	804.65	6114.44	4292.56	219.52	527.85	31.97	28614.28	12.59	0	0	0	108.98	246.31	194.77	34.95	0	0	627.26											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	10	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	68	0	100	0.2	0.2	49.45	150	0	0.15	0	0	102.6	10	30	30	30	0.27	0	0.2	0	0	0	30	30	0	0	0	0	0											11.99	0.36	12.46	-	2.35	3.11	0.22	1.74	6.27	-	4.39	-	-	6.88	5.1	10.73	0.55	1.32	8.62	0.01	2.52	-	-	-	0.27	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.52	0	0	11.99	0.36	12.46	-	2.35	3.11	0.22	1.74	6.27	-	4.39	-	-	6.88	5.1	10.73	0.55	1.32	8.62	0.01	2.52	-	-	-	0.27	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.52	None																																																																																			-	0	0	11.99	0.36	12.46	-	2.35	3.11	0.22	1.74	6.27	-	4.39	-	-	6.88	5.1	10.73	0.55	1.32	8.62	0.01	2.52	-	-	-	0.27	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.52
H0609_003_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1339.66	36.29	1404.59	2032.88	354.28	17.15	1.2	428.56	391.29	898.89	36.02	30.25	4.86	627.26	5962.07	4178.54	219.52	537.06	40.39	26776.91	12.59	0	0	0	126.62	286.18	226.3	40.6	0	0	717.65											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	74	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.25	0	0.2	0	0	0	30	30	0	0	0	0	0											14.57	0.33	8.66	-	2.95	3.37	0.24	1.77	6.52	-	5.55	-	-	7.09	7.45	10.45	0.55	1.34	10.14	0.01	2.52	-	-	-	0.32	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.54	0	0	14.57	0.33	8.66	-	2.95	3.37	0.24	1.77	6.52	-	5.55	-	-	7.09	7.45	10.45	0.55	1.34	10.14	0.01	2.52	-	-	-	0.32	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.54	None																																																																																			-	0	0	14.57	0.33	8.66	-	2.95	3.37	0.24	1.77	6.52	-	5.55	-	-	7.09	7.45	10.45	0.55	1.34	10.14	0.01	2.52	-	-	-	0.32	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.54
H0609_006_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1722.13	46.65	1732.8	2222.09	437.06	20.55	1.43	520.6	482.72	1108.92	43.17	37.32	5.83	773.83	7355.2	5144.88	219.52	662.56	48.41	32972.82	12.59	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											100 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											65.26	109.69	67	0	100	0.2	0.2	49.45	100	0	0.15	0	0	69.59	13.09	21.49	30	20	0.26	0	0.2	0	0	0	30	30	0	0	0	0	0											9.37	0.43	9.67	-	3.64	4.04	0.29	2.15	4.02	-	6.65	-	-	4.49	8.02	9.21	0.55	1.1	12.39	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.46	0	0	9.37	0.43	9.67	-	3.64	4.04	0.29	2.15	4.02	-	6.65	-	-	4.49	8.02	9.21	0.55	1.1	12.39	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.46	None																																																																																			-	0	0	9.37	0.43	9.67	-	3.64	4.04	0.29	2.15	4.02	-	6.65	-	-	4.49	8.02	9.21	0.55	1.1	12.39	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.46
H0609_007_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1395.94	37.81	1404.59	1801.21	354.28	15.75	1.1	422	391.29	898.89	33.1	30.25	4.47	627.26	5962.07	4170.4	219.52	537.06	37.12	26727.51	12.59	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	10	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	67	0	100	0.2	0.2	49.45	150	0	0.15	0	0	102.6	10	30	30	30	0.27	0	0.2	0	0	0	30	30	0	0	0	0	0											11.39	0.35	7.84	-	2.95	3.09	0.22	1.74	4.89	-	5.1	-	-	5.36	4.97	10.43	0.55	1.34	9.86	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.53	0	0	11.39	0.35	7.84	-	2.95	3.09	0.22	1.74	4.89	-	5.1	-	-	5.36	4.97	10.43	0.55	1.34	9.86	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.53	None																																																																																			-	0	0	11.39	0.35	7.84	-	2.95	3.09	0.22	1.74	4.89	-	5.1	-	-	5.36	4.97	10.43	0.55	1.34	9.86	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.53
H0609_011_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1469.68	39.81	2198.65	1759.41	191.58	16.86	1.18	428.56	501.95	891.66	29.56	38.81	5.55	804.65	6394.49	4652.12	219.52	371.55	33.16	28222.79	12.59	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	68	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.27	0	0.2	0	0	0	30	30	0	0	0	0	0											15.99	0.36	12.46	-	1.6	3.31	0.24	1.77	8.37	-	4.55	-	-	9.09	7.99	11.63	0.55	0.93	9	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.26	0	0	15.99	0.36	12.46	-	1.6	3.31	0.24	1.77	8.37	-	4.55	-	-	9.09	7.99	11.63	0.55	0.93	9	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.26	None																																																																																			-	0	0	15.99	0.36	12.46	-	1.6	3.31	0.24	1.77	8.37	-	4.55	-	-	9.09	7.99	11.63	0.55	0.93	9	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.26
H0609_012_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1142.58	30.95	1149.66	1474.29	289.97	13.05	0.91	345.4	320.27	735.74	27.43	24.76	3.7	513.41	4879.95	3413.47	219.52	439.59	30.76	21876.47	12.59	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	67	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.26	0	0.2	0	0	0	30	30	0	0	0	0	0											12.43	0.28	6.42	-	2.42	2.56	0.18	1.42	5.34	-	4.22	-	-	5.8	6.1	8.53	0.55	1.1	8.1	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.91	0	0	12.43	0.28	6.42	-	2.42	2.56	0.18	1.42	5.34	-	4.22	-	-	5.8	6.1	8.53	0.55	1.1	8.1	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.91	None																																																																																			-	0	0	12.43	0.28	6.42	-	2.42	2.56	0.18	1.42	5.34	-	4.22	-	-	5.8	6.1	8.53	0.55	1.1	8.1	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.91
H0609_013_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1469.68	39.81	2198.65	1801.21	252.37	16.64	1.16	432.5	501.95	931.75	29.67	38.81	5.74	804.65	6206.43	4410.67	219.52	418.01	33.27	28537.8	12.59	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.27	0	0.2	0	0	0	30	30	0	0	0	0	0											15.99	0.36	11.36	-	2.1	3.27	0.23	1.78	8.37	-	4.57	-	-	9.09	7.76	11.03	0.55	1.05	8.83	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.78	0	0	15.99	0.36	11.36	-	2.1	3.27	0.23	1.78	8.37	-	4.57	-	-	9.09	7.76	11.03	0.55	1.05	8.83	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.78	None																																																																																			-	0	0	15.99	0.36	11.36	-	2.1	3.27	0.23	1.78	8.37	-	4.57	-	-	9.09	7.76	11.03	0.55	1.05	8.83	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.78
H0609_014_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1437.28	38.93	1404.59	1759.41	354.28	16.92	1.18	422	391.29	898.89	35.55	30.25	4.8	627.26	5962.07	4170.4	219.52	537.06	39.87	26778.44	12.59	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	74	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.25	0	0.2	0	0	0	30	30	0	0	0	0	0											15.63	0.36	8.66	-	2.95	3.32	0.24	1.74	6.52	-	5.47	-	-	7.09	7.45	10.43	0.55	1.34	10.09	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.29	0	0	15.63	0.36	8.66	-	2.95	3.32	0.24	1.74	6.52	-	5.47	-	-	7.09	7.45	10.43	0.55	1.34	10.09	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.29	None																																																																																			-	0	0	15.63	0.36	8.66	-	2.95	3.32	0.24	1.74	6.52	-	5.47	-	-	7.09	7.45	10.43	0.55	1.34	10.09	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.29
H0609_015_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1469.68	39.81	2198.65	1712.3	252.37	15.45	1.08	422	501.95	931.75	27.55	38.81	5.33	804.65	6206.43	4410.67	219.52	418.01	30.89	28474.25	12.59	0	0	0	108.98	246.31	194.77	34.95	0	0	627.26											0 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	20 2 exams/yr	0 1/yr	0	0 exam /yr	800 3/yrs	Not Covered	0	Acupuncture: 10 / 12 visits yr; Routine Chiropractic: 10 / 12 visits yr											0	109.69	62	0	100	0.2	0.2	49.45	0	0	0.15	0	0	3.58	4.68	4.46	30	0	0.28	0	0.2	0	0	0	0	0	0	0	0	0	8.9											-	0.36	11.36	-	2.1	3.03	0.22	1.74	-	-	4.24	-	-	0.24	2.42	1.64	0.55	-	8.62	-	2.52	-	-	-	-	-	-	-	-	-	0.47	-	-	-	-	-	-	-	-	-	-	39.51	0	0	-	0.36	11.36	-	2.1	3.03	0.22	1.74	-	-	4.24	-	-	0.24	2.42	1.64	0.55	-	8.62	-	2.52	-	-	-	-	-	-	-	-	-	0.47	-	-	-	-	-	-	-	-	-	-	39.51	None																																																																																			-	0	0	-	0.36	11.36	-	2.1	3.03	0.22	1.74	-	-	4.24	-	-	0.24	2.42	1.64	0.55	-	8.62	-	2.52	-	-	-	-	-	-	-	-	-	0.47	-	-	-	-	-	-	-	-	-	-	39.51
H0609_018_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1395.94	37.81	1404.59	1801.21	354.28	15.42	1.08	422	391.29	898.89	32.4	30.25	4.37	627.26	5962.07	4170.4	219.52	537.06	36.33	26727.51	12.59	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.27	0	0.2	0	0	0	30	30	0	0	0	0	0											15.18	0.35	7.26	-	2.95	3.03	0.22	1.74	6.52	-	4.99	-	-	7.09	7.45	10.43	0.55	1.34	9.79	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.33	0	0	15.18	0.35	7.26	-	2.95	3.03	0.22	1.74	6.52	-	4.99	-	-	7.09	7.45	10.43	0.55	1.34	9.79	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.33	None																																																																																			-	0	0	15.18	0.35	7.26	-	2.95	3.03	0.22	1.74	6.52	-	4.99	-	-	7.09	7.45	10.43	0.55	1.34	9.79	0.01	2.52	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.33
H0609_019_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1437.28	38.93	1404.59	1759.41	354.28	16.86	1.18	422	391.29	898.89	35.43	30.25	4.78	627.26	5962.07	4170.4	219.52	537.06	39.73	26778.44	12.59	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.25	0	0.2	0	0	0	30	30	0	0	0	0	0											15.63	0.36	7.26	-	2.95	3.31	0.24	1.74	6.52	-	5.46	-	-	7.09	7.45	10.43	0.55	1.34	10.08	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.84	0	0	15.63	0.36	7.26	-	2.95	3.31	0.24	1.74	6.52	-	5.46	-	-	7.09	7.45	10.43	0.55	1.34	10.08	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.84	None																																																																																			-	0	0	15.63	0.36	7.26	-	2.95	3.31	0.24	1.74	6.52	-	5.46	-	-	7.09	7.45	10.43	0.55	1.34	10.08	0.01	2.52	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.84
H0609_020_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1469.68	39.81	2198.65	1712.3	252.37	15.92	1.11	422	501.95	931.75	28.38	38.81	5.49	804.65	6206.43	4410.67	219.52	418.01	31.83	28474.25	12.59	0	0	0	108.98	246.31	194.77	34.95	0	0	627.26											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	68	0	100	0.2	0.2	49.45	200	0	0.15	0	0	135.61	15	30	30	30	0.27	0	0.2	0	0	0	30	30	0	0	0	0	0											15.99	0.36	12.46	-	2.1	3.13	0.22	1.74	8.37	-	4.37	-	-	9.09	7.76	11.03	0.55	1.05	8.7	0.01	2.52	-	-	-	0.27	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.32	0	0	15.99	0.36	12.46	-	2.1	3.13	0.22	1.74	8.37	-	4.37	-	-	9.09	7.76	11.03	0.55	1.05	8.7	0.01	2.52	-	-	-	0.27	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.32	None																																																																																			-	0	0	15.99	0.36	12.46	-	2.1	3.13	0.22	1.74	8.37	-	4.37	-	-	9.09	7.76	11.03	0.55	1.05	8.7	0.01	2.52	-	-	-	0.27	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.32
H0609_801_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1465.13	39.69	1545.75	1853.76	350.87	9.7	0.68	423.04	423.81	936.03	20.15	32.77	2.91	679.39	6091.62	4267.24	211.5	541.11	22.25	27493.22	15.49	0	0	0	113.58	256.7	202.99	36.42	0	0	650.82											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.73	212.68	97.23	0	106.34	0.3	0.3	8.22	245.08	0	0.23	0	0.3	56.38	35.87	45.58	24.31	45.58	0.31	4.71	0.3	0	0	0	0	0	0	0	0	0	0											25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	0	78.99	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	5000																																																																																			-	0	0	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34
H0609_803_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1465.13	39.69	1545.75	1853.76	350.87	9.7	0.68	423.04	423.81	936.03	20.15	32.77	2.91	679.39	6091.62	4267.24	211.5	541.11	22.25	27493.22	15.49	0	0	0	113.58	256.7	202.99	36.42	0	0	650.82											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.73	212.68	97.23	0	106.34	0.3	0.3	8.22	245.08	0	0.23	0	0.3	56.38	35.87	45.58	24.31	45.58	0.31	4.71	0.3	0	0	0	0	0	0	0	0	0	0											25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	0	78.99	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	5000																																																																																			-	0	0	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34
H0609_804_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1465.13	39.69	1545.75	1853.76	350.87	9.7	0.68	423.04	423.81	936.03	20.15	32.77	2.91	679.39	6091.62	4267.24	211.5	541.11	22.25	27493.22	15.49	0	0	0	113.58	256.7	202.99	36.42	0	0	650.82											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.73	212.68	97.23	0	106.34	0.3	0.3	8.22	245.08	0	0.23	0	0.3	56.38	35.87	45.58	24.31	45.58	0.31	4.71	0.3	0	0	0	0	0	0	0	0	0	0											25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	0	78.99	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	5000																																																																																			-	0	0	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34
H0609_805_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1465.13	39.69	1545.75	1853.76	350.87	9.7	0.68	423.04	423.81	936.03	20.15	32.77	2.91	679.39	6091.62	4267.24	211.5	541.11	22.25	27493.22	15.49	0	0	0	113.58	256.7	202.99	36.42	0	0	650.82											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.73	212.68	97.23	0	106.34	0.3	0.3	8.22	245.08	0	0.23	0	0.3	56.38	35.87	45.58	24.31	45.58	0.31	4.71	0.3	0	0	0	0	0	0	0	0	0	0											25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	0	78.99	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34	5000																																																																																			-	0	0	25.97	0.7	12.52	-	3.11	2.91	0.2	0.29	8.66	-	4.65	-	0.87	3.19	18.21	16.21	0.43	2.06	6.91	10.8	4.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.34
H0620_002_0	2007	7	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		965.33	74.52	6759.4	91.49	527.28	340.83	8499.83	133.99	69.38	479.58	105.37	44.23	3.47	109.71	25481.49	774.72	685.46	1.66		142.82	83.53	545.06	423.65		2.91	157.7		51.87				17.78			0.5	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)			(7f1) 0/visit	(18a1) 0/visit						68	68			45			45																								9										5.45	0.42	-	-	1.99	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.01	-	-	-	-	-	-	-	-	-	8.38		0.89	5.45	0.42	-	-	1.99	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.01	-	-	-	-	-	-	-	-	-	8.38		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10			30	30						1.56	0.05	0.68	0.02	0.29	0.12	0.07	0.03	0.26	0.39	0.63	0.03	0	0.1	0.01	1.78	0.1	0		0.17		0.05	0.02		0							0			0	0.02						6.41		0	7.01	0.47	0.68	0.02	2.28	0.12	0.07	0.53	0.26	0.39	0.63	0.03	0	0.1	0.01	1.78	0.1	0	-	0.17	-	0.05	0.02	-	0	-	-	-	-	-	-	0.01	-	-	0	0.02	-	-	-	-	-	14.79
H0621_001_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		313.35	26.34	22.56		11.83	13.07	23.06	80.71	30.93	32.48	36.94	6.02		68.36	25.97	32.37	20.92	4.49	20.83	103.38	18.13	0.12																				0.069903444	7	0.160206089		0	0	0	0	0	0	0.236	0.236	0.236	0	0	0.236	0	0	24	0.236	0.236	0.236																				0.07	0.07	0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				21.9	1.84	3.61	-	2.79	3.08	5.44	19.05	7.3	7.67	8.72	1.42	-	16.13	6.13	7.64	4.94	1.06	4.92	24.4	4.28	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	152.35		0	21.9	1.84	3.61	-	2.79	3.08	5.44	19.05	7.3	7.67	8.72	1.42	-	16.13	6.13	7.64	4.94	1.06	4.92	24.4	4.28	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	152.35																																																																																				-		0	21.9	1.84	3.61	-	2.79	3.08	5.44	19.05	7.3	7.67	8.72	1.42	-	16.13	6.13	7.64	4.94	1.06	4.92	24.4	4.28	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	152.35
H0623_001_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1288.27	9.4	462.17	2205.09	128.58	0.73	0.05	208.64	454.8	838.73	571.86	38.12	390.95	324.06	7371.04	8743.39			322.42		10.12											13.69	0.1	16.46								175 (1-5)/LTAC 950 per admit	950/admit	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-50/ Visit	30-100/ Visit	50/ Visit	0/ Procedure	15-100/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins											175 (1-5)/LTAC 950 per admit	950/admit	15 Coins								121.11	198.12	11.79	10	100	0.2	0.2	49.63	116.5	38.64	45.33	50	0	36.18	10	35			100		0.2											600	950	0.15								13	0.16	0.45	1.84	1.07	0.15	0.01	0.86	4.42	2.7	2.16	0.16	-	0.98	6.14	25.5	-	-	2.69	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	2.47	-	-	-	-	-	-	-	67.47	0	0	13	0.16	0.45	1.84	1.07	0.15	0.01	0.86	4.42	2.7	2.16	0.16	-	0.98	6.14	25.5	-	-	2.69	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	2.47	-	-	-	-	-	-	-	67.47		950/admit	950/admit	20 Coins	20 Coins	100/Trip	40 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		20 Coins	20 Coins					20 Coins													20 Coins								2.41	0.02	0.2	0.27	0.27	0.04		0.27	2.43	2.87			0		1.82	2.19					0.59													0.63								13.99	0	0	15.41	0.17	0.65	2.1	1.34	0.18	0.01	1.13	6.85	5.57	2.16	0.16	-	0.98	7.96	27.69	-	-	2.69	-	2.61	-	-	-	-	-	-	-	-	-	-	0.68	0.01	3.09	-	-	-	-	-	-	-	81.45
H0623_002_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									V		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1284.38	9.37	460.77	2198.41	128.19	0.74	0.06	208.01	453.43	836.19	570.13	38.01	389.77	323.07	7348.74	8716.93			321.44		10.27											13.64	0.1	16.72								175 (1-5)/LTAC 950 per admit	950/admit	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-50/ Visit	30-100/ Visit	50/ Visit	0/ Procedure	15-100/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins											175 (1-5)/LTAC 950 per admit	950/admit	15 Coins								121.11	198.12	11.79	10	100	0.2	0.2	49.63	116.5	38.64	45.33	50	0	36.18	10	35			100		0.2											600	950	0.15								12.96	0.15	0.45	1.83	1.07	0.15	0.01	0.86	4.4	2.69	2.15	0.16	-	0.97	6.12	25.42	-	-	2.68	-	2.05	-	-	-	-	-	-	-	-	-	-	0.68	0.01	2.51	-	-	-	-	-	-	-	67.35	0	0	12.96	0.15	0.45	1.83	1.07	0.15	0.01	0.86	4.4	2.69	2.15	0.16	-	0.97	6.12	25.42	-	-	2.68	-	2.05	-	-	-	-	-	-	-	-	-	-	0.68	0.01	2.51	-	-	-	-	-	-	-	67.35		950/admit	950/admit	20 Coins	20 Coins	100/Trip	40 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		20 Coins	20 Coins					20 Coins													20 Coins								2.4	0.02	0.19	0.27	0.27	0.04		0.26	2.42	2.85			0		1.81	2.18					0.58													0.62								13.91	0	0	15.36	0.17	0.65	2.1	1.34	0.19	0.01	1.12	6.82	5.55	2.15	0.16	-	0.97	7.93	27.6	-	-	2.68	-	2.64	-	-	-	-	-	-	-	-	-	-	0.68	0.01	3.13	-	-	-	-	-	-	-	81.26
H0623_003_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		254.71	1.92	452.69	2159.89	125.95	0.71	0.05	204.37	445.48	821.54	560.14	37.34	382.94	317.41	7219.96	8564.17			315.81		9.86											13.41	0.1	16.03								150/day (days 1-5)/LTAC 950/admit	950/admit	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-50/ Visit	30-100/ Visit	50/ Visit	0/ Procedure	15-100/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins											150/day (days 1-5)/LTAC 950/admit	950/admit	15 Coins								518	950	11.79	10	100	0.2	0.2	49.63	116.5	38.64	45.33	50	0	36.18	10	35			100		0.2											518	950	0.15								10.99	0.15	0.44	1.8	1.05	0.14	0.01	0.85	4.32	2.65	2.12	0.16	-	0.96	6.02	24.98	-	-	2.63	-	1.97	-	-	-	-	-	-	-	-	-	-	0.58	0.01	2.4	-	-	-	-	-	-	-	64.23	0	0	10.99	0.15	0.44	1.8	1.05	0.14	0.01	0.85	4.32	2.65	2.12	0.16	-	0.96	6.02	24.98	-	-	2.63	-	1.97	-	-	-	-	-	-	-	-	-	-	0.58	0.01	2.4	-	-	-	-	-	-	-	64.23		950/stay/LTAC 950/admit	950/admit	15 Coins	15 Coins	100/Trip	40 Coins		50/Visit	15 Coins	15 Coins			0/Procedure		15 Coins	15 Coins					20 Coins													15 Coins								2.36	0.02	0.14	0.19	0.26	0.04		0.26	1.75	2.07			0		1.31	1.58					0.56													0.45								10.98	0	0	13.35	0.17	0.59	1.99	1.31	0.18	0.01	1.1	6.08	4.71	2.12	0.16	-	0.96	7.33	26.55	-	-	2.63	-	2.54	-	-	-	-	-	-	-	-	-	-	0.58	0.01	2.86	-	-	-	-	-	-	-	75.21
H0623_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		265.85	2	472.49	2254.31	131.45	0.76	0.06	260.12	464.96	857.46	584.63	38.98	399.68	331.29	7535.6	8938.58			329.62		10.57											13.99	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.29	0.1	0.35	1.88	1.1	0.19	0.01	0.98	7.75	2.5	2.23	0.32	-	1.04	15.7	26.07	-	-	0.96	-	2.11	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.3	0	0	13.29	0.1	0.35	1.88	1.1	0.19	0.01	0.98	7.75	2.5	2.23	0.32	-	1.04	15.7	26.07	-	-	0.96	-	2.11	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.3		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.36	0.02	0.41	0.56	0.27	0.05		0.27	5.08	6			0		1.9	4.58					0.61																					22.12	0	0	15.66	0.12	0.75	2.44	1.37	0.24	0.01	1.25	12.83	8.5	2.23	0.32	-	1.04	17.6	30.65	-	-	0.96	-	2.73	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	99.42
H0623_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		264.28	1.99	469.7	2241.03	130.68	0.75	0.06	258.59	462.22	852.4	581.18	38.75	397.32	329.34	7491.19	8885.9			327.67		10.45											13.91	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.21	0.1	0.34	1.87	1.09	0.19	0.01	0.97	7.7	2.49	2.22	0.32	-	1.03	15.61	25.92	-	-	0.96	-	2.09	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	76.83	0	0	13.21	0.1	0.34	1.87	1.09	0.19	0.01	0.97	7.7	2.49	2.22	0.32	-	1.03	15.61	25.92	-	-	0.96	-	2.09	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	76.83		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.35	0.02	0.4	0.55	0.27	0.05		0.27	5.02	5.93			0		1.88	4.52					0.61																					21.88	0	0	15.56	0.12	0.75	2.42	1.36	0.24	0.01	1.24	12.73	8.42	2.22	0.32	-	1.03	17.49	30.44	-	-	0.96	-	2.7	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	98.7
H0623_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		265.85	2	472.49	2254.31	131.45	0.76	0.06	260.12	464.96	857.46	584.63	38.98	399.68	331.29	7535.6	8938.58			329.62		10.57											13.99	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.29	0.1	0.35	1.88	1.1	0.19	0.01	0.98	7.75	2.5	2.23	0.32	-	1.04	15.7	26.07	-	-	0.96	-	2.11	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.3	0	0	13.29	0.1	0.35	1.88	1.1	0.19	0.01	0.98	7.75	2.5	2.23	0.32	-	1.04	15.7	26.07	-	-	0.96	-	2.11	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.3		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.36	0.02	0.41	0.56	0.27	0.05		0.27	5.08	6			0		1.9	4.58					0.61																					22.12	0	0	15.66	0.12	0.75	2.44	1.37	0.24	0.01	1.25	12.83	8.5	2.23	0.32	-	1.04	17.6	30.65	-	-	0.96	-	2.73	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	99.42
H0623_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		264.28	1.99	469.7	2241.03	130.68	0.75	0.06	258.59	462.22	852.4	581.18	38.75	397.32	329.34	7491.19	8885.9			327.67		10.45											13.91	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.21	0.1	0.34	1.87	1.09	0.19	0.01	0.97	7.7	2.49	2.22	0.32	-	1.03	15.61	25.92	-	-	0.96	-	2.09	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	76.83	0	0	13.21	0.1	0.34	1.87	1.09	0.19	0.01	0.97	7.7	2.49	2.22	0.32	-	1.03	15.61	25.92	-	-	0.96	-	2.09	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	76.83		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.35	0.02	0.4	0.55	0.27	0.05		0.27	5.02	5.93			0		1.88	4.52					0.61																					21.88	0	0	15.56	0.12	0.75	2.42	1.36	0.24	0.01	1.24	12.73	8.42	2.22	0.32	-	1.03	17.49	30.44	-	-	0.96	-	2.7	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	98.7
H0624_001_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V		V	V																																																-		2501.05	359.04			321.1	28.63	23.89	940.78	381.88	2252.68	937.81	67.06	3.21	2080.6		3548.08		515.83		817.71												330.48		145.48	247.05							(1a) 75 per Day	(1b) 75 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36			36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							7.53	1.08	-	-	0.97	2.76	2.3	1.36	0.38	0.9	0.38	0.07	0.31	2.09	-	1.43	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.1	-	-	-	-	-	-	22.39		24.06	7.53	1.08	-	-	0.97	2.76	2.3	1.36	0.38	0.9	0.38	0.07	0.31	2.09	-	1.43	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.1	-	-	-	-	-	-	22.39																																																																																				-		0	7.53	1.08	-	-	0.97	2.76	2.3	1.36	0.38	0.9	0.38	0.07	0.31	2.09	-	1.43	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.1	-	-	-	-	-	-	22.39
H0624_002_0	2007	8																					4000											D	D	D	V	T	Coin	Coin	V	V	P	Coin	O	Coin	O	V	V	V	P	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1935.41	168.6	723.77	0	292.28	16.16	6.98	594.71	287.19	8573.17	54.84	0	0.27	434.58	3574.22	4188.24	718.9	591.05	0	0	27.51	728.28	0	0	164.02	0	227.28	0	0	0	0											200 (1a)	200 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	150 (9b)	15 (8a 8b)	15/20 (8a 8b)	150 (incl in h5)	30 (12)	30 (3 9d); 60 (5); 40/30 (9c); 150 (9a)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											138.3	138.3	69.15	0	121.01	0.21	0.22	34.58	103.73	4.15	0.11	0	0.21	101.23	10	30	37.5	20.75	0	0	0.21	30	0	0	30	0	30	0	0	0	0											22.31	1.94	4.17	-	2.95	3.35	1.57	1.71	2.48	2.96	5.95	-	0.06	3.67	2.98	10.47	2.25	1.02	-	-	5.71	1.82	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.35		26.54	22.31	1.94	4.17	-	2.95	3.35	1.57	1.71	2.48	2.96	5.95	-	0.06	3.67	2.98	10.47	2.25	1.02	-	-	5.71	1.82	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.35																																																																																				-			22.31	1.94	4.17	-	2.95	3.35	1.57	1.71	2.48	2.96	5.95	-	0.06	3.67	2.98	10.47	2.25	1.02	-	-	5.71	1.82	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.35
H0624_003_0	2007	5																					3400											D	D	D	V	T	Coin	Coin	V	V	P	Coin	O	Coin	O	V	V	V	P	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1935.41	168.6	723.77	0	292.28	16.16	6.98	594.71	287.19	8573.17	54.84	0	0.27	434.58	3574.22	4188.24	718.9	591.05	0	0	27.51	728.28	0	0	164.02	0	227.28	0	0	0	0											200 (1a)	200 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	150 (9b)	15 (8a 8b)	15/20 (8a 8b)	150 (incl in h5)	30 (12)	30 (3 9d); 60 (5); 40/30 (9c); 150 (9a)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											130.32	130.32	65.16	0	114.03	0.2	0.21	32.58	97.74	3.91	0.1	0	0.2	95.39	10	30	37.5	19.55	0	0	0.2	30	0	0	30	0	30	0	0	0	0											21.02	1.83	3.93	-	2.78	3.16	1.5	1.61	2.34	2.79	5.61	-	0.05	3.45	2.98	10.47	2.25	0.96	-	-	5.38	1.82	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.92		29.97	21.02	1.83	3.93	-	2.78	3.16	1.5	1.61	2.34	2.79	5.61	-	0.05	3.45	2.98	10.47	2.25	0.96	-	-	5.38	1.82	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.92																																																																																				-			21.02	1.83	3.93	-	2.78	3.16	1.5	1.61	2.34	2.79	5.61	-	0.05	3.45	2.98	10.47	2.25	0.96	-	-	5.38	1.82	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.92
H0624_004_0	2007	7	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1141.02	88.08	6294.84	88.79	511.72	330.77	8248.94	130.03	67.33	465.43	102.26	42.92	3.37	106.47	23496.28	751.86	665.23	1.61		138.61	77.01	528.97	1200		140.2	166		54.6				17.25			300	295.2						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)			(7f1) 0/visit	(18a1) 0/visit						66	66			44			44																								9										6.3	0.49	-	-	1.88	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.01	-	-	-	-	-	-	-	-	-	9.16		1.21	6.3	0.49	-	-	1.88	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.01	-	-	-	-	-	-	-	-	-	9.16																																																																																				-		0	6.3	0.49	-	-	1.88	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.01	-	-	-	-	-	-	-	-	-	9.16
H0630_013_0	2007	4	j.	j.									Part B Rx	Part B Rx									4000	Generic	Brand									A	A	D		Coin	Coin	Coin	V	V		P	Coin		V	V	V	V	V		V		V			V		V			O	O	S	S																																																		-	0	104.51	6.61	4.6		5.15	5.94	0.4	171.71	159.78		395.97	1.34		97.1	5168.78	868.37	150.88	251.38		203.83		423.35			450.1		46.12			0	80	33.85	3.76									for 1-5 days 275/day 0 days 6-90	for 1-5 days 275/day 0 days 6-90	0 days 1-20 100 days 21-100	0 copay	20 coin/trip up to 500 maximum	20 coinsurance	20 coinsurance	50 waived if admitted to hospital Urgent care 30	350 per visit	0 copay	MRI CT PET Nuclear medicine 200 per procedure	Partial hospitalization-20 coinsurance	0 copay	Pulmonary Rehab 5 Outpatient Services 25 Radiation Therapy 40/procedure	Primary care OV=25	Specialty care OV = 40	15 for Group visit; 25 office visit	Therapies=Primary care OV	0 copay	Primary care OV chg for PA NP Sr care coor. etc		Primary care OV chg			25 per visit; 40 Specialty		25 per visit			Health education classes with reasonable charges between 0-150	3 copay	10 generic/ 30 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets	10 generic/ 30 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets									1198.95	1001	100		0.2	0.2	0.2	50	349.95		199.93	0.2	0	25	24.89	40	25	25		25		25			25		25			15	3	10	30									10.44	0.55	0.04	-	1.03	1.19	0.08	0.72	4.66	-	6.6	0.27	-	0.2	10.72	2.89	0.31	0.52	-	0.42	-	0.88	-	-	0.94	-	0.1	-	-	-	0.02	0.03	0.01	-	-	-	-	-	-	-	-	42.62		0.28	10.44	0.55	0.04	-	1.03	1.19	0.08	0.72	4.66	-	6.6	0.27	-	0.2	10.72	2.89	0.31	0.52	-	0.42	-	0.88	-	-	0.94	-	0.1	-	-	-	0.02	0.03	0.01	-	-	-	-	-	-	-	-	42.62	4000	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		-			10.44	0.55	0.04	-	1.03	1.19	0.08	0.72	4.66	-	6.6	0.27	-	0.2	10.72	2.89	0.31	0.52	-	0.42	-	0.88	-	-	0.94	-	0.1	-	-	-	0.02	0.03	0.01	-	-	-	-	-	-	-	-	42.62
H0630_014_0	2007	6																					3500											A	A	D		Coin	Coin	Coin	V	Coin		Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin		Coin			Coin	O																																																				-	0	324.1	34.64	284.4		22.38	31.54	3.6	712.15	46.65		12.37	1.9		64.48	155.92	83.5	14.58	3.61	15.5	1.25	11.59	5.73			12.38		0.75			0	80											Deductable 952; 61-90 238	Deductable 952; 61-90 238	0 days 1-20 119 days 21-100	0 copay	20 coin/trip up to 500 maximum	20 coinsurance	20 coinsurance	50  Emergency; 20 Coin Urgent care	20 coinsurance	0 copay	20 coinsurance	20 coinsurance	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			20 coinsurance		20 coinsurance			20 coinsurance	3 Copay											989.73	990	119		0.2	0.2	0.2	50	0.2		0.2	0.2		0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2			0.2		0.2			0.2	3											26.73	2.86	2.82	-	4.48	6.31	0.72	2.97	9.33	-	2.47	0.38	-	12.9	31.18	16.7	2.92	0.72	3.1	0.25	2.32	1.15	-	-	2.48	-	0.15	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	132.94		0.27	26.73	2.86	2.82	-	4.48	6.31	0.72	2.97	9.33	-	2.47	0.38	-	12.9	31.18	16.7	2.92	0.72	3.1	0.25	2.32	1.15	-	-	2.48	-	0.15	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	132.94	3500	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			26.73	2.86	2.82	-	4.48	6.31	0.72	2.97	9.33	-	2.47	0.38	-	12.9	31.18	16.7	2.92	0.72	3.1	0.25	2.32	1.15	-	-	2.48	-	0.15	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	132.94
H0630_015_0	2007	3	j.	j.									Part B Rx	Part B Rx									2500	Generic	Brand									A	A	D		Coin	Coin	Coin	V	V	O	P	Coin		V	V	V	V	V	V	V		V			V		V			O	O	S	S																																																		-	0	179.18	5.52	94.03		8.78	11.05	1.15	253.47	249.37		542.59	1.16		133.14	6344.71	1088.94	143.74	290.84		304.22		405.56			559.53		50.3			0	80	51.03	10.45									550 per admission	550 per admission 1-90 days	0 days 1-20 125 days 21-100	0 copay	20 coin/trip up to 500 maximum	20 coinsurance	20 coinsurance	50 waived if admitted to hospital Urgent care 30	250 per visit	0 copay	MRI CT PET Nuclear medicine 125/procedure	Partial hospitalization  20coin	0 copay	Pulmonary Rehab 5 Outpatient Services 20 Radiation Therapy 30/procedure	20 per  Primary care OV	30 per Specialty care OV	15 for Group visit; 20 visit	Primary care OV chg	0 copay	Primary care OV chg for PA NPSt care coor. etc		20 per visit (Part B coverage)			20 per routine visit  30 per specialty		20 per routine visit/test			Health education classes with reasonable charges between 0-150	3 copay	10 generic/ 30 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets	10 generic/ 30 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets									549.83	550	125		0.2	0.2	0.2	50	249.81		124.89	0.2		20	19.73	30	20	20		20		20			20		20			15	3	10	30									8.21	0.25	0.98	-	1.76	2.21	0.23	1.06	5.19	-	5.65	0.23	-	0.22	10.43	2.72	0.24	0.48	-	0.51	-	0.68	-	-	0.93	-	0.08	-	-	-	0.02	0.04	0.03	-	-	-	-	-	-	-	-	42.15		0.74	8.21	0.25	0.98	-	1.76	2.21	0.23	1.06	5.19	-	5.65	0.23	-	0.22	10.43	2.72	0.24	0.48	-	0.51	-	0.68	-	-	0.93	-	0.08	-	-	-	0.02	0.04	0.03	-	-	-	-	-	-	-	-	42.15	2500	none	none	none	None	None	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	None	NOne	None	None	none	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			8.21	0.25	0.98	-	1.76	2.21	0.23	1.06	5.19	-	5.65	0.23	-	0.22	10.43	2.72	0.24	0.48	-	0.51	-	0.68	-	-	0.93	-	0.08	-	-	-	0.02	0.04	0.03	-	-	-	-	-	-	-	-	42.15
H0630_016_0	2007	3	j.	j.									Part B Rx	Part B Rx									2000	Generic	Brand									A	A	D	V	Coin	Coin	Coin	V	V		P	Coin		V	V	V	V	V		V		V			V		V			O	O	S	S																																																		-	0	274.21	6.73	144.11		14.5	21.63	1.7	376.47	374.04		742.41	0.94		193.67	8485.35	1459.85	299.71	402.12		390.76		533.24			644.6		69.21			0	80	87.08	23.16									350 Per admission	350 Per admission 1-90 days	0 days 1-20 100 days 21-100	0 copay	20 coin/trip up to 500 maximum	20 coin	20 coin	50 waived if admitted to hospital Urgent care 30	150 per visit	0 copay	MRI CT PET Nuclear Medicine 100/procedure	20 coinsurance Partial Hosp	0 copay	Pulmonary Rehab 5 Outpatient Services 15 Radiation Therapy 25/procedure	Primary care OV chg 15	Specialty care 25/visit	15 For Group visit  15 office visit	Therapies= Primary care OV chg	0 copay	Primary care OV chg for PA NP Sr care coor etc		15 per visit=Primary care OV chg			15 per routine visit 25 specialty		15 per routine visit/test			Health education classes with reasonable charges between 0-150	3 copay	10 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets	10 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets									348.68	350	100	0	0.2	0.2	0.2	50	148.64	0	98.91	0.2	0	15	13.03	25	15	15		15		15			15		15			15	3	10	25									7.97	0.2	1.2	-	2.9	4.33	0.34	1.57	4.63	-	6.12	0.19	-	0.24	9.21	3.04	0.37	0.5	-	0.49	-	0.67	-	-	0.81	-	0.09	-	-	-	0.02	0.07	0.05	-	-	-	-	-	-	-	-	45		5.75	7.97	0.2	1.2	-	2.9	4.33	0.34	1.57	4.63	-	6.12	0.19	-	0.24	9.21	3.04	0.37	0.5	-	0.49	-	0.67	-	-	0.81	-	0.09	-	-	-	0.02	0.07	0.05	-	-	-	-	-	-	-	-	45	2000	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	Not apply	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0	0									-			7.97	0.2	1.2	-	2.9	4.33	0.34	1.57	4.63	-	6.12	0.19	-	0.24	9.21	3.04	0.37	0.5	-	0.49	-	0.67	-	-	0.81	-	0.09	-	-	-	0.02	0.07	0.05	-	-	-	-	-	-	-	-	45
H0630_805_0	2007	3	j.	j.									Part B Rx	Part B Rx									2950	Generic	Brand									A	A	D		Coin	Coin	Coin	V	Coin	O	Coin	Coin		V	V	V	V	V		V		V			V		V			O	O	Coin	Coin																																																		-	0	180.85	3.24	89.68		8.35	12.78	1.2	241.42	34.01		14.08	1.51		153.36	6984.01	1229.93	132.15	415.06		391.18		454.46			626.46		84.01				80	10.01	2.99									250/day 750 Max. 20 of prof services	250/day 750 Man. 20 of prof services	0 days 1-20 100/day days 21-100	0 copay	20 up to max of 500/trip	20 coinsurance	20 coinsurance	50 copay waived if admitted to hosp Urgent care 30	20 of surgery cost	0 copay	MRI CT  PET scans nuclear Med 20 coin	Partial Hosp 20 coin	0 copay	Pulmonary Rehab 5 Outpatient Services 25  Chiro 25	Primary care OV chg	Specialty care OV chg	15 For Group visit; 25 ov	Therapies = Primary care OV chg	0 copay	Primary care OV chg for PA NP Sr care coor etc		Primary care OV chg.			25 per routine visit 40 specialty		25 per routine visit/test			Health education classes with reasonable charges between 0-150	3 copay	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets									749.91	750	100		0.2	0.2	0.2	49.95	0.2		0.2	0.2		25	24.92	40	25	25		25		25			25		25			15	3	0.25	0.25									11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22		0.21	11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22	2950	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22
H0630_806_0	2007	3	j.	j.									Part B Rx	Part B Rx									2950	Generic	Brand									A	A	D		Coin	Coin	Coin	V	Coin	O	Coin	Coin		V	V	V	V	V		V		V			V		V			O	O	Coin	Coin																																																		-	0	180.85	3.24	89.68		8.35	12.78	1.2	241.42	34.01		14.08	1.51		153.36	6984.01	1229.93	132.15	415.06		391.18		454.46			626.46		84.01				80	10.01	2.99									250/day 750 Max. 20 of prof services	250/day 750 Man. 20 of prof services	0 days 1-20 100/day days 21-100	0 copay	20 up to max of 500/trip	20 coinsurance	20 coinsurance	50 copay waived if admitted to hosp Urgent care 30	20 of surgery cost	0 copay	MRI CT  PET scans nuclear Med 20 coin	Partial Hosp 20 coin	0 copay	Pulmonary Rehab 5 Outpatient Services 25  Chiro 25	Primary care OV chg	Specialty care OV chg	15 For Group visit; 25 ov	Therapies = Primary care OV chg	0 copay	Primary care OV chg for PA NP Sr care coor etc		Primary care OV chg.			25 per routine visit 40 specialty		25 per routine visit/test			Health education classes with reasonable charges between 0-150	3 copay	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets									749.91	750	100		0.2	0.2	0.2	49.95	0.2		0.2	0.2		25	24.92	40	25	25		25		25			25		25			15	3	0.25	0.25									11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22		0.21	11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22	2950	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0							-			11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22
H0630_807_0	2007	2	j.	j.									Part B Rx	Part B Rx									2950	Generic	Brand									A	A	D		Coin	Coin	Coin	V	Coin		Coin	Coin		V	V	V	V	V		V		V			V		V			O	O	Coin	Coin																																																		-	0	180.85	3.24	89.68		8.35	12.78	1.2	241.42	34.01		14.08	1.51		153.36	6984.01	1229.93	132.15	415.06		391.18		454.46			626.46		84.01				80	10.01	2.99									250/day 750 Max. 20 of prof services	250/day 750 Man. 20 of prof services	0 days 1-20 100/day days 21-100	0 copay	20 up to max of 500/trip	20 coinsurance	20 coinsurance	50 copay waived if admitted to hosp; Urgent care 30	20 of surgery cost	0 copay	MRI CT  PET scans nuclear Med 20 coin	Partial Hosp 20 coin	0 copay	Pulmonary Rehab 5 Outpatient Services 25  Radiation Therapy 25	Primary care OV chg 25	Specialty care OV chg	15 For Group visit; 25 ov	Therapies = Primary care OV chg	0 copay	Primary care OV chg for PA NP Sr care coor etc		Primary care OV chg.			25 per routine visit 40 specialty		25 per routine visit/test			Health education classes with reasonable charges between 0-150	3 copay	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets									749.91	750	100		0.2	0.2	0.2	49.95	0.2		0.2	0.2		25	24.92	40	25	25		25		25			25		25			15	3	0.25	0.25									11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22		0.21	11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22	2950	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22
H0630_808_0	2007	3	j.	j.									Part B Rx	Part B Rx									2950	Generic	Brand									A	A	D		Coin	Coin	Coin	V	Coin	O	Coin	Coin		V	V	V	V	V		V		V			V		V			O	O	Coin	Coin																																																		-	0	180.85	3.24	89.68		8.35	12.78	1.2	241.42	34.01		14.08	1.51		153.36	6984.01	1229.93	132.15	415.06		391.18		454.46			626.46		84.01				80	10.01	2.99									250/day 750 Max. 20 of prof services	250/day 750 Man. 20 of prof services	0 days 1-20 100/day days 21-100	0 copay	20 up to max of 500/trip	20 coinsurance	20 coinsurance	50 copay waived if admitted to hospUrgent care 30	20 of surgery cost	0 copay	MRI CT  PET scans nuclear Med 20 coin	Partial Hosp 20 coin	0 copay	Pulmonary Rehab 5 Outpatient Services 25  Chiro 25	Primary care OV chg	Specialty care OV chg	15 For Group visit; 25 ov	Therapies = Primary care OV chg	0 copay	Primary care OV chg for PA NP Sr care coor etc		Primary care OV chg.			25 per routine visit 40 specialty		25 per routine visit/test			Health education classes with reasonable charges between 0-150	3 copay	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets	25 generic/ 25 brand co-pay for Part B drugs except 20 co-insurance for Avonex/RebifIntron A Lupron/Zoladexdiabetic test strips lancets									749.91	750	100		0.2	0.2	0.2	49.95	0.2		0.2	0.2		25	24.92	40	25	25		25		25			25		25			15	3	0.25	0.25									11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22		0.21	11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22	2950	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			11.3	0.2	0.75	-	1.67	2.56	0.24	1	6.8	-	2.82	0.3	-	0.32	14.5	4.1	0.28	0.86	-	0.81	-	0.95	-	-	1.31	-	0.18	-	-	-	0.02	2.5	0.75	-	-	-	-	-	-	-	-	54.22
H0710_001_0	2007	3	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		1574.88	99.06	9708.29	65.21	916.69	18.71	3.66	213.52	138.18	3910.06	170.99	24.71	1.67	383.02	22821.86	1475.05	2298.16	7.48		116.09	123.05	1063.53	1495.15		54.85	157.7						640.9	0.1	0.03	370.82	280.44						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc						(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						135	135			68	18	18	45	23			23		23		9				9		9										32		23								17.78	1.12	-	-	5.17	3.38	0.66	0.8	0.26	-	-	0.05	-	0.72	-	1.11	-	-	-	0.09	-	0.8	-	-	-	-	-	-	-	-	-	1.69	-	0	-	-	-	-	-	-	-	33.63		3.61	17.78	1.12	-	-	5.17	3.38	0.66	0.8	0.26	-	-	0.05	-	0.72	-	1.11	-	-	-	0.09	-	0.8	-	-	-	-	-	-	-	-	-	1.69	-	0	-	-	-	-	-	-	-	33.63		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						2.12	0.05	0.97	0.04	0.69	0.3	0.06	0.05	0.17	0.58	0.7	0.02	0	0.14	0.01	2.17	0.21	0		0.16		0.12	0.09		0.01							0.1	0	0	0.05	0.02						8.84		0	19.9	1.17	0.97	0.04	5.86	3.68	0.72	0.85	0.43	0.58	0.7	0.07	0	0.86	0.01	3.28	0.21	0	-	0.24	-	0.92	0.09	-	0.01	-	-	-	-	-	-	1.79	0	0	0.05	0.02	-	-	-	-	-	42.47
H0710_002_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1650	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T	V	V	P	V	P		O	O	V		V	V																																																-		2546.77	365.6	1714.81		326.97	30.29	25.27	957.98	388.86	2293.86	954.95	68.29	3.4	2118.64		3612.94		525.26		832.66	18.93											336.52		148.14	251.56							(1a) 150 per Day	(1b) 150 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							85	85	20		43	11	11	20	14	6	6	14	11	14		6		6		6	11											6		6	6							18.04	2.59	2.92	-	1.16	3.43	2.86	1.63	0.46	1.08	0.45	0.08	0.39	2.5	-	1.71	-	0.25	-	0.39	2.15	-	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	42.44		32.44	18.04	2.59	2.92	-	1.16	3.43	2.86	1.63	0.46	1.08	0.45	0.08	0.39	2.5	-	1.71	-	0.25	-	0.39	2.15	-	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	42.44		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 per Visit	30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.57	0.17	0.46	0.47	0.09	0.19	0.15	0.05	0.2	0.15	0.13	0.02	0.02	0.25	0.35	0.23	0.05	0.03	0.15	0.78	0.15	0																				6.67		0	20.61	2.76	3.38	0.47	1.24	3.62	3.02	1.68	0.66	1.23	0.59	0.1	0.4	2.75	0.35	1.94	0.05	0.28	0.15	1.17	2.3	0	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	49.1
H0710_003_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		2478.24	224.85	995.7		221	24.87	28.71	612.81	476.38	2391.01	1011.86	76.3	1.32	1438.23		5229.43		493.83		968												279.28		269.84	273.62							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						41	41	20		41	8	11	20	14	3	6	14	11	14		6		6		6												6		6	6							8.56	0.78	1.65	-	0.76	2.06	3.17	1.02	0.55	0.55	0.47	0.09	0.15	1.66	-	2.41	-	0.23	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.13	-	-	-	-	-	-	24.91		20.18	8.56	0.78	1.65	-	0.76	2.06	3.17	1.02	0.55	0.55	0.47	0.09	0.15	1.66	-	2.41	-	0.23	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.13	-	-	-	-	-	-	24.91		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	(16a/16b) 0 per Visit	30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.81	0.11	0.28	0.35	0.06	0.15	0.18	0.04	0.3	0.19	0.19	0.02	0.01	0.21	0.37	0.32	0.03	0.03	0.22	0.94	0.2	0	0.04		0.01		0.01															7.06		0	11.36	0.88	1.93	0.35	0.82	2.21	3.35	1.05	0.85	0.75	0.66	0.11	0.15	1.86	0.37	2.73	0.03	0.26	0.22	1.39	0.2	0	0.04	-	0.01	-	0.01	-	-	-	-	0.13	-	0.12	0.13	-	-	-	-	-	-	31.97
H0712_001_0	2007	7																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1348.42	25.17	1146.23	1717.55	322.49	13.64	2.52	322.54	232.39	2329.34	1123.31	0	652.37	698.98	3711.74	7253.16	168.24	739.35	3294.85	21705.88	5.98	14.15	0	0	439.77	173.06	137.71	5.89	0	203.37	2035.2											175  days 1 - 6	175  days 1 - 6	100  days 8 - 100	0	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 100		0 - 30	30 to 100	10	0 to 30	20 to 30	30	0 - 100	0 to 25	0 -20	0.2	0	Not Covered	25	25	25	0		0	0 to 0											121.65	121.65	60.81	0	100	0.2	0.2	50	135	0	36.25	0	20	63.81	8.11	30	22.5	30	14.55	1.66	0.13	0.2	0	0	25	25	25	0	0	0	0											13.67	0.26	5.81	-	2.69	2.73	0.5	1.34	2.61	-	3.39	-	1.09	3.72	2.51	18.13	0.32	1.85	4	3.01	0.8	2.83	-	-	0.92	0.36	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.81		0	13.67	0.26	5.81	-	2.69	2.73	0.5	1.34	2.61	-	3.39	-	1.09	3.72	2.51	18.13	0.32	1.85	4	3.01	0.8	2.83	-	-	0.92	0.36	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.81	0																																																																																			-		0	13.67	0.26	5.81	-	2.69	2.73	0.5	1.34	2.61	-	3.39	-	1.09	3.72	2.51	18.13	0.32	1.85	4	3.01	0.8	2.83	-	-	0.92	0.36	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.81
H0712_005_0	2007	4																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1500.35	27.94	1755.3	2887.62	8.55	22.42	4.22	5.49	28.51	2154.44	27.79	0	8.69	18.77	5665.2	56.24	1.99	2.68	30.28	123.46	9.36	23.62	1200	0	0	0	0	0	0	353.59	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0.2	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											156.24	127.36	27.01	0	0.2	0	0	0.2	0.2	0	0.15	0	0.13	0.2	0	0.2	0.2	0.2	0.03	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											19.53	0.3	3.95	-	1.71	-	-	1.1	5.7	-	4.17	-	1.16	3.75	-	11.25	0.4	0.54	0.93	10.04	1.25	4.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.51		0	19.53	0.3	3.95	-	1.71	-	-	1.1	5.7	-	4.17	-	1.16	3.75	-	11.25	0.4	0.54	0.93	10.04	1.25	4.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.51	0																																																																																			-		0	19.53	0.3	3.95	-	1.71	-	-	1.1	5.7	-	4.17	-	1.16	3.75	-	11.25	0.4	0.54	0.93	10.04	1.25	4.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.51
H0712_008_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1035.9	18.13	1276	2030.59	323.67	16.4	3.18	252.87	246.4	1546.57	779.43	0	453.22	483.48	4259.23	7966.62	186.25	807.94	3663.82	22998.88	7.06	17	0	381	409.86	162.12	175.66	7.55	0	280.2	2035.2											150  days 1 - 7	150  days 1 - 7	50  days 8 - 100	0	50	20	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	0 - 50		0 - 20	20 to 50	5	0 to 20	10 to 20	20	0 - 50	0 to 25	0 -20	0.2	0	0	25	25	25	0		0	0 to 0											100.62	100.62	27.54	0	45.29	0.18	0.18	45.29	61.14	0	11.32	0	12.08	31.18	3.64	18.12	11.32	18.12	4.57	1.59	0.12	0.18	0	0	22.65	22.65	22.65	0	0	0	0											8.69	0.15	2.93	-	1.22	2.97	0.58	0.95	1.26	-	0.74	-	0.46	1.26	1.29	12.03	0.18	1.22	1.4	3.06	0.86	3.08	-	-	0.77	0.31	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.71		4.76	8.69	0.15	2.93	-	1.22	2.97	0.58	0.95	1.26	-	0.74	-	0.46	1.26	1.29	12.03	0.18	1.22	1.4	3.06	0.86	3.08	-	-	0.77	0.31	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.71	3000																																																																																			-		0	8.69	0.15	2.93	-	1.22	2.97	0.58	0.95	1.26	-	0.74	-	0.46	1.26	1.29	12.03	0.18	1.22	1.4	3.06	0.86	3.08	-	-	0.77	0.31	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.71
H0712_011_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1523.54	27.29	1906.28	2992.11	471.99	24	4.56	349.55	341.54	2157.59	1056.56	0	625.43	667.87	6083.73	11792.84	281.59	1244.01	5206.22	34018.19	10.03	25.59	0	0	586.37	230.99	251.3	10.76	0	392.86	2035.2											75  days 1 - 7	75  days 1 - 7	50  days 8 - 100	0	100	20	20	50	50-ASC/ 75-OP/ 50-Non Surg	0	15 - 100		0 - 10	10 to 50	0	0 to 10	5 to 10	10	0 - 100	0 to 25	0 -20	0.2	0	Not Covered	25	25	25	0		0	0 to 0											55.54	55.54	30.4	0	100	0.2	0.2	50	70	0	36.25	0	6.67	29.25	0	10	6.25	10	14.62	1.73	0.13	0.2	0	0	25	25	25	0	0	0	0											7.05	0.13	4.83	-	3.93	4.8	0.91	1.46	1.99	-	3.19	-	0.35	1.63	-	9.83	0.15	1.04	6.34	4.91	1.34	5.12	-	-	1.22	0.48	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.21		0	7.05	0.13	4.83	-	3.93	4.8	0.91	1.46	1.99	-	3.19	-	0.35	1.63	-	9.83	0.15	1.04	6.34	4.91	1.34	5.12	-	-	1.22	0.48	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.21	0																																																																																			-		0	7.05	0.13	4.83	-	3.93	4.8	0.91	1.46	1.99	-	3.19	-	0.35	1.63	-	9.83	0.15	1.04	6.34	4.91	1.34	5.12	-	-	1.22	0.48	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.21
H0712_017_0	2007	6																					2000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1144.59	20.76	1439.61	2263.01	354.82	18.18	3.43	272.58	267.55	1707.78	839	0	486.35	520.24	4534.45	8637.49	199.77	867.51	3983.87	25350.43	7.55	18.33	0	0	437.99	173.58	187.71	8.08	0	289.63	0											150  days 1 - 6	150  days 1 - 6	100  days 8 - 100	0	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 50		0 - 25	25 to 100	10	0 to 25	15 to 25	25	0 - 50	0 to 25	0 -20	0.2	0	Not Covered	25	25	25	0		0	0 to 0											76.46	76.46	44.59	0	73.33	0.15	0.15	36.67	99	0	17.42	0	12.22	44.85	5.92	18.33	12.83	18.33	7.01	1.24	0.1	0.15	0	0	18.33	18.33	18.33	0	0	0	0											7.29	0.13	5.35	-	2.17	2.67	0.5	0.83	2.21	-	1.22	-	0.5	1.94	2.24	13.2	0.21	1.33	2.33	2.63	0.74	2.69	-	-	0.67	0.27	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.39		18.69	7.29	0.13	5.35	-	2.17	2.67	0.5	0.83	2.21	-	1.22	-	0.5	1.94	2.24	13.2	0.21	1.33	2.33	2.63	0.74	2.69	-	-	0.67	0.27	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.39	2000																																																																																			-		0	7.29	0.13	5.35	-	2.17	2.67	0.5	0.83	2.21	-	1.22	-	0.5	1.94	2.24	13.2	0.21	1.33	2.33	2.63	0.74	2.69	-	-	0.67	0.27	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.39
H0752_002_0	2007	5																					0											D	D	D		Coin	Coin	Coin	V	P		Coin			V	V	V	Coin	V		V	Coin																																																														-	0	1672.7	51.04	1311.14		7.09	3.49	7.39	177.47	270.76		49.88			226.15	5194.1	5743.6	2.72	336.6		95.86	40.62																					140/day up to 2100 max per admit	140/day up to 2100 max per admit	0 for 1st 5 days; 125/day from days 6-100		20 coin	20 coin	20 coin	50 copay	300 per visit		20 coin			25 copay	15 copay	25 copay	50 coin	25 copay		250 IP surgery 200 Am Surg Phys	20 coin																					129.88	104.14	116.02		0.2	0.2	0.2	49.95	299.89		0.07			24.95	14.86	24.99	0.37	23.37		230.27	0.2																					18.1	0.44	12.68	-	1.41	0.7	1.48	0.74	6.77	-	3.32	-	-	0.47	6.43	11.96	1.01	0.66	-	1.84	8.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.13	0	0	18.1	0.44	12.68	-	1.41	0.7	1.48	0.74	6.77	-	3.32	-	-	0.47	6.43	11.96	1.01	0.66	-	1.84	8.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.13	0																																																																																			-	0	0	18.1	0.44	12.68	-	1.41	0.7	1.48	0.74	6.77	-	3.32	-	-	0.47	6.43	11.96	1.01	0.66	-	1.84	8.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.13
H0752_801_0	2007	4																					0											D	D	D		Coin	Coin	Coin	P	Coin		Coin			V	V	V	Coin	V	Coin	V	Coin																																																														-	0	1672.78	51.04	1311.21		7.09	3.49	7.39	177.59	38.56		49.89			226.31	5194.17	5743.6	2.72	336.6	10.16	95.86	40.62																					225/day up to 2250 max per admit	225/day up to 2250 max per admit	160/day		30 coins	30 coins	30 coins	50 copay	30 coins		30 coins			40 copay	20 copay	40 copay	50 coins	40 copay	30 coins	250 IP surgery 200 Am Surg Phys	30 coins																					186.27	149.36	148.51		0.3	0.3	0.3	49.95	0.3		0.07			39.92	19.82	39.98	0.37	37.39	0.3	230.27	0.3																					25.97	0.64	16.23	-	2.11	1.05	2.22	0.74	11.57	-	3.32	-	-	0.75	8.58	19.14	1.01	1.05	3.05	1.84	12.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.44	0	0	25.97	0.64	16.23	-	2.11	1.05	2.22	0.74	11.57	-	3.32	-	-	0.75	8.58	19.14	1.01	1.05	3.05	1.84	12.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.44	0																																																																																			-	0	0	25.97	0.64	16.23	-	2.11	1.05	2.22	0.74	11.57	-	3.32	-	-	0.75	8.58	19.14	1.01	1.05	3.05	1.84	12.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.44
H0752_802_0	2007	4																					0											D	D	D		Coin	Coin	Coin	P	Coin		Coin			V	V	V	Coin	V	Coin	V	Coin																																																														-	0	1672.78	51.04	1311.21		7.09	3.49	7.39	177.59	38.56		49.89			226.31	5194.17	5743.6	2.72	336.6	10.16	95.86	40.62																					225/day up to 2250 max per admit	225/day up to 2250 max per admit	160/day		30 coins	30 coins	30 coins	50 copay	30 coins		30 coins			40 copay	20 copay	40 copay	50 coins	40 copay	30 coins	250 IP surgery 200 Am Surg Phys	30 coins																					186.27	149.36	148.51		0.3	0.3	0.3	49.95	0.3		0.07			39.92	19.82	39.98	0.37	37.39	0.3	230.27	0.3																					25.97	0.64	16.23	-	2.11	1.05	2.22	0.74	11.57	-	3.32	-	-	0.75	8.58	19.14	1.01	1.05	3.05	1.84	12.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.44	0	0	25.97	0.64	16.23	-	2.11	1.05	2.22	0.74	11.57	-	3.32	-	-	0.75	8.58	19.14	1.01	1.05	3.05	1.84	12.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.44	0																																																																																			-	0	0	25.97	0.64	16.23	-	2.11	1.05	2.22	0.74	11.57	-	3.32	-	-	0.75	8.58	19.14	1.01	1.05	3.05	1.84	12.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.44
H0755_001_0	2007	4																					none											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	320.64	3.15	2228.76	0	250.24	13.93	0.94	282.26	26.85	0	1050.43	0	0.23	197.25	5278.15	8133.53	198.3	591.78	0	261.2	11.27	804.37	0	1650.16	487.12	0	77.48	0	0	10400	10400											0/admit	0/admit	50/day days 21-100	0 copay	50 copay	20 DME / 0 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 25 UC	0 ASC / 0 OP	0 copay	0 - 75 per	0 copay	20 coinsurance	25 OP SA / 0 Cardiac Rehab	5 PCP	15 SCP / 15 Chiro / 15 Podiatrist	25 MH	10 Therapy	0 copay	15 Hearing / 0 Preventive	20 coinsurance	15 Vision		0	15 copay		15 copay				0											0	0	11.92	0	50	0.16	0.2	39.75	0	0	32.7	0	0.2	11.58	5.44	14.71	25	10	0	2.9	0.2	15	0	0	15	0	15	0	0	0	0											-	-	2.21	-	1.04	2.27	0.19	0.94	-	-	2.86	-	0.05	0.19	2.39	9.97	0.41	0.49	-	0.06	2.25	1.01	-	-	0.61	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.05	0	0	-	-	2.21	-	1.04	2.27	0.19	0.94	-	-	2.86	-	0.05	0.19	2.39	9.97	0.41	0.49	-	0.06	2.25	1.01	-	-	0.61	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.05	none																								0							0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	2.21	-	1.04	2.27	0.19	0.94	-	-	2.86	-	0.05	0.19	2.39	9.97	0.41	0.49	-	0.06	2.25	1.01	-	-	0.61	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.05
H0755_020_0	2007	5																					700											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	700	1619.58	25.25	2271.72	0	230.16	12.83	0.87	259.35	244.84	0	964.67	0	0.21	183.08	4760.67	7410.55	202.23	537.13	0	238.12	10.39	741.6	0	1485.14	448.22	0	71.48	0	0	9360	9360											0/day	0/day	50/day days 21-100	0 copay	75 copay	20 DME / 0 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 25 UC	50 ASC / 50 OP	0 copay	0 - 75 per	0 copay	20 coinsurance	25 OP SA / 0 Cardiac Rehab	10 PCP	15 SCP / 15 Chiro / 15 Podiatrist	25 MH	25 Therapy	0 copay	15 Hearing / 0 Preventive	20 coinsurance	15 Vision		0	15 copay		15 copay				0											0	0	11.92	0	75	0.16	0.2	39.75	50	0	32.7	0	0.2	25	10.2	14.85	25	13.09	0	3.01	0.2	15	0	0	12.79	0	12.79	0	0	0	0											0	-	2.26	-	1.44	2.09	0.17	0.86	1.02	-	2.63	-	0.04	0.38	4.04	9.17	0.42	0.59	-	0.06	2.08	0.93	-	-	0.48	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.73	0	0.69	0	-	2.26	-	1.44	2.09	0.17	0.86	1.02	-	2.63	-	0.04	0.38	4.04	9.17	0.42	0.59	-	0.06	2.08	0.93	-	-	0.48	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.73	1400	100/day	100/day	50/day days 21-100	0 copay	75 copay	20 DME / 0 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 25 UC	20 coinsurance	20 coinsurance	20 coinsurance	0 copay	20 coinsurance	25 OP SA / 20 Cardiac Rehab	35 PCP	35 SCP / 35 Chiro / 35 Podiatrist	25 MH	20 Therapy	0 coinsurance	35 Hearing / 0 Preventive	20 coinsurance	35 Vision		0	35 copay		35 copay				0											0.93	0	0	0	0.18	0.13	0.01	0.11	0.55	0.15	0.73	0	0.01	0.42	1.35	3.63	0	0.1	0	0.01	0.21	0.24	0	0	0.14	0	0.02	0	0	0	0											8.92	0	0.69	0.93	-	2.26	-	1.62	2.23	0.18	0.97	1.57	0.15	3.36	-	0.05	0.8	5.4	12.8	0.42	0.69	-	0.07	2.29	1.17	-	-	0.62	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.65
H0755_021_0	2007	4																					600											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1177.75	17.63	2420.22	0	274.51	15.28	1.03	309.64	292.77	0	1152.33	0	0.25	216.9	5901.52	9022.69	222.47	635.64	0	290.65	12.37	882.37	0	1650.16	534.36	0	85	0	0	10400	10400											50/day for days 1-6	50/day for days 1-6	75/day days 16-100	0 copay	50 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 25 UC	25 ASC / 25 OP	0 copay	0 - 100 per	0 copay	20 coinsurance	20 OP SA / 0 Cardiac Rehab	0 PCP	15 SCP / 15 Chiro / 15 Podiatrist	20 MH	15 Therapy	0 copay	15 Hearing / 0 Preventive	20 coinsurance	15 Vision		0	15 copay		15 copay				0											42.27	42.27	25.96	0	50	0.2	0.2	39.75	25	0	33.13	0	0.2	15.54	0.64	14.57	20	13.09	0	2.86	0.2	15	0	0	15	0	15	0	0	0	0											4.15	0.06	5.24	-	1.14	3.06	0.21	1.03	0.61	-	3.18	-	0.05	0.28	0.32	10.96	0.37	0.69	-	0.07	2.47	1.1	-	-	0.67	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.76	0	0.77	4.15	0.06	5.24	-	1.14	3.06	0.21	1.03	0.61	-	3.18	-	0.05	0.28	0.32	10.96	0.37	0.69	-	0.07	2.47	1.1	-	-	0.67	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.76	600																								0							0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.15	0.06	5.24	-	1.14	3.06	0.21	1.03	0.61	-	3.18	-	0.05	0.28	0.32	10.96	0.37	0.69	-	0.07	2.47	1.1	-	-	0.67	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.76
H0755_022_0	2007	3																					2400											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1003.78	15.4	1993.69	0	226.13	12.59	0.85	252.33	241.17	0	949.23	0	0.21	178.24	4404.5	6961.38	179.19	523.62	0	220.02	10.19	687.8	0	0	416.52	0	77.94	0	0	10400	10400											200/day for days 1-7	200/day for days 1-7	75/day days 21-100	0 copay	75 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 30 UC	100 ASC / 100 OP	0 copay	0 - 200 per	0 copay	20 coinsurance	30 OP SA / 0 Cardiac Rehab	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy	0 copay	30 Hearing / 0 Preventive	20 coinsurance	30 Vision		0	30 copay		30 copay				0											178.22	178.22	25.96	0	75	0.2	0.2	41.8	100	0	77.07	0	0.2	30	15.7	29.53	30	13.09	0	5.05	0.2	30	0	0	30	0	30	0	0	0	0											14.91	0.23	4.31	-	1.41	2.52	0.17	0.88	2.01	-	6.1	-	0.04	0.45	5.76	17.13	0.45	0.57	-	0.09	2.04	1.72	-	-	1.04	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.02	0	1.85	14.91	0.23	4.31	-	1.41	2.52	0.17	0.88	2.01	-	6.1	-	0.04	0.45	5.76	17.13	0.45	0.57	-	0.09	2.04	1.72	-	-	1.04	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.02	2400																								0							0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.91	0.23	4.31	-	1.41	2.52	0.17	0.88	2.01	-	6.1	-	0.04	0.45	5.76	17.13	0.45	0.57	-	0.09	2.04	1.72	-	-	1.04	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.02
H0755_023_0	2007	1																					1000											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	846.46	12.29	1888.8	0	214.24	11.93	0.81	241.64	228.48	0	899.27	0	0.2	168.86	4215.66	6631.22	169.77	496.09	0	210.05	9.65	651.63	0	0	394.62	0	73.85	0	0	10400	10400											100/day for days 1-5	100/day for days 1-5	75/day days 21-100	0 copay	75 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 25 UC	100 ASC / 100 OP	0 copay	0 - 200 per	0 copay	20 coinsurance	25 OP SA / 0 Cardiac Rehab	15 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MH	25 Therapy	0 copay	25 Hearing / 0 Preventive	20 coinsurance	25 Vision		0	25 copay		25 copay				0											87.84	87.84	25.96	0	75	0.2	0.2	39.75	100	0	77.07	0	0.2	25	15.46	24.68	25	13.09	0	4.87	0.2	25	0	0	25	0	25	0	0	0	0											6.2	0.09	4.09	-	1.34	2.39	0.16	0.8	1.9	-	5.78	-	0.04	0.35	5.43	13.64	0.35	0.54	-	0.09	1.93	1.36	-	-	0.82	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.44	0	0.87	6.2	0.09	4.09	-	1.34	2.39	0.16	0.8	1.9	-	5.78	-	0.04	0.35	5.43	13.64	0.35	0.54	-	0.09	1.93	1.36	-	-	0.82	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.44	1000																								0							0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.2	0.09	4.09	-	1.34	2.39	0.16	0.8	1.9	-	5.78	-	0.04	0.35	5.43	13.64	0.35	0.54	-	0.09	1.93	1.36	-	-	0.82	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.44
H0755_024_0	2007	3																					1000											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1078.34	16.54	2120.15	0	240.48	13.39	0.91	271.24	256.47	0	1009.44	0	0.22	189.55	4731.91	7443.28	190.56	556.84	0	235.77	10.83	731.43	0	0	442.95	0	82.89	0	0	10400	10400											75/day for days 1-7	75/day for days 1-7	75/day days 21-100	0 copay	75 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 25 UC	75 ASC / 75 OP	0 copay	0 - 200 per	0 copay	20 coinsurance	25 OP SA / 0 Cardiac Rehab	15 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MH	25 Therapy	0 copay	25 Hearing / 0 Preventive	20 coinsurance	25 Vision		0	25 copay		25 copay				0											66.34	66.34	25.96	0	75	0.2	0.2	39.75	75	0	77.07	0	0.2	25	15.46	24.68	25	13.09	0	4.87	0.2	25	0	0	25	0	25	0	0	0	0											5.96	0.09	4.59	-	1.5	2.68	0.18	0.9	1.6	-	6.48	-	0.04	0.39	6.1	15.31	0.4	0.61	-	0.1	2.17	1.52	-	-	0.92	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.72	0	0.79	5.96	0.09	4.59	-	1.5	2.68	0.18	0.9	1.6	-	6.48	-	0.04	0.39	6.1	15.31	0.4	0.61	-	0.1	2.17	1.52	-	-	0.92	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.72	1000																								0							0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.96	0.09	4.59	-	1.5	2.68	0.18	0.9	1.6	-	6.48	-	0.04	0.39	6.1	15.31	0.4	0.61	-	0.1	2.17	1.52	-	-	0.92	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.72
H0755_801_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	985.74	13.69	2058.82	0	244.98	9.75	1.13	288.88	288.4	0	1248.17	0	0.26	232.82	5094.51	8421.12	210.02	669.03	0	267.7	11.21	845.03	0	0	0	0	0	0	0	10400	10400											300/day for days 1-6	300/day for days 1-6	75/day days 16-100	0 copay	150 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 40 UC	200 ASC / 200 OP	0 copay	0 - 200 per	0 copay	20 coinsurance	40 OP SA / 0 Cardiac Rehab	40 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	20 coinsurance	40 Vision		0	0 copay		0 copay				0											300	300	25.96	0	150	0.2	0.2	46.63	200	0	50.73	0	0.2	40	39.92	39.74	40	19.04	0	10.25	0.2	40	0	0	0	0	0	0	0	0	0											24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	none		0	0	0								0					0						0	0		0		0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6
H0755_803_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	985.74	13.69	2058.82	0	244.98	9.75	1.13	288.88	288.4	0	1248.17	0	0.26	232.82	5094.51	8421.12	210.02	669.03	0	267.7	11.21	845.03	0	0	0	0	0	0	0	10400	10400											300/day for days 1-6	300/day for days 1-6	75/day days 16-100	0 copay	150 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 40 UC	200 ASC / 200 OP	0 copay	0 - 200 per	0 copay	20 coinsurance	40 OP SA / 0 Cardiac Rehab	40 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	20 coinsurance	40 Vision		0	0 copay		0 copay				0											300	300	25.96	0	150	0.2	0.2	46.63	200	0	50.73	0	0.2	40	39.92	39.74	40	19.04	0	10.25	0.2	40	0	0	0	0	0	0	0	0	0											24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	none		0	0	0								0					0						0	0		0		0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6
H0755_804_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	985.74	13.69	2058.82	0	244.98	9.75	1.13	288.88	288.4	0	1248.17	0	0.26	232.82	5094.51	8421.12	210.02	669.03	0	267.7	11.21	845.03	0	0	0	0	0	0	0	10400	10400											300/day for days 1-6	300/day for days 1-6	75/day days 16-100	0 copay	150 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 40 UC	200 ASC / 200 OP	0 copay	0 - 200 per	0 copay	20 coinsurance	40 OP SA / 0 Cardiac Rehab	40 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	20 coinsurance	40 Vision		0	0 copay		0 copay				0											300	300	25.96	0	150	0.2	0.2	46.63	200	0	50.73	0	0.2	40	39.92	39.74	40	19.04	0	10.25	0.2	40	0	0	0	0	0	0	0	0	0											24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	none		0	0	0								0					0						0	0		0		0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6
H0755_806_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	985.74	13.69	2058.82	0	244.98	9.75	1.13	288.88	288.4	0	1248.17	0	0.26	232.82	5094.51	8421.12	210.02	669.03	0	267.7	11.21	845.03	0	0	0	0	0	0	0	10400	10400											300/day for days 1-6	300/day for days 1-6	75/day days 16-100	0 copay	150 copay	20 DME / 20 Diabetes Monitoring Supplies	20 coinsurance	50 ER / 40 UC	200 ASC / 200 OP	0 copay	0 - 200 per	0 copay	20 coinsurance	40 OP SA / 0 Cardiac Rehab	40 PCP	40 SCP / 40 Chiro / 40 Podiatrist	40 MH	40 Therapy	0 copay	40 Hearing / 0 Preventive	20 coinsurance	40 Vision		0	0 copay		0 copay				0											300	300	25.96	0	150	0.2	0.2	46.63	200	0	50.73	0	0.2	40	39.92	39.74	40	19.04	0	10.25	0.2	40	0	0	0	0	0	0	0	0	0											24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6	none		0	0	0								0					0						0	0		0		0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	24.64	0.34	4.45	-	3.06	1.95	0.23	1.12	4.81	-	5.28	-	0.05	0.78	16.95	27.89	0.7	1.06	-	0.23	2.24	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.6
H0838_020_0	2007	6																																Coin	Coin																																																																																	-		308.68	1.72																																								FFS Standard	FFS Standard																																								0.06	0.06																																								19.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.48			19.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.48																																																																																				-			19.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.48
H0846_004_0	2007	4																					1000											D	Coin	D	V	T	P	P	V	V	V	Coin	V	Coin	V	V	V	V	V	Coin	Coin	Coin	P	P	Coin	Coin	P	P	P	P	P	P																																																				-			5.83			127.22	4.13		367.06			8.03		0.23		0.97	919.96	346.19	716.62		0.01	28.53			6.84	0.92		234.81																50 Coin			150 Copay	20 Coin on Covd Eyewear		50 Copay Waived if Admitted			20 Coin Therapeutic Radiology		20 Coin		20 Copay Vision Exam	20 Copay Vision 15 Chiropractic	15 Copay	15 Copay		20 Coin	20 Coin			50 Coin	20 Copay		20 Copay																0.39			116.03	18		38.66			0.09		0.15		15.47	13.23	11.6	11.6		0.18	0.15			0.39	0.18		15.47															-	2.25	-	-	1.23	0.01	-	1.18	-	-	0.7	-	0.04	-	0	1.01	0.33	0.69	-	0	4.41	-	-	2.65	0.17	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.98		4.38	-	2.25	-	-	1.23	0.01	-	1.18	-	-	0.7	-	0.04	-	0	1.01	0.33	0.69	-	0	4.41	-	-	2.65	0.17	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.98																																																																																				-			-	2.25	-	-	1.23	0.01	-	1.18	-	-	0.7	-	0.04	-	0	1.01	0.33	0.69	-	0	4.41	-	-	2.65	0.17	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.98
H0846_005_0	2007	3																					3000											D	D	D	V	Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	V	V	Coin	Coin	P	Coin	P	P	Coin	V	Coin	V	Coin	P	P	P																																																				-		1477.94	77.56	660.26		4.86	9.57	12.01	332.32	39.11	10.26	22.66		0.23	8.71	3807.47	4668.77	289.53	3.84	25.71		26.08			6.84	131.15		234.81															180 Copay days 1-5	180 Copay days 1-5	90 Copay days 4-100		20 Coins	20 Coins	20 Coins	50 Copay waived if admitted	20 Coins	20 Coins	20 Coins		20 Coins	20 Coins	15 Copay	30 Copay	30 Copay	20 Coins	20 Coins		20 Coins			50 Coins	30 Copay		30 Copay															81.23	81.23	57.71		0.15	0.15	0.15	36.81	0.15	0.15	0.13		0.15	0.14	11.05	22.09	22.09	0.15	0.03		0.15			0.37	22.09		22.09															10	0.53	3.18	-	0.72	1.41	1.77	1.02	5.76	1.51	2.87	-	0.03	1.23	3.5	8.59	0.53	0.57	0.64	-	3.84	-	-	2.52	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.9		18.24	10	0.53	3.18	-	0.72	1.41	1.77	1.02	5.76	1.51	2.87	-	0.03	1.23	3.5	8.59	0.53	0.57	0.64	-	3.84	-	-	2.52	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.9																																																																																				-			10	0.53	3.18	-	0.72	1.41	1.77	1.02	5.76	1.51	2.87	-	0.03	1.23	3.5	8.59	0.53	0.57	0.64	-	3.84	-	-	2.52	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.9
H0846_006_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V	Coin	Coin	P	P	V	Coin	Coin	P	Coin	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-		1487.28	73.14	665.61		108.87	9.23	11.81	316.26	39.19		23.28		0.29	7.92	3558.81	4712.32	292.42	4.17	28.3		1.61			6.84	131.15		234.81															265/day days 1-11	265/day days 1-11	125/day days 1-24		150 Copay	20 Coins	20 Coins	50 Copay waived if admitted	20 Coins		20 Coins		20 Coins	20 Coins	10 Copay	25 Copay	30 Group 40 Individual	20 Coins	20 Coins		20 Coins			50 Coins	25 Copay		25 Copay															159.7	159.7	58.91		108.26	0.14	0.14	36.09	0.14		0.12		0.14	0.14	7.22	18.04	25.26	0.14	0.02		0.14			0.36	18.04		18.04															19.79	0.97	3.27	-	0.98	1.33	1.7	0.95	5.66	-	2.9	-	0.04	1.08	2.14	7.09	0.62	0.6	0.69	-	0.23	-	-	2.47	0.2	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.08		20.46	19.79	0.97	3.27	-	0.98	1.33	1.7	0.95	5.66	-	2.9	-	0.04	1.08	2.14	7.09	0.62	0.6	0.69	-	0.23	-	-	2.47	0.2	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.08																																																																																				-			19.79	0.97	3.27	-	0.98	1.33	1.7	0.95	5.66	-	2.9	-	0.04	1.08	2.14	7.09	0.62	0.6	0.69	-	0.23	-	-	2.47	0.2	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.08
H0846_801_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H0846_802_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H0901_001_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.46 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.46	35	35	35	35	45				0		0															17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09																																																																																				-			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09
H0901_002_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															350 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 125 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															57.09		67.84	20	100	0.2		48	200	25	59.2	25	25	25	10	25	25	25	25	25	45				0		0															7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65			7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65																																																																																				-			7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65
H0901_003_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S		T	V	V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0	0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0		0	3795.51	0		0															992/admission		0 days 1-20 100 21-100	0 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	400 per procedure	47.86 per visit	47.86 X-ray; 20 CAT PET MRI	47.86 per visit	30 per visit	30 per visit	0 per visit	50 per visit; 30 per dialysis visit	50 per visit	50 per visit	50 per visit	50 per visit	45 per script		50 one way trips per year	5 per visit	0 per visit		0 per visit															161.82		40.15	0	100	0.2		48	400	47.86	67.1	47.86	30	50	0	47.86	50	50	50	50	45		0	5	0		0															20.99	-	4.25	-	1.92	3.14	-	1.67	11.47	8.73	6.29	-	-	-	-	26.75	0.82	2.38	3.91	5.91	-	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.82			20.99	-	4.25	-	1.92	3.14	-	1.67	11.47	8.73	6.29	-	-	-	-	26.75	0.82	2.38	3.91	5.91	-	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.82																																																																																				-			20.99	-	4.25	-	1.92	3.14	-	1.67	11.47	8.73	6.29	-	-	-	-	26.75	0.82	2.38	3.91	5.91	-	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.82
H0901_004_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.46 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.46	35	35	35	35	45				0		0															17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09																																																																																				-			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09
H0901_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H0901_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H0902_002_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	5000	1369.62		1118.74	1836.48	202.67	13.83		367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0				0		0															350 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 100 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															57.09		67.84	20	100	0.2		48	200	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															6.52	-	6.32	3.06	1.69	2.77	-	1.47	5.05	4.01	4.18	-	-	-	3.98	12.3	0.36	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.07	0	0	6.52	-	6.32	3.06	1.69	2.77	-	1.47	5.05	4.01	4.18	-	-	-	3.98	12.3	0.36	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.07		20 150 ded 5000 OOP max		20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	100 per trip	20 150 ded 5000 OOP max		50 ER; 35 UC	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	45 per script				20 150 ded 5000 OOP max		20 150 ded 5000 OOP max															3.51		0.57	0.51	0.17	0.29		0.15	0.36	0.12	0.35	0	0.11	0.39	0.46	0.57	0.02	0.06	0.42	1.54	0.03				0.06		0.02															9.71	150	6.03	10.03	-	6.89	3.57	1.86	3.06	-	1.62	5.41	4.14	4.53	-	0.11	0.39	4.44	12.87	0.38	1.11	2.14	4.14	0.03	-	-	-	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.78
H0902_003_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	7500	1369.62		1118.74	1836.48	202.67	13.83		367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.4 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.4	35	35	35	35	45				0		0															15.83	-	6.32	3.06	1.69	2.77	-	1.47	5.05	5.62	5.42	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.13	0	0	15.83	-	6.32	3.06	1.69	2.77	-	1.47	5.05	5.62	5.42	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.13		30 500 ded 7500 OOP max		30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	100 per trip	30 500 ded 7500 OOP max		50 ER; 35 UC	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	45 per script				30 500 ded 7500 OOP max		30 500 ded 7500 OOP max															5.75		0.93	0.84	0.19	0.48		0.16	0.59	0.2	0.57	0	0.19	0.63	0.75	0.93	0.04	0.1	0.69	2.52	0.09				0.1		0.03															15.77	500	9.23	21.57	-	7.26	3.9	1.87	3.24	-	1.63	5.64	5.82	6	-	0.19	0.63	8.71	17.85	0.54	1.57	3.1	6.15	0.09	-	-	-	0.1	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.89
H0902_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	150 per trip	30 500 ded unlimited OOP max	0	50 ER; 50 UC	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	20 coinsurance	0			30 500 ded unlimited OOP max		30 500 ded unlimited OOP max															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0			0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H0902_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	150 per trip	30 500 ded unlimited OOP max	0	50 ER; 50 UC	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	20 coinsurance	0			30 500 ded unlimited OOP max		30 500 ded unlimited OOP max															792	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0			0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H0974_001_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		300.28	41.58	77.27	43.04	12.66	23.43	23.57	684.12	29.41	15.31	9.45	3.56	2.39	67.58	52.97	106.34	16.8	3.1	25.6	34.84	29.45	0	0	0	0	0	0	0	0	0	5.76											ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14B Immunizations. PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture. No member cost sharing for other services.											0.08	0.08	0.16	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0.24	0	0											23.21	3.21	12.35	-	2.99	5.53	5.56	2.85	6.94	3.61	2.23	0.84	0.56	15.95	12.5	25.1	3.96	0.73	6.04	8.22	6.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.35	126		23.21	3.21	12.35	-	2.99	5.53	5.56	2.85	6.94	3.61	2.23	0.84	0.56	15.95	12.5	25.1	3.96	0.73	6.04	8.22	6.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.35																																																																																				-			23.21	3.21	12.35	-	2.99	5.53	5.56	2.85	6.94	3.61	2.23	0.84	0.56	15.95	12.5	25.1	3.96	0.73	6.04	8.22	6.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.35
H1013_011_0	2007	5																																																																																																																		-				835.39					193.14	86.89		19.09		0	27.92							863			701.32																		0 copay	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	50 copay @ Hospital PBP L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	20 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay													15.55					50	100		50		25	25							9.5			85.3																		-	-	1.08	-	-	-	-	0.8	0.72	-	0.08	-	-	0.06	-	-	-	-	-	-	0.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.42			-	-	1.08	-	-	-	-	0.8	0.72	-	0.08	-	-	0.06	-	-	-	-	-	-	0.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.42																	20 Travel Benefit Copay																																									0.02																										0.02			-	-	1.08	-	-	-	-	0.8	0.72	-	0.08	-	-	0.06	-	0.02	-	-	-	-	0.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.43
H1013_021_0	2007	3																																																																																																																		-		1866.08		1049.17					314.52	71.5		1367.45		0.14	83.26		9762.89					1133			701.32																		50/day (days 1-5)	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	100 copay @ Hospital PBP; 25 copay @ Diagnostic Center L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	15 copay per visit	0 copay	0 copay	0 copay	0 copay	40 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		15.55					50	100		27.84		25	25		15					21.23			85.3																		5.3	-	1.36	-	-	-	-	1.31	0.6	-	3.17	-	0	0.17	-	12.2	-	-	-	-	2	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.1			5.3	-	1.36	-	-	-	-	1.31	0.6	-	3.17	-	0	0.17	-	12.2	-	-	-	-	2	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.1																	15 Travel Benefit Copay																																									0.01																										0.01			5.3	-	1.36	-	-	-	-	1.31	0.6	-	3.17	-	0	0.17	-	12.22	-	-	-	-	2	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.12
H1013_022_0	2007	3																																																																																																																		-		1471.52		609.82		230.32			227.96	90.81		32.31		0.01	61.56		9587.75					558.98			701.32																		50/day (days 1-5)	0 copay	55 per day (days 8 through 34)  PBP L.2	0 copay	100 copay PBP L.10	0 copay	0 copay	50 copay PBP L.4a	250 copay @ Hospital PBP L.9a	Included in OP-Facility Other	100 copay @ Hospital PBP L.8a/8b	0 copay	50 copay @ Hospital PBP L.12	50 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	20 copay per visit	0 copay	0 copay	0 copay	0 copay	40 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		28.51		100			50	250		100		50	50		20					21.23			85.3																		4.18	-	1.45	-	1.92	-	-	0.95	1.89	-	0.27	-	0	0.26	-	15.98	-	-	-	-	0.99	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.87			4.18	-	1.45	-	1.92	-	-	0.95	1.89	-	0.27	-	0	0.26	-	15.98	-	-	-	-	0.99	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.87																	20 Travel Benefit Copay																																									0.02																										0.02			4.18	-	1.45	-	1.92	-	-	0.95	1.89	-	0.27	-	0	0.26	-	16	-	-	-	-	0.99	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.88
H1013_023_0	2007	3																																																																																																																		-		1615.9		711.84					236.24	91.13		1755.83		0.02	71.86		9887.54					514.14			701.32																		50/day (days 1-5)	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	100 copay @ Hospital PBP; 25 copay @ Diagnostic Center L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	15 copay per visit	0 copay	0 copay	0 copay	0 copay	40 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		15.55					50	100		26.61		25	25		15					21.23			85.3																		4.59	-	0.92	-	-	-	-	0.98	0.76	-	3.89	-	0	0.15	-	12.36	-	-	-	-	0.91	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.55			4.59	-	0.92	-	-	-	-	0.98	0.76	-	3.89	-	0	0.15	-	12.36	-	-	-	-	0.91	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.55																	15 Travel Benefit Copay																																									0.01																										0.01			4.59	-	0.92	-	-	-	-	0.98	0.76	-	3.89	-	0	0.15	-	12.37	-	-	-	-	0.91	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.56
H1013_024_0	2007	5																																																							P																																																											-																									3043.09																		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay																																		17.51																		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44
H1013_026_0	2007	5																																																																																																																		-		1519.65		714.17					195.9	248.14		28.34		0	60.22	4732	4748.67					668.24			701.32																		50 per day (1-5)	0 copay	55 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	50 copay @ Hospital PBP L.8a	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	5 copay per visit	35 copay per visit	0 copay	0 copay	0 copay	0 copay	50 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		28.51					50	47.5		50		25	25	5	35					25.66			85.3																		4.31	-	1.7	-	-	-	-	0.82	0.98	-	0.12	-	-	0.13	1.97	13.85	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.29			4.31	-	1.7	-	-	-	-	0.82	0.98	-	0.12	-	-	0.13	1.97	13.85	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.29																35 coinsurance	35 coinsurance																																								15.44	25.65																										41.08			4.31	-	1.7	-	-	-	-	0.82	0.98	-	0.12	-	-	0.13	17.41	39.5	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.37
H1016_001_0	2007	5	h.6.										OP Facility - Other											MH Substance Abuse										D	D	D	P	T	Coin	Coin	V	V	V	V	V	V	V	P	P	V	P	P	P	S	O	T	P	P	P	P	P	O	V	Coin	V										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		1828.99	1.18	961.44	2097.07	230.11	0.4	0	240.71	338.55	119.66	1315.36	43.63	34.41	1863.13	7415.87	21214.56	435.33	168.15	3723.43	0	6.45	0	35.48	0	4.23	0	47.07	0	0	1512.67	0	0										50/Day for Days 1-5 unlimited days.	50/Day for Days 1-5	100 for Days 21-100	No Cost Sharing	50/Trip	20 Coinsurance	20 Coinsurance for Diabetes Supplies Only	50 per ER Visit; 25 per Urgent Care Visit	50/Episode	No Cost Sharing	25 Copayment	No Cost Sharing	No Cost Sharing	25 Copayment for Diagnostic Testing; 10 Copayment for OP Rehab	0/Visit Copayment	10/Visit Copayment	10/Visit Copayment for Individual; 5/Visit Copayment for Group	10/Visit Copayment	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	10/Visit Copayment	10/Visit Copayment	10/Visit Copayment	10/Pair (1 pair per year limit)	No Cost Sharing	Not Applicable	No Cost Sharing	No Cost Sharing	10/Visit Copayment for Individual; 5/Visit Copayment for Group										21.32	50	41.19	0	50	0.2	0.1	49.7	50	0	25	0	0	0.15	0	2.21	9.5	10	0	0	0	0	0	10	10	10	10	0	0	0	0	9.5										3.25	0	3.3	-	0.96	0.08	-	1	1.41	-	2.74	-	-	0.02	0	3.9	0.34	0.14	-	-	-	-	-	-	0	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.2			3.25	0	3.3	-	0.96	0.08	-	1	1.41	-	2.74	-	-	0.02	0	3.9	0.34	0.14	-	-	-	-	-	-	0	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.2																																																																																				-			3.25	0	3.3	-	0.96	0.08	-	1	1.41	-	2.74	-	-	0.02	0	3.9	0.34	0.14	-	-	-	-	-	-	0	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.2
H1016_002_0	2007	6	h.6.										OP Facility - Other											MH Substance Abuse										D	D	D	P	T	Coin	Coin	V	V	V	V	V	V	V	P	P	V	P	P	P	S	O	T	P	P	P	P	P	O	V	Coin	V										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		1754.84	0.66	820.63	2705.69	319.18	0.25	0.01	324.48	386.51	132.31	1309.22	85.19	24.73	1510.82	8677.55	22799.23	467.9	419.65	4233.83	0	5.12	0	0.2	0	2.14	0.1	42.43	0	0	1.74	0	0										150/Day for Days 1-7 unlimited days	150/Day for Days 1-7	110 for Days 21-100	No Cost Sharing	50/Trip	20/Device	20 for Diabetes Supplies Only	50 per ER Visit; 25 per Urgent Care Visit	125/Episode	No Cost Sharing	25 Copayment	No Cost Sharing	No Cost Sharing	25 Copayment for Diagnostic Testing; 20 Copayment for OP Rehab	0/Visit Copayment	20/Visit Copayment	20/Visit Copayment for Individual; 10/Visit Copayment for Group	20/Visit Copayment	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	20/Visit Copayment	20/Visit Copayment	10/Pair (1 pair per year limit)	20/Visit Copayment	No Cost Sharing	Not Applicable	No Cost Sharing	No Cost Sharing	20/Visit Copayment for Individual; 10/Visit Copayment for Group										78.5	175	45.31	0	50	0.2	0.1	48.86	125	0	25	0	0	0.35	0	4.59	18.5	20	0	0	0	0	0	20	20	10	20	0	0	0	0	18.5										11.48	0.01	3.1	-	1.33	0.05	0	1.32	4.03	-	2.73	-	-	0.04	-	8.72	0.72	0.7	-	-	-	-	-	-	0	0	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.3			11.48	0.01	3.1	-	1.33	0.05	0	1.32	4.03	-	2.73	-	-	0.04	-	8.72	0.72	0.7	-	-	-	-	-	-	0	0	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.3																																																																																				-			11.48	0.01	3.1	-	1.33	0.05	0	1.32	4.03	-	2.73	-	-	0.04	-	8.72	0.72	0.7	-	-	-	-	-	-	0	0	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.3
H1016_017_0	2007	5	h.6.										OP Facility - Other											MH Substance Abuse													P	T	Coin	Coin	V	V	V	V	V	V	V	P	P	V	P	P	P	S	O	T	P	P	P	P	P	O	V	Coin	V													0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-					811.71	319.18	0.25	0.01	324.48	386.51	132.31	1309.22	85.19	24.73	1510.82	8677.55	22799.23	467.9	419.65	4233.83	0	5.12	0	0.2	0	2.14	0.1	42.43	0	0	1.74	0	0													No Cost Sharing	50/Trip	20/Device	20 for Diabetes Supplies Only	50 per ER Visit; 25 per Urgent Care Visit	150/Episode	No Cost Sharing	25 Copayment	No Cost Sharing	No Cost Sharing	25 Copayment for Diagnostic Testing; 20 Copayment for OP Rehab	0/Visit Copayment	20/Visit Copayment	20/Visit Copayment for Individual; 10/Visit Copayment for Group	20/Visit Copayment	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	20/Visit Copayment	20/Visit Copayment	10/Pair (1 pair per year limit)	20/Visit Copayment	No Cost Sharing	Not Applicable	No Cost Sharing	No Cost Sharing	20/Visit Copayment for Individual; 10/Visit Copayment for Group													0	50	0.2	0.1	48.86	150	0	25	0	0	0.35	0	4.59	18.5	20	0	0	0	0	0	20	20	10	20	0	0	0	0	18.5										-	-	-	-	1.33	0.05	0	1.32	4.83	-	2.73	-	-	0.04	-	8.72	0.72	0.7	-	-	-	-	-	-	0	0	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.52			-	-	-	-	1.33	0.05	0	1.32	4.83	-	2.73	-	-	0.04	-	8.72	0.72	0.7	-	-	-	-	-	-	0	0	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.52																																																																																				-			-	-	-	-	1.33	0.05	0	1.32	4.83	-	2.73	-	-	0.04	-	8.72	0.72	0.7	-	-	-	-	-	-	0	0	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.52
H1019_001_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		Coin				Coin		Coin					D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0	0								-		1509.07	14.64	1614.29	2949	326.93	241.84	18.2	277.76	202.43	138.2	94.23	6.28	161.07	53.4	7544.7	5385.78			258.71		4.82				0		0					79.42	0.77	12391.02								25/day (1-10)	25/day (1-10)	0/day (1-6) 25/day (7-100)	0/Visit	100/ Trip	0/ Procedure	0/ Procedure	25-50/ Visit	100/ Visit	0/ Visit	0-50/ Visit	25/ Visit	5/ Procedure	0-50/ Visit	0/ Visit	5/ Visit			50/ Visit		20 Coins				See PBP for details		See PBP for details					25/day (1-10)	25/day (1-10)	0/Procedure								21.58	21.58	7.27	0	100	0	0	45	100	0	10	25	5	4.12	0	5			50		0.2				0		0					21.58	21.58	0								2.71	0.03	0.98	-	2.72	-	-	1.04	1.69	-	0.08	0.01	0.07	0.02	-	2.24	-	-	1.08	-	0.96	-	-	-	-	-	-	-	-	-	-	0.14	0	-	-	-	-	-	-	-	-	13.78	0	0	2.71	0.03	0.98	-	2.72	-	-	1.04	1.69	-	0.08	0.01	0.07	0.02	-	2.24	-	-	1.08	-	0.96	-	-	-	-	-	-	-	-	-	-	0.14	0	-	-	-	-	-	-	-	-	13.78																																																																																				-			2.71	0.03	0.98	-	2.72	-	-	1.04	1.69	-	0.08	0.01	0.07	0.02	-	2.24	-	-	1.08	-	0.96	-	-	-	-	-	-	-	-	-	-	0.14	0	-	-	-	-	-	-	-	-	13.78
H1019_002_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		Coin			Coin			Coin					D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0			0					0	0	0								-		1626.78	14.88	1403.41	2443.57	387.62	347.33	26.14	212.12	193.99	158.41	108.01	7.2	339.7	61.2	7298.81	4993.26			245.94		5.02			0			0					85.62	0.78	3981.56								0/day (1-90)	0/day (1-90)	0/day (1-6) 50/day (7-100)	0/Visit	50/ Trip	0/ Procedure	0/ Procedure	0-50/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		20 Coins			See PBP for details			See PBP for details					0/day (1-90)	0/day (1-90)	0/Procedure								0	0	14.55	0	50	0	0	40	0	0	0	0	0	0	0	0			0		0.2			0			0					0	0	0								-	-	1.7	-	1.62	-	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.03	0	0	-	-	1.7	-	1.62	-	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.03																																																																																				-			-	-	1.7	-	1.62	-	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.03
H1019_004_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		Coin			Coin								D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1424.12	13.82	1523.41	2570.52	332.93	210.8	15.87	282.85	206.14	140.73	95.95	6.4	140.4	54.37	6827.78	4694.55			230.54		3.83			0								74.95	0.73	11213.59								200/day (1-10)	200/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	0/ Procedure	0/ Procedure	25-50/ Visit	100/ Visit	0/ Visit	0-50/ Visit	200/ Visit	0/ Procedure	0-50/ Visit	0/ Visit	0/ Visit			0-50/ Visit		20 Coins			See PBP for Details								200/day (1-10)	200/day (1-7)	0/Procedure								172.66	155.92	29.09	0	100	0	0	45	100	0	10	200	0	0	0	0			20.37		0.2			0								172.66	155.92	0								20.49	0.18	3.69	-	2.77	-	-	1.06	1.72	-	0.08	0.11	-	-	-	-	-	-	0.39	-	0.77	-	-	-	-	-	-	-	-	-	-	1.08	0.01	-	-	-	-	-	-	-	-	32.35	0	0	20.49	0.18	3.69	-	2.77	-	-	1.06	1.72	-	0.08	0.11	-	-	-	-	-	-	0.39	-	0.77	-	-	-	-	-	-	-	-	-	-	1.08	0.01	-	-	-	-	-	-	-	-	32.35																																																																																				-			20.49	0.18	3.69	-	2.77	-	-	1.06	1.72	-	0.08	0.11	-	-	-	-	-	-	0.39	-	0.77	-	-	-	-	-	-	-	-	-	-	1.08	0.01	-	-	-	-	-	-	-	-	32.35
H1019_005_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S				Coin							D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0							0	0	0								-		1309.54	11.98	1129.73	1967.04	312.03	279.59	21.04	170.75	156.16	127.52	86.95	5.8	273.45	49.27	5875.43	4019.5			197.98		174.06				0							68.92	0.63	3205.09								150/day (1-10)	150/day (1-7)	0/day (1-6) 75/day (7-100)	0/Visit	100/ Trip	0/ Procedure	0/ Procedure	0-50/ Visit	50-100/ Visit	0/ Visit	0-50/ Visit	100/ Visit	0/ Procedure	0-50/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts				See PBP for details							150/day (1-10)	150/day (1-7)	0/Procedure								129.5	116.94	21.82	0	100	0	0	40	66.5	0	10	100	0	0	0	0			0		0				0							129.5	116.94	0								14.13	0.12	2.05	-	2.6	-	-	0.57	0.87	-	0.07	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	21.21	0	0	14.13	0.12	2.05	-	2.6	-	-	0.57	0.87	-	0.07	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	21.21																																																																																				-			14.13	0.12	2.05	-	2.6	-	-	0.57	0.87	-	0.07	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	21.21
H1019_006_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S			Coin	Coin							D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-		1704.93	15.59	1470.83	2560.95	406.24	364.01	27.4	222.31	203.31	166.02	113.2	7.55	356.01	64.14	7649.42	5233.12			257.75		226.62			0	0							89.73	0.82	4172.82								0/day (1-90)	0/day (1-90)	0/day (1-6) 50/day (7-100)	0/Visit	50/ Trip	0/ Procedure	0/ Procedure	0-50/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts			See PBP for details	See PBP for details							0/day (1-90)	0/day (1-90)	0/Procedure								0	0	14.55	0	50	0	0	40	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-	-	1.78	-	1.69	-	-	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.22	0	0	-	-	1.78	-	1.69	-	-	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.22																																																																																				-			-	-	1.78	-	1.69	-	-	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.22
H1019_010_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S											D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1432.49	16.22	2204.05	2655.31	320.54	99.23	7.47	280.62	231.45	242.86	165.59	11.04	232.02	93.83	8019.27	5600.45			272.5		331.5											75.39	0.85	5904.57								50/day (1-10)	50/day (1-10)	0/day (1-6) 50/day (7-100)	0/Visit	100/ Trip	0/ Procedure	0/ Procedure	25-50/ Visit	0-50/ Visit	0/ Visit	0/ Visit	50/ Visit	5/ Procedure	0-10/ Visit	0/ Visit	5/ Visit			0/ Visit		0/ Scripts											50/day (1-10)	50/day (1-10)	0/Procedure								43.17	43.16	14.54	0	100	0	0	45	16.5	0	0	50	5	5.29	0	5			0		0											43.17	43.17	0								5.15	0.06	2.67	-	2.67	-	-	1.05	0.32	-	-	0.05	0.1	0.04	-	2.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.27	0	-	-	-	-	-	-	-	-	14.72	0	0	5.15	0.06	2.67	-	2.67	-	-	1.05	0.32	-	-	0.05	0.1	0.04	-	2.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.27	0	-	-	-	-	-	-	-	-	14.72																																																																																				-			5.15	0.06	2.67	-	2.67	-	-	1.05	0.32	-	-	0.05	0.1	0.04	-	2.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.27	0	-	-	-	-	-	-	-	-	14.72
H1019_011_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S			Coin								D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1558.38	17.64	2397.74	2888.65	348.71	107.95	8.13	305.28	251.79	264.2	180.14	12.01	252.41	102.08	8724.01	6092.62			296.45		360.63			0								82.02	0.93	6423.46								150/day (1-10)	150/day (1-10)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	20/ Procedure	20/ Procedure	25-50/ Visit	50-100/ Visit	20/ Visit	20/ Visit	150/ Visit	15/ Procedure	0-20/ Visit	0/ Visit	15/ Visit			0-20/ Visit		0/ Scripts			See PBP for details								150/day (1-10)	150/day (1-10)	0/Procedure								129.49	129.49	29.09	0	100	20	20	45	66.5	20	20	150	15	14.71	0	15			8.22		0			0								129.5	129.49	0								16.82	0.19	5.81	-	2.91	0.18	0.01	1.14	1.4	0.44	0.3	0.15	0.32	0.13	-	7.62	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	0.89	0.01	-	-	-	-	-	-	-	-	38.5	0	0	16.82	0.19	5.81	-	2.91	0.18	0.01	1.14	1.4	0.44	0.3	0.15	0.32	0.13	-	7.62	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	0.89	0.01	-	-	-	-	-	-	-	-	38.5																																																																																				-			16.82	0.19	5.81	-	2.91	0.18	0.01	1.14	1.4	0.44	0.3	0.15	0.32	0.13	-	7.62	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	0.89	0.01	-	-	-	-	-	-	-	-	38.5
H1019_014_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	Coin	V	V	V	V	V	P	V	V	V			V		S			Coin			Coin					D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0			0					0	0	0								-		1070.47	12.78	1149.99	2447.03	180.88	490.83	0.07	205.8	188.99	92.74	63.23	4.22	491.33	35.83	7653.01	3730.69			227.77		126.6			0			0					56.34	0.67	8254.71								100/day (1-5)	100/day (1-5)	0/day (1-9) 50/day (10-100)	0/Visit	100/ Trip	0/ Procedure	20 Coins	25-50/ Visit	50-75/ Visit	0/ Visit	0-25/ Visit	50/ Visit	20/ Procedure	0-30/ Visit	0/ Visit	20/ Visit			25/ Visit		0/ Scripts			See PBP for details			See PBP for details					100/day (1-5)	100/day (1-5)	0/Procedure								68.02	68.02	11.12	0	100	0	0.2	45	66.75	0	5	50	20	20	0	20			25		0			0			0					68.02	68.02	0								6.07	0.07	1.07	-	1.51	-	0.01	0.77	1.05	-	0.03	0.02	0.82	0.06	-	6.22	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	0.32	0	-	-	-	-	-	-	-	-	18.49	0	0	6.07	0.07	1.07	-	1.51	-	0.01	0.77	1.05	-	0.03	0.02	0.82	0.06	-	6.22	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	0.32	0	-	-	-	-	-	-	-	-	18.49																																																																																				-			6.07	0.07	1.07	-	1.51	-	0.01	0.77	1.05	-	0.03	0.02	0.82	0.06	-	6.22	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	0.32	0	-	-	-	-	-	-	-	-	18.49
H1019_021_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S			Coin	Coin		Coin					D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0	0								-		1231.51	13.94	1894.81	2282.75	275.57	85.31	6.42	241.25	198.98	208.78	142.35	9.49	199.46	80.67	6894.13	4814.68			234.27		284.99			0	0		0					64.82	0.73	5076.13								100/day (1-10)	100/day (1-10)	0/day (1-6) 75/day (7-100)	0/Visit	100/ Trip	20/ Procedure	20/ Procedure	25-50/ Visit	50-75/ Visit	20/ Visit	20/ Visit	100/ Visit	20/ Procedure	0-20/ Visit	0/ Visit	20/ Visit			0-20/ Visit		0/ Scripts			See PBP for details	See PBP for details		See PBP for details					100/day (1-10)	100/day (1-10)	0/Procedure								86.33	86.33	21.82	0	100	20	20	45	58.25	20	20	100	20	18.82	0	20			8.22		0			0	0		0					86.33	86.33	0								8.86	0.1	3.44	-	2.3	0.14	0.01	0.9	0.97	0.35	0.24	0.08	0.33	0.13	-	8.02	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	0.47	0.01	-	-	-	-	-	-	-	-	26.5	0	0	8.86	0.1	3.44	-	2.3	0.14	0.01	0.9	0.97	0.35	0.24	0.08	0.33	0.13	-	8.02	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	0.47	0.01	-	-	-	-	-	-	-	-	26.5																																																																																				-			8.86	0.1	3.44	-	2.3	0.14	0.01	0.9	0.97	0.35	0.24	0.08	0.33	0.13	-	8.02	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	0.47	0.01	-	-	-	-	-	-	-	-	26.5
H1019_023_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S				Coin		Coin					D	P									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0									-		1711.09	16.6	1830.39	3343.78	370.7	274.21	20.64	314.94	229.53	156.7	106.84	7.12	182.63	60.54	8554.69	6106.76			293.35		213.9				0		0					90.06	14049.77									0/day (-)	0/day (-)	0/day (1-6) 0/day (7-25)	0/Visit	0/ Trip	0/ Procedure	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts				See PBP for details		See PBP for details					0/day (1-5)	0/Procedure									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0									-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1019_024_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S			Coin								D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1905.23	17.42	1643.63	2861.83	453.97	406.78	30.62	248.42	227.19	185.53	126.5	8.43	397.84	71.68	8548.12	5847.94			288.04		253.25			0								100.28	0.92	4663.06								0/day (1-90)	0/day (1-90)	0/day (1-6) 0/day (7-25)	0/Visit	0/ Trip	0/ Procedure	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts			See PBP for details								0/day (1-90)	0/day (1-90)	0/Procedure								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1019_025_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S			Coin			Coin					D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0			0					0	0	0								-		1628.06	18.43	2504.95	3017.82	364.3	112.78	8.49	318.93	263.05	276.01	188.19	12.55	263.69	106.64	9114.1	6365.05			309.71		376.76			0			0					85.69	0.97	6710.69								0/day (1-7)	0/day (1-7)	0/day (1-4) 0/day (5-25)	0/Visit	0/ Trip	0/ Procedure	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts			See PBP for details			See PBP for details					0/day (1-7)	0/day (1-7)	0/Procedure								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0			0					0	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1019_026_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	Coin	V	V	V	V	V	P	V	V	V			V		S				Coin		Coin					D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0	0								-		1249.83	14.92	1342.67	2857.03	211.19	573.07	0.09	240.28	220.65	108.28	73.83	4.92	573.65	41.84	8935.3	4355.77			265.93		147.81				0		0					65.78	0.79	9637.81								0/day (1-10)	0/day (1-10)	0/day (1-6) 0/day (7-100)	0/Visit	0/ Trip	0/ Procedure	0 Coins	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts				See PBP for details		See PBP for details					0/day (1-10)	0/day (1-10)	0/Procedure								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1026_001_0	2007	2	f.2	h.6.	i.7	g.2.	h.7.						OP Facility - Emergency	OP Facility - Other	Professional	OP Facility - Surgery	OP Facility - Other							Urgent Care	Substance Abuse and MH	Allergy Shots	Ambulatory Surgical Center	Rehab						D	D	D		T	O		V	V					V		V	V	V														V	V	O	V	V																																															-		1274.39	29.09	938.63		247.72	0.14		234.18	206.43					746.42		5613	18.75	624.39														0.11	28.79	5003.49	163.78	433.98						150 for days 1-5	150 for days 1-5	75 for days 7-25	0	100 per transport	500 per electric wheelchair	0	50 per visit	250 per visit to outpatient facility	0	0		0	50 per non-surgical outpatient visit	0 for PCP visits and physical exams	15 per visit	15 per visit	15 per visit	0		0	0		0 for limited cleanings exams x-rays								15 per visit	15 per visit	6 per shot	100 per visit	15 per visit						132.15	126.53	35.05		100	500		50	250					50		15	15	15														15	15	6	100	15						14.03	0.31	2.74	-	2.06	0.01	-	0.98	4.3	-	-	-	-	3.11	-	7.02	0.02	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0.04	2.5	1.36	0.54	-	-	-	-	-	39.8			14.03	0.31	2.74	-	2.06	0.01	-	0.98	4.3	-	-	-	-	3.11	-	7.02	0.02	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0.04	2.5	1.36	0.54	-	-	-	-	-	39.8																																																																																				-			14.03	0.31	2.74	-	2.06	0.01	-	0.98	4.3	-	-	-	-	3.11	-	7.02	0.02	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0.04	2.5	1.36	0.54	-	-	-	-	-	39.8
H1026_801_0	2007	5																																Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin						Coin	Coin	Coin																																																													-		297.02		27.92	0.19	8.18	3.57		21.28	55.3					62.37						265.16	2.43	31.08																				For all IP visits MH and Acute		FFS coin for all SNF visits	FFS coin for all HH	FFS coin for all Amb	FFS coin for all DME		FFS coin for all OP -ER	FFS coin for all OP -Surg					FFS coin for all OP -Oth						FFS coin for all Professional	FFS coin for all Part B Rx	FFS coin for all Other																				0.07		0.17	0	0.24	0.24		0.24	0.24					0.24						0.24	0.24	0.24																				21.4	-	4.82	-	1.93	0.84	-	5.02	13.05	-	-	-	-	14.72	-	-	-	-	-	62.58	0.57	7.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.27			21.4	-	4.82	-	1.93	0.84	-	5.02	13.05	-	-	-	-	14.72	-	-	-	-	-	62.58	0.57	7.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.27																																																																																				-			21.4	-	4.82	-	1.93	0.84	-	5.02	13.05	-	-	-	-	14.72	-	-	-	-	-	62.58	0.57	7.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.27
H1026_802_0	2007	5																																Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin						Coin	Coin	Coin																																																													-		297.02		27.92	0.19	8.18	3.57		21.28	55.3					62.37						265.16	2.43	31.08																				For all IP visits MH and Acute		FFS coin for all SNF visits	FFS coin for all HH	FFS coin for all Amb	FFS coin for all DME		FFS coin for all OP -ER	FFS coin for all OP -Surg					FFS coin for all OP -Oth						FFS coin for all Professional	FFS coin for all Part B Rx	FFS coin for all Other																				0.07		0.17	0	0.24	0.24		0.24	0.24					0.24						0.24	0.24	0.24																				21.4	-	4.82	-	1.93	0.84	-	5.02	13.05	-	-	-	-	14.72	-	-	-	-	-	62.58	0.57	7.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.27			21.4	-	4.82	-	1.93	0.84	-	5.02	13.05	-	-	-	-	14.72	-	-	-	-	-	62.58	0.57	7.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.27																																																																																				-			21.4	-	4.82	-	1.93	0.84	-	5.02	13.05	-	-	-	-	14.72	-	-	-	-	-	62.58	0.57	7.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	132.27
H1032_002_0	2007	4																					2000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1645.97	29.71	827.19	437.92	220.65	6.8	1.23	246.83	218.32	2225.98	1099.24	0	641.82	685.73	1618.96	2980.98	66.98	289.71	1502.55	8768.59	8.46	4.39	0	381	782.5	567.85	33.45	1.98	0	1	547.2											100  days 1 - 5	100  days 1 - 5	50  days 15 - 100	10	100	0	20	50	50-ASC/ 100-OP/ 50-Non Surg	0	15 - 75		0 - 15	15 to 50	0	0 to 15	5 to 15	15	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											50.73	50.73	14.22	7.95	79.52	0	0.16	39.76	71.57	0	23.86	0	7.95	25.33	0	11.93	5.96	11.93	9.59	0.91	0.11	0	0	10	7.95	7.95	7.95	0	0	0	0											6.96	0.13	0.98	0.29	1.46	-	0.2	0.82	1.3	-	2.19	-	0.43	1.45	-	2.96	0.03	0.29	1.2	0.66	0.9	-	-	0.32	0.52	0.38	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.48		9.99	6.96	0.13	0.98	0.29	1.46	-	0.2	0.82	1.3	-	2.19	-	0.43	1.45	-	2.96	0.03	0.29	1.2	0.66	0.9	-	-	0.32	0.52	0.38	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.48	2000																																																																																			-		0	6.96	0.13	0.98	0.29	1.46	-	0.2	0.82	1.3	-	2.19	-	0.43	1.45	-	2.96	0.03	0.29	1.2	0.66	0.9	-	-	0.32	0.52	0.38	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.48
H1032_004_0	2007	4																					2000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1637.09	30.25	830.16	439.49	221.44	6.85	1.21	247.72	219.1	2250.77	1102.11	0	635.87	680.72	1597.98	2963.31	65.62	282.31	1520.41	8837.02	8.49	4.4	0	381	789.88	570.2	33.58	1.98	0	1	547.2											200  days 1 - 5	200  days 1 - 5	50  days 15 - 100	10	100	0	20	50	50-ASC/ 100-OP/ 50-Non Surg	0	15 - 75		0 - 20	20 to 50	0	0 to 20	10 to 20	20	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											95.48	95.48	13.38	7.48	74.84	0	0.15	37.42	67.36	0	22.45	0	9.98	25.8	0	14.97	9.36	14.97	9.01	0.86	0.1	0	0	10	7.48	7.48	7.48	0	0	0	0											13.03	0.24	0.93	0.27	1.38	-	0.18	0.77	1.23	-	2.06	-	0.53	1.46	-	3.7	0.05	0.35	1.14	0.63	0.85	-	-	0.32	0.49	0.36	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30		15.75	13.03	0.24	0.93	0.27	1.38	-	0.18	0.77	1.23	-	2.06	-	0.53	1.46	-	3.7	0.05	0.35	1.14	0.63	0.85	-	-	0.32	0.49	0.36	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30	2000																																																																																			-		0	13.03	0.24	0.93	0.27	1.38	-	0.18	0.77	1.23	-	2.06	-	0.53	1.46	-	3.7	0.05	0.35	1.14	0.63	0.85	-	-	0.32	0.49	0.36	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30
H1032_008_0	2007	4																					0											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1633.73	27.6	667.97	333.09	232.48	4.43	0.94	239.17	146.35	1918.51	1028.01	0	597.97	634.29	1940.84	3718.06	90.74	403.74	1638.61	10159.21	2.18	10.63	0	381	276.9	196.1	41.84	2.41	0	0	547.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	0	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 0		0 - 0	0	0	0 to 0	0 to 0	0	0 - 0	0 to 4	0 -20	0	0	0	0	0	0	0		0	0 to 0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1.26	0.13	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.07	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.36		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.07	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.36	0																																																																																			-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.07	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.36
H1032_010_0	2007	6																					3500											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1517.8	25.37	622.07	308.11	214.73	3.99	0.9	222.35	136.07	1825.83	919.37	0	551.23	586.4	1711.47	3232.39	76.61	332.04	1425.12	9516.53	2	9.7	0	381	262.2	174.82	38.66	2.1	0	0	547.2											50  days 1 - 5	50  days 1 - 5	50  days 8 - 100	0	100	0	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 50		0 - 20	20 to 100	0	0 to 20	10 to 20	20	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											30.41	30.41	28.99	0	95.34	0	0.19	47.67	128.71	0	22.64	0	12.71	55.63	0	19.07	11.92	19.07	9.15	1.58	0.13	0	0	10	9.53	9.53	9.53	0	0	0	0											3.85	0.06	1.5	-	1.71	-	0.17	0.88	1.46	-	1.73	-	0.58	2.72	-	5.14	0.08	0.53	1.09	1.26	0.26	-	-	0.32	0.21	0.14	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.7		3.75	3.85	0.06	1.5	-	1.71	-	0.17	0.88	1.46	-	1.73	-	0.58	2.72	-	5.14	0.08	0.53	1.09	1.26	0.26	-	-	0.32	0.21	0.14	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.7	3500																																																																																			-		0	3.85	0.06	1.5	-	1.71	-	0.17	0.88	1.46	-	1.73	-	0.58	2.72	-	5.14	0.08	0.53	1.09	1.26	0.26	-	-	0.32	0.21	0.14	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.7
H1032_012_0	2007	4																					3000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1460.71	25.55	653.07	344.8	185.16	7.69	1.4	258.2	206.32	1654.29	827.68	0	492.02	524.14	1448.73	2624.18	56.38	254.49	1243.02	7711.69	4.84	4.83	0	381	735.6	529.47	18.97	1.11	0	0	547.2											100  days 1 - 5	100  days 1 - 5	75  days 8 - 100	10	100	0	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	15 - 75		0 - 35	35 to 50	5	0 to 35	25 to 35	35	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											55.76	55.76	39.86	8.74	87.41	0	0.17	43.71	59	0	26.22	0	20.4	36.89	3.51	30.59	24.04	30.59	10.59	1.18	0.12	0	0	10	8.74	8.74	8.74	0	0	0	0											6.79	0.12	2.17	0.25	1.35	-	0.24	0.94	1.01	-	1.81	-	0.84	1.61	0.42	6.69	0.11	0.65	1.1	0.76	0.57	-	-	0.32	0.54	0.39	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.68		8.45	6.79	0.12	2.17	0.25	1.35	-	0.24	0.94	1.01	-	1.81	-	0.84	1.61	0.42	6.69	0.11	0.65	1.1	0.76	0.57	-	-	0.32	0.54	0.39	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.68	3000																																																																																			-		0	6.79	0.12	2.17	0.25	1.35	-	0.24	0.94	1.01	-	1.81	-	0.84	1.61	0.42	6.69	0.11	0.65	1.1	0.76	0.57	-	-	0.32	0.54	0.39	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.68
H1032_014_0	2007	4																					3000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1593.24	27.46	950.91	424.17	203.09	6.62	1.22	259.89	151.91	1809.61	909.51	0	543.97	578.91	1340.02	2428.59	54.38	236.93	1135.36	7041.62	4	3.5	0	381	867.56	624.77	18.69	1.1	0	0	547.2											50  days 1 - 5	50  days 1 - 5	50  days 8 - 100	10	100	0	20	50	25-ASC/ 50-OP/ 50-Non Surg	0	15 - 75		0 - 20	20 to 50	0	0 to 20	10 to 20	20	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											29.3	29.3	27.93	9.19	91.86	0	0.18	45.93	43.64	0	27.56	0	12.25	31.59	0	17.28	11.48	18.37	11.14	1.26	0.12	0	0	10	9.19	9.19	9.19	0	0	0	0											3.89	0.07	2.21	0.32	1.55	-	0.22	0.99	0.55	-	2.09	-	0.56	1.52	-	3.5	0.05	0.36	1.05	0.74	0.49	-	-	0.32	0.66	0.48	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.66		3.66	3.89	0.07	2.21	0.32	1.55	-	0.22	0.99	0.55	-	2.09	-	0.56	1.52	-	3.5	0.05	0.36	1.05	0.74	0.49	-	-	0.32	0.66	0.48	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.66	3000																																																																																			-		0	3.89	0.07	2.21	0.32	1.55	-	0.22	0.99	0.55	-	2.09	-	0.56	1.52	-	3.5	0.05	0.36	1.05	0.74	0.49	-	-	0.32	0.66	0.48	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.66
H1032_019_0	2007	6																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1106.36	17.19	662.44	457.19	152.81	6.47	1.3	254.58	247.89	1609.15	832.04	0	516.25	546.2	1924.95	3387.72	75.9	341.65	1449.05	8974.27	2.21	3.11	0	381	709.87	531.17	27.34	1.67	0	0	547.2											0  Unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	15 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	23.75	0	0	0	0	0	0	0	9.69	1.49	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.26	1.06	-	-	1.65	-	-	-	-	-	-	-	1.17	1.11	0.3	-	-	0.32	0.59	0.44	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.92		0	-	-	-	-	-	-	0.26	1.06	-	-	1.65	-	-	-	-	-	-	-	1.17	1.11	0.3	-	-	0.32	0.59	0.44	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.92	0																																																																																			-		0	-	-	-	-	-	-	0.26	1.06	-	-	1.65	-	-	-	-	-	-	-	1.17	1.11	0.3	-	-	0.32	0.59	0.44	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.92
H1032_025_0	2007	6																					2500											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1404.35	27.85	898.96	1820.03	442.98	19.85	3.34	387.8	390.07	2535.73	1242.64	0	681.4	735.8	4499.02	8211.36	166.04	712.78	4294.25	22668.22	7.1	4762.44	0	381	438.72	316.45	188.02	11.05	0	263.62	0											150  days 1 - 5	150  days 1 - 5	100  days 10 - 30	10	100	20	20	50	150-ASC/ 150-OP/ 150-Non Surg	5	15 - 75		25 - 25	25 to 150	10	0 to 25	15 to 25	25	0 - 75	0 to 20	0 -20	0	0	10	20	0	20	0		0	0											76.17	76.17	33.41	7.96	79.61	0.16	0.16	39.8	119.41	3.98	23.88	0	19.9	68.37	6.52	19.9	13.93	19.9	9.53	2.38	0.11	0	0	10	15.92	0	15.92	0	0	0	0											8.91	0.18	2.5	1.21	2.94	3.16	0.53	1.29	3.88	0.84	2.47	-	1.13	4.19	2.44	13.62	0.19	1.18	3.41	4.5	0.76	-	-	0.32	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.49		15.45	8.91	0.18	2.5	1.21	2.94	3.16	0.53	1.29	3.88	0.84	2.47	-	1.13	4.19	2.44	13.62	0.19	1.18	3.41	4.5	0.76	-	-	0.32	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.49	2500																																																																																			-		0	8.91	0.18	2.5	1.21	2.94	3.16	0.53	1.29	3.88	0.84	2.47	-	1.13	4.19	2.44	13.62	0.19	1.18	3.41	4.5	0.76	-	-	0.32	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.49
H1032_028_0	2007	8																					2000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1426.27	25.16	599.74	314.38	170.78	5.73	1.05	264.56	212.51	1936.09	963	0	567.9	605.76	1629.89	2966.26	65.07	288.92	1481.35	8675.24	5.59	4.41	0	381	776.47	567.58	29.81	1.78	0	0	2035.2											150  days 1 - 5	150  days 1 - 5	50  days 8 - 100	10	100	0	20	50	50-ASC/ 100-OP/ 50-Non Surg	0	15 - 75		0 - 20	15 to 100	0	0 to 15	10 to 20	15	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											75.82	75.82	24.09	7.92	79.24	0	0.16	39.62	71.32	0	23.77	0	10.57	44.27	0	11.89	9.91	11.89	9.58	0.96	0.11	0	0	10	7.92	7.92	7.92	0	0	0	0											9.01	0.16	1.2	0.21	1.13	-	0.17	0.87	1.26	-	1.91	-	0.5	2.23	-	2.94	0.05	0.29	1.18	0.69	0.59	-	-	0.32	0.51	0.37	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.63		10.27	9.01	0.16	1.2	0.21	1.13	-	0.17	0.87	1.26	-	1.91	-	0.5	2.23	-	2.94	0.05	0.29	1.18	0.69	0.59	-	-	0.32	0.51	0.37	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.63	2000																																																																																			-		0	9.01	0.16	1.2	0.21	1.13	-	0.17	0.87	1.26	-	1.91	-	0.5	2.23	-	2.94	0.05	0.29	1.18	0.69	0.59	-	-	0.32	0.51	0.37	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.63
H1032_029_0	2007	7																					3000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1278.07	22.88	537.36	378.78	158	6.18	1.12	320.61	214.31	2109.85	1043.98	0	611.26	652.78	1861.15	3378.88	73.31	319.86	1718.22	10036.9	4.79	484.57	0	381	707.79	516.27	45.17	2.68	0	26.78	547.2											250  days 1 - 5	250  days 1 - 5	50  days 8 - 100	10	100	0	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 25	25 to 100	0	0 to 25	15 to 25	25	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											139.38	139.38	26.57	8.74	87.4	0	0.17	43.7	117.99	0	26.22	0	14.57	53.4	0	21.85	15.29	21.85	10.55	1.07	0.12	0	0	10	8.74	8.74	8.74	0	0	0	0											14.84	0.27	1.19	0.28	1.15	-	0.2	1.17	2.11	-	2.28	-	0.74	2.91	-	6.15	0.09	0.58	1.51	0.9	0.56	-	-	0.32	0.52	0.38	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.17		8.46	14.84	0.27	1.19	0.28	1.15	-	0.2	1.17	2.11	-	2.28	-	0.74	2.91	-	6.15	0.09	0.58	1.51	0.9	0.56	-	-	0.32	0.52	0.38	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.17	3000																																																																																			-		0	14.84	0.27	1.19	0.28	1.15	-	0.2	1.17	2.11	-	2.28	-	0.74	2.91	-	6.15	0.09	0.58	1.51	0.9	0.56	-	-	0.32	0.52	0.38	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.17
H1032_031_0	2007	5																					3000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	656.54	8.78	568.11	991.07	212.31	7.6	1.93	220.13	167.97	1153.32	612.83	0	393.06	413.74	3242.47	5415.75	118.66	541.17	2394.8	15145.53	4.53	3076.66	0	381	435.29	327.57	129.43	7.94	0	213.14	547.2											50  days 1 - 5	50  days 1 - 5	100  days 8 - 100	10	100	0	20	50	50-ASC/ 150-OP/ 150-Non Surg	0	15 - 75		0 - 30	30 to 150	0	0 to 30	20 to 30	30	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											29.55	29.55	56.33	9.26	92.63	0	0.19	46.32	129.69	0	27.79	0	18.53	80.46	0	27.79	20.84	27.79	11.44	1.86	0.12	0	0	10	9.26	9.26	9.26	0	0	0	0											1.62	0.02	2.67	0.77	1.64	-	0.36	0.85	1.82	-	1.42	-	0.61	2.77	-	12.54	0.21	1.25	2.28	2.34	0.56	-	-	0.32	0.34	0.25	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.73		3.12	1.62	0.02	2.67	0.77	1.64	-	0.36	0.85	1.82	-	1.42	-	0.61	2.77	-	12.54	0.21	1.25	2.28	2.34	0.56	-	-	0.32	0.34	0.25	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.73	3000																																																																																			-		0	1.62	0.02	2.67	0.77	1.64	-	0.36	0.85	1.82	-	1.42	-	0.61	2.77	-	12.54	0.21	1.25	2.28	2.34	0.56	-	-	0.32	0.34	0.25	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.73
H1032_032_0	2007	2																					3000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	763.6	9.65	344.39	396.73	114.59	5.5	1.27	176.99	200.41	1259.92	678.33	0	441.77	463.94	1889.63	3040.22	65.68	300.19	1353.21	8348.71	2.04	544.22	0	381	572.67	447.66	41.64	2.65	0	41.1	547.2											100  days 1 - 5	100  days 1 - 5	50  days 15 - 100	0	100	0	20	50	25-ASC/ 100-OP/ 100-Non Surg	0	15 - 50		0 - 25	25 to 100	5	0 to 25	15 to 25	25	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											60.2	60.2	16.88	0	94.37	0	0.19	47.18	87.29	0	22.41	0	15.73	57.04	3.68	23.59	16.51	23.59	9.27	1.56	0.13	0	0	10	9.44	9.44	9.44	0	0	0	0											3.83	0.05	0.48	-	0.9	-	0.24	0.7	1.46	-	1.27	-	0.58	2.21	0.58	5.98	0.09	0.59	1.05	1.09	0.26	-	-	0.32	0.45	0.35	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.49		2.01	3.83	0.05	0.48	-	0.9	-	0.24	0.7	1.46	-	1.27	-	0.58	2.21	0.58	5.98	0.09	0.59	1.05	1.09	0.26	-	-	0.32	0.45	0.35	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.49	3000																																																																																			-		0	3.83	0.05	0.48	-	0.9	-	0.24	0.7	1.46	-	1.27	-	0.58	2.21	0.58	5.98	0.09	0.59	1.05	1.09	0.26	-	-	0.32	0.45	0.35	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.49
H1032_033_0	2007	6																					3000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	663.58	8.12	368.88	438.38	123.94	6.07	1.42	168.87	131.05	964.58	521.99	0	341.94	358.78	1741.24	2775.89	59.56	274.87	1231.59	7594.99	2.23	1014.99	0	381	563.68	442.77	48.68	3.12	0	77.7	547.2											150  days 1 - 5	150  days 1 - 5	100  days 8 - 100	10	100	0	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 30	30 to 100	5	0 to 30	20 to 30	30	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											88.59	88.59	56.3	9.26	92.58	0	0.19	46.29	124.99	0	27.77	0	18.52	58.37	3.6	27.77	20.83	27.77	11.51	1.57	0.12	0	0	10	9.26	9.26	9.26	0	0	0	0											4.9	0.06	1.73	0.34	0.96	-	0.26	0.65	1.36	-	1.21	-	0.53	1.75	0.52	6.42	0.1	0.64	1.18	0.99	0.28	-	-	0.32	0.43	0.34	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.01		3.14	4.9	0.06	1.73	0.34	0.96	-	0.26	0.65	1.36	-	1.21	-	0.53	1.75	0.52	6.42	0.1	0.64	1.18	0.99	0.28	-	-	0.32	0.43	0.34	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.01	3000																																																																																			-		0	4.9	0.06	1.73	0.34	0.96	-	0.26	0.65	1.36	-	1.21	-	0.53	1.75	0.52	6.42	0.1	0.64	1.18	0.99	0.28	-	-	0.32	0.43	0.34	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.01
H1032_035_0	2007	7																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1464.19	23.81	988.12	856.86	240.81	8.43	1.64	285.33	227.57	1985.07	1025.88	0	620.54	658.05	2704.71	4861.8	109.53	490.3	2106.98	12903.29	9.67	1670.63	0	381	639.35	470.34	82.55	4.95	0	103.21	547.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.08	1.22	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.33	1.19	-	-	1.07	-	-	-	-	-	-	-	0.89	1.31	1.3	-	-	0.32	0.53	0.39	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.39		0	-	-	-	-	-	-	0.33	1.19	-	-	1.07	-	-	-	-	-	-	-	0.89	1.31	1.3	-	-	0.32	0.53	0.39	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.39	0																																																																																			-		0	-	-	-	-	-	-	0.33	1.19	-	-	1.07	-	-	-	-	-	-	-	0.89	1.31	1.3	-	-	0.32	0.53	0.39	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.39
H1032_036_0	2007	3																					3000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1338.88	24.37	812.99	952.83	287.75	10.52	1.88	298.49	220.94	2285.35	1143.83	0	657.64	702.77	3432.19	6300.88	137.9	600.17	3147.86	18106.68	6.58	3292.83	0	381	606.22	432.26	135.83	7.89	0	181.2	547.2											150  days 1 - 5	150  days 1 - 5	100  days 8 - 100	0	100	20	20	50	50-ASC/ 100-OP/ 50-Non Surg	0	0 - 75		0 - 25	25 to 100	0	0 to 25	15 to 25	25	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											85.13	85.13	54.1	0	88.97	0.18	0.18	44.48	80.07	0	16.68	0	14.83	54.38	0	22.24	15.57	22.24	6.71	1.16	0.12	0	0	10	8.9	8.9	8.9	0	0	0	0											9.5	0.17	3.67	-	2.13	1.87	0.33	1.11	1.47	-	1.59	-	0.81	3.18	-	11.68	0.18	1.11	1.76	1.75	0.78	-	-	0.32	0.45	0.32	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.3		6.55	9.5	0.17	3.67	-	2.13	1.87	0.33	1.11	1.47	-	1.59	-	0.81	3.18	-	11.68	0.18	1.11	1.76	1.75	0.78	-	-	0.32	0.45	0.32	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.3	3000																																																																																			-		0	9.5	0.17	3.67	-	2.13	1.87	0.33	1.11	1.47	-	1.59	-	0.81	3.18	-	11.68	0.18	1.11	1.76	1.75	0.78	-	-	0.32	0.45	0.32	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.3
H1032_037_0	2007	3																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1234.55	20.14	592.4	442.45	206.64	5.84	1.15	224.77	203.49	1696.75	873.85	0	525.8	558.02	2039.25	3634.11	80.7	361.44	1657.49	9707.3	5.68	757.79	0	381	602.56	450.54	53.68	3.27	0	47.7	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.12	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.23	0.94	-	-	0.91	-	-	-	-	-	-	-	0.7	0.91	0.76	-	-	0.32	0.5	0.38	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.68		0	-	-	-	-	-	-	0.23	0.94	-	-	0.91	-	-	-	-	-	-	-	0.7	0.91	0.76	-	-	0.32	0.5	0.38	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.68	0																																																																																			-		0	-	-	-	-	-	-	0.23	0.94	-	-	0.91	-	-	-	-	-	-	-	0.7	0.91	0.76	-	-	0.32	0.5	0.38	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.68
H1032_038_0	2007	3																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1099.59	18.1	715.03	932.21	248.25	9.62	1.87	274.43	239.45	1798.83	924.19	0	554.03	588.3	3126.23	5596.09	124.36	556.29	2558.18	14957.82	5.59	2389.38	0	381	514.19	384.33	103.6	6.31	0	149.49	2035.2											50  days 1 - 5	50  days 1 - 5	0  days 1 - 100	0	0	0	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	0 - 50		0 - 0	0 to 25	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											31.9	31.9	0	0	0	0	0.2	50	45	0	12.5	0	0	11.96	0	0	0	0	5.07	1.11	0.13	0	0	10	10	10	10	0	0	0	0											2.92	0.05	-	-	-	-	0.37	1.14	0.9	-	0.96	-	-	0.59	-	-	-	-	1.08	1.38	0.75	-	-	0.32	0.43	0.32	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.3		0	2.92	0.05	-	-	-	-	0.37	1.14	0.9	-	0.96	-	-	0.59	-	-	-	-	1.08	1.38	0.75	-	-	0.32	0.43	0.32	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.3	0																																																																																			-		0	2.92	0.05	-	-	-	-	0.37	1.14	0.9	-	0.96	-	-	0.59	-	-	-	-	1.08	1.38	0.75	-	-	0.32	0.43	0.32	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.3
H1032_040_0	2007	4																					0											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1052.71	15.68	456.42	483.6	207	6.52	1.57	202.67	117.88	1273.35	694.43	0	424.11	447.28	2368.19	4186.95	97.68	441.44	1835.74	11265.83	2.81	1164.67	0	0	0	0	0	0	0	74.49	547.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	0	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 0		0 - 0	0	0	0 to 0	0 to 0	0	0 - 0	0 to 4	0 -20	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1.38	0.13	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.29	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.67		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.29	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.67	0																																																																																			-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.29	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.67
H1032_041_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1551.25	24.99	580.16	423.79	185.18	6.24	1.22	269.67	277.81	1777.16	910.67	0	558.63	592.11	1886.68	3376.2	75.98	340.48	1445.25	8956.99	4.14	283.17	0	381	612.69	453.75	30.93	1.87	0	17.66	547.2											0  per day per admission/unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	15 - 100		0 - 0	0	0	0 to 0	0 to 0	0	0 - 100	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	36.25	0	0	0	0	0	0	0	16.27	1.45	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.24	1.12	-	-	2.75	-	-	-	-	-	-	-	1.96	1.09	0.55	-	-	0.32	0.51	0.38	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.95		0	-	-	-	-	-	-	0.24	1.12	-	-	2.75	-	-	-	-	-	-	-	1.96	1.09	0.55	-	-	0.32	0.51	0.38	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.95	0																																																																																			-		0	-	-	-	-	-	-	0.24	1.12	-	-	2.75	-	-	-	-	-	-	-	1.96	1.09	0.55	-	-	0.32	0.51	0.38	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.95
H1032_042_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1632.58	28.75	667.97	333.09	232.48	4.43	0.89	239.17	146.35	1968.49	989.22	0	591.53	629.54	1831.04	3542.62	87.46	375.49	1557.8	10528.34	2.16	10.63	0	381	283.31	189.7	41.96	2.29	0	0	547.2											50  days 1 - 5	50  days 1 - 5	50  days 15 - 100	0	100	0	20	50	25-ASC/ 100-OP/ 50-Non Surg	0	15 - 75		0 - 10	10 to 50	0	0 to 10	0 to 10	10	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											31.9	31.9	17.88	0	100	0	0.2	50	87.5	0	30	0	6.67	29.18	0	10	2.5	10	12.11	1.59	0.13	0	0	10	10	10	10	0	0	0	0											4.34	0.08	1	-	1.94	-	0.18	1	1.07	-	2.47	-	0.33	1.53	-	2.95	0.02	0.31	1.57	1.4	0.29	-	-	0.32	0.24	0.16	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.21		0	4.34	0.08	1	-	1.94	-	0.18	1	1.07	-	2.47	-	0.33	1.53	-	2.95	0.02	0.31	1.57	1.4	0.29	-	-	0.32	0.24	0.16	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.21	0																																																																																			-		0	4.34	0.08	1	-	1.94	-	0.18	1	1.07	-	2.47	-	0.33	1.53	-	2.95	0.02	0.31	1.57	1.4	0.29	-	-	0.32	0.24	0.16	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.21
H1032_043_0	2007	5																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1059.72	16.23	515.45	1256.01	258.21	10.14	2.32	210.58	178.27	1297.12	676.49	0	424.24	448.11	3664.53	6469.97	150.15	664.81	2857.17	18622.53	5.27	3548.88	0	0	0	0	0	0	0	220.15	547.2											50  days 1 - 5	50  days 1 - 5	50  days 15 - 100	0	100	0	20	50	50-ASC/ 100-OP/ 50-Non Surg	0	15 - 75		0 - 15	15 to 50	0	0 to 15	5 to 15	15	0 - 75	0 to 10	0 -20	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											31.9	31.9	17.88	0	100	0	0.2	50	90	0	30	0	10	31.65	0	15	7.5	15	12.25	1.79	0.13	0	0	0	0	0	0	0	0	0	0											2.82	0.04	0.77	-	2.15	-	0.46	0.88	1.34	-	1.69	-	0.35	1.18	-	8.09	0.09	0.83	2.92	2.78	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.1		0	2.82	0.04	0.77	-	2.15	-	0.46	0.88	1.34	-	1.69	-	0.35	1.18	-	8.09	0.09	0.83	2.92	2.78	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.1	0																																																																																			-		0	2.82	0.04	0.77	-	2.15	-	0.46	0.88	1.34	-	1.69	-	0.35	1.18	-	8.09	0.09	0.83	2.92	2.78	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.1
H1032_044_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1471.76	25.57	971.01	1863.64	410.91	13.97	2.85	307.18	247.84	1929.38	985.85	0	585.99	623.03	4977.45	9656.01	231.98	1026.41	3984.3	26467.49	6.63	4858.8	0	381	633.03	428.07	164.14	9.04	0	254.23	547.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.05	1.42	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.57	1.28	-	-	1.03	-	-	-	-	-	-	-	1.68	3.12	0.89	-	-	0.32	0.53	0.36	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.91		0	-	-	-	-	-	-	0.57	1.28	-	-	1.03	-	-	-	-	-	-	-	1.68	3.12	0.89	-	-	0.32	0.53	0.36	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.91	0																																																																																			-		0	-	-	-	-	-	-	0.57	1.28	-	-	1.03	-	-	-	-	-	-	-	1.68	3.12	0.89	-	-	0.32	0.53	0.36	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.91
H1032_060_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1445.45	23.79	1071.47	2478.73	509.42	17.86	4.08	372.59	359.34	2201.41	1127.04	0	671.93	714.09	7687.63	14777.43	353.92	1568.92	6027.46	39687.16	10.26	8991.35	1200	381	693.86	467.22	297.37	16.32	0	480.55	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.06	1.52	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.82	1.55	-	-	1.17	-	-	-	-	-	-	-	2.54	5.01	1.38	-	-	0.32	0.58	0.39	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.01		0	-	-	-	-	-	-	0.82	1.55	-	-	1.17	-	-	-	-	-	-	-	2.54	5.01	1.38	-	-	0.32	0.58	0.39	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.01	0																																																																																			-		0	-	-	-	-	-	-	0.82	1.55	-	-	1.17	-	-	-	-	-	-	-	2.54	5.01	1.38	-	-	0.32	0.58	0.39	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.01
H1032_061_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1413.56	23	1242.58	2364.29	510.54	22.2	4.36	353.26	339.27	2057.33	1060.31	0	638.69	677.72	6693.44	11912.69	264.48	1185	5429.63	31814.57	9.87	6872.84	1200	381	606.05	453.49	259.74	15.84	0	435.61	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.12	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.87	1.47	-	-	1.1	-	-	-	-	-	-	-	2.3	2.97	1.32	-	-	0.32	0.51	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.46		0	-	-	-	-	-	-	0.87	1.47	-	-	1.1	-	-	-	-	-	-	-	2.3	2.97	1.32	-	-	0.32	0.51	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.46	0																																																																																			-		0	-	-	-	-	-	-	0.87	1.47	-	-	1.1	-	-	-	-	-	-	-	2.3	2.97	1.32	-	-	0.32	0.51	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.46
H1032_063_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1429.38	23.15	1256.68	2396.99	516.7	22.33	4.4	358.63	344.19	2083.75	1075.08	0	648.65	688.12	6790.27	12061.03	267.69	1200.03	5491.61	32201.33	9.97	6964.33	1200	381	614.98	461.57	263.56	16.12	0	443.31	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.08	1.12	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.88	1.49	-	-	1.12	-	-	-	-	-	-	-	2.32	3.01	1.34	-	-	0.32	0.51	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.6		0	-	-	-	-	-	-	0.88	1.49	-	-	1.12	-	-	-	-	-	-	-	2.32	3.01	1.34	-	-	0.32	0.51	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.6	0																																																																																			-		0	-	-	-	-	-	-	0.88	1.49	-	-	1.12	-	-	-	-	-	-	-	2.32	3.01	1.34	-	-	0.32	0.51	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.6
H1032_064_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1560.07	25.88	1332.09	2524.74	571.2	22.83	4.36	372.43	358.18	2179.52	1120.75	0	672.76	714.24	7283.86	13225.94	298.74	1333.8	5737.51	35132.68	9.77	7705.59	1200	381	658.74	481.3	282.32	16.81	0	467.11	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.2	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.87	1.55	-	-	1.17	-	-	-	-	-	-	-	2.42	3.51	1.31	-	-	0.32	0.55	0.4	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.34		0	-	-	-	-	-	-	0.87	1.55	-	-	1.17	-	-	-	-	-	-	-	2.42	3.51	1.31	-	-	0.32	0.55	0.4	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.34	0																																																																																			-		0	-	-	-	-	-	-	0.87	1.55	-	-	1.17	-	-	-	-	-	-	-	2.42	3.51	1.31	-	-	0.32	0.55	0.4	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.34
H1032_065_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1475.66	24.26	1261.52	2402.98	540.97	21.34	4.11	355.59	341.51	2070.94	1067.31	0	642.89	682.18	6936.44	12538.15	282.88	1264.44	5436.72	33292.61	9.23	7314.37	1200	381	627.66	461.88	269	16.13	0	447.86	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 One way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.2	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.82	1.48	-	-	1.11	-	-	-	-	-	-	-	2.3	3.32	1.24	-	-	0.32	0.52	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.72		0	-	-	-	-	-	-	0.82	1.48	-	-	1.11	-	-	-	-	-	-	-	2.3	3.32	1.24	-	-	0.32	0.52	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.72	0																																																																																			-		0	-	-	-	-	-	-	0.82	1.48	-	-	1.11	-	-	-	-	-	-	-	2.3	3.32	1.24	-	-	0.32	0.52	0.38	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.72
H1032_066_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1699.29	29.89	1015.73	3025.57	590.62	23.29	4.69	352.67	341.33	2108.84	1073.73	0	634.66	675.35	7580.19	14834.12	357.71	1580.02	6112.02	40729.61	11.11	9017.96	1200	381	682.89	457.88	292.67	15.99	0	462.38	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.05	1.4	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.94	1.47	-	-	1.12	-	-	-	-	-	-	-	2.57	4.75	1.49	-	-	0.32	0.57	0.38	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.85		0	-	-	-	-	-	-	0.94	1.47	-	-	1.12	-	-	-	-	-	-	-	2.57	4.75	1.49	-	-	0.32	0.57	0.38	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.85	0																																																																																			-		0	-	-	-	-	-	-	0.94	1.47	-	-	1.12	-	-	-	-	-	-	-	2.57	4.75	1.49	-	-	0.32	0.57	0.38	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.85
H1032_069_0	2007	7																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1232.35	23.42	1163.75	1780.74	406.89	15.08	2.86	302.75	300.78	1972.27	950.68	0	536.14	576.16	5085.69	10373.25	243.55	1085.3	5354.39	30022.06	6.56	7256.94	0	381	495.38	348.99	212.31	12.19	0	307.21	547.2											225  days 1 - 5	225  days 1 - 5	119  days 21 - 100	10	100	0	20	50	125-ASC/ 200-OP/ 150-Non Surg	0	15 - 75		0 - 35	35 to 100	10	0 to 35	25 to 35	35	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											143.53	143.53	27.01	10	100	0	0.2	50	187.5	0	30	0	23.33	66.5	8.15	35	27.5	35	11.99	1.45	0.13	0	0	10	10	10	10	0	0	0	0											14.74	0.28	2.62	1.48	3.39	-	0.57	1.26	4.7	-	2.38	-	1.04	3.19	3.45	30.26	0.56	3.17	5.35	3.62	0.88	-	-	0.32	0.41	0.29	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.14		0	14.74	0.28	2.62	1.48	3.39	-	0.57	1.26	4.7	-	2.38	-	1.04	3.19	3.45	30.26	0.56	3.17	5.35	3.62	0.88	-	-	0.32	0.41	0.29	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.14	0																																																																																			-		0	14.74	0.28	2.62	1.48	3.39	-	0.57	1.26	4.7	-	2.38	-	1.04	3.19	3.45	30.26	0.56	3.17	5.35	3.62	0.88	-	-	0.32	0.41	0.29	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.14
H1032_070_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1006.16	16.55	635.48	1139.9	247.76	12.97	2.41	255.06	172.26	1609.23	829.3	0	512.39	542.48	3206.41	5631	122.97	543.92	2801.18	16572.04	6.19	2925.97	0	381	570.1	432.19	130.58	8.07	0	180.27	547.2											50  days 1 - 5	50  days 1 - 5	100  days 15 - 100	0	100	0	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 25	25 to 100	0	0 to 25	15 to 25	25	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											31.9	31.9	35.77	0	100	0	0.2	50	135	0	30	0	16.67	60.76	0	25	17.5	25	12.16	1.3	0.13	0	0	10	10	10	10	0	0	0	0											2.67	0.04	1.89	-	2.06	-	0.48	1.06	1.94	-	2.07	-	0.71	2.75	-	11.73	0.18	1.13	2.84	1.8	0.83	-	-	0.32	0.48	0.36	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.46		0	2.67	0.04	1.89	-	2.06	-	0.48	1.06	1.94	-	2.07	-	0.71	2.75	-	11.73	0.18	1.13	2.84	1.8	0.83	-	-	0.32	0.48	0.36	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.46	0																																																																																			-		0	2.67	0.04	1.89	-	2.06	-	0.48	1.06	1.94	-	2.07	-	0.71	2.75	-	11.73	0.18	1.13	2.84	1.8	0.83	-	-	0.32	0.48	0.36	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.46
H1032_073_0	2007	7																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1405.91	27.11	791.7	790.12	248.39	10.5	1.79	302.59	210.77	2273.76	1096.21	0	618.38	664.5	2659.32	5018.44	108.98	478.24	2774.77	15210.89	9.34	7.07	0	381	692.1	492.98	94.33	5.48	0	112.39	547.2											200  days 1 - 5	200  days 1 - 5	100  days 15 - 100	10	100	0	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 30	30 to 100	10	0 to 30	20 to 30	30	0 - 75	0 to 10	0 -20	0.2	0	10	10	10	10	0		0	0 to 0											127.58	127.58	35.77	10	100	0	0.2	50	135	0	30	0	20	63.92	8.14	30	22.5	30	11.99	1.18	0.13	0.2	0	10	10	10	10	0	0	0	0											14.95	0.29	2.36	0.66	2.07	-	0.36	1.26	2.37	-	2.74	-	1.03	3.54	1.8	12.55	0.2	1.2	2.77	1.5	1.25	1.41	-	0.32	0.58	0.41	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.7		0	14.95	0.29	2.36	0.66	2.07	-	0.36	1.26	2.37	-	2.74	-	1.03	3.54	1.8	12.55	0.2	1.2	2.77	1.5	1.25	1.41	-	0.32	0.58	0.41	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.7	0																																																																																			-		0	14.95	0.29	2.36	0.66	2.07	-	0.36	1.26	2.37	-	2.74	-	1.03	3.54	1.8	12.55	0.2	1.2	2.77	1.5	1.25	1.41	-	0.32	0.58	0.41	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.7
H1032_077_0	2007	6																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1082.63	17.9	971.44	1524.46	368.9	14.31	2.76	260.83	250.8	1525.39	784.63	0	471.22	500.24	4986.25	8956.17	200.26	895.66	3979.1	23313.96	6.14	5184.55	0	381	451.19	333.19	193.37	11.64	0	321.98	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.18	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.55	1.09	-	-	0.82	-	-	-	-	-	-	-	1.68	2.3	0.82	-	-	0.32	0.38	0.28	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.39		0	-	-	-	-	-	-	0.55	1.09	-	-	0.82	-	-	-	-	-	-	-	1.68	2.3	0.82	-	-	0.32	0.38	0.28	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.39	0																																																																																			-		0	-	-	-	-	-	-	0.55	1.09	-	-	0.82	-	-	-	-	-	-	-	1.68	2.3	0.82	-	-	0.32	0.38	0.28	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.39
H1032_079_0	2007	7																					0											D	D	D	V	Coin	Coin	Coin	Coin	V	V	V	V	V	V	V	V	Coin	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1390.42	26.61	1010.04	1817.53	7.42	19.61	3.4	4.28	358.1	2363.63	1134.07	0	635.18	683.39	4756.42	8528.83	1.46	760.81	4447.7	24273.68	7.28	5047.95	0	0	0	0	0	0	0	291.94	0											200  days 1 - 5	200  days 1 - 5	119  days 21 - 100	0	0	20	20	0	100-ASC/ 200-OP/ 150-Non Surg	0	15 - 75		0 - 35	35 to 150	10	0 to 35	0.2 to 0.2	35	0 - 75	0 to 26	0 -20	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											127.58	127.58	27.01	0	0.2	0.2	0.2	0.2	185	0	30	0	23.33	90.77	8.13	35	0.2	35	12.02	1	0.13	0	0	0	0	0	0	0	0	0	0											14.78	0.28	2.27	-	1.48	3.92	0.68	0.86	5.52	-	2.84	-	1.24	5.17	3.22	24.88	0.29	2.22	4.45	2.02	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.1		0	14.78	0.28	2.27	-	1.48	3.92	0.68	0.86	5.52	-	2.84	-	1.24	5.17	3.22	24.88	0.29	2.22	4.45	2.02	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.1	0																																																																																			-		0	14.78	0.28	2.27	-	1.48	3.92	0.68	0.86	5.52	-	2.84	-	1.24	5.17	3.22	24.88	0.29	2.22	4.45	2.02	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.1
H1032_085_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1563.57	28.61	1256.05	2349.38	8.6	22.61	3.93	4.91	25.24	2070.41	25.37	0	7.84	16.9	6257.99	67.22	2.05	2.89	5632.84	150.16	8.44	7409.54	0	381	604.6	427.24	259.11	14.92	0	394.62	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											135.43	120.13	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.62	0.09	0.13	0	0	0	0	0	0	0	0	0	0											17.65	0.29	2.83	-	1.72	-	-	0.98	5.05	-	1.27	-	1.18	3.38	-	13.44	0.41	0.58	1.23	13.36	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.49		0	17.65	0.29	2.83	-	1.72	-	-	0.98	5.05	-	1.27	-	1.18	3.38	-	13.44	0.41	0.58	1.23	13.36	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.49	0																																																																																			-		0	17.65	0.29	2.83	-	1.72	-	-	0.98	5.05	-	1.27	-	1.18	3.38	-	13.44	0.41	0.58	1.23	13.36	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.49
H1032_086_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1594.53	29.31	1279.49	2386.81	8.87	23.34	4.04	5.03	25.92	2105.69	26.07	0	8.04	17.34	6350.08	69.21	2.11	2.97	5738.47	154.98	8.65	7540.52	0	381	613.78	429.98	263.05	15.02	0	398.75	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											135.97	120.22	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.65	0.09	0.13	0	0	0	0	0	0	0	0	0	0											18.07	0.29	2.88	-	1.77	-	-	1.01	5.18	-	1.3	-	1.21	3.47	-	13.84	0.42	0.59	1.26	13.78	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.25		0	18.07	0.29	2.88	-	1.77	-	-	1.01	5.18	-	1.3	-	1.21	3.47	-	13.84	0.42	0.59	1.26	13.78	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.25	0																																																																																			-		0	18.07	0.29	2.88	-	1.77	-	-	1.01	5.18	-	1.3	-	1.21	3.47	-	13.84	0.42	0.59	1.26	13.78	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.25
H1032_088_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1792.95	34.15	931.02	3116.1	9.19	24.3	4.44	5.83	30.26	2064.16	30.62	0	9.33	20.17	6868.16	97.37	2.46	5.08	6317.97	160.38	10.05	9421.11	0	381	666.4	418.97	285.6	14.63	0	416.16	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											128.52	116.87	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.43	0.09	0.13	0	0	0	0	0	0	0	0	0	0											19.2	0.33	2.1	-	1.84	-	-	1.17	6.05	-	1.53	-	1.4	4.03	-	19.47	0.49	1.02	1.28	14.02	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.28		0	19.2	0.33	2.1	-	1.84	-	-	1.17	6.05	-	1.53	-	1.4	4.03	-	19.47	0.49	1.02	1.28	14.02	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.28	0																																																																																			-		0	19.2	0.33	2.1	-	1.84	-	-	1.17	6.05	-	1.53	-	1.4	4.03	-	19.47	0.49	1.02	1.28	14.02	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.28
H1032_089_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1438.28	26.23	970.89	2341.9	6.67	17.5	3.73	5.35	27.6	2145.02	27.77	0	8.52	18.4	6892.71	100.77	2.32	5.34	6150.89	158.07	9.18	9353.9	0	381	667.72	416	286.17	14.53	0	423.97	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											134.78	120.12	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.6	0.1	0.13	0	0	0	0	0	0	0	0	0	0											16.15	0.26	2.19	-	1.33	-	-	1.07	5.52	-	1.39	-	1.28	3.68	-	20.15	0.46	1.07	1.33	15.17	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.29		0	16.15	0.26	2.19	-	1.33	-	-	1.07	5.52	-	1.39	-	1.28	3.68	-	20.15	0.46	1.07	1.33	15.17	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.29	0																																																																																			-		0	16.15	0.26	2.19	-	1.33	-	-	1.07	5.52	-	1.39	-	1.28	3.68	-	20.15	0.46	1.07	1.33	15.17	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.29
H1032_091_0	2007	5																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1129.13	19.24	990.86	1801.97	404.02	17.69	3.35	270.22	261.48	1614.67	812.23	0	486.34	517.49	4851.34	8787.79	189.95	830.68	4267.95	25135.21	7.49	5366.62	0	381	465.99	344.41	199.71	12.03	0	324.05	547.2											0  unlimited	0  0	0  days 8 - 100	10	100	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	15 - 75		0 - 20	20	0	0 to 20	10 to 20	20	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	10	100	0	0.2	50	0	0	30	0	13.33	20	0	15.09	12.5	20	12.13	1.29	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	1.5	3.37	-	0.67	1.13	-	-	2.03	-	0.54	0.86	-	11.05	0.2	1.38	4.31	2.71	1	-	-	0.32	0.39	0.29	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.92		0	-	-	-	1.5	3.37	-	0.67	1.13	-	-	2.03	-	0.54	0.86	-	11.05	0.2	1.38	4.31	2.71	1	-	-	0.32	0.39	0.29	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.92	0																																																																																			-		0	-	-	-	1.5	3.37	-	0.67	1.13	-	-	2.03	-	0.54	0.86	-	11.05	0.2	1.38	4.31	2.71	1	-	-	0.32	0.39	0.29	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.92
H1032_092_0	2007	5																					2000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1143.9	19.82	981.95	1815.89	410.65	17.92	3.35	270.79	262.88	1635.63	818.33	0	486.44	518.2	4863.83	8681.83	188.2	826.23	4348.05	25537.36	7.43	5424.86	0	381	468.02	345.02	200.58	12.05	0	320.83	547.2											100  days 1 - 5	100  days 1 - 5	50  days 8 - 100	10	100	0	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	15 - 75		0 - 25	25 to 50	0	0 to 25	15 to 25	25	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											50.3	50.3	23.97	7.89	78.86	0	0.16	39.43	53.23	0	23.66	0	13.14	29.18	0	19.71	13.8	19.71	9.55	1	0.11	0	0	10	7.89	7.89	7.89	0	0	0	0											4.8	0.08	1.96	1.19	2.7	-	0.53	0.89	1.17	-	1.61	-	0.53	1.26	-	14.26	0.22	1.36	3.46	2.13	0.78	-	-	0.32	0.31	0.23	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.92		10.62	4.8	0.08	1.96	1.19	2.7	-	0.53	0.89	1.17	-	1.61	-	0.53	1.26	-	14.26	0.22	1.36	3.46	2.13	0.78	-	-	0.32	0.31	0.23	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.92	2000																																																																																			-		0	4.8	0.08	1.96	1.19	2.7	-	0.53	0.89	1.17	-	1.61	-	0.53	1.26	-	14.26	0.22	1.36	3.46	2.13	0.78	-	-	0.32	0.31	0.23	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.92
H1032_097_0	2007	5																					0											D	D	D	V	T	O	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	769.5	11.27	684.96	1342.8	276.97	9.87	2.16	3	210.73	1244.85	646.54	0	403.39	426.43	3841.93	6660.71	148.02	677.04	3140.13	18547.58	5.11	19.11	0	0	0	0	0	0	0	277.52	547.2											250  days 1 - 5	250  days 1 - 5	114  days 21 - 100	10	100	0	20	0	150-ASC/ 200-OP/ 150-Non Surg	0	15 - 75		0 - 40	40 to 150	10	0 to 40	30 to 40	40	0 - 75	0 to 24	0 -20	0.2	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											159.48	159.48	25.88	10	100	0	0.2	0.2	190	0	30	0	26.67	92.36	7.88	40	32.5	40	12.26	1.96	0.13	0.2	0	0	0	0	0	0	0	0	0											10.23	0.15	1.48	1.12	2.31	-	0.43	0.6	3.34	-	1.62	-	0.9	3.28	2.52	22.2	0.4	2.26	3.21	3.02	0.68	3.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.57		0	10.23	0.15	1.48	1.12	2.31	-	0.43	0.6	3.34	-	1.62	-	0.9	3.28	2.52	22.2	0.4	2.26	3.21	3.02	0.68	3.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.57	0																																																																																			-		0	10.23	0.15	1.48	1.12	2.31	-	0.43	0.6	3.34	-	1.62	-	0.9	3.28	2.52	22.2	0.4	2.26	3.21	3.02	0.68	3.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.57
H1032_098_0	2007	5																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	668.13	8.04	587.14	1304.42	258.09	10.85	2.71	206.15	191.43	1063.83	577.79	0	380.05	398.52	3699.8	5874.49	125.12	581.82	2615.13	16061.1	6.93	12.43	0	0	0	0	0	0	0	286.44	547.2											250  days 1 - 5	250  days 1 - 5	100  days 15 - 100	0	100	0	20	50	100-ASC/ 200-OP/ 150-Non Surg	0	15 - 75		0 - 35	35 to 150	15	0 to 35	25 to 35	35	0 - 75	0 to 10	0 -20	0.2	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											159.48	159.48	35.77	0	100	0	0.2	50	185	0	30	0	23.33	89.26	11.65	35	27.5	35	12.44	1.59	0.13	0.2	0	0	0	0	0	0	0	0	0											8.88	0.11	1.75	-	2.15	-	0.54	0.86	2.95	-	1.44	-	0.74	2.96	3.59	17.13	0.29	1.7	2.71	2.12	0.93	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.34		0	8.88	0.11	1.75	-	2.15	-	0.54	0.86	2.95	-	1.44	-	0.74	2.96	3.59	17.13	0.29	1.7	2.71	2.12	0.93	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.34	0																																																																																			-		0	8.88	0.11	1.75	-	2.15	-	0.54	0.86	2.95	-	1.44	-	0.74	2.96	3.59	17.13	0.29	1.7	2.71	2.12	0.93	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.34
H1032_101_0	2007	3																					1500											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1764.97	31.8	1244.02	2293.86	591.32	24.09	4.39	400.03	391.22	2476.34	1241.24	0	715.38	764.18	6579.43	12052.56	273.01	1185.26	6369.43	35177.76	9.62	7520.23	1200	381	633.81	463.82	271.63	16.2	0	427.92	2035.2											50  days 1 - 5	50  days 1 - 5	50  days 8 - 100	0	0	0	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	0 - 50		0 - 15	15 to 25	0	0 to 15	5 to 15	15	0 - 50	0 to 10	0 -20	0	24 round trips per year	10	10	10	10	0		0	0 to 50											23.98	23.98	22.86	0	0	0	0.15	37.59	33.83	0	9.4	0	7.52	14.9	0	11.28	5.64	11.28	3.78	0.8	0.1	0	0	10	7.52	7.52	7.52	0	0	0	0											3.53	0.06	2.37	-	-	-	0.66	1.25	1.1	-	0.97	-	0.45	0.95	-	11.33	0.13	1.11	2.01	2.35	0.97	-	-	0.32	0.4	0.29	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42		9.94	3.53	0.06	2.37	-	-	-	0.66	1.25	1.1	-	0.97	-	0.45	0.95	-	11.33	0.13	1.11	2.01	2.35	0.97	-	-	0.32	0.4	0.29	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	1500																																																																																			-		0	3.53	0.06	2.37	-	-	-	0.66	1.25	1.1	-	0.97	-	0.45	0.95	-	11.33	0.13	1.11	2.01	2.35	0.97	-	-	0.32	0.4	0.29	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42
H1032_102_0	2007	3																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1518.5	25.04	1362.41	2146.08	518.01	20.09	3.88	366.89	352.63	2142.39	1102.78	0	663.01	703.72	7009.86	12573.97	281.07	1257.57	5584.27	32734.23	8.64	7282.41	1200	381	634.41	468.89	271.89	16.37	0	453.61	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.19	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.78	1.53	-	-	1.15	-	-	-	-	-	-	-	2.36	3.24	1.16	-	-	0.32	0.53	0.39	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.67		0	-	-	-	-	-	-	0.78	1.53	-	-	1.15	-	-	-	-	-	-	-	2.36	3.24	1.16	-	-	0.32	0.53	0.39	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.67	0																																																																																			-		0	-	-	-	-	-	-	0.78	1.53	-	-	1.15	-	-	-	-	-	-	-	2.36	3.24	1.16	-	-	0.32	0.53	0.39	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.67
H1032_104_0	2007	6																					2000											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1496.45	25.79	1390.09	2353.14	502.2	18.22	3.69	388.34	378.24	2371.83	1196.07	0	696.18	742.55	6596.78	12622.86	304.12	1316.49	6323.89	35709.89	8.57	8552.62	1200	381	634.8	464.56	272.06	16.22	0	434	2035.2											100  days 1 - 5	100  days 1 - 5	50  days 8 - 100	0	50	0	0	50	25-ASC/ 75-OP/ 50-Non Surg	0	0 - 50		0 - 20	20 to 50	0	0 to 20	10 to 20	20	0 - 50	0 to 3	0 -20	0	24 one way Trips per year	0	0	0	0	0		0	0 to 0											49.74	49.74	23.71	0	38.99	0	0	38.99	52.63	0	9.75	0	10.4	26.84	0	15.59	9.75	15.59	3.93	0.96	0.1	0	0	0	0	0	0	0	0	0	0											6.2	0.11	2.75	-	1.63	-	-	1.26	1.66	-	0.97	-	0.6	1.66	-	16.4	0.25	1.71	2.07	2.86	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.04		11.61	6.2	0.11	2.75	-	1.63	-	-	1.26	1.66	-	0.97	-	0.6	1.66	-	16.4	0.25	1.71	2.07	2.86	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.04	2000																																																																																			-		0	6.2	0.11	2.75	-	1.63	-	-	1.26	1.66	-	0.97	-	0.6	1.66	-	16.4	0.25	1.71	2.07	2.86	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.04
H1032_106_0	2007	3																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1482.94	23.04	1365.46	2611.36	583.46	25.3	5.02	394.55	332.06	1946.31	1016.64	0	638.77	674.51	7285.77	12787.91	285.13	1283.61	5768.22	34509.69	11.64	24.16	1200	381	661.27	506.33	283.4	17.68	0	488.36	2035.2											0  unlimited	0  days 1 - 190	0  days  1 - 100	0	50	0	20	0	0-ASC/ 0-OP/ 0-Non Surg	0	15 - 75		0 - 0	0	0	0 to 0	0 to 0	0	0 - 75	0 to 10	0 -20	0.2	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	50	0	0.2	0	0	0	30	0	0	0	0	0	0	0	12.22	1.14	0.13	0.2	0	10	10	10	10	0	0	0	0											-	-	-	-	2.43	-	1	-	-	-	2.54	-	-	-	-	-	-	-	5.87	3.26	1.56	4.83	-	0.32	0.55	0.42	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03		0	-	-	-	-	2.43	-	1	-	-	-	2.54	-	-	-	-	-	-	-	5.87	3.26	1.56	4.83	-	0.32	0.55	0.42	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03	0																																																																																			-		0	-	-	-	-	2.43	-	1	-	-	-	2.54	-	-	-	-	-	-	-	5.87	3.26	1.56	4.83	-	0.32	0.55	0.42	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03
H1032_107_0	2007	3																					0											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2084.6	37.63	1099.81	2810.43	760.21	36.15	7.04	476.6	389.46	2425.5	1283.76	0	720.21	767.35	8105.37	16383.98	410.88	1811.46	7244.02	45195.07	16.57	10316.58	1200	381	730.16	496.93	312.93	17.35	0	494.06	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	0	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 0		0 - 0	0	0	0 to 0	0 to 0	0	0 - 0	0 to 4	0 -20	0	24 one way trips per year	0	0	0	0	0		0	0 to 0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1.19	0.13	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.48	2.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.71		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.48	2.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.71	0																																																																																			-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.48	2.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.71
H1032_113_0	2007	5																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1103.67	17.9	825.89	1905.89	390.61	13.66	3.15	287.52	276.67	1685.54	856.14	0	519.24	551.35	5893.74	11228.22	267.89	1189.64	4529.16	30128.46	7.95	6831.47	0	381	532.42	361.8	228.18	12.63	0	372.6	547.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	15 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	23.75	0	0	0	0	0	0	0	9.63	1.76	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.63	1.2	-	-	1.69	-	-	-	-	-	-	-	3.63	4.41	1.06	-	-	0.32	0.44	0.3	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.88		0	-	-	-	-	-	-	0.63	1.2	-	-	1.69	-	-	-	-	-	-	-	3.63	4.41	1.06	-	-	0.32	0.44	0.3	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.88	0																																																																																			-		0	-	-	-	-	-	-	0.63	1.2	-	-	1.69	-	-	-	-	-	-	-	3.63	4.41	1.06	-	-	0.32	0.44	0.3	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.88
H1032_122_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1555.68	28.58	1335.01	1871.96	7.61	19.96	3.54	4.45	22.89	2075.36	23	0	7.09	15.3	6054.22	63.24	1.96	2.62	5589.06	143.54	7.64	7022.84	0	381	584.9	415.62	250.67	14.51	0	381.86	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											142.07	122.31	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.92	0.09	0.13	0	0	0	0	0	0	0	0	0	0											18.42	0.29	3.01	-	1.52	-	-	0.89	4.58	-	1.15	-	1.06	3.06	-	12.65	0.39	0.52	1.36	12.68	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.61		0	18.42	0.29	3.01	-	1.52	-	-	0.89	4.58	-	1.15	-	1.06	3.06	-	12.65	0.39	0.52	1.36	12.68	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.61	0																																																																																			-		0	18.42	0.29	3.01	-	1.52	-	-	0.89	4.58	-	1.15	-	1.06	3.06	-	12.65	0.39	0.52	1.36	12.68	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.61
H1032_123_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1740.58	32.92	1174.41	2085.3	8.83	23.29	4.06	5.13	26.57	2371.63	26.81	0	8.14	17.59	5989.77	61.88	2	2.56	6158.27	140.52	8.76	7049.57	0	381	579.67	416.64	248.43	14.55	0	371.86	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											139.15	120.7	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.43	0.08	0.13	0	0	0	0	0	0	0	0	0	0											20.18	0.33	2.64	-	1.77	-	-	1.03	5.31	-	1.34	-	1.22	3.52	-	12.38	0.4	0.51	1.25	11.43	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.48		0	20.18	0.33	2.64	-	1.77	-	-	1.03	5.31	-	1.34	-	1.22	3.52	-	12.38	0.4	0.51	1.25	11.43	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.48	0																																																																																			-		0	20.18	0.33	2.64	-	1.77	-	-	1.03	5.31	-	1.34	-	1.22	3.52	-	12.38	0.4	0.51	1.25	11.43	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.48
H1032_124_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1483.11	27.06	1237.91	2302.47	8.81	23.13	4.13	5.24	26.98	2061.66	27.12	0	8.36	18.04	5950.57	59.73	1.93	2.4	5662.02	147.76	9	6794.66	0	381	574.72	415.64	246.31	14.51	0	376.3	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											157.99	128.06	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.6	0.09	0.13	0	0	0	0	0	0	0	0	0	0											19.53	0.29	2.79	-	1.76	-	-	1.05	5.4	-	1.36	-	1.25	3.61	-	11.95	0.39	0.48	1.23	12.66	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.93		0	19.53	0.29	2.79	-	1.76	-	-	1.05	5.4	-	1.36	-	1.25	3.61	-	11.95	0.39	0.48	1.23	12.66	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.93	0																																																																																			-		0	19.53	0.29	2.79	-	1.76	-	-	1.05	5.4	-	1.36	-	1.25	3.61	-	11.95	0.39	0.48	1.23	12.66	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.93
H1032_125_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1689.38	31.93	1145.09	2340.48	9.16	24.14	4.18	5.26	27.25	3070.96	27.4	0	8.23	17.82	5806.81	51.77	1.8	1.73	5335.53	144.94	8.87	6062.08	0	381	561.88	416.83	240.8	14.56	0	361.01	1488											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											144.59	122.7	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	1.83	0.08	0.13	0	0	0	0	0	0	0	0	0	0											20.36	0.33	2.58	-	1.83	-	-	1.05	5.45	-	1.37	-	1.24	3.56	-	10.35	0.36	0.35	0.81	12.12	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.94		0	20.36	0.33	2.58	-	1.83	-	-	1.05	5.45	-	1.37	-	1.24	3.56	-	10.35	0.36	0.35	0.81	12.12	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.94	0																																																																																			-		0	20.36	0.33	2.58	-	1.83	-	-	1.05	5.45	-	1.37	-	1.24	3.56	-	10.35	0.36	0.35	0.81	12.12	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.94
H1032_126_0	2007	4																					1500											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1745.92	31.59	1222.41	2562.92	573.07	25.59	4.51	499.17	492.95	3189.82	1576.45	0	887.31	951.35	6453.25	11302.36	236.69	1031.18	5687.37	31156.57	9.55	6675.69	1200	381	622.04	466.27	266.59	16.28	0	418.49	2035.2											75  days 1 - 5	75  days 1 - 5	50  days 8 - 100	0	0	0	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	0 - 50		0 - 20	20 to 50	5	0 to 20	10 to 20	20	0 - 50	0 to 10	0 -20	0	24  one way trips per year	10	10	10	10	0		0	0 to 50											33.18	33.18	21.08	0	0	0	0.14	34.67	46.81	0	8.67	0	9.25	23.93	2.79	13.87	8.67	13.87	3.5	0.67	0.09	0	0	10	6.93	6.93	6.93	0	0	0	0											4.83	0.09	2.15	-	-	-	0.63	1.44	1.92	-	1.14	-	0.68	1.9	1.5	13.06	0.17	1.19	1.66	1.73	0.89	-	-	0.32	0.36	0.27	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.07		15.81	4.83	0.09	2.15	-	-	-	0.63	1.44	1.92	-	1.14	-	0.68	1.9	1.5	13.06	0.17	1.19	1.66	1.73	0.89	-	-	0.32	0.36	0.27	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.07	1500																																																																																			-		0	4.83	0.09	2.15	-	-	-	0.63	1.44	1.92	-	1.14	-	0.68	1.9	1.5	13.06	0.17	1.19	1.66	1.73	0.89	-	-	0.32	0.36	0.27	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.07
H1032_127_0	2007	5																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1522.04	27.86	1222.55	2286.07	8.37	22.01	3.83	4.77	24.55	2014.85	24.68	0	7.62	16.44	6088.61	65.42	1.99	2.81	5482.63	146.16	8.21	7211.16	0	381	588.26	415.61	252.11	14.51	0	383.78	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											139.13	121.4	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.62	0.09	0.13	0	0	0	0	0	0	0	0	0	0											17.65	0.28	2.75	-	1.67	-	-	0.95	4.91	-	1.23	-	1.14	3.29	-	13.08	0.4	0.56	1.19	13.01	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.23		0	17.65	0.28	2.75	-	1.67	-	-	0.95	4.91	-	1.23	-	1.14	3.29	-	13.08	0.4	0.56	1.19	13.01	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.23	0																																																																																			-		0	17.65	0.28	2.75	-	1.67	-	-	0.95	4.91	-	1.23	-	1.14	3.29	-	13.08	0.4	0.56	1.19	13.01	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.23
H1032_128_0	2007	4																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1408.93	25.4	1283.71	2127.7	6.52	17.05	3.35	4.53	23.27	2203.13	23.34	0	7.19	15.51	5978.12	70.74	1.96	3.73	5981.87	142.75	7.74	8031.36	0	381	577.18	415.42	247.36	14.51	0	379.2	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											145.62	124.1	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	3.03	0.09	0.13	0	0	0	0	0	0	0	0	0	0											17.1	0.26	2.89	-	1.3	-	-	0.91	4.65	-	1.17	-	1.08	3.1	-	14.15	0.39	0.75	1.51	13.46	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.76		0	17.1	0.26	2.89	-	1.3	-	-	0.91	4.65	-	1.17	-	1.08	3.1	-	14.15	0.39	0.75	1.51	13.46	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.76	0																																																																																			-		0	17.1	0.26	2.89	-	1.3	-	-	0.91	4.65	-	1.17	-	1.08	3.1	-	14.15	0.39	0.75	1.51	13.46	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.76
H1032_129_0	2007	5																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1438.95	26.5	991.04	1762.48	474.22	19.25	3.44	315.99	310.4	1984.93	973.91	0	563.52	602.98	5157.69	9462.46	207.58	904.07	5046.89	28107.71	7.49	5972.99	0	381	498.2	363.23	213.51	12.68	0	329.35	547.2											0  unlimited	0  0	50  days 8 - 100	10	100	0	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	15 - 75		0 - 25	25	0	0 to 25	15 to 25	25	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											0	0	30.4	10	100	0	0.2	50	45	0	30	0	16.67	25	0	25	17.5	25	12.06	1.24	0.13	0	0	10	10	10	10	0	0	0	0											-	-	2.51	1.47	3.95	-	0.69	1.32	1.16	-	2.43	-	0.78	1.26	-	19.71	0.3	1.88	5.07	2.91	1	-	-	0.32	0.42	0.3	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.68		0	-	-	2.51	1.47	3.95	-	0.69	1.32	1.16	-	2.43	-	0.78	1.26	-	19.71	0.3	1.88	5.07	2.91	1	-	-	0.32	0.42	0.3	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.68	0																																																																																			-		0	-	-	2.51	1.47	3.95	-	0.69	1.32	1.16	-	2.43	-	0.78	1.26	-	19.71	0.3	1.88	5.07	2.91	1	-	-	0.32	0.42	0.3	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.68
H1032_130_0	2007	4																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1361.8	23.83	1220.21	2265.97	9.16	23.98	4.12	4.92	25.28	1585.36	25.41	0	8.22	17.6	5746.77	55.14	1.83	2.29	5384.31	140.62	8.85	6549.38	0	381	552.95	414.09	236.98	14.46	0	375.74	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											163.26	130.61	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	3.13	0.09	0.13	0	0	0	0	0	0	0	0	0	0											18.53	0.26	2.75	-	1.83	-	-	0.98	5.06	-	1.27	-	1.23	3.52	-	11.03	0.37	0.46	1.4	12.66	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.53		0	18.53	0.26	2.75	-	1.83	-	-	0.98	5.06	-	1.27	-	1.23	3.52	-	11.03	0.37	0.46	1.4	12.66	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.53	0																																																																																			-		0	18.53	0.26	2.75	-	1.83	-	-	0.98	5.06	-	1.27	-	1.23	3.52	-	11.03	0.37	0.46	1.4	12.66	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.53
H1032_131_0	2007	6																					3000											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	832.59	12.97	697.35	1427.95	313.09	12.27	2.46	214.83	204.82	1219.81	629.82	0	390.08	412.83	3925.49	6753.86	144.65	660.33	3120.6	19317	5.62	4285.27	0	381	375.13	280.24	160.77	9.79	0	276.39	547.2											250  days 1 - 5	250  days 1 - 5	100  days 8 - 100	0	0	0	20	50	100-ASC/ 250-OP/ 150-Non Surg	0	15 - 75		0 - 35	35 to 150	10	0 to 35	25 to 35	35	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											142.59	142.59	54.37	0	0	0	0.18	44.71	201.18	0	26.82	0	20.86	80.31	7.09	31.29	24.59	31.29	10.94	1.32	0.12	0	0	10	8.94	8.94	8.94	0	0	0	0											9.89	0.15	3.16	-	-	-	0.44	0.8	3.43	-	1.41	-	0.68	2.76	2.32	17.61	0.3	1.72	2.84	2.12	0.67	-	-	0.32	0.28	0.21	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.24		6.03	9.89	0.15	3.16	-	-	-	0.44	0.8	3.43	-	1.41	-	0.68	2.76	2.32	17.61	0.3	1.72	2.84	2.12	0.67	-	-	0.32	0.28	0.21	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.24	3000																																																																																			-		0	9.89	0.15	3.16	-	-	-	0.44	0.8	3.43	-	1.41	-	0.68	2.76	2.32	17.61	0.3	1.72	2.84	2.12	0.67	-	-	0.32	0.28	0.21	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.24
H1032_132_0	2007	5																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1124.42	18.7	1017.85	1919.35	446.16	19.53	3.58	241.48	230.79	1382.96	710.9	0	437.83	463.78	4968.07	8762.45	191.46	845.56	4377.86	25863.89	7.98	17.56	0	381	476.45	360.54	204.19	12.59	0	336.88	547.2											0  unlimited	0  per day	50  days 8 - 100	0	100	0	20	50	25-ASC/ 75-OP/ 25-Non Surg	0	15 - 75		0 - 25	25	0	0 to 25	15 to 25	25	0 - 75	0 to 10	0 -20	0.2	0	10	10	10	10	0		0	0 to 0											0	0	30.4	0	100	0	0.2	50	65	0	30	0	16.67	25	0	25	17.5	25	12.15	1.29	0.13	0.2	0	10	10	10	10	0	0	0	0											-	-	2.58	-	3.72	-	0.72	1.01	1.25	-	1.78	-	0.61	0.97	-	18.26	0.28	1.76	4.43	2.78	1.07	3.51	-	0.32	0.4	0.3	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.9		0	-	-	2.58	-	3.72	-	0.72	1.01	1.25	-	1.78	-	0.61	0.97	-	18.26	0.28	1.76	4.43	2.78	1.07	3.51	-	0.32	0.4	0.3	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.9	0																																																																																			-		0	-	-	2.58	-	3.72	-	0.72	1.01	1.25	-	1.78	-	0.61	0.97	-	18.26	0.28	1.76	4.43	2.78	1.07	3.51	-	0.32	0.4	0.3	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.9
H1032_133_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1274.87	22.55	1121.21	1641.04	425.15	16.66	3.05	287.06	279.36	1748.28	882.76	0	514.89	549.01	5209.86	9459.4	210.39	913.83	4652.6	26911.99	6.66	5925.84	0	381	501.9	362.07	215.1	12.64	0	339.51	547.2											75  days 1 - 5	75  days 1 - 5	50  days 8 - 100	0	100	20	20	50	25-ASC/ 100-OP/ 50-Non Surg	0	0 - 75		0 - 20	20 to 50	0	0 to 20	10 to 20	20	0 - 75	0 to 10	0 -20	0	0	10	10	10	10	0		0	0 to 0											43.7	43.7	27.77	0	91.35	0.18	0.18	45.67	79.93	0	17.13	0	12.18	31.44	0	18.27	11.42	18.27	6.91	1.22	0.12	0	0	10	9.13	9.13	9.13	0	0	0	0											4.64	0.08	2.59	-	3.24	3.04	0.56	1.09	1.86	-	1.26	-	0.52	1.44	-	14.4	0.2	1.39	2.68	2.74	0.82	-	-	0.32	0.38	0.28	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.7		4.11	4.64	0.08	2.59	-	3.24	3.04	0.56	1.09	1.86	-	1.26	-	0.52	1.44	-	14.4	0.2	1.39	2.68	2.74	0.82	-	-	0.32	0.38	0.28	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.7	3000																																																																																			-		0	4.64	0.08	2.59	-	3.24	3.04	0.56	1.09	1.86	-	1.26	-	0.52	1.44	-	14.4	0.2	1.39	2.68	2.74	0.82	-	-	0.32	0.38	0.28	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.7
H1032_134_0	2007	4																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1473	26.81	1229.88	2290.94	8.7	22.84	4.09	5.19	26.7	2049.87	26.83	0	8.28	17.87	5926.32	59.06	1.91	2.38	5624.23	145.88	8.92	6758.08	0	381	572.23	415.55	245.24	14.51	0	375.63	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											157.21	127.84	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.59	0.09	0.13	0	0	0	0	0	0	0	0	0	0											19.3	0.29	2.77	-	1.74	-	-	1.04	5.34	-	1.34	-	1.24	3.57	-	11.81	0.38	0.48	1.21	12.51	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.21		0	19.3	0.29	2.77	-	1.74	-	-	1.04	5.34	-	1.34	-	1.24	3.57	-	11.81	0.38	0.48	1.21	12.51	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.21	0																																																																																			-		0	19.3	0.29	2.77	-	1.74	-	-	1.04	5.34	-	1.34	-	1.24	3.57	-	11.81	0.38	0.48	1.21	12.51	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.21
H1032_135_0	2007	4																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1483.58	27.07	1238.28	2303	8.81	23.14	4.13	5.24	26.99	2062.2	27.14	0	8.37	18.05	5951.7	59.76	1.93	2.4	5663.76	147.84	9.01	6796.35	0	381	574.83	415.64	246.36	14.51	0	376.33	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											158.02	128.07	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.6	0.09	0.13	0	0	0	0	0	0	0	0	0	0											19.54	0.29	2.79	-	1.76	-	-	1.05	5.4	-	1.36	-	1.25	3.61	-	11.95	0.39	0.48	1.23	12.67	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.97		0	19.54	0.29	2.79	-	1.76	-	-	1.05	5.4	-	1.36	-	1.25	3.61	-	11.95	0.39	0.48	1.23	12.67	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.97	0																																																																																			-		0	19.54	0.29	2.79	-	1.76	-	-	1.05	5.4	-	1.36	-	1.25	3.61	-	11.95	0.39	0.48	1.23	12.67	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.97
H1032_136_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1477.77	24.3	1263.32	2406.39	541.74	21.37	4.11	356.09	341.99	2073.88	1068.82	0	643.8	683.14	6946.27	12556.01	283.28	1266.24	5444.47	33340.06	9.24	7324.78	1200	381	628.55	462.53	269.38	16.15	0	448.49	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 One way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.2	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.82	1.48	-	-	1.11	-	-	-	-	-	-	-	2.3	3.32	1.24	-	-	0.32	0.52	0.39	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.74		0	-	-	-	-	-	-	0.82	1.48	-	-	1.11	-	-	-	-	-	-	-	2.3	3.32	1.24	-	-	0.32	0.52	0.39	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.74	0																																																																																			-		0	-	-	-	-	-	-	0.82	1.48	-	-	1.11	-	-	-	-	-	-	-	2.3	3.32	1.24	-	-	0.32	0.52	0.39	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.74
H1032_137_0	2007	4																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1442.21	23.48	1267.73	2411.41	520.83	22.66	4.45	360.24	346	2098.59	1081.43	0	651.27	691.09	6826.3	12152.2	269.81	1208.79	5539.51	32455.42	10.07	7010.27	1200	381	618.06	462.37	264.88	16.15	0	444.08	2035.2											0  unlimited	0  0	0  days 1 - 100	0	0	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 10	0 -20	0	24 one way trips per year	10	10	10	10	0		0	0 to 0											0	0	0	0	0	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.07	1.12	0.13	0	0	10	10	10	10	0	0	0	0											-	-	-	-	-	-	0.89	1.5	-	-	1.13	-	-	-	-	-	-	-	2.34	3.03	1.35	-	-	0.32	0.52	0.39	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.68		0	-	-	-	-	-	-	0.89	1.5	-	-	1.13	-	-	-	-	-	-	-	2.34	3.03	1.35	-	-	0.32	0.52	0.39	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.68	0																																																																																			-		0	-	-	-	-	-	-	0.89	1.5	-	-	1.13	-	-	-	-	-	-	-	2.34	3.03	1.35	-	-	0.32	0.52	0.39	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.68
H1032_138_0	2007	4																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1522.04	27.86	1222.55	2286.07	8.37	22.01	3.83	4.77	24.55	2014.85	24.68	0	7.62	16.44	6088.61	65.42	1.99	2.81	5482.63	146.16	8.21	7211.16	0	381	588.26	415.61	252.11	14.51	0	383.78	2035.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											139.13	121.4	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.2	0.2	2.62	0.09	0.13	0	0	0	0	0	0	0	0	0	0											17.65	0.28	2.75	-	1.67	-	-	0.95	4.91	-	1.23	-	1.14	3.29	-	13.08	0.4	0.56	1.19	13.01	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.23		0	17.65	0.28	2.75	-	1.67	-	-	0.95	4.91	-	1.23	-	1.14	3.29	-	13.08	0.4	0.56	1.19	13.01	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.23	0																																																																																			-		0	17.65	0.28	2.75	-	1.67	-	-	0.95	4.91	-	1.23	-	1.14	3.29	-	13.08	0.4	0.56	1.19	13.01	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.23
H1034_001_0	2007	4																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		1334.98	24.09	1002.47	2258.51	69.13	9.76	25628.3	288.45	266.49	2242.26	905.1	0	53.58	593.08	8804.47	13952.3	205.65	600.81	5415.58	15657.19	412.78	1016.87	1953.49	3038	522.23	322.7	223.63	2.54	0	0	12036.48											200 per day days 1 - 6	200 per day days 1 - 6	75 per day days 8 - 100	0 copay	75 copay	10 coinsurance	Effective copay 0 or 10 coinsurance	50 copay	100 copay	Effective copay 0 or 20	Effective copay 0 or 50		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	25 copay	20 copay	0 copay	Effective copay 0 or 20	0 copay	Effective copay 0 or 20	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											141.67	141.28	56.9	0	75	0.1	0.42	50	100	4.3	11.91	0	20	10.05	0.69	15.08	25	20	0	1.14	0	16	3.5	0	0	0	0	0.5	0	0	0											15.76	0.28	4.75	-	0.43	0.98	0.89	1.2	2.22	0.8	0.9	-	0.09	0.5	0.51	17.53	0.43	1	-	1.49	-	1.36	0.57	-	-	-	-	1.27	-	-	0	-	-	-	-	-	-	-	-	-	-	52.97			15.76	0.28	4.75	-	0.43	0.98	0.89	1.2	2.22	0.8	0.9	-	0.09	0.5	0.51	17.53	0.43	1	-	1.49	-	1.36	0.57	-	-	-	-	1.27	-	-	0	-	-	-	-	-	-	-	-	-	-	52.97																																																																																				-			15.76	0.28	4.75	-	0.43	0.98	0.89	1.2	2.22	0.8	0.9	-	0.09	0.5	0.51	17.53	0.43	1	-	1.49	-	1.36	0.57	-	-	-	-	1.27	-	-	0	-	-	-	-	-	-	-	-	-	-	52.97
H1034_003_0	2007	5																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		1264.86	22.66	1102.96	2815.8	69.56	9.53	24206.89	273.82	240.73	2084.82	827.99	0	49.56	550.07	9512.99	14473.92	225.34	657.76	5621.46	17674.86	376.81	1081.45	1953.49	3038	577.61	303.38	246.99	2.39	0	0	12038.97											200 per day days 1 - 6	200 per day days 1 - 6	75 per day days 8 - 100	0 copay	75 copay	10 coinsurance	Effective copay 0 or 10 coinsurance	50 copay	100 copay	Effective copay 0 or 20	Effective copay 0 or 50		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	25 copay	20 copay	0 copay	Effective copay 0 or 20	0 copay	Effective copay 0 or 20	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											141.67	141.28	56.9	0	75	0.1	0.45	50	100	4.28	11.91	0	20	9.94	0.71	15.73	25	20	0	1.15	0	16.57	3.5	0	0	0	0	0.5	0	0	0											14.93	0.27	5.23	-	0.43	0.95	0.91	1.14	2.01	0.74	0.82	-	0.08	0.46	0.56	18.97	0.47	1.1	-	1.7	-	1.49	0.57	-	-	-	-	1.19	-	-	0	-	-	-	-	-	-	-	-	-	-	54.03			14.93	0.27	5.23	-	0.43	0.95	0.91	1.14	2.01	0.74	0.82	-	0.08	0.46	0.56	18.97	0.47	1.1	-	1.7	-	1.49	0.57	-	-	-	-	1.19	-	-	0	-	-	-	-	-	-	-	-	-	-	54.03																																																																																				-			14.93	0.27	5.23	-	0.43	0.95	0.91	1.14	2.01	0.74	0.82	-	0.08	0.46	0.56	18.97	0.47	1.1	-	1.7	-	1.49	0.57	-	-	-	-	1.19	-	-	0	-	-	-	-	-	-	-	-	-	-	54.03
H1034_004_0	2007	5																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		1683.1	31.33	1202.79	3440.96	77.96	10.56	25339.6	286.93	238.77	2134.07	841.18	0	50.56	563.18	9867.91	14864.94	237.27	671.19	5678.42	18208.79	378.29	1210.29	2264.15	3038	575.61	314.11	246.98	2.48	0	0	12038.34											90 per day days 1 - 6	90 per day days 1 - 6	50 per day days 8 - 90	0 copay	50 per trip	10 coinsurance	Effective copay 0 or 10 coinsurance	50 copay	Effective copay 25 or 50	Effective copay 0 or 20	Effective copay 0 to 100		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 or 25	20 copay	20 copay	0 copay	Effective copay 0 or 10	0 copay	0 copay	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											63.57	63.57	37.93	0	50	0.1	0.46	50	41.67	4.26	11.9	0	20	9.79	0.7	12.47	20	20	0	0.62	0	0	3.5	0	0	0	0	0.5	0	0	0											8.92	0.17	3.8	-	0.32	1.06	0.97	1.2	0.83	0.76	0.83	-	0.08	0.46	0.58	15.45	0.4	1.12	-	0.94	-	-	0.66	-	-	-	-	1.24	-	-	0	-	-	-	-	-	-	-	-	-	-	39.78			8.92	0.17	3.8	-	0.32	1.06	0.97	1.2	0.83	0.76	0.83	-	0.08	0.46	0.58	15.45	0.4	1.12	-	0.94	-	-	0.66	-	-	-	-	1.24	-	-	0	-	-	-	-	-	-	-	-	-	-	39.78																																																																																				-			8.92	0.17	3.8	-	0.32	1.06	0.97	1.2	0.83	0.76	0.83	-	0.08	0.46	0.58	15.45	0.4	1.12	-	0.94	-	-	0.66	-	-	-	-	1.24	-	-	0	-	-	-	-	-	-	-	-	-	-	39.78
H1034_005_0	2007	5																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		986.01	17.75	741.42	1670.86	51.11	6.6	18942.25	213.44	197.19	1658.39	669.55	0	39.68	439	6511.08	10312.79	151.98	443.83	4000.68	11562.78	305.54	752.45	1953.49	3038	386.25	239.15	165.4	1.88	0	0	12027.02											200 per day days 1 - 6	200 per day days 1 - 6	75 per day days 8 - 100	0 copay	75 copay	10 coinsurance	Effective copay 0 or 10 coinsurance	50 copay	100 copay	Effective copay 0 or 20	Effective copay 0 or 50		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	25 copay	20 copay	0 copay	Effective copay 0 or 20	0 copay	Effective copay 0 or 20	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											141.67	141.28	56.9	0	75	0.1	0.38	50	100	4.31	11.91	0	20	10.05	0.68	15.07	25	20	0	1.14	0	16	3.5	0	0	0	0	0.5	0	0	0											11.64	0.21	3.52	-	0.32	0.66	0.6	0.89	1.64	0.6	0.66	-	0.07	0.37	0.37	12.95	0.32	0.74	-	1.1	-	1	0.57	-	-	-	-	0.94	-	-	0	-	-	-	-	-	-	-	-	-	-	39.17			11.64	0.21	3.52	-	0.32	0.66	0.6	0.89	1.64	0.6	0.66	-	0.07	0.37	0.37	12.95	0.32	0.74	-	1.1	-	1	0.57	-	-	-	-	0.94	-	-	0	-	-	-	-	-	-	-	-	-	-	39.17																																																																																				-			11.64	0.21	3.52	-	0.32	0.66	0.6	0.89	1.64	0.6	0.66	-	0.07	0.37	0.37	12.95	0.32	0.74	-	1.1	-	1	0.57	-	-	-	-	0.94	-	-	0	-	-	-	-	-	-	-	-	-	-	39.17
H1034_006_0	2007	5																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		971.51	17.45	846.16	2162.54	53.38	6.7	18583.89	209.92	184.55	1599.15	634.96	0	37.96	421.53	7306.95	11120.43	173.24	505.91	4321.53	13599.75	288.75	830.02	1953.49	3038	443.65	232.16	189.71	1.83	0	0	12029.89											200 per day days 1 - 6	200 per day days 1 - 6	75 per day days 8 - 100	0 copay	75 copay	10 coinsurance	Effective copay 0 or 10 coinsurance	50 copay	100 copay	Effective copay 0 or 20	Effective copay 0 or 50		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	25 copay	20 copay	0 copay	Effective copay 0 or 20	0 copay	Effective copay 0 or 20	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											141.67	141.28	56.9	0	75	0.1	0.41	50	100	4.27	11.9	0	20	9.95	0.7	15.7	25	20	0	1.16	0	16.57	3.5	0	0	0	0	0.5	0	0	0											11.47	0.21	4.01	-	0.33	0.67	0.64	0.87	1.54	0.57	0.63	-	0.06	0.35	0.43	14.55	0.36	0.84	-	1.31	-	1.15	0.57	-	-	-	-	0.91	-	-	0	-	-	-	-	-	-	-	-	-	-	41.48			11.47	0.21	4.01	-	0.33	0.67	0.64	0.87	1.54	0.57	0.63	-	0.06	0.35	0.43	14.55	0.36	0.84	-	1.31	-	1.15	0.57	-	-	-	-	0.91	-	-	0	-	-	-	-	-	-	-	-	-	-	41.48																																																																																				-			11.47	0.21	4.01	-	0.33	0.67	0.64	0.87	1.54	0.57	0.63	-	0.06	0.35	0.43	14.55	0.36	0.84	-	1.31	-	1.15	0.57	-	-	-	-	0.91	-	-	0	-	-	-	-	-	-	-	-	-	-	41.48
H1034_007_0	2007	5																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		1270.06	23.5	915.37	2603.34	59.15	7.32	19204.53	218.38	181.71	1706.94	678.56	0	38.56	429.07	7899.07	11775.48	179.22	506.52	4601.23	14373.45	288.21	852.39	2264.15	3038	436.32	240.12	187.21	1.9	0	0	12029.17											90 per day days 1 - 6	90 per day days 1 - 6	50 per day days 8 - 100	0 copay	50 copay	10 coinsurance	0 copay or 10 coinsurance	50 copay	Effective copay 25 or 50	Effective copay 0 or 20	Effective copay 0 or 50		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	20 copay	20 copay	0 copay	Effective copay 0 to 10	0 copay	Effective copay 0 or 10	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											63.14	63.57	37.93	0	50	0.1	0.42	50	41.67	4.07	11.75	0	20	9.78	0.61	1.24	20	20	0	0.62	0	8.33	3.5	0	0	0	0	0.5	0	0	0											6.68	0.12	2.89	-	0.25	0.73	0.67	0.91	0.63	0.58	0.66	-	0.06	0.35	0.4	1.22	0.3	0.84	-	0.75	-	0.59	0.66	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	20.26			6.68	0.12	2.89	-	0.25	0.73	0.67	0.91	0.63	0.58	0.66	-	0.06	0.35	0.4	1.22	0.3	0.84	-	0.75	-	0.59	0.66	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	20.26																																																																																				-			6.68	0.12	2.89	-	0.25	0.73	0.67	0.91	0.63	0.58	0.66	-	0.06	0.35	0.4	1.22	0.3	0.84	-	0.75	-	0.59	0.66	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	20.26
H1034_018_0	2007	5																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1915.79	34.61	1576.03	3763.44	98.52	33736.33	34391.37	477.03	345.99	3142.99	1288.84	0	71.21	789.87	13180.69	20477.95	347.76	995.69	7954.64	24931.82	541.49	1575.39	3200	3038	737.38	421.47	315.76	27.45	0	0	12049.19											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1034_019_0	2007	3																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		998.87	17.98	767.91	1631.71	51.52	6.71	19089.21	215.22	198.83	1671.89	675.06	0	40.02	442.73	6448.97	10147.04	148.35	432.68	3943.38	11596.81	308.14	746.38	1953.49	3038	381.22	241.65	163.25	1.9	0	0	1226.76											200 per day days 1 - 6	200 per day days 1 - 6	75 per day days 8 - 100	0 copay	75 copay	10 coinsurance	Effective copay 0 or 10 coinsurance	50 copay	100 copay	Effective copay 0 or 20	Effective copay 0 or 50		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	25 copay	20 copay	0 copay	Effective copay 0 or 20	0 copay	Effective copay 0 or 20	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											141.67	141.28	56.9	0	75	0.1	0.39	50	100	4.31	11.91	0	20	10.05	0.67	15.07	25	20	0	1.1	0	15.93	3.5	0	0	0	0	0.5	0	0	0.03											11.79	0.21	3.64	-	0.32	0.67	0.62	0.9	1.66	0.6	0.67	-	0.07	0.37	0.36	12.74	0.31	0.72	-	1.06	-	0.99	0.57	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	39.23			11.79	0.21	3.64	-	0.32	0.67	0.62	0.9	1.66	0.6	0.67	-	0.07	0.37	0.36	12.74	0.31	0.72	-	1.06	-	0.99	0.57	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	39.23																																																																																				-			11.79	0.21	3.64	-	0.32	0.67	0.62	0.9	1.66	0.6	0.67	-	0.07	0.37	0.36	12.74	0.31	0.72	-	1.06	-	0.99	0.57	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	39.23
H1034_020_0	2007	4																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		953.74	16.91	835.22	2123.97	52.63	6.59	18284.59	207.91	182.75	1579.74	627.95	0	37.74	418.25	7172.25	10901.81	169.34	493.46	4225.11	13241	286.53	817.68	1953.49	3038	435.55	231.84	186.25	1.83	0	0	1229.55											200 per day days 1 - 6	200 per day days 1 - 6	75 per day days 8 - 100	0 copay	75 copay	10 coinsurance	Effective copay 0 or 10 coinsurance	50 copay	100 copay	Effective copay 0 or 20	Effective copay 0 or 50		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	25 copay	20 copay	0 copay	Effective copay 0 or 20	0 copay	Effective copay 0 or 20	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											141.67	141.28	56.9	0	75	0.1	0.41	50	100	4.3	11.92	0	20	9.93	0.7	15.74	25	20	0	1.14	0	16.55	3.5	0	0	0	0	0.5	0	0	0.03											11.26	0.2	3.96	-	0.33	0.66	0.63	0.87	1.52	0.57	0.62	-	0.06	0.35	0.42	14.3	0.35	0.82	-	1.26	-	1.13	0.57	-	-	-	-	0.91	-	-	0	-	-	-	-	-	-	-	-	-	-	40.79			11.26	0.2	3.96	-	0.33	0.66	0.63	0.87	1.52	0.57	0.62	-	0.06	0.35	0.42	14.3	0.35	0.82	-	1.26	-	1.13	0.57	-	-	-	-	0.91	-	-	0	-	-	-	-	-	-	-	-	-	-	40.79																																																																																				-			11.26	0.2	3.96	-	0.33	0.66	0.63	0.87	1.52	0.57	0.62	-	0.06	0.35	0.42	14.3	0.35	0.82	-	1.26	-	1.13	0.57	-	-	-	-	0.91	-	-	0	-	-	-	-	-	-	-	-	-	-	40.79
H1034_021_0	2007	4																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	Coin	O	O	O																																																				-		1270.73	23.51	915.55	2604.44	59.17	7.32	19211.38	218.42	181.74	1707.42	678.73	0	38.56	429.14	7902.37	11780.65	179.31	506.78	4603.48	14381.75	288.26	852.65	2264.15	3038	436.48	240.12	187.28	1.9	0	0	12029.18											90 per day day 1 - 6	90 per day day 1 - 6	50 per day days 8 - 100	0 copay	50 copay	10 coinsurance	0 copay or 10 coinsurance	50 copay	Effective copay 25 or 50	Effective copay 0 or 20	Effective copay 0 or 100		20 copay	Effective copay 0 or 20	Effective copay 0 to 25	Effective copay 0 to 25	20 copay	20 copay	0 copay	Effective copay 0 to 10	0 copay	Effective copay 0 or 10	3.50 copay	0 copay	0 copay	0 copay	0 copay	50 coinsurance			Effective copay 0 or 50											63.14	63.57	37.93	0	50	0.1	0.42	50	41.67	4.07	11.75	0	20	9.78	0.61	1.24	20	20	0	0.62	0	8.33	3.5	0	0	0	0	0.5	0	0	0											6.69	0.12	2.89	-	0.25	0.73	0.67	0.91	0.63	0.58	0.66	-	0.06	0.35	0.4	1.22	0.3	0.84	-	0.75	-	0.59	0.66	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	20.27			6.69	0.12	2.89	-	0.25	0.73	0.67	0.91	0.63	0.58	0.66	-	0.06	0.35	0.4	1.22	0.3	0.84	-	0.75	-	0.59	0.66	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	20.27																																																																																				-			6.69	0.12	2.89	-	0.25	0.73	0.67	0.91	0.63	0.58	0.66	-	0.06	0.35	0.4	1.22	0.3	0.84	-	0.75	-	0.59	0.66	-	-	-	-	0.95	-	-	0	-	-	-	-	-	-	-	-	-	-	20.27
H1034_801_0	2007	2																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.74	0.14	0	0	0.21	0.35	0.45	0.16	0.75	0.52	0.76	0	0.03	0.63	1.75	4.35	0.05	0.17	1.37	1.77	0.18	0.3																				29.66		1239.9	22.44	1074.69	2221.58	5.9	9.59	12.58	4.44	20.75	14.36	21.07	0	0.72	17.6	48.54	120.77	1.5	4.61	38.15	49.09	4.99	8.26	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits																				10.34	5.12	72.97	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.07	0.01	6.53	-	1.18	1.92	2.52	0.89	4.15	2.87	4.21	-	0.14	3.52	9.71	24.15	0.3	0.92	7.63	9.82	1	1.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.19	Medicare deductible		16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86																																																																																				-			16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86
H1034_802_0	2007	2																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.74	0.14	0	0	0.21	0.35	0.45	0.16	0.75	0.52	0.76	0	0.03	0.63	1.75	4.35	0.05	0.17	1.37	1.77	0.18	0.3																				29.66		1239.9	22.44	1074.69	2221.58	5.9	9.59	12.58	4.44	20.75	14.36	21.07	0	0.72	17.6	48.54	120.77	1.5	4.61	38.15	49.09	4.99	8.26	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits																				10.34	5.12	72.97	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.07	0.01	6.53	-	1.18	1.92	2.52	0.89	4.15	2.87	4.21	-	0.14	3.52	9.71	24.15	0.3	0.92	7.63	9.82	1	1.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.19	Medicare deductible		16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86																																																																																				-			16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86
H1034_803_0	2007	4																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.74	0.14	0	0	0.21	0.35	0.45	0.16	0.75	0.52	0.76	0	0.03	0.63	1.75	4.35	0.05	0.17	1.37	1.77	0.18	0.3																				29.66		1239.9	22.44	1074.69	2221.58	5.9	9.59	12.58	4.44	20.75	14.36	21.07	0	0.72	17.6	48.54	120.77	1.5	4.61	38.15	49.09	4.99	8.26	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits																				10.34	5.12	72.97	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.07	0.01	6.53	-	1.18	1.92	2.52	0.89	4.15	2.87	4.21	-	0.14	3.52	9.71	24.15	0.3	0.92	7.63	9.82	1	1.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.19	Medicare deductible		16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86																																																																																				-			16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86
H1034_804_0	2007	4																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.74	0.14	0	0	0.21	0.35	0.45	0.16	0.75	0.52	0.76	0	0.03	0.63	1.75	4.35	0.05	0.17	1.37	1.77	0.18	0.3																				29.66		1239.9	22.44	1074.69	2221.58	5.9	9.59	12.58	4.44	20.75	14.36	21.07	0	0.72	17.6	48.54	120.77	1.5	4.61	38.15	49.09	4.99	8.26	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits																				10.34	5.12	72.97	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.07	0.01	6.53	-	1.18	1.92	2.52	0.89	4.15	2.87	4.21	-	0.14	3.52	9.71	24.15	0.3	0.92	7.63	9.82	1	1.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.19	Medicare deductible		16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86																																																																																				-			16.8	0.15	6.53	-	1.39	2.26	2.97	1.05	4.9	3.39	4.97	-	0.17	4.15	11.46	28.5	0.35	1.09	9	11.58	1.18	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.86
H1035_002_0	2007	7																					3100											D	D	D		T	COIN	O	V	V		V	V		O	V	V	V	V	V	V	COIN			V	V	V	V															0	0	0		0	0	0	0	0		0	0		0	0	0	0	0	0	0	0			0	0	0	0															-		1427.03	40.96	589.04		125.4	8.26	1318.61	302.95	315.99		1138.61	18.42		724.73	2898.25	5656.68	134.49	729.57		6242.61	28.69			303.79	283.52																	PBP Line 1a: 200/day for days 1-3; 100/day for days 4-5; 0/day for days 6-90; 0/day for Lifetime Reserve days 1-60	PBP Line 1b: 200/day for days 1-3; 100/day for days 4-5; 0/day for days 6-90; 0/day for Lifetime Reserve days 1-60	PBP Line 2: 0/day for days 1-7; 50/day for days 8-100	PBP Line 6: 0 copay	PBP Line 10a: 100 per service	PBP Line 11a: 15 coinsurance per item	PBP Lines 11b and 11c: 15 coinsurance per item; 0 copay for Diabetes self-monitoring training; 10 copay for 50 test strips/sensors; 10 copay for lancets; 0 copay for glucometer.	PBP Lines 4a and 4b: 50 copay per ER visit; 30 copay per urgent care visit	PBP Lines 9a and 9b: 75-100 copay per hospital outpatient service/surgery as follows - 100 copay per cardiac catherization angioplasty endoscopy outpatient surgery and 23-hour observation stay; 75 copay per advanced imaging and nuclear study colonoscopy and flexible sigmoidoscopy. 75-100 copay per ASC service as follows - 100 copay per ASC service except 75 copay per advanced imaging and nuclear study colonoscopy and flexible sigmoidoscopy.	PBP Line 8a: 0 copay	PBP Line 8b: 0-75 copay. 75 copay per CT Scan MRI MRA PET Scan or Nuclear Study	PBP Lines 9a and 9b: 100 copay per 23-hour observation stay	PBP Line 12: 0 copay	PBP Lines 7h 8b and 9c: 20 copay per individual therapy visit 10 per group therapy visit 25 per individual therapy visit with a psychiatrist; 75 copay per PET Scan.	PBP Line 7a: 10 per visit	PBP Line 7d: 25 copay per visit	PBP Lines 7e and 7h: 20 copay per individual therapy visit 10 per group therapy visit 25 per individual therapy visit with a psychiatrist.	PBP Lines 7c and 7i: 15 copay per occupational therapy physical therapy speech therapy visit.	PBP Line 8b: 0 copay	PBP Lines 7b and 7f: 10 copay per chiropractic visit; 10 copay per podiatry visit	PBP Line 15: 25 coinsurance	PBP Lines 13a: 0 copay	PBP Line 10b: 0 copay if approved by FHCP	PBP Line 16a: 12 copay per visit	PBP Line 17a: 15 copay per visit with an optometrist; 25 copay per visit with an ophthalmologist	PBP Line 17b: 0 copay	PBP Line 18a: 0 copay per visit															108.57	95.04	17.86		100	0.09	12.98	46.14	95.39		37.43	100.32		2.54	10	19.37	22.41	15		1.41	0.15			12	14.62																	12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23	0	4.51	12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23	3100																																																																																			-			12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23
H1035_006_0	2007	6																					3100											D	D	D		T	COIN	O	V	V		V	V		O	V	V	V	V	V	V	COIN			V	V	V	V															0	0	0		0	0	0	0	0		0	0		0	0	0	0	0	0	0	0			0	0	0	0															-		1427.03	40.96	589.04		125.4	8.26	1318.61	302.95	315.99		1138.61	18.42		724.73	2898.25	5656.68	134.49	729.57		6242.61	28.69			303.79	283.52																	PBP Line 1a: 200/day for days 1-3; 100/day for days 4-5; 0/day for days 6-90; 0/day for Lifetime Reserve days 1-60	PBP Line 1b: 200/day for days 1-3; 100/day for days 4-5; 0/day for days 6-90; 0/day for Lifetime Reserve days 1-60	PBP Line 2: 0/day for days 1-7; 50/day for days 8-100	PBP Line 6: 0 copay	PBP Line 10a: 100 per service	PBP Line 11a: 15 coinsurance per item	PBP Lines 11b and 11c: 15 coinsurance per item; 0 copay for Diabetes self-monitoring training; 10 copay for 50 test strips/sensors; 10 copay for lancets; 0 copay for glucometer.	PBP Lines 4a and 4b: 50 copay per ER visit; 30 copay per urgent care visit	PBP Lines 9a and 9b: 75-100 copay per hospital outpatient service/surgery as follows - 100 copay per cardiac catherization angioplasty endoscopy outpatient surgery and 23-hour observation stay; 75 copay per advanced imaging and nuclear study colonoscopy and flexible sigmoidoscopy. 75-100 copay per ASC service as follows - 100 copay per ASC service except 75 copay per advanced imaging and nuclear study colonoscopy and flexible sigmoidoscopy.	PBP Line 8a: 0 copay	PBP Line 8b: 0-75 copay. 75 copay per CT Scan MRI MRA PET Scan or Nuclear Study	PBP Lines 9a and 9b: 100 copay per 23-hour observation stay	PBP Line 12: 0 copay	PBP Lines 7h 8b and 9c: 20 copay per individual therapy visit 10 per group therapy visit 25 per individual therapy visit with a psychiatrist; 75 copay per PET Scan.	PBP Line 7a: 10 per visit	PBP Line 7d: 25 copay per visit	PBP Lines 7e and 7h: 20 copay per individual therapy visit 10 per group therapy visit 25 per individual therapy visit with a psychiatrist.	PBP Lines 7c and 7i: 15 copay per occupational therapy physical therapy speech therapy visit.	PBP Line 8b: 0 copay	PBP Lines 7b and 7f: 10 copay per chiropractic visit; 10 copay per podiatry visit	PBP Line 15: 25 coinsurance	PBP Lines 13a: 0 copay	PBP Line 10b: 0 copay if approved by FHCP	PBP Line 16a: 12 copay per visit	PBP Line 17a: 15 copay per visit with an optometrist; 25 copay per visit with an ophthalmologist	PBP Line 17b: 0 copay	PBP Line 18a: 0 copay per visit															108.57	95.04	17.86		100	0.09	12.98	46.14	95.39		37.43	100.32		2.54	10	19.37	22.41	15		1.41	0.15			12	14.62																	12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23	0	4.51	12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23	3100																																																																																			-			12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23
H1035_007_0	2007	2																					3100											D	D	D		T	COIN	O	V	V		V	V		O	V	V	V	V	V	V	COIN			V	V	V	V															0	0	0		0	0	0	0	0		0	0		0	0	0	0	0	0	0	0			0	0	0	0															-		1427.03	40.96	589.04		125.4	8.26	1318.61	302.95	315.99		1138.61	18.42		724.73	2898.25	5656.68	134.49	729.57		6242.61	28.69			303.79	283.52																	PBP Line 1a: 200/day for days 1-3; 100/day for days 4-5; 0/day for days 6-90; 0/day for Lifetime Reserve days 1-60	PBP Line 1b: 200/day for days 1-3; 100/day for days 4-5; 0/day for days 6-90; 0/day for Lifetime Reserve days 1-60	PBP Line 2: 0/day for days 1-7; 50/day for days 8-100	PBP Line 6: 0 copay	PBP Line 10a: 100 per service	PBP Line 11a: 15 coinsurance per item	PBP Lines 11b and 11c: 15 coinsurance per item; 0 copay for Diabetes self-monitoring training; 10 copay for 50 test strips/sensors; 10 copay for lancets; 0 copay for glucometer.	PBP Lines 4a and 4b: 50 copay per ER visit; 30 copay per urgent care visit	PBP Lines 9a and 9b: 75-100 copay per hospital outpatient service/surgery as follows - 100 copay per cardiac catherization angioplasty endoscopy outpatient surgery and 23-hour observation stay; 75 copay per advanced imaging and nuclear study colonoscopy and flexible sigmoidoscopy. 75-100 copay per ASC service as follows - 100 copay per ASC service except 75 copay per advanced imaging and nuclear study colonoscopy and flexible sigmoidoscopy.	PBP Line 8a: 0 copay	PBP Line 8b: 0-75 copay. 75 copay per CT Scan MRI MRA PET Scan or Nuclear Study	PBP Lines 9a and 9b: 100 copay per 23-hour observation stay	PBP Line 12: 0 copay	PBP Lines 7h 8b and 9c: 20 copay per individual therapy visit 10 per group therapy visit 25 per individual therapy visit with a psychiatrist; 75 copay per PET Scan.	PBP Line 7a: 10 per visit	PBP Line 7d: 25 copay per visit	PBP Lines 7e and 7h: 20 copay per individual therapy visit 10 per group therapy visit 25 per individual therapy visit with a psychiatrist.	PBP Lines 7c and 7i: 15 copay per occupational therapy physical therapy speech therapy visit.	PBP Line 8b: 0 copay	PBP Lines 7b and 7f: 10 copay per chiropractic visit; 10 copay per podiatry visit	PBP Line 15: 25 coinsurance	PBP Lines 13a: 0 copay	PBP Line 10b: 0 copay if approved by FHCP	PBP Line 16a: 12 copay per visit	PBP Line 17a: 15 copay per visit with an optometrist; 25 copay per visit with an ophthalmologist	PBP Line 17b: 0 copay	PBP Line 18a: 0 copay per visit															108.57	95.04	17.86		100	0.09	12.98	46.14	95.39		37.43	100.32		2.54	10	19.37	22.41	15		1.41	0.15			12	14.62																	12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23	0	4.51	12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23	3100																																																																																			-			12.91	0.32	0.88	-	1.05	0.76	1.43	1.16	2.51	-	3.55	0.15	-	0.15	2.42	9.13	0.25	0.91	-	0.73	4.25	-	-	0.3	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.23
H1036_011_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S											A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1698.27	16.48	1816.67	3318.72	367.92	0.91	20.49	312.58	227.81	155.53	106.04	7.07	181.26	60.09	7884.34	6060.99			279.02		212.29											21.32	0.87	10.97								155/day (1-10)	150/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	125/ Trip	0 - 20 Coins	0/ Procedure	20-50/ Visit	100-200/ Visit	0-25/ Visit	0-75/ Visit	200/ Visit	0/ Procedure	25-75/ Visit	0/ Visit	30/ Visit			25/ Visit		0/ Scripts											1500/admit	150/day (1-7)	0 Coins								133.81	116.94	29.09	0	125	0	0	44	133	19.32	11.67	200	0	31.76	0	30			25		0											1500	116.94	0								18.94	0.16	4.4	-	3.83	0	-	1.15	2.52	0.25	0.1	0.12	-	0.16	-	15.15	-	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	2.67	0.01	-	-	-	-	-	-	-	-	50.05	0	0	18.94	0.16	4.4	-	3.83	0	-	1.15	2.52	0.25	0.1	0.12	-	0.16	-	15.15	-	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	2.67	0.01	-	-	-	-	-	-	-	-	50.05																																																																																				-			18.94	0.16	4.4	-	3.83	0	-	1.15	2.52	0.25	0.1	0.12	-	0.16	-	15.15	-	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	2.67	0.01	-	-	-	-	-	-	-	-	50.05
H1036_025_0	2007	3	s.	t.									Inpatient Facility	Professional									3100	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1142.93	13.64	1227.83	2796.55	171.26	1.03	42.22	194.86	178.94	87.81	59.87	3.99	561.5	33.93	8192.57	4263.57			249.22		119.86											0.72	5.63									110/day (1-7)	110/day (1-7)	0/day (1-9) 50/day (10-100)	0/Visit	100/ Trip	0 - 20 Coins	0/ Procedure	20-50/ Visit	100/ Visit	0-100/ Visit	0-100/ Visit	100/ Visit	100/ Procedure	25-100/ Visit	0/ Visit	25/ Visit			50/ Visit		0/ Scripts											110/day (1-7)	10 Coins									73.47	73.47	9.52	0	85.68	0	0	37.7	85.68	66.21	18.56	85.68	85.68	32.76	0	21.42			42.84		0											73.47	0.09									7	0.08	0.97	-	1.22	0	-	0.61	1.28	0.48	0.09	0.03	4.01	0.09	-	7.61	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	24.87	0	4.16	7	0.08	0.97	-	1.22	0	-	0.61	1.28	0.48	0.09	0.03	4.01	0.09	-	7.61	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	24.87	3100																																																																																			-			7	0.08	0.97	-	1.22	0	-	0.61	1.28	0.48	0.09	0.03	4.01	0.09	-	7.61	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	24.87
H1036_034_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S				Coin							A	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0							0	0	0								-		1669.33	15.27	1440.12	2625.54	365.41	0.43	28.09	199.96	182.87	149.33	101.82	6.79	364.99	57.7	7611.37	5365.11			259.63		203.84				0							17.72	0.8	4152.06								105/day (1-10)	105/day (1-10)	0/day (1-6) 75/day (7-100)	0/Visit	100/ Trip	0 - 20 Coins	0/ Procedure	20-50/ Visit	75-100/ Visit	0-25/ Visit	0-50/ Visit	150/ Visit	0/ Procedure	10-50/ Visit	0/ Visit	10/ Visit			25/ Visit		0/ Scripts				See PBP for details							1500/admit	105/day (1-10)	0/Procedure								90.65	90.65	21.82	0	100	0	0	44	83.25	19.32	9.17	150	0	15.29	0	10			25		0				0							1500	90.65	0								12.61	0.12	2.62	-	3.05	0	-	0.73	1.27	0.24	0.08	0.08	-	0.07	-	4.47	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	2.21	0.01	-	-	-	-	-	-	-	-	28.1	0	0	12.61	0.12	2.62	-	3.05	0	-	0.73	1.27	0.24	0.08	0.08	-	0.07	-	4.47	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	2.21	0.01	-	-	-	-	-	-	-	-	28.1																																																																																				-			12.61	0.12	2.62	-	3.05	0	-	0.73	1.27	0.24	0.08	0.08	-	0.07	-	4.47	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	2.21	0.01	-	-	-	-	-	-	-	-	28.1
H1036_035_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S			Coin	Coin		Coin					A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0	0								-		1492.35	16.9	2296.14	2900.69	311.24	0.6	0.05	272.47	224.73	235.81	160.78	10.72	253.46	91.11	8670.87	6118.01			295.9		321.88			0	0		0					19.14	0.89	7.03								155/day (1-10)	150/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	0 - 20 Coins	0 Coins	20-50/ Visit	125-150/ Visit	0-25/ Visit	0-75/ Visit	150/ Visit	0/ Procedure	10-75/ Visit	0/ Visit	30/ Visit			50/ Visit		0/ Scripts			See PBP for details	See PBP for details		See PBP for details					1500/admit	150/day (1-7)	0 Coins								133.81	116.94	29.09	0	100	0	0	44	133.25	19.32	10.17	150	0	31.76	0	30			50		0			0	0		0					1500	116.94	0								16.64	0.16	5.57	-	2.59	0	-	1	2.5	0.38	0.14	0.13	-	0.24	-	15.3	-	-	1.23	-	-	-	-	-	-	-	-	-	-	-	-	2.39	0.01	-	-	-	-	-	-	-	-	48.28	0	0	16.64	0.16	5.57	-	2.59	0	-	1	2.5	0.38	0.14	0.13	-	0.24	-	15.3	-	-	1.23	-	-	-	-	-	-	-	-	-	-	-	-	2.39	0.01	-	-	-	-	-	-	-	-	48.28																																																																																				-			16.64	0.16	5.57	-	2.59	0	-	1	2.5	0.38	0.14	0.13	-	0.24	-	15.3	-	-	1.23	-	-	-	-	-	-	-	-	-	-	-	-	2.39	0.01	-	-	-	-	-	-	-	-	48.28
H1036_037_0	2007	3	s.	t.									Inpatient Facility	Professional										Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1602.46	183.14	1518.11	2486.9	379.43	0.45	0.03	590.52	148.16	471.91	321.75	21.45	259.72	182.33	11830.83	4513.11			327.01		644.15											9.64	2.1									115/day (1-10)	115/day (1-10)	0/day (1-13) 100/day (14-100)	0/Visit	125/ Trip	20 Coins	20 Coins	30-50/ Visit	100/ Visit	0/ Visit	0-100/ Visit	50/ Visit	0/ Procedure	0-100/ Visit	0/ Visit	30/ Visit			100/ Visit		0/ Scripts											115/day (1-10)	20 Coins									99.28	99.28	15.73	0	125	0.2	0.2	46	100	0	48.33	50	0	24.71	0	30			100		0											99.28	0.2									13.26	1.52	1.99	-	3.95	0.09	0.01	2.26	1.23	-	1.3	0.09	-	0.38	-	11.28	-	-	2.73	-	-	-	-	-	-	-	-	-	-	-	-	0.08	0.42	-	-	-	-	-	-	-	-	40.58	0	0	13.26	1.52	1.99	-	3.95	0.09	0.01	2.26	1.23	-	1.3	0.09	-	0.38	-	11.28	-	-	2.73	-	-	-	-	-	-	-	-	-	-	-	-	0.08	0.42	-	-	-	-	-	-	-	-	40.58																																																																																				-			13.26	1.52	1.99	-	3.95	0.09	0.01	2.26	1.23	-	1.3	0.09	-	0.38	-	11.28	-	-	2.73	-	-	-	-	-	-	-	-	-	-	-	-	0.08	0.42	-	-	-	-	-	-	-	-	40.58
H1036_040_0	2007	5	s.	t.									Inpatient Facility	Professional									3100	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1156.93	13.81	1242.88	2830.83	173.36	1.04	42.74	197.25	181.13	88.89	60.61	4.04	568.39	34.34	8292.99	4315.82			252.28		121.33											0.73	5.69									110/day (1-7)	110/day (1-7)	0/day (1-9) 100/day (10-100)	0/Visit	100/ Trip	0 - 20 Coins	0/ Procedure	20-50/ Visit	100/ Visit	0-100/ Visit	0-100/ Visit	100/ Visit	100/ Procedure	25-100/ Visit	0/ Visit	25/ Visit			50/ Visit		0/ Scripts											110/day (1-7)	10 Coins									72.78	72.78	18.87	0	84.87	0	0	37.34	84.87	65.58	18.39	84.87	84.87	32.45	0	21.22			42.43		0											72.78	0.08									7.02	0.08	1.95	-	1.23	0	-	0.61	1.28	0.49	0.09	0.03	4.02	0.09	-	7.63	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	25.91	0	4.62	7.02	0.08	1.95	-	1.23	0	-	0.61	1.28	0.49	0.09	0.03	4.02	0.09	-	7.63	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	25.91	3100																																																																																			-			7.02	0.08	1.95	-	1.23	0	-	0.61	1.28	0.49	0.09	0.03	4.02	0.09	-	7.63	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	25.91
H1036_044_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1414.16	7.87	1303.47	2029.45	158.43	0.2	0.02	342.33	244.24	510.94	348.37	23.22	242.78	197.41	8690.52	4801.07			269.94		6.74											74.43	0.41	1.62								155/day (1-10)	150/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	150/ Visit	0/ Visit	0-25/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	10/ Visit	30/ Visit			30/ Visit		20 Coins											155/day (1-10)	150/day (1-7)	20 Coins								133.81	116.94	29.09	0	100	0.2	0.2	46	150	0	5	100	0	37.94	10	30			30		0.2											133.81	116.94	0.2								15.77	0.08	3.16	-	1.32	0.04	0	1.31	3.05	-	0.15	0.19	-	0.62	7.24	12	-	-	0.67	-	1.35	-	-	-	-	-	-	-	-	-	-	0.83	0	0.32	-	-	-	-	-	-	-	48.12	0	0	15.77	0.08	3.16	-	1.32	0.04	0	1.31	3.05	-	0.15	0.19	-	0.62	7.24	12	-	-	0.67	-	1.35	-	-	-	-	-	-	-	-	-	-	0.83	0	0.32	-	-	-	-	-	-	-	48.12																																																																																				-			15.77	0.08	3.16	-	1.32	0.04	0	1.31	3.05	-	0.15	0.19	-	0.62	7.24	12	-	-	0.67	-	1.35	-	-	-	-	-	-	-	-	-	-	0.83	0	0.32	-	-	-	-	-	-	-	48.12
H1036_047_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1282.74	14.06	1173.58	2626.27	210.98	0.14	0.01	283.45	267	176.76	120.52	8.03	256.94	68.29	5991	5259.81			225.11		241.28											67.51	0.74	6.03								155/day (1-10)	150/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	150/ Trip	0 - 20 Coins	0 Coins	40-50/ Visit	150/ Visit	0-100/ Visit	0-150/ Visit	150/ Visit	100/ Procedure	25-150/ Visit	0/ Visit	25/ Visit			25/ Visit		0/ Scripts											155/day (1-10)	150/day (1-7)	20 Coins								133.81	116.94	29.09	0	150	0	0	48	150	77.27	24.17	150	100	38.24	0	25			25		0											133.81	116.94	0.2								14.3	0.14	2.84	-	2.64	0	-	1.13	3.34	1.14	0.24	0.1	2.14	0.22	-	10.96	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	0.75	0.01	1.21	-	-	-	-	-	-	-	41.63	0	0	14.3	0.14	2.84	-	2.64	0	-	1.13	3.34	1.14	0.24	0.1	2.14	0.22	-	10.96	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	0.75	0.01	1.21	-	-	-	-	-	-	-	41.63																																																																																				-			14.3	0.14	2.84	-	2.64	0	-	1.13	3.34	1.14	0.24	0.1	2.14	0.22	-	10.96	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	0.75	0.01	1.21	-	-	-	-	-	-	-	41.63
H1036_052_0	2007	3	s.	t.									Inpatient Facility	Professional									3100	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1136.83	13.57	1221.27	2781.62	170.35	1.02	42	193.82	177.98	87.34	59.55	3.97	558.51	33.75	8148.84	4240.81			247.89		119.22											0.71	5.55									110/day (1-7)	110/day (1-7)	0/day (1-9) 100/day (10-100)	0/Visit	100/ Trip	0 - 20 Coins	0/ Procedure	15-50/ Visit	100/ Visit	0-50/ Visit	0-50/ Visit	100/ Visit	50/ Procedure	25-50/ Visit	0/ Visit	25/ Visit			50/ Visit		0/ Scripts											110/day (1-7)	10 Coins									74.36	74.36	19.27	0	86.71	0	0	37.28	86.71	33.5	11.56	86.71	43.35	25.5	0	21.68			43.35		0											74.36	0.09									7.04	0.08	1.96	-	1.23	0	-	0.6	1.29	0.24	0.06	0.03	2.02	0.07	-	7.66	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	23.67	0	3.63	7.04	0.08	1.96	-	1.23	0	-	0.6	1.29	0.24	0.06	0.03	2.02	0.07	-	7.66	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	23.67	3100																																																																																			-			7.04	0.08	1.96	-	1.23	0	-	0.6	1.29	0.24	0.06	0.03	2.02	0.07	-	7.66	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	0	0.48	-	-	-	-	-	-	-	-	23.67
H1036_053_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			Coin		Coin			Coin	Coin		Coin					A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0	0								-		1564.2	15.18	1673.26	3056.72	338.87	0.8	18.87	287.91	209.82	143.25	97.67	6.51	166.95	55.35	7261.91	5582.51			2.72		4.75			0	0		0					19.64	0.8	9.64								0/day (-)	0/day (-)	0/day (-) 0/day (-)	0/Visit	100/ Trip	0 - 20 Coins	0/ Procedure	0-50/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0 Coins		20 Coins			See PBP for details	See PBP for details		See PBP for details					1500/admit	0/day	0 Coins								0	0	0	0	100	0	0	40	0	0	0	0	0	0	0	0			0		0.2			0	0		0					1500	0	0								-	-	-	-	2.82	0	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	0.95	-	-	-	-	-	-	-	-	-	-	2.45	-	-	-	-	-	-	-	-	-	7.19	0	0	-	-	-	-	2.82	0	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	0.95	-	-	-	-	-	-	-	-	-	-	2.45	-	-	-	-	-	-	-	-	-	7.19																																																																																				-			-	-	-	-	2.82	0	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	0.95	-	-	-	-	-	-	-	-	-	-	2.45	-	-	-	-	-	-	-	-	-	7.19
H1036_054_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S				Coin		Coin					A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0	0								-		1828.41	16.72	1577.35	2875.74	400.23	0.47	30.77	219.02	200.3	163.56	111.52	7.43	399.77	63.2	8336.67	5876.36			284.37		223.27				0		0					19.41	0.88	4.64								0/day (1-7)	0/day (1-7)	0/day (1-6) 25/day (7-100)	0/Visit	50/ Trip	0 - 20 Coins	0/ Procedure	20-50/ Visit	25-50/ Visit	0-20/ Visit	0-25/ Visit	0/ Visit	0/ Procedure	0-25/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts				See PBP for details		See PBP for details					1500/admit	0/day	0 Coins								0	0	7.27	0	50	0	0	44	33.25	15.45	3.83	0	0	3.53	0	0			0		0				0		0					1500	0	0								-	-	0.96	-	1.67	0	-	0.8	0.55	0.21	0.04	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.43	-	-	-	-	-	-	-	-	-	6.67	0	0	-	-	0.96	-	1.67	0	-	0.8	0.55	0.21	0.04	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.43	-	-	-	-	-	-	-	-	-	6.67																																																																																				-			-	-	0.96	-	1.67	0	-	0.8	0.55	0.21	0.04	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.43	-	-	-	-	-	-	-	-	-	6.67
H1036_056_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin				Coin		Coin					D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0	0								-		1303.9	7.25	1201.84	1871.22	146.08	0.18	0.01	315.64	225.19	471.11	321.21	21.41	223.85	182.02	8012.94	4426.75			248.89		5.84				0		0					68.63	0.38	1.4								50/day (1-7)	50/day (1-7)	0/day (1-6) 50/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	50/ Visit	0/ Visit	0-50/ Visit	50/ Visit	0/ Procedure	20-50/ Visit	5/ Visit	20/ Visit			100/ Visit		20 Coins				See PBP for details		See PBP for details					50/day (1-7)	50/day (1-7)	20 Coins								38.98	38.98	14.55	0	100	0.2	0.2	46	50	0	10	50	0	23.53	5	20			100		0.2				0		0					38.98	38.98	0.2								4.24	0.02	1.46	-	1.22	0.04	0	1.21	0.94	-	0.27	0.09	-	0.36	3.34	7.38	-	-	2.07	-	1.17	-	-	-	-	-	-	-	-	-	-	0.22	0	0.28	-	-	-	-	-	-	-	24.3	0	0	4.24	0.02	1.46	-	1.22	0.04	0	1.21	0.94	-	0.27	0.09	-	0.36	3.34	7.38	-	-	2.07	-	1.17	-	-	-	-	-	-	-	-	-	-	0.22	0	0.28	-	-	-	-	-	-	-	24.3																																																																																				-			4.24	0.02	1.46	-	1.22	0.04	0	1.21	0.94	-	0.27	0.09	-	0.36	3.34	7.38	-	-	2.07	-	1.17	-	-	-	-	-	-	-	-	-	-	0.22	0	0.28	-	-	-	-	-	-	-	24.3
H1036_062_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S						Coin					A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0						0					0	0	0								-		1445.4	16.36	2223.9	2809.43	301.45	0.6	0.04	263.9	217.66	228.39	155.72	10.38	245.48	88.24	8398.07	5925.52			286.59		311.76						0					18.54	0.86	6.97								55/day (1-10)	55/day (1-10)	0/day (1-6) 50/day (7-100)	0/Visit	100/ Trip	0 - 20 Coins	0 Coins	30-50/ Visit	50-100/ Visit	0-20/ Visit	0-50/ Visit	100/ Visit	20/ Procedure	0-50/ Visit	0/ Visit	10/ Visit			0/ Visit		0/ Scripts						See PBP for details					1500/admit	55/day (1-10)	0 Coins								47.48	47.48	14.55	0	100	0	0	46	66.5	15.45	6.33	100	20	11.76	0	10			0		0						0					1500	47.48	0								5.72	0.06	2.7	-	2.51	0	-	1.01	1.21	0.29	0.08	0.09	0.41	0.09	-	4.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.32	0	-	-	-	-	-	-	-	-	21.43	0	0	5.72	0.06	2.7	-	2.51	0	-	1.01	1.21	0.29	0.08	0.09	0.41	0.09	-	4.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.32	0	-	-	-	-	-	-	-	-	21.43																																																																																				-			5.72	0.06	2.7	-	2.51	0	-	1.01	1.21	0.29	0.08	0.09	0.41	0.09	-	4.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.32	0	-	-	-	-	-	-	-	-	21.43
H1036_063_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin					A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0	0								-		1417.72	16.05	2181.32	2755.65	295.68	0.55	0.04	258.85	213.5	224.02	152.74	10.18	240.79	86.55	8237.3	5812.09			281.1		6.24			0	0		0					18.18	0.84	6.45								50/day (1-7)	50/day (1-7)	0/day (1-6) 50/day (7-100)	0/Visit	100/ Trip	0 - 20 Coins	0 Coins	0-50/ Visit	0/ Visit	0/ Visit	0/ Visit	50/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		20 Coins			See PBP for details	See PBP for details		See PBP for details					1500/admit	50/day (1-7)	0 Coins								64.63	55.73	14.54	0	100	0	0	40	0	0	0	50	0	0	0	0			0		0.2			0	0		0					1500	55.73	0								7.64	0.07	2.64	-	2.46	0	-	0.86	-	-	-	0.04	-	-	-	-	-	-	-	-	1.25	-	-	-	-	-	-	-	-	-	-	2.27	0	-	-	-	-	-	-	-	-	17.25	0	0	7.64	0.07	2.64	-	2.46	0	-	0.86	-	-	-	0.04	-	-	-	-	-	-	-	-	1.25	-	-	-	-	-	-	-	-	-	-	2.27	0	-	-	-	-	-	-	-	-	17.25																																																																																				-			7.64	0.07	2.64	-	2.46	0	-	0.86	-	-	-	0.04	-	-	-	-	-	-	-	-	1.25	-	-	-	-	-	-	-	-	-	-	2.27	0	-	-	-	-	-	-	-	-	17.25
H1036_065_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S			Coin			Coin					A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0			0					0	0	0								-		1647.49	15.99	1762.36	3219.49	356.92	0.87	0.07	303.24	221	150.88	102.87	6.86	175.84	58.29	7648.61	5879.78			270.68		205.95			0			0					20.68	0.84	10.48								25/day (1-10)	25/day (1-10)	0/day (1-6) 25/day (7-100)	0/Visit	100/ Trip	0 - 20 Coins	0 Coins	20-50/ Visit	50-100/ Visit	0-20/ Visit	0-25/ Visit	50/ Visit	0/ Procedure	5-25/ Visit	0/ Visit	5/ Visit			25/ Visit		0/ Scripts			See PBP for details			See PBP for details					1500/admit	25/day (1-10)	0 Coins								21.58	21.58	7.27	0	100	0	0	44	66.5	15.45	6.33	50	0	7.65	0	5			25		0			0			0					1500	21.58	0								2.96	0.03	1.07	-	2.97	0	-	1.11	1.22	0.19	0.05	0.03	-	0.04	-	2.45	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	2.59	0	-	-	-	-	-	-	-	-	15.29	0	0	2.96	0.03	1.07	-	2.97	0	-	1.11	1.22	0.19	0.05	0.03	-	0.04	-	2.45	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	2.59	0	-	-	-	-	-	-	-	-	15.29																																																																																				-			2.96	0.03	1.07	-	2.97	0	-	1.11	1.22	0.19	0.05	0.03	-	0.04	-	2.45	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	2.59	0	-	-	-	-	-	-	-	-	15.29
H1036_067_0	2007	5	s.	t.									Inpatient Facility	Professional									2900	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S				Coin		Coin					D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0									-		1121.21	13.38	1204.5	2743.42	168.01	0.95	0.07	191.16	175.54	86.14	58.73	3.92	550.84	33.28	8036.93	4182.57			244.49		117.59				0		0					0.7	5.18									50/day (1-5)	50/day (1-5)	0/day (1-9) 50/day (10-100)	0/Visit	100/ Trip	0 - 20 Coins	0 Coins	10-50/ Visit	50/ Visit	0-50/ Visit	0-50/ Visit	50/ Visit	50/ Procedure	10-50/ Visit	0/ Visit	10/ Visit			50/ Visit		0/ Scripts				See PBP for details		See PBP for details					50/day (1-5)	10 Coins									31.83	31.83	10.4	0	93.6	0	0	39.31	46.8	36.17	12.48	46.8	46.8	15.97	0	9.36			46.8		0				0		0					31.83	0.09									2.97	0.04	1.04	-	1.31	0	-	0.63	0.68	0.26	0.06	0.02	2.15	0.04	-	3.26	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	0	0.49	-	-	-	-	-	-	-	-	13.91	0	0.95	2.97	0.04	1.04	-	1.31	0	-	0.63	0.68	0.26	0.06	0.02	2.15	0.04	-	3.26	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	0	0.49	-	-	-	-	-	-	-	-	13.91	2900																																																																																			-			2.97	0.04	1.04	-	1.31	0	-	0.63	0.68	0.26	0.06	0.02	2.15	0.04	-	3.26	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	0	0.49	-	-	-	-	-	-	-	-	13.91
H1036_068_0	2007	5	s.	t.									Inpatient Facility	Professional										Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1485.33	169.75	1407.15	2305.12	351.7	0.39	0.03	536.41	137.33	437.41	298.24	19.88	240.74	169	10966.08	4183.23			303.11		597.07											8.93	1.8									105/day (1-5)	105/day (1-5)	0/day (1-4) 75/day (5-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100/ Visit	0-100/ Visit	0-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	5/ Visit	35/ Visit			75/ Visit		0/ Scripts											105/day (1-5)	20 Coins									71.42	71.42	26.34	0	100	0.2	0.2	47.24	100	77.27	24.17	100	0	42.06	5	35			75		0											71.42	0.2									8.84	1.01	3.09	-	2.93	0.08	0.01	2.11	1.14	2.82	0.6	0.17	-	0.59	4.57	12.2	-	-	1.89	-	-	-	-	-	-	-	-	-	-	-	-	0.05	0.36	-	-	-	-	-	-	-	-	42.46	0	0	8.84	1.01	3.09	-	2.93	0.08	0.01	2.11	1.14	2.82	0.6	0.17	-	0.59	4.57	12.2	-	-	1.89	-	-	-	-	-	-	-	-	-	-	-	-	0.05	0.36	-	-	-	-	-	-	-	-	42.46																																																																																				-			8.84	1.01	3.09	-	2.93	0.08	0.01	2.11	1.14	2.82	0.6	0.17	-	0.59	4.57	12.2	-	-	1.89	-	-	-	-	-	-	-	-	-	-	-	-	0.05	0.36	-	-	-	-	-	-	-	-	42.46
H1036_074_0	2007	4	s.	t.									Inpatient Facility	Professional									2900	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1122.11	13.39	1205.46	2745.62	168.14	0.95	41.45	191.31	175.68	86.21	58.78	3.92	551.28	33.31	8043.37	4185.92			244.68		117.68											0.7	5.2									60/day (1-5)	60/day (1-5)	0/day (1-9) 50/day (10-100)	0/Visit	100/ Trip	0 - 20 Coins	0/ Procedure	20-50/ Visit	100/ Visit	0-100/ Visit	0-100/ Visit	50/ Visit	100/ Procedure	20-100/ Visit	0/ Visit	20/ Visit			50/ Visit		0/ Scripts											60/day (1-5)	10 Coins									36.18	36.18	9.85	0	88.64	0	0	39	88.64	68.49	19.21	44.32	88.64	30.24	0	17.73			44.32		0											36.18	0.09									3.38	0.04	0.99	-	1.24	0	-	0.62	1.3	0.49	0.09	0.01	4.07	0.08	-	6.18	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	0	0.46	-	-	-	-	-	-	-	-	19.89	0	2.55	3.38	0.04	0.99	-	1.24	0	-	0.62	1.3	0.49	0.09	0.01	4.07	0.08	-	6.18	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	0	0.46	-	-	-	-	-	-	-	-	19.89	2900																																																																																			-			3.38	0.04	0.99	-	1.24	0	-	0.62	1.3	0.49	0.09	0.01	4.07	0.08	-	6.18	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	0	0.46	-	-	-	-	-	-	-	-	19.89
H1036_077_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S											A	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1659.32	15.17	1431.48	2609.79	363.21	0.42	27.92	198.76	181.77	148.44	101.21	6.75	362.8	57.35	7565.71	5332.93			258.08		202.62											17.61	0.8	4127.16								0/day (-)	0/day (-)	0/day (-) 0/day (-)	0/Visit	0/ Trip	0 Coins	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts											1500/admit	0/day	0/Procedure								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											1500	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.2	-	-	-	-	-	-	-	-	-	2.2	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.2	-	-	-	-	-	-	-	-	-	2.2																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.2	-	-	-	-	-	-	-	-	-	2.2
H1036_081_0	2007	5	s.	t.									Inpatient Facility	Professional										Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1638.03	187.2	1551.81	2542.1	387.85	0.48	0.04	603.63	151.44	482.38	328.9	21.93	265.49	186.38	12093.46	4613.3			334.27		658.45											9.85	2.24									185/day (1-10)	175/day (1-7)	0/day (1-6) 125/day (7-100)	0/Visit	150/ Trip	20 Coins	20 Coins	30-50/ Visit	150-200/ Visit	0-50/ Visit	0-150/ Visit	175/ Visit	50/ Procedure	35-150/ Visit	5/ Visit	35/ Visit			75/ Visit		0/ Scripts											175/day (1-7)	20 Coins									159.71	136.43	36.36	0	150	0.2	0.2	46	166.5	38.64	42.5	175	50	37.65	5	35			75		0											136.43	0.2									21.8	2.13	4.7	-	4.85	0.1	0.01	2.31	2.1	1.55	1.16	0.32	1.11	0.58	5.04	13.46	-	-	2.09	-	-	-	-	-	-	-	-	-	-	-	-	0.11	0.45	-	-	-	-	-	-	-	-	63.87	0	0	21.8	2.13	4.7	-	4.85	0.1	0.01	2.31	2.1	1.55	1.16	0.32	1.11	0.58	5.04	13.46	-	-	2.09	-	-	-	-	-	-	-	-	-	-	-	-	0.11	0.45	-	-	-	-	-	-	-	-	63.87																																																																																				-			21.8	2.13	4.7	-	4.85	0.1	0.01	2.31	2.1	1.55	1.16	0.32	1.11	0.58	5.04	13.46	-	-	2.09	-	-	-	-	-	-	-	-	-	-	-	-	0.11	0.45	-	-	-	-	-	-	-	-	63.87
H1036_099_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S						Coin					D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0						0					0	0	0								-		1661.09	9.24	1531.07	2383.81	186.09	0.25	0.02	402.11	286.88	600.16	409.2	27.28	285.17	231.88	10207.96	5639.38			317.07		819.22						0					87.43	0.49	1.95								0/day (1-5)	0/day (1-5)	0/day (1-6) 0/day (7-100)	0/Visit	0/ Trip	0 Coins	0 Coins	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts						See PBP for details					0/day (1-5)	0/day (1-5)	0 Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0						0					0	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1036_100_0	2007	7	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1533.68	16.81	1403.16	3140.04	252.25	0.18	0.01	338.9	319.23	211.34	144.1	9.61	307.21	81.65	7163.01	6288.77			269.14		288.48											80.72	0.88	7.44								0/day (1-10)	0/day (1-10)	0/day (1-7) 0/day (8-100)	0/Visit	0/ Trip	0 Coins	0 Coins	0-20/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts											0/day (1-10)	0/day (1-10)	0 Coins								0	0	0	0	0	0	0	16	0	0	0	0	0	0	0	0			0		0											0	0	0								-	-	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.45	0	0	-	-	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.45																																																																																				-			-	-	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.45
H1036_101_0	2007	7	s.	t.									Inpatient Facility	Professional										Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S											D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1989.5	227.37	1884.78	3087.55	471.07	0.61	0.05	733.15	183.94	585.88	399.47	26.63	322.45	226.36	14688.29	5603.15			405.99		799.73											11.97	2.84									0/day (1-7)	0/day (1-7)	0/day (1-6) 0/day (7-100)	0/Visit	0/ Trip	0 Coins	0 Coins	0-10/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts											0/day (1-7)	0 Coins									0	0	0	0	0	0	0	8	0	0	0	0	0	0	0	0			0		0											0	0									-	-	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.49	0	0	-	-	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.49																																																																																				-			-	-	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.49
H1036_102_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	P	V	V	V	V	V	P	V	V	V			V		S				Coin							D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0							0	0	0								-		1336.19	15.95	1435.45	3269.45	200.22	1.27	49.36	227.81	209.2	102.66	70	4.67	656.45	39.66	9577.94	4984.54			291.37		140.13				0							70.33	0.84	6.91								0/day (1-5)	0/day (1-5)	0/day (1-9) 0/day (10-100)	0/Visit	0/ Trip	0 Coins	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts				See PBP for details							1500/day (-)	0/day (1-5)	0 Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0							1500	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.79	-	-	-	-	-	-	-	-	-	8.79	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.79	-	-	-	-	-	-	-	-	-	8.79																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.79	-	-	-	-	-	-	-	-	-	8.79
H1036_103_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S				Coin		Coin					A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0	0								-		1896.8	18.41	2029.05	3706.7	410.93	1.03	0.08	349.13	254.44	173.71	118.44	7.9	202.45	67.11	8806.07	6769.56			311.64		237.11				0		0					23.81	0.97	12.38								0/day (1-7)	0/day (1-7)	0/day (1-6) 0/day (7-100)	0/Visit	0/ Trip	0 Coins	0 Coins	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts				See PBP for details		See PBP for details					1500/admit	0/day	0 Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					1500	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98	-	-	-	-	-	-	-	-	-	2.98	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98	-	-	-	-	-	-	-	-	-	2.98																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98	-	-	-	-	-	-	-	-	-	2.98
H1036_104_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		S			Coin								A	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1681.91	19.04	2587.8	3269.14	350.78	0.71	0.05	307.08	253.28	265.76	181.2	12.08	285.65	102.68	9772.26	6895.13			333.48		362.77			0								21.57	1	8.32								0/day (1-7)	0/day (1-7)	0/day (1-6) 0/day (7-100)	0/Visit	0/ Trip	0 Coins	0 Coins	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts			See PBP for details								1500/admit	0/day (1-7)	0 Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								1500	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.7	-	-	-	-	-	-	-	-	-	2.7	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.7	-	-	-	-	-	-	-	-	-	2.7																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.7	-	-	-	-	-	-	-	-	-	2.7
H1036_801_0	2007	5	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0									-		1501.72	14.57	1606.43	2934.64	325.34	0.75	0.06	270.88	201.44	137.53	21.88	6.25	160.28	53.14	6971.87	5359.54			246.73		4.45			0	0		0					79.04	0.77									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52	0	0	25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52																																																																																				-			25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52
H1036_806_0	2007	6	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1501.7	14.57	1606.4	2934.6	325.34	0.75	0.06	270.88	201.44	137.52	21.88	6.25	160.28	53.13	6971.77	5359.47			246.72		4.45											79.04	0.77									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52	0	0	25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52																																																																																				-			25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52
H1036_807_0	2007	5	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0									-		1501.72	14.57	1606.43	2934.64	325.34	0.75	0.06	270.88	201.44	137.53	21.88	6.25	160.28	53.14	6971.87	5359.54			246.73		4.45			0	0		0					79.04	0.77									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52	0	0	25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52																																																																																				-			25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52
H1036_808_0	2007	6	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1501.7	14.57	1606.4	2934.6	325.34	0.75	0.06	270.88	201.44	137.52	21.88	6.25	160.28	53.13	6971.77	5359.47			246.72		4.45											79.04	0.77									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52	0	0	25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52																																																																																				-			25.54	0.25	1.47	-	2.71	0.15	0.01	1.07	3.36	0.98	0.15	0.05	-	0.21	11.62	15.63	-	-	3.08	-	0.89	-	-	-	-	-	-	-	-	-	-	1.34	0.01	-	-	-	-	-	-	-	-	68.52
H1045_001_0	2007	3																																A	A	D	V	T	O	O	V	V	V	V	V	V	V	P	P	P	P	P	P	Coin	O	T	P	P	P	P	P	O	V	P																																																				-									330.32													10.8			550																									50 per ER visit; waived if admitted													20 Coinsurance			12 per visit																									50													0.035			12																		-	-	-	-	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	0.38	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.3			-	-	-	-	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	0.38	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.3																																																																																				-			-	-	-	-	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	0.38	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.3
H1045_005_0	2007	3																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	P	P	P	P	P	P	Coin	O	T	P	P	P	P	P	O	V	P																																																				-									275.27	120.59												9.52			550																									50 per ER visit; waived if admitted	50												20 Coinsurance			12 Copay																									50	50												0.04			12																		-	-	-	-	-	-	-	1.15	0.5	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.53			-	-	-	-	-	-	-	1.15	0.5	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.53																																																																																				-			-	-	-	-	-	-	-	1.15	0.5	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.53
H1045_008_0	2007	4																																A	A	D	V	T	O	O	V	V	V	V	V	V	V	P	P	P	P	P	P	Coin	O	T	P	P	P	P	P	O	V	P																																																				-		0.03															0.01					10.8			4		2.23																30 Gastric Bypass Surgery															30 Gastric Bypass Surgery					20 Coinsurance			Various Copays		150 Copay for contact lenses																0.3															0.3					0.04			94.5		150																0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	0.38	-	-	0.03	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.44			0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	0.38	-	-	0.03	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.44																																																																																				-			0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	0.38	-	-	0.03	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.44
H1045_009_0	2007	3																																A	A	D	V	T	O	O	V	V	V	V	V	V	V	P	P	P	P	P	P	Coin	O	T	P	P	P	P	P	O	V	P																																																				-									330.32													10.8			550																									50 per ER visit; waived if admitted													20 Coinsurance			12 per visit																									50													0.035			12																		-	-	-	-	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	0.38	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.3			-	-	-	-	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	0.38	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.3																																																																																				-			-	-	-	-	-	-	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	0.38	-	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.3
H1076_003_0	2007	3																																																																																																																		-		1866.08		1049.17					314.52	71.5		1367.45		0.14	83.26		9762.89					1133			701.32																		50/day (days 1-5)	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	100 copay @ Hospital PBP; 25 copay @ Diagnostic Center L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	15 copay per visit	0 copay	0 copay	0 copay	0 copay	40 per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		15.55					50	100		27.84		25	25		15					21.23			85.3																		5.3	-	1.36	-	-	-	-	1.31	0.6	-	3.17	-	0	0.17	-	12.2	-	-	-	-	2	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.1			5.3	-	1.36	-	-	-	-	1.31	0.6	-	3.17	-	0	0.17	-	12.2	-	-	-	-	2	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.1																	15 Travel Benefit Copay																																									0.01																										0.01			5.3	-	1.36	-	-	-	-	1.31	0.6	-	3.17	-	0	0.17	-	12.22	-	-	-	-	2	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.12
H1076_010_0	2007	6																																																																																																																		-																						770.41			701.32																		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	30 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay																															16.34			85.3																		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.05	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.03			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.05	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.03																20 Travel Benefit Copay																																									0.02																											0.02			-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	-	-	-	-	-	1.05	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.05
H1076_011_0	2007	6																																																							P																																																											-																									3043.09																		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay																																		17.51																		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44
H1076_016_0	2007	3																																																																																																																		-		1711.74		1393.12		349.54			331.36	74.42		1496.84		0	216.55		11858.27					827			701.32																		50/day (days 1-5)	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	100 copay PBP L.10	0 copay	0 copay	50 copay PBP L.4a	250 copay @ Hospital PBP L.9a	Included in OP-Facility Other	150 copay @ Hospital PBP; 50 copay @ Diagnostic Center L.8a/8b	0 copay	50 copay @ Hospital PBP L.12	50 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	20 copay per visit	0 copay	0 copay	0 copay	0 copay	40 copay PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		15.55		100			50	250		52.19		50	50		20					21.23			85.3																		4.86	-	1.81	-	2.91	-	-	1.38	1.55	-	6.51	-	-	0.9	-	19.76	-	-	-	-	1.46	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.13			4.86	-	1.81	-	2.91	-	-	1.38	1.55	-	6.51	-	-	0.9	-	19.76	-	-	-	-	1.46	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.13																	20 Travel Benefit Copay																																									0.02																										0.02			4.86	-	1.81	-	2.91	-	-	1.38	1.55	-	6.51	-	-	0.9	-	19.78	-	-	-	-	1.46	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.15
H1076_020_0	2007	5																																																																																																																		-				714.17					195.9	248.14		28.34		0.03	60.22	4754.55	10414.68					668.24			701.32																		0 copay	0 copay	55 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital; 25 copay @ ASC (PBP L.9ab)	Included in OP-Facility Other	50 copay @ Hospital PBP L.8a	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	5 copay per visit	20 copay per visit	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay													28.51					50	47.5		50		25	25	5	20					25.66			85.3																		-	-	1.7	-	-	-	-	0.82	0.98	-	0.12	-	0	0.13	1.98	17.36	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.49			-	-	1.7	-	-	-	-	0.82	0.98	-	0.12	-	0	0.13	1.98	17.36	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.49																30 coinsurance	30 coinsurance																																								4.14	11.94																										16.08			-	-	1.7	-	-	-	-	0.82	0.98	-	0.12	-	0	0.13	6.12	29.3	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.57
H1076_022_0	2007	5																																																																																																																		-		1519.65		714.17					195.9	248.14		1224.64		0.03	60.22	4160.23	9112.85					668.24			701.32																		50 per day (days 1-5) PBP L.1a	0 copay	55 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	250 copay @ Hospital PBP L.9a	Included in OP-Facility Other	150 copay @ Hospital; 50 copay @ Outpatient Diagnostic Center PBP L.8a8b	0 copay	50 copay @ Hospital PBP L.12	50 copay @ Hospital PBP L.9a 8a 7c 7j	5 copay per visit	35 copay per visit	0 copay	0 copay	0 copay	0 copay	50 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		28.51					50	81.25		52.31		50	50	5	35					25.66			85.3																		4.31	-	1.7	-	-	-	-	0.82	1.68	-	5.34	-	0	0.25	1.73	26.58	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.82			4.31	-	1.7	-	-	-	-	0.82	1.68	-	5.34	-	0	0.25	1.73	26.58	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.82																30 coinsurance	30 coinsurance																																								5.87	17.79																										23.66			4.31	-	1.7	-	-	-	-	0.82	1.68	-	5.34	-	0	0.25	7.6	44.37	-	-	-	-	1.43	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.48
H1080_004_0	2007	11																					4100											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1674.73	98.06	1000.01	0	141.1	16.04	10.25	364.03	48.99	12824.66	53.77	0	0.21	27.08	6330.32	5963.28	392.1	4.69	0	0	34.77	2052.09	0	0	44.02	0	220.6	0	0	0	0											295 (1a)	295 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	20/30 (9b)	5 (8a 8b)	15/20/30 (8a 8b)	20/30 (incl in h5)	30 (12)	20/30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20/30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											186.55	186.55	101.18	0	110.66	0.19	0.2	30.75	0.17	1.26	0.11	0	0.19	0.19	10	20	37.5	0.13	0	0	0.19	20	0	0	20	0	20	0	0	0	0											26.03	1.52	8.43	-	1.3	3.04	2.1	0.93	8.24	1.35	6.08	-	0.04	5.14	5.28	9.94	1.23	0.59	-	-	6.6	3.42	-	-	0.07	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.71		41.27	26.03	1.52	8.43	-	1.3	3.04	2.1	0.93	8.24	1.35	6.08	-	0.04	5.14	5.28	9.94	1.23	0.59	-	-	6.6	3.42	-	-	0.07	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.71																																																																																				-			26.03	1.52	8.43	-	1.3	3.04	2.1	0.93	8.24	1.35	6.08	-	0.04	5.14	5.28	9.94	1.23	0.59	-	-	6.6	3.42	-	-	0.07	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.71
H1080_011_0	2007	12																					4200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1077.89	94.87	740.8	0	84.51	12.29	7.4	315.07	43.86	9504.43	59.6	0	0.03	15.99	4291.72	4651.8	378.12	4.28	0	0	20.03	1391.6	0	0	61.04	0	201.51	0	0	0	0											295/325 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	15/25 (9b)	10 (8a 8b)	15/15/25 (8a 8b)	15/25 (incl in h5)	30 (12)	15/25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	28 (7b 7d 7f 7g)	40/30 (7e 7h)	15/25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 28 (17a 18a 16b)	0 n/c (10b)	0 (16a 16b1-16b5)	28 (17a)	0 n/c (17b1-17b5)	28 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											209.03	207.34	105.43	0	123	0.21	0.22	34.66	0.15	2.81	0.09	0	0.21	0.18	15	28	37.5	0.11	0	0	0.21	28	0	0	28	0	28	0	0	0	0											18.78	1.64	6.51	-	0.87	2.59	1.63	0.91	6.57	2.23	5.49	-	0.01	2.81	5.36	10.85	1.18	0.45	-	-	4.22	3.25	-	-	0.14	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.95		23.03	18.78	1.64	6.51	-	0.87	2.59	1.63	0.91	6.57	2.23	5.49	-	0.01	2.81	5.36	10.85	1.18	0.45	-	-	4.22	3.25	-	-	0.14	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.95		325 (1a)	0 n/c (1b)	0 n/c (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 0 n/c (5 9c)	40 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											4.95	0	0	0.17	0.11	0.34	0.21	0.1	0.99	0.48	1.07	0	0	0.36	1.46	1.44	0.12	0.12	0	0	0.56	0.43	0	0	0.02	0	0.06	0	0	0	0											13		0	23.73	1.64	6.51	0.17	0.98	2.93	1.83	1.01	7.56	2.7	6.56	-	0.01	3.17	6.83	12.29	1.31	0.57	-	-	4.78	3.68	-	-	0.16	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.95
H1080_036_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1100	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T	V						O	O																																																				-		2362.51	373.82	1203.5		280.5	29.88	25.88	961.22					3.65								19.78																					(1a) 25 per Day	(1b) 25 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 50 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 0 per Visit	(8a) 0 per Visit	(8b) 0 per Visit	(9a) 0 per Visit	(12) 20 Coinsurance	(9a) 0 per Visit	(7a) 0 per Visit	(7d) 0 per Visit	(7h) 0 per Visit	(7c) 0 per Visit	0 per Visit	(7g) 0 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit						(14a) 0	(13a1) 0											18	18	25		35	14	14	28					14								14																					3.45	0.55	2.53	-	0.82	4.19	3.63	2.22	-	-	-	-	0.51	-	-	-	-	-	-	-	2.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.67		8.81	3.45	0.55	2.53	-	0.82	4.19	3.63	2.22	-	-	-	-	0.51	-	-	-	-	-	-	-	2.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.67																																																																																				-		0	3.45	0.55	2.53	-	0.82	4.19	3.63	2.22	-	-	-	-	0.51	-	-	-	-	-	-	-	2.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.67
H1080_037_0	2007	2																					3800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1674.73	98.06	1000.01	0	141.1	16.04	10.25	364.03	48.99	12824.66	53.77	0	0.21	27.08	6330.32	5963.28	392.1	4.69	0	0	34.77	2052.09	0	0	44.02	0	220.6	0	0	0	0											295 (1a)	295 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	20/30 (9b)	15 (8a 8b)	15/20/30 (8a 8b)	20/30 (incl in h5)	30 (12)	20/30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20/30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											177.94	177.94	96.51	0	105.56	0.18	0.2	29.33	0.16	3.62	0.11	0	0.18	0.18	10	20	37.5	0.12	0	0	0.18	20	0	0	20	0	20	0	0	0	0											24.83	1.45	8.04	-	1.24	2.9	2.02	0.89	7.86	3.87	5.8	-	0.04	4.9	5.28	9.94	1.23	0.57	-	-	6.29	3.42	-	-	0.07	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.01		46.24	24.83	1.45	8.04	-	1.24	2.9	2.02	0.89	7.86	3.87	5.8	-	0.04	4.9	5.28	9.94	1.23	0.57	-	-	6.29	3.42	-	-	0.07	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.01																																																																																				-			24.83	1.45	8.04	-	1.24	2.9	2.02	0.89	7.86	3.87	5.8	-	0.04	4.9	5.28	9.94	1.23	0.57	-	-	6.29	3.42	-	-	0.07	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.01
H1080_038_0	2007	7																					3800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1077.89	94.87	740.8	0	84.51	12.29	7.4	315.07	43.86	9504.43	59.6	0	0.03	15.99	4291.72	4651.8	378.12	4.28	0	0	20.03	1391.6	0	0	61.04	0	201.51	0	0	0	0											295/325 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	15/25 (9b)	15 (8a 8b)	15/15/25 (8a 8b)	15/25 (incl in h5)	30 (12)	15/25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	15/25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											200.39	198.77	101.07	0	117.92	0.2	0.21	33.23	0.14	4.04	0.09	0	0.2	0.17	15	25	37.5	0.1	0	0	0.2	25	0	0	25	0	25	0	0	0	0											18	1.57	6.24	-	0.83	2.48	1.57	0.87	6.3	3.2	5.26	-	0.01	2.69	5.36	9.69	1.18	0.43	-	-	4.05	2.9	-	-	0.13	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.19		25.79	18	1.57	6.24	-	0.83	2.48	1.57	0.87	6.3	3.2	5.26	-	0.01	2.69	5.36	9.69	1.18	0.43	-	-	4.05	2.9	-	-	0.13	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.19		325 (1a)	0 n/c (1b)	0 n/c (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 0 n/c (5 9c)	40 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											4.95	0	0	0.17	0.11	0.34	0.21	0.1	0.99	0.48	1.07	0	0	0.36	1.46	1.44	0.12	0.12	0	0	0.56	0.43	0	0	0.02	0	0.06	0	0	0	0											13		0	22.95	1.57	6.24	0.17	0.94	2.83	1.78	0.97	7.29	3.68	6.33	-	0.01	3.05	6.83	11.13	1.31	0.55	-	-	4.61	3.33	-	-	0.15	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.19
H1080_801_0	2007	4																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1522.86	92.71	852.67	0	121.28	15.1	9.88	343.12	46.07	12344.37	57.77	0	0.15	23.97	5684.91	5932.39	371.87	4.5	0	0	32.9	2134.99	0	0	42.88	0	209.47	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	30 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											235.01	235.01	100.72	0	117.51	0.17	0.18	33.57	0.17	4.03	0.13	0	0.2	0.17	30	35	37.5	0.17	0	0	0.2	35	0	0	35	0	35	0	0	0	0											29.82	1.82	7.16	-	1.19	2.54	1.78	0.96	7.73	4.14	7.26	-	0.03	4.02	14.21	17.3	1.16	0.75	-	-	6.63	6.23	-	-	0.13	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.48		36.92	29.82	1.82	7.16	-	1.19	2.54	1.78	0.96	7.73	4.14	7.26	-	0.03	4.02	14.21	17.3	1.16	0.75	-	-	6.63	6.23	-	-	0.13	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.48																																																																																				-			29.82	1.82	7.16	-	1.19	2.54	1.78	0.96	7.73	4.14	7.26	-	0.03	4.02	14.21	17.3	1.16	0.75	-	-	6.63	6.23	-	-	0.13	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.48
H1099_001_0	2007	5																					3100											D	D	D		T	Coin	Coin	V	V						V	V	V	V									V																																																								-		1764.84	95.39	784.18		302.71	7.57	0.63	769.43	542.64						5677.65	3785.1	463.13	1031.85									101.16															200 (Days 1-4)	200 (Days 1-4)	75 (Days 1-14)		150	15	15	50	200						10 OV; 0 Preventive	25	25	25									15															122.83	122.83	53.95		149.87	0.15	0.15	49.96	199.83						8.49	24.98	24.98	14.99									14.99															18.07	0.98	3.53	-	3.78	1.13	0.09	3.2	9.04	-	-	-	-	-	4.02	7.88	0.96	1.29	-	-	-	-	-	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.09		0.05	18.07	0.98	3.53	-	3.78	1.13	0.09	3.2	9.04	-	-	-	-	-	4.02	7.88	0.96	1.29	-	-	-	-	-	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.09																																																																																				-			18.07	0.98	3.53	-	3.78	1.13	0.09	3.2	9.04	-	-	-	-	-	4.02	7.88	0.96	1.29	-	-	-	-	-	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.09
H1099_006_0	2007	5																					3100											Coin	Coin	Coin		Coin	Coin	Coin	V	Coin						V	V	V	V																																																																	-		204.93	4.13	23.62		4.11	7.57	0.63	769.43	21.19						5677.65	3785.1	463.13	1031.85																								15	15	15		15	15	15	50	15						10	25	25	30																								0.15	0.15	0.15		0.15	0.15	0.15	49.84	0.15						8.47	34.89	34.89	29.9																								30.64	0.62	3.53	-	0.61	1.13	0.09	3.2	3.17	-	-	-	-	-	4.01	11	1.35	2.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.92		0.2	30.64	0.62	3.53	-	0.61	1.13	0.09	3.2	3.17	-	-	-	-	-	4.01	11	1.35	2.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.92																																																																																				-			30.64	0.62	3.53	-	0.61	1.13	0.09	3.2	3.17	-	-	-	-	-	4.01	11	1.35	2.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.92
H1099_008_0	2007	2																					2000											D	D	D		T	Coin	Coin	V	V						V	V	V	V																																																																	-		2344.31	126.71	1737.76		570.13	15.79	1.32	1045.88	507.95						2344.31	2344.31	2344.31	2344.31																								250/Benefit  Period	250/Benefit  Period	25 Days 1-14 then 0		50	10	10	50	150						10	20	20	15																								53.1	53.1	18		50	0.1	0.1	50	150						8.5	20	20	15																								10.37	0.56	2.61	-	2.38	1.58	0.13	4.36	6.35	-	-	-	-	-	1.66	3.91	3.91	2.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.74		0	10.37	0.56	2.61	-	2.38	1.58	0.13	4.36	6.35	-	-	-	-	-	1.66	3.91	3.91	2.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.74																																																																																				-			10.37	0.56	2.61	-	2.38	1.58	0.13	4.36	6.35	-	-	-	-	-	1.66	3.91	3.91	2.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.74
H1099_009_0	2007	1																					3100											D	D	D		T	Coin	Coin	V	V						V	V	V	V									V																																																								-		1764.84	95.39	784.18		302.71	7.57	0.63	769.43	542.64						5677.65	3785.1	463.13	1031.85									101.16															200 (Days 1-4)	200 (Days 1-4)	75 (Days 1-14)		150	15	15	50	200						10 OV; 0 Preventive	25	25	25									15															122.83	122.83	53.95		149.88	0.15	0.15	49.96	199.83						8.49	24.98	24.98	14.99									14.99															18.07	0.98	3.53	-	3.78	1.13	0.09	3.2	9.04	-	-	-	-	-	4.02	7.88	0.96	1.29	-	-	-	-	-	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.09		0.04	18.07	0.98	3.53	-	3.78	1.13	0.09	3.2	9.04	-	-	-	-	-	4.02	7.88	0.96	1.29	-	-	-	-	-	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.09																																																																																				-			18.07	0.98	3.53	-	3.78	1.13	0.09	3.2	9.04	-	-	-	-	-	4.02	7.88	0.96	1.29	-	-	-	-	-	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.09
H1099_802_0	2007	1																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin																																																																				-		241.59		27.29	27.61	4.74	13.84		8.94	24.48					81.59	320.17																											Medicare FFS Cost Sharing																																									0.08		0.18		0.24	0.24		0.24	0.24					0.24	0.24																											19.29	-	4.91	-	1.12	3.27	-	2.11	5.78	-	-	-	-	19.25	75.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.29			19.29	-	4.91	-	1.12	3.27	-	2.11	5.78	-	-	-	-	19.25	75.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.29																																																																																				-			19.29	-	4.91	-	1.12	3.27	-	2.11	5.78	-	-	-	-	19.25	75.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.29
H1099_803_0	2007	1																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin																																																																				-		241.59		27.29	27.61	4.74	13.84		8.94	24.48					81.59	320.17																											Medicare FFS Cost Sharing																																									0.08		0.18		0.24	0.24		0.24	0.24					0.24	0.24																											19.29	-	4.91	-	1.12	3.27	-	2.11	5.78	-	-	-	-	19.25	75.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.29			19.29	-	4.91	-	1.12	3.27	-	2.11	5.78	-	-	-	-	19.25	75.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.29																																																																																				-			19.29	-	4.91	-	1.12	3.27	-	2.11	5.78	-	-	-	-	19.25	75.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.29
H1108_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						2400	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1690.75	132.02	8776.75	25.43	1195.22	30.59	2.4	167.38	141.48	2396.45	166.91	31.44	4.62	127.61	32556.24	1125.71	497.61	30.08		25.21	85.66	671.82	2634.11		2.21	157.7		51.87				109.12			2.21	280.44						(1a) 175/day	(1b) 175/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 35/visit	(8a) 0/visit	(8b) 0/visit	(9a) 35/visit	(12) 0/proc	(9a) 35/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 15/visit	(7e/7h) 32.5/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 15/visit	(15) 0/proc	(16b/17a) 15/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)			(7f1) 0/visit	(18a1) 0/visit						162	162			69	19	19	46	32			32		32		14	30			14		14										32										22.83	1.78	-	-	6.92	5.67	0.44	0.65	0.38	-	-	0.08	-	0.34	-	1.3	1.25	-	-	0.03	-	0.78	-	-	-	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	42.75		3.41	22.83	1.78	-	-	6.92	5.67	0.44	0.65	0.38	-	-	0.08	-	0.34	-	1.3	1.25	-	-	0.03	-	0.78	-	-	-	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	42.75		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35			30	30						2.26	0.04	0.78	0.01	0.58	0.48	0.04	0.04	0.13	0.47	0.68	0.04	0.01	0.05	0.01	1.81	0.08	0		0.07		0.09	0.29		0							0.02			0	0.02						8		0	25.09	1.83	0.78	0.01	7.49	6.15	0.48	0.68	0.52	0.47	0.68	0.12	0.01	0.4	0.01	3.11	1.33	0	-	0.1	-	0.87	0.29	-	0	-	-	-	-	-	-	0.31	-	-	0	0.02	-	-	-	-	-	50.75
H1108_002_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2454.3	352.33	1652.54		315.1	28.13	23.47	923.19	374.74	2210.57	920.28	65.81	3.16	2041.71		3481.75		506.18		802.43												324.3		142.77	242.43							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							34	34	16		34	9	9	16	11	5	5	11	9	11		5		5		5												5		5	5							7.02	1.01	2.27	-	0.9	2.58	2.15	1.27	0.36	0.84	0.35	0.06	0.29	1.95	-	1.33	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	23.14		27.41	7.02	1.01	2.27	-	0.9	2.58	2.15	1.27	0.36	0.84	0.35	0.06	0.29	1.95	-	1.33	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	23.14		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.38	0.16	0.43	0.44	0.08	0.17	0.14	0.05	0.19	0.14	0.12	0.02	0.02	0.23	0.34	0.21	0.04	0.03	0.14	0.72	0.14	0																				6.2		0	9.41	1.17	2.7	0.44	0.98	2.75	2.29	1.32	0.54	0.98	0.48	0.08	0.31	2.18	0.34	1.54	0.04	0.22	0.14	1.03	0.14	0	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	29.35
H1108_006_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V																																															-		2400.7	217.82	964.57		214.08	23.34	26.94	593.64	461.47	2316.2	980.2	73.91	1.24	1393.24		5065.83		478.38		937.72												270.54		261.4	265.06							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						42	42	20		42	8	11	20	14	3	6	14	11	14		6		6		6												6		6	6							8.46	0.77	1.63	-	0.75	1.97	3.04	1	0.54	0.54	0.46	0.09	0.14	1.64	-	2.38	-	0.22	-	0.44	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.12	-	-	-	-	-	-	24.45		18.93	8.46	0.77	1.63	-	0.75	1.97	3.04	1	0.54	0.54	0.46	0.09	0.14	1.64	-	2.38	-	0.22	-	0.44	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.12	-	-	-	-	-	-	24.45		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.63	0.1	0.26	0.33	0.06	0.14	0.16	0.04	0.29	0.18	0.18	0.02	0.01	0.2	0.36	0.3	0.03	0.03	0.2	0.88	0.18	0	0.04		0.01		0.01															6.64		0	11.09	0.87	1.89	0.33	0.81	2.12	3.2	1.04	0.83	0.73	0.64	0.11	0.15	1.83	0.36	2.68	0.03	0.26	0.2	1.32	0.18	0	0.04	-	0.01	-	0.01	-	-	-	-	0.13	-	0.12	0.12	-	-	-	-	-	-	31.09
H1109_001_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				225/day 1-10	225/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent care	150	35	35 routine 100 complex	35	30	35	25	35 Spec; 30 Renal Dialysis	35	35	35	35	45	0																				183.69	183.69	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	25	34.46	35	35	35	35	45	0																				23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32			23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32																																																																																				-			23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32
H1109_002_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	0	0	50 ER 25 Urgent care	150	30	30 routine 100 complex	30	30	30	15	30	30	30	30	30	45	0																				122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	30	53.94	30	30	30	15	30	30	30	30	30	45	0																				15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68																																																																																				-			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68
H1109_003_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				50/day 1-10	50/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	0	0	50 ER 25 Urgent care	150	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45	0																				40.82	40.82	65.39	20	100	0.2	0.2	46.75	150	25	50.65	25	25	25	10	25	25	25	25	25	45	0																				5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	4.56	4.75	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.31			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	4.56	4.75	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.31																																																																																				-			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	4.56	4.75	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.31
H1109_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1300	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5319.24	6747.88	193.76	1121.23	1532.39	2779.34	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					15.57	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.91			15.57	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.91																																																																																				-			15.57	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.91
H1109_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1300	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5319.24	6747.88	193.76	1121.23	1532.39	2779.34	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					15.57	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.91			15.57	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.91																																																																																				-			15.57	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.51	19.68	0.57	3.27	4.47	8.11	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.91
H1110_001_0	2007	6																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5	0	0	0											150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 urgent care	150	35	35 routine 100 complex	35	30	35	20	35 Spec; 30 Renal Dialysis	35	35	35	35	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	500 Every 3 Years	N/A	Fitness	0											122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	20	34.4	35	35	35	35	45	0	0	0	0	0	0	0	0	0	0											13.98	0.27	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.49			13.98	0.27	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.49		30	30	30	30	100	30	30	50 ER 30 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45	0	Not Covered	Not Covered	30	0	30	0	N/A	Not Covered	0											4.96	0.04	0.8	0.72	0.16	0.41	0.03	0.14	0.51	0.18	0.09	0	0.16	0.55	0.64	0.81	0.03	0.09	0.6	2.17	0.08	0	0	0	0.08	0	0.02	0	0	0	0											13.27	500	12.53	18.94	0.31	6.9	3.78	1.85	3.18	0.2	1.57	4.29	5.79	4.81	-	0.16	0.55	8.61	17.73	0.54	1.55	3.01	5.81	0.08	-	-	-	0.08	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.77
H1110_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1144	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4680.93	5938.14	170.51	986.68	1348.5	2445.82	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															13.7	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.08			13.7	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.08		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		21.62	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.68	18.61	0.55	3.01	4.89	10.6	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.35
H1110_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1144	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4680.93	5938.14	170.51	986.68	1348.5	2445.82	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															13.7	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.08			13.7	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.08		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		21.62	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.68	18.61	0.55	3.01	4.89	10.6	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.35
H1111_002_0	2007	6																					2650											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3750	1783.23	155.34	848.74	0	240.03	12.69	5.48	443.99	28.13	6400.45	39.14	0	0.19	21.41	2935.23	3439.49	590.38	1.64	0	0	19.64	598.11	0	0	134.7	0	186.65	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											153.55	153.55	78.07	0	91.09	0.16	0.18	26.02	0.16	1.04	0.12	0	0.16	0.16	15	30	37.5	0.16	0	0	0.16	30	0	0	30	0	30	0	0	0	0											22.82	1.99	5.52	-	1.82	1.98	1	0.96	4.39	0.56	4.6	-	0.03	3.35	3.67	8.6	1.84	0.26	-	-	3.07	1.5	-	-	0.34	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.75		47.93	22.82	1.99	5.52	-	1.82	1.98	1	0.96	4.39	0.56	4.6	-	0.03	3.35	3.67	8.6	1.84	0.26	-	-	3.07	1.5	-	-	0.34	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.75		375 (1a)	375 (1b)	185 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.74	0.24	0.64	0.53	0.43	0.47	0.23	0.23	1.05	0.53	1.12	0	0.01	0.8	1.37	2.2	0.46	0.06	0	0	0.73	0.38	0	0	0.09	0	0.12	0	0	0	0											14.42		7.1	25.55	2.23	6.16	0.53	2.26	2.45	1.23	1.19	5.44	1.08	5.72	-	0.04	4.14	5.04	10.8	2.3	0.32	-	-	3.8	1.88	-	-	0.42	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.17
H1111_003_0	2007	3																					2250											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3250	1783.23	155.34	848.74	0	240.03	12.69	5.48	443.99	28.13	6400.45	39.14	0	0.19	21.41	2935.23	3439.49	590.38	1.64	0	0	19.64	598.11	0	0	134.7	0	186.65	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											140.33	140.33	71.35	0	83.25	0.14	0.17	23.78	0.14	2.85	0.11	0	0.14	0.14	15	30	37.5	0.14	0	0	0.14	30	0	0	30	0	30	0	0	0	0											20.85	1.82	5.05	-	1.67	1.81	0.94	0.88	4.01	1.52	4.2	-	0.03	3.06	3.67	8.6	1.84	0.23	-	-	2.8	1.5	-	-	0.34	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.29		53.53	20.85	1.82	5.05	-	1.67	1.81	0.94	0.88	4.01	1.52	4.2	-	0.03	3.06	3.67	8.6	1.84	0.23	-	-	2.8	1.5	-	-	0.34	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.29		375 (1a)	375 (1b)	185 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.65	0.23	0.62	0.29	0.42	0.46	0.2	0.22	1.01	0.51	1.08	0	0.01	0.77	0.75	1.21	0.25	0.06	0	0	0.71	0.21	0	0	0.05	0	0.07	0	0	0	0											11.79		9.73	23.51	2.05	5.67	0.29	2.09	2.27	1.14	1.1	5.03	2.04	5.29	-	0.03	3.83	4.42	9.81	2.1	0.29	-	-	3.51	1.71	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.07
H1111_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2253.03	356.5	1151.8		258.38	25.35	21.96	870.3	377.36	1979.82	928.84	64.29	3.04	1954.42		3565.51		533.35		829.91												278.6		158.53	235.84							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							6.81	1.08	1.67	-	0.78	2.45	2.12	1.26	0.38	0.8	0.37	0.06	0.29	1.97	-	1.44	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.1	-	-	-	-	-	-	22.32		23.83	6.81	1.08	1.67	-	0.78	2.45	2.12	1.26	0.38	0.8	0.37	0.06	0.29	1.97	-	1.44	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.1	-	-	-	-	-	-	22.32																																																																																				-		0	6.81	1.08	1.67	-	0.78	2.45	2.12	1.26	0.38	0.8	0.37	0.06	0.29	1.97	-	1.44	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.1	-	-	-	-	-	-	22.32
H1111_801_0	2007	3																					4200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2035.21	177.29	968.67	0	307.36	16.25	7.01	568.52	36.02	8195.7	50.12	0	0.24	27.41	3758.53	4404.22	755.97	2.1	0	0	25.14	765.88	0	0	172.48	0	239	0	0	0	0											325 (1a)	325 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	30 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											195.93	195.93	96.46	0	105.5	0.18	0.2	30.14	0.18	3.62	0.14	0	0.18	0.18	30	35	37.5	0.18	0	0	0.18	35	0	0	35	0	35	0	0	0	0											33.23	2.89	7.79	-	2.7	2.94	1.42	1.43	6.52	2.47	6.82	-	0.04	4.96	9.4	12.85	2.36	0.38	-	-	4.55	2.23	-	-	0.5	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.18		51.22	33.23	2.89	7.79	-	2.7	2.94	1.42	1.43	6.52	2.47	6.82	-	0.04	4.96	9.4	12.85	2.36	0.38	-	-	4.55	2.23	-	-	0.5	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.18																																																																																				-			33.23	2.89	7.79	-	2.7	2.94	1.42	1.43	6.52	2.47	6.82	-	0.04	4.96	9.4	12.85	2.36	0.38	-	-	4.55	2.23	-	-	0.5	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.18
H1112_001_0	2007	8																					3150											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1325.31	24.81	845.86	1786.18	441.41	19.61	3.42	293.38	289.47	1869.43	910.84	0	521.78	559.25	4586.54	8337.38	173.76	781.01	4368.29	25147.83	7.35	5166.81	0	381	444.49	343.66	190.5	12	0	289.39	547.2											250  days 1 - 5	250  days 1 - 5	119  days 21 - 100	0	100	20	20	50	100-ASC/ 200-OP/ 150-Non Surg	0	15 - 75		0 - 35	35 to 150	15	0 to 35	25 to 35	35	0 - 75	0 to 20	0 -20	0	0	10	20	20	20	0		0	0 to 0											138.67	138.67	23.47	0	86.96	0.17	0.17	43.48	160.87	0	26.09	0	20.29	78.76	10.55	30.43	23.91	30.43	10.47	1.22	0.12	0	0	10.27	17.39	17.39	17.39	0	0	0	0											15.31	0.29	1.65	-	3.2	3.41	0.6	1.06	3.88	-	1.98	-	0.88	3.67	4.03	21.15	0.35	1.98	3.81	2.57	0.86	-	-	0.33	0.64	0.5	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.42		10.8	15.31	0.29	1.65	-	3.2	3.41	0.6	1.06	3.88	-	1.98	-	0.88	3.67	4.03	21.15	0.35	1.98	3.81	2.57	0.86	-	-	0.33	0.64	0.5	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.42	3150																																																																																			-		0	15.31	0.29	1.65	-	3.2	3.41	0.6	1.06	3.88	-	1.98	-	0.88	3.67	4.03	21.15	0.35	1.98	3.81	2.57	0.86	-	-	0.33	0.64	0.5	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.42
H1112_003_0	2007	6																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1328.47	25.35	818.23	1721.39	431.62	19.24	3.3	283.17	280.55	1828.36	885.13	0	502.35	539.27	4394.96	8132.3	177.98	764.4	4265.17	24458.85	7.05	4987.53	0	381	425.97	328.75	182.56	11.48	0	271.59	2035.2											100  days 1 - 8	100  days 1 - 8	119  days 21 - 100	0	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 20	20 to 100	5	0 to 20	10 to 20	20	0 - 75	0 to 20	0 -20	0	0	10	20	20	20	0		0	0 to 0											77.66	77.66	27.01	0	100	0.2	0.2	50	135	0	30	0	13.33	58.72	4.06	20	12.5	20	12.02	1.38	0.13	0	0	10	20	20	20	0	0	0	0											8.6	0.16	1.84	-	3.6	3.85	0.66	1.18	3.16	-	2.21	-	0.56	2.64	1.49	13.55	0.19	1.27	4.27	2.81	0.95	-	-	0.32	0.71	0.55	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.87		0	8.6	0.16	1.84	-	3.6	3.85	0.66	1.18	3.16	-	2.21	-	0.56	2.64	1.49	13.55	0.19	1.27	4.27	2.81	0.95	-	-	0.32	0.71	0.55	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.87	0																																																																																			-		0	8.6	0.16	1.84	-	3.6	3.85	0.66	1.18	3.16	-	2.21	-	0.56	2.64	1.49	13.55	0.19	1.27	4.27	2.81	0.95	-	-	0.32	0.71	0.55	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.87
H1112_005_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1796.66	33.31	1152.54	2414	591.18	26.22	4.62	396.12	389.84	2503.36	1243.26	0	705.62	755.56	6240.49	11350.11	248.16	1073.21	5947.21	33793.72	9.96	6975.83	1200	381	602.79	466.58	258.34	16.29	0	397.43	2035.2											100  days 1 - 6	100  days 1 - 6	50  days 8 - 100	0	100	20	20	50	25-ASC/ 75-OP/ 25-Non Surg	0	0 - 50		0 - 20	20 to 25	0	0 to 20	10 to 20	20	0 - 50	0 to 20	0 -20	0	24 One-way trips per year	10	20	20	20	0		0	0 to 0											69.51	69.51	30.4	0	100	0.2	0.2	50	65	0	12.5	0	13.33	22.41	0	20	12.5	20	5.02	1.43	0.13	0	0	10	20	20	20	0	0	0	0											10.41	0.19	2.92	-	4.93	5.24	0.92	1.65	2.11	-	1.3	-	0.78	1.41	-	18.92	0.26	1.79	2.49	4.02	1.33	-	-	0.32	1	0.78	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.2		0	10.41	0.19	2.92	-	4.93	5.24	0.92	1.65	2.11	-	1.3	-	0.78	1.41	-	18.92	0.26	1.79	2.49	4.02	1.33	-	-	0.32	1	0.78	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.2	0																																																																																			-		0	10.41	0.19	2.92	-	4.93	5.24	0.92	1.65	2.11	-	1.3	-	0.78	1.41	-	18.92	0.26	1.79	2.49	4.02	1.33	-	-	0.32	1	0.78	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.2
H1112_006_0	2007	3																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1673.6	31.14	1062.18	2223.42	9.21	24.22	4.26	5.36	27.67	2310.63	27.86	0	8.52	18.4	5746.32	51.15	1.87	1.95	5488.48	129.34	9.17	6426.59	0	381	554.77	429.21	237.76	14.99	0	364.71	2035.2											9520 (1-60) 238 (61-90) 476 (91+)  0	9520 (1-60) 238 (61-90) 476 (91+) - 238  0	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											148.67	124.35	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.13	0.2	0	0.2	0.2	0.2	2.12	0.08	0.13	0	0	0	0	0	0	0	0	0	0											20.73	0.32	2.39	-	1.84	-	-	1.07	5.53	-	1.39	-	1.14	3.68	-	10.23	0.37	0.39	0.97	10.82	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.12		0	20.73	0.32	2.39	-	1.84	-	-	1.07	5.53	-	1.39	-	1.14	3.68	-	10.23	0.37	0.39	0.97	10.82	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.12	0																																																																																			-		0	20.73	0.32	2.39	-	1.84	-	-	1.07	5.53	-	1.39	-	1.14	3.68	-	10.23	0.37	0.39	0.97	10.82	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.12
H1112_011_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1465.94	28.03	891.96	1916.39	481.79	21.49	3.68	315.34	312.65	2040.95	986.89	0	559.15	600.42	4875.42	8971.64	186.66	836.49	4759.65	27275.23	7.85	5554.18	0	381	473.73	365.4	203.03	12.76	0	300.86	547.2											200  days 1 - 6	200  days 1 - 6	100  days 8 - 100	0	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 35	35 to 100	10	0 to 35	25 to 35	35	0 - 75	0 to 20	0 -20	0	0	10	20	20	20	0		0	0 to 0											117.89	117.89	51.56	0	84.8	0.17	0.17	42.4	114.48	0	25.44	0	19.79	56.37	6.89	29.68	23.32	29.68	10.19	1.17	0.11	0	0	10	16.96	16.96	16.96	0	0	0	0											14.4	0.28	3.83	-	3.4	3.65	0.62	1.11	2.98	-	2.09	-	0.92	2.82	2.8	22.19	0.36	2.07	4.04	2.65	0.89	-	-	0.32	0.67	0.52	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.91		13.01	14.4	0.28	3.83	-	3.4	3.65	0.62	1.11	2.98	-	2.09	-	0.92	2.82	2.8	22.19	0.36	2.07	4.04	2.65	0.89	-	-	0.32	0.67	0.52	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.91	3000																																																																																			-		0	14.4	0.28	3.83	-	3.4	3.65	0.62	1.11	2.98	-	2.09	-	0.92	2.82	2.8	22.19	0.36	2.07	4.04	2.65	0.89	-	-	0.32	0.67	0.52	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.91
H1170_002_0	2007	4																					2700											A	A	D	V	T	Coin	Coin	V	Coin	V	Coin		V	V	V	V	V	V	Coin	V	S				V		V			V	O	V	V																																																		-		251.78	8.49	375.12		110.02	10.43	1.89	283.53	52.27		25.43			10.51	3572.32	2407.6	173.4	216.31	10.04	117.23	503.88				437.5		39.08			18.14	303.74	245.48	425.97									700 per Admission	700 per Admission	100/day for days 11-100	0 copay per visit	150 per trip	20 coinsurance	20 coinsurance	50 per visit	20 coinsurance	0 copay per visit	20 coinsurance		0 copay per visit	40 per visit	25 per visit	40 per visit	blended ***	40 per visit	20 coinsurance	30 per visit	14 generic 30 brand				40 per visit		40 per visit			0 - 75 copay (varies by class)	Non-covered Rx (14 generic 30 brand)	Physical exams/immunizations	Other non-covered svcs									648.5	648.5	100	0	150	0.2	0.2	50	0.2	0	0.2		0	40	25	40	39.09	40	0.2	30	22				40		40			20.16	27.32	20.49	15.24									13.61	0.46	3.13	-	1.38	2.09	0.38	1.18	10.45	-	5.09	-	-	0.04	7.44	8.03	0.56	0.72	2.01	0.29	0.92	-	-	-	1.46	-	0.13	-	-	0.03	0.69	0.42	0.54	-	-	-	-	-	-	-	-	61.04		1.11	13.61	0.46	3.13	-	1.38	2.09	0.38	1.18	10.45	-	5.09	-	-	0.04	7.44	8.03	0.56	0.72	2.01	0.29	0.92	-	-	-	1.46	-	0.13	-	-	0.03	0.69	0.42	0.54	-	-	-	-	-	-	-	-	61.04	2700																																																																																			-			13.61	0.46	3.13	-	1.38	2.09	0.38	1.18	10.45	-	5.09	-	-	0.04	7.44	8.03	0.56	0.72	2.01	0.29	0.92	-	-	-	1.46	-	0.13	-	-	0.03	0.69	0.42	0.54	-	-	-	-	-	-	-	-	61.04
H1170_008_0	2007	5																					2700											A	A	D	V	T	Coin	Coin	V	Coin	V	Coin		V	V	V	V	V	V	Coin	V	S				V		V			V	O	V	V																																																		-		417.83	13.57	934.82		212.13	18.45	0.36	412.83	58.32		24.6			9.98	3431.94	2209.87	247.84	190.7	11.78	132.85	685				384.26		24.28			27.86	268.89	173.66	500.67									750 per Admission	750 per Admission	100/day for days 11-100	copay per visit	150 per trip	20 coinsurance	20 coinsurance	50 per visit	15 coinsurance	copay per visit	15 coinsurance		copay per visit	40 per visit	25 per visit	40 per visit	40 individual / 20 group	40 per visit	15 coinsurance	30 per visit	14 generic 30 brand				40 per visit		40 per visit			0 - 75 copay (varies by class)	Non-covered Rx (14 generic 30 brand)	Physicals/immunizations 0-20	Other non-covered svcs 0-40									696.8	696.8	100	0	150	0.2	0.2	50	0.15	0	0.15		0	40	25	40	39.19	40	0.15	30	22				40		40			16.14	22	17.73	10.81									24.26	0.79	7.79	-	2.65	3.69	0.07	1.72	8.75	-	3.69	-	-	0.03	7.15	7.37	0.81	0.64	1.77	0.33	1.26	-	-	-	1.28	-	0.08	-	-	0.04	0.49	0.26	0.45	-	-	-	-	-	-	-	-	75.36		2.28	24.26	0.79	7.79	-	2.65	3.69	0.07	1.72	8.75	-	3.69	-	-	0.03	7.15	7.37	0.81	0.64	1.77	0.33	1.26	-	-	-	1.28	-	0.08	-	-	0.04	0.49	0.26	0.45	-	-	-	-	-	-	-	-	75.36	2700																																																																																			-			24.26	0.79	7.79	-	2.65	3.69	0.07	1.72	8.75	-	3.69	-	-	0.03	7.15	7.37	0.81	0.64	1.77	0.33	1.26	-	-	-	1.28	-	0.08	-	-	0.04	0.49	0.26	0.45	-	-	-	-	-	-	-	-	75.36
H1170_801_0	2007	2																					3000											Coin	Coin	Coin		T	Coin	Coin	V	Coin	Coin	Coin			Coin	V	V	V	Coin	Coin	V	S						Coin				V	Coin										19.19	0.21	1.52			0.57	0.04		4.47	2.01	2.16			2.64				0.18	1.43																							34.42		106.92	1.17	8.48		61.38	3.16	0.2	219.3	24.9	11.22	12.03			14.68	3444.35	2751.28	196.62	0.99	7.99	132.75	563.45						0.02				70.72	0.08										20 coinsurance	20 coinsurance	20 coinsurance		150 per trip	20 coinsurance	20 coinsurance	50 per visit	20 coinsurance	20 coinsurance	20 coinsurance			20 coinsurance	35 per visit	50 per visit	50 individual/25 group	20 coinsurance	20 coinsurance	After-hours care	5 - 40 range						20 coinsurance				35 per visit	20 cojnsurance										0.2	0.2	0.2		150	0.2	0.2	50	0.2	0.2	0.2			0.2	35	50	45	0.2	0.2	40	20						0.2				35	0.2										21.38	0.23	1.7	-	0.77	0.63	0.04	0.91	4.98	2.24	2.41	-	-	2.94	10.05	11.46	0.74	0.2	1.6	0.44	0.94	-	-	-	-	-	0	-	-	-	0.21	0.02	-	-	-	-	-	-	-	-	-	63.88	500	39.59	40.57	0.44	3.22	-	0.77	1.2	0.08	0.91	9.45	4.25	4.57	-	-	5.58	10.05	11.46	0.74	0.38	3.03	0.44	0.94	-	-	-	-	-	0	-	-	-	0.21	0.02	-	-	-	-	-	-	-	-	-	98.3	3000																																																																																			-			40.57	0.44	3.22	-	0.77	1.2	0.08	0.91	9.45	4.25	4.57	-	-	5.58	10.05	11.46	0.74	0.38	3.03	0.44	0.94	-	-	-	-	-	0	-	-	-	0.21	0.02	-	-	-	-	-	-	-	-	-	98.3
H1170_802_0	2007	3																					3000											Coin	Coin	Coin		T	Coin	Coin	V	Coin	Coin	Coin			Coin	V	V	V	Coin	Coin	V	S						Coin				V	Coin										19.19	0.21	1.52			0.57	0.04		4.47	2.01	2.16			2.64				0.18	1.43																							34.42		106.92	1.17	8.48		61.38	3.16	0.2	219.3	24.9	11.22	12.03			14.68	3444.35	2751.28	196.62	0.99	7.99	132.75	563.45						0.02				70.72	0.08										20 coinsurance	20 coinsurance	20 coinsurance		150 per trip	20 coinsurance	20 coinsurance	50 per visit	20 coinsurance	20 coinsurance	20 coinsurance			20 coinsurance	35 per visit	50 per visit	50 individual/25 group	20 coinsurance	20 coinsurance	After-hours care	5 - 40 range						20 coinsurance				35 per visit	20 cojnsurance										0.2	0.2	0.2		150	0.2	0.2	50	0.2	0.2	0.2			0.2	35	50	45	0.2	0.2	40	20						0.2				35	0.2										21.38	0.23	1.7	-	0.77	0.63	0.04	0.91	4.98	2.24	2.41	-	-	2.94	10.05	11.46	0.74	0.2	1.6	0.44	0.94	-	-	-	-	-	0	-	-	-	0.21	0.02	-	-	-	-	-	-	-	-	-	63.88	500	39.59	40.57	0.44	3.22	-	0.77	1.2	0.08	0.91	9.45	4.25	4.57	-	-	5.58	10.05	11.46	0.74	0.38	3.03	0.44	0.94	-	-	-	-	-	0	-	-	-	0.21	0.02	-	-	-	-	-	-	-	-	-	98.3	3000																																																																																			-			40.57	0.44	3.22	-	0.77	1.2	0.08	0.91	9.45	4.25	4.57	-	-	5.58	10.05	11.46	0.74	0.38	3.03	0.44	0.94	-	-	-	-	-	0	-	-	-	0.21	0.02	-	-	-	-	-	-	-	-	-	98.3
H1230_001_0	2007	8																					3000												Coin	A		Coin	Coin		V	V		O				V	V	Coin	V	V	V	O				V	Coin	V			V																																																					-			0.01	62.35		7.11	0.67		256.57	504.97		2526				8975.09	1432.89	2.38	521.05	1953.94	13.03	170.71				18.4	0.01	40.89			9.2													20 191-220	50/day 21 to 100 days		Twenty percent	Twenty percent	e.2 combined in e.1	50/visit	14/visit		5 per Test				14/visit	14/visit	20 for 1st 20 visit & 50 for visit 21+	14	14	14	10/generic & 40 brand				14/visit	Twenty Percent	14/visit			14/visit													0.2	130.75		0.2	0.2		50	14		5				14	14	0.2	14.28	14.31	18.42	25				14	0.2	14			14												-	0	0.68	-	1.42	0.13	-	1.07	0.59	-	1.05	-	-	-	10.47	1.67	0.48	0.62	2.33	0.02	0.36	-	-	-	0.02	0	0.05	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	20.97	0	0	-	0	0.68	-	1.42	0.13	-	1.07	0.59	-	1.05	-	-	-	10.47	1.67	0.48	0.62	2.33	0.02	0.36	-	-	-	0.02	0	0.05	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	20.97	3000																																																																																			-			-	0	0.68	-	1.42	0.13	-	1.07	0.59	-	1.05	-	-	-	10.47	1.67	0.48	0.62	2.33	0.02	0.36	-	-	-	0.02	0	0.05	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	20.97
H1230_801_0	2007	4																					3000											Coin				Coin	Coin		V	V	Coin	Coin				V	V	Coin	V	Coin	Coin	O	P			V	Coin	V			V																																																					-		82.7				6.34	0.34		250.87	524.17	44.1	49.35				9100.58	1452.92	2.37	528.34	29.2	26.75	170.3				7.14	0.11	50.99			5.1												20Room & Board	Mental Health incl. in a.1.			Twenty percent	Twenty percent		50/visit	30	Twenty percent	Twenty percent				30/visit	30/visit	20 for 1st 20 visit & 50 for visit 21+	30	20 IP Radiology	20 IP Lab	10/generic & 40 brand				30/visit	20 lense/contact post cataract	30/visit			30/visit												0.2				0.2	0.2		50	30	0.2	0.2				30	30	0.2	30	0.2	0.2	25				30	0.2	30			30												16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82			16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82	3000																																																																																			-			16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82
H1230_802_0	2007	4																					3000											Coin				Coin	Coin		V	V	Coin	Coin				V	V	Coin	]	Coin	Coin	O	P			V	Coin	V			V																																																					-		82.7				6.34	0.34		250.87	524.17	44.1	49.35				9100.58	1452.92	2.37	528.34	29.2	26.75	170.3				7.14	0.11	50.99			5.1												20Room & Board	a.2. included in a.1			Twenty percent	Twenty percent	e.2 included in e.1	50/visit	30	Twenty percent	Twenty percent				30/visit	30/visit	20 for 1st 20 visit & 50 for visit 21+	30	20 IP Radiology	20 IP Lab	10/generic & 40 brand				30/visit	20 lense/contact post cataract	30/visit			30/visit												0.2				0.2	0.2		50	30	0.2	0.2				30	30	0.2	30	0.2	0.2	25				30	0.2	30			30												16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82			16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82	3000																																																																																			-			16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82
H1230_803_0	2007	7																					3000											Coin				Coin	Coin		V	V	Coin	Coin				V	V	Coin	V	Coin	Coin	O	P			V	Coin	V			V																																																					-		82.7				6.34	0.34		250.87	524.17	44.1	49.35				9100.58	1452.92	2.37	528.34	29.2	26.75	170.3				7.14	0.11	50.99			5.1												20Room & Board	Mental Health incl. in a.1.			Twenty percent	Twenty percent	e.2 included in e.1	50/visit	30	Twenty percent	Twenty percent				30/visit	30/visit	20 for 1st 20 visit & 50 for visit 21+	30	20 IP Radiology	20 IP Lab	10/generic & 40 brand				30/visit	20 lense/contact post cataract	30/visit			30/visit												0.2				0.2	0.2		50	30	0.2	0.2				30	30	0.2	30	0.2	0.2	25				30	0.2	30			30												16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82		6.41	16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82	3000																																																																																			-			16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82
H1230_804_0	2007	7																					3000											Coin				Coin	Coin		V	V	Coin	Coin				V	V	Coin	V	Coin	Coin	O				V	Coin	V			V																																																					-		82.7				6.34	0.34		250.87	524.17	44.1	49.35				9100.58	1452.92	2.37	528.34	29.2	26.75	170.3				7.14	0.11	50.99			5.1												20Room & Board	a.2. included in a.1			Twenty percent	Twenty percent	e.2 combine in e.1	50/visit	30	Twenty percent	Twenty percent				30/visit	30/visit	20 for 1st 20 visit & 50 for visit 21+	30	20 IP Radiology	20 IP Lab	10/generic & 40 brand				30/visit	20 lense/contact post cataract	30/visit			30/visit												0.2				0.2	0.2		50	30	0.2	0.2				30	30	0.2	30	0.2	0.2	25				30	0.2	30			30												16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82			16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82	3000																																																																																			-			16.54	-	-	-	1.27	0.07	-	1.05	1.31	8.82	9.87	-	-	-	22.75	3.63	0.47	1.32	5.84	5.35	0.35	-	-	-	0.02	0.02	0.13	-	-	0.01	-	-	-	-	-	-	-	-	-	-	-	78.82
H1254_001_0	2007	2																					3100											D	D	D	Coin	Coin	Coin	Coin	Coin	Coin		Coin	V	V	Coin	P	P	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		2023.8	114.5	865.35	0	6.59	8.18	11.27	10.44	31.35		30.07	0	0	9.73	4529.08	5350.5	2.39	4.23	0	2.5	26.55	30.94	0	0	0	0	0	0	0	0	0											1a: 190 days 1-5	1b: 190 days 1-5	2a: 0 days 1-3 115 days 4-100	6:15	10a: 20	11a: 20	11b-c: 20	4: 20 Emergency and Urgent	9a-b: 20		8b: 20 Lab Radiation Therapy X-Ray		12:  Renal Dialysis	7c 7i 9d: 20 Rehab	7a 14c: 30	7b 7d 7f 7g: 50	7e7h 9c: 20	7c 7i 9d: 20		50 Eyewear	15:20	17a 18a:  50 copay																				55.69	55.69	68.28	0	0.14	0.14	0.14	0.14	0.14		0.14	0	0	0.14	20.64	34.4	0.14	0.14	0	0.47	0.14	50	0	0	0	0	0	0	0	0	0											9.39	0.53	4.92	-	0.91	1.13	1.55	1.44	4.31	-	4.14	-	-	1.34	7.79	15.34	0.33	0.58	-	1.17	3.65	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.65		27.36	9.39	0.53	4.92	-	0.91	1.13	1.55	1.44	4.31	-	4.14	-	-	1.34	7.79	15.34	0.33	0.58	-	1.17	3.65	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.65																																																																																				-		0	9.39	0.53	4.92	-	0.91	1.13	1.55	1.44	4.31	-	4.14	-	-	1.34	7.79	15.34	0.33	0.58	-	1.17	3.65	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.65
H1254_002_0	2007	2																					3100											D	D	D	Coin	Coin	Coin	Coin	Coin	Coin		Coin	V	V	Coin	P	P	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		2149.28	83.99	702.89	0	8.05	14.2	17.97	19.17	41.29		34.01	0	0	6.6	4352.69	4722.34	1.74	4.54	0	2.17	22.25	24.19	0	0	0	0	0	0	0	0	0											1a: 190 days 1-5	1b: 190 days 1-5	2a: 0 days 1-3 115 days 4-100	6:15	10a: 20	11a: 20	11b-c: 20	4: 20 Emergency and Urgent	9a-b: 20		8b: 20 Lab Radiation Therapy X-Ray		12:  Renal Dialysis	7c 7i 9d: 20 Rehab	7a 14c: 30	7b 7d 7f 7g: 50	7e7h 9c: 20	7c 7i 9d: 20		50 Eyewear	15:20	17a 18a:  50 copay																				55.33	55.33	67.85	0	0.14	0.14	0.14	0.14	0.14		0.14	0	0	0.14	20.51	34.18	0.14	0.14	0	0.41	0.14	50	0	0	0	0	0	0	0	0	0											9.91	0.39	3.97	-	1.1	1.94	2.46	2.62	5.65	-	4.65	-	-	0.9	7.44	13.45	0.24	0.62	-	0.89	3.04	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.37		28.26	9.91	0.39	3.97	-	1.1	1.94	2.46	2.62	5.65	-	4.65	-	-	0.9	7.44	13.45	0.24	0.62	-	0.89	3.04	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.37																																																																																				-		0	9.91	0.39	3.97	-	1.1	1.94	2.46	2.62	5.65	-	4.65	-	-	0.9	7.44	13.45	0.24	0.62	-	0.89	3.04	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.37
H1254_003_0	2007	2																					3100											D	D	D	Coin	Coin	Coin	Coin	Coin	Coin		Coin	V	Coin	Coin	P	P	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1773.58	90.66	1060.69	0	6.12	10.45	14.23	16.88	42.88		34.1	0	0	9.86	5078.07	5332.66	2.29	2.56	0	2.76	27.25	28.28	0	0	0	0	0	0	0	0	0											1a: 190 days 1-5	1b: 190 days 1-5	2a: 0 days 1-3 115 days 4-100	6:15	10a: 20	11a: 20	11b-c: 20	4: 20 Emergency and Urgent	9a-b: 20		8b: 20 Lab Radiation Therapy X-Ray		12:  Renal Dialysis	7c 7i 9d: 20 Rehab	7a 14c: 30	7b 7d 7f 7g: 50	7e7h 9c: 20	7c 7i 9d: 20		50 Eyewear	15:20	17a 18a:  50 copay																				54.35	54.35	66.64	0	0.13	0.13	0.13	0.13	0.13		0.13	0	0	0.13	20.14	33.57	0.13	0.13	0	0.42	0.13	50	0	0	0	0	0	0	0	0	0											8.03	0.41	5.89	-	0.82	1.4	1.91	2.27	5.76	-	4.58	-	-	1.32	8.52	14.92	0.31	0.34	-	1.16	3.66	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.43		30.92	8.03	0.41	5.89	-	0.82	1.4	1.91	2.27	5.76	-	4.58	-	-	1.32	8.52	14.92	0.31	0.34	-	1.16	3.66	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.43																																																																																				-		0	8.03	0.41	5.89	-	0.82	1.4	1.91	2.27	5.76	-	4.58	-	-	1.32	8.52	14.92	0.31	0.34	-	1.16	3.66	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.43
H1254_801_0	2007	5																					3100											D	D	D	V	P	Coin	P	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	S	P	P	P	P	P	P	P	P	P	P																																																				-		1897.01	48.39	905.03	0	133.58	10.38	1248.42	415.44	422.47	0	1108.09	0	0	250.94	4849.19	4713.85	243.87	648.73	0	4.93	891	0	0	0	0	0	0	0	0	0	0											1a: 250 per admit up to 750	1b: 250 per admit up to 751	2a: 0 days 1-15 50 days 16-100		10a: 50	11a: 15	11b-c: 20 Supplies 15 Prosthetics	4: 50 Emergency and Urgent	9a-b: 125		8: 15 x-ray 50 hi-tech x-ray			7c 7i: 30 Rehab	7a14c: 15	7b 7d 7f 7g 17a 18a: 30	7e7h 9c: 30	7c 7i: 30		50 copay	15:20 Copay per 30 day supply																					36.65	25.61	20.12	0	40.39	0.12	17.4	40.39	100.98	0	28.75	0	0	24.24	12.12	24.24	24.24	24.24	0	0.5	19	0	0	0	0	0	0	0	0	0	0											5.79	0.1	1.52	-	0.45	1.26	1.81	1.4	3.56	-	2.66	-	-	0.51	4.9	9.52	0.49	1.31	-	2.44	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.12		9.72	5.79	0.1	1.52	-	0.45	1.26	1.81	1.4	3.56	-	2.66	-	-	0.51	4.9	9.52	0.49	1.31	-	2.44	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.12																																																																																				-		0	5.79	0.1	1.52	-	0.45	1.26	1.81	1.4	3.56	-	2.66	-	-	0.51	4.9	9.52	0.49	1.31	-	2.44	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.12
H1286_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2164.45	201.54	7579.42	142.05	533.14	1199.16	5828	153.33	101.8	3167.1	140.8	27.84	3.64	236.73	106.08	1062.35	1380.04	16.3		221.82	224.75	1084.72	2137.5		133.19	157.7		51.87				90.41	0.23	0.06	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						62	62			62			41	21			21		21																		8										11.16	1.04	-	-	2.75	-	-	0.53	0.17	-	-	0.05	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	16.17		3.43	11.16	1.04	-	-	2.75	-	-	0.53	0.17	-	-	0.05	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	16.17		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						2.51	0.07	0.64	0.07	0.29	0.25	0.08	0.03	0.15	0.47	0.52	0.03	0	0.09	0.01	1.35	0.12	0		0.13		0.09	0.11		0.02							0	0	0	0.02	0.02						7.08		0	13.67	1.11	0.64	0.07	3.04	0.25	0.08	0.56	0.33	0.47	0.52	0.08	0	0.49	0.01	1.35	0.12	0	-	0.13	-	0.09	0.11	-	0.02	-	-	-	-	-	-	0.07	0	0	0.02	0.02	-	-	-	-	-	23.24
H1286_002_0	2007	6																					2300											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3000	1749.78	152.43	832.82	0	235.53	12.22	5.27	435.66	27.09	6280.36	37.69	0	0.18	20.61	2880.16	3374.96	579.3	1.58	0	0	18.91	586.86	0	0	132.17	0	183.14	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											137.44	137.44	74.97	0	87.46	0.15	0.18	24.99	0.15	1	0.12	0	0.15	0.15	5	20	37.5	0.15	0	0	0.15	20	0	0	20	0	20	0	0	0	0											20.04	1.75	5.2	-	1.72	1.83	0.94	0.91	4.06	0.52	4.34	-	0.03	3.09	1.2	5.62	1.81	0.24	-	-	2.83	0.98	-	-	0.22	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.63		47.24	20.04	1.75	5.2	-	1.72	1.83	0.94	0.91	4.06	0.52	4.34	-	0.03	3.09	1.2	5.62	1.81	0.24	-	-	2.83	0.98	-	-	0.22	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.63		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.34	0.2	0.52	0.67	0.37	0.4	0.2	0.2	1.17	0.45	1.25	0	0.01	0.89	1.43	2.16	0.45	0.07	0	0	0.61	0.38	0	0	0.08	0	0.12	0	0	0	0											13.97		8.9	22.38	1.95	5.72	0.67	2.09	2.23	1.14	1.1	5.23	0.98	5.59	-	0.03	3.98	2.63	7.79	2.26	0.3	-	-	3.45	1.35	-	-	0.3	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.61
H1286_003_0	2007	4																					1900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	2500	1749.78	152.43	832.82	0	235.53	12.22	5.27	435.66	27.09	6280.36	37.69	0	0.18	20.61	2880.16	3374.96	579.3	1.58	0	0	18.91	586.86	0	0	132.17	0	183.14	0	0	0	0											225 (1a)	225 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	8 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	15 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 15 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	15 (17a)	0 n/c (17b1-17b5)	15 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											112.81	112.81	50.14	0	87.74	0.15	0.18	25.07	0.1	3.01	0.08	0	0.15	0.1	8	15	37.5	0.1	0	0	0.15	15	0	0	15	0	15	0	0	0	0											16.45	1.43	3.48	-	1.72	1.84	0.94	0.91	2.72	1.57	2.99	-	0.03	2.07	1.92	4.22	1.81	0.16	-	-	2.84	0.73	-	-	0.17	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.23		38.64	16.45	1.43	3.48	-	1.72	1.84	0.94	0.91	2.72	1.57	2.99	-	0.03	2.07	1.92	4.22	1.81	0.16	-	-	2.84	0.73	-	-	0.17	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.23		325 (1a)	325 (1b)	125 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	40 (incl in h2)	30 (14i)	30 (15)	0 (13a); 25 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.12	0.18	0.39	0.26	0.39	0.41	0.18	0.2	0.92	0.47	1.01	0	0.01	0.7	0.69	0.79	0.23	0.05	0	0	0.64	0.14	0	0	0.03	0	0.04	0	0	0	0											9.85		9.32	18.57	1.62	3.87	0.26	2.11	2.25	1.12	1.11	3.63	2.05	4	-	0.03	2.77	2.61	5.01	2.04	0.21	-	-	3.48	0.87	-	-	0.2	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.08
H1286_004_0	2007	7																					2900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3600	1729.97	150.7	823.39	0	232.86	11.94	5.15	430.73	26.48	6209.26	36.84	0	0.18	20.15	2847.55	3336.75	572.74	1.54	0	0	18.48	580.22	0	0	130.67	0	181.07	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											154.27	154.27	84.15	0	98.17	0.17	0.19	28.05	0.17	1.12	0.13	0	0.17	0.17	10	25	37.5	0.17	0	0	0.17	25	0	0	25	0	25	0	0	0	0											22.24	1.94	5.77	-	1.91	2.01	0.99	1.01	4.46	0.58	4.76	-	0.03	3.39	2.37	6.95	1.79	0.26	-	-	3.11	1.21	-	-	0.27	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.43		40.82	22.24	1.94	5.77	-	1.91	2.01	0.99	1.01	4.46	0.58	4.76	-	0.03	3.39	2.37	6.95	1.79	0.26	-	-	3.11	1.21	-	-	0.27	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.43		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.54	0.22	0.56	0.66	0.4	0.43	0.21	0.21	1.26	0.49	1.34	0	0.01	0.96	1.41	2.14	0.45	0.07	0	0	0.66	0.37	0	0	0.08	0	0.12	0	0	0	0											14.6		7.9	24.78	2.16	6.34	0.66	2.31	2.44	1.21	1.22	5.71	1.07	6.1	-	0.04	4.35	3.79	9.09	2.24	0.33	-	-	3.77	1.58	-	-	0.36	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.02
H1286_005_0	2007	4																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3000	1729.97	150.7	823.39	0	232.86	11.94	5.15	430.73	26.48	6209.26	36.84	0	0.18	20.15	2847.55	3336.75	572.74	1.54	0	0	18.48	580.22	0	0	130.67	0	181.07	0	0	0	0											225 (1a)	225 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	8 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	15 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 15 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	15 (17a)	0 n/c (17b1-17b5)	15 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											126.69	126.69	56.31	0	98.54	0.17	0.19	28.15	0.11	3.38	0.09	0	0.17	0.11	8	15	37.5	0.11	0	0	0.17	15	0	0	15	0	15	0	0	0	0											18.26	1.59	3.86	-	1.91	2.02	1	1.01	2.98	1.75	3.28	-	0.03	2.27	1.9	4.17	1.79	0.17	-	-	3.12	0.73	-	-	0.16	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.24		33.35	18.26	1.59	3.86	-	1.91	2.02	1	1.01	2.98	1.75	3.28	-	0.03	2.27	1.9	4.17	1.79	0.17	-	-	3.12	0.73	-	-	0.16	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.24		325 (1a)	325 (1b)	125 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	40 (incl in h2)	30 (14i)	30 (15)	0 (13a); 25 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.29	0.2	0.42	0.28	0.42	0.44	0.19	0.22	0.98	0.51	1.08	0	0.01	0.75	0.74	0.86	0.25	0.06	0	0	0.68	0.15	0	0	0.03	0	0.05	0	0	0	0											10.6		8.26	20.55	1.79	4.28	0.28	2.33	2.46	1.19	1.23	3.96	2.26	4.36	-	0.04	3.02	2.64	5.03	2.04	0.23	-	-	3.81	0.87	-	-	0.2	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.84
H1286_801_0	2007	7																					4000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	4500	1825.8	159.05	869	0	245.76	12.67	5.47	454.59	28.09	6553.24	39.08	0	0.19	21.37	3005.3	3521.6	604.47	1.63	0	0	19.6	612.36	0	0	137.91	0	191.1	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											171.07	171.07	93.31	0	108.86	0.19	0.21	31.1	0.19	3.73	0.14	0	0.19	0.19	35	35	37.5	0.19	0	0	0.19	35	0	0	35	0	35	0	0	0	0											26.03	2.27	6.76	-	2.23	2.36	1.14	1.18	5.24	2.04	5.6	-	0.04	3.99	8.77	10.27	1.89	0.31	-	-	3.66	1.79	-	-	0.4	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.5		37.98	26.03	2.27	6.76	-	2.23	2.36	1.14	1.18	5.24	2.04	5.6	-	0.04	3.99	8.77	10.27	1.89	0.31	-	-	3.66	1.79	-	-	0.4	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.5		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.92	0.25	0.65	0.41	0.46	0.49	0.21	0.24	1.45	0.56	1.55	0	0.01	1.11	1.53	1.52	0.28	0.08	0	0	0.76	0.26	0	0	0.06	0	0.08	0	0	0	0											14.9		10.4	28.95	2.52	7.41	0.41	2.69	2.86	1.35	1.42	6.69	2.6	7.15	-	0.04	5.1	10.29	11.79	2.17	0.39	-	-	4.42	2.05	-	-	0.46	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.4
H1302_001_0	2007	4																					1500											A	A	D	coin	coin	coin	coin	V	coin	coin	coin	coin	coin	V	V	V	V	V	coin	V	coin	V	T	P	V	V	V	V	O	O	V																																																				-		235.08	3.24	322.83	26.93	5.33	11.62	7.17	404.91	23.29	8.8	23.94	0	0.3	611.55	3531.96	3305.52	140.22	1207.44	20.6	7378.56	6.48	561.6	0	0	323.37	0	0	0	0	0	0											500/admit	500/admit	25 copay for days 8-19	10 Coinsurance	10 Coinsurance	10 Coinsurance	10 Coinsurance Prosthetics	50 ER; 20 Urgent Care	10 Coinsurance	10 Coinsurance	10 Coinsurance		10 Coinsurance	20 CORF; 10 OT/PT/ST/Cardiac Rehab	20 PCP Copay	20 Specialist Copay	20 MH Copay	20 Copay	10 Coinsurance	20 Copay Part B Rx	10 Coinsurance	20 Copay			20 Vision Copay																	445.64	444.44	24.9	0.1	0.1	0.1	0.09	43.57	0.1	0.1	0.1	0	0.1	20.01	20.01	20	19.68	19.98	0.1	4.37	0.1	20.09	0	0	20.04	0	0	0	0	0	0											8.73	0.12	0.67	2.69	0.53	1.16	0.65	1.47	2.33	0.88	2.39	-	0.03	1.02	5.89	5.51	0.23	2.01	2.06	2.69	0.65	0.94	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.19		1.08	8.73	0.12	0.67	2.69	0.53	1.16	0.65	1.47	2.33	0.88	2.39	-	0.03	1.02	5.89	5.51	0.23	2.01	2.06	2.69	0.65	0.94	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.19	4500	750/admit	750/admit	50 copay	25 Coinsurance	10 Coinsurance	25 Coinsurance	25 Coinsurance	50 ER; 20 Urgent Care	25 Coinsurance	25 Coinsurance	25 Coinsurance	No Copay	10 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Part B Rx	25 Coinsurance	25 Coinsurance	No Copay	No Copay	25 Coinsurance	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay											1.35	0.02	0.42	0.53	0.05	0.27	0.17	0.13	0.52	0.2	0.55	0	0	0.34	0.6	1.78	0.02	0.06	0.46	0.65	0.14	0.09	0	0	0.05	0	0	0	0	0	0											8.4		3.29	10.08	0.14	1.09	3.22	0.58	1.43	0.82	1.6	2.85	1.08	2.94	-	0.03	1.36	6.49	7.29	0.25	2.07	2.52	3.34	0.79	1.03	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.59
H1302_002_0	2007	3																					1500											A	A	D	coin	coin	coin	coin	V	coin	coin	coin	coin	coin	V	V	V	V	V	coin	V	coin	V	T	P	V	V	V	V	O	O	O																																																				-		106.83	1.17	130.68	14.96	2.51	5.19	3.36	174.06	14.21	4.78	13.58	0	0.19	248.31	2068.74	1851.93	75.69	621.81	11.74	3541.14	4.09	330.39	0	0	196.65	0	0	0	0	0	0											500/admit	500/admit	25 copay for days 8-19	10 Coinsurance	10 Coinsurance	10 Coinsurance	10 Coinsurance Prosthetics	50 ER; 20 Urgent Care	10 Coinsurance	10 Coinsurance	10 Coinsurance		10 Coinsurance	20 CORF; 10 OT/PT/ST/Cardiac Rehab	20 PCP Copay	20 Specialist Copay	20 MH Copay	20 Copay	10 Coinsurance	20 Copay Part B Rx	10 Coinsurance	20 Copay			20 Vision Copay																	474.02	512.82	24.79	0.1	0.1	0.1	0.09	41.37	0.1	0.1	0.1	0	0.16	19.81	20.01	20.02	20.61	20.07	0.1	3.9	0.1	19.98	0	0	20.14	0	0	0	0	0	0											4.22	0.05	0.27	1.49	0.25	0.52	0.31	0.6	1.42	0.48	1.36	-	0.03	0.41	3.45	3.09	0.13	1.04	1.17	1.15	0.41	0.55	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.73		0.23	4.22	0.05	0.27	1.49	0.25	0.52	0.31	0.6	1.42	0.48	1.36	-	0.03	0.41	3.45	3.09	0.13	1.04	1.17	1.15	0.41	0.55	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.73	4500	750/admit	750/admit	50 copay	25 Coinsurance	10 Coinsurance	25 Coinsurance	25 Coinsurance	50 ER; 20 Urgent Care	25 Coinsurance	25 Coinsurance	25 Coinsurance	No Copay	10 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Part B Rx	25 Coinsurance	25 Coinsurance	No Copay	No Copay	25 Coinsurance	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay											0.85	0.01	0.27	0.34	0.03	0.17	0.1	0.08	0.33	0.13	0.35	0	0	0.21	0.37	1.12	0.01	0.04	0.29	0.41	0.09	0.06	0	0	0.03	0	0	0	0	0	0											5.29		1.39	5.07	0.06	0.54	1.83	0.28	0.69	0.41	0.68	1.75	0.61	1.71	-	0.03	0.62	3.82	4.21	0.14	1.08	1.46	1.56	0.5	0.61	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.02
H1302_004_0	2007	1																					1500											A	A	D	coin	coin	coin	coin	V	coin	coin	coin	coin	coin	V	V	V	V	V	coin	V	coin	V	T	P	V	V	V	V	O	O	V																																																				-		147.42	2.07	203.31	16.16	3.42	7.52	4.63	251.73	14.26	5.45	14.83	0	0.18	381.78	2117.79	1998	86.22	748.17	12.27	3535.2	4.09	330.39	0	0	196.65	0	0	0	0	0	0											500/admit	500/admit	25 copay for days 8-19	10 Coinsurance	10 Coinsurance	10 Coinsurance	10 Coinsurance Prosthetics	50 ER; 20 Urgent Care	10 Coinsurance	10 Coinsurance	10 Coinsurance		10 Coinsurance	20 CORF; 10 OT/PT/ST/Cardiac Rehab	20 PCP Copay	20 Specialist Copay	20 MH Copay	20 Copay	10 Coinsurance	20 Copay Part B Rx	10 Coinsurance	20 Copay			20 Vision Copay																	463.17	463.77	24.79	0.1	0.1	0.1	0.09	43.86	0.1	0.1	0.1	0	0.11	20.12	20	20	19.49	20.05	0.1	3.9	0.1	19.98	0	0	20.14	0	0	0	0	0	0											5.69	0.08	0.42	1.62	0.34	0.76	0.42	0.92	1.42	0.55	1.49	-	0.02	0.64	3.53	3.33	0.14	1.25	1.22	1.15	0.41	0.55	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.28		0.46	5.69	0.08	0.42	1.62	0.34	0.76	0.42	0.92	1.42	0.55	1.49	-	0.02	0.64	3.53	3.33	0.14	1.25	1.22	1.15	0.41	0.55	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.28	4500	750/admit	750/admit	50 copay	25 Coinsurance	10 Coinsurance	25 Coinsurance	25 Coinsurance	50 ER; 20 Urgent Care	25 Coinsurance	25 Coinsurance	25 Coinsurance	No Copay	10 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Part B Rx	25 Coinsurance	25 Coinsurance	No Copay	No Copay	25 Coinsurance	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay											0.89	0.01	0.28	0.35	0.03	0.18	0.11	0.08	0.34	0.13	0.36	0	0	0.22	0.39	1.18	0.01	0.04	0.31	0.41	0.09	0.06	0	0	0.03	0	0	0	0	0	0											5.5		1.49	6.58	0.09	0.7	1.97	0.37	0.94	0.53	1	1.76	0.68	1.85	-	0.02	0.86	3.92	4.51	0.15	1.29	1.53	1.56	0.5	0.61	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.78
H1302_005_0	2007	1																					1500											A	A	D	coin	coin	coin	coin	V	coin	coin	coin	coin	coin	V	V	V	V	V	coin	V	coin	V	T	P	V	V	V	V	O	O	V																																																				-		104.85	1.17	127.08	14.8	2.42	4.99	3.23	173.25	13.32	4.44	12.62	0	0.18	247.86	2059.47	1838.07	74.25	607.59	11.18	3535.2	4.09	330.39	0	0	196.65	0	0	0	0	0	0											500/admit	500/admit	25 copay for days 8-19	10 Coinsurance	10 Coinsurance	10 Coinsurance	10 Coinsurance Prosthetics	50 ER; 20 Urgent Care	10 Coinsurance	10 Coinsurance	10 Coinsurance		10 Coinsurance	20 CORF; 10 OT/PT/ST/Cardiac Rehab	20 PCP Copay	20 Specialist Copay	20 MH Copay	20 Copay	10 Coinsurance	20 Copay Part B Rx	10 Coinsurance	20 Copay			20 Vision Copay																	474.96	512.82	24.55	0.1	0.1	0.1	0.09	41.56	0.1	0.1	0.1	0	0.17	19.85	19.99	19.98	19.39	19.95	0.1	3.9	0.1	19.98	0	0	20.14	0	0	0	0	0	0											4.15	0.05	0.26	1.48	0.24	0.5	0.3	0.6	1.33	0.44	1.26	-	0.03	0.41	3.43	3.06	0.12	1.01	1.13	1.15	0.41	0.55	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.24		0.23	4.15	0.05	0.26	1.48	0.24	0.5	0.3	0.6	1.33	0.44	1.26	-	0.03	0.41	3.43	3.06	0.12	1.01	1.13	1.15	0.41	0.55	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.24	4500	750/admit	750/admit	50 copay	25 Coinsurance	10 Coinsurance	25 Coinsurance	25 Coinsurance	50 ER; 20 Urgent Care	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	10 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Coinsurance	25 Part B Rx	25 Coinsurance	25 Coinsurance	No Copay	No Copay	25 Coinsurance	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay											0.85	0.01	0.27	0.34	0.03	0.17	0.1	0.08	0.33	0.13	0.35	0	0	0.21	0.37	1.12	0.01	0.04	0.29	0.41	0.09	0.06	0	0	0.03	0	0	0	0	0	0											5.29		1.39	5	0.06	0.53	1.82	0.27	0.67	0.4	0.68	1.66	0.57	1.61	-	0.03	0.62	3.8	4.18	0.13	1.05	1.42	1.56	0.5	0.61	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.53
H1303_001_0	2007	6																					2900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3600	1793.27	156.22	853.51	0	241.38	12.83	5.54	446.49	28.45	6436.46	39.58	0	0.19	21.65	2951.75	3458.84	593.7	1.66	0	0	19.86	601.45	0	0	135.46	0	187.7	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											150.96	150.96	82.34	0	96.06	0.16	0.19	27.45	0.16	1.1	0.13	0	0.16	0.16	10	25	37.5	0.16	0	0	0.16	25	0	0	25	0	25	0	0	0	0											22.56	1.97	5.86	-	1.93	2.11	1.05	1.02	4.69	0.59	4.96	-	0.03	3.57	2.46	7.21	1.86	0.27	-	-	3.27	1.25	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.32		44.01	22.56	1.97	5.86	-	1.93	2.11	1.05	1.02	4.69	0.59	4.96	-	0.03	3.57	2.46	7.21	1.86	0.27	-	-	3.27	1.25	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.32		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.57	0.22	0.57	0.71	0.41	0.45	0.22	0.22	1.32	0.5	1.4	0	0.01	1	1.48	2.21	0.46	0.08	0	0	0.69	0.39	0	0	0.09	0	0.12	0	0	0	0											15.1		8.57	25.13	2.19	6.43	0.71	2.34	2.56	1.28	1.24	6	1.09	6.35	-	0.04	4.57	3.94	9.42	2.32	0.35	-	-	3.96	1.64	-	-	0.37	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.42
H1303_003_0	2007	3																					2700											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3300	1793.27	156.22	853.51	0	241.38	12.83	5.54	446.49	28.45	6436.46	39.58	0	0.19	21.65	2951.75	3458.84	593.7	1.66	0	0	19.86	601.45	0	0	135.46	0	187.7	0	0	0	0											265 (1a)	265 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	8 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	15 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 15 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	15 (17a)	0 n/c (17b1-17b5)	15 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											148.7	148.7	56.11	0	98.2	0.17	0.19	28.06	0.11	3.37	0.09	0	0.17	0.11	8	15	37.5	0.11	0	0	0.17	15	0	0	15	0	15	0	0	0	0											22.22	1.94	3.99	-	1.98	2.16	1.07	1.04	3.19	1.81	3.48	-	0.03	2.43	1.97	4.32	1.86	0.19	-	-	3.34	0.75	-	-	0.17	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.17		37.97	22.22	1.94	3.99	-	1.98	2.16	1.07	1.04	3.19	1.81	3.48	-	0.03	2.43	1.97	4.32	1.86	0.19	-	-	3.34	0.75	-	-	0.17	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.17		365 (1a)	365 (1b)	100 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.67	0.23	0.35	0.3	0.44	0.48	0.21	0.23	1.06	0.53	1.15	0	0.01	0.8	0.78	1.07	0.26	0.06	0	0	0.74	0.19	0	0	0.04	0	0.06	0	0	0	0											11.64		9.02	24.89	2.17	4.34	0.3	2.41	2.64	1.27	1.27	4.25	2.34	4.63	-	0.04	3.24	2.74	5.39	2.12	0.25	-	-	4.08	0.94	-	-	0.21	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.8
H1303_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2140.35	338.67	1090.33		254.12	25.02	21.68	870.84	377.59	1981.05	929.42	64.33	3.06	1955.64		3375.23		512.36		785.62												278.77		150.07	223.25							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							6.5	1.03	1.59	-	0.77	2.43	2.11	1.27	0.38	0.8	0.38	0.07	0.3	1.98	-	1.37	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.76		23.02	6.5	1.03	1.59	-	0.77	2.43	2.11	1.27	0.38	0.8	0.38	0.07	0.3	1.98	-	1.37	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.76		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.04	0.14	0.27	0.35	0.06	0.15	0.13	0.05	0.18	0.13	0.12	0.01	0.02	0.2	0.33	0.21	0.04	0.03	0.14	0.67	0.14	0																				5.43		0	8.54	1.17	1.86	0.35	0.83	2.59	2.24	1.32	0.56	0.93	0.5	0.08	0.31	2.18	0.33	1.58	0.04	0.24	0.14	0.99	0.14	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	27.19
H1303_801_0	2007	5																					4200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	4800	1882.93	164.03	896.19	0	253.45	13.47	5.82	468.81	29.87	6758.29	41.56	0	0.2	22.73	3099.34	3631.78	623.38	1.74	0	0	20.85	631.52	0	0	142.23	0	197.08	0	0	0	0											325 (1a)	325 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											196.03	196.03	90.47	0	105.55	0.18	0.2	30.16	0.18	3.62	0.14	0	0.18	0.18	35	35	37.5	0.18	0	0	0.18	35	0	0	35	0	35	0	0	0	0											30.76	2.68	6.76	-	2.23	2.44	1.18	1.18	5.41	2.04	5.72	-	0.04	4.12	9.04	10.59	1.95	0.31	-	-	3.77	1.84	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.04		44.93	30.76	2.68	6.76	-	2.23	2.44	1.18	1.18	5.41	2.04	5.72	-	0.04	4.12	9.04	10.59	1.95	0.31	-	-	3.77	1.84	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.04		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.04	0.27	0.68	0.44	0.48	0.53	0.23	0.26	1.56	0.59	1.65	0	0.01	1.19	1.6	1.58	0.29	0.09	0	0	0.82	0.28	0	0	0.06	0	0.09	0	0	0	0											15.71		10.7	33.8	2.94	7.43	0.44	2.71	2.97	1.41	1.43	6.97	2.63	7.37	-	0.04	5.3	10.64	12.17	2.24	0.41	-	-	4.59	2.12	-	-	0.48	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.75
H1304_001_0	2007	3																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	816.01	11.82	1427.63	1239	1028.42	3.21	200.37	226.23	230.8	1509.33	764.76	0	0	1627.38	6990.56	845.27	199.71	804.32	3941.86	569.2	772.12	181.96	0	1413.7	494.87	259.92	79.03	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.5	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											6.8	0.1	-	-	4.29	1.62	-	0.94	-	-	-	-	-	-	2.91	0.35	0.08	0.34	-	0.24	-	-	-	-	0.21	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.9	0	0	6.8	0.1	-	-	4.29	1.62	-	0.94	-	-	-	-	-	-	2.91	0.35	0.08	0.34	-	0.24	-	-	-	-	0.21	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.9	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.58	0.04	0.72	0.22	0.06	0.2	0.01	0.13	0.36	0.26	0.51			0.66	0.74	0.3	0.02	0.02	0.42	1.65	0.07			0.05	0.05	0.04	0.01															10.12	250	6.32	10.38	0.14	0.72	0.22	4.35	1.82	0.01	1.07	0.36	0.26	0.51	-	-	0.66	3.65	0.65	0.1	0.36	0.42	1.89	0.07	-	-	0.05	0.26	0.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.02
H1304_002_0	2007	3																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	816.01	11.82	1427.63	1239	1028.42	3.21	200.37	226.23	230.8	1509.33	764.76	0	0	1627.38	6990.56	845.27	199.71	804.32	3941.86	569.2	772.12	181.96	0	1413.7	494.87	259.92	79.03	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.5	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											6.8	0.1	-	-	4.29	1.62	-	0.94	-	-	-	-	-	-	2.91	0.35	0.08	0.34	-	0.24	-	-	-	-	0.21	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.9	0	0	6.8	0.1	-	-	4.29	1.62	-	0.94	-	-	-	-	-	-	2.91	0.35	0.08	0.34	-	0.24	-	-	-	-	0.21	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.9	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.58	0.04	0.72	0.22	0.06	0.2	0.01	0.13	0.36	0.26	0.51			0.66	0.74	0.3	0.02	0.02	0.42	1.65	0.07			0.05	0.05	0.04	0.01															10.12	250	6.32	10.38	0.14	0.72	0.22	4.35	1.82	0.01	1.07	0.36	0.26	0.51	-	-	0.66	3.65	0.65	0.1	0.36	0.42	1.89	0.07	-	-	0.05	0.26	0.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.02
H1304_004_0	2007	3																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	816.01	11.82	1427.63	1239	1028.42	3.21	200.37	226.23	230.8	1509.33	764.76	0	0	1627.38	6990.56	845.27	199.71	804.32	3941.86	569.2	772.12	181.96	0	1413.7	494.87	259.92	79.03	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.5	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											6.8	0.1	-	-	4.29	1.62	-	0.94	-	-	-	-	-	-	2.91	0.35	0.08	0.34	-	0.24	-	-	-	-	0.21	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.9	0	0	6.8	0.1	-	-	4.29	1.62	-	0.94	-	-	-	-	-	-	2.91	0.35	0.08	0.34	-	0.24	-	-	-	-	0.21	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.9	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.58	0.04	0.72	0.22	0.06	0.2	0.01	0.13	0.36	0.26	0.51			0.66	0.74	0.3	0.02	0.02	0.42	1.65	0.07			0.05	0.05	0.04	0.01															10.12	250	6.32	10.38	0.14	0.72	0.22	4.35	1.82	0.01	1.07	0.36	0.26	0.51	-	-	0.66	3.65	0.65	0.1	0.36	0.42	1.89	0.07	-	-	0.05	0.26	0.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.02
H1340_002_0	2007	2																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2233.1	47.14	1159.43	2094.83	9.11	24.54	4.19	5.33	28.98	2954.83	28.99	0	8.59	18.77	23.53	52.38	1.73	1192.43	26.76	33143.68	9.25	5924.45	0	699.2	338.4	260.8	48.3	6.1	0	296.05	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0	0exam;10-20/20-50 compreh dent;1000max bft	0	1pr glasses/cont per yr 140 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											103.22	37.62	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	3.81	0.2	0	0	7.37	0	10	0	10	0	0	0											19.21	0.15	2.61	-	1.82	4.91	0.84	1.07	5.8	-	5.8	-	1.72	3.75	4.54	10.48	0.87	-	4.55	10.52	1.85	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	81.13		0	19.21	0.15	2.61	-	1.82	4.91	0.84	1.07	5.8	-	5.8	-	1.72	3.75	4.54	10.48	0.87	-	4.55	10.52	1.85	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	81.13	0																								50 (500 max bft)	50 coinsurance; 70 max bft	50 coinsurance; 70 max bft	50 coinsurance	50 coinsurance																																					1.61	0.18	0.18	0.03	0.06														2.06		0	19.21	0.15	2.61	-	1.82	4.91	0.84	1.07	5.8	-	5.8	-	1.72	3.75	4.54	10.48	0.87	-	4.55	10.52	1.85	-	-	2.04	0.18	0.4	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	83.19
H1340_003_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2109.45	44.53	979.67	1832.4	9.05	24.38	4.08	5.12	27.85	2705.98	27.69	0	8.25	18.04	24.93	50.64	1.58	1040.16	27.91	31532.83	8.89	5250.54	0	699.2	338.4	260.8	48.3	6.1	0	302.29	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0	0exam;10-20/20-50 compreh dent;1000max bft	0	1pr glasses/cont per yr 260 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											111.78	40.74	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	3.84	0.2	0	0	7.37	0	10	0	10	0	0	0											19.65	0.15	2.21	-	1.81	4.88	0.82	1.02	5.57	-	5.54	-	1.65	3.61	4.81	10.13	0.79	-	4.75	10.09	1.78	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	79.89		0	19.65	0.15	2.21	-	1.81	4.88	0.82	1.02	5.57	-	5.54	-	1.65	3.61	4.81	10.13	0.79	-	4.75	10.09	1.78	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	79.89	0																								50 (500 max bft)	50 coinsurance; 100 max bft	50 coinsurance; 100 max bft	50 coinsurance	50 coinsurance																																					1.61	0.18	0.26	0.03	0.06														2.14		0	19.65	0.15	2.21	-	1.81	4.88	0.82	1.02	5.57	-	5.54	-	1.65	3.61	4.81	10.13	0.79	-	4.75	10.09	1.78	-	-	2.04	0.18	0.48	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	82.03
H1340_004_0	2007	4																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2195.32	46.34	1381.14	2676.61	10.92	29.41	4.77	5.86	31.89	3151.59	31.78	0	9.45	20.66	21.99	54.15	1.97	1337.36	32.77	34901.75	10.17	6565.85	0	648.8	338.4	260.8	48.3	6.1	0	285.46	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0	0exam;10-20/20-50 compreh dent;1000max bft	0	1pr glasses/cont per yr 260 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											111.32	40.57	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	4.15	0.2	0	0	8.19	0	10	0	10	0	0	0											20.37	0.16	3.11	-	2.18	5.88	0.95	1.17	6.38	-	6.36	-	1.89	4.13	4.24	10.83	0.99	-	5.57	12.08	2.03	-	-	0.44	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	88.99		0	20.37	0.16	3.11	-	2.18	5.88	0.95	1.17	6.38	-	6.36	-	1.89	4.13	4.24	10.83	0.99	-	5.57	12.08	2.03	-	-	0.44	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	88.99	0																								50 (500 max bft)	50 coinsurance; 100 max bft	50 coinsurance; 100 max bft	50 coinsurance	50 coinsurance																																					1.87	0.18	0.26	0.03	0.06														2.4		0	20.37	0.16	3.11	-	2.18	5.88	0.95	1.17	6.38	-	6.36	-	1.89	4.13	4.24	10.83	0.99	-	5.57	12.08	2.03	-	-	2.31	0.18	0.48	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	91.39
H1340_005_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2079.08	43.89	1222.85	1942.42	8.59	23.14	4.08	5.31	28.88	3363.53	29.01	0	8.56	18.71	23.59	50.21	1.58	1100.3	26.78	32172.14	9.21	5516.7	0	0	338.4	260.8	48.3	6.1	0	294.62	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0		0	1pr glasses/cont per yr 260 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											108.72	39.62	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	3.89	0.2	0	0	0	0	10	0	10	0	0	0											18.84	0.14	2.75	-	1.72	4.63	0.82	1.06	5.78	-	5.8	-	1.71	3.74	4.56	10.04	0.79	-	4.55	10.44	1.84	-	-	-	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	79.43		0	18.84	0.14	2.75	-	1.72	4.63	0.82	1.06	5.78	-	5.8	-	1.71	3.74	4.56	10.04	0.79	-	4.55	10.44	1.84	-	-	-	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	79.43	0																								0	50 coinsurance; 100 max bft	50 coinsurance; 100 max bft	50 coinsurance	50 coinsurance																																					0	0.18	0.26	0.03	0.06														0.53		0	18.84	0.14	2.75	-	1.72	4.63	0.82	1.06	5.78	-	5.8	-	1.71	3.74	4.56	10.04	0.79	-	4.55	10.44	1.84	-	-	-	0.18	0.48	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	79.96
H1340_006_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1341.37	28.31	772.82	1347.88	7.42	19.99	3.63	471.31	364.76	2528.47	27.54	0	7.75	676	4706.61	9287.05	0.91	822.35	21.36	103.91	8.35	11.48	0	0	0	0	0	0	0	224.41	549.29											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.48	4	0.73	-	-	-	1.38	-	1.55	-	-	-	0	-	0.68	0.76	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.58		0	-	-	-	-	1.48	4	0.73	-	-	-	1.38	-	1.55	-	-	-	0	-	0.68	0.76	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.58	0																																																																																			-		0	-	-	-	-	1.48	4	0.73	-	-	-	1.38	-	1.55	-	-	-	0	-	0.68	0.76	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.58
H1340_007_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1794.65	37.88	1081.85	1982.54	9.71	26.14	4.02	436.49	337.82	2341.69	27.01	0	7.61	626.06	4929.89	10449.35	1.12	1031.24	27.82	123.17	8.19	17.33	0	0	0	0	0	0	0	235.06	549.4											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.94	5.23	0.8	-	-	-	1.35	-	1.52	-	-	-	0.01	-	0.89	1.12	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.86		0	-	-	-	-	1.94	5.23	0.8	-	-	-	1.35	-	1.52	-	-	-	0.01	-	0.89	1.12	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.86	0																																																																																			-		0	-	-	-	-	1.94	5.23	0.8	-	-	-	1.35	-	1.52	-	-	-	0.01	-	0.89	1.12	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.86
H1340_008_0	2007	5																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1634.83	34.51	1096.95	1706.3	7.25	19.53	3.71	545.62	422.28	2927.17	28.93	0	8.15	782.59	4831.69	9945.19	1.03	941.03	22.89	113.41	8.78	14.68	0	0	0	0	0	0	0	230.37	549.34											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.45	3.91	0.74	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.73	0.97	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.88		0	-	-	-	-	1.45	3.91	0.74	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.73	0.97	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.88	0																																																																																			-		0	-	-	-	-	1.45	3.91	0.74	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.73	0.97	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.88
H1340_009_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1667.49	35.2	1081.24	1720.7	8.15	21.96	3.74	474.12	366.94	2543.56	27.27	0	7.68	680.03	4847.16	10170.86	1.11	989.66	26.01	120.9	8.27	16.44	0	0	0	0	0	0	0	231.11	549.31											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.63	4.39	0.75	-	-	-	1.36	-	1.54	-	-	-	0.01	-	0.83	1.09	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.59		0	-	-	-	-	1.63	4.39	0.75	-	-	-	1.36	-	1.54	-	-	-	0.01	-	0.83	1.09	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.59	0																																																																																			-		0	-	-	-	-	1.63	4.39	0.75	-	-	-	1.36	-	1.54	-	-	-	0.01	-	0.83	1.09	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.59
H1340_010_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1934.29	40.83	1143.49	2337.61	9.46	25.48	4.08	473.53	366.49	2540.43	28.39	0	8	679.19	4960.14	10594.71	1.18	1056.69	28.79	131.54	8.61	18.22	0	0	0	0	0	0	0	236.5	549.37											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.89	5.1	0.82	-	-	-	1.42	-	1.6	-	-	-	0.01	-	0.92	1.21	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.96		0	-	-	-	-	1.89	5.1	0.82	-	-	-	1.42	-	1.6	-	-	-	0.01	-	0.92	1.21	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.96	0																																																																																			-		0	-	-	-	-	1.89	5.1	0.82	-	-	-	1.42	-	1.6	-	-	-	0.01	-	0.92	1.21	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.96
H1340_011_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1962.41	41.42	1190.85	2228.04	10.07	27.12	4.24	470.24	363.94	2522.76	28.92	0	8.15	674.47	5052.59	10837.11	1.25	1086.97	29.29	135.95	8.78	19.28	0	0	0	0	0	0	0	240.91	549.36											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	2.01	5.42	0.85	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.93	1.27	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.57		0	-	-	-	-	2.01	5.42	0.85	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.93	1.27	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.57	0																																																																																			-		0	-	-	-	-	2.01	5.42	0.85	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.93	1.27	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.57
H1340_012_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1666.1	35.09	1115.52	1872.53	7.97	21.46	3.68	365.09	372.47	10.03	25.42	0	7.56	690.27	4196.62	8507.6	186.74	782.8	4741.44	119.78	8.14	15.46	0	0	419.18	0	179.65	0	0	223.57	2.12											250  Days 1 - 5	250  Days 1 - 5	119  days 21 - 100	0	0.2	0.3	0.3	50	75-ASC/ 150-OP/ 150-Non Surg	0.2	0.2		0.2	40 to 150	15	40	30 to 40	40	Phy. Off. 10-40 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	50											145.44	145.44	24.64	0	0.18	0.27	0.27	45.6	129.96	0.18	0.18	0	0.18	85.63	11.5	36.48	29.64	36.48	14.87	0.1	0.18	0	0	0	18.24	0	18.24	0	0	0	45.6											20.19	0.43	2.29	-	1.45	5.87	1.01	1.39	4.03	1.83	4.64	-	1.38	4.93	4.02	25.86	0.46	2.38	5.87	12.22	1.48	-	-	-	0.64	-	0.27	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	102.65		9.91	20.19	0.43	2.29	-	1.45	5.87	1.01	1.39	4.03	1.83	4.64	-	1.38	4.93	4.02	25.86	0.46	2.38	5.87	12.22	1.48	-	-	-	0.64	-	0.27	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	102.65	3650																																																																																			-		0	20.19	0.43	2.29	-	1.45	5.87	1.01	1.39	4.03	1.83	4.64	-	1.38	4.93	4.02	25.86	0.46	2.38	5.87	12.22	1.48	-	-	-	0.64	-	0.27	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	102.65
H1340_013_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1589.32	33.55	899.76	1681.75	8.27	22.27	3.81	359.39	366.65	10.36	26.33	0	7.84	679.5	4423.78	8803.22	187.9	787.65	4643.36	116.02	8.44	15.42	0	0	441.88	0	189.38	0	0	235.67	549.38											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.51	131.51	26.41	0	0.18	0.23	0.23	45.81	105.83	0.18	0.18	0	0.18	70.23	7.71	32.07	25.2	32.07	13.61	0.09	0.18	0	0	0	18.32	0	18.32	0	0	0	0.31											17.42	0.37	1.98	-	1.52	5.1	0.87	1.37	3.23	1.9	4.82	-	1.44	3.98	2.84	23.53	0.39	2.1	5.26	10.91	1.55	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	91.56		8.48	17.42	0.37	1.98	-	1.52	5.1	0.87	1.37	3.23	1.9	4.82	-	1.44	3.98	2.84	23.53	0.39	2.1	5.26	10.91	1.55	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	91.56	3650																																																																																			-		0	17.42	0.37	1.98	-	1.52	5.1	0.87	1.37	3.23	1.9	4.82	-	1.44	3.98	2.84	23.53	0.39	2.1	5.26	10.91	1.55	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	91.56
H1340_014_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1756.39	37.07	1030.82	2046.83	8.8	23.69	3.93	363.02	370.35	10.45	26.5	0	7.89	686.36	4300.73	8777.03	194.54	815.5	4880.85	124.93	8.5	16.72	0	0	429.58	0	184.11	0	0	229.11	549.33											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.28	131.28	26.35	0	0.18	0.23	0.23	45.73	105.64	0.18	0.18	0	0.18	70.11	7.69	32.01	25.15	32.01	13.89	0.09	0.18	0	0	0	18.29	0	18.29	0	0	0	0.3											19.21	0.41	2.26	-	1.61	5.42	0.9	1.38	3.26	1.91	4.85	-	1.44	4.01	2.76	23.41	0.41	2.18	5.65	11.25	1.55	-	-	-	0.65	-	0.28	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	94.82		8.91	19.21	0.41	2.26	-	1.61	5.42	0.9	1.38	3.26	1.91	4.85	-	1.44	4.01	2.76	23.41	0.41	2.18	5.65	11.25	1.55	-	-	-	0.65	-	0.28	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	94.82	3650																																																																																			-		0	19.21	0.41	2.26	-	1.61	5.42	0.9	1.38	3.26	1.91	4.85	-	1.44	4.01	2.76	23.41	0.41	2.18	5.65	11.25	1.55	-	-	-	0.65	-	0.28	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	94.82
H1340_015_0	2007	5																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1772.5	37.41	1053.23	2012.76	8.92	24.02	3.94	369.48	376.94	10.41	26.48	0	7.86	698.56	4452.82	9133.26	203.91	854.78	5042.79	129.14	8.47	17.95	0	0	444.78	0	190.62	0	0	237.21	549.36											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.39	131.39	26.37	0	0.18	0.23	0.23	45.77	105.74	0.18	0.18	0	0.18	70.17	7.7	32.04	25.18	32.04	14.11	0.09	0.18	0	0	0	18.31	0	18.31	0	0	0	0.31											19.41	0.41	2.31	-	1.63	5.5	0.9	1.41	3.32	1.91	4.85	-	1.44	4.08	2.86	24.39	0.43	2.28	5.93	11.43	1.55	-	-	-	0.68	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	97.02		9.01	19.41	0.41	2.31	-	1.63	5.5	0.9	1.41	3.32	1.91	4.85	-	1.44	4.08	2.86	24.39	0.43	2.28	5.93	11.43	1.55	-	-	-	0.68	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	97.02	3650																																																																																			-		0	19.41	0.41	2.31	-	1.63	5.5	0.9	1.41	3.32	1.91	4.85	-	1.44	4.08	2.86	24.39	0.43	2.28	5.93	11.43	1.55	-	-	-	0.68	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	97.02
H1340_016_0	2007	4																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1621.05	34.22	1025.96	1974.03	9.01	24.28	3.94	366.08	373.47	10.31	26.26	0	7.8	692.14	4657.9	9596.66	215.63	903.87	5302.01	138.64	8.4	20.44	0	0	465.26	0	199.4	0	0	248.14	549.34											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.33	131.33	26.35	0	0.18	0.23	0.23	45.75	105.69	0.18	0.18	0	0.18	70.14	7.7	32.03	25.16	32.03	15.4	0.08	0.18	0	0	0	18.3	0	18.3	0	0	0	0.31											17.74	0.37	2.25	-	1.65	5.55	0.9	1.4	3.29	1.89	4.81	-	1.43	4.05	2.99	25.61	0.45	2.41	6.8	11.71	1.54	-	-	-	0.71	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	97.86		9.11	17.74	0.37	2.25	-	1.65	5.55	0.9	1.4	3.29	1.89	4.81	-	1.43	4.05	2.99	25.61	0.45	2.41	6.8	11.71	1.54	-	-	-	0.71	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	97.86	3650																																																																																			-		0	17.74	0.37	2.25	-	1.65	5.55	0.9	1.4	3.29	1.89	4.81	-	1.43	4.05	2.99	25.61	0.45	2.41	6.8	11.71	1.54	-	-	-	0.71	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	97.86
H1340_017_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2139.11	45.15	859.92	3300.38	10.14	27.31	4.42	370.13	377.61	11.42	29.29	0	8.74	699.8	4930.18	10072.26	223.6	937.28	5592.1	151.46	9.41	21.43	0	0	492.46	0	211.05	0	0	262.64	549.42											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											130.66	130.66	26.22	0	0.18	0.23	0.23	45.52	105.15	0.18	0.18	0	0.18	69.78	7.66	31.86	25.03	31.86	14.67	0.08	0.18	0	0	0	18.21	0	18.21	0	0	0	0.3											23.29	0.49	1.88	-	1.85	6.22	1.01	1.4	3.31	2.08	5.33	-	1.59	4.07	3.15	26.74	0.47	2.49	6.84	12.12	1.71	-	-	-	0.75	-	0.32	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	107.12		10.57	23.29	0.49	1.88	-	1.85	6.22	1.01	1.4	3.31	2.08	5.33	-	1.59	4.07	3.15	26.74	0.47	2.49	6.84	12.12	1.71	-	-	-	0.75	-	0.32	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	107.12	3650																																																																																			-		0	23.29	0.49	1.88	-	1.85	6.22	1.01	1.4	3.31	2.08	5.33	-	1.59	4.07	3.15	26.74	0.47	2.49	6.84	12.12	1.71	-	-	-	0.75	-	0.32	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	107.12
H1340_801_0	2007	4																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1783.43	37.65	1202.12	1894.63	7.79	20.97	3.67	4.76	25.87	2673.35	25.83	0	7.67	16.76	19.25	47.49	1.66	2.11	4871.92	118.92	8.26	17.89	0	0	0	0	0	0	0	237.14	0											952  0 (1-60) 238 (61 - 90) 476 (91+)	952  0 (1-60) 238 (61 - 90) 476 (91+)	119  Days 21-100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2		0.2	0.2	0.2	0.2	0.5 to 0.5	0.2	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0.2	0	Not covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.8	52.03	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0.2	10.45	0.1	0.2	0.2	0	0	0	0	0	0	0	0	0											21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9	0																																																																																			-		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9
H1340_802_0	2007	4																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1783.43	37.65	1202.12	1894.63	7.79	20.97	3.67	4.76	25.87	2673.35	25.83	0	7.67	16.76	19.25	47.49	1.66	2.11	4871.92	118.92	8.26	17.89	0	0	0	0	0	0	0	237.14	0											952  0 (1-60) 238 (61 - 90) 476 (91+)	952  0 (1-60) 238 (61 - 90) 476 (91+)	119  Days 21-100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2		0.2	0.2	0.2	0.2	0.5 to 0.5	0.2	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0.2	0	Not covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.8	52.03	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0.2	10.45	0.1	0.2	0.2	0	0	0	0	0	0	0	0	0											21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9	0																																																																																			-		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9
H1350_001_0	2007	4																																A	A	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	O	O	T	P	V	V	V	V	O	O	O																																																				-		0	0	95.55	0	0	0	0	342.54	0	0	0	0	0	727.22	4960.55	3837.35	241.52	649.61	0	0	0	0	0	0	1.65	0	0.91	0	0	0	0													25 copay for days 8-19					50 ER; 20 Urgent Care						20 CORF; 10 OT/PT/ST/Cardiac Rehab	10 PCP Copay	20 Specialist Copay	20 MH Copay	20 CORF; 10 OT/PT/ST							20 Vision Copay		10 Hearing Copay															0	0	25	0	0	0	0	44.55	0	0	0	0	0	10.51	10	20	20	11	0	20	0	20	0	0	20	0	10	0	0	0	0											-	-	0.2	-	-	-	-	1.27	-	-	-	-	-	0.64	4.13	6.4	0.4	0.6	-	-	-	-	-	-	0	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.64			-	-	0.2	-	-	-	-	1.27	-	-	-	-	-	0.64	4.13	6.4	0.4	0.6	-	-	-	-	-	-	0	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.64																																																																																				-			-	-	0.2	-	-	-	-	1.27	-	-	-	-	-	0.64	4.13	6.4	0.4	0.6	-	-	-	-	-	-	0	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.64
H1350_002_0	2007	4																																A	A	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		0	0	283.6	0	0	10.89	6.84	340.8	0	0	0	0	0	491.6	3805.4	3368.8	148.2	1303.7	0	1055.5	0	584.3	0	0	341.2	0	151.7	0	0	0	0													25 copay for days 8-19					50 ER; 20 Urgent Care						20 CORF; 10 OT/PT/ST/Cardiac Rehab	10 PCP Copay	20 Specialist Copay	20 MH Copay	20 CORF; 10 OT/PT/ST		20 Copay		20 Copay			20 Vision Copay		10 Hearing Copay															0	0	25	0	0	0	0	42.1	0	0	0	0	0	10.53	10	20	20	11	0	20	0	20	0	0	20	0	10	0	0	0	0											-	-	0.59	-	-	-	-	1.2	-	-	-	-	-	0.43	3.17	5.61	0.25	1.2	-	1.76	-	0.97	-	-	0.57	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.87			-	-	0.59	-	-	-	-	1.2	-	-	-	-	-	0.43	3.17	5.61	0.25	1.2	-	1.76	-	0.97	-	-	0.57	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.87																																																																																				-			-	-	0.59	-	-	-	-	1.2	-	-	-	-	-	0.43	3.17	5.61	0.25	1.2	-	1.76	-	0.97	-	-	0.57	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.87
H1350_006_0	2007	1																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	V	O	O	O																																																				-		0	0	279.2	0	0	0	0	359.7	0	0	0	0	0	538.3	3504.2	3106.7	128.3	1130.5	0	924.3	0	536.6	0	0	312.5	0	139.3	0	0	0	0													25 copay for days 8-19					50 ER; 20 Urgent Care						20 CORF; 10 OT/PT/ST/Cardiac Rehab	10 PCP Copay	20 Specialist Copay	20 MH Copay	20 CORF; 10 OT/PT/ST		20 Copay		20 Copay			20 Vision Copay		10 Hearing Copay															0	0	25	0	0	0	0	43.13	0	0	0	0	0	10.52	10	20	20	11	0	20	0	20	0	0	20	0	10	0	0	0	0											-	-	0.58	-	-	-	-	1.29	-	-	-	-	-	0.47	2.92	5.18	0.21	1.04	-	1.54	-	0.89	-	-	0.52	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.77			-	-	0.58	-	-	-	-	1.29	-	-	-	-	-	0.47	2.92	5.18	0.21	1.04	-	1.54	-	0.89	-	-	0.52	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.77																																																																																				-			-	-	0.58	-	-	-	-	1.29	-	-	-	-	-	0.47	2.92	5.18	0.21	1.04	-	1.54	-	0.89	-	-	0.52	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.77
H1350_007_0	2007	1																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		0	0	244.4	0	0	0	0	294.5	0	0	0	0	0	427.1	3220.5	2853.7	126	1112.4	0	908.9	0	493.7	0	0	287.8	0	128.2	0	0	0	0													25 copay for days 8-19					50 ER; 20 Urgent Care						20 CORF; 10 OT/PT/ST/Cardiac Rehab	10 PCP Copay	20 Specialist Copay	20 MH Copay	20 CORF; 10 OT/PT/ST		20 Copay		20 Copay			20 Vision Copay		10 Hearing Copay															0	0	25	0	0	0	0	42.28	0	0	0	0	0	10.53	10	20	20	11	0	20	0	20	0	0	20	0	10	0	0	0	0											-	-	0.51	-	-	-	-	1.04	-	-	-	-	-	0.37	2.68	4.76	0.21	1.02	-	1.51	-	0.82	-	-	0.48	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.52			-	-	0.51	-	-	-	-	1.04	-	-	-	-	-	0.37	2.68	4.76	0.21	1.02	-	1.51	-	0.82	-	-	0.48	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.52																																																																																				-			-	-	0.51	-	-	-	-	1.04	-	-	-	-	-	0.37	2.68	4.76	0.21	1.02	-	1.51	-	0.82	-	-	0.48	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.52
H1350_802_0	2007	2																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		0	0	307	0	0	0	0	395.9	0	0	0	0	0	584.6	4104.9	3630.3	152.7	1334.2	0	978.9	0	0	0	0	0	0	0	0	0	0	0													25 copay for days 8-19					50 ER; 20 Urgent Care						20 CORF; 10 OT/PT/ST/Cardiac Rehab	10 PCP Copay	20 Specialist Copay	20 MH Copay	20 CORF; 10 OT/PT/ST		20 Copay																						0	0	25	0	0	0	0	42.65	0	0	0	0	0	10.53	10	20	20	11	0	20	0	0	0	0	0	0	0	0	0	0	0											-	-	0.64	-	-	-	-	1.41	-	-	-	-	-	0.51	3.42	6.05	0.25	1.22	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.14			-	-	0.64	-	-	-	-	1.41	-	-	-	-	-	0.51	3.42	6.05	0.25	1.22	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.14																																																																																				-			-	-	0.64	-	-	-	-	1.41	-	-	-	-	-	0.51	3.42	6.05	0.25	1.22	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.14
H1406_006_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1343.57	85.59	764.51	2495	243.03	0.42	0.03	226.49	282.11	162.07	110.5	7.37	729.29	62.62	5543.76	4595.94			202.88		6.83											70.71	4.5	1.75								175/day (1-7)	175/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	0-200/ Visit	0-75/ Visit	0-200/ Visit	200/ Visit	0/ Procedure	0-75/ Visit	15/ Visit	30/ Visit			30/ Visit		20 Coins											500/day (1-7)	175/day (1-7)	20 Coins								136.43	136.43	29.09	0	100	0.2	0.2	46.33	66	57.95	25	200	0	36.18	15	30			30		0.2											389.8	136.43	0.2								15.28	0.97	1.85	-	2.03	0.08	0.01	0.87	1.55	0.78	0.23	0.12	-	0.19	6.93	11.49	-	-	0.51	-	1.37	-	-	-	-	-	-	-	-	-	-	2.3	0.05	0.35	-	-	-	-	-	-	-	46.96	0	0	15.28	0.97	1.85	-	2.03	0.08	0.01	0.87	1.55	0.78	0.23	0.12	-	0.19	6.93	11.49	-	-	0.51	-	1.37	-	-	-	-	-	-	-	-	-	-	2.3	0.05	0.35	-	-	-	-	-	-	-	46.96																																																																																				-			15.28	0.97	1.85	-	2.03	0.08	0.01	0.87	1.55	0.78	0.23	0.12	-	0.19	6.93	11.49	-	-	0.51	-	1.37	-	-	-	-	-	-	-	-	-	-	2.3	0.05	0.35	-	-	-	-	-	-	-	46.96
H1406_013_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1143.88	72.87	650.89	2124.19	206.91	0.3	0.02	192.83	240.18	137.98	94.08	6.27	620.9	53.31	4719.82	3912.87			172.72		4.95											60.2	3.84	1.27								225/day (1-8)	195/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	0-200/ Visit	0-100/ Visit	0-200/ Visit	200/ Visit	0/ Procedure	0-100/ Visit	10/ Visit	35/ Visit			50/ Visit		20 Coins											500/day (1-7)	195/day (1-7)	20 Coins								183.08	152.02	29.09	0	100	0.2	0.2	46.33	66	77.27	26.67	200	0	40.59	10	35			50		0.2											389.8	152.02	0.2								17.45	0.92	1.58	-	1.72	0.06	0	0.74	1.32	0.89	0.21	0.1	-	0.18	3.93	11.41	-	-	0.72	-	0.99	-	-	-	-	-	-	-	-	-	-	1.96	0.05	0.25	-	-	-	-	-	-	-	44.5	0	0	17.45	0.92	1.58	-	1.72	0.06	0	0.74	1.32	0.89	0.21	0.1	-	0.18	3.93	11.41	-	-	0.72	-	0.99	-	-	-	-	-	-	-	-	-	-	1.96	0.05	0.25	-	-	-	-	-	-	-	44.5																																																																																				-			17.45	0.92	1.58	-	1.72	0.06	0	0.74	1.32	0.89	0.21	0.1	-	0.18	3.93	11.41	-	-	0.72	-	0.99	-	-	-	-	-	-	-	-	-	-	1.96	0.05	0.25	-	-	-	-	-	-	-	44.5
H1406_014_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1296.73	82.61	737.86	2408.03	234.56	0.39	0.03	218.59	272.28	156.42	106.65	7.11	703.87	60.43	5350.5	4435.72			195.8		6.37											68.25	4.35	1.63								175/day (1-7)	175/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	0-200/ Visit	0-75/ Visit	0-200/ Visit	200/ Visit	0/ Procedure	0-75/ Visit	15/ Visit	30/ Visit			30/ Visit		20 Coins											500/day (1-7)	175/day (1-7)	20 Coins								136.43	136.43	29.09	0	100	0.2	0.2	46.33	66	57.95	25	200	0	36.18	15	30			30		0.2											389.8	136.43	0.2								14.74	0.94	1.79	-	1.95	0.08	0.01	0.84	1.5	0.76	0.22	0.12	-	0.18	6.69	11.09	-	-	0.49	-	1.27	-	-	-	-	-	-	-	-	-	-	2.22	0.05	0.33	-	-	-	-	-	-	-	45.26	0	0	14.74	0.94	1.79	-	1.95	0.08	0.01	0.84	1.5	0.76	0.22	0.12	-	0.18	6.69	11.09	-	-	0.49	-	1.27	-	-	-	-	-	-	-	-	-	-	2.22	0.05	0.33	-	-	-	-	-	-	-	45.26																																																																																				-			14.74	0.94	1.79	-	1.95	0.08	0.01	0.84	1.5	0.76	0.22	0.12	-	0.18	6.69	11.09	-	-	0.49	-	1.27	-	-	-	-	-	-	-	-	-	-	2.22	0.05	0.33	-	-	-	-	-	-	-	45.26
H1406_022_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1118.27	71.24	636.31	2076.63	202.28	0.29	0.02	188.51	234.8	134.89	91.97	6.13	607	52.12	4614.15	3825.26			168.86		4.73											58.86	3.75	1.21								225/day (1-8)	195/day (1-7)	0/day (1-6) 100/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	0-200/ Visit	0-100/ Visit	0-200/ Visit	200/ Visit	0/ Procedure	0-100/ Visit	10/ Visit	35/ Visit			50/ Visit		20 Coins											500/day (1-7)	195/day (1-7)	20 Coins								183.08	152.02	29.09	0	100	0.2	0.2	46.33	66	77.27	26.67	200	0	40.59	10	35			50		0.2											389.8	152.02	0.2								17.06	0.9	1.54	-	1.69	0.06	0	0.73	1.29	0.87	0.2	0.1	-	0.18	3.85	11.16	-	-	0.7	-	0.95	-	-	-	-	-	-	-	-	-	-	1.91	0.05	0.24	-	-	-	-	-	-	-	43.48	0	0	17.06	0.9	1.54	-	1.69	0.06	0	0.73	1.29	0.87	0.2	0.1	-	0.18	3.85	11.16	-	-	0.7	-	0.95	-	-	-	-	-	-	-	-	-	-	1.91	0.05	0.24	-	-	-	-	-	-	-	43.48																																																																																				-			17.06	0.9	1.54	-	1.69	0.06	0	0.73	1.29	0.87	0.2	0.1	-	0.18	3.85	11.16	-	-	0.7	-	0.95	-	-	-	-	-	-	-	-	-	-	1.91	0.05	0.24	-	-	-	-	-	-	-	43.48
H1406_024_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S											D	D	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1305.61	83.18	371.46	2424.51	236.16	397.4	29.91	220.09	274.14	157.49	107.38	7.16	708.68	60.85	5387.13	4466.09			197.14		214.97											68.72	4.38	2220.56								0/day (-)	0/day (-)	0/day (1-100)	0/Visit	0/ Trip	0/ Procedure	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts											0/day (-)	0/day	0/Procedure								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1406_801_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1224.25	77.99	696.62	2273.43	221.45	0.35	0.03	206.37	257.06	147.67	23.49	6.71	664.52	57.06	5051.43	4187.78			184.86		5.67											64.43	4.1									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53	0	0	20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53																																																																																				-			20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53
H1406_802_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1224.28	77.99	696.63	2273.48	221.45	0.35	0.03	206.38	257.06	147.68	23.49	6.71	664.54	57.06	5051.54	4187.87			184.86		5.67											64.44	4.1									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53	0	0	20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53																																																																																				-			20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53
H1406_803_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1224.28	77.99	696.63	2273.48	221.45	0.35	0.03	206.38	257.06	147.68	23.49	6.71	664.54	57.06	5051.54	4187.87			184.86		5.67											64.44	4.1									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53	0	0	20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53																																																																																				-			20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53
H1406_804_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1224.28	77.99	696.63	2273.48	221.45	0.35	0.03	206.38	257.06	147.68	23.49	6.71	664.54	57.06	5051.54	4187.87			184.86		5.67											64.44	4.1									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53	0	0	20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53																																																																																				-			20.82	1.33	0.64	-	1.85	0.07	0.01	0.81	4.28	1.05	0.16	0.06	-	0.22	8.42	12.21	-	-	2.31	-	1.13	-	-	-	-	-	-	-	-	-	-	1.1	0.07	-	-	-	-	-	-	-	-	56.53
H1407_001_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		361.82	10.23	4244.51	1997.77	9.75	0.51	0.04	18.93	40.26	65.18	66.66	2.96	28.29	25.18	8937.11	9530.35			2.57		10.37											0.54	10.85	41.48								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								368.36	368.36	23.22	0	0.13	0.13	0.13	0.13	0.13	0.13	0	0.13	0.13	0.13	10.05	20.09			0.13		0.13											368.36	0.13	0.12								11.11	0.31	8.21	-	1.31	0.07	0.01	2.54	5.39	8.73	-	0.4	3.79	3.37	7.48	15.96	-	-	0.34	-	1.39	-	-	-	-	-	-	-	-	-	-	0.02	1.45	5.16	-	-	-	-	-	-	-	77.03	0	46.61	11.11	0.31	8.21	-	1.31	0.07	0.01	2.54	5.39	8.73	-	0.4	3.79	3.37	7.48	15.96	-	-	0.34	-	1.39	-	-	-	-	-	-	-	-	-	-	0.02	1.45	5.16	-	-	-	-	-	-	-	77.03	5000																																																																																			-		0	11.11	0.31	8.21	-	1.31	0.07	0.01	2.54	5.39	8.73	-	0.4	3.79	3.37	7.48	15.96	-	-	0.34	-	1.39	-	-	-	-	-	-	-	-	-	-	0.02	1.45	5.16	-	-	-	-	-	-	-	77.03
H1407_003_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		2138.37	93.01	4286.75	2017.65	233.53	0.52	0.04	239.24	396.35	1481.17	942.56	67.33	1310.37	572.27	9026.04	9625.19			373.17		10.58											4.9	11.06	3.02								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								85.77	85.77	24.28	0	70.06	0.14	0.14	32.23	57.17	27.07	40.03	35.03	35.03	35.03	10.51	21.02			70.06		0.14											85.77	0.14	0								15.28	0.66	8.67	-	1.36	0.07	0.01	0.64	1.89	3.34	3.14	0.2	3.82	1.67	7.9	16.86	-	-	2.18	-	1.48	-	-	-	-	-	-	-	-	-	-	0.03	1.55	-	-	-	-	-	-	-	-	70.78	0	30.25	15.28	0.66	8.67	-	1.36	0.07	0.01	0.64	1.89	3.34	3.14	0.2	3.82	1.67	7.9	16.86	-	-	2.18	-	1.48	-	-	-	-	-	-	-	-	-	-	0.03	1.55	-	-	-	-	-	-	-	-	70.78	5000																																																																																			-		0	15.28	0.66	8.67	-	1.36	0.07	0.01	0.64	1.89	3.34	3.14	0.2	3.82	1.67	7.9	16.86	-	-	2.18	-	1.48	-	-	-	-	-	-	-	-	-	-	0.03	1.55	-	-	-	-	-	-	-	-	70.78
H1415_004_0	2007	3											Professional											Colerectal										A	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V	coin	V	T	V	V		V																																																								-		201	30	272		46	1		207	118	180.89	744.57	34.18	237.88	633.49	4000.4	1492.58	198.05	28.64	109.13	33.2	1	197	1831	34	112.83		41					200										500 Per Admit	500 PER ADMISSION	125 PER DAY		100 COPAY	0		50 COPAY	100 COPAY	100 COPAY	250 COPAY	200 Copay	30 COPAY	15 COPAY	0 copay	30 COPAY	30 COPAY	15 copay	75 COPAY	10 COPAY	20 coins 1000 OOP max	15 COPAY	3.50 COPAY	30 COPAY	30 COPAY		30 COPAY					50 Copay										500	500	112.5		100	0.2		50	100	100	250	200	30	15	0	30	30	15	75	10	0.2	15	3.5	30	30		30					50										8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.83			8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.83																																																																																				-			8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.83
H1415_005_0	2007	4																																D	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V		V	T	V	V		V																																																								-																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																																																								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1415_008_0	2007	3											Professional										1500	colorectal										A	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V		V	T	V	V		V					v																																																			-		201	30	272		46	1		207	118	180.89	744.57	34.18	237.88	633.49	4000.4	1492.58	198.05	28.64	109.13	33.2		197	1831	34	112.83		41					44										500 PER ADMISSION	500 PER ADMISSION	125 PER DAY		100 COPAY	20		50 COPAY	40 copay	100 COPAY	250 COPAY	200 COPAY	30 COPAY	15 COPAY	0 copay	30 COPAY	30 COPAY	15 Copay	75 COPAY	30 Copay		20 coins 1000 OOP max	3.50 COPAY	30 COPAY	30 COPAY		30 COPAY					50 copay										500	500	112.5		100	0.2		50	40	100	250	200	30	15	0	30	30	15	75	30		15	3.5	30	30		30					50										8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.08	-	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	39.45		0	8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.08	-	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	39.45																																																																																				-			8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.08	-	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	39.45
H1415_009_0	2007	3											Professional											Colerectal										A	A	D	V	T	COIN	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	coin	V	T	V	V		V					V																																																			-		201	30	272	100	46	1	1	207	118	180.89	744.57	34.18	237.88	633.49	4000.4	1492.58	198.05	28.64	109.13	33.2	1	197	1831	34	112.83		41					200										500 per admission	500 PER ADMISSION	125 PER DAY	0 copay	100 COPAY	20 coins	20 coins	50 COPAY	100 COPAY	100 COPAY	250 COPAY	200 COPAY	30 COPAY	15 COPAY	0 copay	30 COPAY	30 COPAY	15 Copay	75 COPAY	10 COPAY	20 coins 1000 OOP max	15 COPAY	3.50 COPAY	30 COPAY	30 COPAY		30 COPAY					50 Copay										500	500	112.5	0	100	0.2	0.2	50	100	100	250	200	30	15	0	30	30	15	75	10	0.2	15	3.5	30	30		30					50										8.38	1.25	2.55	-	0.38	0.2	0.2	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	41.03			8.38	1.25	2.55	-	0.38	0.2	0.2	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	41.03																																																																																				-			8.38	1.25	2.55	-	0.38	0.2	0.2	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	41.03
H1415_010_0	2007	3																																																																																																																		-																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																																																				-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1415_012_0	2007	3											Professional										1500	Colerectal										A	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V	coin	V	T	V	V		V																																																								-		201	30	272		46	1		207	118	180.89	744.57	34.18	237.88	633.49	4000.4	1492.58	198.05	28.64	109.13	33.2	1	197	1831	34	112.83		41					200										500 Per Admit	500 PER ADMISSION	125 PER DAY		100 COPAY	0		50 COPAY	40 copay	100 COPAY	250 COPAY	200 Copay	30 COPAY	15 COPAY	0 copay	30 COPAY	30 COPAY	15 copay	75 COPAY	10 COPAY	20 coins 1000 OOP max	15 COPAY	3.50 COPAY	30 COPAY	30 COPAY		30 COPAY					50 Copay										500	500	112.5		100	0.2		50	40	100	250	200	30	15	0	30	30	15	75	10	0.2	15	3.5	30	30		30					50										8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.24		0	8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.24																																																																																				-			8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.24
H1415_013_0	2007	3											Professional										1500	Colorectal										A	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V	coin	V	T	V	V		V					V																																																			-		201	30	272		46	1		207	118	180.89	744.57	34.18	237.88	633.49	4000.4	1492.58	198.05	28.64	109.13	33.2	1	197	1831	34	112.83		41					200										500 Per Admit	500 PER ADMISSION	125 PER DAY		100 COPAY	0		50 COPAY	100 COPAY	100 COPAY	250 COPAY	200 Copay	30 COPAY	15 COPAY	0 copay	30 COPAY	30 COPAY	15 copay	75 COPAY	10 COPAY	20 coins 1000 OOP max	15 COPAY	3.50 COPAY	30 COPAY	30 COPAY		30 COPAY					50 Copay										500	500	112.5		100	0.2		50	100	100	250	200	30	15	0	30	30	15	75	10	0.2	15	3.5	30	30		30					50										8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.83		0	8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.83																																																																																				-			8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.98	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.83
H1415_014_0	2007	3											Professional										1500	Colorectal										A	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V	coin	V	T	V	V		V																																																								-		201	30	272		46	1		207	118	180.89	744.57	34.18	237.88	633.49	4000.4	1492.58	198.05	28.64	109.13	33.2	1	197	1831	34	112.83		41					200										500 Per Admit	500 PER ADMISSION	125 PER DAY		100 COPAY	0		50 COPAY	40 copay	100 COPAY	250 COPAY	200 Copay	30 COPAY	15 COPAY	0 copay	30 COPAY	30 COPAY	15 copay	75 COPAY	10 COPAY	20 coins 1000 OOP max	15 COPAY	3.50 COPAY	30 COPAY	30 COPAY		30 COPAY					50 Copay										500	500	112.5		100	0.2		50	40	100	250	200	30	15	0	30	30	15	75	10	0.2	15	3.5	30	30		30					50										8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.24		0	8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.24																																																																																				-			8.38	1.25	2.55	-	0.38	0.2	-	0.86	0.39	1.51	15.51	0.57	0.59	0.79	-	3.73	0.5	0.04	0.68	0.03	0.2	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.83	-	-	-	-	-	-	-	-	-	40.24
H1415_802_0	2007	3											Professional											Colorectal										D	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V		V	T	V	V		V					V																																																			-		1350	30	272		46	15.15		207	118	180.89	744.57	34.18	237.88	633.49	4000.4	1492.58	198.05	28.64	109.13	33.2		197	1831	34	112.83		41					44										225 per day	500 per admission	125 per day		100 copay	0 copay		50 copay	100 copay	100 copay	250 copay	0 copay	30 copay	15 copay	25 copay	30 copay	30 copay	15 copay	75 copay	10 copay		15 copay	3.50/Trip	30 copay	30 copay		30 copay					50 copay										213.75	500	112.5		100	0.2		50	100	100	250	0	30	15	25	30	30	15	75	10		15	3.5	30	30		30					50										24.05	1.25	2.55	-	0.38	3.03	-	0.86	0.98	1.51	15.51	-	0.59	0.79	8.33	3.73	0.5	0.04	0.68	0.03	-	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	66.25			24.05	1.25	2.55	-	0.38	3.03	-	0.86	0.98	1.51	15.51	-	0.59	0.79	8.33	3.73	0.5	0.04	0.68	0.03	-	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	66.25																																																																																				-			24.05	1.25	2.55	-	0.38	3.03	-	0.86	0.98	1.51	15.51	-	0.59	0.79	8.33	3.73	0.5	0.04	0.68	0.03	-	0.25	0.53	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	66.25
H1415_804_0	2007	6											Professional											Colorectal										D	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V		V	T	V	V		V					V																																																			-		1353	29.19	837.9		247.02	15.15		221.48	237.3	541.65	539.22	24.75	172.27		6145.67	2293	304.26	458.77	167.65	51		447.07	150	34	112.83		41					44										225 per day	500 per admission	125 per day		100 copay	0 copay		50 copay	100 copay	100 copay	250 copay	200 copay	30 copay	15 copay	25 copay	30 copay	30 copay	15 copay	75 copay	10 copay		15 copay	3.50/Trip	30 copay	30 copay		30 copay					50 copay										213.75	500	112.5		100	0.2		50	100	100	250	200	30	15	25	30	30	15	75	10		15	3.5	30	30		30					50										24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	0.41	0.43	-	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	79.97			24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	0.41	0.43	-	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	79.97																																																																																				-			24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	0.41	0.43	-	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	79.97
H1415_805_0	2007	3											Professional											Colorectal										D	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V		V	T	V	V		V					V																																																			-		1353	29.19	837.9		247.02	15.15		221.48	237.3	541.65	539.22	24.75	172.27	633.49	6145.67	2293	304.26	458.77	167.65	51		447.07	150	34	112.83		41					44										225 per day	500 per admission	125 per day		100 copay	0 copay		50 copay	100 copay	100 copay	250 copay	0 copay	30 copay	15 copay	25 copay	30 copay	30 copay	15 copay	75 copay	10 copay		15 copay	3.50/Trip	30 copay	30 copay		30 copay					50 copay										213.75	500	112.5		100	0.2		50	100	100	250	0	30	15	25	30	30	15	75	10		15	3.5	30	30		30					50										24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	-	0.43	0.79	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	80.35			24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	-	0.43	0.79	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	80.35																																																																																				-			24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	-	0.43	0.79	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	80.35
H1415_806_0	2007	6											Professional											Colorectal										D	D	D	V	T	COIN		V	P	P	P	P	P	P	V	V	V	V	V	V		V	T	V	V		V					V																																																			-		1353	29.19	837.9		247.02	15.15		221.48	237.3	541.65	539.22	24.75	172.27		6145.67	2293	304.26	458.77	167.65	51		447.07	150	34	112.83		41					44										225 per day	500 per admission	125 per day		100 copay	0 copay		50 copay	100 copay	100 copay	250 copay	200 copay	30 copay	15 copay	25 copay	30 copay	30 copay	15 copay	75 copay	10 copay		15 copay	3.50/Trip	30 copay	30 copay		30 copay					50 copay										213.75	500	112.5		100	0.2		50	100	100	250	200	30	15	25	30	30	15	75	10		15	3.5	30	30		30					50										24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	0.41	0.43	-	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	79.97			24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	0.41	0.43	-	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	79.97																																																																																				-			24.1	1.22	7.86	-	2.06	3.03	-	0.92	1.98	4.51	11.23	0.41	0.43	-	12.8	5.73	0.76	0.57	1.05	0.04	-	0.56	0.04	0.09	0.28	-	0.1	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	79.97
H1416_001_0	2007	7																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1641.67	32.42	1210.87	1754.83	397.74	18.22	3.41	326.12	325.76	2161.33	1033.24	0	575.55	619.81	4271.96	8309.1	184.08	821.67	4312.82	23782.33	7.74	14.59	0	381	415.98	177	178.28	24.72	0	258.8	0											200 days 1 - 7	200 days 1 - 7	119  days 21 - 100	10	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	0 - 100		0 - 35	35 to 100	10	0 to 35	25 to 35	35	0 - 100	0 to 25	0 -20	0.2	0	0	25	25	25	0		0	0 to 0											137.46	137.46	27.01	10	100	0.2	0.2	50	135	0	32.5	0	23.33	66.57	8.14	35	27.5	35	13	1.58	0.13	0.2	0	0	25	25	25	0	0	0	0											18.8	0.37	2.73	1.46	3.31	3.64	0.68	1.36	3.66	-	2.8	-	1.12	3.44	2.9	24.23	0.42	2.4	4.67	3.13	1.04	2.92	-	-	0.87	0.37	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.7		0	18.8	0.37	2.73	1.46	3.31	3.64	0.68	1.36	3.66	-	2.8	-	1.12	3.44	2.9	24.23	0.42	2.4	4.67	3.13	1.04	2.92	-	-	0.87	0.37	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.7	0																																																																																			-		0	18.8	0.37	2.73	1.46	3.31	3.64	0.68	1.36	3.66	-	2.8	-	1.12	3.44	2.9	24.23	0.42	2.4	4.67	3.13	1.04	2.92	-	-	0.87	0.37	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.7
H1416_002_0	2007	7																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1003.5	19.49	625.76	910.23	207.87	9.31	1.76	224.62	191.7	1316.2	633.6	0	356.62	383.37	5029.84	9627.08	212.71	952.22	4944.77	27455.72	4.01	7.57	0	381	214.62	89.95	91.98	12.57	0	137.15	547.2											125  days 1 - 7	125  limited to 190 days/lifetime.	100  days 8 - 100	10	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	0 - 100		0 - 35	35 to 100	10	0 to 35	25 to 35	35	0 - 100	0 to 25	0 -20	0.2	0	0	25	25	25	0		0	0 to 0											88.43	88.43	60.81	10	100	0.2	0.2	50	135	0	25	0	23.33	66.51	8.11	35	27.5	35	10.02	1.62	0.13	0.2	0	0	25	25	25	0	0	0	0											7.39	0.14	3.17	0.76	1.73	1.86	0.35	0.94	2.16	-	1.32	-	0.69	2.12	3.4	28.08	0.49	2.78	4.13	3.71	0.54	1.51	-	-	0.45	0.19	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.1		0	7.39	0.14	3.17	0.76	1.73	1.86	0.35	0.94	2.16	-	1.32	-	0.69	2.12	3.4	28.08	0.49	2.78	4.13	3.71	0.54	1.51	-	-	0.45	0.19	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.1	0																																																																																			-		0	7.39	0.14	3.17	0.76	1.73	1.86	0.35	0.94	2.16	-	1.32	-	0.69	2.12	3.4	28.08	0.49	2.78	4.13	3.71	0.54	1.51	-	-	0.45	0.19	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.1
H1416_003_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2098.2	40.36	1619.51	2333.57	520.97	24.04	4.58	427.32	423.77	2767.72	1359.77	0	757.6	813.58	5809.9	11100.47	257.53	1106.32	5704.37	31295.32	10.41	19.7	1200	381	562.14	235.1	240.92	32.84	0	364.6	2035.2											100  days 1 - 5	100  limited to 190 days/lifetime.	0  days 1 - 100	10	100	20	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	0 - 50		0 - 20	20 to 25	5	0 to 20	10 to 20	20	0 - 50	0 to 25	0 -20	0.2	3.5	0	25	25	25	0		0	0 to 0											61.89	61.89	0	10	100	0.2	0.2	50	45	0	12.5	0	13.33	22.42	4.05	20	12.5	20	5.02	1.6	0.13	0.2	3.5	0	25	25	25	0	0	0	0											10.82	0.21	-	1.94	4.34	4.81	0.92	1.78	1.59	-	1.42	-	0.84	1.52	1.96	18.5	0.27	1.84	2.38	4.17	1.39	3.94	0.35	-	1.17	0.49	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.16		0	10.82	0.21	-	1.94	4.34	4.81	0.92	1.78	1.59	-	1.42	-	0.84	1.52	1.96	18.5	0.27	1.84	2.38	4.17	1.39	3.94	0.35	-	1.17	0.49	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.16	0																																																																																			-		0	10.82	0.21	-	1.94	4.34	4.81	0.92	1.78	1.59	-	1.42	-	0.84	1.52	1.96	18.5	0.27	1.84	2.38	4.17	1.39	3.94	0.35	-	1.17	0.49	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.16
H1416_007_0	2007	4																					0											D	D	D	V	T	O	Coin	V	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2027.66	39.76	1460.24	2207.37	486.13	22.52	4.24	398.64	29.49	2622.86	28.91	0	8.94	19.39	5297.97	47.43	1.91	2.07	24.95	133	9.63	18.18	0	381	0	0	0	0	0	323.93	2035.2											952  0 (1-60)  238 (61-90) 476 (91+)	952 - 238  0 (1-60)  238 (61-90) 476 (91+)	119  days 21 - 100	0	0	0	20	50	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											137.21	119.5	27.01	0	0	0	0.2	50	0.2	0	0.15	0	0.15	0.2	0	0.2	0.2	0.2	0.03	0.06	0.13	0.2	0	0	0	0	0	0	0	0	0											23.18	0.4	3.29	-	-	-	0.85	1.66	5.9	-	4.34	-	1.34	3.88	-	9.49	0.38	0.41	0.78	7.95	1.29	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.76		0	23.18	0.4	3.29	-	-	-	0.85	1.66	5.9	-	4.34	-	1.34	3.88	-	9.49	0.38	0.41	0.78	7.95	1.29	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.76	0																																																																																			-		0	23.18	0.4	3.29	-	-	-	0.85	1.66	5.9	-	4.34	-	1.34	3.88	-	9.49	0.38	0.41	0.78	7.95	1.29	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.76
H1416_009_0	2007	6																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1601.59	30.53	1210.35	1798.15	399.46	18.28	3.5	327.69	324.19	2106.17	1021.87	0	581.83	624.25	4497.07	8460.02	189.58	837	4295.32	24032.47	7.96	15.09	0	381	435.39	182.3	186.6	25.46	0	286.04	547.2											0  days 1 - 7	0  days 1 - 7	25  days 8 - 100	10	100	20	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	0 - 100		0 - 30	30 to 25	10	0 to 30	20 to 30	30	0 - 100	0 to 25	0 -20	0.2	0	0	25	25	25	0		0	0 to 0											0	0	15.2	10	100	0.2	0.2	50	45	0	25	0	20	27.58	8.08	30	22.5	30	10.05	1.65	0.13	0.2	0	0	25	25	25	0	0	0	0											-	-	1.53	1.5	3.33	3.66	0.7	1.37	1.22	-	2.13	-	0.97	1.43	3.03	21.15	0.36	2.09	3.6	3.31	1.07	3.02	-	-	0.91	0.38	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.12		0	-	-	1.53	1.5	3.33	3.66	0.7	1.37	1.22	-	2.13	-	0.97	1.43	3.03	21.15	0.36	2.09	3.6	3.31	1.07	3.02	-	-	0.91	0.38	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.12	0																																																																																			-		0	-	-	1.53	1.5	3.33	3.66	0.7	1.37	1.22	-	2.13	-	0.97	1.43	3.03	21.15	0.36	2.09	3.6	3.31	1.07	3.02	-	-	0.91	0.38	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.12
H1417_001_0	2007	3																					1500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	173.48	1.27	103.79	16.49	0	6.59	4.02	220.28	97.11	82.98	50.25	0.88	0	17.12	2752.13	3570.85	5.6	15.49	105.5	240.41	6.98	0	0	0	14.01	0	5.1	0	1.25	0	0											PBP: 1A IP Acute - 0 per admit (unlimited days)	1B IP Psych - 0 per admit (unlimited days)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 10	11B Pros./Med Supp. - 10; 11C Diabetes Mon Supplies - 10	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10	7A Primary Care - 10; 14B Immunizations - 0; 14C Routine Physical Exams - 10; 14D Pap - 0; 14D Pelvic - 10; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 10	7B Chiropractic Services - 10; 7D Physician Specialist - 10; 7F Podiatry Services - 10	5 Partial Hosp - 10; 7E Mental Health - 10; 7H Psychiatric Services - 10	3 CORF - 10; 7C Occupational Therapy - 10; 7I PT and ST Services - 10	7D Physician Specialist - 10	7G Other Health Care - 10; 9C Outpatient Sub Abuse - 10; 16B Comp Dental - 10; 17A Eye Exams (Medicare Covered) - 10; 18A Hearing Exams (Medicare Covered) - 10	15 Medicare Part B Rx Drugs - 0	13A Blood - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - 10	17B Eye Wear - not covered	18A Hearing Exams (Routine) - 10	18B Hearing Aids - not covered	4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 10	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											0	0	0	0	0	0.1	0.1	49.48	0	0	0	0	0	10	10	10	10	10	10	10	0	0	0	0	10	0	10	0	49.48	0	0											-	-	-	-	-	0.66	0.4	0.91	-	-	-	-	-	0.01	2.29	2.98	0	0.01	0.09	0.2	-	-	-	-	0.01	-	0	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	7.58	0	0.07	-	-	-	-	-	0.66	0.4	0.91	-	-	-	-	-	0.01	2.29	2.98	0	0.01	0.09	0.2	-	-	-	-	0.01	-	0	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	7.58	0	PBP: 1A IP Acute - 175 per day for days 1-5 (unlimited days)	1B IP Psych - 175 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 10 per day	10A Ambulance - 0 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 30	9B ASC Services - 100	8A Outpatient C/D/T - 30	8B Outpatient X-Rays - 30	9A Outpatient Hospital - 100	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 30	7A Primary Care - 30; 14B Immunizations - 0; 14C Routine Physical Exams - 30; 14D Pap - 0; 14D Pelvic - 30; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 30	7B Chiropractic Services - 30; 7D Physician Specialist - 30; 7F Podiatry Services - 30	5 Partial Hosp - 30; 7E Mental Health - 30; 7H Psychiatric Services - 30	3 CORF - 30; 7C Occupational Therapy - 30; 7I PT and ST Services - 30	7D Physician Specialist - 30	7G Other Health Care - 30; 9C Outpatient Sub Abuse - 30; 16B Comp Dental - 30; 17A Eye Exams (Medicare Covered) - 30; 18A Hearing Exams (Medicare Covered) - 30	15 Medicare Part B Rx Drugs - 0	13A Blood - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - 30	17B Eye Wear - not covered	18A Hearing Exams (Routine) - 30	18B Hearing Aids - not covered	4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 30	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											2.53	0.03	0.22	0.05	0.01	0.36	0.22	0.23	0.27	0.08	0.11	0	0	0.08	1.78	2.47	0.01	0.02	0.13	0.23	0.02	0			0.02		0.01		0													8.88	110	0	2.53	0.03	0.22	0.05	0.01	1.02	0.62	1.13	0.27	0.08	0.11	0	0	0.1	4.08	5.45	0.01	0.03	0.22	0.43	0.02	0	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	16.46
H1417_002_0	2007	5																					1500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	173.48	1.27	103.79	16.49	0	6.59	4.02	220.28	97.11	82.98	50.25	0.88	0	17.12	2752.13	3570.85	5.6	15.49	105.5	240.41	6.98	0	0	0	14.01	0	5.1	0	1.25	0	0											PBP: 1A IP Acute - 0 per admit (unlimited days)	1B IP Psych - 0 per admit (unlimited days)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 10	11B Pros./Med Supp. - 10; 11C Diabetes Mon Supplies - 10	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10	7A Primary Care - 10; 14B Immunizations - 0; 14C Routine Physical Exams - 10; 14D Pap - 0; 14D Pelvic - 10; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 10	7B Chiropractic Services - 10; 7D Physician Specialist - 10; 7F Podiatry Services - 10	5 Partial Hosp - 10; 7E Mental Health - 10; 7H Psychiatric Services - 10	3 CORF - 10; 7C Occupational Therapy - 10; 7I PT and ST Services - 10	7D Physician Specialist - 10	7G Other Health Care - 10; 9C Outpatient Sub Abuse - 10; 16B Comp Dental - 10; 17A Eye Exams (Medicare Covered) - 10; 18A Hearing Exams (Medicare Covered) - 10	15 Medicare Part B Rx Drugs - 0	13A Blood - 0			17A Eye Exams (Routine) - 10		18A Hearing Exams (Routine) - 10		4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 10	14A Health Ed/Wellness - 0												0	0	0	0	0	0.1	0.1	49.48	0	0	0	0	0	10	10	10	10	10	10	10	0	0	0	0	10	0	10	0	49.48	0	0											-	-	-	-	-	0.66	0.4	0.91	-	-	-	-	-	0.01	2.29	2.98	0	0.01	0.09	0.2	-	-	-	-	0.01	-	0	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	7.58	0	0.07	-	-	-	-	-	0.66	0.4	0.91	-	-	-	-	-	0.01	2.29	2.98	0	0.01	0.09	0.2	-	-	-	-	0.01	-	0	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	7.58	0	PBP: 1A IP Acute - 175 per day for days 1-5 (unlimited days)	1B IP Psych - 175 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 10 per day	10A Ambulance - 0 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 30	9B ASC Services - 100	8A Outpatient C/D/T - 30	8B Outpatient X-Rays - 30	9A Outpatient Hospital - 100	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 30	7A Primary Care - 30; 14B Immunizations - 0; 14C Routine Physical Exams - 30; 14D Pap - 0; 14D Pelvic - 30; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 30	7B Chiropractic Services - 30; 7D Physician Specialist - 30; 7F Podiatry Services - 30	5 Partial Hosp - 30; 7E Mental Health - 30; 7H Psychiatric Services - 30	3 CORF - 30; 7C Occupational Therapy - 30; 7I PT and ST Services - 30	7D Physician Specialist - 30	7G Other Health Care - 30; 9C Outpatient Sub Abuse - 30; 16B Comp Dental - 30; 17A Eye Exams (Medicare Covered) - 30; 18A Hearing Exams (Medicare Covered) - 30	15 Medicare Part B Rx Drugs - 0	13A Blood - 0			17A Eye Exams (Routine) - 30		18A Hearing Exams (Routine) - 30		4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 30	14A Health Ed/Wellness - 0												2.53	0.03	0.22	0.05	0.01	0.36	0.22	0.23	0.27	0.08	0.11	0	0	0.08	1.78	2.47	0.01	0.02	0.13	0.23	0.02	0			0.02		0.01		0													8.88	110	0	2.53	0.03	0.22	0.05	0.01	1.02	0.62	1.13	0.27	0.08	0.11	0	0	0.1	4.08	5.45	0.01	0.03	0.22	0.43	0.02	0	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	16.46
H1417_003_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	170.81	1.25	396.27	16.31	67.07	6.57	4.01	219.37	43.12	4.1	3.04	1.72	0	33.29	2656.28	3446.49	4.38	12.07	101.69	231.72	13.43	0.5	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 125 per day for days 1-5 (unlimited days)	1B IP Psych - 125 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 0 per day	10A Ambulance - 100 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 35	9B ASC Services - 10	8A Outpatient C/D/T - 10	8B Outpatient X-Rays - 10	9A Outpatient Hospital - 10	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10;	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 35; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 35	7B Chiropractic Services - 35; 7D Physician Specialist - 35; 7F Podiatry Services - 35	5 Partial Hosp - 35; 7E Mental Health - 35; 7H Psychiatric Services - 35	3 CORF - 35; 7C Occupational Therapy - 35; 7I PT and ST Services - 35	7D Physician Specialist - 35	7G Other Health Care - 35; 9C Outpatient Sub Abuse - 35; 16B Comp Dental - 35; 17A Eye Exams (Medicare Covered) - 35; 18A Hearing Exams (Medicare Covered) - 35	15 Medicare Part B Rx Drugs - 10	13A Blood - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - not covered	17B Eye Wear - not covered	18A Hearing Exams (Routine) - not covered	18B Hearing Aids - not covered	4A Emergency Care Worldwide Coverage - not covered; 4B Urgent Care Worldwide Coverage - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											380.66	500.21	48	0	100	0.2	0.2	49.81	0.1	0.1	0.1	0.1	0	0.1	20	35	35	35	35	35	0.1	0	0	0	0	0	0	0	0	0	0											5.42	0.05	1.59	-	0.56	1.31	0.8	0.91	4.31	0.41	0.3	0.17	-	3.33	4.43	10.05	0.01	0.04	0.3	0.68	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.01	0	17.89	5.42	0.05	1.59	-	0.56	1.31	0.8	0.91	4.31	0.41	0.3	0.17	-	3.33	4.43	10.05	0.01	0.04	0.3	0.68	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.01	0	PBP: 1A IP Acute - 180 per day for days 1-5 (unlimited days)	1B IP Psych - 180 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 115 per day for days 21-100	6 Home Health - 20 per day	10A Ambulance - 15	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 15	9B ASC Services - 15	8A Outpatient C/D/T - 15	8B Outpatient X-Rays - 15	9A Outpatient Hospital - 15	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 15;	7A Primary Care - 15; 14B Immunizations - 0; 14C Routine Physical Exams - 15; 14D Pap - 0; 14D Pelvic - 15; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 15	7B Chiropractic Services - 15; 7D Physician Specialist - 15; 7F Podiatry Services - 15	5 Partial Hosp - 15; 7E Mental Health - 15; 7H Psychiatric Services - 15	3 CORF - 15; 7C Occupational Therapy - 15; 7I PT and ST Services - 15	7D Physician Specialist - 15	7G Other Health Care - 15; 9C Outpatient Sub Abuse - 15; 16B Comp Dental - 15; 17A Eye Exams (Medicare Covered) - 15; 18A Hearing Exams (Medicare Covered) - 15	15 Medicare Part B Rx Drugs - 15	13A Blood - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - not covered	17B Eye Wear - not covered	18A Hearing Exams (Routine) - not covered	18B Hearing Aids - not covered	4A Emergency Care Worldwide Coverage - not covered; 4B Urgent Care Worldwide Coverage - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											2.84	0.03	0.6	0.1	0.14	0.36	0.22	0.2	1.71	0.19	0.21	0.07		1.34	0.93	3.87	0	0.04	0.85	1.86	0.53	0																				16.11	200	1.26	8.26	0.08	2.19	0.1	0.7	1.68	1.02	1.11	6.02	0.6	0.52	0.24	-	4.67	5.36	13.92	0.01	0.08	1.15	2.54	1.87	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.12
H1417_004_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	170.81	1.25	396.27	16.31	67.07	6.57	4.01	219.37	43.12	4.1	3.04	1.72	0	33.29	2656.28	3446.49	4.38	12.07	101.69	231.72	13.43	0.5	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 125 per day for days 1-5 (unlimited days)	1B IP Psych - 125 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 0 per day	10A Ambulance - 100 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 35	9B ASC Services - 10	8A Outpatient C/D/T - 10	8B Outpatient X-Rays - 10	9A Outpatient Hospital - 10	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10;	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 35; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 35	7B Chiropractic Services - 35; 7D Physician Specialist - 35; 7F Podiatry Services - 35	5 Partial Hosp - 35; 7E Mental Health - 35; 7H Psychiatric Services - 35	3 CORF - 35; 7C Occupational Therapy - 35; 7I PT and ST Services - 35	7D Physician Specialist - 35	7G Other Health Care - 35; 9C Outpatient Sub Abuse - 35; 16B Comp Dental - 35; 17A Eye Exams (Medicare Covered) - 35; 18A Hearing Exams (Medicare Covered) - 35	15 Medicare Part B Rx Drugs - 10	13A Blood - 0								14A Health Ed/Wellness - 0												380.66	500.21	48	0	100	0.2	0.2	49.81	0.1	0.1	0.1	0.1	0	0.1	20	35	35	35	35	35	0.1	0	0	0	0	0	0	0	0	0	0											5.42	0.05	1.59	-	0.56	1.31	0.8	0.91	4.31	0.41	0.3	0.17	-	3.33	4.43	10.05	0.01	0.04	0.3	0.68	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.01	0	17.89	5.42	0.05	1.59	-	0.56	1.31	0.8	0.91	4.31	0.41	0.3	0.17	-	3.33	4.43	10.05	0.01	0.04	0.3	0.68	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.01	0	PBP: 1A IP Acute - 180 per day for days 1-5 (unlimited days)	1B IP Psych - 180 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 115 per day for days 21-100	6 Home Health - 20 per day	10A Ambulance - 15	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 15	9B ASC Services - 15	8A Outpatient C/D/T - 15	8B Outpatient X-Rays - 15	9A Outpatient Hospital - 15	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 15;	7A Primary Care - 15; 14B Immunizations - 0; 14C Routine Physical Exams - 15; 14D Pap - 0; 14D Pelvic - 15; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 15	7B Chiropractic Services - 15; 7D Physician Specialist - 15; 7F Podiatry Services - 15	5 Partial Hosp - 15; 7E Mental Health - 15; 7H Psychiatric Services - 15	3 CORF - 15; 7C Occupational Therapy - 15; 7I PT and ST Services - 15	7D Physician Specialist - 15	7G Other Health Care - 15; 9C Outpatient Sub Abuse - 15; 16B Comp Dental - 15; 17A Eye Exams (Medicare Covered) - 15; 18A Hearing Exams (Medicare Covered) - 15	15 Medicare Part B Rx Drugs - 15	13A Blood - 0								14A Health Ed/Wellness - 0												2.84	0.03	0.6	0.1	0.14	0.36	0.22	0.2	1.71	0.19	0.21	0.07		1.34	0.93	3.87	0	0.04	0.85	1.86	0.53	0																				16.11	200	1.26	8.26	0.08	2.19	0.1	0.7	1.68	1.02	1.11	6.02	0.6	0.52	0.24	-	4.67	5.36	13.92	0.01	0.08	1.15	2.54	1.87	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.12
H1417_005_0	2007	5																					1500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	173.48	1.27	103.79	16.49	0	6.59	4.02	220.28	97.11	82.98	50.25	0.88	0	17.12	2752.13	3570.85	5.6	15.49	105.5	240.41	6.98	0	0	0	14.01	0	5.1	0	1.25	0	0											PBP: 1A IP Acute - 0 per admit (unlimited days)	1B IP Psych - 0 per admit (unlimited days)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 10	11B Pros./Med Supp. - 10; 11C Diabetes Mon Supplies - 10	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10	7A Primary Care - 10; 14B Immunizations - 0; 14C Routine Physical Exams - 10; 14D Pap - 0; 14D Pelvic - 10; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 10	7B Chiropractic Services - 10; 7D Physician Specialist - 10; 7F Podiatry Services - 10	5 Partial Hosp - 10; 7E Mental Health - 10; 7H Psychiatric Services - 10	3 CORF - 10; 7C Occupational Therapy - 10; 7I PT and ST Services - 10	7D Physician Specialist - 10	7G Other Health Care - 10; 9C Outpatient Sub Abuse - 10; 16B Comp Dental - 10; 17A Eye Exams (Medicare Covered) - 10; 18A Hearing Exams (Medicare Covered) - 10	15 Medicare Part B Rx Drugs - 0	13A Blood - 0			17A Eye Exams (Routine) - 10		18A Hearing Exams (Routine) - 10		4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 10	14A Health Ed/Wellness - 0												0	0	0	0	0	0.1	0.1	49.48	0	0	0	0	0	10	10	10	10	10	10	10	0	0	0	0	10	0	10	0	49.48	0	0											-	-	-	-	-	0.66	0.4	0.91	-	-	-	-	-	0.01	2.29	2.98	0	0.01	0.09	0.2	-	-	-	-	0.01	-	0	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	7.58	0	0.07	-	-	-	-	-	0.66	0.4	0.91	-	-	-	-	-	0.01	2.29	2.98	0	0.01	0.09	0.2	-	-	-	-	0.01	-	0	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	7.58	0	PBP: 1A IP Acute - 175 per day for days 1-5 (unlimited days)	1B IP Psych - 175 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 10 per day	10A Ambulance - 0 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 30	9B ASC Services - 100	8A Outpatient C/D/T - 30	8B Outpatient X-Rays - 30	9A Outpatient Hospital - 100	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 30	7A Primary Care - 30; 14B Immunizations - 0; 14C Routine Physical Exams - 30; 14D Pap - 0; 14D Pelvic - 30; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 30	7B Chiropractic Services - 30; 7D Physician Specialist - 30; 7F Podiatry Services - 30	5 Partial Hosp - 30; 7E Mental Health - 30; 7H Psychiatric Services - 30	3 CORF - 30; 7C Occupational Therapy - 30; 7I PT and ST Services - 30	7D Physician Specialist - 30	7G Other Health Care - 30; 9C Outpatient Sub Abuse - 30; 16B Comp Dental - 30; 17A Eye Exams (Medicare Covered) - 30; 18A Hearing Exams (Medicare Covered) - 30	15 Medicare Part B Rx Drugs - 0	13A Blood - 0			17A Eye Exams (Routine) - 30		18A Hearing Exams (Routine) - 30		4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 30	14A Health Ed/Wellness - 0												2.53	0.03	0.22	0.05	0.01	0.36	0.22	0.23	0.27	0.08	0.11	0	0	0.08	1.78	2.47	0.01	0.02	0.13	0.23	0.02	0			0.02		0.01		0													8.88	110	0	2.53	0.03	0.22	0.05	0.01	1.02	0.62	1.13	0.27	0.08	0.11	0	0	0.1	4.08	5.45	0.01	0.03	0.22	0.43	0.02	0	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	16.46
H1417_006_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	170.81	1.25	396.27	16.31	67.07	6.57	4.01	219.37	43.12	4.1	3.04	1.72	0	33.29	2656.28	3446.49	4.38	12.07	101.69	231.72	13.43	0.5	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 125 per day for days 1-5 (unlimited days)	1B IP Psych - 125 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 0 per day	10A Ambulance - 100 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 35	9B ASC Services - 10	8A Outpatient C/D/T - 10	8B Outpatient X-Rays - 10	9A Outpatient Hospital - 10	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10;	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 35; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 35	7B Chiropractic Services - 35; 7D Physician Specialist - 35; 7F Podiatry Services - 35	5 Partial Hosp - 35; 7E Mental Health - 35; 7H Psychiatric Services - 35	3 CORF - 35; 7C Occupational Therapy - 35; 7I PT and ST Services - 35	7D Physician Specialist - 35	7G Other Health Care - 35; 9C Outpatient Sub Abuse - 35; 16B Comp Dental - 35; 17A Eye Exams (Medicare Covered) - 35; 18A Hearing Exams (Medicare Covered) - 35	15 Medicare Part B Rx Drugs - 10	13A Blood - 0								14A Health Ed/Wellness - 0												380.66	500.21	48	0	100	0.2	0.2	49.81	0.1	0.1	0.1	0.1	0	0.1	20	35	35	35	35	35	0.1	0	0	0	0	0	0	0	0	0	0											5.42	0.05	1.59	-	0.56	1.31	0.8	0.91	4.31	0.41	0.3	0.17	-	3.33	4.43	10.05	0.01	0.04	0.3	0.68	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.01	0	17.89	5.42	0.05	1.59	-	0.56	1.31	0.8	0.91	4.31	0.41	0.3	0.17	-	3.33	4.43	10.05	0.01	0.04	0.3	0.68	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.01	0	PBP: 1A IP Acute - 180 per day for days 1-5 (unlimited days)	1B IP Psych - 180 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 115 per day for days 21-100	6 Home Health - 20 per day	10A Ambulance - 15	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 15	9B ASC Services - 15	8A Outpatient C/D/T - 15	8B Outpatient X-Rays - 15	9A Outpatient Hospital - 15	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 15;	7A Primary Care - 15; 14B Immunizations - 0; 14C Routine Physical Exams - 15; 14D Pap - 0; 14D Pelvic - 15; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 15	7B Chiropractic Services - 15; 7D Physician Specialist - 15; 7F Podiatry Services - 15	5 Partial Hosp - 15; 7E Mental Health - 15; 7H Psychiatric Services - 15	3 CORF - 15; 7C Occupational Therapy - 15; 7I PT and ST Services - 15	7D Physician Specialist - 15	7G Other Health Care - 15; 9C Outpatient Sub Abuse - 15; 16B Comp Dental - 15; 17A Eye Exams (Medicare Covered) - 15; 18A Hearing Exams (Medicare Covered) - 15	15 Medicare Part B Rx Drugs - 15	13A Blood - 0								14A Health Ed/Wellness - 0												2.84	0.03	0.6	0.1	0.14	0.36	0.22	0.2	1.71	0.19	0.21	0.07		1.34	0.93	3.87	0	0.04	0.85	1.86	0.53	0																				16.11	200	1.26	8.26	0.08	2.19	0.1	0.7	1.68	1.02	1.11	6.02	0.6	0.52	0.24	-	4.67	5.36	13.92	0.01	0.08	1.15	2.54	1.87	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.12
H1417_801_0	2007	5																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	135.28	0.7	29.36	2.34	2.72	5.68	3.47	17.32	39.75	3.74	2.85	1.57	0	30.39	20.83	88.51	0.01	0.7	19.54	44.54	13.19	0.46	0	0	0	0	0	0	0	0	0											8.3 FFS Medicare Actuarially Equivalent Cost Sharing	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	19.8 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.27	0.06	5.82	-	0.64	1.34	0.82	4.09	9.38	0.88	0.67	0.37	-	7.17	4.92	20.89	0	0.16	4.61	10.51	3.11	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.83	0	0	11.27	0.06	5.82	-	0.64	1.34	0.82	4.09	9.38	0.88	0.67	0.37	-	7.17	4.92	20.89	0	0.16	4.61	10.51	3.11	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.83	0	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	19.8 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											2.82	0.01	1.46		0.16	0.34	0.2	1.02	2.35	0.22	0.17	0.09		1.79	1.23	5.22	0	0.04	1.15	2.63	0.78	0.03																				21.71	0	0	14.08	0.07	7.28	-	0.8	1.68	1.02	5.11	11.73	1.1	0.84	0.46	-	8.97	6.15	26.11	0	0.21	5.77	13.14	3.89	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.54
H1417_802_0	2007	6																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	135.28	0.7	29.36	2.34	2.72	5.68	3.47	17.32	39.75	3.74	2.85	1.57	0	30.39	20.83	88.51	0.01	0.7	19.54	44.54	13.19	0.46	0	0	0	0	0	0	0	0	0											8.3 FFS Medicare Actuarially Equivalent Cost Sharing	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	19.8 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.27	0.06	5.82	-	0.64	1.34	0.82	4.09	9.38	0.88	0.67	0.37	-	7.17	4.92	20.89	0	0.16	4.61	10.51	3.11	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.83	0	0	11.27	0.06	5.82	-	0.64	1.34	0.82	4.09	9.38	0.88	0.67	0.37	-	7.17	4.92	20.89	0	0.16	4.61	10.51	3.11	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.83	0	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	19.8 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											2.82	0.01	1.46		0.16	0.34	0.2	1.02	2.35	0.22	0.17	0.09		1.79	1.23	5.22	0	0.04	1.15	2.63	0.78	0.03																				21.71	0	0	14.08	0.07	7.28	-	0.8	1.68	1.02	5.11	11.73	1.1	0.84	0.46	-	8.97	6.15	26.11	0	0.21	5.77	13.14	3.89	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.54
H1417_808_0	2007	6																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	133.36	0.69	29.26	2.35	2.75	5.66	3.46	17.52	40.19	3.78	2.89	1.58	0	30.73	20.78	88.28	0.01	0.7	19.49	44.42	13.33	0.46	0	0	0	0	0	0	0	0	0											8.3 FFS Medicare Actuarially Equivalent Cost Sharing	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	19.8 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.11	0.06	5.81	-	0.65	1.34	0.82	4.13	9.48	0.89	0.68	0.37	-	7.25	4.9	20.83	0	0.16	4.6	10.48	3.15	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.83	0	0	11.11	0.06	5.81	-	0.65	1.34	0.82	4.13	9.48	0.89	0.68	0.37	-	7.25	4.9	20.83	0	0.16	4.6	10.48	3.15	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.83	0	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	8.3 FFS Medicare Actuarially Equivalent Cost Sharing	19.8 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											2.78	0.01	1.45		0.16	0.33	0.2	1.03	2.37	0.22	0.17	0.09		1.81	1.23	5.21	0	0.04	1.15	2.62	0.79	0.03																				21.71	0	0	13.88	0.07	7.26	-	0.81	1.67	1.02	5.17	11.86	1.11	0.85	0.47	-	9.06	6.13	26.04	0	0.21	5.75	13.1	3.93	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.54
H1418_002_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1287.23	9.39	461.79	2203.29	128.48	0.75	0.06	254.23	454.43	838.05	571.4	38.09	390.63	323.79	7365.05	8736.28			322.16		10.36			8.44								13.68	0.1	16.85								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 50								550/admit	550/admit	20 Coins								111.02	114.7	34.66	0	100	0.2	0.2	46	81.6	38.64	50	50	50	33.53	10	30			100		0.2			0.08								550	550	0.2								11.91	0.09	1.33	-	1.07	0.15	0.01	0.97	3.09	2.7	2.38	0.16	1.63	0.9	6.14	21.84	-	-	2.68	-	2.07	-	-	0.65	-	-	-	-	-	-	-	0.63	0	3.37	-	-	-	-	-	-	-	63.78	0	0	11.91	0.09	1.33	-	1.07	0.15	0.01	0.97	3.09	2.7	2.38	0.16	1.63	0.9	6.14	21.84	-	-	2.68	-	2.07	-	-	0.65	-	-	-	-	-	-	-	0.63	0	3.37	-	-	-	-	-	-	-	63.78		800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-55										30 Coins								2.33	0.02	0.34	0.46	0.31	0.03		0.3	4.18	4.93			0.04		4.35	5.16					0.67			2.12										1.08								26.32	500	0.95	14.23	0.11	1.67	0.46	1.38	0.18	0.01	1.28	7.27	7.63	2.38	0.16	1.67	0.9	10.49	27	-	-	2.68	-	2.75	-	-	2.77	-	-	-	-	-	-	-	0.63	0	4.45	-	-	-	-	-	-	-	90.1
H1418_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		268.1	2.02	476.5	2273.47	132.57	0.79	0.06	262.33	468.91	864.74	589.6	39.31	403.07	334.1	7599.63	9014.53			332.42		11.03											14.11	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03	0	0	13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.38	0.02	0.42	0.57	0.28	0.05		0.27	5.17	6.1			0		1.94	4.66					0.63																					22.48	0	0	15.79	0.12	0.76	2.46	1.38	0.25	0.01	1.26	12.99	8.63	2.25	0.33	-	1.05	17.77	30.95	-	-	0.97	-	2.83	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	100.51
H1418_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		268.1	2.02	476.5	2273.47	132.57	0.79	0.06	262.33	468.91	864.74	589.6	39.31	403.07	334.1	7599.63	9014.53			332.42		11.03											14.11	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03	0	0	13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.38	0.02	0.42	0.57	0.28	0.05		0.27	5.17	6.1			0		1.94	4.66					0.63																					22.48	0	0	15.79	0.12	0.76	2.46	1.38	0.25	0.01	1.26	12.99	8.63	2.25	0.33	-	1.05	17.77	30.95	-	-	0.97	-	2.83	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	100.51
H1418_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		268.1	2.02	476.5	2273.47	132.57	0.79	0.06	262.33	468.91	864.74	589.6	39.31	403.07	334.1	7599.63	9014.53			332.42		11.03											14.11	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03	0	0	13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.38	0.02	0.42	0.57	0.28	0.05		0.27	5.17	6.1			0		1.94	4.66					0.63																					22.48	0	0	15.79	0.12	0.76	2.46	1.38	0.25	0.01	1.26	12.99	8.63	2.25	0.33	-	1.05	17.77	30.95	-	-	0.97	-	2.83	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	100.51
H1418_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		268.1	2.02	476.5	2273.47	132.57	0.79	0.06	262.33	468.91	864.74	589.6	39.31	403.07	334.1	7599.63	9014.53			332.42		11.03											14.11	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03	0	0	13.41	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.82	2.52	2.25	0.33	-	1.05	15.83	26.29	-	-	0.97	-	2.21	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.03		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.38	0.02	0.42	0.57	0.28	0.05		0.27	5.17	6.1			0		1.94	4.66					0.63																					22.48	0	0	15.79	0.12	0.76	2.46	1.38	0.25	0.01	1.26	12.99	8.63	2.25	0.33	-	1.05	17.77	30.95	-	-	0.97	-	2.83	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	100.51
H1419_001_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-7	150/day 1-7	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 Urgent care	100	30	30 routine 100 complex	30	30	30	10	30	30	30	30	30	45	0																				107.77	107.77	65.39	0	100	0.2	0.2	46.75	100	30	53.94	30	30	30	10	30	30	30	30	30	45	0																				13.98	0.27	6.93	-	1.92	3.14	0.2	1.63	2.87	5.47	5.05	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.57			13.98	0.27	6.93	-	1.92	3.14	0.2	1.63	2.87	5.47	5.05	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.57																																																																																				-			13.98	0.27	6.93	-	1.92	3.14	0.2	1.63	2.87	5.47	5.05	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.57
H1419_002_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				100/day 1-7	100/day 1-7	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 Urgent care	100	30	30 routine 100 complex	30	30	30	5	30	30	30	30	30	45	0																				71.85	71.85	65.39	0	100	0.2	0.2	46.75	100	30	53.94	30	30	30	5	30	30	30	30	30	45	0																				9.32	0.18	6.93	-	1.92	3.14	0.2	1.63	2.87	5.47	5.05	-	-	-	2.26	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.56			9.32	0.18	6.93	-	1.92	3.14	0.2	1.63	2.87	5.47	5.05	-	-	-	2.26	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.56																																																																																				-			9.32	0.18	6.93	-	1.92	3.14	0.2	1.63	2.87	5.47	5.05	-	-	-	2.26	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.56
H1419_003_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				0	0	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 urgent care	100	15	15 routine 100 complex	15	15	15	0	15	15	15	15	15	45	0																				0	0	65.39	0	100	0.2	0.2	46.75	100	15	44.07	15	15	15	0	15	15	15	15	15	45	0																				-	-	6.93	-	1.92	3.14	0.2	1.63	2.87	2.73	4.13	-	-	-	-	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.84			-	-	6.93	-	1.92	3.14	0.2	1.63	2.87	2.73	4.13	-	-	-	-	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.84																																																																																				-			-	-	6.93	-	1.92	3.14	0.2	1.63	2.87	2.73	4.13	-	-	-	-	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.84
H1419_004_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	18.07																					992 per stay	992 per stay	0/day 1-20 100/day 21-100	0	100	20	20	50 (Waived if Admitted) 25 (Not Waived if Admitted)	400	50	50 routine 20 complex	50	30	50	0	50 Specialist 30 Renal Dialysis	50	50	50	50	20																					161.82	161.82	40.15	0	100	0.2	0.2	46.75	400	50	84.2	50	30	50	0	47.86	50	50	50	50	0.2																					20.99	0.41	4.25	-	1.92	3.14	0.2	1.63	11.47	9.12	7.89	-	-	-	-	26.75	0.82	2.38	3.91	5.91	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.41			20.99	0.41	4.25	-	1.92	3.14	0.2	1.63	11.47	9.12	7.89	-	-	-	-	26.75	0.82	2.38	3.91	5.91	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.41																																																																																				-			20.99	0.41	4.25	-	1.92	3.14	0.2	1.63	11.47	9.12	7.89	-	-	-	-	26.75	0.82	2.38	3.91	5.91	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.41
H1419_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H1419_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H1420_001_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	5000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0																					150/day 1-7	150/day 1-7	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 urgent care	100	30	30 routine 100 complex	30	30	30	10	30	30	30	30	30	45																					107.77	107.77	65.39	0	100	0.2	0.2	46.75	100	30	53.94	30	30	30	10	30	30	30	30	30	45																					12.3	0.24	6.1	-	1.69	2.77	0.18	1.43	2.52	4.81	4.45	-	-	-	3.98	14.76	0.43	1.26	2.06	3.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.1			12.3	0.24	6.1	-	1.69	2.77	0.18	1.43	2.52	4.81	4.45	-	-	-	3.98	14.76	0.43	1.26	2.06	3.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.1		30	30	30	30	100	30	30	50 ER 30 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45				30		30															4.96	0	0.8	0.72	0.16	0.41	0	0.14	0.51	0.18	0.5	0	0.16	0.55	0.64	0.81	0.03	0.09	0.6	2.17	0.08				0.08		0.02															13.61	500	12.53	17.26	0.24	6.9	0.72	1.85	3.18	0.18	1.57	3.03	4.99	4.94	-	0.16	0.55	4.63	15.56	0.47	1.34	2.66	5.29	0.08	-	-	-	0.08	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.71
H1420_002_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	5000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0																					0	0	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 urgent care	100	15	15 routine 100 complex	15	15	15	0	15	15	15	15	15	45																					0	0	65.39	0	100	0.2	0.2	46.75	100	15	44.07	15	15	15	0	15	15	15	15	15	45																					-	-	6.1	-	1.69	2.77	0.18	1.43	2.52	2.41	3.63	-	-	-	-	7.38	0.22	0.63	1.03	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.54			-	-	6.1	-	1.69	2.77	0.18	1.43	2.52	2.41	3.63	-	-	-	-	7.38	0.22	0.63	1.03	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.54		30	30	30	30	100	30	30	50 ER 30 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45				30		30															4.96	0	0.8	0.72	0.16	0.41	0	0.14	0.51	0.18	0.5	0	0.16	0.55	0.64	0.81	0.03	0.09	0.6	2.17	0.08				0.08		0.02															13.61	500	12.53	4.96	-	6.9	0.72	1.85	3.18	0.18	1.57	3.03	2.58	4.13	-	0.16	0.55	0.64	8.18	0.25	0.71	1.63	3.73	0.08	-	-	-	0.08	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.15
H1420_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	V	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	0	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.52			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	0	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.52		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	0.28	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.79
H1420_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	V	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	0	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.52			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	0	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.52		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	0.28	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.79
H1463_001_0	2007	3																					500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	213.91	1.56	0	0	0	8.08	4.93	259.76	0	0	0	0.7	0	13.59	3451.07	4471.27	4.82	0	131.46	299.56	8.31	0	0	0	15.96	0	3.75	0	1.54	0	0											PBP: 1A IP Acute - 100 per admit (unlimited days)	1B IP Psych - 100 per admit (unlimited days)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 10	11B Pros./Med Supp. - 10; 11C Diabetes Mon Supplies - 10	4A Emergency Care - 50; 4B Urgent Care - 20	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 0	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 20; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 20	7B Chiropractic Services - 20; 7D Physician Specialist - 20; 7F Podiatry Services - 20	5 Partial Hosp - 20; 7E Mental Health - 20; 7H Psychiatric Services - 20	3 CORF - 0; 7C Occupational Therapy - 0; 7I PT and ST Services - 0	7D Physician Specialist - 20	7G Other Health Care - 20; 9C Outpatient Sub Abuse - 20; 16B Comp Dental - 20; 17A Eye Exams (Medicare Covered) - 20; 18A Hearing Exams (Medicare Covered) - 20	15 Medicare Part B Rx Drugs - 0	13A Blood - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - 20	17B Eye Wear - not covered	18A Hearing Exams (Routine) - 20	18B Hearing Aids - not covered	4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 20	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											100	100	0	0	0	0.1	0.1	49.61	0	0	0	0	0	0	20	20	20	0	20	20	0	0	0	0	20	0	20	0	49.61	0	0											1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14	0	15.59	1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14	0																																																																																			-	0	0	1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14
H1463_002_0	2007	2																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	209.17	1.53	468.45	0	76.62	7.99	4.88	257.14	50.93	4.83	3.56	2.02	0	39.28	3380.73	4380.14	5.26	14.33	128.86	293.62	15.86	0.58	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 125 per day for days 1-5 (unlimited days)	1B IP Psych - 125 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 0 per day	10A Ambulance - 100 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 35	9B ASC Services - 10	8A Outpatient C/D/T - 10	8B Outpatient X-Rays - 10	9A Outpatient Hospital - 10	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 35; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 35	7B Chiropractic Services - 35; 7D Physician Specialist - 35; 7F Podiatry Services - 35	5 Partial Hosp - 35; 7E Mental Health - 35; 7H Psychiatric Services - 35	3 CORF - 35; 7C Occupational Therapy - 35; 7I PT and ST Services - 35	7D Physician Specialist - 35	7G Other Health Care - 35; 9C Outpatient Sub Abuse - 35; 16B Comp Dental - 35; 17A Eye Exams (Medicare Covered) - 35; 18A Hearing Exams (Medicare Covered) - 35	15 Medicare Part B Rx Drugs - 10	13A Blood - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - not covered	17B Eye Wear - not covered	18A Hearing Exams (Routine) - not covered	18B Hearing Aids - not covered	4A Emergency Care Worldwide Coverage - not covered; 4B Urgent Care Worldwide Coverage - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											380.66	500.21	48	0	100	0.2	0.2	49.81	0.1	0.1	0.1	0.1	0	0.1	20	35	35	35	35	35	0.1	0	0	0	0	0	0	0	0	0	0											6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2	0	22.81	6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2	0																																																																																			-	0	0	6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2
H1463_003_0	2007	4																					500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	213.91	1.56	0	0	0	8.08	4.93	259.76	0	0	0	0.7	0	13.59	3451.07	4471.27	4.82	0	131.46	299.56	8.31	0	0	0	15.96	0	3.75	0	1.54	0	0											PBP: 1A IP Acute - 100 per admit (unlimited days)	1B IP Psych - 100 per admit (unlimited days)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 10	11B Pros./Med Supp. - 10; 11C Diabetes Mon Supplies - 10	4A Emergency Care - 50; 4B Urgent Care - 20	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 0	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 20; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 20	7B Chiropractic Services - 20; 7D Physician Specialist - 20; 7F Podiatry Services - 20	5 Partial Hosp - 20; 7E Mental Health - 20; 7H Psychiatric Services - 20	3 CORF - 0; 7C Occupational Therapy - 0; 7I PT and ST Services - 0	7D Physician Specialist - 20	7G Other Health Care - 20; 9C Outpatient Sub Abuse - 20; 16B Comp Dental - 20; 17A Eye Exams (Medicare Covered) - 20; 18A Hearing Exams (Medicare Covered) - 20	15 Medicare Part B Rx Drugs - 0	13A Blood - 0			17A Eye Exams (Routine) - 20		18A Hearing Exams (Routine) - 20		4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 20	14A Health Ed/Wellness - 0												100	100	0	0	0	0.1	0.1	49.61	0	0	0	0	0	0	20	20	20	0	20	20	0	0	0	0	20	0	20	0	49.61	0	0											1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14	0	15.59	1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14	0																																																																																			-	0	0	1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14
H1463_004_0	2007	4																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	209.17	1.53	468.45	0	76.62	7.99	4.88	257.14	50.93	4.83	3.56	2.02	0	39.28	3380.73	4380.14	5.26	14.33	128.86	293.62	15.86	0.58	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 125 per day for days 1-5 (unlimited days)	1B IP Psych - 125 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 0 per day	10A Ambulance - 100 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 35	9B ASC Services - 10	8A Outpatient C/D/T - 10	8B Outpatient X-Rays - 10	9A Outpatient Hospital - 10	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 35; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 35	7B Chiropractic Services - 35; 7D Physician Specialist - 35; 7F Podiatry Services - 35	5 Partial Hosp - 35; 7E Mental Health - 35; 7H Psychiatric Services - 35	3 CORF - 35; 7C Occupational Therapy - 35; 7I PT and ST Services - 35	7D Physician Specialist - 35	7G Other Health Care - 35; 9C Outpatient Sub Abuse - 35; 16B Comp Dental - 35; 17A Eye Exams (Medicare Covered) - 35; 18A Hearing Exams (Medicare Covered) - 35	15 Medicare Part B Rx Drugs - 10	13A Blood - 0								14A Health Ed/Wellness - 0												380.66	500.21	48	0	100	0.2	0.2	49.81	0.1	0.1	0.1	0.1	0	0.1	20	35	35	35	35	35	0.1	0	0	0	0	0	0	0	0	0	0											6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2	0	22.81	6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2	0																																																																																			-	0	0	6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2
H1463_005_0	2007	4																					500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	213.91	1.56	0	0	0	8.08	4.93	259.76	0	0	0	0.7	0	13.59	3451.07	4471.27	4.82	0	131.46	299.56	8.31	0	0	0	15.96	0	3.75	0	1.54	0	0											PBP: 1A IP Acute - 100 per admit (unlimited days)	1B IP Psych - 100 per admit (unlimited days)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 10	11B Pros./Med Supp. - 10; 11C Diabetes Mon Supplies - 10	4A Emergency Care - 50; 4B Urgent Care - 20	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 0	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 20; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 20	7B Chiropractic Services - 20; 7D Physician Specialist - 20; 7F Podiatry Services - 20	5 Partial Hosp - 20; 7E Mental Health - 20; 7H Psychiatric Services - 20	3 CORF - 0; 7C Occupational Therapy - 0; 7I PT and ST Services - 0	7D Physician Specialist - 20	7G Other Health Care - 20; 9C Outpatient Sub Abuse - 20; 16B Comp Dental - 20; 17A Eye Exams (Medicare Covered) - 20; 18A Hearing Exams (Medicare Covered) - 20	15 Medicare Part B Rx Drugs - 0	13A Blood - 0			17A Eye Exams (Routine) - 20		18A Hearing Exams (Routine) - 20		4A Emergency Care Worldwide Coverage - 50; 4B Urgent Care Worldwide Coverage - 20	14A Health Ed/Wellness - 0												100	100	0	0	0	0.1	0.1	49.61	0	0	0	0	0	0	20	20	20	0	20	20	0	0	0	0	20	0	20	0	49.61	0	0											1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14	0	15.59	1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14	0																																																																																			-	0	0	1.78	0.01	-	-	-	0.81	0.49	1.07	-	-	-	-	-	-	5.75	7.45	0.01	-	0.22	0.5	-	-	-	-	0.03	-	0.01	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	18.14
H1463_006_0	2007	4																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	209.17	1.53	468.45	0	76.62	7.99	4.88	257.14	50.93	4.83	3.56	2.02	0	39.28	3380.73	4380.14	5.26	14.33	128.86	293.62	15.86	0.58	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 125 per day for days 1-5 (unlimited days)	1B IP Psych - 125 per day for days 1-5 (unlimited days)	2 SNF - 0 per day for days 1-20 100 per day for days 21-100	6 Home Health - 0 per day	10A Ambulance - 100 per trip	11A DME - 20	11B Pros./Med Supp. - 20; 11C Diabetes Mon Supplies - 20	4A Emergency Care - 50; 4B Urgent Care - 35	9B ASC Services - 10	8A Outpatient C/D/T - 10	8B Outpatient X-Rays - 10	9A Outpatient Hospital - 10	12 Renal Dialysis - 0	9D Cardiac Rehab Svcs - 10	7A Primary Care - 20; 14B Immunizations - 0; 14C Routine Physical Exams - 20; 14D Pap - 0; 14D Pelvic - 35; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 35	7B Chiropractic Services - 35; 7D Physician Specialist - 35; 7F Podiatry Services - 35	5 Partial Hosp - 35; 7E Mental Health - 35; 7H Psychiatric Services - 35	3 CORF - 35; 7C Occupational Therapy - 35; 7I PT and ST Services - 35	7D Physician Specialist - 35	7G Other Health Care - 35; 9C Outpatient Sub Abuse - 35; 16B Comp Dental - 35; 17A Eye Exams (Medicare Covered) - 35; 18A Hearing Exams (Medicare Covered) - 35	15 Medicare Part B Rx Drugs - 10	13A Blood - 0								14A Health Ed/Wellness - 0												380.66	500.21	48	0	100	0.2	0.2	49.81	0.1	0.1	0.1	0.1	0	0.1	20	35	35	35	35	35	0.1	0	0	0	0	0	0	0	0	0	0											6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2	0	22.81	6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2	0																																																																																			-	0	0	6.64	0.06	1.87	-	0.64	1.6	0.98	1.07	5.09	0.48	0.36	0.2	-	3.93	5.63	12.78	0.02	0.04	0.38	0.86	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2
H1463_801_0	2007	5																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	176.76	0.86	36.91	2.61	3.45	7.21	4.4	20.48	47.15	4.42	3.37	1.86	0	36.02	27.85	118.21	0.02	0.93	26.09	59.45	15.64	0.54	0	0	0	0	0	0	0	0	0											8.4 FFS Medicare Actuarially Equivalent Cost Sharing	8.4 FFS Medicare Actuarially Equivalent Cost Sharing	19.5 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.79	0.07	7.18	-	0.81	1.7	1.04	4.83	11.13	1.04	0.79	0.44	-	8.5	6.57	27.9	0	0.22	6.16	14.03	3.69	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04	0	0	14.79	0.07	7.18	-	0.81	1.7	1.04	4.83	11.13	1.04	0.79	0.44	-	8.5	6.57	27.9	0	0.22	6.16	14.03	3.69	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04	0																																																																																			-	0	0	14.79	0.07	7.18	-	0.81	1.7	1.04	4.83	11.13	1.04	0.79	0.44	-	8.5	6.57	27.9	0	0.22	6.16	14.03	3.69	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04
H1463_802_0	2007	5																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	176.76	0.86	36.91	2.61	3.45	7.21	4.4	20.48	47.15	4.42	3.37	1.86	0	36.02	27.85	118.21	0.02	0.93	26.09	59.45	15.64	0.54	0	0	0	0	0	0	0	0	0											8.4 FFS Medicare Actuarially Equivalent Cost Sharing	8.4 FFS Medicare Actuarially Equivalent Cost Sharing	19.5 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.79	0.07	7.18	-	0.81	1.7	1.04	4.83	11.13	1.04	0.79	0.44	-	8.5	6.57	27.9	0	0.22	6.16	14.03	3.69	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04	0	0	14.79	0.07	7.18	-	0.81	1.7	1.04	4.83	11.13	1.04	0.79	0.44	-	8.5	6.57	27.9	0	0.22	6.16	14.03	3.69	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04	0																																																																																			-	0	0	14.79	0.07	7.18	-	0.81	1.7	1.04	4.83	11.13	1.04	0.79	0.44	-	8.5	6.57	27.9	0	0.22	6.16	14.03	3.69	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04
H1463_808_0	2007	5																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	174.4	0.84	36.8	2.62	3.49	7.2	4.39	20.71	47.69	4.47	3.4	1.88	0	36.42	27.78	117.94	0.02	0.93	26.03	59.32	15.81	0.54	0	0	0	0	0	0	0	0	0											8.4 FFS Medicare Actuarially Equivalent Cost Sharing	8.4 FFS Medicare Actuarially Equivalent Cost Sharing	19.5 FFS Medicare Actuarially Equivalent Cost Sharing	0.0 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	23.6 FFS Medicare Actuarially Equivalent Cost Sharing	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.59	0.07	7.16	-	0.82	1.7	1.04	4.89	11.25	1.05	0.8	0.44	-	8.6	6.56	27.83	0	0.22	6.14	14	3.73	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04	0	0	14.59	0.07	7.16	-	0.82	1.7	1.04	4.89	11.25	1.05	0.8	0.44	-	8.6	6.56	27.83	0	0.22	6.14	14	3.73	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04	0																																																																																			-	0	0	14.59	0.07	7.16	-	0.82	1.7	1.04	4.89	11.25	1.05	0.8	0.44	-	8.6	6.56	27.83	0	0.22	6.14	14	3.73	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.04
H1468_004_0	2007	2																																A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-		316.07	6.07	0	0	249.88	22.45	9.07	467.92	0	0	0	11.49	0	36.64	4353.87	2740.27	431.83	0	0	0	24.85	542.38	9.58	0	23.49	0	6.01	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a. no copay 16b/17a. 10-15 copay 17b. no copay 18a. 15 copay	10b. 25 copay		17a1. 10 - 15 copay		18a1. 10 - 15 copay			14a. 10 nutrition 0 other												150	150	0	0	50	0.01	0.1	38.61	0	0	0	20	0	20	10	15	20	0	0	0	0.1	12.5	25	0	12.5	0	12.5	0	0	0	0											3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47	0	0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47																																																																																				-		0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47
H1468_005_0	2007	3																																A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-		316.07	6.07	0	0	249.88	22.45	9.07	467.92	0	0	0	11.49	0	36.64	4353.87	2740.27	431.83	0	0	0	24.85	542.38	9.58	0	23.49	0	6.01	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a. no copay 16b/17a. 10-15 copay 17b. no copay 18a. 15 copay	10b. 25 copay		17a1. 10 - 15 copay		18a1. 10 - 15 copay			14a. 10 nutrition 0 other												150	150	0	0	50	0.01	0.1	38.61	0	0	0	20	0	20	10	15	20	0	0	0	0.1	12.5	25	0	12.5	0	12.5	0	0	0	0											3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47	0	0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47																																																																																				-		0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47
H1468_006_0	2007	2																																A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-		316.07	6.07	0	0	249.88	22.45	9.07	467.92	0	0	0	11.49	0	36.64	4353.87	2740.27	431.83	0	0	0	24.85	542.38	9.58	0	23.49	0	6.01	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a. no copay 16b/17a. 10-15 copay 17b. no copay 18a. 15 copay	10b. 25 copay		17a1. 10 - 15 copay		18a1. 10 - 15 copay			14a. 10 nutrition 0 other												150	150	0	0	50	0.01	0.1	38.61	0	0	0	20	0	20	10	15	20	0	0	0	0.1	12.5	25	0	12.5	0	12.5	0	0	0	0											3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47	0	0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47																																																																																				-		0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47
H1468_007_0	2007	4																																A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-		316.07	6.07	0	0	249.88	22.45	9.07	467.92	0	0	0	11.49	0	36.64	4353.87	2740.27	431.83	0	0	0	24.85	542.38	9.58	0	23.49	0	6.01	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a. no copay 16b/17a. 10-15 copay 17b. no copay 18a. 15 copay	10b. 25 copay		17a1. 10 - 15 copay		18a1. 10 - 15 copay			14a. 10 nutrition 0 other												150	150	0	0	50	0.01	0.1	38.61	0	0	0	20	0	20	10	15	20	0	0	0	0.1	12.5	25	0	12.5	0	12.5	0	0	0	0											3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47	0	0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47																																																																																				-		0	3.95	0.08	-	-	1.04	0.16	0.91	1.51	-	-	-	0.02	-	0.06	3.63	3.43	0.72	-	-	-	2.36	0.56	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.47
H1509_001_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1723.21	136.4	658.76	0	201.5	11.48	5.14	461.81	24.2	6687.48	38.2	0	0.15	17.5	3335.87	3790.79	521.37	3.01	0	0	17.3	632.45	0	0	149.52	38.74	172.76	0	0	0	0											275 (1a)	275 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											157.9	157.9	77.51	0	100.48	0.17	0.19	28.71	0.11	1.15	0.09	0	0.17	0.11	10	30	37.5	0.11	0	0	0.17	30	0	0	30	15	30	0	0	0	0											22.67	1.79	4.26	-	1.69	1.98	1	1.1	2.78	0.64	3.42	-	0.03	2.01	2.78	9.48	1.63	0.35	-	-	2.98	1.58	-	-	0.37	0.05	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.01		34.42	22.67	1.79	4.26	-	1.69	1.98	1	1.1	2.78	0.64	3.42	-	0.03	2.01	2.78	9.48	1.63	0.35	-	-	2.98	1.58	-	-	0.37	0.05	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.01	2800	375 (1a)	375 (1b)	185 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	30 (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.69	0.21	0.51	0.41	0.37	0.43	0.22	0.24	0.91	0.56	1.12	0	0.01	0.66	1.54	2.77	0.41	0.11	0	0	0.65	0.47	0	0	0.11	0.01	0.13	0	0	0	0											14.56		6.42	25.36	2.01	4.76	0.41	2.06	2.41	1.22	1.35	3.69	1.2	4.54	-	0.03	2.67	4.32	12.25	2.03	0.46	-	-	3.63	2.05	-	-	0.48	0.06	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.57
H1509_003_0	2007	4																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1723.21	136.4	658.76	0	201.5	11.48	5.14	461.81	24.2	6687.48	38.2	0	0.15	17.5	3335.87	3790.79	521.37	3.01	0	0	17.3	632.45	0	0	149.52	38.74	172.76	0	0	0	0											275 (1a)	275 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											145.85	145.85	71.6	0	92.81	0.16	0.18	26.52	0.11	3.18	0.08	0	0.16	0.11	10	30	37.5	0.11	0	0	0.16	30	0	0	30	15	30	0	0	0	0											20.94	1.66	3.93	-	1.56	1.83	0.94	1.02	2.57	1.77	3.15	-	0.02	1.86	2.78	9.48	1.63	0.32	-	-	2.75	1.58	-	-	0.37	0.05	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.65		39.01	20.94	1.66	3.93	-	1.56	1.83	0.94	1.02	2.57	1.77	3.15	-	0.02	1.86	2.78	9.48	1.63	0.32	-	-	2.75	1.58	-	-	0.37	0.05	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.65	2400	375 (1a)	375 (1b)	185 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	30 (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.48	0.2	0.47	0.22	0.34	0.4	0.18	0.22	0.85	0.52	1.04	0	0.01	0.61	0.82	1.47	0.21	0.1	0	0	0.6	0.25	0	0	0.06	0.01	0.07	0	0	0	0											11.13		9.85	23.43	1.85	4.4	0.22	1.9	2.23	1.12	1.24	3.41	2.29	4.19	-	0.03	2.47	3.6	10.95	1.84	0.42	-	-	3.36	1.83	-	-	0.43	0.05	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.78
H1509_004_0	2007	6	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2130.72	337.14	1085.43		252.98	24.8	21.48	866.92	375.89	1972.13	925.23	64.04	3.09	1946.83		3360.04		510.06		782.09												277.52		149.39	222.25							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							37	37	18		37	10	10	18	12	5	5	12	10	12		5		5		5												5		5	5							6.49	1.03	1.59	-	0.77	2.42	2.09	1.27	0.38	0.8	0.38	0.06	0.3	1.98	-	1.36	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.7		22.84	6.49	1.03	1.59	-	0.77	2.42	2.09	1.27	0.38	0.8	0.38	0.06	0.3	1.98	-	1.36	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.7		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.04	0.14	0.27	0.34	0.06	0.15	0.13	0.05	0.18	0.13	0.12	0.02	0.02	0.2	0.33	0.2	0.04	0.03	0.14	0.64	0.13	0																				5.36		0	8.53	1.17	1.86	0.34	0.83	2.57	2.22	1.31	0.56	0.93	0.5	0.08	0.32	2.18	0.33	1.56	0.04	0.24	0.14	0.96	0.13	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	27.06
H1509_801_0	2007	4																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1809.37	143.22	691.69	0	211.57	12.06	5.4	484.9	25.41	7021.86	40.11	0	0.16	18.37	3502.66	3980.33	547.44	3.16	0	0	18.16	664.07	0	0	155.67	0	181.4	0	0	0	0											330 (1a)	330 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											204.21	204.21	92.82	0	108.29	0.19	0.21	30.94	0.19	3.71	0.14	0	0.19	0.19	35	35	37.5	0.19	0	0	0.19	35	0	0	35	0	35	0	0	0	0											30.79	2.44	5.35	-	1.91	2.24	1.11	1.25	4.72	2.17	5.61	-	0.03	3.41	10.22	11.61	1.71	0.59	-	-	3.37	1.94	-	-	0.45	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.44		39.85	30.79	2.44	5.35	-	1.91	2.24	1.11	1.25	4.72	2.17	5.61	-	0.03	3.41	10.22	11.61	1.71	0.59	-	-	3.37	1.94	-	-	0.45	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.44	4400	40 (1a)	40 (1b)	40 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											5.12	0.16	0.47	0.36	0.42	0.49	0.22	0.27	1.38	0.64	1.64	0	0.01	1	1.86	1.8	0.26	0.17	0	0	0.74	0.3	0	0	0.07	0	0.08	0	0	0	0											17.48		10.76	35.91	2.6	5.82	0.36	2.33	2.73	1.33	1.52	6.1	2.81	7.25	-	0.04	4.41	12.08	13.41	1.97	0.76	-	-	4.11	2.24	-	-	0.52	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.91
H1510_001_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1270.17	9.27	455.67	2174.1	126.77	0.73	0.05	205.71	448.41	826.94	563.83	37.59	385.46	319.5	7267.45	8620.51			317.89		10.09											66.85	0.49	16.41								175/day (1-5)	175/day (1-5)	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-75/ Visit	50-75/ Visit	50/ Visit	0/ Procedure	35-75/ Visit	10/ Visit	35/ Visit			50/ Visit		20 Coins											175/day (1-5)	175/day (1-5)	20 Coins								119.04	119.03	11.79	10	100	0.2	0.2	49.63	116.5	57.95	54.17	50	0	42.06	10	35			50		0.2											119.04	119.03	0.2								12.6	0.09	0.45	1.81	1.06	0.15	0.01	0.85	4.35	3.99	2.55	0.16	-	1.12	6.06	25.14	-	-	1.32	-	2.02	-	-	-	-	-	-	-	-	-	-	0.66	0	3.28	-	-	-	-	-	-	-	67.67	0	0	12.6	0.09	0.45	1.81	1.06	0.15	0.01	0.85	4.35	3.99	2.55	0.16	-	1.12	6.06	25.14	-	-	1.32	-	2.02	-	-	-	-	-	-	-	-	-	-	0.66	0	3.28	-	-	-	-	-	-	-	67.67		25 Coins	25 Coins	25 Coins	25 Coins	100/Trip	25 Coins		50/Visit	25 Coins	25 Coins			0/Procedure		25 Coins	25 Coins					20 Coins													25 Coins								8.2	0.03	0.27	0.37	0.3	0.03		0.3	3.39	4			0		2.54	3.05					0.66													0.87								24.02	500	0.96	20.8	0.12	0.72	2.18	1.36	0.17	0.01	1.15	7.74	8	2.55	0.16	-	1.12	8.59	28.2	-	-	1.32	-	2.67	-	-	-	-	-	-	-	-	-	-	0.66	0	4.15	-	-	-	-	-	-	-	91.69
H1510_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1268.82	9.26	455.19	2171.78	126.64	0.72	0.05	250.6	447.93	826.06	563.23	37.55	385.05	319.16	7259.72	8611.34			317.55		10.06											13.48	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									121.11	125.13	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.12	25.12	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.44	0	0	12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.12	25.12	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.44		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.72	5.57			0		1.77	4.25					0.57																					20.63	0	0	15.08	0.11	0.71	2.33	1.32	0.23	0.01	1.2	12.18	7.98	2.15	0.31	-	1	16.89	29.36	-	-	0.93	-	2.58	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.07
H1510_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		252.22	1.9	448.27	2138.79	124.72	0.7	0.05	246.79	441.13	813.51	554.67	36.98	379.2	314.31	7149.42	8480.51			312.72		9.76											13.27	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.61	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.89	24.73	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.28	0	0	12.61	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.89	24.73	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.28		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.37	0.5	0.26	0.04		0.26	4.58	5.4			0		1.71	4.12					0.55																					20.05	0	0	14.85	0.11	0.7	2.28	1.3	0.22	0.01	1.19	11.93	7.77	2.12	0.31	-	0.99	16.61	28.85	-	-	0.91	-	2.51	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	93.33
H1510_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.11	1.93	455.19	2171.78	126.64	0.72	0.05	250.6	447.93	826.06	563.23	37.55	385.05	319.16	7259.72	8611.34			317.55		10.06											13.48	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.12	25.12	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.44	0	0	12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.12	25.12	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.44		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.72	5.57			0		1.77	4.25					0.57																					20.63	0	0	15.08	0.11	0.71	2.33	1.32	0.23	0.01	1.2	12.18	7.98	2.15	0.31	-	1	16.89	29.36	-	-	0.93	-	2.58	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.07
H1510_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		252.22	1.9	448.27	2138.79	124.72	0.7	0.05	246.79	441.13	813.51	554.67	36.98	379.2	314.31	7149.42	8480.51			312.72		9.76											13.27	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.61	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.89	24.73	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.28	0	0	12.61	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.89	24.73	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.28		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.37	0.5	0.26	0.04		0.26	4.58	5.4			0		1.71	4.12					0.55																					20.05	0	0	14.85	0.11	0.7	2.28	1.3	0.22	0.01	1.19	11.93	7.77	2.12	0.31	-	0.99	16.61	28.85	-	-	0.91	-	2.51	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	93.33
H1511_001_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	390.64	7.28	585.09		316.32	12.32	4.15	354.96	452.92	928.08	1113.02	49.85	30.71	0.88	5809.44	1925.29	4.8	461.41			221.37				21.71		162					1062.19	21.46	82.81	393.32	116.41	0.04	874.28	2.48			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			404.73	456.87	68.25		68.25	0.18	0.18	45.5	159.24	46.46	54.22	159.24	31.5	22.75	9.1	22.75	22.75	22.75			27.5				22.75		22.75					22.75	45.5	22.75	22.75	9.1	0.18	22.75	22.75			13.18	0.28	3.33	-	1.8	2.24	0.76	1.35	6.01	3.59	5.03	0.66	0.08	0	4.41	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.85		5.23	13.18	0.28	3.33	-	1.8	2.24	0.76	1.35	6.01	3.59	5.03	0.66	0.08	0	4.41	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.85	2750																																																																																			-			13.18	0.28	3.33	-	1.8	2.24	0.76	1.35	6.01	3.59	5.03	0.66	0.08	0	4.41	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.85
H1511_005_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	2251.58	56.43	585.09		316.32	12.32	4.15	354.96	452.92	928.08	1113.02	49.85	30.71	0.88	5809.44	1925.29	4.8	461.41			221.37				21.71		162					1062.19	21.46	82.81	393.32	116.41	0.04	874.28	2.48			150/day with 1500 yearly max	150/day with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			88.26	89.94	68.55		68.55	0.18	0.18	45.7	137.1	46.67	54.47	137.1	31.64	22.85	9.14	22.85	22.85	22.85			27.63				22.85		22.85					22.85	45.7	22.85	22.85	9.14	0.18	22.85	22.85			16.56	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.67	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.6		5.23	16.56	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.67	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.6	2750																																																																																			-			16.56	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.67	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.6
H1511_801_0	2007	4	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	374.45	4.96	316.4		0.25	13.56	6.15	301.47	541.19	954.28	1240.5	42.78	10.67	0	6595.06	2237.64	2.76	736.78			252.54				31.11		162					1128.51	24.68	146.7	479.68	159.47	0.05	1014.24	3.16			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			406.58	423.83	68.36		68.36	0.18	0.18	45.57	159.51	46.75	55.15	159.51	31.9	22.79	9.11	22.79	22.79	22.79			34.36				22.79		22.79					22.79	45.57	22.79	22.79	9.11	0.18	22.79	22.79			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85		5.23	12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85	2750																																																																																			-			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85
H1511_803_0	2007	2	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	374.45	4.96	316.4		0.25	13.56	6.15	301.47	541.19	954.28	1240.5	42.78	10.67	0	6595.06	2237.64	2.76	736.78			252.54				31.11		162					1128.51	24.68	146.7	479.68	159.47	0.05	1014.24	3.16			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			406.58	423.83	68.36		68.36	0.18	0.18	45.57	159.51	46.75	55.15	159.51	31.9	22.79	9.11	22.79	22.79	22.79			34.36				22.79		22.79					22.79	45.57	22.79	22.79	9.11	0.18	22.79	22.79			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85		5.23	12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85	2750																																																																																			-			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85
H1607_001_0	2007	6	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	281.55	10.57	312.94		116.01	10.15	4.31	281.73	474.36	734.15	1022.97	39.32	5.97	0.17	4333.34	1565.67	7.84	387.74			253.91				18.15		33.53					1178.12	23.15	77.49	254.95	97.8	0.04	618.17	1.25			750/admit with 1500 yearly max	750/admit with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	15 copay	20 coinsurance	25 copay	25 copay			601.14	570.88	75		75	0.2	0.2	50	175	51.45	60.78	175	34.63	25	10	25	25	25			31.5				25		25					25	50	25	25	13.88	0.2	25	25			14.1	0.5	1.96	-	0.73	2.03	0.86	1.17	6.92	3.15	5.18	0.57	0.02	0	3.61	3.26	0.02	0.81	-	-	0.67	-	-	-	0.04	-	0.07	-	-	-	-	2.45	0.1	0.16	0.53	0.11	0.01	1.29	0	-	-	50.32		1.84	14.1	0.5	1.96	-	0.73	2.03	0.86	1.17	6.92	3.15	5.18	0.57	0.02	0	3.61	3.26	0.02	0.81	-	-	0.67	-	-	-	0.04	-	0.07	-	-	-	-	2.45	0.1	0.16	0.53	0.11	0.01	1.29	0	-	-	50.32	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			16.45	0.03	1.29		0.1	0.23	0.74	0.21	1.28	0.65	0.97	0.01	0	0	1.06	0.67	0	0.06			0.19				0		0					0.29	0.03	0	0.03	0.08	0.01	0.17	0			24.56		0.63	30.55	0.53	3.25	-	0.83	2.26	1.6	1.38	8.19	3.79	6.15	0.59	0.02	0	4.67	3.94	0.02	0.87	-	-	0.85	-	-	-	0.04	-	0.07	-	-	-	-	2.75	0.13	0.17	0.56	0.19	0.02	1.45	0	-	-	74.88
H1607_002_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	1598.99	57.9	312.94		116.01	10.15	4.31	281.73	474.36	734.15	1022.97	39.32	5.97	0.17	4333.34	1565.67	7.84	387.74			253.91				18.15		33.53					1178.12	23.15	77.49	254.95	97.8	0.04	618.17	1.25			175/day with 1750 yearly max	175/day with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	20 copay	10 copay	20 copay	20 copay	20 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 copay	50 copay	20 copay	20 copay	10 copay	20 coinsurance	20 copay	20 copay			116.54	137.36	75		75	0.2	0.2	50	150	51.45	60.78	150	34.63	20	10	20	20	20			31.5				20		20					20	50	20	20	10	0.2	20	20			15.53	0.66	1.96	-	0.73	2.03	0.86	1.17	5.93	3.15	5.18	0.49	0.02	0	3.61	2.61	0.01	0.65	-	-	0.67	-	-	-	0.03	-	0.06	-	-	-	-	1.96	0.1	0.13	0.42	0.08	0.01	1.03	0	-	-	49.07		1.83	15.53	0.66	1.96	-	0.73	2.03	0.86	1.17	5.93	3.15	5.18	0.49	0.02	0	3.61	2.61	0.01	0.65	-	-	0.67	-	-	-	0.03	-	0.06	-	-	-	-	1.96	0.1	0.13	0.42	0.08	0.01	1.03	0	-	-	49.07	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			16.5	0.03	1.29		0.1	0.23	0.74	0.21	1.28	0.65	0.97	0.01	0	0	1.06	0.67	0	0.06			0.19				0		0					0.29	0.03	0	0.03	0.08	0.01	0.17	0			24.62		0.64	32.02	0.69	3.25	-	0.83	2.26	1.61	1.38	7.21	3.8	6.16	0.51	0.02	0	4.67	3.28	0.01	0.71	-	-	0.85	-	-	-	0.03	-	0.06	-	-	-	-	2.26	0.13	0.13	0.46	0.16	0.02	1.2	0	-	-	73.7
H1607_801_0	2007	4	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	298.43	3.96	252.16		0.2	10.65	4.83	240.27	431.31	760.53	988.64	34.1	8.5	0	5256.08	1783.34	2.2	587.19			201.27				24.79		129.6					899.39	19.67	116.91	382.29	127.09	0.04	808.32	2.52			750/admit with 1500 yearly max	750/admit with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			535.47	558.19	72.02		72.02	0.19	0.19	48.02	168.06	49.25	58.11	168.06	33.61	24.01	9.6	24.01	24.01	24.01			36.2				24.01		24.01					24.01	48.02	24.01	24.01	9.6	0.19	24.01	24.01			13.32	0.18	1.51	-	0	2.05	0.93	0.96	6.04	3.12	4.79	0.48	0.02	0	4.21	3.57	0	1.17	-	-	0.61	-	-	-	0.05	-	0.26	-	-	-	-	1.8	0.08	0.23	0.76	0.1	0.01	1.62	0.01	-	-	47.88		1.98	13.32	0.18	1.51	-	0	2.05	0.93	0.96	6.04	3.12	4.79	0.48	0.02	0	4.21	3.57	0	1.17	-	-	0.61	-	-	-	0.05	-	0.26	-	-	-	-	1.8	0.08	0.23	0.76	0.1	0.01	1.62	0.01	-	-	47.88	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			12.02	0.07	1.59		0	0.86	0.39	0.27	1.84	0.41	1.1	0.04	0.01	0	4.58	2.82	0	0.33			0.17				0		0					0.36	0.03	0.02	0.15	0.06	0	0.74	0			27.88		0.49	25.33	0.26	3.1	-	0	2.91	1.32	1.23	7.88	3.53	5.89	0.52	0.03	0	8.79	6.39	0.01	1.51	-	-	0.78	-	-	-	0.05	-	0.26	-	-	-	-	2.16	0.11	0.26	0.91	0.16	0.01	2.36	0.01	-	-	75.76
H1608_001_0	2007	7	h.6.	h.7.	i.7.	i.8.	g.2						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery						1500	Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						D	D	D	Coin	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	P	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-	5000	1590.89	75.79	654.93		214.52	1.25	0.15	257.83	521.55	0.8	18.57	1.29	12.6	12.8	2905.22	3782.57	245.96	402.25	0.44		8.6				167.05		4.06							1184.52	399.14							1a 150 days 1-7	1b 150 days 1-7	2 75 days 7-26		10a 115	11a 30	11b 3011c 10	4a 504b 50	9a 1009b 100	8a 20	8b 20	9a 20	12 20	9a 209d 20	14c 107a 10	17a 3018a 307b 207d 30	7e 30	7c 257i 25	8b 20		0.2				17a 30		18a 30							8b 15	8a 15							30.75	30.62	10.05		43.13	0.11	0.05	18.75	37.5	0.08	0.08	0.08	0.2	0.08	10	29.45	11.25	9.38	0.08		0.12				30		30							5.63	5.63							4.08	0.19	0.55	-	0.77	0.14	0.01	0.4	1.63	0.06	1.39	0.1	2.52	0.96	2.42	9.28	0.23	0.31	0.03	-	1.06	-	-	-	0.42	-	0.01	-	-	-	-	-	-	0.56	0.19	-	-	-	-	-	-	27.32		20.08	4.08	0.19	0.55	-	0.77	0.14	0.01	0.4	1.63	0.06	1.39	0.1	2.52	0.96	2.42	9.28	0.23	0.31	0.03	-	1.06	-	-	-	0.42	-	0.01	-	-	-	-	-	-	0.56	0.19	-	-	-	-	-	-	27.32		0.2	20	0.2	0	115	0	0	50	0	0	0.2	0.2	0.2	0	0	0.2	0	0	20	0.2	0.2				0.2	0.2	0				0.2			0.2	0.2							3.51	0	0.35	0.29	0.18	0.03	0	0.09	0.46	0.01	0.25	0.02	0.19	0.29	0.31	1.1	0.03	0.06	0.2	0.18	0.16				0.02	0.03	0				0			0.06	0.06							7.88		6.43	7.58	0.19	0.89	0.29	0.95	0.17	0.01	0.5	2.09	0.07	1.64	0.12	2.71	1.25	2.73	10.38	0.26	0.38	0.24	0.18	1.22	-	-	-	0.43	0.03	0.01	-	-	-	0	-	-	0.61	0.24	-	-	-	-	-	-	35.19
H1608_801_0	2007	7	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		201.72	4.74	20.49		6.25	1.38	0.14	8	40.55	0.88	20.43	1.41	13.86	14.08	27.43	99.84	2.84	3.52	20.66	15.54	9.12													3.87	5.31							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54			17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54		FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							3.01	0	0.49		0.21	0.04	0	0.29	1.09	0.03	0.6	0.05	0.46	0.67	0.7	2.58		0.15	0.52	0.43	0.28													0.1	0.13							11.84			20.62	0.42	3.36	-	1.69	0.37	0.04	2.18	10.66	0.24	5.42	0.38	3.73	4	7.18	26.14	0.67	0.98	5.4	4.1	2.44	-	-	-	-	-	-	-	-	-	-	-	-	1.01	1.39	-	-	-	-	-	-	102.38
H1608_802_0	2007	5	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		201.72	4.74	20.49		6.25	1.38	0.14	8	40.55	0.88	20.43	1.41	13.86	14.08	27.43	99.84	2.84	3.52	20.66	15.54	9.12													3.87	5.31							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54			17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54		FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							3.01	0	0.49		0.21	0.04	0	0.29	1.09	0.03	0.6	0.05	0.46	0.67	0.7	2.58		0.15	0.52	0.43	0.28													0.1	0.13							11.84			20.62	0.42	3.36	-	1.69	0.37	0.04	2.18	10.66	0.24	5.42	0.38	3.73	4	7.18	26.14	0.67	0.98	5.4	4.1	2.44	-	-	-	-	-	-	-	-	-	-	-	-	1.01	1.39	-	-	-	-	-	-	102.38
H1608_803_0	2007	5	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		201.72	4.74	20.49		6.25	1.38	0.14	8	40.55	0.88	20.43	1.41	13.86	14.08	27.43	99.84	2.84	3.52	20.66	15.54	9.12													3.87	5.31							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54			17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54		FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							3.01	0	0.49		0.21	0.04	0	0.29	1.09	0.03	0.6	0.05	0.46	0.67	0.7	2.58		0.15	0.52	0.43	0.28													0.1	0.13							11.84			20.62	0.42	3.36	-	1.69	0.37	0.04	2.18	10.66	0.24	5.42	0.38	3.73	4	7.18	26.14	0.67	0.98	5.4	4.1	2.44	-	-	-	-	-	-	-	-	-	-	-	-	1.01	1.39	-	-	-	-	-	-	102.38
H1608_806_0	2007	7	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		201.72	4.74	20.49		6.25	1.38	0.14	8	40.55	0.88	20.43	1.41	13.86	14.08	27.43	99.84	2.84	3.52	20.66	15.54	9.12													3.87	5.31							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54			17.61	0.41	2.87	-	1.48	0.33	0.03	1.89	9.57	0.21	4.82	0.33	3.27	3.32	6.47	23.56	0.67	0.83	4.88	3.67	2.15	-	-	-	-	-	-	-	-	-	-	-	-	0.91	1.25	-	-	-	-	-	-	90.54		FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 14.0		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							3.01	0	0.49		0.21	0.04	0	0.29	1.09	0.03	0.6	0.05	0.46	0.67	0.7	2.58		0.15	0.52	0.43	0.28													0.1	0.13							11.84			20.62	0.42	3.36	-	1.69	0.37	0.04	2.18	10.66	0.24	5.42	0.38	3.73	4	7.18	26.14	0.67	0.98	5.4	4.1	2.44	-	-	-	-	-	-	-	-	-	-	-	-	1.01	1.39	-	-	-	-	-	-	102.38
H1609_001_0	2007	8	h.6.	h.7.	i.7.	i.8.	g.2						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery						1400	Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						D	D	D	Coin	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	P	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		1732.48	82.5	712.91		228.86	1.35	0.16	275.06	556.4	0.85	19.81	1.37	13.46	13.65	3162.36	4117.43	267.73	429.13	0.48		9.32				181.84		4.42							1289.38	434.47							1a 150 days 1-7	1b 150 days 1-7	2 75 days 7-22		10a 115	11a 30	11b 3011c 10	4a 504b 50	9a 509b 50	8a 20	8b 20	9a 20	12 20	9a 209d 20	14c 107a 10	17a 3018a 307b 207d 30	7e 30	7c 257i 25	8b 20		0.2				17a 30		18a 30							8b 20	8a 15							30.35	30.23	9.92		42.57	0.11	0.05	18.51	18.51	0.07	0.07	0.07	0.2	0.07	10	29.45	11.1	9.25	0.07		0.12				30		11.1							7.4	5.55							4.38	0.21	0.59	-	0.81	0.15	0.01	0.42	0.86	0.06	1.47	0.1	2.69	1.01	2.64	10.11	0.25	0.33	0.04	-	1.16	-	-	-	0.45	-	0	-	-	-	-	-	-	0.8	0.2	-	-	-	-	-	-	28.73		20.69	4.38	0.21	0.59	-	0.81	0.15	0.01	0.42	0.86	0.06	1.47	0.1	2.69	1.01	2.64	10.11	0.25	0.33	0.04	-	1.16	-	-	-	0.45	-	0	-	-	-	-	-	-	0.8	0.2	-	-	-	-	-	-	28.73																																																																																				-			4.38	0.21	0.59	-	0.81	0.15	0.01	0.42	0.86	0.06	1.47	0.1	2.69	1.01	2.64	10.11	0.25	0.33	0.04	-	1.16	-	-	-	0.45	-	0	-	-	-	-	-	-	0.8	0.2	-	-	-	-	-	-	28.73
H1609_002_0	2007	7	h.6.	h.7.	i.7.	i.8.	g.2						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery						1000	Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						D	D	D	Coin	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	P	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		1732.48	82.5	712.91		233.52	1.36	0.16	280.66	567.72	0.87	20.21	1.4	13.72	13.93	3162.36	4117.43	267.73	437.86	0.48		9.43				181.84		4.42							1289.38	434.47							1a 125 days 1-7	1b 125 days 1-7	2 75 days 7-19		10a 115	11a 10	11b 1011c 10	4a 504b 50	9a 509b 50	8a 10	8b 10	9a 10	12 10	9a 109d 10	14c 107a 10	17a 1518a 157b 157d 15	7e 15	7c 157i 15	8b 10		0.2				17a 15		18a 15							8b 15	8a 15							22.16	22.03	8.68		37.22	0.03	0.03	16.18	16.18	0.03	0.03	0.03	0.1	0.03	10	14.79	4.85	4.85	0.03		0.09				15		4.85							4.85	4.85							3.2	0.15	0.52	-	0.72	0.04	0.01	0.38	0.77	0.03	0.65	0.05	1.37	0.45	2.64	5.08	0.11	0.18	0.02	-	0.83	-	-	-	0.23	-	0	-	-	-	-	-	-	0.52	0.18	-	-	-	-	-	-	18.11		17.05	3.2	0.15	0.52	-	0.72	0.04	0.01	0.38	0.77	0.03	0.65	0.05	1.37	0.45	2.64	5.08	0.11	0.18	0.02	-	0.83	-	-	-	0.23	-	0	-	-	-	-	-	-	0.52	0.18	-	-	-	-	-	-	18.11																																																																																				-			3.2	0.15	0.52	-	0.72	0.04	0.01	0.38	0.77	0.03	0.65	0.05	1.37	0.45	2.64	5.08	0.11	0.18	0.02	-	0.83	-	-	-	0.23	-	0	-	-	-	-	-	-	0.52	0.18	-	-	-	-	-	-	18.11
H1609_003_0	2007	8	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant																																																																																								-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H1609_801_0	2007	6	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		219.65	5.16	22.3		6.67	1.49	0.15	8.53	43.26	0.94	21.79	1.51	14.81	15.02	29.86	108.68	3.09	3.79	22.49	16.91	9.88													4.22	5.78							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 13.8		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97																																																																																				-			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97
H1609_802_0	2007	4	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		219.65	5.16	22.3		6.67	1.49	0.15	8.53	43.26	0.94	21.79	1.51	14.81	15.02	29.86	108.68	3.09	3.79	22.49	16.91	9.88													4.22	5.78							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 13.8		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97																																																																																				-			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97
H1609_803_0	2007	4	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		219.65	5.16	22.3		6.67	1.49	0.15	8.53	43.26	0.94	21.79	1.51	14.81	15.02	29.86	108.68	3.09	3.79	22.49	16.91	9.88													4.22	5.78							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 13.8		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97																																																																																				-			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97
H1609_806_0	2007	6	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		219.65	5.16	22.3		6.67	1.49	0.15	8.53	43.26	0.94	21.79	1.51	14.81	15.02	29.86	108.68	3.09	3.79	22.49	16.91	9.88													4.22	5.78							FFS Medicare 8.7	FFS Medicare 8.7	FFS Medicare 13.8		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6													FFS Medicare 23.6	FFS Medicare 23.6							0.09	0.09	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24													0.24	0.24							19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97																																																																																				-			19.18	0.45	3.08	-	1.57	0.35	0.04	2.01	10.21	0.22	5.14	0.36	3.5	3.54	7.05	25.65	0.73	0.89	5.31	3.99	2.33	-	-	-	-	-	-	-	-	-	-	-	-	1	1.36	-	-	-	-	-	-	97.97
H1689_002_0	2007	6																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	629.66	8.56	1634.06	26.71	246.13	25.69	1.19	385.7	379.63	0	1257.56	0	0.23	717.73	4025.94	5222.14	1.11	502.43	0	243.96	7.46	634.18	0	0	2.77	0	153.66	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.66	10	24.96	0.5	25	0	8.63	0.2	25	0	0	0.5	0	25	0	0	0	0											10.49	0.13	3.25	4.01	3.08	7.71	0.36	1.33	3.16	-	0.77	-	0.04	1.47	3.35	10.86	0.56	1.05	-	0.18	1.52	1.32	-	-	1.38	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.34	0	0	10.49	0.13	3.25	4.01	3.08	7.71	0.36	1.33	3.16	-	0.77	-	0.04	1.47	3.35	10.86	0.56	1.05	-	0.18	1.52	1.32	-	-	1.38	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.34	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.49	0.13	3.25	4.01	3.08	7.71	0.36	1.33	3.16	-	0.77	-	0.04	1.47	3.35	10.86	0.56	1.05	-	0.18	1.52	1.32	-	-	1.38	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.34
H1689_003_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	750.26	9.85	2385.55	37.08	181.06	20.33	0.95	359.51	342.75	0	1134	0	0.25	648.58	3959.38	5249.47	1.18	535.65	0	243.81	0	651.57	0	0	3.25	0	157.36	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											9.38	0.05	1.18	5.56	1.51	6.1	0.28	1.09	2.86	-	0.7	-	0.04	0.54	3.3	4.37	0.59	0.45	-	0.07	-	0.54	-	-	1.62	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.37	0	0	9.38	0.05	1.18	5.56	1.51	6.1	0.28	1.09	2.86	-	0.7	-	0.04	0.54	3.3	4.37	0.59	0.45	-	0.07	-	0.54	-	-	1.62	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.37	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.38	0.05	1.18	5.56	1.51	6.1	0.28	1.09	2.86	-	0.7	-	0.04	0.54	3.3	4.37	0.59	0.45	-	0.07	-	0.54	-	-	1.62	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.37
H1689_004_0	2007	7																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	766.82	10.07	2452.46	38.03	183.52	20.7	0.93	358.14	351.16	0	1166.32	0	0.25	662.13	3826.09	5061.2	1.2	502.63	0	232.06	7.9	600.69	0	0	3.19	0	154.52	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.63	10	24.96	0.5	25	0	8.6	0.2	25	0	0	0.5	0	25	0	0	0	0											12.78	0.15	4.87	5.7	2.29	6.21	0.28	1.24	2.93	-	0.72	-	0.04	1.36	3.19	10.53	0.6	1.05	-	0.17	1.61	1.25	-	-	1.59	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.88	0	0	12.78	0.15	4.87	5.7	2.29	6.21	0.28	1.24	2.93	-	0.72	-	0.04	1.36	3.19	10.53	0.6	1.05	-	0.17	1.61	1.25	-	-	1.59	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.88	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.78	0.15	4.87	5.7	2.29	6.21	0.28	1.24	2.93	-	0.72	-	0.04	1.36	3.19	10.53	0.6	1.05	-	0.17	1.61	1.25	-	-	1.59	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.88
H1689_006_0	2007	7																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	708.95	8.85	715.63	22.4	197.79	19.19	0.97	262.73	262.09	0	864.92	0	0.21	512.65	3750.86	4707.2	0.96	442.75	0	227.95	7.91	602.29	0	0	2.52	0	117.69	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.56	10	24.96	0.5	25	0	8.64	0.2	25	0	0	0.5	0	25	0	0	0	0											11.82	0.13	1.42	3.36	2.47	5.76	0.29	0.91	2.18	-	0.53	-	0.04	1.05	3.12	9.79	0.48	0.92	-	0.16	1.61	1.25	-	-	1.26	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.82	0	0	11.82	0.13	1.42	3.36	2.47	5.76	0.29	0.91	2.18	-	0.53	-	0.04	1.05	3.12	9.79	0.48	0.92	-	0.16	1.61	1.25	-	-	1.26	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.82	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.82	0.13	1.42	3.36	2.47	5.76	0.29	0.91	2.18	-	0.53	-	0.04	1.05	3.12	9.79	0.48	0.92	-	0.16	1.61	1.25	-	-	1.26	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.82
H1689_007_0	2007	3	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12	F.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	OP Facility - Emergency			Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Urgent Care		D	A	D		T	Coin	Coin	V	V		V	V	V	V	V	V	Coin	V			Coin				V		V					V	V	V	V	V	V	Coin	V	V																																											-		2242.92	7.16	569.11		286.09	11.71	3.94	343.96	442.56		1087.01	48.7	30.93	0.87	5838.99	1933.61	0.08	465.85			5.99				21.72		162					1066.32	21.59	83.7	396.02	116.88	12.24	14.57	2.48	2.97		150/day with 750 yearly max	300/admit with NO yearly max	25/day for days 21 to 100		100 copay	30 coinsurance	30 coinsurance	50 copay	100 copay		25 copay for Lower/Higher Tier	100 copay	25 copay for in-home/facility	10 copay	10 copay	10 copay	50 coinsurance	10 copay			0 coinsurance				10 copay		10 copay					10 copay	0 copay	10 copay	10 copay	10 copay	10 copay	50 coinsurance	10 copay	10 copay		65.5	300	25		100	0.3	0.3	50	100		25	100	25	10	10	10	0.5	10			0				10		10					10	0	10	10	10	10	0.5	10	10		12.24	0.18	1.19	-	2.38	3.51	1.18	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.28	0	0	-	44.29			12.24	0.18	1.19	-	2.38	3.51	1.18	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.28	0	0	-	44.29																																																																																				-			12.24	0.18	1.19	-	2.38	3.51	1.18	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.28	0	0	-	44.29
H1689_008_0	2007	2	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12	F.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	OP Facility - Emergency			Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Urgent Care		D	A	D		T	Coin	Coin	V	V		V	V	V	V	V	V	Coin	V			Coin				V		V					V	V	V	V	V	V	Coin	V	V																																											-		2242.92	7.16	569.11		286.09	12.31	4.14	343.96	442.56		1087.01	48.7	30.93	0.87	5838.99	1933.61	0.08	465.85			6.3				21.72		162					1066.32	21.59	83.7	396.02	116.88	12.24	15.32	2.48	2.97		150/day with 750 yearly max	300/admit with NO yearly max	25/day for days 21 to 100		100 copay	30 coinsurance	30 coinsurance	50 copay	100 copay		25 copay for Lower/Higher Tier	100 copay	25 copay for in-home/facility	10 copay	10 copay	10 copay	50 coinsurance	10 copay			0 coinsurance				10 copay		10 copay					10 copay	0 copay	10 copay	10 copay	10 copay	10 copay	50 coinsurance	10 copay	10 copay		65.5	300	25		100	0.3	0.3	50	100		25	100	25	10	10	10	0.5	10			0				10		10					10	0	10	10	10	10	0.5	10	10		12.24	0.18	1.19	-	2.38	3.69	1.24	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.66	0	0	-	44.9			12.24	0.18	1.19	-	2.38	3.69	1.24	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.66	0	0	-	44.9																																																																																				-			12.24	0.18	1.19	-	2.38	3.69	1.24	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.66	0	0	-	44.9
H1689_009_0	2007	2																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	704.18	8.86	1429.82	30.3	197.13	17.71	0.87	493.72	473.45	0	1558.87	0	0.17	891.07	3395.63	4347.8	0.82	426.63	0	209.25	0	560.67	0	0	2	0	115.47	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.45	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.57	0	10	0	0	0.5	0	10	0	0	0	0											8.8	0.04	0.71	4.55	1.64	5.31	0.26	1.5	3.95	-	0.96	-	0.03	0.74	2.83	3.62	0.41	0.36	-	0.06	-	0.47	-	-	1	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.33	0	0	8.8	0.04	0.71	4.55	1.64	5.31	0.26	1.5	3.95	-	0.96	-	0.03	0.74	2.83	3.62	0.41	0.36	-	0.06	-	0.47	-	-	1	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.33	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.8	0.04	0.71	4.55	1.64	5.31	0.26	1.5	3.95	-	0.96	-	0.03	0.74	2.83	3.62	0.41	0.36	-	0.06	-	0.47	-	-	1	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.33
H1689_010_0	2007	7																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	716.36	9.05	1442.35	30.7	200.53	18.06	0.87	494.41	488.57	0	1611.7	0	0.17	917.36	3258.26	4156.77	0.83	395.67	0	197.76	10.07	513.49	0	0	1.94	0	111.98	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.79	10	24.96	0.5	25	0	8.64	0.2	25	0	0	0.5	0	25	0	0	0	0											11.94	0.14	2.86	4.6	2.51	5.42	0.26	1.71	4.07	-	0.99	-	0.03	1.9	2.71	8.64	0.42	0.82	-	0.14	2.05	1.07	-	-	0.97	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	0	0	11.94	0.14	2.86	4.6	2.51	5.42	0.26	1.71	4.07	-	0.99	-	0.03	1.9	2.71	8.64	0.42	0.82	-	0.14	2.05	1.07	-	-	0.97	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.94	0.14	2.86	4.6	2.51	5.42	0.26	1.71	4.07	-	0.99	-	0.03	1.9	2.71	8.64	0.42	0.82	-	0.14	2.05	1.07	-	-	0.97	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5
H1689_011_0	2007	2	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12	F.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	OP Facility - Emergency			Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Urgent Care		D	A	D		T	Coin	Coin	V	V		V	V	V	V	V	V	Coin	V			Coin				V		V					V	V	V	V	V	V	Coin	V	V																																											-		2242.92	7.16	569.11		286.09	12.31	4.14	343.96	442.56		1087.01	48.7	30.93	0.87	5838.99	1933.61	0.08	465.85			6.3				21.72		162					1066.32	21.59	83.7	396.02	116.88	12.24	15.32	2.48	2.97		150/day with 750 yearly max	300/admit with NO yearly max	25/day for days 21 to 100		100 copay	30 coinsurance	30 coinsurance	50 copay	100 copay		25 copay for Lower/Higher Tier	100 copay	25 copay for in-home/facility	10 copay	10 copay	10 copay	50 coinsurance	10 copay			0 coinsurance				10 copay		10 copay					10 copay	0 copay	10 copay	10 copay	10 copay	10 copay	50 coinsurance	10 copay	10 copay		65.5	300	25		100	0.3	0.3	50	100		25	100	25	10	10	10	0.5	10			0				10		10					10	0	10	10	10	10	0.5	10	10		12.24	0.18	1.19	-	2.38	3.69	1.24	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.66	0	0	-	44.9			12.24	0.18	1.19	-	2.38	3.69	1.24	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.66	0	0	-	44.9																																																																																				-			12.24	0.18	1.19	-	2.38	3.69	1.24	1.43	3.69	-	2.26	0.41	0.06	0	4.87	1.61	0.04	0.39	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.89	-	0.07	0.33	0.1	0.01	7.66	0	0	-	44.9
H1689_012_0	2007	3																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	839.49	10.83	999.93	22.16	210.53	17.67	0.84	347.08	333.03	0	1123.09	0	0.2	644.31	3993.63	5055.06	0.94	462.65	0	244.24	0	680.6	0	0	2.97	0	156.96	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.17	10	10	9.99	0.5	10	0	3.59	0	10	0	0	0.5	0	10	0	0	0	0											10.49	0.05	0.5	3.32	1.75	5.3	0.25	1.05	2.78	-	0.69	-	0.03	0.54	3.33	4.21	0.47	0.39	-	0.07	-	0.57	-	-	1.49	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.41	0	0	10.49	0.05	0.5	3.32	1.75	5.3	0.25	1.05	2.78	-	0.69	-	0.03	0.54	3.33	4.21	0.47	0.39	-	0.07	-	0.57	-	-	1.49	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.41	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.49	0.05	0.5	3.32	1.75	5.3	0.25	1.05	2.78	-	0.69	-	0.03	0.54	3.33	4.21	0.47	0.39	-	0.07	-	0.57	-	-	1.49	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.41
H1689_013_0	2007	8																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	863.08	11.16	1006.33	22.35	215.2	18.16	0.84	347.29	341.16	0	1154.21	0	0.2	656.92	3883.88	4902.54	0.96	433.58	0	233.69	9.93	631.3	0	0	2.94	0	155.24	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.67	10	24.96	0.5	25	0	8.69	0.2	25	0	0	0.5	0	25	0	0	0	0											14.38	0.17	2	3.35	2.69	5.45	0.25	1.2	2.84	-	0.71	-	0.03	1.35	3.24	10.2	0.48	0.9	-	0.17	2.03	1.32	-	-	1.47	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.55	0	0	14.38	0.17	2	3.35	2.69	5.45	0.25	1.2	2.84	-	0.71	-	0.03	1.35	3.24	10.2	0.48	0.9	-	0.17	2.03	1.32	-	-	1.47	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.55	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.38	0.17	2	3.35	2.69	5.45	0.25	1.2	2.84	-	0.71	-	0.03	1.35	3.24	10.2	0.48	0.9	-	0.17	2.03	1.32	-	-	1.47	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.55
H1689_015_0	2007	7																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	705.97	8.83	1240.11	10.3	169.92	12.33	0.62	266.62	264.71	0	888.88	0	0.22	526.25	3143.61	4304.28	0.99	498.78	0	194.84	7.74	522.77	0	0	1.98	0	103.3	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.49	10	24.95	0.5	24.11	0	8.47	0.2	25	0	0	0.5	0	25	0	0	0	0											11.77	0.13	2.46	1.54	2.12	3.7	0.19	0.92	2.21	-	0.55	-	0.04	1.07	2.62	8.95	0.5	1	-	0.14	1.58	1.09	-	-	0.99	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.78	0	0	11.77	0.13	2.46	1.54	2.12	3.7	0.19	0.92	2.21	-	0.55	-	0.04	1.07	2.62	8.95	0.5	1	-	0.14	1.58	1.09	-	-	0.99	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.78	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.77	0.13	2.46	1.54	2.12	3.7	0.19	0.92	2.21	-	0.55	-	0.04	1.07	2.62	8.95	0.5	1	-	0.14	1.58	1.09	-	-	0.99	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.78
H1689_801_0	2007	5																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H1689_802_0	2007	4																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H1689_803_0	2007	5																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H1716_001_0	2007	3	s.	t.									Inpatient Facility	Professional									5000	Mental Health Level 2	Physician Administered Injectibles									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin						V			V		A	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0						0					0	0									-	9000	1282.99	8.89	437.26	2086.24	121.65	0.67	0.05	197.4	430.29	793.53	541.04	36.07	369.88	306.59	6973.78	8272.17			305.04		9.29						0					0.1	15.12									750/admit	750/admit	0/day (1-7) 100/day (8-100)	5/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100/ Visit	5-50/ Visit	0-100/ Visit	50/ Visit	0/ Procedure	0-100/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins						0					750/admit	20 Coins									110.2	119.84	20.35	3.83	76.62	0.15	0.15	38.03	76.62	30.47	40.86	38.31	0	26.59	7.66	26.82			76.62		0.15						0					574.66	0.15									11.78	0.09	0.74	0.67	0.78	0.1	0.01	0.63	2.75	2.02	1.84	0.12	-	0.68	4.45	18.49	-	-	1.95	-	1.42	-	-	-	-	-	-	-	-	-	-	0	2.32	-	-	-	-	-	-	-	-	50.82	0	15.51	11.78	0.09	0.74	0.67	0.78	0.1	0.01	0.63	2.75	2.02	1.84	0.12	-	0.68	4.45	18.49	-	-	1.95	-	1.42	-	-	-	-	-	-	-	-	-	-	0	2.32	-	-	-	-	-	-	-	-	50.82	9000	30 Coins	30 Coins	25 Coins	25 Coins	100/Trip	25 Coins		50/Visit	25 Coins	25 Coins			0/Procedure		25 Coins	25 Coins					20 Coins						0						25 Coins									5.63	0.02	0.16	0.21	0.18	0.01		0.18	1.94	2.29			0		1.45	1.75					0.38						0						0.5									14.7	0	5.93	17.41	0.11	0.9	0.88	0.96	0.12	0.01	0.8	4.69	4.31	1.84	0.12	-	0.68	5.91	20.23	-	-	1.95	-	1.8	-	-	-	-	-	-	-	-	-	-	0	2.82	-	-	-	-	-	-	-	-	65.52
H1716_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.57	1.93	456	2175.64	126.86	0.73	0.05	251.04	448.73	827.53	564.23	37.62	385.73	319.73	7272.6	8626.62			318.11		10.11											13.5	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58	0	0	12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.74	5.59			0		1.77	4.27					0.57																					20.71	0	0	15.11	0.11	0.72	2.33	1.32	0.23	0.01	1.21	12.22	8.01	2.16	0.31	-	1	16.93	29.43	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.29
H1716_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.57	1.93	456	2175.64	126.86	0.73	0.05	251.04	448.73	827.53	564.23	37.62	385.73	319.73	7272.6	8626.62			318.11		10.11											13.5	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58	0	0	12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.74	5.59			0		1.77	4.27					0.57																					20.71	0	0	15.11	0.11	0.72	2.33	1.32	0.23	0.01	1.21	12.22	8.01	2.16	0.31	-	1	16.93	29.43	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.29
H1716_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.57	1.93	456	2175.64	126.86	0.73	0.05	251.04	448.73	827.53	564.23	37.62	385.73	319.73	7272.6	8626.62			318.11		10.11											13.5	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58	0	0	12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.74	5.59			0		1.77	4.27					0.57																					20.71	0	0	15.11	0.11	0.72	2.33	1.32	0.23	0.01	1.21	12.22	8.01	2.16	0.31	-	1	16.93	29.43	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.29
H1716_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.57	1.93	456	2175.64	126.86	0.73	0.05	251.04	448.73	827.53	564.23	37.62	385.73	319.73	7272.6	8626.62			318.11		10.11											13.5	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58	0	0	12.83	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.16	0.31	-	1	15.15	25.16	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.58		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.74	5.59			0		1.77	4.27					0.57																					20.71	0	0	15.11	0.11	0.72	2.33	1.32	0.23	0.01	1.21	12.22	8.01	2.16	0.31	-	1	16.93	29.43	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.29
H1717_001_0	2007	7																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1694.31	156.75	578	0	168.38	12.37	6.73	359.92	30.58	6631.65	37.89	0	0.21	17.95	3198.25	3891	504.14	1.92	0	0	29.46	824.66	0	0	101.96	0	182.47	0	0	0	0											275 (1a)	275 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											178.66	178.66	87.7	0	113.69	0.19	0.21	32.48	0.13	3.9	0.1	0	0.19	0.13	15	25	37.5	0.13	0	0	0.19	25	0	0	25	0	25	0	0	0	0											25.22	2.33	4.22	-	1.6	2.41	1.41	0.97	3.97	2.15	3.82	-	0.04	2.33	4	8.11	1.58	0.25	-	-	5.74	1.72	-	-	0.21	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.48		30.31	25.22	2.33	4.22	-	1.6	2.41	1.41	0.97	3.97	2.15	3.82	-	0.04	2.33	4	8.11	1.58	0.25	-	-	5.74	1.72	-	-	0.21	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.48	4100	30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											4.07	0.14	0.36	0.45	0.35	0.53	0.31	0.21	1.31	0.63	1.26	0	0.01	0.77	1.76	2.49	0.39	0.08	0	0	1.26	0.54	0	0	0.07	0	0.12	0	0	0	0											17.1		6.05	29.3	2.47	4.58	0.45	1.95	2.94	1.72	1.19	5.28	2.78	5.08	-	0.05	3.1	5.76	10.6	1.97	0.33	-	-	7	2.25	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.58
H1717_003_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1694.31	156.75	578	0	168.38	12.37	6.73	359.92	30.58	6631.65	37.89	0	0.21	17.95	3198.25	3891	504.14	1.92	0	0	29.46	824.66	0	0	101.96	0	182.47	0	0	0	0											275 (1a)	275 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											167.92	167.92	82.44	0	106.86	0.18	0.2	30.53	0.12	3.66	0.09	0	0.18	0.12	15	25	37.5	0.12	0	0	0.18	25	0	0	25	0	25	0	0	0	0											23.71	2.19	3.97	-	1.5	2.27	1.34	0.92	3.73	2.02	3.59	-	0.04	2.19	4	8.11	1.58	0.23	-	-	5.4	1.72	-	-	0.21	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.1		33.69	23.71	2.19	3.97	-	1.5	2.27	1.34	0.92	3.73	2.02	3.59	-	0.04	2.19	4	8.11	1.58	0.23	-	-	5.4	1.72	-	-	0.21	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.1	3500	30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.83	0.13	0.34	0.45	0.33	0.5	0.29	0.2	1.23	0.59	1.18	0	0.01	0.72	1.76	2.49	0.39	0.08	0	0	1.18	0.54	0	0	0.07	0	0.12	0	0	0	0											16.43		6.73	27.54	2.32	4.31	0.45	1.83	2.76	1.64	1.12	4.96	2.62	4.77	-	0.05	2.92	5.76	10.6	1.97	0.31	-	-	6.58	2.25	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.53
H1717_006_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2234.55	353.57	1138.32		265.3	27.27	23.63	909.16	394.21	2068.23	970.32	67.16	3.33	2041.71		3523.78		534.91		820.2												291.04		156.67	233.08							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							6.61	1.05	1.62	-	0.79	2.58	2.24	1.29	0.39	0.82	0.38	0.07	0.32	2.01	-	1.39	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	22.35		24.85	6.61	1.05	1.62	-	0.79	2.58	2.24	1.29	0.39	0.82	0.38	0.07	0.32	2.01	-	1.39	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	22.35		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.23	0.16	0.29	0.38	0.07	0.17	0.14	0.05	0.19	0.14	0.13	0.02	0.02	0.22	0.35	0.23	0.05	0.03	0.16	0.74	0.15	0																				5.91		0	8.84	1.2	1.91	0.38	0.85	2.75	2.38	1.34	0.58	0.96	0.52	0.08	0.33	2.23	0.35	1.62	0.05	0.25	0.16	1.06	0.15	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	28.26
H1717_801_0	2007	8																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1779.03	164.59	606.9	0	176.8	12.99	7.07	377.91	32.11	6963.23	39.79	0	0.22	18.85	3358.16	4085.55	529.35	2.02	0	0	30.93	865.89	0	0	107.05	0	191.59	0	0	0	0											350 (1a)	350 (1b)	135 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											214.21	214.21	82.62	0	107.1	0.15	0.17	30.6	0.18	3.67	0.14	0	0.18	0.18	25	30	37.5	0.18	0	0	0.18	30	0	0	30	0	30	0	0	0	0											31.76	2.94	4.18	-	1.58	1.99	1.18	0.96	5.9	2.13	5.5	-	0.04	3.46	7	10.21	1.65	0.37	-	-	5.68	2.16	-	-	0.27	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.43		42.73	31.76	2.94	4.18	-	1.58	1.99	1.18	0.96	5.9	2.13	5.5	-	0.04	3.46	7	10.21	1.65	0.37	-	-	5.68	2.16	-	-	0.27	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.43	4500	40 (1a)	40 (1b)	40 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											5.37	0.18	0.47	0.63	0.35	0.52	0.31	0.21	1.73	0.62	1.61	0	0.01	1.01	1.95	2.62	0.41	0.11	0	0	1.25	0.57	0	0	0.07	0	0.12	0	0	0	0											20.12		8.68	37.13	3.12	4.65	0.63	1.92	2.51	1.49	1.18	7.62	2.75	7.11	-	0.05	4.47	8.95	12.83	2.07	0.48	-	-	6.93	2.73	-	-	0.34	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.55
H1804_001_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		219.54	6.72	1221.71	2272.06	6.76	0.52	0.04	13.56	39.06	42.6	57.44	1.94	3.58	16.46	7378.89	5931.13			1.68		6.78											0.35	11.04	27.11								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								426.99	426.99	26.91	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.65	23.29			0.16		0.16											426.99	0.16	0.14								7.81	0.24	2.74	-	1.05	0.08	0.01	2.11	6.06	6.61	-	0.3	0.56	2.56	7.16	11.51	-	-	0.26	-	1.05	-	-	-	-	-	-	-	-	-	-	0.01	1.71	3.91	-	-	-	-	-	-	-	55.74	0	20.45	7.81	0.24	2.74	-	1.05	0.08	0.01	2.11	6.06	6.61	-	0.3	0.56	2.56	7.16	11.51	-	-	0.26	-	1.05	-	-	-	-	-	-	-	-	-	-	0.01	1.71	3.91	-	-	-	-	-	-	-	55.74	5000																																																																																			-		0	7.81	0.24	2.74	-	1.05	0.08	0.01	2.11	6.06	6.61	-	0.3	0.56	2.56	7.16	11.51	-	-	0.26	-	1.05	-	-	-	-	-	-	-	-	-	-	0.01	1.71	3.91	-	-	-	-	-	-	-	55.74
H1804_005_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		233.79	6.31	919.74	2273.58	12.43	0.53	0.04	16.84	40.01	41.51	27.78	1.89	3.23	16.04	11999.56	9421.92			2.67		6.6											0.33	13.83	26.41								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								402.4	402.4	25.36	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	10.97	21.95			0.15		0.15											402.4	0.15	0.14								7.84	0.21	1.94	-	1.82	0.08	0.01	2.46	5.85	6.07	-	0.28	0.47	2.35	10.97	17.23	-	-	0.39	-	0.97	-	-	-	-	-	-	-	-	-	-	0.01	2.02	3.59	-	-	-	-	-	-	-	64.57	0	28.92	7.84	0.21	1.94	-	1.82	0.08	0.01	2.46	5.85	6.07	-	0.28	0.47	2.35	10.97	17.23	-	-	0.39	-	0.97	-	-	-	-	-	-	-	-	-	-	0.01	2.02	3.59	-	-	-	-	-	-	-	64.57	5000																																																																																			-		0	7.84	0.21	1.94	-	1.82	0.08	0.01	2.46	5.85	6.07	-	0.28	0.47	2.35	10.97	17.23	-	-	0.39	-	0.97	-	-	-	-	-	-	-	-	-	-	0.01	2.02	3.59	-	-	-	-	-	-	-	64.57
H1804_006_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		191.44	9.58	906.89	2316.74	7.7	0.59	0.04	15.45	36.92	39.4	41.13	1.79	5.13	15.22	10572.85	6878.2			2.28		6.27											0.5	13.65	25.07								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								420.68	420.68	26.51	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.47	22.95			0.15		0.15											420.68	0.15	0.14								6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	57.99	0	22.13	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	57.99	5000																																																																																			-		0	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	57.99
H1804_007_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		190.14	9.52	900.77	2301.1	7.6	0.58	0.04	15.24	36.42	38.86	40.85	1.77	5.06	15.02	10501.49	6831.78			2.25		6.18											0.5	13.47	24.73								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								421.83	421.83	26.59	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.5	23.01			0.15		0.15											421.83	0.15	0.14								6.68	0.33	2	-	1.17	0.09	0.01	2.34	5.59	5.96	-	0.27	0.78	2.3	10.07	13.1	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.07	3.52	-	-	-	-	-	-	-	57.58	0	21.7	6.68	0.33	2	-	1.17	0.09	0.01	2.34	5.59	5.96	-	0.27	0.78	2.3	10.07	13.1	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.07	3.52	-	-	-	-	-	-	-	57.58	5000																																																																																			-		0	6.68	0.33	2	-	1.17	0.09	0.01	2.34	5.59	5.96	-	0.27	0.78	2.3	10.07	13.1	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.07	3.52	-	-	-	-	-	-	-	57.58
H1804_008_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		193.61	9.69	917.19	2343.05	7.87	0.6	0.05	15.79	37.75	40.28	41.59	1.83	5.25	15.56	10692.93	6956.32			2.34		6.41											0.51	13.96	25.63								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								418.79	418.79	26.39	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.42	22.84			0.15		0.15											418.79	0.15	0.14								6.76	0.34	2.02	-	1.2	0.09	0.01	2.4	5.75	6.13	-	0.28	0.8	2.37	10.18	13.24	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.13	3.62	-	-	-	-	-	-	-	58.66	0	22.85	6.76	0.34	2.02	-	1.2	0.09	0.01	2.4	5.75	6.13	-	0.28	0.8	2.37	10.18	13.24	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.13	3.62	-	-	-	-	-	-	-	58.66	5000																																																																																			-		0	6.76	0.34	2.02	-	1.2	0.09	0.01	2.4	5.75	6.13	-	0.28	0.8	2.37	10.18	13.24	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.13	3.62	-	-	-	-	-	-	-	58.66
H1804_009_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		191.27	9.57	906.1	2314.72	7.69	0.59	0.04	15.41	36.84	39.32	41.09	1.79	5.12	15.19	10563.61	6872.19			2.28		6.26											0.5	13.63	25.02								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								420.85	420.85	26.52	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.48	22.96			0.15		0.15											420.85	0.15	0.14								6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.64	6.02	-	0.27	0.78	2.32	10.1	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	57.93	0	22.07	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.64	6.02	-	0.27	0.78	2.32	10.1	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	57.93	5000																																																																																			-		0	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.64	6.02	-	0.27	0.78	2.32	10.1	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	57.93
H1804_011_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		237.25	6.4	933.33	2307.16	12.79	0.55	0.04	17.33	41.18	42.72	28.19	1.94	3.33	16.5	12176.78	9561.07			2.75		6.8											0.34	14.24	27.18								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								399.86	399.86	25.2	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	10.91	21.81			0.15		0.15											399.86	0.15	0.14								7.91	0.21	1.96	-	1.86	0.08	0.01	2.52	5.99	6.21	-	0.28	0.48	2.4	11.07	17.38	-	-	0.4	-	0.99	-	-	-	-	-	-	-	-	-	-	0.01	2.07	3.67	-	-	-	-	-	-	-	65.49	0	30.07	7.91	0.21	1.96	-	1.86	0.08	0.01	2.52	5.99	6.21	-	0.28	0.48	2.4	11.07	17.38	-	-	0.4	-	0.99	-	-	-	-	-	-	-	-	-	-	0.01	2.07	3.67	-	-	-	-	-	-	-	65.49	5000																																																																																			-		0	7.91	0.21	1.96	-	1.86	0.08	0.01	2.52	5.99	6.21	-	0.28	0.48	2.4	11.07	17.38	-	-	0.4	-	0.99	-	-	-	-	-	-	-	-	-	-	0.01	2.07	3.67	-	-	-	-	-	-	-	65.49
H1804_013_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		201.65	10.09	955.29	2440.37	8.54	0.65	0.05	17.13	40.95	43.7	43.32	1.99	5.69	16.89	11137.04	7245.24			2.53		6.95											0.53	15.15	27.81								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								411.77	411.77	25.95	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.23	22.46			0.15		0.15											411.77	0.15	0.14								6.92	0.35	2.07	-	1.28	0.1	0.01	2.57	6.13	6.54	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.19	0	25.65	6.92	0.35	2.07	-	1.28	0.1	0.01	2.57	6.13	6.54	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.19	5000																																																																																			-		0	6.92	0.35	2.07	-	1.28	0.1	0.01	2.57	6.13	6.54	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.19
H1804_014_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		202.42	10.13	958.94	2449.7	8.62	0.66	0.05	17.28	41.3	44.07	43.49	2	5.74	17.03	11179.62	7272.94			2.56		7.01											0.53	15.27	28.05								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								411.06	411.06	25.91	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.21	22.42			0.15		0.15											411.06	0.15	0.14								6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.59	-	0.3	0.86	2.55	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.45	0	25.94	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.59	-	0.3	0.86	2.55	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.45	5000																																																																																			-		0	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.59	-	0.3	0.86	2.55	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.45
H1804_016_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		193.78	9.7	917.99	2345.08	7.89	0.6	0.05	15.83	37.84	40.38	41.63	1.84	5.26	15.6	10702.19	6962.35			2.34		6.42											0.51	13.99	25.69								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								418.61	418.61	26.38	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.42	22.83			0.15		0.15											418.61	0.15	0.14								6.76	0.34	2.02	-	1.2	0.09	0.01	2.41	5.76	6.15	-	0.28	0.8	2.37	10.18	13.25	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.13	3.63	-	-	-	-	-	-	-	58.73	0	22.92	6.76	0.34	2.02	-	1.2	0.09	0.01	2.41	5.76	6.15	-	0.28	0.8	2.37	10.18	13.25	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.13	3.63	-	-	-	-	-	-	-	58.73	5000																																																																																			-		0	6.76	0.34	2.02	-	1.2	0.09	0.01	2.41	5.76	6.15	-	0.28	0.8	2.37	10.18	13.25	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.13	3.63	-	-	-	-	-	-	-	58.73
H1804_018_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		203.82	10.2	965.54	2466.56	8.73	0.67	0.05	17.5	41.84	44.65	43.79	2.03	5.82	17.25	11256.58	7323.01			2.59		7.1											0.54	15.47	28.41								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								409.9	409.9	25.83	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.18	22.36			0.15		0.15											409.9	0.15	0.14								6.96	0.35	2.08	-	1.3	0.1	0.01	2.61	6.24	6.65	-	0.3	0.87	2.57	10.49	13.64	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.31	3.93	-	-	-	-	-	-	-	61.87	0	26.43	6.96	0.35	2.08	-	1.3	0.1	0.01	2.61	6.24	6.65	-	0.3	0.87	2.57	10.49	13.64	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.31	3.93	-	-	-	-	-	-	-	61.87	5000																																																																																			-		0	6.96	0.35	2.08	-	1.3	0.1	0.01	2.61	6.24	6.65	-	0.3	0.87	2.57	10.49	13.64	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.31	3.93	-	-	-	-	-	-	-	61.87
H1804_019_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		199.89	10	946.94	2419.05	8.39	0.64	0.05	16.83	40.23	42.93	42.94	1.95	5.59	16.59	11039.75	7181.95			2.49		6.83											0.53	14.88	27.32								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								413.32	413.32	26.05	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.27	22.54			0.15		0.15											413.32	0.15	0.14								6.88	0.34	2.06	-	1.26	0.1	0.01	2.53	6.05	6.45	-	0.29	0.84	2.49	10.37	13.49	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.81	-	-	-	-	-	-	-	60.64	0	25.01	6.88	0.34	2.06	-	1.26	0.1	0.01	2.53	6.05	6.45	-	0.29	0.84	2.49	10.37	13.49	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.81	-	-	-	-	-	-	-	60.64	5000																																																																																			-		0	6.88	0.34	2.06	-	1.26	0.1	0.01	2.53	6.05	6.45	-	0.29	0.84	2.49	10.37	13.49	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.81	-	-	-	-	-	-	-	60.64
H1804_020_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		202.21	10.12	957.95	2447.16	8.6	0.66	0.05	17.24	41.21	43.97	43.44	2	5.73	16.99	11168.03	7265.4			2.55		7											0.53	15.24	27.98								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								411.25	411.25	25.92	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.22	22.43			0.15		0.15											411.25	0.15	0.14								6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.16	6.58	-	0.3	0.86	2.54	10.44	13.58	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.38	0	25.86	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.16	6.58	-	0.3	0.86	2.54	10.44	13.58	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.38	5000																																																																																			-		0	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.16	6.58	-	0.3	0.86	2.54	10.44	13.58	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.38
H1804_022_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		182.95	9.16	866.67	2213.99	7.03	0.54	0.04	14.1	33.7	35.97	39.3	1.63	4.69	13.9	10103.92	6573.14			2.09		5.72											0.48	12.46	22.89								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								428.25	428.25	26.99	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.68	23.36			0.16		0.16											428.25	0.16	0.14								6.53	0.33	1.95	-	1.09	0.08	0.01	2.2	5.25	5.6	-	0.25	0.73	2.16	9.83	12.8	-	-	0.32	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.3	0	19.42	6.53	0.33	1.95	-	1.09	0.08	0.01	2.2	5.25	5.6	-	0.25	0.73	2.16	9.83	12.8	-	-	0.32	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.3	5000																																																																																			-		0	6.53	0.33	1.95	-	1.09	0.08	0.01	2.2	5.25	5.6	-	0.25	0.73	2.16	9.83	12.8	-	-	0.32	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.3
H1804_023_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		234.86	7.19	1306.98	2430.64	7.74	0.59	0.04	15.52	44.69	48.74	61.45	2.22	4.09	18.83	7893.91	6345.1			1.92		7.75											0.38	12.64	31.02								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								415.34	415.34	26.18	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.33	22.65			0.15		0.15											415.34	0.15	0.14								8.13	0.25	2.85	-	1.17	0.09	0.01	2.34	6.75	7.36	-	0.33	0.62	2.84	7.45	11.98	-	-	0.29	-	1.17	-	-	-	-	-	-	-	-	-	-	0.01	1.91	4.35	-	-	-	-	-	-	-	59.91	0	24.92	8.13	0.25	2.85	-	1.17	0.09	0.01	2.34	6.75	7.36	-	0.33	0.62	2.84	7.45	11.98	-	-	0.29	-	1.17	-	-	-	-	-	-	-	-	-	-	0.01	1.91	4.35	-	-	-	-	-	-	-	59.91	5000																																																																																			-		0	8.13	0.25	2.85	-	1.17	0.09	0.01	2.34	6.75	7.36	-	0.33	0.62	2.84	7.45	11.98	-	-	0.29	-	1.17	-	-	-	-	-	-	-	-	-	-	0.01	1.91	4.35	-	-	-	-	-	-	-	59.91
H1804_025_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		221.33	6.77	1231.71	2290.66	6.88	0.53	0.04	13.8	39.74	43.34	57.91	1.97	3.64	16.75	7439.29	5979.67			1.71		6.9											0.36	11.24	27.58								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								425.55	425.55	26.82	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.61	23.21			0.15		0.15											425.55	0.15	0.14								7.85	0.24	2.75	-	1.06	0.08	0.01	2.14	6.15	6.71	-	0.3	0.56	2.59	7.2	11.57	-	-	0.26	-	1.07	-	-	-	-	-	-	-	-	-	-	0.01	1.74	3.96	-	-	-	-	-	-	-	56.25	0	20.97	7.85	0.24	2.75	-	1.06	0.08	0.01	2.14	6.15	6.71	-	0.3	0.56	2.59	7.2	11.57	-	-	0.26	-	1.07	-	-	-	-	-	-	-	-	-	-	0.01	1.74	3.96	-	-	-	-	-	-	-	56.25	5000																																																																																			-		0	7.85	0.24	2.75	-	1.06	0.08	0.01	2.14	6.15	6.71	-	0.3	0.56	2.59	7.2	11.57	-	-	0.26	-	1.07	-	-	-	-	-	-	-	-	-	-	0.01	1.74	3.96	-	-	-	-	-	-	-	56.25
H1804_061_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		194.08	9.71	919.42	2348.75	7.93	0.61	0.05	15.9	38	40.55	41.69	1.84	5.28	15.67	10718.91	6973.23			2.35		6.45											0.51	14.05	25.8								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								418.28	418.28	26.36	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.41	22.82			0.15		0.15											418.28	0.15	0.14								6.77	0.34	2.02	-	1.21	0.09	0.01	2.42	5.78	6.17	-	0.28	0.8	2.38	10.19	13.26	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.14	3.64	-	-	-	-	-	-	-	58.85	0	23.04	6.77	0.34	2.02	-	1.21	0.09	0.01	2.42	5.78	6.17	-	0.28	0.8	2.38	10.19	13.26	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.14	3.64	-	-	-	-	-	-	-	58.85	5000																																																																																			-		0	6.77	0.34	2.02	-	1.21	0.09	0.01	2.42	5.78	6.17	-	0.28	0.8	2.38	10.19	13.26	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.14	3.64	-	-	-	-	-	-	-	58.85
H1804_063_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		196.71	9.85	931.86	2380.51	8.13	0.62	0.05	16.3	38.97	41.59	42.26	1.89	5.42	16.07	10863.86	7067.52			2.41		6.62											0.52	14.41	26.47								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.07	416.07	26.22	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.35	22.69			0.15		0.15											416.07	0.15	0.14								6.82	0.34	2.04	-	1.23	0.09	0.01	2.47	5.9	6.29	-	0.29	0.82	2.43	10.27	13.37	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.72	-	-	-	-	-	-	-	59.64	0	23.91	6.82	0.34	2.04	-	1.23	0.09	0.01	2.47	5.9	6.29	-	0.29	0.82	2.43	10.27	13.37	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.72	-	-	-	-	-	-	-	59.64	5000																																																																																			-		0	6.82	0.34	2.04	-	1.23	0.09	0.01	2.47	5.9	6.29	-	0.29	0.82	2.43	10.27	13.37	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.72	-	-	-	-	-	-	-	59.64
H1804_066_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		192.48	9.63	911.84	2329.37	7.79	0.59	0.04	15.61	37.32	39.82	41.35	1.81	5.19	15.39	10630.48	6915.7			2.31		6.34											0.51	13.8	25.34								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								419.77	419.77	26.46	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.45	22.9			0.15		0.15											419.77	0.15	0.14								6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.59	-	-	-	-	-	-	-	58.32	0	22.47	6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.59	-	-	-	-	-	-	-	58.32	5000																																																																																			-		0	6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.59	-	-	-	-	-	-	-	58.32
H1804_067_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		190.22	9.52	901.15	2302.07	7.61	0.58	0.04	15.25	36.46	38.91	40.87	1.77	5.07	15.03	10505.89	6834.64			2.26		6.19											0.5	13.48	24.76								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								421.75	421.75	26.58	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.5	23			0.15		0.15											421.75	0.15	0.14								6.69	0.33	2	-	1.17	0.09	0.01	2.34	5.59	5.97	-	0.27	0.78	2.31	10.07	13.1	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.07	3.53	-	-	-	-	-	-	-	57.61	0	21.74	6.69	0.33	2	-	1.17	0.09	0.01	2.34	5.59	5.97	-	0.27	0.78	2.31	10.07	13.1	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.07	3.53	-	-	-	-	-	-	-	57.61	5000																																																																																			-		0	6.69	0.33	2	-	1.17	0.09	0.01	2.34	5.59	5.97	-	0.27	0.78	2.31	10.07	13.1	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.07	3.53	-	-	-	-	-	-	-	57.61
H1804_068_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		205.28	10.27	972.48	2484.29	8.86	0.68	0.05	17.76	42.45	45.3	44.1	2.06	5.9	17.5	11337.5	7375.65			2.63		7.21											0.54	15.7	28.83								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								408.61	408.61	25.75	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.14	22.29			0.15		0.15											408.61	0.15	0.14								6.99	0.35	2.09	-	1.32	0.1	0.01	2.64	6.31	6.73	-	0.31	0.88	2.6	10.53	13.7	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.33	3.98	-	-	-	-	-	-	-	62.33	0	26.98	6.99	0.35	2.09	-	1.32	0.1	0.01	2.64	6.31	6.73	-	0.31	0.88	2.6	10.53	13.7	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.33	3.98	-	-	-	-	-	-	-	62.33	5000																																																																																			-		0	6.99	0.35	2.09	-	1.32	0.1	0.01	2.64	6.31	6.73	-	0.31	0.88	2.6	10.53	13.7	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.33	3.98	-	-	-	-	-	-	-	62.33
H1804_070_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		205.66	10.29	974.27	2488.85	8.89	0.68	0.05	17.84	42.64	45.5	44.18	2.07	5.93	17.58	11358.31	7389.19			2.64		7.24											0.54	15.77	28.95								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								408.25	408.25	25.73	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.13	22.27			0.15		0.15											408.25	0.15	0.14								7	0.35	2.09	-	1.32	0.1	0.01	2.65	6.33	6.75	-	0.31	0.88	2.61	10.54	13.71	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.34	3.99	-	-	-	-	-	-	-	62.46	0	27.14	7	0.35	2.09	-	1.32	0.1	0.01	2.65	6.33	6.75	-	0.31	0.88	2.61	10.54	13.71	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.34	3.99	-	-	-	-	-	-	-	62.46	5000																																																																																			-		0	7	0.35	2.09	-	1.32	0.1	0.01	2.65	6.33	6.75	-	0.31	0.88	2.61	10.54	13.71	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.34	3.99	-	-	-	-	-	-	-	62.46
H1804_075_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		190.86	9.55	904.18	2309.8	7.65	0.58	0.04	15.35	36.69	39.15	41	1.78	5.1	15.13	10541.18	6857.6			2.27		6.23											0.5	13.57	24.91								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								421.21	421.21	26.55	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.49	22.97			0.15		0.15											421.21	0.15	0.14								6.7	0.34	2	-	1.17	0.09	0.01	2.35	5.62	6	-	0.27	0.78	2.32	10.09	13.13	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.08	3.54	-	-	-	-	-	-	-	57.8	0	21.93	6.7	0.34	2	-	1.17	0.09	0.01	2.35	5.62	6	-	0.27	0.78	2.32	10.09	13.13	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.08	3.54	-	-	-	-	-	-	-	57.8	5000																																																																																			-		0	6.7	0.34	2	-	1.17	0.09	0.01	2.35	5.62	6	-	0.27	0.78	2.32	10.09	13.13	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.08	3.54	-	-	-	-	-	-	-	57.8
H1804_077_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		197.36	9.88	934.96	2388.43	8.18	0.63	0.05	16.41	39.23	41.86	42.4	1.9	5.45	16.17	10900.01	7091.04			2.43		6.66											0.52	14.51	26.64								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								415.5	415.5	26.19	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.33	22.66			0.15		0.15											415.5	0.15	0.14								6.83	0.34	2.04	-	1.24	0.09	0.01	2.48	5.93	6.33	-	0.29	0.82	2.44	10.29	13.39	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.19	3.74	-	-	-	-	-	-	-	59.85	0	24.13	6.83	0.34	2.04	-	1.24	0.09	0.01	2.48	5.93	6.33	-	0.29	0.82	2.44	10.29	13.39	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.19	3.74	-	-	-	-	-	-	-	59.85	5000																																																																																			-		0	6.83	0.34	2.04	-	1.24	0.09	0.01	2.48	5.93	6.33	-	0.29	0.82	2.44	10.29	13.39	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.19	3.74	-	-	-	-	-	-	-	59.85
H1804_078_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		208.58	10.44	988.09	2524.16	9.14	0.7	0.05	18.34	43.83	46.78	44.81	2.13	6.09	18.07	11519.46	7494.02			2.71		7.44											0.55	16.21	29.77								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								405.77	405.77	25.57	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.07	22.13			0.15		0.15											405.77	0.15	0.14								7.05	0.35	2.11	-	1.35	0.1	0.01	2.71	6.47	6.9	-	0.31	0.9	2.67	10.62	13.82	-	-	0.4	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	2.39	4.08	-	-	-	-	-	-	-	63.36	0	28.22	7.05	0.35	2.11	-	1.35	0.1	0.01	2.71	6.47	6.9	-	0.31	0.9	2.67	10.62	13.82	-	-	0.4	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	2.39	4.08	-	-	-	-	-	-	-	63.36	5000																																																																																			-		0	7.05	0.35	2.11	-	1.35	0.1	0.01	2.71	6.47	6.9	-	0.31	0.9	2.67	10.62	13.82	-	-	0.4	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	2.39	4.08	-	-	-	-	-	-	-	63.36
H1804_081_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		236.82	7.25	1317.89	2450.92	7.87	0.6	0.05	15.79	45.48	49.6	61.96	2.25	4.16	19.16	7959.78	6398.04			1.95		7.89											0.38	12.86	31.56								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								413.81	413.81	26.08	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.29	22.57			0.15		0.15											413.81	0.15	0.14								8.17	0.25	2.86	-	1.18	0.09	0.01	2.38	6.84	7.46	-	0.34	0.63	2.88	7.49	12.03	-	-	0.29	-	1.19	-	-	-	-	-	-	-	-	-	-	0.01	1.93	4.41	-	-	-	-	-	-	-	60.46	0	25.55	8.17	0.25	2.86	-	1.18	0.09	0.01	2.38	6.84	7.46	-	0.34	0.63	2.88	7.49	12.03	-	-	0.29	-	1.19	-	-	-	-	-	-	-	-	-	-	0.01	1.93	4.41	-	-	-	-	-	-	-	60.46	5000																																																																																			-		0	8.17	0.25	2.86	-	1.18	0.09	0.01	2.38	6.84	7.46	-	0.34	0.63	2.88	7.49	12.03	-	-	0.29	-	1.19	-	-	-	-	-	-	-	-	-	-	0.01	1.93	4.41	-	-	-	-	-	-	-	60.46
H1804_083_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		202.34	10.13	958.56	2448.71	8.6	0.66	0.05	17.25	41.24	44.01	43.47	2	5.73	17	11175.13	7270.02			2.55		7											0.53	15.25	28.01								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								411.17	411.17	25.91	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.21	22.43			0.15		0.15											411.17	0.15	0.14								6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.58	-	0.3	0.86	2.54	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.41	0	25.9	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.58	-	0.3	0.86	2.54	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.41	5000																																																																																			-		0	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.58	-	0.3	0.86	2.54	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.41
H1804_086_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		191.76	9.6	908.42	2320.63	7.72	0.59	0.04	15.49	37.03	39.51	41.19	1.8	5.15	15.27	10590.59	6889.75			2.29		6.29											0.51	13.69	25.15								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								420.42	420.42	26.5	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.47	22.93			0.15		0.15											420.42	0.15	0.14								6.72	0.34	2.01	-	1.18	0.09	0.01	2.37	5.66	6.04	-	0.27	0.79	2.33	10.12	13.17	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.57	-	-	-	-	-	-	-	58.08	0	22.23	6.72	0.34	2.01	-	1.18	0.09	0.01	2.37	5.66	6.04	-	0.27	0.79	2.33	10.12	13.17	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.57	-	-	-	-	-	-	-	58.08	5000																																																																																			-		0	6.72	0.34	2.01	-	1.18	0.09	0.01	2.37	5.66	6.04	-	0.27	0.79	2.33	10.12	13.17	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.57	-	-	-	-	-	-	-	58.08
H1804_087_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		204.54	10.24	968.96	2475.3	8.8	0.67	0.05	17.64	42.16	44.99	43.94	2.04	5.86	17.38	11296.48	7348.97			2.61		7.16											0.54	15.59	28.63								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								409.24	409.24	25.79	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.16	22.32			0.15		0.15											409.24	0.15	0.14								6.98	0.35	2.08	-	1.31	0.1	0.01	2.62	6.27	6.7	-	0.3	0.87	2.59	10.51	13.67	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.32	3.96	-	-	-	-	-	-	-	62.11	0	26.71	6.98	0.35	2.08	-	1.31	0.1	0.01	2.62	6.27	6.7	-	0.3	0.87	2.59	10.51	13.67	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.32	3.96	-	-	-	-	-	-	-	62.11	5000																																																																																			-		0	6.98	0.35	2.08	-	1.31	0.1	0.01	2.62	6.27	6.7	-	0.3	0.87	2.59	10.51	13.67	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.32	3.96	-	-	-	-	-	-	-	62.11
H1804_088_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		201.69	10.1	955.48	2440.87	8.56	0.65	0.05	17.17	41.03	43.78	43.33	1.99	5.7	16.92	11139.32	7246.72			2.54		6.97											0.53	15.17	27.86								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								411.66	411.66	25.94	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.23	22.45			0.15		0.15											411.66	0.15	0.14								6.92	0.35	2.07	-	1.28	0.1	0.01	2.57	6.14	6.55	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.23	0	25.7	6.92	0.35	2.07	-	1.28	0.1	0.01	2.57	6.14	6.55	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.23	5000																																																																																			-		0	6.92	0.35	2.07	-	1.28	0.1	0.01	2.57	6.14	6.55	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.23
H1804_089_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		188.35	9.43	892.25	2279.34	7.46	0.57	0.04	14.95	35.74	38.14	40.46	1.73	4.97	14.74	10402.16	6767.16			2.21		6.07											0.5	13.22	24.27								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								423.41	423.41	26.69	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.55	23.1			0.15		0.15											423.41	0.15	0.14								6.65	0.33	1.98	-	1.15	0.09	0.01	2.3	5.5	5.87	-	0.27	0.77	2.27	10.01	13.02	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.04	3.47	-	-	-	-	-	-	-	57.02	0	21.13	6.65	0.33	1.98	-	1.15	0.09	0.01	2.3	5.5	5.87	-	0.27	0.77	2.27	10.01	13.02	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.04	3.47	-	-	-	-	-	-	-	57.02	5000																																																																																			-		0	6.65	0.33	1.98	-	1.15	0.09	0.01	2.3	5.5	5.87	-	0.27	0.77	2.27	10.01	13.02	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.04	3.47	-	-	-	-	-	-	-	57.02
H1804_090_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		200.63	10.04	950.45	2428	8.46	0.65	0.05	16.97	40.56	43.29	43.1	1.97	5.64	16.72	11080.58	7208.51			2.51		6.89											0.53	15	27.55								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								412.63	412.63	26.01	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.25	22.51			0.15		0.15											412.63	0.15	0.14								6.9	0.35	2.06	-	1.27	0.1	0.01	2.55	6.09	6.49	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.88	0	25.29	6.9	0.35	2.06	-	1.27	0.1	0.01	2.55	6.09	6.49	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.88	5000																																																																																			-		0	6.9	0.35	2.06	-	1.27	0.1	0.01	2.55	6.09	6.49	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.88
H1804_091_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								6000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		193.26	9.67	915.51	2338.76	7.85	0.6	0.05	15.75	37.65	40.18	41.52	1.83	5.23	15.52	10673.33	6943.57			2.33		6.39											0.51	13.92	25.57								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								440.09	440.09	27.74	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	12	24			0.16		0.16											440.09	0.16	0.15								7.09	0.35	2.12	-	1.26	0.1	0.01	2.52	6.03	6.43	-	0.29	0.84	2.48	10.68	13.89	-	-	0.37	-	1.02	-	-	-	-	-	-	-	-	-	-	0.02	2.23	3.8	-	-	-	-	-	-	-	61.51	0	19.09	7.09	0.35	2.12	-	1.26	0.1	0.01	2.52	6.03	6.43	-	0.29	0.84	2.48	10.68	13.89	-	-	0.37	-	1.02	-	-	-	-	-	-	-	-	-	-	0.02	2.23	3.8	-	-	-	-	-	-	-	61.51	6000																																																																																			-		0	7.09	0.35	2.12	-	1.26	0.1	0.01	2.52	6.03	6.43	-	0.29	0.84	2.48	10.68	13.89	-	-	0.37	-	1.02	-	-	-	-	-	-	-	-	-	-	0.02	2.23	3.8	-	-	-	-	-	-	-	61.51
H1804_093_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								6000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		205.82	10.3	975.05	2490.84	8.93	0.68	0.05	17.9	42.8	45.67	44.22	2.08	5.95	17.65	11367.39	7395.1			2.65		7.27											0.54	15.83	29.06								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								429.45	429.45	27.07	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.71	23.42			0.16		0.16											429.45	0.16	0.15								7.37	0.37	2.2	-	1.39	0.11	0.01	2.8	6.68	7.13	-	0.32	0.93	2.76	11.09	14.44	-	-	0.41	-	1.13	-	-	-	-	-	-	-	-	-	-	0.02	2.47	4.21	-	-	-	-	-	-	-	65.85	0	23.13	7.37	0.37	2.2	-	1.39	0.11	0.01	2.8	6.68	7.13	-	0.32	0.93	2.76	11.09	14.44	-	-	0.41	-	1.13	-	-	-	-	-	-	-	-	-	-	0.02	2.47	4.21	-	-	-	-	-	-	-	65.85	6000																																																																																			-		0	7.37	0.37	2.2	-	1.39	0.11	0.01	2.8	6.68	7.13	-	0.32	0.93	2.76	11.09	14.44	-	-	0.41	-	1.13	-	-	-	-	-	-	-	-	-	-	0.02	2.47	4.21	-	-	-	-	-	-	-	65.85
H1804_094_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		191.1	9.57	905.32	2312.71	7.67	0.59	0.04	15.39	36.78	39.25	41.05	1.78	5.11	15.17	10554.47	6866.25			2.28		6.24											0.5	13.6	24.98								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								420.99	420.99	26.53	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.48	22.96			0.15		0.15											420.99	0.15	0.14								6.7	0.34	2	-	1.17	0.09	0.01	2.36	5.63	6.01	-	0.27	0.78	2.32	10.1	13.14	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.08	3.55	-	-	-	-	-	-	-	57.88	0	22.02	6.7	0.34	2	-	1.17	0.09	0.01	2.36	5.63	6.01	-	0.27	0.78	2.32	10.1	13.14	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.08	3.55	-	-	-	-	-	-	-	57.88	5000																																																																																			-		0	6.7	0.34	2	-	1.17	0.09	0.01	2.36	5.63	6.01	-	0.27	0.78	2.32	10.1	13.14	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.08	3.55	-	-	-	-	-	-	-	57.88
H1804_095_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		192.56	9.64	912.22	2330.34	7.79	0.6	0.04	15.63	37.36	39.87	41.37	1.81	5.19	15.41	10634.93	6918.59			2.31		6.34											0.51	13.82	25.37								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								419.68	419.68	26.45	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.45	22.89			0.15		0.15											419.68	0.15	0.14								6.73	0.34	2.01	-	1.19	0.09	0.01	2.39	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.6	-	-	-	-	-	-	-	58.35	0	22.51	6.73	0.34	2.01	-	1.19	0.09	0.01	2.39	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.6	-	-	-	-	-	-	-	58.35	5000																																																																																			-		0	6.73	0.34	2.01	-	1.19	0.09	0.01	2.39	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.6	-	-	-	-	-	-	-	58.35
H1804_097_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		183.03	9.16	867.08	2215.03	7.04	0.54	0.04	14.12	33.75	36.01	39.32	1.64	4.69	13.91	10108.69	6576.24			2.09		5.73											0.48	12.48	22.92								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								428.15	428.15	26.98	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.68	23.35			0.16		0.16											428.15	0.16	0.14								6.53	0.33	1.95	-	1.1	0.08	0.01	2.2	5.25	5.61	-	0.25	0.73	2.17	9.84	12.8	-	-	0.33	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.33	0	19.45	6.53	0.33	1.95	-	1.1	0.08	0.01	2.2	5.25	5.61	-	0.25	0.73	2.17	9.84	12.8	-	-	0.33	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.33	5000																																																																																			-		0	6.53	0.33	1.95	-	1.1	0.08	0.01	2.2	5.25	5.61	-	0.25	0.73	2.17	9.84	12.8	-	-	0.33	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.33
H1804_098_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		198.14	9.92	938.66	2397.88	8.25	0.63	0.05	16.54	39.53	42.18	42.57	1.92	5.5	16.3	10943.12	7119.09			2.45		6.71											0.52	14.62	26.84								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								414.83	414.83	26.14	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.31	22.63			0.15		0.15											414.83	0.15	0.14								6.85	0.34	2.05	-	1.24	0.1	0.01	2.49	5.96	6.36	-	0.29	0.83	2.46	10.32	13.42	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.21	3.76	-	-	-	-	-	-	-	60.09	0	24.4	6.85	0.34	2.05	-	1.24	0.1	0.01	2.49	5.96	6.36	-	0.29	0.83	2.46	10.32	13.42	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.21	3.76	-	-	-	-	-	-	-	60.09	5000																																																																																			-		0	6.85	0.34	2.05	-	1.24	0.1	0.01	2.49	5.96	6.36	-	0.29	0.83	2.46	10.32	13.42	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.21	3.76	-	-	-	-	-	-	-	60.09
H1804_099_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		195.64	9.79	926.81	2367.62	8.04	0.61	0.05	16.13	38.55	41.14	42.03	1.87	5.36	15.9	10805.03	7029.25			2.39		6.55											0.52	14.26	26.18								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.99	416.99	26.28	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.37	22.75			0.15		0.15											416.99	0.15	0.14								6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.85	6.24	-	0.28	0.81	2.41	10.24	13.32	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.16	3.69	-	-	-	-	-	-	-	59.31	0	23.54	6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.85	6.24	-	0.28	0.81	2.41	10.24	13.32	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.16	3.69	-	-	-	-	-	-	-	59.31	5000																																																																																			-		0	6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.85	6.24	-	0.28	0.81	2.41	10.24	13.32	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.16	3.69	-	-	-	-	-	-	-	59.31
H1804_103_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		189.99	9.51	900.04	2299.22	7.59	0.58	0.04	15.22	36.39	38.83	40.81	1.76	5.06	15	10492.88	6826.18			2.25		6.18											0.5	13.46	24.71								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								421.93	421.93	26.59	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.51	23.01			0.15		0.15											421.93	0.15	0.14								6.68	0.33	1.99	-	1.16	0.09	0.01	2.34	5.58	5.96	-	0.27	0.78	2.3	10.06	13.09	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.52	-	-	-	-	-	-	-	57.54	0	21.67	6.68	0.33	1.99	-	1.16	0.09	0.01	2.34	5.58	5.96	-	0.27	0.78	2.3	10.06	13.09	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.52	-	-	-	-	-	-	-	57.54	5000																																																																																			-		0	6.68	0.33	1.99	-	1.16	0.09	0.01	2.34	5.58	5.96	-	0.27	0.78	2.3	10.06	13.09	-	-	0.35	-	0.95	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.52	-	-	-	-	-	-	-	57.54
H1804_122_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		201.68	10.09	955.4	2440.66	8.54	0.65	0.05	17.13	40.94	43.69	43.33	1.99	5.69	16.88	11138.36	7246.1			2.53		6.95											0.53	15.14	27.8								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								411.78	411.78	25.95	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.23	22.46			0.15		0.15											411.78	0.15	0.14								6.92	0.35	2.07	-	1.28	0.1	0.01	2.56	6.13	6.54	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.19	0	25.64	6.92	0.35	2.07	-	1.28	0.1	0.01	2.56	6.13	6.54	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.19	5000																																																																																			-		0	6.92	0.35	2.07	-	1.28	0.1	0.01	2.56	6.13	6.54	-	0.3	0.85	2.53	10.42	13.56	-	-	0.38	-	1.04	-	-	-	-	-	-	-	-	-	-	0.02	2.27	3.87	-	-	-	-	-	-	-	61.19
H1804_123_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		200.25	10.02	948.65	2423.4	8.42	0.64	0.05	16.89	40.37	43.08	43.02	1.96	5.61	16.64	11059.62	7194.87			2.5		6.85											0.53	14.93	27.41								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								413.02	413.02	26.03	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.26	22.53			0.15		0.15											413.02	0.15	0.14								6.89	0.34	2.06	-	1.26	0.1	0.01	2.54	6.06	6.47	-	0.29	0.84	2.5	10.38	13.51	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.82	-	-	-	-	-	-	-	60.74	0	25.13	6.89	0.34	2.06	-	1.26	0.1	0.01	2.54	6.06	6.47	-	0.29	0.84	2.5	10.38	13.51	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.82	-	-	-	-	-	-	-	60.74	5000																																																																																			-		0	6.89	0.34	2.06	-	1.26	0.1	0.01	2.54	6.06	6.47	-	0.29	0.84	2.5	10.38	13.51	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.82	-	-	-	-	-	-	-	60.74
H1804_125_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		206.39	10.33	977.73	2497.71	8.95	0.68	0.05	17.95	42.91	45.79	44.34	2.08	5.97	17.69	11398.72	7415.48			2.66		7.29											0.54	15.87	29.14								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								407.66	407.66	25.69	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.12	22.24			0.15		0.15											407.66	0.15	0.14								7.01	0.35	2.09	-	1.33	0.1	0.01	2.66	6.36	6.79	-	0.31	0.88	2.62	10.56	13.74	-	-	0.39	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	2.35	4.01	-	-	-	-	-	-	-	62.68	0	27.39	7.01	0.35	2.09	-	1.33	0.1	0.01	2.66	6.36	6.79	-	0.31	0.88	2.62	10.56	13.74	-	-	0.39	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	2.35	4.01	-	-	-	-	-	-	-	62.68	5000																																																																																			-		0	7.01	0.35	2.09	-	1.33	0.1	0.01	2.66	6.36	6.79	-	0.31	0.88	2.62	10.56	13.74	-	-	0.39	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	2.35	4.01	-	-	-	-	-	-	-	62.68
H1804_126_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		184.5	9.23	874.04	2232.8	7.15	0.55	0.04	14.35	34.29	36.59	39.64	1.66	4.77	14.14	10189.78	6629			2.12		5.82											0.49	12.68	23.28								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								426.85	426.85	26.9	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.64	23.28			0.16		0.16											426.85	0.16	0.14								6.56	0.33	1.96	-	1.11	0.08	0.01	2.23	5.32	5.68	-	0.26	0.74	2.19	9.89	12.86	-	-	0.33	-	0.9	-	-	-	-	-	-	-	-	-	-	0.02	1.97	3.36	-	-	-	-	-	-	-	55.79	0	19.9	6.56	0.33	1.96	-	1.11	0.08	0.01	2.23	5.32	5.68	-	0.26	0.74	2.19	9.89	12.86	-	-	0.33	-	0.9	-	-	-	-	-	-	-	-	-	-	0.02	1.97	3.36	-	-	-	-	-	-	-	55.79	5000																																																																																			-		0	6.56	0.33	1.96	-	1.11	0.08	0.01	2.23	5.32	5.68	-	0.26	0.74	2.19	9.89	12.86	-	-	0.33	-	0.9	-	-	-	-	-	-	-	-	-	-	0.02	1.97	3.36	-	-	-	-	-	-	-	55.79
H1804_127_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		195.83	9.8	927.69	2369.87	8.07	0.62	0.05	16.18	38.66	41.26	42.07	1.88	5.38	15.94	10815.29	7035.93			2.39		6.56											0.52	14.3	26.26								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.78	416.78	26.27	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.37	22.73			0.15		0.15											416.78	0.15	0.14								6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.86	6.25	-	0.28	0.81	2.42	10.24	13.33	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.69	-	-	-	-	-	-	-	59.39	0	23.63	6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.86	6.25	-	0.28	0.81	2.42	10.24	13.33	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.69	-	-	-	-	-	-	-	59.39	5000																																																																																			-		0	6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.86	6.25	-	0.28	0.81	2.42	10.24	13.33	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.69	-	-	-	-	-	-	-	59.39
H1804_128_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		194.56	9.74	921.7	2354.56	7.96	0.61	0.05	15.96	38.15	40.72	41.8	1.85	5.3	15.73	10745.42	6990.47			2.36		6.48											0.51	14.11	25.91								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								417.91	417.91	26.34	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.4	22.79			0.15		0.15											417.91	0.15	0.14								6.78	0.34	2.02	-	1.21	0.09	0.01	2.43	5.8	6.19	-	0.28	0.81	2.39	10.21	13.28	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.14	3.66	-	-	-	-	-	-	-	58.98	0	23.19	6.78	0.34	2.02	-	1.21	0.09	0.01	2.43	5.8	6.19	-	0.28	0.81	2.39	10.21	13.28	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.14	3.66	-	-	-	-	-	-	-	58.98	5000																																																																																			-		0	6.78	0.34	2.02	-	1.21	0.09	0.01	2.43	5.8	6.19	-	0.28	0.81	2.39	10.21	13.28	-	-	0.36	-	0.98	-	-	-	-	-	-	-	-	-	-	0.02	2.14	3.66	-	-	-	-	-	-	-	58.98
H1804_129_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		211.74	10.6	1003.09	2562.47	9.43	0.72	0.05	18.91	45.21	48.24	45.49	2.19	6.29	18.64	11694.29	7607.76			2.8		7.68											0.56	16.72	30.7								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								403	403	25.4	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	10.99	21.98			0.15		0.15											403	0.15	0.14								7.11	0.36	2.12	-	1.38	0.11	0.01	2.77	6.63	7.07	-	0.32	0.92	2.73	10.71	13.94	-	-	0.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	2.45	4.18	-	-	-	-	-	-	-	64.35	0	29.47	7.11	0.36	2.12	-	1.38	0.11	0.01	2.77	6.63	7.07	-	0.32	0.92	2.73	10.71	13.94	-	-	0.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	2.45	4.18	-	-	-	-	-	-	-	64.35	5000																																																																																			-		0	7.11	0.36	2.12	-	1.38	0.11	0.01	2.77	6.63	7.07	-	0.32	0.92	2.73	10.71	13.94	-	-	0.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	2.45	4.18	-	-	-	-	-	-	-	64.35
H1804_130_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		182.8	9.15	865.98	2212.22	7.02	0.54	0.04	14.08	33.66	35.92	39.27	1.63	4.68	13.88	10095.85	6567.89			2.08		5.71											0.48	12.45	22.86								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								428.36	428.36	27	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.68	23.37			0.16		0.16											428.36	0.16	0.14								6.53	0.33	1.95	-	1.09	0.08	0.01	2.19	5.24	5.6	-	0.25	0.73	2.16	9.83	12.79	-	-	0.32	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.26	0	19.38	6.53	0.33	1.95	-	1.09	0.08	0.01	2.19	5.24	5.6	-	0.25	0.73	2.16	9.83	12.79	-	-	0.32	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.26	5000																																																																																			-		0	6.53	0.33	1.95	-	1.09	0.08	0.01	2.19	5.24	5.6	-	0.25	0.73	2.16	9.83	12.79	-	-	0.32	-	0.89	-	-	-	-	-	-	-	-	-	-	0.02	1.94	3.31	-	-	-	-	-	-	-	55.26
H1804_131_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		196.09	9.81	928.95	2373.09	8.08	0.62	0.05	16.21	38.75	41.35	42.13	1.88	5.39	15.98	10830	7045.49			2.4		6.58											0.52	14.33	26.31								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.57	416.57	26.25	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.36	22.72			0.15		0.15											416.57	0.15	0.14								6.81	0.34	2.03	-	1.22	0.09	0.01	2.46	5.87	6.26	-	0.28	0.82	2.42	10.25	13.34	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.7	-	-	-	-	-	-	-	59.46	0	23.71	6.81	0.34	2.03	-	1.22	0.09	0.01	2.46	5.87	6.26	-	0.28	0.82	2.42	10.25	13.34	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.7	-	-	-	-	-	-	-	59.46	5000																																																																																			-		0	6.81	0.34	2.03	-	1.22	0.09	0.01	2.46	5.87	6.26	-	0.28	0.82	2.42	10.25	13.34	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.7	-	-	-	-	-	-	-	59.46
H1804_132_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		196.32	9.83	930.02	2375.83	8.11	0.62	0.05	16.26	38.86	41.46	42.17	1.88	5.4	16.02	10842.5	7053.63			2.4		6.6											0.52	14.37	26.39								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.35	416.35	26.24	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.36	22.71			0.15		0.15											416.35	0.15	0.14								6.81	0.34	2.03	-	1.23	0.09	0.01	2.46	5.88	6.28	-	0.29	0.82	2.43	10.26	13.35	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.71	-	-	-	-	-	-	-	59.54	0	23.79	6.81	0.34	2.03	-	1.23	0.09	0.01	2.46	5.88	6.28	-	0.29	0.82	2.43	10.26	13.35	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.71	-	-	-	-	-	-	-	59.54	5000																																																																																			-		0	6.81	0.34	2.03	-	1.23	0.09	0.01	2.46	5.88	6.28	-	0.29	0.82	2.43	10.26	13.35	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.71	-	-	-	-	-	-	-	59.54
H1804_133_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		217.54	10.89	1030.58	2632.71	9.95	0.76	0.06	19.96	47.71	50.91	46.73	2.31	6.63	19.67	12014.81	7816.28			2.95		8.1											0.57	17.64	32.4								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								398.07	398.07	25.09	0	0.14	0.14	0.14	0.14	0.14	0.14	0	0.14	0.14	0.14	10.86	21.71			0.14		0.14											398.07	0.14	0.13								7.22	0.36	2.15	-	1.44	0.11	0.01	2.89	6.91	7.37	-	0.33	0.96	2.85	10.87	14.14	-	-	0.43	-	1.17	-	-	-	-	-	-	-	-	-	-	0.02	2.55	4.35	-	-	-	-	-	-	-	66.14	0	31.78	7.22	0.36	2.15	-	1.44	0.11	0.01	2.89	6.91	7.37	-	0.33	0.96	2.85	10.87	14.14	-	-	0.43	-	1.17	-	-	-	-	-	-	-	-	-	-	0.02	2.55	4.35	-	-	-	-	-	-	-	66.14	5000																																																																																			-		0	7.22	0.36	2.15	-	1.44	0.11	0.01	2.89	6.91	7.37	-	0.33	0.96	2.85	10.87	14.14	-	-	0.43	-	1.17	-	-	-	-	-	-	-	-	-	-	0.02	2.55	4.35	-	-	-	-	-	-	-	66.14
H1804_137_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		191.52	9.59	907.27	2317.71	7.71	0.59	0.04	15.45	36.94	39.42	41.14	1.79	5.14	15.23	10577.25	6881.07			2.29		6.27											0.5	13.66	25.08								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								420.63	420.63	26.51	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.47	22.94			0.15		0.15											420.63	0.15	0.14								6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.16	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	58.01	0	22.15	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.16	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	58.01	5000																																																																																			-		0	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.16	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	58.01
H1804_138_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		200.32	10.03	949	2424.31	8.43	0.64	0.05	16.9	40.4	43.11	43.04	1.96	5.62	16.66	11063.76	7197.57			2.5		6.86											0.53	14.94	27.44								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								412.94	412.94	26.03	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.26	22.52			0.15		0.15											412.94	0.15	0.14								6.89	0.35	2.06	-	1.27	0.1	0.01	2.54	6.07	6.47	-	0.29	0.84	2.5	10.38	13.51	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.83	-	-	-	-	-	-	-	60.77	0	25.16	6.89	0.35	2.06	-	1.27	0.1	0.01	2.54	6.07	6.47	-	0.29	0.84	2.5	10.38	13.51	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.83	-	-	-	-	-	-	-	60.77	5000																																																																																			-		0	6.89	0.35	2.06	-	1.27	0.1	0.01	2.54	6.07	6.47	-	0.29	0.84	2.5	10.38	13.51	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.83	-	-	-	-	-	-	-	60.77
H1804_143_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		200.16	10.02	948.21	2422.28	8.41	0.64	0.05	16.88	40.34	43.04	43	1.96	5.61	16.63	11054.51	7191.55			2.5		6.85											0.53	14.92	27.39								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								413.08	413.08	26.03	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.27	22.53			0.15		0.15											413.08	0.15	0.14								6.89	0.34	2.06	-	1.26	0.1	0.01	2.53	6.06	6.47	-	0.29	0.84	2.5	10.38	13.5	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.82	-	-	-	-	-	-	-	60.72	0	25.1	6.89	0.34	2.06	-	1.26	0.1	0.01	2.53	6.06	6.47	-	0.29	0.84	2.5	10.38	13.5	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.82	-	-	-	-	-	-	-	60.72	5000																																																																																			-		0	6.89	0.34	2.06	-	1.26	0.1	0.01	2.53	6.06	6.47	-	0.29	0.84	2.5	10.38	13.5	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.82	-	-	-	-	-	-	-	60.72
H1804_144_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V		Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0		0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		199.2	9.97	943.65	2410.65		0.64	0.05	16.71	39.95	42.63	42.79	1.94	5.55	16.47	11001.4	7157			2.47		6.78											0.52	14.77	27.13								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit		20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.42	416.42	26.24	0		0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.36	22.71			0.15		0.15											416.42	0.15	0.14								6.91	0.35	2.06	-	-	0.1	0.01	2.53	6.05	6.46	-	0.29	0.84	2.49	10.41	13.55	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.81	-	-	-	-	-	-	-	59.52	0	23.9	6.91	0.35	2.06	-	-	0.1	0.01	2.53	6.05	6.46	-	0.29	0.84	2.49	10.41	13.55	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.81	-	-	-	-	-	-	-	59.52	5000																																																																																			-		0	6.91	0.35	2.06	-	-	0.1	0.01	2.53	6.05	6.46	-	0.29	0.84	2.49	10.41	13.55	-	-	0.37	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.24	3.81	-	-	-	-	-	-	-	59.52
H1804_145_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		211.28	10.58	1000.91	2556.91	9.41	0.72	0.05	18.88	45.12	48.14	45.39	2.19	6.27	18.6	11668.92	7591.26			2.79		7.66											0.56	16.68	30.64								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								403.26	403.26	25.42	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11	22			0.15		0.15											403.26	0.15	0.14								7.1	0.36	2.12	-	1.38	0.11	0.01	2.77	6.62	7.06	-	0.32	0.92	2.73	10.69	13.91	-	-	0.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	2.45	4.17	-	-	-	-	-	-	-	64.26	0	29.35	7.1	0.36	2.12	-	1.38	0.11	0.01	2.77	6.62	7.06	-	0.32	0.92	2.73	10.69	13.91	-	-	0.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	2.45	4.17	-	-	-	-	-	-	-	64.26	5000																																																																																			-		0	7.1	0.36	2.12	-	1.38	0.11	0.01	2.77	6.62	7.06	-	0.32	0.92	2.73	10.69	13.91	-	-	0.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	2.45	4.17	-	-	-	-	-	-	-	64.26
H1804_146_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		213.65	10.69	1012.12	2585.55	9.6	0.73	0.06	19.24	46	49.09	45.9	2.23	6.4	18.97	11799.6	7676.27			2.85		7.81											0.56	17.01	31.24								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								401.41	401.41	25.3	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	10.95	21.89			0.15		0.15											401.41	0.15	0.14								7.15	0.36	2.13	-	1.4	0.11	0.01	2.81	6.71	7.17	-	0.33	0.93	2.77	10.76	14.01	-	-	0.42	-	1.14	-	-	-	-	-	-	-	-	-	-	0.02	2.48	4.23	-	-	-	-	-	-	-	64.93	0	30.2	7.15	0.36	2.13	-	1.4	0.11	0.01	2.81	6.71	7.17	-	0.33	0.93	2.77	10.76	14.01	-	-	0.42	-	1.14	-	-	-	-	-	-	-	-	-	-	0.02	2.48	4.23	-	-	-	-	-	-	-	64.93	5000																																																																																			-		0	7.15	0.36	2.13	-	1.4	0.11	0.01	2.81	6.71	7.17	-	0.33	0.93	2.77	10.76	14.01	-	-	0.42	-	1.14	-	-	-	-	-	-	-	-	-	-	0.02	2.48	4.23	-	-	-	-	-	-	-	64.93
H1804_147_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		228.45	6.16	898.74	2221.65	206.12	0.52	0.04	244	379.87	597.21	407.19	27.15	838.21	230.74	11725.5	9206.73			418.81		6.43											12.02	0.32	13.47								550/admit	550/admit	0/day (1-6) 125/day (7-100)	0/Visit	100/ Trip	20 Coins	20 Coins	10-50/ Visit	25-100/ Visit	15-100/ Visit	0-100/ Visit	100/ Visit	25/ Procedure	25-100/ Visit	10/ Visit	25/ Visit			25/ Visit		20 Coins											550/admit	950/admit	20 Coins								550	950	36.36	0	100	0.2	0.2	42.3	49.75	80.68	29.17	100	25	38.24	10	25			25		0.2											550	950	0.2								10.47	0.49	2.72	-	1.72	0.1	0.01	0.86	1.57	4.02	0.99	0.23	1.75	0.74	9.77	19.18	-	-	0.87	-	1.29	-	-	-	-	-	-	-	-	-	-	0.55	0.03	2.69	-	-	-	-	-	-	-	60.04	0	0	10.47	0.49	2.72	-	1.72	0.1	0.01	0.86	1.57	4.02	0.99	0.23	1.75	0.74	9.77	19.18	-	-	0.87	-	1.29	-	-	-	-	-	-	-	-	-	-	0.55	0.03	2.69	-	-	-	-	-	-	-	60.04																																																																																				-		0	10.47	0.49	2.72	-	1.72	0.1	0.01	0.86	1.57	4.02	0.99	0.23	1.75	0.74	9.77	19.18	-	-	0.87	-	1.29	-	-	-	-	-	-	-	-	-	-	0.55	0.03	2.69	-	-	-	-	-	-	-	60.04
H1804_148_0	2007	6	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		196.71	9.85	931.86	2380.53	8.13	0.62	0.05	16.31	38.97	41.59	42.26	1.89	5.42	16.07	10863.94	7067.58			2.41		6.62											0.52	14.41	26.47								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.07	416.07	26.22	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.35	22.69			0.15		0.15											416.07	0.15	0.14								6.82	0.34	2.04	-	1.23	0.09	0.01	2.47	5.9	6.29	-	0.29	0.82	2.43	10.27	13.37	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.72	-	-	-	-	-	-	-	59.64	0	23.91	6.82	0.34	2.04	-	1.23	0.09	0.01	2.47	5.9	6.29	-	0.29	0.82	2.43	10.27	13.37	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.72	-	-	-	-	-	-	-	59.64	5000																																																																																			-		0	6.82	0.34	2.04	-	1.23	0.09	0.01	2.47	5.9	6.29	-	0.29	0.82	2.43	10.27	13.37	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.18	3.72	-	-	-	-	-	-	-	59.64
H1804_149_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		192.49	9.63	911.87	2329.44	7.79	0.59	0.04	15.61	37.32	39.83	41.35	1.81	5.19	15.39	10630.82	6915.92			2.31		6.34											0.51	13.8	25.34								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								419.77	419.77	26.46	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.45	22.9			0.15		0.15											419.77	0.15	0.14								6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.59	-	-	-	-	-	-	-	58.32	0	22.48	6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.59	-	-	-	-	-	-	-	58.32	5000																																																																																			-		0	6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.7	6.08	-	0.28	0.79	2.35	10.14	13.2	-	-	0.35	-	0.97	-	-	-	-	-	-	-	-	-	-	0.02	2.11	3.59	-	-	-	-	-	-	-	58.32
H1804_150_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		202.34	10.13	958.57	2448.76	8.6	0.66	0.05	17.26	41.24	44.01	43.47	2	5.73	17	11175.33	7270.15			2.55		7											0.53	15.25	28.01								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								411.16	411.16	25.91	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.21	22.43			0.15		0.15											411.16	0.15	0.14								6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.58	-	0.3	0.86	2.54	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.41	0	25.9	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.58	-	0.3	0.86	2.54	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.41	5000																																																																																			-		0	6.93	0.35	2.07	-	1.29	0.1	0.01	2.58	6.17	6.58	-	0.3	0.86	2.54	10.44	13.59	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.28	3.89	-	-	-	-	-	-	-	61.41
H1804_151_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		188.35	9.43	892.26	2279.36	7.46	0.57	0.04	14.96	35.75	38.15	40.46	1.73	4.97	14.74	10402.27	6767.23			2.21		6.07											0.5	13.22	24.27								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								423.41	423.41	26.69	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.55	23.1			0.15		0.15											423.41	0.15	0.14								6.65	0.33	1.98	-	1.15	0.09	0.01	2.3	5.5	5.87	-	0.27	0.77	2.27	10.01	13.02	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.04	3.47	-	-	-	-	-	-	-	57.02	0	21.13	6.65	0.33	1.98	-	1.15	0.09	0.01	2.3	5.5	5.87	-	0.27	0.77	2.27	10.01	13.02	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.04	3.47	-	-	-	-	-	-	-	57.02	5000																																																																																			-		0	6.65	0.33	1.98	-	1.15	0.09	0.01	2.3	5.5	5.87	-	0.27	0.77	2.27	10.01	13.02	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.04	3.47	-	-	-	-	-	-	-	57.02
H1804_152_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		200.64	10.04	950.48	2428.08	8.46	0.65	0.05	16.97	40.57	43.29	43.1	1.97	5.64	16.73	11080.94	7208.75			2.51		6.89											0.53	15	27.55								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								412.63	412.63	26.01	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.25	22.51			0.15		0.15											412.63	0.15	0.14								6.9	0.35	2.06	-	1.27	0.1	0.01	2.55	6.09	6.5	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.89	0	25.3	6.9	0.35	2.06	-	1.27	0.1	0.01	2.55	6.09	6.5	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.89	5000																																																																																			-		0	6.9	0.35	2.06	-	1.27	0.1	0.01	2.55	6.09	6.5	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.89
H1804_153_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1121.23	87.02	915.12	2337.75	142.68	0.6	0.05	254.83	377.52	912.97	580.98	41.5	1090.99	352.74	10668.71	6940.57			352.33		6.38											4.58	13.9	1.82								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.9	95.9	27.15	0	78.32	0.16	0.16	36.03	63.91	30.26	44.76	39.16	39.16	39.16	11.75	23.5			78.32		0.16											95.9	0.16	0								8.96	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.59	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.4	0	15.05	8.96	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.59	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.4	5000																																																																																			-		0	8.96	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.59	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.4
H1804_154_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1171.75	90.94	956.35	2443.08	149.11	0.65	0.05	266.31	394.53	954.1	607.16	43.37	1140.15	368.63	11149.43	7253.3			368.2		6.97											4.79	15.17	1.99								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.71	94.71	26.81	0	77.35	0.15	0.15	35.58	63.12	29.89	44.2	38.68	38.68	38.68	11.6	23.21			77.35		0.15											94.71	0.15	0								9.25	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.67	1.19	10.78	14.03	-	-	2.37	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.3	0	16.48	9.25	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.67	1.19	10.78	14.03	-	-	2.37	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.3	5000																																																																																			-		0	9.25	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.67	1.19	10.78	14.03	-	-	2.37	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.3
H1804_155_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1185.4	92	967.48	2471.52	150.84	0.67	0.05	269.41	399.13	965.21	614.23	43.87	1153.43	372.92	11279.23	7337.74			372.49		7.14											4.84	15.54	2.04								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.39	94.39	26.72	0	77.09	0.15	0.15	35.46	62.91	29.79	44.05	38.55	38.55	38.55	11.56	23.13			77.09		0.15											94.39	0.15	0								9.32	0.72	2.15	-	0.97	0.1	0.01	0.8	2.09	2.4	2.25	0.14	3.7	1.2	10.87	14.14	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.8	0	16.88	9.32	0.72	2.15	-	0.97	0.1	0.01	0.8	2.09	2.4	2.25	0.14	3.7	1.2	10.87	14.14	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.8	5000																																																																																			-		0	9.32	0.72	2.15	-	0.97	0.1	0.01	0.8	2.09	2.4	2.25	0.14	3.7	1.2	10.87	14.14	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.8
H1804_156_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1258.83	41.49	928.9	2296.2	213.04	0.54	0.04	252.18	392.62	617.25	392.8	28.06	866.34	238.48	12118.96	9515.68			432.87		6.74											2.18	14.11	1.92								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.31	93.31	26.42	0	76.21	0.15	0.15	35.06	62.19	29.45	43.55	38.11	38.11	38.11	11.43	22.86			76.21		0.15											93.31	0.15	0								9.79	0.32	2.04	-	1.35	0.08	0.01	0.74	2.03	1.51	1.43	0.09	2.75	0.76	11.55	18.13	-	-	2.75	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.15	-	-	-	-	-	-	-	-	58.53	0	18.27	9.79	0.32	2.04	-	1.35	0.08	0.01	0.74	2.03	1.51	1.43	0.09	2.75	0.76	11.55	18.13	-	-	2.75	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.15	-	-	-	-	-	-	-	-	58.53	5000																																																																																			-		0	9.79	0.32	2.04	-	1.35	0.08	0.01	0.74	2.03	1.51	1.43	0.09	2.75	0.76	11.55	18.13	-	-	2.75	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.15	-	-	-	-	-	-	-	-	58.53
H1804_157_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1277.42	42.11	942.61	2330.12	216.18	0.56	0.04	255.91	398.42	626.37	398.6	28.47	879.14	242	12297.95	9656.22			439.26		6.93											2.22	14.52	1.98								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								92.91	92.91	26.3	0	75.88	0.15	0.15	34.91	61.92	29.32	43.36	37.94	37.94	37.94	11.38	22.76			75.88		0.15											92.91	0.15	0								9.89	0.33	2.07	-	1.37	0.08	0.01	0.74	2.06	1.53	1.44	0.09	2.78	0.77	11.67	18.32	-	-	2.78	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.2	-	-	-	-	-	-	-	-	59.18	0	18.81	9.89	0.33	2.07	-	1.37	0.08	0.01	0.74	2.06	1.53	1.44	0.09	2.78	0.77	11.67	18.32	-	-	2.78	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.2	-	-	-	-	-	-	-	-	59.18	5000																																																																																			-		0	9.89	0.33	2.07	-	1.37	0.08	0.01	0.74	2.06	1.53	1.44	0.09	2.78	0.77	11.67	18.32	-	-	2.78	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.2	-	-	-	-	-	-	-	-	59.18
H1804_158_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1072.95	83.27	875.71	2237.08	136.53	0.55	0.04	243.85	361.27	873.65	555.96	39.71	1044.01	337.55	10209.31	6641.71			337.16		5.84											4.38	12.73	1.67								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.1	97.1	27.49	0	79.31	0.16	0.16	36.48	64.72	30.64	45.32	39.65	39.65	39.65	11.9	23.79			79.31		0.16											97.1	0.16	0								8.68	0.67	2.01	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.12	10.12	13.17	-	-	2.23	-	0.93	-	-	-	-	-	-	-	-	-	-	0.04	2.02	-	-	-	-	-	-	-	-	52.57	0	13.72	8.68	0.67	2.01	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.12	10.12	13.17	-	-	2.23	-	0.93	-	-	-	-	-	-	-	-	-	-	0.04	2.02	-	-	-	-	-	-	-	-	52.57	5000																																																																																			-		0	8.68	0.67	2.01	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.12	10.12	13.17	-	-	2.23	-	0.93	-	-	-	-	-	-	-	-	-	-	0.04	2.02	-	-	-	-	-	-	-	-	52.57
H1804_159_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1161.51	90.14	947.99	2421.72	147.8	0.64	0.05	263.98	391.08	945.76	601.85	42.99	1130.18	365.41	11051.96	7189.89			364.98		6.85											4.74	14.91	1.96								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.95	94.95	26.88	0	77.55	0.16	0.16	35.67	63.28	29.96	44.31	38.77	38.77	38.77	11.63	23.26			77.55		0.16											94.95	0.16	0								9.19	0.71	2.12	-	0.96	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.65	1.18	10.71	13.94	-	-	2.36	-	1.06	-	-	-	-	-	-	-	-	-	-	0.04	2.31	-	-	-	-	-	-	-	-	55.91	0	16.19	9.19	0.71	2.12	-	0.96	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.65	1.18	10.71	13.94	-	-	2.36	-	1.06	-	-	-	-	-	-	-	-	-	-	0.04	2.31	-	-	-	-	-	-	-	-	55.91	5000																																																																																			-		0	9.19	0.71	2.12	-	0.96	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.65	1.18	10.71	13.94	-	-	2.36	-	1.06	-	-	-	-	-	-	-	-	-	-	0.04	2.31	-	-	-	-	-	-	-	-	55.91
H1804_160_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1146.87	89.01	936.04	2391.2	145.94	0.63	0.05	260.65	386.15	933.84	594.26	42.45	1115.94	360.8	10912.65	7099.26			360.38		6.68											4.68	14.54	1.91								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.29	95.29	26.98	0	77.83	0.16	0.16	35.8	63.51	30.07	44.47	38.91	38.91	38.91	11.67	23.35			77.83		0.16											95.29	0.16	0								9.11	0.71	2.1	-	0.95	0.1	0.01	0.78	2.04	2.34	2.2	0.14	3.62	1.17	10.62	13.81	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.26	-	-	-	-	-	-	-	-	55.37	0	15.77	9.11	0.71	2.1	-	0.95	0.1	0.01	0.78	2.04	2.34	2.2	0.14	3.62	1.17	10.62	13.81	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.26	-	-	-	-	-	-	-	-	55.37	5000																																																																																			-		0	9.11	0.71	2.1	-	0.95	0.1	0.01	0.78	2.04	2.34	2.2	0.14	3.62	1.17	10.62	13.81	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.26	-	-	-	-	-	-	-	-	55.37
H1804_161_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1137.72	88.3	928.57	2372.12	144.78	0.62	0.05	258.57	383.07	926.39	589.52	42.11	1107.03	357.92	10825.57	7042.61			357.51		6.58											4.65	14.33	1.88								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.5	95.5	27.04	0	78	0.16	0.16	35.88	63.65	30.14	44.57	39	39	39	11.7	23.4			78		0.16											95.5	0.16	0								9.05	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.33	2.19	0.14	3.6	1.16	10.56	13.73	-	-	2.32	-	1.03	-	-	-	-	-	-	-	-	-	-	0.04	2.24	-	-	-	-	-	-	-	-	55.03	0	15.52	9.05	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.33	2.19	0.14	3.6	1.16	10.56	13.73	-	-	2.32	-	1.03	-	-	-	-	-	-	-	-	-	-	0.04	2.24	-	-	-	-	-	-	-	-	55.03	5000																																																																																			-		0	9.05	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.33	2.19	0.14	3.6	1.16	10.56	13.73	-	-	2.32	-	1.03	-	-	-	-	-	-	-	-	-	-	0.04	2.24	-	-	-	-	-	-	-	-	55.03
H1804_162_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1153.12	89.49	941.14	2404.23	146.74	0.63	0.05	262.08	388.26	938.93	597.5	42.68	1122.02	362.77	10972.13	7137.96			362.35		6.75											4.71	14.7	1.93								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.14	95.14	26.94	0	77.71	0.16	0.16	35.75	63.41	30.02	44.4	38.85	38.85	38.85	11.66	23.31			77.71		0.16											95.14	0.16	0								9.14	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.66	13.87	-	-	2.35	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.6	0	15.95	9.14	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.66	13.87	-	-	2.35	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.6	5000																																																																																			-		0	9.14	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.66	13.87	-	-	2.35	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.6
H1804_163_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1182.29	91.76	964.95	2465.05	150.45	0.67	0.05	268.71	398.08	962.68	612.62	43.76	1150.4	371.95	11249.69	7318.53			371.51		7.09											4.83	15.44	2.03								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.46	94.46	26.74	0	77.15	0.15	0.15	35.49	62.96	29.81	44.09	38.58	38.58	38.58	11.57	23.15			77.15		0.15											94.46	0.15	0								9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.12	-	-	2.39	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.38	-	-	-	-	-	-	-	-	56.69	0	16.79	9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.12	-	-	2.39	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.38	-	-	-	-	-	-	-	-	56.69	5000																																																																																			-		0	9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.12	-	-	2.39	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.38	-	-	-	-	-	-	-	-	56.69
H1804_164_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1173.88	91.1	958.08	2447.51	149.38	0.66	0.05	266.79	395.25	955.83	608.26	43.45	1142.22	369.3	11169.64	7266.45			368.87		6.99											4.79	15.23	2								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.66	94.66	26.8	0	77.31	0.15	0.15	35.56	63.09	29.87	44.18	38.66	38.66	38.66	11.6	23.19			77.31		0.15											94.66	0.15	0								9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.79	14.04	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.37	0	16.54	9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.79	14.04	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.37	5000																																																																																			-		0	9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.79	14.04	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.37
H1804_165_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1238.55	96.12	1010.87	2582.35	157.61	0.73	0.06	281.49	417.02	1008.49	641.77	45.84	1205.15	389.65	11785.01	7666.78			389.19		7.81											5.06	17.02	2.23								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.17	93.17	26.38	0	76.09	0.15	0.15	35	62.09	29.4	43.48	38.05	38.05	38.05	11.41	22.83			76.09		0.15											93.17	0.15	0								9.62	0.75	2.22	-	1	0.11	0.01	0.82	2.16	2.47	2.33	0.15	3.82	1.24	11.21	14.59	-	-	2.47	-	1.19	-	-	-	-	-	-	-	-	-	-	0.04	2.59	-	-	-	-	-	-	-	-	58.76	0	18.46	9.62	0.75	2.22	-	1	0.11	0.01	0.82	2.16	2.47	2.33	0.15	3.82	1.24	11.21	14.59	-	-	2.47	-	1.19	-	-	-	-	-	-	-	-	-	-	0.04	2.59	-	-	-	-	-	-	-	-	58.76	5000																																																																																			-		0	9.62	0.75	2.22	-	1	0.11	0.01	0.82	2.16	2.47	2.33	0.15	3.82	1.24	11.21	14.59	-	-	2.47	-	1.19	-	-	-	-	-	-	-	-	-	-	0.04	2.59	-	-	-	-	-	-	-	-	58.76
H1804_166_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1122.22	87.09	915.92	2339.79	142.8	0.6	0.05	255.05	377.85	913.77	581.49	41.53	1091.95	353.05	10678.06	6946.65			352.64		6.39											4.58	13.93	1.83								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.87	95.87	27.14	0	78.3	0.16	0.16	36.02	63.9	30.25	44.75	39.15	39.15	39.15	11.75	23.49			78.3		0.16											95.87	0.16	0								8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.44	0	15.08	8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.44	5000																																																																																			-		0	8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.44
H1804_167_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1182.1	91.74	964.79	2464.65	150.42	0.67	0.05	268.66	398.02	962.53	612.52	43.75	1150.22	371.89	11247.86	7317.34			371.45		7.09											4.83	15.45	2.03								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.47	94.47	26.74	0	77.15	0.15	0.15	35.49	62.96	29.81	44.09	38.58	38.58	38.58	11.57	23.15			77.15		0.15											94.47	0.15	0								9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.11	-	-	2.39	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.38	-	-	-	-	-	-	-	-	56.68	0	16.78	9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.11	-	-	2.39	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.38	-	-	-	-	-	-	-	-	56.68	5000																																																																																			-		0	9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.11	-	-	2.39	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.38	-	-	-	-	-	-	-	-	56.68
H1804_168_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1186.64	92.09	968.5	2474.11	151	0.67	0.05	269.69	399.54	966.22	614.87	43.92	1154.63	373.31	11291.05	7345.43			372.88		7.15											4.85	15.58	2.04								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.36	94.36	26.71	0	77.07	0.15	0.15	35.45	62.89	29.78	44.04	38.53	38.53	38.53	11.56	23.12			77.07		0.15											94.36	0.15	0								9.33	0.72	2.16	-	0.97	0.1	0.01	0.8	2.09	2.4	2.26	0.14	3.71	1.2	10.88	14.15	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.85	0	16.92	9.33	0.72	2.16	-	0.97	0.1	0.01	0.8	2.09	2.4	2.26	0.14	3.71	1.2	10.88	14.15	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.85	5000																																																																																			-		0	9.33	0.72	2.16	-	0.97	0.1	0.01	0.8	2.09	2.4	2.26	0.14	3.71	1.2	10.88	14.15	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.85
H1804_169_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		220.46	6.75	1226.85	2281.62	6.84	0.52	0.04	13.71	39.5	43.08	57.68	1.96	3.62	16.64	7409.92	5956.07			1.7		6.85											0.36	11.17	27.41								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								426.13	426.13	26.86	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.62	23.24			0.15		0.15											426.13	0.15	0.14								7.83	0.24	2.75	-	1.06	0.08	0.01	2.13	6.12	6.68	-	0.3	0.56	2.58	7.18	11.54	-	-	0.26	-	1.06	-	-	-	-	-	-	-	-	-	-	0.01	1.73	3.94	-	-	-	-	-	-	-	56.05	0	20.76	7.83	0.24	2.75	-	1.06	0.08	0.01	2.13	6.12	6.68	-	0.3	0.56	2.58	7.18	11.54	-	-	0.26	-	1.06	-	-	-	-	-	-	-	-	-	-	0.01	1.73	3.94	-	-	-	-	-	-	-	56.05	5000																																																																																			-		0	7.83	0.24	2.75	-	1.06	0.08	0.01	2.13	6.12	6.68	-	0.3	0.56	2.58	7.18	11.54	-	-	0.26	-	1.06	-	-	-	-	-	-	-	-	-	-	0.01	1.73	3.94	-	-	-	-	-	-	-	56.05
H1804_170_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1103.37	42.13	1239.05	2304.31	128.62	0.53	0.04	249.61	474.23	1281.6	815.56	58.25	1065.45	495.16	7483.61	6015.3			270.09		6.99											2.22	11.39	2								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.33	97.33	27.55	0	79.49	0.16	0.16	36.57	64.87	30.71	45.42	39.75	39.75	39.75	11.92	23.85			79.49		0.16											97.33	0.16	0								8.95	0.34	2.85	-	0.85	0.09	0.01	0.76	2.56	3.28	3.09	0.19	3.53	1.64	7.44	11.95	-	-	1.79	-	1.11	-	-	-	-	-	-	-	-	-	-	0.02	1.81	-	-	-	-	-	-	-	-	52.25	0	13.48	8.95	0.34	2.85	-	0.85	0.09	0.01	0.76	2.56	3.28	3.09	0.19	3.53	1.64	7.44	11.95	-	-	1.79	-	1.11	-	-	-	-	-	-	-	-	-	-	0.02	1.81	-	-	-	-	-	-	-	-	52.25	5000																																																																																			-		0	8.95	0.34	2.85	-	0.85	0.09	0.01	0.76	2.56	3.28	3.09	0.19	3.53	1.64	7.44	11.95	-	-	1.79	-	1.11	-	-	-	-	-	-	-	-	-	-	0.02	1.81	-	-	-	-	-	-	-	-	52.25
H1804_171_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		218.95	6.7	1218.48	2266.05	6.72	0.52	0.04	13.49	38.85	42.37	57.29	1.93	3.56	16.37	7359.38	5915.44			1.67		6.74											0.35	10.99	26.96								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								427.44	427.44	26.94	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.66	23.32			0.16		0.16											427.44	0.16	0.14								7.8	0.24	2.74	-	1.05	0.08	0.01	2.1	6.04	6.59	-	0.3	0.55	2.54	7.15	11.49	-	-	0.26	-	1.05	-	-	-	-	-	-	-	-	-	-	0.01	1.71	3.89	-	-	-	-	-	-	-	55.58	0	20.29	7.8	0.24	2.74	-	1.05	0.08	0.01	2.1	6.04	6.59	-	0.3	0.55	2.54	7.15	11.49	-	-	0.26	-	1.05	-	-	-	-	-	-	-	-	-	-	0.01	1.71	3.89	-	-	-	-	-	-	-	55.58	5000																																																																																			-		0	7.8	0.24	2.74	-	1.05	0.08	0.01	2.1	6.04	6.59	-	0.3	0.55	2.54	7.15	11.49	-	-	0.26	-	1.05	-	-	-	-	-	-	-	-	-	-	0.01	1.71	3.89	-	-	-	-	-	-	-	55.58
H1804_172_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1095.82	41.84	1230.57	2288.53	127.74	0.53	0.04	247.9	470.98	1272.83	809.98	57.86	1058.16	491.77	7432.38	5974.12			268.24		6.88											2.2	11.2	1.96								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.53	97.53	27.61	0	79.66	0.16	0.16	36.64	65	30.78	45.52	39.83	39.83	39.83	11.95	23.9			79.66		0.16											97.53	0.16	0								8.91	0.34	2.83	-	0.85	0.08	0.01	0.76	2.55	3.26	3.07	0.19	3.51	1.63	7.4	11.9	-	-	1.78	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.78	-	-	-	-	-	-	-	-	51.97	0	13.27	8.91	0.34	2.83	-	0.85	0.08	0.01	0.76	2.55	3.26	3.07	0.19	3.51	1.63	7.4	11.9	-	-	1.78	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.78	-	-	-	-	-	-	-	-	51.97	5000																																																																																			-		0	8.91	0.34	2.83	-	0.85	0.08	0.01	0.76	2.55	3.26	3.07	0.19	3.51	1.63	7.4	11.9	-	-	1.78	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.78	-	-	-	-	-	-	-	-	51.97
H1804_173_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		217.34	6.65	1209.48	2249.31	6.63	0.51	0.04	13.29	38.29	41.76	56.86	1.9	3.51	16.14	7305.01	5871.75			1.64		6.64											0.35	10.83	26.58								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								428.66	428.66	27.02	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.69	23.38			0.16		0.16											428.66	0.16	0.14								7.76	0.24	2.72	-	1.03	0.08	0.01	2.07	5.97	6.51	-	0.3	0.55	2.52	7.12	11.44	-	-	0.26	-	1.04	-	-	-	-	-	-	-	-	-	-	0.01	1.69	3.85	-	-	-	-	-	-	-	55.15	0	19.85	7.76	0.24	2.72	-	1.03	0.08	0.01	2.07	5.97	6.51	-	0.3	0.55	2.52	7.12	11.44	-	-	0.26	-	1.04	-	-	-	-	-	-	-	-	-	-	0.01	1.69	3.85	-	-	-	-	-	-	-	55.15	5000																																																																																			-		0	7.76	0.24	2.72	-	1.03	0.08	0.01	2.07	5.97	6.51	-	0.3	0.55	2.52	7.12	11.44	-	-	0.26	-	1.04	-	-	-	-	-	-	-	-	-	-	0.01	1.69	3.85	-	-	-	-	-	-	-	55.15
H1804_174_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1087.76	41.54	1221.52	2271.7	126.8	0.52	0.04	246.08	467.52	1263.47	804.03	57.43	1050.38	488.16	7377.74	5930.2			266.27		6.78											2.19	11.04	1.94								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.74	97.74	27.67	0	79.83	0.16	0.16	36.72	65.14	30.84	45.62	39.91	39.91	39.91	11.97	23.95			79.83		0.16											97.74	0.16	0								8.86	0.34	2.82	-	0.84	0.08	0.01	0.75	2.54	3.25	3.06	0.19	3.49	1.62	7.36	11.83	-	-	1.77	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	1.76	-	-	-	-	-	-	-	-	51.68	0	13.06	8.86	0.34	2.82	-	0.84	0.08	0.01	0.75	2.54	3.25	3.06	0.19	3.49	1.62	7.36	11.83	-	-	1.77	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	1.76	-	-	-	-	-	-	-	-	51.68	5000																																																																																			-		0	8.86	0.34	2.82	-	0.84	0.08	0.01	0.75	2.54	3.25	3.06	0.19	3.49	1.62	7.36	11.83	-	-	1.77	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	1.76	-	-	-	-	-	-	-	-	51.68
H1804_175_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		216.75	6.63	1206.18	2243.19	6.59	0.51	0.04	13.23	38.1	41.55	56.71	1.89	3.49	16.05	7285.12	5855.75			1.64		6.61											0.35	10.77	26.44								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								429.11	429.11	27.04	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.7	23.41			0.16		0.16											429.11	0.16	0.14								7.75	0.24	2.72	-	1.03	0.08	0.01	2.06	5.94	6.48	-	0.29	0.54	2.5	7.1	11.42	-	-	0.26	-	1.03	-	-	-	-	-	-	-	-	-	-	0.01	1.68	3.83	-	-	-	-	-	-	-	54.99	0	19.7	7.75	0.24	2.72	-	1.03	0.08	0.01	2.06	5.94	6.48	-	0.29	0.54	2.5	7.1	11.42	-	-	0.26	-	1.03	-	-	-	-	-	-	-	-	-	-	0.01	1.68	3.83	-	-	-	-	-	-	-	54.99	5000																																																																																			-		0	7.75	0.24	2.72	-	1.03	0.08	0.01	2.06	5.94	6.48	-	0.29	0.54	2.5	7.1	11.42	-	-	0.26	-	1.03	-	-	-	-	-	-	-	-	-	-	0.01	1.68	3.83	-	-	-	-	-	-	-	54.99
H1804_176_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1084.84	41.42	1218.24	2265.6	126.46	0.52	0.04	245.42	466.27	1260.08	801.87	57.28	1047.56	486.85	7357.92	5914.27			265.55		6.74											2.18	10.99	1.93								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.8	97.8	27.69	0	79.88	0.16	0.16	36.74	65.18	30.86	45.65	39.94	39.94	39.94	11.98	23.96			79.88		0.16											97.8	0.16	0								8.84	0.34	2.81	-	0.84	0.08	0.01	0.75	2.53	3.24	3.05	0.19	3.49	1.62	7.35	11.81	-	-	1.77	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	1.76	-	-	-	-	-	-	-	-	51.57	0	12.99	8.84	0.34	2.81	-	0.84	0.08	0.01	0.75	2.53	3.24	3.05	0.19	3.49	1.62	7.35	11.81	-	-	1.77	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	1.76	-	-	-	-	-	-	-	-	51.57	5000																																																																																			-		0	8.84	0.34	2.81	-	0.84	0.08	0.01	0.75	2.53	3.24	3.05	0.19	3.49	1.62	7.35	11.81	-	-	1.77	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	1.76	-	-	-	-	-	-	-	-	51.57
H1804_177_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		230.2	7.04	1281.06	2382.44	7.44	0.57	0.04	14.93	43	46.89	60.23	2.13	3.94	18.12	7737.37	6219.27			1.85		7.46											0.37	12.16	29.84								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								418.77	418.77	26.39	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.42	22.84			0.15		0.15											418.77	0.15	0.14								8.03	0.25	2.82	-	1.13	0.09	0.01	2.27	6.55	7.14	-	0.32	0.6	2.76	7.36	11.84	-	-	0.28	-	1.14	-	-	-	-	-	-	-	-	-	-	0.01	1.85	4.22	-	-	-	-	-	-	-	58.67	0	23.54	8.03	0.25	2.82	-	1.13	0.09	0.01	2.27	6.55	7.14	-	0.32	0.6	2.76	7.36	11.84	-	-	0.28	-	1.14	-	-	-	-	-	-	-	-	-	-	0.01	1.85	4.22	-	-	-	-	-	-	-	58.67	5000																																																																																			-		0	8.03	0.25	2.82	-	1.13	0.09	0.01	2.27	6.55	7.14	-	0.32	0.6	2.76	7.36	11.84	-	-	0.28	-	1.14	-	-	-	-	-	-	-	-	-	-	0.01	1.85	4.22	-	-	-	-	-	-	-	58.67
H1804_178_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1152.15	44	1293.83	2406.18	134.3	0.58	0.04	260.65	495.2	1338.26	851.62	60.83	1112.56	517.06	7814.48	6281.25			282.03		7.61											2.32	12.4	2.17								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.13	96.13	27.22	0	78.52	0.16	0.16	36.12	64.07	30.34	44.87	39.26	39.26	39.26	11.78	23.56			78.52		0.16											96.13	0.16	0								9.23	0.35	2.93	-	0.88	0.09	0.01	0.78	2.64	3.38	3.18	0.2	3.64	1.69	7.67	12.33	-	-	1.85	-	1.19	-	-	-	-	-	-	-	-	-	-	0.02	1.95	-	-	-	-	-	-	-	-	54.03	0	14.78	9.23	0.35	2.93	-	0.88	0.09	0.01	0.78	2.64	3.38	3.18	0.2	3.64	1.69	7.67	12.33	-	-	1.85	-	1.19	-	-	-	-	-	-	-	-	-	-	0.02	1.95	-	-	-	-	-	-	-	-	54.03	5000																																																																																			-		0	9.23	0.35	2.93	-	0.88	0.09	0.01	0.78	2.64	3.38	3.18	0.2	3.64	1.69	7.67	12.33	-	-	1.85	-	1.19	-	-	-	-	-	-	-	-	-	-	0.02	1.95	-	-	-	-	-	-	-	-	54.03
H1804_179_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		230.2	7.04	1281.05	2382.42	7.44	0.57	0.04	14.93	43	46.89	60.23	2.13	3.94	18.12	7737.29	6219.21			1.85		7.46											0.37	12.16	29.84								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								418.77	418.77	26.39	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.42	22.84			0.15		0.15											418.77	0.15	0.14								8.03	0.25	2.82	-	1.13	0.09	0.01	2.27	6.55	7.14	-	0.32	0.6	2.76	7.36	11.84	-	-	0.28	-	1.14	-	-	-	-	-	-	-	-	-	-	0.01	1.85	4.22	-	-	-	-	-	-	-	58.67	0	23.54	8.03	0.25	2.82	-	1.13	0.09	0.01	2.27	6.55	7.14	-	0.32	0.6	2.76	7.36	11.84	-	-	0.28	-	1.14	-	-	-	-	-	-	-	-	-	-	0.01	1.85	4.22	-	-	-	-	-	-	-	58.67	5000																																																																																			-		0	8.03	0.25	2.82	-	1.13	0.09	0.01	2.27	6.55	7.14	-	0.32	0.6	2.76	7.36	11.84	-	-	0.28	-	1.14	-	-	-	-	-	-	-	-	-	-	0.01	1.85	4.22	-	-	-	-	-	-	-	58.67
H1804_180_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		217.13	5.86	854.18	2111.5	10.72	0.46	0.03	14.53	34.51	35.8	25.8	1.63	2.79	13.83	11144.14	8750.26			2.31		5.7											0.31	11.93	22.78								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								414.95	414.95	26.15	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.32	22.63			0.15		0.15											414.95	0.15	1681.36								7.51	0.2	1.86	-	1.62	0.07	0.01	2.19	5.21	5.4	-	0.25	0.42	2.09	10.51	16.5	-	-	0.35	-	0.86	-	-	-	-	-	-	-	-	-	-	0.01	1.8	3.19	-	-	-	-	-	-	-	60.05	0	23.67	7.51	0.2	1.86	-	1.62	0.07	0.01	2.19	5.21	5.4	-	0.25	0.42	2.09	10.51	16.5	-	-	0.35	-	0.86	-	-	-	-	-	-	-	-	-	-	0.01	1.8	3.19	-	-	-	-	-	-	-	60.05	5000																																																																																			-		0	7.51	0.2	1.86	-	1.62	0.07	0.01	2.19	5.21	5.4	-	0.25	0.42	2.09	10.51	16.5	-	-	0.35	-	0.86	-	-	-	-	-	-	-	-	-	-	0.01	1.8	3.19	-	-	-	-	-	-	-	60.05
H1804_181_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1169.1	38.54	862.68	2132.52	197.85	0.47	0.04	234.21	364.63	573.25	364.8	26.06	804.59	221.48	11255.09	8837.37			402.01		5.81											2.03	12.17	1.66								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.33	95.33	26.99	0	77.86	0.16	0.16	35.81	63.53	30.08	44.49	38.93	38.93	38.93	11.68	23.36			77.86		0.16											95.33	0.16	0								9.29	0.31	1.94	-	1.28	0.07	0.01	0.7	1.93	1.44	1.35	0.08	2.61	0.72	10.95	17.2	-	-	2.61	-	0.9	-	-	-	-	-	-	-	-	-	-	0.02	1.9	-	-	-	-	-	-	-	-	55.31	0	15.73	9.29	0.31	1.94	-	1.28	0.07	0.01	0.7	1.93	1.44	1.35	0.08	2.61	0.72	10.95	17.2	-	-	2.61	-	0.9	-	-	-	-	-	-	-	-	-	-	0.02	1.9	-	-	-	-	-	-	-	-	55.31	5000																																																																																			-		0	9.29	0.31	1.94	-	1.28	0.07	0.01	0.7	1.93	1.44	1.35	0.08	2.61	0.72	10.95	17.2	-	-	2.61	-	0.9	-	-	-	-	-	-	-	-	-	-	0.02	1.9	-	-	-	-	-	-	-	-	55.31
H1804_184_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1115.11	86.54	910.12	2324.97	141.9	0.59	0.04	253.44	375.46	907.98	577.81	41.27	1085.03	350.81	10610.42	6902.65			350.4		6.31											4.55	13.75	1.8								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.04	96.04	27.19	0	78.44	0.16	0.16	36.08	64.01	30.31	44.82	39.22	39.22	39.22	11.77	23.53			78.44		0.16											96.04	0.16	0								8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.55	1.15	10.4	13.54	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.16	-	-	-	-	-	-	-	-	54.17	0	14.89	8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.55	1.15	10.4	13.54	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.16	-	-	-	-	-	-	-	-	54.17	5000																																																																																			-		0	8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.55	1.15	10.4	13.54	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.16	-	-	-	-	-	-	-	-	54.17
H1804_185_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1203.37	93.39	982.16	2509.01	153.13	0.69	0.05	273.5	405.18	979.85	623.54	44.54	1170.92	378.58	11450.3	7449.04			378.14		7.35											4.92	16.01	2.1								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.97	93.97	26.61	0	76.75	0.15	0.15	35.31	62.63	29.65	43.86	38.38	38.38	38.38	11.51	23.03			76.75		0.15											93.97	0.15	0								9.42	0.73	2.18	-	0.98	0.11	0.01	0.8	2.11	2.42	2.28	0.14	3.74	1.21	10.99	14.29	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.46	-	-	-	-	-	-	-	-	57.47	0	17.41	9.42	0.73	2.18	-	0.98	0.11	0.01	0.8	2.11	2.42	2.28	0.14	3.74	1.21	10.99	14.29	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.46	-	-	-	-	-	-	-	-	57.47	5000																																																																																			-		0	9.42	0.73	2.18	-	0.98	0.11	0.01	0.8	2.11	2.42	2.28	0.14	3.74	1.21	10.99	14.29	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.46	-	-	-	-	-	-	-	-	57.47
H1804_186_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1205.59	93.57	983.97	2513.64	153.41	0.69	0.05	274	405.93	981.66	624.69	44.62	1173.08	379.28	11471.42	7462.77			378.84		7.38											4.92	16.08	2.11								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.92	93.92	26.59	0	76.71	0.15	0.15	35.29	62.6	29.64	43.83	38.36	38.36	38.36	11.51	23.01			76.71		0.15											93.92	0.15	0								9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.42	2.28	0.14	3.75	1.21	11	14.31	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.47	-	-	-	-	-	-	-	-	57.55	0	17.47	9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.42	2.28	0.14	3.75	1.21	11	14.31	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.47	-	-	-	-	-	-	-	-	57.55	5000																																																																																			-		0	9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.42	2.28	0.14	3.75	1.21	11	14.31	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.47	-	-	-	-	-	-	-	-	57.55
H1804_187_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1081.55	83.94	882.73	2255.01	137.63	0.56	0.04	245.81	364.16	880.66	560.42	40.03	1052.38	340.25	10291.13	6694.93			339.86		5.94											4.42	12.93	1.7								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.88	96.88	27.43	0	79.13	0.16	0.16	36.4	64.57	30.57	45.22	39.56	39.56	39.56	11.87	23.74			79.13		0.16											96.88	0.16	0								8.73	0.68	2.02	-	0.91	0.09	0.01	0.75	1.96	2.24	2.11	0.13	3.47	1.12	10.18	13.24	-	-	2.24	-	0.94	-	-	-	-	-	-	-	-	-	-	0.04	2.05	-	-	-	-	-	-	-	-	52.9	0	13.95	8.73	0.68	2.02	-	0.91	0.09	0.01	0.75	1.96	2.24	2.11	0.13	3.47	1.12	10.18	13.24	-	-	2.24	-	0.94	-	-	-	-	-	-	-	-	-	-	0.04	2.05	-	-	-	-	-	-	-	-	52.9	5000																																																																																			-		0	8.73	0.68	2.02	-	0.91	0.09	0.01	0.75	1.96	2.24	2.11	0.13	3.47	1.12	10.18	13.24	-	-	2.24	-	0.94	-	-	-	-	-	-	-	-	-	-	0.04	2.05	-	-	-	-	-	-	-	-	52.9
H1804_188_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1151.95	89.4	940.18	2401.78	146.59	0.63	0.05	261.81	387.86	937.98	596.89	42.64	1120.88	362.4	10960.95	7130.69			361.98		6.74											4.71	14.69	1.93								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.17	95.17	26.94	0	77.73	0.16	0.16	35.76	63.43	30.03	44.42	38.86	38.86	38.86	11.66	23.32			77.73		0.16											95.17	0.16	0								9.14	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.65	13.86	-	-	2.34	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.56	0	15.92	9.14	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.65	13.86	-	-	2.34	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.56	5000																																																																																			-		0	9.14	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.65	13.86	-	-	2.34	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.56
H1804_189_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1173.34	91.06	957.65	2446.4	149.31	0.66	0.05	266.67	395.07	955.4	607.98	43.43	1141.7	369.13	11164.55	7263.14			368.7		6.98											4.79	15.22	2								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.67	94.67	26.8	0	77.32	0.15	0.15	35.57	63.09	29.87	44.18	38.66	38.66	38.66	11.6	23.2			77.32		0.15											94.67	0.15	0								9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.79	14.04	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.35	0	16.53	9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.79	14.04	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.35	5000																																																																																			-		0	9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.79	14.04	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.35	-	-	-	-	-	-	-	-	56.35
H1804_190_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		189.54	9.49	897.93	2293.84	7.55	0.58	0.04	15.14	36.19	38.62	40.72	1.76	5.03	14.92	10468.36	6810.23			2.24		6.14											0.5	13.38	24.57								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								422.36	422.36	26.62	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.52	23.04			0.15		0.15											422.36	0.15	0.14								6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.07	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.5	-	-	-	-	-	-	-	57.39	0	21.51	6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.07	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.5	-	-	-	-	-	-	-	57.39	5000																																																																																			-		0	6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.07	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.5	-	-	-	-	-	-	-	57.39
H1804_191_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		206.89	10.36	980.11	2503.77	8.99	0.69	0.05	18.03	43.11	46	44.45	2.09	5.99	17.77	11426.41	7433.49			2.67		7.32											0.55	15.94	29.27								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								407.24	407.24	25.67	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.11	22.21			0.15		0.15											407.24	0.15	0.14								7.02	0.35	2.1	-	1.33	0.1	0.01	2.67	6.38	6.81	-	0.31	0.89	2.63	10.58	13.76	-	-	0.39	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	2.36	4.03	-	-	-	-	-	-	-	62.82	0	27.57	7.02	0.35	2.1	-	1.33	0.1	0.01	2.67	6.38	6.81	-	0.31	0.89	2.63	10.58	13.76	-	-	0.39	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	2.36	4.03	-	-	-	-	-	-	-	62.82	5000																																																																																			-		0	7.02	0.35	2.1	-	1.33	0.1	0.01	2.67	6.38	6.81	-	0.31	0.89	2.63	10.58	13.76	-	-	0.39	-	1.08	-	-	-	-	-	-	-	-	-	-	0.02	2.36	4.03	-	-	-	-	-	-	-	62.82
H1804_192_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		205.35	10.28	972.82	2485.14	8.86	0.68	0.05	17.77	42.48	45.33	44.12	2.06	5.91	17.52	11341.38	7378.18			2.63		7.21											0.54	15.71	28.85								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								408.55	408.55	25.75	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.14	22.28			0.15		0.15											408.55	0.15	0.14								6.99	0.35	2.09	-	1.32	0.1	0.01	2.64	6.31	6.74	-	0.31	0.88	2.6	10.53	13.7	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.33	3.98	-	-	-	-	-	-	-	62.35	0	27.01	6.99	0.35	2.09	-	1.32	0.1	0.01	2.64	6.31	6.74	-	0.31	0.88	2.6	10.53	13.7	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.33	3.98	-	-	-	-	-	-	-	62.35	5000																																																																																			-		0	6.99	0.35	2.09	-	1.32	0.1	0.01	2.64	6.31	6.74	-	0.31	0.88	2.6	10.53	13.7	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.33	3.98	-	-	-	-	-	-	-	62.35
H1804_193_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1111.13	86.23	906.87	2316.68	141.39	0.59	0.04	252.53	374.12	904.74	575.74	41.12	1081.16	349.56	10572.56	6878.02			349.15		6.27											4.54	13.65	1.79								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.14	96.14	27.22	0	78.52	0.16	0.16	36.12	64.07	30.34	44.87	39.26	39.26	39.26	11.78	23.56			78.52		0.16											96.14	0.16	0								8.9	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.15	0.13	3.54	1.14	10.38	13.5	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	54.02	0	14.77	8.9	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.15	0.13	3.54	1.14	10.38	13.5	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	54.02	5000																																																																																			-		0	8.9	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.15	0.13	3.54	1.14	10.38	13.5	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	54.02
H1804_194_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1212.81	94.13	989.86	2528.69	154.33	0.7	0.05	275.64	408.36	987.54	628.43	44.89	1180.1	381.55	11540.12	7507.47			381.1		7.46											4.95	16.26	2.13								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.76	93.76	26.54	0	76.58	0.15	0.15	35.23	62.49	29.59	43.76	38.29	38.29	38.29	11.49	22.97			76.58		0.15											93.76	0.15	0								9.48	0.74	2.19	-	0.98	0.11	0.01	0.81	2.13	2.43	2.29	0.14	3.77	1.22	11.05	14.37	-	-	2.43	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.49	-	-	-	-	-	-	-	-	57.81	0	17.68	9.48	0.74	2.19	-	0.98	0.11	0.01	0.81	2.13	2.43	2.29	0.14	3.77	1.22	11.05	14.37	-	-	2.43	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.49	-	-	-	-	-	-	-	-	57.81	5000																																																																																			-		0	9.48	0.74	2.19	-	0.98	0.11	0.01	0.81	2.13	2.43	2.29	0.14	3.77	1.22	11.05	14.37	-	-	2.43	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.49	-	-	-	-	-	-	-	-	57.81
H1804_195_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1203.79	93.43	982.5	2509.87	153.18	0.69	0.05	273.59	405.32	980.19	623.76	44.55	1171.32	378.71	11454.23	7451.59			378.27		7.36											4.92	16.03	2.1								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.96	93.96	26.6	0	76.75	0.15	0.15	35.3	62.62	29.65	43.85	38.37	38.37	38.37	11.51	23.02			76.75		0.15											93.96	0.15	0								9.43	0.73	2.18	-	0.98	0.11	0.01	0.8	2.12	2.42	2.28	0.14	3.75	1.21	10.99	14.3	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.46	-	-	-	-	-	-	-	-	57.48	0	17.42	9.43	0.73	2.18	-	0.98	0.11	0.01	0.8	2.12	2.42	2.28	0.14	3.75	1.21	10.99	14.3	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.46	-	-	-	-	-	-	-	-	57.48	5000																																																																																			-		0	9.43	0.73	2.18	-	0.98	0.11	0.01	0.8	2.12	2.42	2.28	0.14	3.75	1.21	10.99	14.3	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.46	-	-	-	-	-	-	-	-	57.48
H1804_196_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1072.44	83.23	875.29	2236.01	136.47	0.55	0.04	243.74	361.09	873.24	555.7	39.69	1043.52	337.39	10204.43	6638.53			336.99		5.84											4.38	12.71	1.67								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.12	97.12	27.5	0	79.32	0.16	0.16	36.49	64.73	30.65	45.33	39.66	39.66	39.66	11.9	23.8			79.32		0.16											97.12	0.16	0								8.68	0.67	2.01	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.12	10.12	13.16	-	-	2.23	-	0.93	-	-	-	-	-	-	-	-	-	-	0.04	2.02	-	-	-	-	-	-	-	-	52.55	0	13.7	8.68	0.67	2.01	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.12	10.12	13.16	-	-	2.23	-	0.93	-	-	-	-	-	-	-	-	-	-	0.04	2.02	-	-	-	-	-	-	-	-	52.55	5000																																																																																			-		0	8.68	0.67	2.01	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.12	10.12	13.16	-	-	2.23	-	0.93	-	-	-	-	-	-	-	-	-	-	0.04	2.02	-	-	-	-	-	-	-	-	52.55
H1804_197_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1128.33	87.57	920.91	2352.54	143.58	0.61	0.05	256.44	379.91	918.74	584.66	41.76	1097.9	354.97	10736.23	6984.49			354.56		6.46											4.61	14.08	1.85								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.73	95.73	27.1	0	78.19	0.16	0.16	35.97	63.8	30.21	44.68	39.09	39.09	39.09	11.73	23.46			78.19		0.16											95.73	0.16	0								9	0.7	2.08	-	0.94	0.09	0.01	0.77	2.02	2.31	2.18	0.14	3.58	1.16	10.49	13.65	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.67	0	15.25	9	0.7	2.08	-	0.94	0.09	0.01	0.77	2.02	2.31	2.18	0.14	3.58	1.16	10.49	13.65	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.67	5000																																																																																			-		0	9	0.7	2.08	-	0.94	0.09	0.01	0.77	2.02	2.31	2.18	0.14	3.58	1.16	10.49	13.65	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.67
H1804_198_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1209.84	93.89	987.44	2522.49	153.95	0.7	0.05	274.97	407.36	985.12	626.89	44.78	1177.21	380.61	11511.83	7489.06			380.17		7.43											4.94	16.19	2.12								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.83	93.83	26.56	0	76.63	0.15	0.15	35.25	62.53	29.61	43.79	38.32	38.32	38.32	11.49	22.99			76.63		0.15											93.83	0.15	0								9.46	0.73	2.19	-	0.98	0.11	0.01	0.81	2.12	2.43	2.29	0.14	3.76	1.22	11.03	14.35	-	-	2.43	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.48	-	-	-	-	-	-	-	-	57.7	0	17.6	9.46	0.73	2.19	-	0.98	0.11	0.01	0.81	2.12	2.43	2.29	0.14	3.76	1.22	11.03	14.35	-	-	2.43	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.48	-	-	-	-	-	-	-	-	57.7	5000																																																																																			-		0	9.46	0.73	2.19	-	0.98	0.11	0.01	0.81	2.12	2.43	2.29	0.14	3.76	1.22	11.03	14.35	-	-	2.43	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.48	-	-	-	-	-	-	-	-	57.7
H1804_199_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1122.68	87.13	916.3	2340.77	142.86	0.6	0.05	255.16	378.01	914.15	581.73	41.55	1092.41	353.19	10682.52	6949.55			352.78		6.4											4.59	13.93	1.83								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.86	95.86	27.14	0	78.3	0.16	0.16	36.02	63.89	30.25	44.74	39.15	39.15	39.15	11.74	23.49			78.3		0.16											95.86	0.16	0								8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.45	0	15.1	8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.45	5000																																																																																			-		0	8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.45
H1804_200_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1174.32	91.14	958.45	2448.44	149.43	0.66	0.05	266.89	395.4	956.2	608.49	43.46	1142.65	369.44	11173.86	7269.2			369.01		7											4.8	15.24	2								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.65	94.65	26.8	0	77.3	0.15	0.15	35.56	63.08	29.87	44.17	38.65	38.65	38.65	11.6	23.19			77.3		0.15											94.65	0.15	0								9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.8	14.05	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.39	0	16.56	9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.8	14.05	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.39	5000																																																																																			-		0	9.26	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.8	14.05	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.39
H1804_201_0	2007	6	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1107.75	42.3	1243.97	2313.45	129.13	0.54	0.04	250.6	476.11	1286.69	818.8	58.49	1069.68	497.13	7513.31	6039.17			271.16		7.03											2.23	11.46	2.01								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.22	97.22	27.52	0	79.4	0.16	0.16	36.53	64.79	30.68	45.37	39.7	39.7	39.7	11.91	23.82			79.4		0.16											97.22	0.16	0								8.97	0.34	2.85	-	0.85	0.09	0.01	0.76	2.57	3.29	3.1	0.19	3.54	1.64	7.46	11.99	-	-	1.79	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	1.82	-	-	-	-	-	-	-	-	52.41	0	13.59	8.97	0.34	2.85	-	0.85	0.09	0.01	0.76	2.57	3.29	3.1	0.19	3.54	1.64	7.46	11.99	-	-	1.79	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	1.82	-	-	-	-	-	-	-	-	52.41	5000																																																																																			-		0	8.97	0.34	2.85	-	0.85	0.09	0.01	0.76	2.57	3.29	3.1	0.19	3.54	1.64	7.46	11.99	-	-	1.79	-	1.12	-	-	-	-	-	-	-	-	-	-	0.02	1.82	-	-	-	-	-	-	-	-	52.41
H1804_202_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1140.53	88.52	930.87	2377.98	145.13	0.62	0.05	259.21	384.02	928.68	590.98	42.21	1109.77	358.81	10852.35	7060.03			358.39		6.61											4.66	14.39	1.89								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.44	95.44	27.02	0	77.95	0.16	0.16	35.86	63.61	30.12	44.54	38.97	38.97	38.97	11.69	23.38			77.95		0.16											95.44	0.16	0								9.07	0.7	2.1	-	0.94	0.1	0.01	0.77	2.04	2.33	2.19	0.14	3.6	1.17	10.57	13.76	-	-	2.33	-	1.03	-	-	-	-	-	-	-	-	-	-	0.04	2.24	-	-	-	-	-	-	-	-	55.13	0	15.6	9.07	0.7	2.1	-	0.94	0.1	0.01	0.77	2.04	2.33	2.19	0.14	3.6	1.17	10.57	13.76	-	-	2.33	-	1.03	-	-	-	-	-	-	-	-	-	-	0.04	2.24	-	-	-	-	-	-	-	-	55.13	5000																																																																																			-		0	9.07	0.7	2.1	-	0.94	0.1	0.01	0.77	2.04	2.33	2.19	0.14	3.6	1.17	10.57	13.76	-	-	2.33	-	1.03	-	-	-	-	-	-	-	-	-	-	0.04	2.24	-	-	-	-	-	-	-	-	55.13
H1804_203_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1241.25	96.33	1013.07	2587.97	157.95	0.73	0.06	282.1	417.93	1010.69	643.17	45.94	1207.77	390.49	11810.67	7683.47			390.04		7.83											5.07	17.05	2.24								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.11	93.11	26.36	0	76.05	0.15	0.15	34.98	62.06	29.38	43.46	38.02	38.02	38.02	11.41	22.81			76.05		0.15											93.11	0.15	0								9.63	0.75	2.23	-	1	0.11	0.01	0.82	2.16	2.47	2.33	0.15	3.83	1.24	11.23	14.61	-	-	2.47	-	1.19	-	-	-	-	-	-	-	-	-	-	0.04	2.59	-	-	-	-	-	-	-	-	58.85	0	18.54	9.63	0.75	2.23	-	1	0.11	0.01	0.82	2.16	2.47	2.33	0.15	3.83	1.24	11.23	14.61	-	-	2.47	-	1.19	-	-	-	-	-	-	-	-	-	-	0.04	2.59	-	-	-	-	-	-	-	-	58.85	5000																																																																																			-		0	9.63	0.75	2.23	-	1	0.11	0.01	0.82	2.16	2.47	2.33	0.15	3.83	1.24	11.23	14.61	-	-	2.47	-	1.19	-	-	-	-	-	-	-	-	-	-	0.04	2.59	-	-	-	-	-	-	-	-	58.85
H1804_204_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1071.59	83.17	874.6	2234.23	136.36	0.55	0.04	243.54	360.81	872.54	555.25	39.66	1042.69	337.12	10196.32	6633.25			336.73		5.83											4.38	12.7	1.67								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.14	97.14	27.5	0	79.34	0.16	0.16	36.5	64.74	30.65	45.34	39.67	39.67	39.67	11.9	23.8			79.34		0.16											97.14	0.16	0								8.67	0.67	2	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.11	10.11	13.16	-	-	2.23	-	0.92	-	-	-	-	-	-	-	-	-	-	0.04	2.01	-	-	-	-	-	-	-	-	52.52	0	13.68	8.67	0.67	2	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.11	10.11	13.16	-	-	2.23	-	0.92	-	-	-	-	-	-	-	-	-	-	0.04	2.01	-	-	-	-	-	-	-	-	52.52	5000																																																																																			-		0	8.67	0.67	2	-	0.9	0.09	0.01	0.74	1.95	2.23	2.1	0.13	3.45	1.11	10.11	13.16	-	-	2.23	-	0.92	-	-	-	-	-	-	-	-	-	-	0.04	2.01	-	-	-	-	-	-	-	-	52.52
H1804_205_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1149.52	89.21	938.2	2396.72	146.28	0.63	0.05	261.26	387.05	936	595.64	42.55	1118.52	361.64	10937.87	7115.67			361.22		6.71											4.7	14.62	1.92								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.23	95.23	26.96	0	77.78	0.16	0.16	35.78	63.47	30.05	44.44	38.89	38.89	38.89	11.67	23.33			77.78		0.16											95.23	0.16	0								9.12	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.34	2.21	0.14	3.62	1.17	10.63	13.84	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.27	-	-	-	-	-	-	-	-	55.47	0	15.85	9.12	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.34	2.21	0.14	3.62	1.17	10.63	13.84	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.27	-	-	-	-	-	-	-	-	55.47	5000																																																																																			-		0	9.12	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.34	2.21	0.14	3.62	1.17	10.63	13.84	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.27	-	-	-	-	-	-	-	-	55.47
H1804_206_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1167.68	90.62	953.02	2434.58	148.59	0.65	0.05	265.38	393.16	950.78	605.04	43.22	1136.18	367.35	11110.63	7228.06			366.92		6.92											4.77	15.07	1.98								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.8	94.8	26.84	0	77.43	0.15	0.15	35.62	63.18	29.92	44.25	38.71	38.71	38.71	11.61	23.23			77.43		0.15											94.8	0.15	0								9.22	0.72	2.13	-	0.96	0.1	0.01	0.79	2.07	2.37	2.23	0.14	3.67	1.19	10.75	13.99	-	-	2.37	-	1.07	-	-	-	-	-	-	-	-	-	-	0.04	2.33	-	-	-	-	-	-	-	-	56.14	0	16.37	9.22	0.72	2.13	-	0.96	0.1	0.01	0.79	2.07	2.37	2.23	0.14	3.67	1.19	10.75	13.99	-	-	2.37	-	1.07	-	-	-	-	-	-	-	-	-	-	0.04	2.33	-	-	-	-	-	-	-	-	56.14	5000																																																																																			-		0	9.22	0.72	2.13	-	0.96	0.1	0.01	0.79	2.07	2.37	2.23	0.14	3.67	1.19	10.75	13.99	-	-	2.37	-	1.07	-	-	-	-	-	-	-	-	-	-	0.04	2.33	-	-	-	-	-	-	-	-	56.14
H1804_207_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1118.85	86.83	913.17	2332.78	142.37	0.6	0.04	254.29	376.72	911.03	579.75	41.41	1088.68	351.99	10646.05	6925.83			351.58		6.35											4.57	13.84	1.82								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.95	95.95	27.17	0	78.37	0.16	0.16	36.05	63.95	30.28	44.78	39.19	39.19	39.19	11.76	23.51			78.37		0.16											95.95	0.16	0								8.95	0.69	2.07	-	0.93	0.09	0.01	0.76	2.01	2.3	2.16	0.14	3.55	1.15	10.43	13.57	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.17	-	-	-	-	-	-	-	-	54.31	0	14.99	8.95	0.69	2.07	-	0.93	0.09	0.01	0.76	2.01	2.3	2.16	0.14	3.55	1.15	10.43	13.57	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.17	-	-	-	-	-	-	-	-	54.31	5000																																																																																			-		0	8.95	0.69	2.07	-	0.93	0.09	0.01	0.76	2.01	2.3	2.16	0.14	3.55	1.15	10.43	13.57	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.17	-	-	-	-	-	-	-	-	54.31
H1804_208_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1157.32	89.82	944.57	2412.98	147.27	0.64	0.05	263.03	389.67	942.35	599.68	42.83	1126.1	364.09	11012.05	7163.93			363.66		6.79											4.73	14.8	1.94								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.04	95.04	26.91	0	77.63	0.16	0.16	35.71	63.34	29.99	44.36	38.81	38.81	38.81	11.64	23.29			77.63		0.16											95.04	0.16	0								9.17	0.71	2.12	-	0.95	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.64	1.18	10.69	13.9	-	-	2.35	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.3	-	-	-	-	-	-	-	-	55.76	0	16.07	9.17	0.71	2.12	-	0.95	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.64	1.18	10.69	13.9	-	-	2.35	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.3	-	-	-	-	-	-	-	-	55.76	5000																																																																																			-		0	9.17	0.71	2.12	-	0.95	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.64	1.18	10.69	13.9	-	-	2.35	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.3	-	-	-	-	-	-	-	-	55.76
H1804_209_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1222.67	94.89	997.9	2549.23	155.59	0.71	0.05	277.88	411.68	995.56	633.54	45.25	1189.69	384.65	11633.87	7568.46			384.2		7.59											4.99	16.53	2.17								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.53	93.53	26.48	0	76.39	0.15	0.15	35.14	62.34	29.52	43.65	38.2	38.2	38.2	11.46	22.92			76.39		0.15											93.53	0.15	0								9.53	0.74	2.2	-	0.99	0.11	0.01	0.81	2.14	2.45	2.3	0.14	3.79	1.22	11.11	14.45	-	-	2.45	-	1.16	-	-	-	-	-	-	-	-	-	-	0.04	2.53	-	-	-	-	-	-	-	-	58.17	0	17.98	9.53	0.74	2.2	-	0.99	0.11	0.01	0.81	2.14	2.45	2.3	0.14	3.79	1.22	11.11	14.45	-	-	2.45	-	1.16	-	-	-	-	-	-	-	-	-	-	0.04	2.53	-	-	-	-	-	-	-	-	58.17	5000																																																																																			-		0	9.53	0.74	2.2	-	0.99	0.11	0.01	0.81	2.14	2.45	2.3	0.14	3.79	1.22	11.11	14.45	-	-	2.45	-	1.16	-	-	-	-	-	-	-	-	-	-	0.04	2.53	-	-	-	-	-	-	-	-	58.17
H1804_210_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1185.27	45.26	1331.02	2475.34	138.16	0.62	0.05	268.14	509.43	1376.73	876.1	62.58	1144.53	531.92	8039.07	6461.78			290.13		8.05											2.38	13.12	2.3								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.37	95.37	27	0	77.9	0.16	0.16	35.83	63.56	30.1	44.51	38.95	38.95	38.95	11.68	23.37			77.9		0.16											95.37	0.16	0								9.42	0.36	2.99	-	0.9	0.1	0.01	0.8	2.7	3.45	3.25	0.2	3.71	1.73	7.83	12.58	-	-	1.88	-	1.25	-	-	-	-	-	-	-	-	-	-	0.02	2.04	-	-	-	-	-	-	-	-	55.23	0	15.67	9.42	0.36	2.99	-	0.9	0.1	0.01	0.8	2.7	3.45	3.25	0.2	3.71	1.73	7.83	12.58	-	-	1.88	-	1.25	-	-	-	-	-	-	-	-	-	-	0.02	2.04	-	-	-	-	-	-	-	-	55.23	5000																																																																																			-		0	9.42	0.36	2.99	-	0.9	0.1	0.01	0.8	2.7	3.45	3.25	0.2	3.71	1.73	7.83	12.58	-	-	1.88	-	1.25	-	-	-	-	-	-	-	-	-	-	0.02	2.04	-	-	-	-	-	-	-	-	55.23
H1804_211_0	2007	5	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		186.37	9.33	882.91	2255.47	7.3	0.56	0.04	14.63	34.98	37.32	40.04	1.7	4.86	14.42	10293.22	6696.29			2.16		5.94											0.49	12.94	23.75								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								425.19	425.19	26.8	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.6	23.19			0.15		0.15											425.19	0.15	0.14								6.6	0.33	1.97	-	1.13	0.09	0.01	2.26	5.41	5.77	-	0.26	0.75	2.23	9.95	12.94	-	-	0.33	-	0.92	-	-	-	-	-	-	-	-	-	-	0.02	2	3.41	-	-	-	-	-	-	-	56.38	0	20.49	6.6	0.33	1.97	-	1.13	0.09	0.01	2.26	5.41	5.77	-	0.26	0.75	2.23	9.95	12.94	-	-	0.33	-	0.92	-	-	-	-	-	-	-	-	-	-	0.02	2	3.41	-	-	-	-	-	-	-	56.38	5000																																																																																			-		0	6.6	0.33	1.97	-	1.13	0.09	0.01	2.26	5.41	5.77	-	0.26	0.75	2.23	9.95	12.94	-	-	0.33	-	0.92	-	-	-	-	-	-	-	-	-	-	0.02	2	3.41	-	-	-	-	-	-	-	56.38
H1804_212_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		189.56	9.49	898	2294.01	7.55	0.58	0.04	15.14	36.19	38.62	40.72	1.76	5.03	14.92	10469.11	6810.72			2.24		6.14											0.5	13.38	24.58								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								422.35	422.35	26.62	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.52	23.04			0.15		0.15											422.35	0.15	0.14								6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.08	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.51	-	-	-	-	-	-	-	57.39	0	21.51	6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.08	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.51	-	-	-	-	-	-	-	57.39	5000																																																																																			-		0	6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.08	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.51	-	-	-	-	-	-	-	57.39
H1804_213_0	2007	6	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1092.53	84.79	891.69	2277.9	139.03	0.57	0.04	248.3	367.86	889.6	566.11	40.44	1063.06	343.71	10395.6	6762.9			343.31		6.06											4.46	13.19	1.73								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.6	96.6	27.35	0	78.9	0.16	0.16	36.29	64.38	30.48	45.09	39.45	39.45	39.45	11.83	23.67			78.9		0.16											96.6	0.16	0								8.79	0.68	2.03	-	0.91	0.09	0.01	0.75	1.97	2.26	2.13	0.13	3.49	1.13	10.25	13.34	-	-	2.26	-	0.96	-	-	-	-	-	-	-	-	-	-	0.04	2.08	-	-	-	-	-	-	-	-	53.31	0	14.26	8.79	0.68	2.03	-	0.91	0.09	0.01	0.75	1.97	2.26	2.13	0.13	3.49	1.13	10.25	13.34	-	-	2.26	-	0.96	-	-	-	-	-	-	-	-	-	-	0.04	2.08	-	-	-	-	-	-	-	-	53.31	5000																																																																																			-		0	8.79	0.68	2.03	-	0.91	0.09	0.01	0.75	1.97	2.26	2.13	0.13	3.49	1.13	10.25	13.34	-	-	2.26	-	0.96	-	-	-	-	-	-	-	-	-	-	0.04	2.08	-	-	-	-	-	-	-	-	53.31
H1804_214_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1111.22	86.24	906.95	2316.87	141.4	0.59	0.04	252.55	374.15	904.82	575.79	41.13	1081.25	349.59	10573.46	6878.6			349.18		6.27											4.54	13.65	1.79								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.14	96.14	27.22	0	78.52	0.16	0.16	36.12	64.07	30.34	44.87	39.26	39.26	39.26	11.78	23.56			78.52		0.16											96.14	0.16	0								8.9	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.15	0.13	3.54	1.14	10.38	13.5	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	54.02	0	14.78	8.9	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.15	0.13	3.54	1.14	10.38	13.5	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	54.02	5000																																																																																			-		0	8.9	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.15	0.13	3.54	1.14	10.38	13.5	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	54.02
H1804_215_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		189.56	9.49	898	2294.03	7.55	0.58	0.04	15.14	36.19	38.62	40.72	1.76	5.03	14.92	10469.21	6810.78			2.24		6.14											0.5	13.39	24.58								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								422.35	422.35	26.62	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.52	23.04			0.15		0.15											422.35	0.15	0.14								6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.08	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.51	-	-	-	-	-	-	-	57.39	0	21.51	6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.08	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.51	-	-	-	-	-	-	-	57.39	5000																																																																																			-		0	6.67	0.33	1.99	-	1.16	0.09	0.01	2.33	5.56	5.93	-	0.27	0.77	2.29	10.05	13.08	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.06	3.51	-	-	-	-	-	-	-	57.39
H1804_216_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1114.64	86.51	909.74	2324	141.84	0.59	0.04	253.33	375.3	907.6	577.56	41.25	1084.58	350.66	10605.97	6899.75			350.25		6.31											4.55	13.74	1.8								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.05	96.05	27.19	0	78.45	0.16	0.16	36.09	64.02	30.31	44.83	39.23	39.23	39.23	11.77	23.54			78.45		0.16											96.05	0.16	0								8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.55	1.15	10.4	13.53	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.16	-	-	-	-	-	-	-	-	54.15	0	14.87	8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.55	1.15	10.4	13.53	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.16	-	-	-	-	-	-	-	-	54.15	5000																																																																																			-		0	8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.55	1.15	10.4	13.53	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.16	-	-	-	-	-	-	-	-	54.15
H1804_217_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1135.94	88.16	927.12	2368.42	144.55	0.61	0.05	258.17	382.48	924.94	588.6	42.04	1105.31	357.37	10808.68	7031.63			356.95		6.55											4.64	14.27	1.87								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.55	95.55	27.05	0	78.04	0.16	0.16	35.9	63.68	30.15	44.59	39.02	39.02	39.02	11.71	23.41			78.04		0.16											95.55	0.16	0								9.04	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.19	0.14	3.59	1.16	10.54	13.72	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.23	-	-	-	-	-	-	-	-	54.96	0	15.47	9.04	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.19	0.14	3.59	1.16	10.54	13.72	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.23	-	-	-	-	-	-	-	-	54.96	5000																																																																																			-		0	9.04	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.19	0.14	3.59	1.16	10.54	13.72	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.23	-	-	-	-	-	-	-	-	54.96
H1804_218_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1124.1	87.24	917.46	2343.72	143.04	0.6	0.05	255.48	378.49	915.3	582.46	41.6	1093.78	353.64	10695.98	6958.31			353.23		6.41											4.59	13.97	1.83								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.83	95.83	27.13	0	78.27	0.16	0.16	36	63.87	30.24	44.72	39.13	39.13	39.13	11.74	23.48			78.27		0.16											95.83	0.16	0								8.98	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.31	2.17	0.14	3.57	1.15	10.46	13.62	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.19	-	-	-	-	-	-	-	-	54.51	0	15.13	8.98	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.31	2.17	0.14	3.57	1.15	10.46	13.62	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.19	-	-	-	-	-	-	-	-	54.51	5000																																																																																			-		0	8.98	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.31	2.17	0.14	3.57	1.15	10.46	13.62	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.19	-	-	-	-	-	-	-	-	54.51
H1804_219_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1199.03	93.06	978.61	2499.95	152.58	0.69	0.05	272.51	403.72	976.31	621.29	44.38	1166.69	377.21	11408.94	7422.12			376.77		7.3											4.9	15.9	2.09								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.07	94.07	26.63	0	76.83	0.15	0.15	35.34	62.7	29.69	43.91	38.42	38.42	38.42	11.53	23.05			76.83		0.15											94.07	0.15	0								9.4	0.73	2.17	-	0.98	0.11	0.01	0.8	2.11	2.42	2.27	0.14	3.74	1.21	10.96	14.26	-	-	2.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.04	2.44	-	-	-	-	-	-	-	-	57.31	0	17.28	9.4	0.73	2.17	-	0.98	0.11	0.01	0.8	2.11	2.42	2.27	0.14	3.74	1.21	10.96	14.26	-	-	2.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.04	2.44	-	-	-	-	-	-	-	-	57.31	5000																																																																																			-		0	9.4	0.73	2.17	-	0.98	0.11	0.01	0.8	2.11	2.42	2.27	0.14	3.74	1.21	10.96	14.26	-	-	2.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.04	2.44	-	-	-	-	-	-	-	-	57.31
H1804_220_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1182.35	91.76	965	2465.17	150.45	0.67	0.05	268.72	398.1	962.73	612.65	43.76	1150.46	371.96	11250.23	7318.88			371.53		7.1											4.83	15.48	2.03								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.46	94.46	26.74	0	77.15	0.15	0.15	35.49	62.95	29.81	44.08	38.57	38.57	38.57	11.57	23.14			77.15		0.15											94.46	0.15	0								9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.12	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.39	-	-	-	-	-	-	-	-	56.69	0	16.79	9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.12	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.39	-	-	-	-	-	-	-	-	56.69	5000																																																																																			-		0	9.31	0.72	2.15	-	0.97	0.1	0.01	0.79	2.09	2.39	2.25	0.14	3.7	1.2	10.85	14.12	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.39	-	-	-	-	-	-	-	-	56.69
H1804_221_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1104.06	85.69	901.1	2301.94	140.49	0.58	0.04	250.93	371.74	898.99	572.08	40.86	1074.29	347.34	10505.32	6834.28			346.93		6.19											4.51	13.48	1.77								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.31	96.31	27.27	0	78.66	0.16	0.16	36.19	64.19	30.39	44.95	39.33	39.33	39.33	11.8	23.6			78.66		0.16											96.31	0.16	0								8.86	0.69	2.05	-	0.92	0.09	0.01	0.76	1.99	2.28	2.14	0.13	3.52	1.14	10.33	13.44	-	-	2.27	-	0.97	-	-	-	-	-	-	-	-	-	-	0.04	2.12	-	-	-	-	-	-	-	-	53.75	0	14.58	8.86	0.69	2.05	-	0.92	0.09	0.01	0.76	1.99	2.28	2.14	0.13	3.52	1.14	10.33	13.44	-	-	2.27	-	0.97	-	-	-	-	-	-	-	-	-	-	0.04	2.12	-	-	-	-	-	-	-	-	53.75	5000																																																																																			-		0	8.86	0.69	2.05	-	0.92	0.09	0.01	0.76	1.99	2.28	2.14	0.13	3.52	1.14	10.33	13.44	-	-	2.27	-	0.97	-	-	-	-	-	-	-	-	-	-	0.04	2.12	-	-	-	-	-	-	-	-	53.75
H1804_222_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1176.11	91.28	959.91	2452.17	149.66	0.66	0.05	267.3	396	957.65	609.42	43.53	1144.39	370	11190.91	7280.29			369.57		7.02											4.8	15.3	2.01								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.6	94.6	26.78	0	77.27	0.15	0.15	35.54	63.05	29.85	44.15	38.63	38.63	38.63	11.59	23.18			77.27		0.15											94.6	0.15	0								9.27	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.81	14.06	-	-	2.38	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.46	0	16.61	9.27	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.81	14.06	-	-	2.38	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.46	5000																																																																																			-		0	9.27	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.81	14.06	-	-	2.38	-	1.09	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.46
H1804_223_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1132.88	87.92	924.62	2362.02	144.16	0.61	0.05	257.47	381.44	922.45	587.01	41.93	1102.32	356.4	10779.51	7012.65			355.99		6.52											4.63	14.2	1.86								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.62	95.62	27.07	0	78.1	0.16	0.16	35.92	63.73	30.17	44.63	39.05	39.05	39.05	11.71	23.43			78.1		0.16											95.62	0.16	0								9.03	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.18	0.14	3.59	1.16	10.52	13.69	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.22	-	-	-	-	-	-	-	-	54.84	0	15.38	9.03	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.18	0.14	3.59	1.16	10.52	13.69	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.22	-	-	-	-	-	-	-	-	54.84	5000																																																																																			-		0	9.03	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.18	0.14	3.59	1.16	10.52	13.69	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.22	-	-	-	-	-	-	-	-	54.84
H1804_224_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1206.5	93.64	984.71	2515.53	153.53	0.7	0.05	274.21	406.23	982.4	625.16	44.65	1173.96	379.56	11480.04	7468.38			379.12		7.41											4.93	16.14	2.12								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.9	93.9	26.58	0	76.69	0.15	0.15	35.28	62.58	29.63	43.82	38.35	38.35	38.35	11.5	23.01			76.69		0.15											93.9	0.15	0								9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.43	2.28	0.14	3.75	1.21	11.01	14.32	-	-	2.42	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.48	-	-	-	-	-	-	-	-	57.59	0	17.5	9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.43	2.28	0.14	3.75	1.21	11.01	14.32	-	-	2.42	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.48	-	-	-	-	-	-	-	-	57.59	5000																																																																																			-		0	9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.43	2.28	0.14	3.75	1.21	11.01	14.32	-	-	2.42	-	1.14	-	-	-	-	-	-	-	-	-	-	0.04	2.48	-	-	-	-	-	-	-	-	57.59
H1804_225_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1134.96	88.08	926.32	2366.36	144.42	0.61	0.05	257.95	382.14	924.14	588.09	42.01	1104.35	357.06	10799.31	7025.53			356.64		6.54											4.64	14.24	1.87								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.57	95.57	27.06	0	78.06	0.16	0.16	35.91	63.7	30.16	44.6	39.03	39.03	39.03	11.71	23.42			78.06		0.16											95.57	0.16	0								9.04	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.19	0.14	3.59	1.16	10.54	13.71	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.22	-	-	-	-	-	-	-	-	54.92	0	15.44	9.04	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.19	0.14	3.59	1.16	10.54	13.71	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.22	-	-	-	-	-	-	-	-	54.92	5000																																																																																			-		0	9.04	0.7	2.09	-	0.94	0.1	0.01	0.77	2.03	2.32	2.19	0.14	3.59	1.16	10.54	13.71	-	-	2.32	-	1.02	-	-	-	-	-	-	-	-	-	-	0.04	2.22	-	-	-	-	-	-	-	-	54.92
H1804_226_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1194.79	92.73	975.15	2491.1	152.04	0.68	0.05	271.54	402.29	972.86	619.09	44.22	1162.56	375.88	11368.58	7395.87			375.44		7.24											4.88	15.78	2.07								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.17	94.17	26.66	0	76.92	0.15	0.15	35.38	62.76	29.72	43.95	38.46	38.46	38.46	11.54	23.07			76.92		0.15											94.17	0.15	0								9.38	0.73	2.17	-	0.97	0.1	0.01	0.8	2.1	2.41	2.27	0.14	3.73	1.2	10.93	14.22	-	-	2.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.43	-	-	-	-	-	-	-	-	57.15	0	17.15	9.38	0.73	2.17	-	0.97	0.1	0.01	0.8	2.1	2.41	2.27	0.14	3.73	1.2	10.93	14.22	-	-	2.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.43	-	-	-	-	-	-	-	-	57.15	5000																																																																																			-		0	9.38	0.73	2.17	-	0.97	0.1	0.01	0.8	2.1	2.41	2.27	0.14	3.73	1.2	10.93	14.22	-	-	2.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.43	-	-	-	-	-	-	-	-	57.15
H1804_227_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		191.49	9.58	907.15	2317.4	7.71	0.59	0.04	15.45	36.94	39.42	41.14	1.79	5.14	15.23	10575.86	6880.17			2.29		6.27											0.5	13.66	25.08								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								420.64	420.64	26.51	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.47	22.94			0.15		0.15											420.64	0.15	0.14								6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	58	0	22.15	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	58	5000																																																																																			-		0	6.71	0.34	2	-	1.18	0.09	0.01	2.36	5.65	6.03	-	0.27	0.79	2.33	10.11	13.15	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.09	3.56	-	-	-	-	-	-	-	58
H1804_228_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		198.62	9.94	940.94	2403.71	8.29	0.63	0.05	16.63	39.74	42.41	42.67	1.93	5.53	16.38	10969.76	7136.42			2.46		6.75											0.52	14.7	26.99								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								414.39	414.39	26.12	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.3	22.6			0.15		0.15											414.39	0.15	0.14								6.86	0.34	2.05	-	1.25	0.1	0.01	2.51	5.99	6.39	-	0.29	0.83	2.47	10.33	13.44	-	-	0.37	-	1.02	-	-	-	-	-	-	-	-	-	-	0.02	2.21	3.78	-	-	-	-	-	-	-	60.25	0	24.57	6.86	0.34	2.05	-	1.25	0.1	0.01	2.51	5.99	6.39	-	0.29	0.83	2.47	10.33	13.44	-	-	0.37	-	1.02	-	-	-	-	-	-	-	-	-	-	0.02	2.21	3.78	-	-	-	-	-	-	-	60.25	5000																																																																																			-		0	6.86	0.34	2.05	-	1.25	0.1	0.01	2.51	5.99	6.39	-	0.29	0.83	2.47	10.33	13.44	-	-	0.37	-	1.02	-	-	-	-	-	-	-	-	-	-	0.02	2.21	3.78	-	-	-	-	-	-	-	60.25
H1804_229_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		205.8	10.3	974.92	2490.52	8.9	0.68	0.05	17.85	42.66	45.52	44.21	2.07	5.93	17.59	11365.94	7394.15			2.64		7.24											0.54	15.78	28.97								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								408.18	408.18	25.73	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.13	22.26			0.15		0.15											408.18	0.15	0.14								7	0.35	2.09	-	1.32	0.1	0.01	2.65	6.33	6.76	-	0.31	0.88	2.61	10.54	13.72	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.34	3.99	-	-	-	-	-	-	-	62.49	0	27.17	7	0.35	2.09	-	1.32	0.1	0.01	2.65	6.33	6.76	-	0.31	0.88	2.61	10.54	13.72	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.34	3.99	-	-	-	-	-	-	-	62.49	5000																																																																																			-		0	7	0.35	2.09	-	1.32	0.1	0.01	2.65	6.33	6.76	-	0.31	0.88	2.61	10.54	13.72	-	-	0.39	-	1.07	-	-	-	-	-	-	-	-	-	-	0.02	2.34	3.99	-	-	-	-	-	-	-	62.49
H1804_230_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1122.53	87.12	916.18	2340.46	142.84	0.6	0.05	255.12	377.96	914.03	581.65	41.55	1092.26	353.15	10681.1	6948.63			352.74		6.4											4.59	13.93	1.83								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.86	95.86	27.14	0	78.3	0.16	0.16	36.02	63.89	30.25	44.74	39.15	39.15	39.15	11.74	23.49			78.3		0.16											95.86	0.16	0								8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.45	0	15.09	8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.45	5000																																																																																			-		0	8.97	0.7	2.07	-	0.93	0.09	0.01	0.77	2.01	2.3	2.17	0.14	3.56	1.15	10.45	13.6	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.18	-	-	-	-	-	-	-	-	54.45
H1804_231_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1164.34	90.36	950.3	2427.63	148.16	0.65	0.05	264.63	392.04	948.07	603.32	43.09	1132.94	366.3	11078.91	7207.42			365.87		6.88											4.76	14.99	1.97								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.88	94.88	26.86	0	77.49	0.15	0.15	35.65	63.23	29.94	44.28	38.75	38.75	38.75	11.62	23.25			77.49		0.15											94.88	0.15	0								9.21	0.71	2.13	-	0.96	0.1	0.01	0.79	2.07	2.37	2.23	0.14	3.66	1.18	10.73	13.96	-	-	2.36	-	1.07	-	-	-	-	-	-	-	-	-	-	0.04	2.32	-	-	-	-	-	-	-	-	56.02	0	16.27	9.21	0.71	2.13	-	0.96	0.1	0.01	0.79	2.07	2.37	2.23	0.14	3.66	1.18	10.73	13.96	-	-	2.36	-	1.07	-	-	-	-	-	-	-	-	-	-	0.04	2.32	-	-	-	-	-	-	-	-	56.02	5000																																																																																			-		0	9.21	0.71	2.13	-	0.96	0.1	0.01	0.79	2.07	2.37	2.23	0.14	3.66	1.18	10.73	13.96	-	-	2.36	-	1.07	-	-	-	-	-	-	-	-	-	-	0.04	2.32	-	-	-	-	-	-	-	-	56.02
H1804_232_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1206.41	93.63	984.64	2515.34	153.52	0.69	0.05	274.19	406.2	982.32	625.11	44.65	1173.87	379.53	11479.18	7467.83			379.09		7.39											4.93	16.09	2.11								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.9	93.9	26.59	0	76.7	0.15	0.15	35.28	62.58	29.63	43.83	38.35	38.35	38.35	11.5	23.01			76.7		0.15											93.9	0.15	0								9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.43	2.28	0.14	3.75	1.21	11.01	14.32	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.47	-	-	-	-	-	-	-	-	57.58	0	17.49	9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.43	2.28	0.14	3.75	1.21	11.01	14.32	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.47	-	-	-	-	-	-	-	-	57.58	5000																																																																																			-		0	9.44	0.73	2.18	-	0.98	0.11	0.01	0.81	2.12	2.43	2.28	0.14	3.75	1.21	11.01	14.32	-	-	2.42	-	1.13	-	-	-	-	-	-	-	-	-	-	0.04	2.47	-	-	-	-	-	-	-	-	57.58
H1804_233_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1113.74	86.44	909	2322.12	141.72	0.59	0.04	253.12	375	906.86	577.1	41.22	1083.7	350.38	10597.4	6894.17			349.97		6.3											4.55	13.73	1.8								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.08	96.08	27.2	0	78.47	0.16	0.16	36.1	64.03	30.32	44.84	39.23	39.23	39.23	11.77	23.54			78.47		0.16											96.08	0.16	0								8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.54	1.15	10.39	13.52	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.15	-	-	-	-	-	-	-	-	54.12	0	14.85	8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.54	1.15	10.39	13.52	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.15	-	-	-	-	-	-	-	-	54.12	5000																																																																																			-		0	8.92	0.69	2.06	-	0.93	0.09	0.01	0.76	2	2.29	2.16	0.13	3.54	1.15	10.39	13.52	-	-	2.29	-	0.99	-	-	-	-	-	-	-	-	-	-	0.04	2.15	-	-	-	-	-	-	-	-	54.12
H1804_234_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1120.27	86.94	914.33	2335.74	142.56	0.6	0.04	254.61	377.2	912.18	580.48	41.46	1090.06	352.43	10659.54	6934.6			352.02		6.37											4.58	13.88	1.82								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.92	95.92	27.16	0	78.34	0.16	0.16	36.04	63.93	30.27	44.77	39.17	39.17	39.17	11.75	23.5			78.34		0.16											95.92	0.16	0								8.95	0.69	2.07	-	0.93	0.09	0.01	0.76	2.01	2.3	2.17	0.14	3.56	1.15	10.44	13.58	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.17	-	-	-	-	-	-	-	-	54.36	0	15.03	8.95	0.69	2.07	-	0.93	0.09	0.01	0.76	2.01	2.3	2.17	0.14	3.56	1.15	10.44	13.58	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.17	-	-	-	-	-	-	-	-	54.36	5000																																																																																			-		0	8.95	0.69	2.07	-	0.93	0.09	0.01	0.76	2.01	2.3	2.17	0.14	3.56	1.15	10.44	13.58	-	-	2.3	-	1	-	-	-	-	-	-	-	-	-	-	0.04	2.17	-	-	-	-	-	-	-	-	54.36
H1804_235_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1128.77	87.6	921.27	2353.46	143.64	0.61	0.05	256.54	380.06	919.1	584.88	41.78	1098.33	355.11	10740.44	6987.23			354.7		6.47											4.61	14.09	1.85								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.72	95.72	27.1	0	78.18	0.16	0.16	35.96	63.79	30.2	44.67	39.09	39.09	39.09	11.73	23.45			78.18		0.16											95.72	0.16	0								9	0.7	2.08	-	0.94	0.09	0.01	0.77	2.02	2.31	2.18	0.14	3.58	1.16	10.5	13.66	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.69	0	15.27	9	0.7	2.08	-	0.94	0.09	0.01	0.77	2.02	2.31	2.18	0.14	3.58	1.16	10.5	13.66	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.69	5000																																																																																			-		0	9	0.7	2.08	-	0.94	0.09	0.01	0.77	2.02	2.31	2.18	0.14	3.58	1.16	10.5	13.66	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.69
H1804_236_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1150.85	89.32	939.29	2399.5	146.45	0.63	0.05	261.56	387.49	937.08	596.33	42.59	1119.81	362.05	10950.52	7123.9			361.63		6.73											4.7	14.66	1.92								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.19	95.19	26.95	0	77.75	0.16	0.16	35.76	63.44	30.04	44.43	38.87	38.87	38.87	11.66	23.32			77.75		0.16											95.19	0.16	0								9.13	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.64	13.85	-	-	2.34	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.52	0	15.89	9.13	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.64	13.85	-	-	2.34	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.52	5000																																																																																			-		0	9.13	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.64	13.85	-	-	2.34	-	1.05	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.52
H1804_237_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1275.26	98.97	1040.83	2658.88	162.28	0.78	0.06	289.83	429.38	1038.38	660.79	47.2	1240.86	401.19	12134.27	7893.99			400.73		8.26											5.21	18	2.36								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								92.35	92.35	26.15	0	75.43	0.15	0.15	34.7	61.55	29.14	43.1	37.71	37.71	37.71	11.31	22.63			75.43		0.15											92.35	0.15	0								9.81	0.76	2.27	-	1.02	0.12	0.01	0.84	2.2	2.52	2.37	0.15	3.9	1.26	11.44	14.89	-	-	2.52	-	1.25	-	-	-	-	-	-	-	-	-	-	0.04	2.71	-	-	-	-	-	-	-	-	60.08	0	19.57	9.81	0.76	2.27	-	1.02	0.12	0.01	0.84	2.2	2.52	2.37	0.15	3.9	1.26	11.44	14.89	-	-	2.52	-	1.25	-	-	-	-	-	-	-	-	-	-	0.04	2.71	-	-	-	-	-	-	-	-	60.08	5000																																																																																			-		0	9.81	0.76	2.27	-	1.02	0.12	0.01	0.84	2.2	2.52	2.37	0.15	3.9	1.26	11.44	14.89	-	-	2.52	-	1.25	-	-	-	-	-	-	-	-	-	-	0.04	2.71	-	-	-	-	-	-	-	-	60.08
H1804_238_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1252.41	97.2	1022.18	2611.25	159.37	0.75	0.06	284.64	421.69	1019.78	648.95	46.35	1218.64	394.01	11916.91	7752.59			393.55		7.97											5.12	17.35	2.28								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								92.86	92.86	26.29	0	75.84	0.15	0.15	34.89	61.89	29.3	43.34	37.92	37.92	37.92	11.38	22.75			75.84		0.15											92.86	0.15	0								9.69	0.75	2.24	-	1.01	0.11	0.01	0.83	2.17	2.49	2.34	0.15	3.85	1.25	11.3	14.7	-	-	2.49	-	1.21	-	-	-	-	-	-	-	-	-	-	0.04	2.63	-	-	-	-	-	-	-	-	59.26	0	18.87	9.69	0.75	2.24	-	1.01	0.11	0.01	0.83	2.17	2.49	2.34	0.15	3.85	1.25	11.3	14.7	-	-	2.49	-	1.21	-	-	-	-	-	-	-	-	-	-	0.04	2.63	-	-	-	-	-	-	-	-	59.26	5000																																																																																			-		0	9.69	0.75	2.24	-	1.01	0.11	0.01	0.83	2.17	2.49	2.34	0.15	3.85	1.25	11.3	14.7	-	-	2.49	-	1.21	-	-	-	-	-	-	-	-	-	-	0.04	2.63	-	-	-	-	-	-	-	-	59.26
H1804_239_0	2007	6	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1098.76	41.96	1233.87	2294.67	128.08	0.53	0.04	248.57	472.25	1276.24	812.15	58.01	1061	493.09	7452.32	5990.15			268.96		6.91											2.21	11.26	1.98								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.45	97.45	27.59	0	79.59	0.16	0.16	36.61	64.95	30.75	45.48	39.8	39.8	39.8	11.94	23.88			79.59		0.16											97.45	0.16	0								8.92	0.34	2.84	-	0.85	0.08	0.01	0.76	2.56	3.27	3.08	0.19	3.52	1.64	7.41	11.92	-	-	1.78	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.79	-	-	-	-	-	-	-	-	52.08	0	13.35	8.92	0.34	2.84	-	0.85	0.08	0.01	0.76	2.56	3.27	3.08	0.19	3.52	1.64	7.41	11.92	-	-	1.78	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.79	-	-	-	-	-	-	-	-	52.08	5000																																																																																			-		0	8.92	0.34	2.84	-	0.85	0.08	0.01	0.76	2.56	3.27	3.08	0.19	3.52	1.64	7.41	11.92	-	-	1.78	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.79	-	-	-	-	-	-	-	-	52.08
H1804_240_0	2007	6	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1175.45	44.88	1319.99	2454.83	137.02	0.61	0.05	265.92	505.21	1365.32	868.84	62.06	1135.05	527.51	7972.46	6408.24			287.73		7.91											2.36	12.89	2.26								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.6	95.6	27.07	0	78.08	0.16	0.16	35.92	63.71	30.17	44.62	39.04	39.04	39.04	11.71	23.42			78.08		0.16											95.6	0.16	0								9.36	0.36	2.98	-	0.89	0.09	0.01	0.8	2.68	3.43	3.23	0.2	3.69	1.72	7.78	12.51	-	-	1.87	-	1.24	-	-	-	-	-	-	-	-	-	-	0.02	2.01	-	-	-	-	-	-	-	-	54.87	0	15.4	9.36	0.36	2.98	-	0.89	0.09	0.01	0.8	2.68	3.43	3.23	0.2	3.69	1.72	7.78	12.51	-	-	1.87	-	1.24	-	-	-	-	-	-	-	-	-	-	0.02	2.01	-	-	-	-	-	-	-	-	54.87	5000																																																																																			-		0	9.36	0.36	2.98	-	0.89	0.09	0.01	0.8	2.68	3.43	3.23	0.2	3.69	1.72	7.78	12.51	-	-	1.87	-	1.24	-	-	-	-	-	-	-	-	-	-	0.02	2.01	-	-	-	-	-	-	-	-	54.87
H1804_241_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1186.13	92.05	968.08	2473.05	150.94	0.67	0.05	269.58	399.37	965.81	614.6	43.9	1154.14	373.15	11286.18	7342.27			372.72		7.14											4.84	15.56	2.04								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.37	94.37	26.72	0	77.08	0.15	0.15	35.46	62.9	29.78	44.04	38.54	38.54	38.54	11.56	23.12			77.08		0.15											94.37	0.15	0								9.33	0.72	2.16	-	0.97	0.1	0.01	0.8	2.09	2.4	2.26	0.14	3.71	1.2	10.87	14.15	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.83	0	16.9	9.33	0.72	2.16	-	0.97	0.1	0.01	0.8	2.09	2.4	2.26	0.14	3.71	1.2	10.87	14.15	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.83	5000																																																																																			-		0	9.33	0.72	2.16	-	0.97	0.1	0.01	0.8	2.09	2.4	2.26	0.14	3.71	1.2	10.87	14.15	-	-	2.39	-	1.1	-	-	-	-	-	-	-	-	-	-	0.04	2.4	-	-	-	-	-	-	-	-	56.83
H1804_242_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		204.39	10.23	968.25	2473.49	8.78	0.67	0.05	17.61	42.1	44.93	43.91	2.04	5.85	17.36	11288.18	7343.57			2.6		7.15											0.54	15.57	28.59								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								409.36	409.36	25.8	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.16	22.33			0.15		0.15											409.36	0.15	0.14								6.97	0.35	2.08	-	1.31	0.1	0.01	2.62	6.27	6.69	-	0.3	0.87	2.58	10.5	13.66	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.32	3.95	-	-	-	-	-	-	-	62.06	0	26.66	6.97	0.35	2.08	-	1.31	0.1	0.01	2.62	6.27	6.69	-	0.3	0.87	2.58	10.5	13.66	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.32	3.95	-	-	-	-	-	-	-	62.06	5000																																																																																			-		0	6.97	0.35	2.08	-	1.31	0.1	0.01	2.62	6.27	6.69	-	0.3	0.87	2.58	10.5	13.66	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.32	3.95	-	-	-	-	-	-	-	62.06
H1804_243_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1198.14	92.99	977.89	2498.1	152.46	0.68	0.05	272.31	403.42	975.59	620.83	44.35	1165.83	376.93	11400.52	7416.65			376.49		7.29											4.89	15.88	2.08								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.09	94.09	26.64	0	76.85	0.15	0.15	35.35	62.71	29.69	43.91	38.43	38.43	38.43	11.53	23.06			76.85		0.15											94.09	0.15	0								9.39	0.73	2.17	-	0.98	0.11	0.01	0.8	2.11	2.41	2.27	0.14	3.73	1.21	10.95	14.25	-	-	2.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.04	2.44	-	-	-	-	-	-	-	-	57.28	0	17.25	9.39	0.73	2.17	-	0.98	0.11	0.01	0.8	2.11	2.41	2.27	0.14	3.73	1.21	10.95	14.25	-	-	2.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.04	2.44	-	-	-	-	-	-	-	-	57.28	5000																																																																																			-		0	9.39	0.73	2.17	-	0.98	0.11	0.01	0.8	2.11	2.41	2.27	0.14	3.73	1.21	10.95	14.25	-	-	2.41	-	1.12	-	-	-	-	-	-	-	-	-	-	0.04	2.44	-	-	-	-	-	-	-	-	57.28
H1804_244_0	2007	3	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		204.39	10.23	968.25	2473.47	8.78	0.67	0.05	17.61	42.1	44.93	43.91	2.04	5.85	17.36	11288.12	7343.53			2.6		7.15											10.76	0.54	15.57	28.59							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							408.65	408.65	25.75	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.14	22.29			0.15		0.15											408.65	408.65	0.15	0.14							6.96	0.35	2.08	-	1.31	0.1	0.01	2.62	6.26	6.68	-	0.3	0.87	2.58	10.48	13.64	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.31	3.94	-	-	-	-	-	-	62.32	0	26.92	6.96	0.35	2.08	-	1.31	0.1	0.01	2.62	6.26	6.68	-	0.3	0.87	2.58	10.48	13.64	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.31	3.94	-	-	-	-	-	-	62.32	5000																																																																																			-		0	6.96	0.35	2.08	-	1.31	0.1	0.01	2.62	6.26	6.68	-	0.3	0.87	2.58	10.48	13.64	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.31	3.94	-	-	-	-	-	-	62.32
H1804_245_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		179.52	8.99	850.44	2172.52	6.77	0.52	0.04	13.57	32.45	34.62	38.57	1.57	4.51	13.38	9914.65	6450.01			2.01		5.51											0.47	12	22.03								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								431.33	431.33	27.18	0	0.16	0.16	0.16	0.16	0.16	0.16	0	0.16	0.16	0.16	11.76	23.53			0.16		0.16											431.33	0.16	0.15								6.45	0.32	1.93	-	1.06	0.08	0.01	2.13	5.09	5.43	-	0.25	0.71	2.1	9.72	12.65	-	-	0.31	-	0.86	-	-	-	-	-	-	-	-	-	-	0.02	1.88	3.21	-	-	-	-	-	-	-	54.2	0	18.38	6.45	0.32	1.93	-	1.06	0.08	0.01	2.13	5.09	5.43	-	0.25	0.71	2.1	9.72	12.65	-	-	0.31	-	0.86	-	-	-	-	-	-	-	-	-	-	0.02	1.88	3.21	-	-	-	-	-	-	-	54.2	5000																																																																																			-		0	6.45	0.32	1.93	-	1.06	0.08	0.01	2.13	5.09	5.43	-	0.25	0.71	2.1	9.72	12.65	-	-	0.31	-	0.86	-	-	-	-	-	-	-	-	-	-	0.02	1.88	3.21	-	-	-	-	-	-	-	54.2
H1804_246_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1052.35	81.67	858.9	2194.13	133.91	0.53	0.04	239.17	354.33	856.88	545.29	38.95	1023.97	331.07	10013.31	6514.19			330.68		5.62											4.3	12.24	1.61								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								97.65	97.65	27.65	0	79.76	0.16	0.16	36.69	65.08	30.82	45.58	39.88	39.88	39.88	11.96	23.93			79.76		0.16											97.65	0.16	0								8.56	0.66	1.98	-	0.89	0.08	0.01	0.73	1.92	2.2	2.07	0.13	3.4	1.1	9.98	12.99	-	-	2.2	-	0.9	-	-	-	-	-	-	-	-	-	-	0.03	1.95	-	-	-	-	-	-	-	-	51.8	0	13.15	8.56	0.66	1.98	-	0.89	0.08	0.01	0.73	1.92	2.2	2.07	0.13	3.4	1.1	9.98	12.99	-	-	2.2	-	0.9	-	-	-	-	-	-	-	-	-	-	0.03	1.95	-	-	-	-	-	-	-	-	51.8	5000																																																																																			-		0	8.56	0.66	1.98	-	0.89	0.08	0.01	0.73	1.92	2.2	2.07	0.13	3.4	1.1	9.98	12.99	-	-	2.2	-	0.9	-	-	-	-	-	-	-	-	-	-	0.03	1.95	-	-	-	-	-	-	-	-	51.8
H1804_247_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		203.91	10.21	965.97	2467.64	8.73	0.67	0.05	17.51	41.86	44.67	43.8	2.03	5.82	17.26	11261.52	7326.23			2.59		7.11											0.54	15.48	28.42								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								409.84	409.84	25.83	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.18	22.36			0.15		0.15											409.84	0.15	0.14								6.96	0.35	2.08	-	1.3	0.1	0.01	2.61	6.24	6.66	-	0.3	0.87	2.57	10.49	13.65	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.31	3.93	-	-	-	-	-	-	-	61.89	0	26.45	6.96	0.35	2.08	-	1.3	0.1	0.01	2.61	6.24	6.66	-	0.3	0.87	2.57	10.49	13.65	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.31	3.93	-	-	-	-	-	-	-	61.89	5000																																																																																			-		0	6.96	0.35	2.08	-	1.3	0.1	0.01	2.61	6.24	6.66	-	0.3	0.87	2.57	10.49	13.65	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.02	2.31	3.93	-	-	-	-	-	-	-	61.89
H1804_248_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1195.38	92.77	975.64	2492.35	152.11	0.68	0.05	271.68	402.49	973.35	619.4	44.24	1163.15	376.07	11374.28	7399.58			375.63		7.25											4.88	15.79	2.07								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.16	94.16	26.66	0	76.9	0.15	0.15	35.38	62.75	29.71	43.95	38.45	38.45	38.45	11.54	23.07			76.9		0.15											94.16	0.15	0								9.38	0.73	2.17	-	0.97	0.1	0.01	0.8	2.1	2.41	2.27	0.14	3.73	1.21	10.93	14.23	-	-	2.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.43	-	-	-	-	-	-	-	-	57.17	0	17.17	9.38	0.73	2.17	-	0.97	0.1	0.01	0.8	2.1	2.41	2.27	0.14	3.73	1.21	10.93	14.23	-	-	2.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.43	-	-	-	-	-	-	-	-	57.17	5000																																																																																			-		0	9.38	0.73	2.17	-	0.97	0.1	0.01	0.8	2.1	2.41	2.27	0.14	3.73	1.21	10.93	14.23	-	-	2.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.43	-	-	-	-	-	-	-	-	57.17
H1804_249_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		203.91	10.21	965.97	2467.64	8.73	0.67	0.05	17.51	41.86	44.67	43.8	2.03	5.82	17.26	11261.52	7326.23			2.59		7.11											10.73	0.54	15.48	28.42							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							409.13	409.13	25.79	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.16	22.32			0.15		0.15											409.13	409.13	0.15	0.14							6.95	0.35	2.08	-	1.3	0.1	0.01	2.61	6.23	6.64	-	0.3	0.87	2.57	10.47	13.62	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.3	3.93	-	-	-	-	-	-	62.15	0	26.71	6.95	0.35	2.08	-	1.3	0.1	0.01	2.61	6.23	6.64	-	0.3	0.87	2.57	10.47	13.62	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.3	3.93	-	-	-	-	-	-	62.15	5000																																																																																			-		0	6.95	0.35	2.08	-	1.3	0.1	0.01	2.61	6.23	6.64	-	0.3	0.87	2.57	10.47	13.62	-	-	0.39	-	1.06	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.3	3.93	-	-	-	-	-	-	62.15
H1804_250_0	2007	7	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		209.42	10.48	992.1	2534.39	9.22	0.7	0.05	18.48	44.18	47.15	44.99	2.14	6.14	18.22	11566.14	7524.4			2.73		7.5											0.55	16.34	30								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								405.04	405.04	25.53	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.05	22.09			0.15		0.15											405.04	0.15	0.14								7.07	0.35	2.11	-	1.36	0.1	0.01	2.72	6.51	6.94	-	0.32	0.9	2.68	10.65	13.85	-	-	0.4	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	2.41	4.1	-	-	-	-	-	-	-	63.62	0	28.54	7.07	0.35	2.11	-	1.36	0.1	0.01	2.72	6.51	6.94	-	0.32	0.9	2.68	10.65	13.85	-	-	0.4	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	2.41	4.1	-	-	-	-	-	-	-	63.62	5000																																																																																			-		0	7.07	0.35	2.11	-	1.36	0.1	0.01	2.72	6.51	6.94	-	0.32	0.9	2.68	10.65	13.85	-	-	0.4	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	2.41	4.1	-	-	-	-	-	-	-	63.62
H1804_251_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		187.73	9.4	889.34	2271.89	7.4	0.57	0.04	14.85	35.48	37.86	40.33	1.72	4.93	14.63	10368.14	6745.03			2.2		6.02											0.49	13.12	24.1								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								423.99	423.99	26.72	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.56	23.13			0.15		0.15											423.99	0.15	0.14								6.63	0.33	1.98	-	1.14	0.09	0.01	2.29	5.47	5.84	-	0.27	0.76	2.26	9.99	13	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.02	3.45	-	-	-	-	-	-	-	56.81	0	20.91	6.63	0.33	1.98	-	1.14	0.09	0.01	2.29	5.47	5.84	-	0.27	0.76	2.26	9.99	13	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.02	3.45	-	-	-	-	-	-	-	56.81	5000																																																																																			-		0	6.63	0.33	1.98	-	1.14	0.09	0.01	2.29	5.47	5.84	-	0.27	0.76	2.26	9.99	13	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.02	3.45	-	-	-	-	-	-	-	56.81
H1804_252_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1100.49	85.41	898.19	2294.49	140.04	0.58	0.04	250.11	370.54	896.08	570.23	40.73	1070.81	346.21	10471.31	6812.15			345.81		6.14											4.5	13.38	1.76								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.4	96.4	27.29	0	78.74	0.16	0.16	36.22	64.25	30.42	44.99	39.37	39.37	39.37	11.81	23.62			78.74		0.16											96.4	0.16	0								8.84	0.69	2.04	-	0.92	0.09	0.01	0.75	1.98	2.27	2.14	0.13	3.51	1.14	10.31	13.41	-	-	2.27	-	0.97	-	-	-	-	-	-	-	-	-	-	0.04	2.11	-	-	-	-	-	-	-	-	53.61	0	14.48	8.84	0.69	2.04	-	0.92	0.09	0.01	0.75	1.98	2.27	2.14	0.13	3.51	1.14	10.31	13.41	-	-	2.27	-	0.97	-	-	-	-	-	-	-	-	-	-	0.04	2.11	-	-	-	-	-	-	-	-	53.61	5000																																																																																			-		0	8.84	0.69	2.04	-	0.92	0.09	0.01	0.75	1.98	2.27	2.14	0.13	3.51	1.14	10.31	13.41	-	-	2.27	-	0.97	-	-	-	-	-	-	-	-	-	-	0.04	2.11	-	-	-	-	-	-	-	-	53.61
H1804_253_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		187.73	9.4	889.34	2271.89	7.4	0.57	0.04	14.85	35.48	37.86	40.33	1.72	4.93	14.63	10368.15	6745.03			2.2		6.02											9.88	0.49	13.12	24.1							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							423.28	423.28	26.68	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.54	23.09			0.15		0.15											423.28	423.28	0.15	0.14							6.62	0.33	1.98	-	1.14	0.09	0.01	2.28	5.46	5.83	-	0.26	0.76	2.25	9.97	12.98	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.02	3.44	-	-	-	-	-	-	57.06	0	21.14	6.62	0.33	1.98	-	1.14	0.09	0.01	2.28	5.46	5.83	-	0.26	0.76	2.25	9.97	12.98	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.02	3.44	-	-	-	-	-	-	57.06	5000																																																																																			-		0	6.62	0.33	1.98	-	1.14	0.09	0.01	2.28	5.46	5.83	-	0.26	0.76	2.25	9.97	12.98	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.02	3.44	-	-	-	-	-	-	57.06
H1804_254_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		200.66	10.04	950.57	2428.31	8.46	0.65	0.05	16.96	40.53	43.25	43.11	1.97	5.64	16.71	11082.03	7209.46			2.51		6.88											0.53	14.99	27.52								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								412.66	412.66	26.01	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.25	22.51			0.15		0.15											412.66	0.15	0.14								6.9	0.35	2.06	-	1.27	0.1	0.01	2.54	6.08	6.49	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.87	0	25.28	6.9	0.35	2.06	-	1.27	0.1	0.01	2.54	6.08	6.49	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.87	5000																																																																																			-		0	6.9	0.35	2.06	-	1.27	0.1	0.01	2.54	6.08	6.49	-	0.3	0.85	2.51	10.39	13.52	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.02	2.25	3.84	-	-	-	-	-	-	-	60.87
H1804_255_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1176.26	91.29	960.03	2452.48	149.68	0.66	0.05	267.33	396.05	957.77	609.49	43.54	1144.54	370.05	11192.3	7281.19			369.62		7.02											4.8	15.29	2.01								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.6	94.6	26.78	0	77.27	0.15	0.15	35.54	63.05	29.85	44.15	38.63	38.63	38.63	11.59	23.18			77.27		0.15											94.6	0.15	0								9.27	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.81	14.06	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.46	0	16.61	9.27	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.81	14.06	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.46	5000																																																																																			-		0	9.27	0.72	2.14	-	0.96	0.1	0.01	0.79	2.08	2.38	2.24	0.14	3.68	1.19	10.81	14.06	-	-	2.38	-	1.08	-	-	-	-	-	-	-	-	-	-	0.04	2.36	-	-	-	-	-	-	-	-	56.46
H1804_256_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		200.66	10.04	950.57	2428.31	8.46	0.65	0.05	16.96	40.53	43.25	43.11	1.97	5.64	16.71	11082.03	7209.46			2.51		6.88											10.56	0.53	14.99	27.52							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							411.95	411.95	25.96	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.23	22.47			0.15		0.15											411.95	411.95	0.15	0.14							6.89	0.34	2.06	-	1.27	0.1	0.01	2.54	6.07	6.48	-	0.29	0.84	2.5	10.38	13.5	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.25	3.83	-	-	-	-	-	-	61.13	0	25.53	6.89	0.34	2.06	-	1.27	0.1	0.01	2.54	6.07	6.48	-	0.29	0.84	2.5	10.38	13.5	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.25	3.83	-	-	-	-	-	-	61.13	5000																																																																																			-		0	6.89	0.34	2.06	-	1.27	0.1	0.01	2.54	6.07	6.48	-	0.29	0.84	2.5	10.38	13.5	-	-	0.38	-	1.03	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.25	3.83	-	-	-	-	-	-	61.13
H1804_257_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		196.28	9.82	929.84	2375.35	8.09	0.62	0.05	16.23	38.8	41.4	42.17	1.88	5.39	16	10840.31	7052.2			2.4		6.59											0.52	14.35	26.35								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.45	416.45	26.25	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.36	22.72			0.15		0.15											416.45	0.15	0.14								6.81	0.34	2.03	-	1.23	0.09	0.01	2.46	5.88	6.27	-	0.28	0.82	2.42	10.26	13.35	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.7	-	-	-	-	-	-	-	59.51	0	23.76	6.81	0.34	2.03	-	1.23	0.09	0.01	2.46	5.88	6.27	-	0.28	0.82	2.42	10.26	13.35	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.7	-	-	-	-	-	-	-	59.51	5000																																																																																			-		0	6.81	0.34	2.03	-	1.23	0.09	0.01	2.46	5.88	6.27	-	0.28	0.82	2.42	10.26	13.35	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.7	-	-	-	-	-	-	-	59.51
H1804_258_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1150.6	89.3	939.09	2398.98	146.42	0.63	0.05	261.5	387.41	936.88	596.2	42.59	1119.57	361.98	10948.18	7122.38			361.56		6.72											4.7	14.64	1.92								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.2	95.2	26.95	0	77.76	0.16	0.16	35.77	63.45	30.04	44.43	38.88	38.88	38.88	11.66	23.33			77.76		0.16											95.2	0.16	0								9.13	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.64	13.85	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.51	0	15.88	9.13	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.64	13.85	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.51	5000																																																																																			-		0	9.13	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.35	2.21	0.14	3.63	1.17	10.64	13.85	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.28	-	-	-	-	-	-	-	-	55.51
H1804_259_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		196.28	9.82	929.84	2375.35	8.09	0.62	0.05	16.23	38.8	41.4	42.17	1.88	5.39	16	10840.31	7052.2			2.4		6.59											10.33	0.52	14.35	26.35							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							415.74	415.74	26.2	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.34	22.68			0.15		0.15											415.74	415.74	0.15	0.14							6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.87	6.26	-	0.28	0.82	2.42	10.24	13.33	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.17	3.7	-	-	-	-	-	-	59.76	0	24	6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.87	6.26	-	0.28	0.82	2.42	10.24	13.33	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.17	3.7	-	-	-	-	-	-	59.76	5000																																																																																			-		0	6.8	0.34	2.03	-	1.22	0.09	0.01	2.45	5.87	6.26	-	0.28	0.82	2.42	10.24	13.33	-	-	0.36	-	1	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.17	3.7	-	-	-	-	-	-	59.76
H1804_260_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		185.81	9.3	880.26	2248.7	7.25	0.55	0.04	14.55	34.77	37.11	39.92	1.69	4.83	14.34	10262.33	6676.2			2.15		5.9											0.49	12.86	23.61								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								425.68	425.68	26.83	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.61	23.22			0.15		0.15											425.68	0.15	0.14								6.59	0.33	1.97	-	1.12	0.09	0.01	2.25	5.38	5.74	-	0.26	0.75	2.22	9.93	12.92	-	-	0.33	-	0.91	-	-	-	-	-	-	-	-	-	-	0.02	1.99	3.39	-	-	-	-	-	-	-	56.21	0	20.31	6.59	0.33	1.97	-	1.12	0.09	0.01	2.25	5.38	5.74	-	0.26	0.75	2.22	9.93	12.92	-	-	0.33	-	0.91	-	-	-	-	-	-	-	-	-	-	0.02	1.99	3.39	-	-	-	-	-	-	-	56.21	5000																																																																																			-		0	6.59	0.33	1.97	-	1.12	0.09	0.01	2.25	5.38	5.74	-	0.26	0.75	2.22	9.93	12.92	-	-	0.33	-	0.91	-	-	-	-	-	-	-	-	-	-	0.02	1.99	3.39	-	-	-	-	-	-	-	56.21
H1804_261_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1089.26	84.54	889.02	2271.08	138.61	0.57	0.04	247.56	366.76	886.93	564.41	40.32	1059.88	342.68	10364.45	6742.63			342.28		6.02											4.45	13.12	1.72								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.68	96.68	27.37	0	78.97	0.16	0.16	36.32	64.44	30.51	45.12	39.48	39.48	39.48	11.84	23.69			78.97		0.16											96.68	0.16	0								8.78	0.68	2.03	-	0.91	0.09	0.01	0.75	1.97	2.26	2.12	0.13	3.49	1.13	10.23	13.31	-	-	2.25	-	0.95	-	-	-	-	-	-	-	-	-	-	0.04	2.07	-	-	-	-	-	-	-	-	53.19	0	14.17	8.78	0.68	2.03	-	0.91	0.09	0.01	0.75	1.97	2.26	2.12	0.13	3.49	1.13	10.23	13.31	-	-	2.25	-	0.95	-	-	-	-	-	-	-	-	-	-	0.04	2.07	-	-	-	-	-	-	-	-	53.19	5000																																																																																			-		0	8.78	0.68	2.03	-	0.91	0.09	0.01	0.75	1.97	2.26	2.12	0.13	3.49	1.13	10.23	13.31	-	-	2.25	-	0.95	-	-	-	-	-	-	-	-	-	-	0.04	2.07	-	-	-	-	-	-	-	-	53.19
H1804_262_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		185.81	9.3	880.26	2248.7	7.25	0.55	0.04	14.55	34.77	37.11	39.92	1.69	4.83	14.34	10262.34	6676.2			2.15		5.9											9.78	0.49	12.86	23.61							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							424.97	424.97	26.78	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.59	23.18			0.15		0.15											424.97	424.97	0.15	0.14							6.58	0.33	1.96	-	1.12	0.09	0.01	2.25	5.37	5.73	-	0.26	0.75	2.22	9.91	12.9	-	-	0.33	-	0.91	-	-	-	-	-	-	-	-	-	-	0.35	0.02	1.99	3.39	-	-	-	-	-	-	56.46	0	20.53	6.58	0.33	1.96	-	1.12	0.09	0.01	2.25	5.37	5.73	-	0.26	0.75	2.22	9.91	12.9	-	-	0.33	-	0.91	-	-	-	-	-	-	-	-	-	-	0.35	0.02	1.99	3.39	-	-	-	-	-	-	56.46	5000																																																																																			-		0	6.58	0.33	1.96	-	1.12	0.09	0.01	2.25	5.37	5.73	-	0.26	0.75	2.22	9.91	12.9	-	-	0.33	-	0.91	-	-	-	-	-	-	-	-	-	-	0.35	0.02	1.99	3.39	-	-	-	-	-	-	56.46
H1804_263_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		195.95	9.81	928.29	2371.4	8.06	0.62	0.05	16.17	38.65	41.25	42.1	1.87	5.37	15.94	10822.29	7040.48			2.39		6.56											0.52	14.3	26.25								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								416.75	416.75	26.27	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.37	22.73			0.15		0.15											416.75	0.15	0.14								6.81	0.34	2.03	-	1.22	0.09	0.01	2.45	5.86	6.25	-	0.28	0.81	2.42	10.25	13.34	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.69	-	-	-	-	-	-	-	59.4	0	23.63	6.81	0.34	2.03	-	1.22	0.09	0.01	2.45	5.86	6.25	-	0.28	0.81	2.42	10.25	13.34	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.69	-	-	-	-	-	-	-	59.4	5000																																																																																			-		0	6.81	0.34	2.03	-	1.22	0.09	0.01	2.45	5.86	6.25	-	0.28	0.81	2.42	10.25	13.34	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.02	2.17	3.69	-	-	-	-	-	-	-	59.4
H1804_264_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1148.69	89.15	937.53	2395	146.17	0.63	0.05	261.07	386.77	935.32	595.21	42.51	1117.71	361.38	10929.98	7110.54			360.95		6.69											4.69	14.58	1.91								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.25	95.25	26.97	0	77.79	0.16	0.16	35.78	63.48	30.06	44.45	38.9	38.9	38.9	11.67	23.34			77.79		0.16											95.25	0.16	0								9.12	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.34	2.2	0.14	3.62	1.17	10.63	13.83	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.27	-	-	-	-	-	-	-	-	55.43	0	15.82	9.12	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.34	2.2	0.14	3.62	1.17	10.63	13.83	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.27	-	-	-	-	-	-	-	-	55.43	5000																																																																																			-		0	9.12	0.71	2.11	-	0.95	0.1	0.01	0.78	2.05	2.34	2.2	0.14	3.62	1.17	10.63	13.83	-	-	2.34	-	1.04	-	-	-	-	-	-	-	-	-	-	0.04	2.27	-	-	-	-	-	-	-	-	55.43
H1804_265_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		195.96	9.81	928.35	2371.55	8.06	0.62	0.05	16.17	38.65	41.25	42.1	1.87	5.37	15.94	10822.97	7040.92			2.39		6.56											10.31	0.52	14.3	26.25							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							416.04	416.04	26.22	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.35	22.69			0.15		0.15											416.04	416.04	0.15	0.14							6.79	0.34	2.03	-	1.22	0.09	0.01	2.45	5.85	6.24	-	0.28	0.81	2.41	10.23	13.31	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.16	3.69	-	-	-	-	-	-	59.65	0	23.88	6.79	0.34	2.03	-	1.22	0.09	0.01	2.45	5.85	6.24	-	0.28	0.81	2.41	10.23	13.31	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.16	3.69	-	-	-	-	-	-	59.65	5000																																																																																			-		0	6.79	0.34	2.03	-	1.22	0.09	0.01	2.45	5.85	6.24	-	0.28	0.81	2.41	10.23	13.31	-	-	0.36	-	0.99	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.16	3.69	-	-	-	-	-	-	59.65
H1804_266_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		189.2	9.47	896.3	2289.66	7.52	0.57	0.04	15.08	36.05	38.47	40.64	1.75	5.01	14.86	10449.28	6797.81			2.23		6.12											0.5	13.33	24.48								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								422.68	422.68	26.64	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.53	23.06			0.15		0.15											422.68	0.15	0.14								6.66	0.33	1.99	-	1.16	0.09	0.01	2.32	5.54	5.91	-	0.27	0.77	2.28	10.04	13.06	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.05	3.49	-	-	-	-	-	-	-	57.27	0	21.39	6.66	0.33	1.99	-	1.16	0.09	0.01	2.32	5.54	5.91	-	0.27	0.77	2.28	10.04	13.06	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.05	3.49	-	-	-	-	-	-	-	57.27	5000																																																																																			-		0	6.66	0.33	1.99	-	1.16	0.09	0.01	2.32	5.54	5.91	-	0.27	0.77	2.28	10.04	13.06	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.02	2.05	3.49	-	-	-	-	-	-	-	57.27
H1804_267_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1109.1	86.08	905.21	2312.45	141.13	0.59	0.04	252.07	373.44	903.09	574.69	41.05	1079.19	348.92	10553.25	6865.46			348.51		6.24											4.53	13.6	1.78								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								96.19	96.19	27.23	0	78.56	0.16	0.16	36.14	64.11	30.35	44.89	39.28	39.28	39.28	11.78	23.57			78.56		0.16											96.19	0.16	0								8.89	0.69	2.05	-	0.92	0.09	0.01	0.76	2	2.28	2.15	0.13	3.53	1.14	10.36	13.48	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	53.94	0	14.72	8.89	0.69	2.05	-	0.92	0.09	0.01	0.76	2	2.28	2.15	0.13	3.53	1.14	10.36	13.48	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	53.94	5000																																																																																			-		0	8.89	0.69	2.05	-	0.92	0.09	0.01	0.76	2	2.28	2.15	0.13	3.53	1.14	10.36	13.48	-	-	2.28	-	0.98	-	-	-	-	-	-	-	-	-	-	0.04	2.14	-	-	-	-	-	-	-	-	53.94
H1804_268_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		189.2	9.47	896.3	2289.66	7.52	0.57	0.04	15.08	36.05	38.47	40.64	1.75	5.01	14.86	10449.28	6797.81			2.23		6.12											9.96	0.5	13.33	24.48							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							421.97	421.97	26.59	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.51	23.02			0.15		0.15											421.97	421.97	0.15	0.14							6.65	0.33	1.99	-	1.15	0.09	0.01	2.31	5.53	5.9	-	0.27	0.77	2.28	10.02	13.04	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.05	3.49	-	-	-	-	-	-	57.53	0	21.62	6.65	0.33	1.99	-	1.15	0.09	0.01	2.31	5.53	5.9	-	0.27	0.77	2.28	10.02	13.04	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.05	3.49	-	-	-	-	-	-	57.53	5000																																																																																			-		0	6.65	0.33	1.99	-	1.15	0.09	0.01	2.31	5.53	5.9	-	0.27	0.77	2.28	10.02	13.04	-	-	0.34	-	0.94	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.05	3.49	-	-	-	-	-	-	57.53
H1804_269_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		192.2	9.62	910.51	2325.99	7.76	0.59	0.04	15.57	37.21	39.71	41.29	1.8	5.17	15.34	10615.05	6905.66			2.3		6.32											0.51	13.76	25.27								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								420.02	420.02	26.47	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.45	22.91			0.15		0.15											420.02	0.15	0.14								6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.68	6.06	-	0.28	0.79	2.34	10.13	13.18	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.1	3.58	-	-	-	-	-	-	-	58.23	0	22.38	6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.68	6.06	-	0.28	0.79	2.34	10.13	13.18	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.1	3.58	-	-	-	-	-	-	-	58.23	5000																																																																																			-		0	6.73	0.34	2.01	-	1.19	0.09	0.01	2.38	5.68	6.06	-	0.28	0.79	2.34	10.13	13.18	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.02	2.1	3.58	-	-	-	-	-	-	-	58.23
H1804_270_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1126.69	87.44	919.57	2349.13	143.37	0.6	0.05	256.07	379.36	917.41	583.81	41.7	1096.31	354.46	10720.68	6974.38			354.04		6.44											4.6	14.04	1.84								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								95.77	95.77	27.11	0	78.22	0.16	0.16	35.98	63.83	30.22	44.7	39.11	39.11	39.11	11.73	23.47			78.22		0.16											95.77	0.16	0								8.99	0.7	2.08	-	0.93	0.09	0.01	0.77	2.02	2.31	2.17	0.14	3.57	1.16	10.48	13.64	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.61	0	15.21	8.99	0.7	2.08	-	0.93	0.09	0.01	0.77	2.02	2.31	2.17	0.14	3.57	1.16	10.48	13.64	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.61	5000																																																																																			-		0	8.99	0.7	2.08	-	0.93	0.09	0.01	0.77	2.02	2.31	2.17	0.14	3.57	1.16	10.48	13.64	-	-	2.31	-	1.01	-	-	-	-	-	-	-	-	-	-	0.04	2.2	-	-	-	-	-	-	-	-	54.61
H1804_271_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		192.2	9.62	910.51	2325.99	7.76	0.59	0.04	15.57	37.21	39.71	41.29	1.8	5.17	15.34	10615.05	6905.66			2.3		6.32											10.12	0.51	13.76	25.27							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							419.3	419.3	26.43	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.44	22.87			0.15		0.15											419.3	419.3	0.15	0.14							6.72	0.34	2.01	-	1.18	0.09	0.01	2.37	5.67	6.05	-	0.28	0.79	2.34	10.12	13.16	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.1	3.58	-	-	-	-	-	-	58.48	0	22.61	6.72	0.34	2.01	-	1.18	0.09	0.01	2.37	5.67	6.05	-	0.28	0.79	2.34	10.12	13.16	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.1	3.58	-	-	-	-	-	-	58.48	5000																																																																																			-		0	6.72	0.34	2.01	-	1.18	0.09	0.01	2.37	5.67	6.05	-	0.28	0.79	2.34	10.12	13.16	-	-	0.35	-	0.96	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.1	3.58	-	-	-	-	-	-	58.48
H1804_272_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		197.82	9.9	937.12	2393.95	8.24	0.63	0.05	16.52	39.49	42.14	42.5	1.92	5.49	16.28	10925.23	7107.45			2.44		6.7											0.52	14.6	26.82								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								414.99	414.99	26.15	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.32	22.64			0.15		0.15											414.99	0.15	0.14								6.84	0.34	2.04	-	1.24	0.09	0.01	2.49	5.96	6.36	-	0.29	0.83	2.46	10.3	13.41	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.2	3.76	-	-	-	-	-	-	-	60.03	0	24.34	6.84	0.34	2.04	-	1.24	0.09	0.01	2.49	5.96	6.36	-	0.29	0.83	2.46	10.3	13.41	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.2	3.76	-	-	-	-	-	-	-	60.03	5000																																																																																			-		0	6.84	0.34	2.04	-	1.24	0.09	0.01	2.49	5.96	6.36	-	0.29	0.83	2.46	10.3	13.41	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.02	2.2	3.76	-	-	-	-	-	-	-	60.03
H1804_273_0	2007	2	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		203.22	10.17	962.71	2459.33	8.68	0.66	0.05	17.41	41.6	44.4	43.66	2.02	5.78	17.15	11223.59	7301.55			2.57		7.06											0.54	15.39	28.25								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								410.4	410.4	25.87	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.19	22.39			0.15		0.15											410.4	0.15	0.14								6.95	0.35	2.08	-	1.3	0.1	0.01	2.6	6.21	6.63	-	0.3	0.86	2.56	10.47	13.62	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.3	3.92	-	-	-	-	-	-	-	61.69	0	26.22	6.95	0.35	2.08	-	1.3	0.1	0.01	2.6	6.21	6.63	-	0.3	0.86	2.56	10.47	13.62	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.3	3.92	-	-	-	-	-	-	-	61.69	5000																																																																																			-		0	6.95	0.35	2.08	-	1.3	0.1	0.01	2.6	6.21	6.63	-	0.3	0.86	2.56	10.47	13.62	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.02	2.3	3.92	-	-	-	-	-	-	-	61.69
H1804_274_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1159.62	90	946.44	2417.78	147.56	0.64	0.05	263.55	390.45	944.22	600.87	42.92	1128.34	364.81	11033.94	7178.17			364.39		6.84											4.74	14.9	1.95								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.99	94.99	26.89	0	77.58	0.16	0.16	35.69	63.31	29.97	44.33	38.79	38.79	38.79	11.64	23.27			77.58		0.16											94.99	0.16	0								9.18	0.71	2.12	-	0.95	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.65	1.18	10.7	13.92	-	-	2.36	-	1.06	-	-	-	-	-	-	-	-	-	-	0.04	2.31	-	-	-	-	-	-	-	-	55.85	0	16.14	9.18	0.71	2.12	-	0.95	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.65	1.18	10.7	13.92	-	-	2.36	-	1.06	-	-	-	-	-	-	-	-	-	-	0.04	2.31	-	-	-	-	-	-	-	-	55.85	5000																																																																																			-		0	9.18	0.71	2.12	-	0.95	0.1	0.01	0.78	2.06	2.36	2.22	0.14	3.65	1.18	10.7	13.92	-	-	2.36	-	1.06	-	-	-	-	-	-	-	-	-	-	0.04	2.31	-	-	-	-	-	-	-	-	55.85
H1804_275_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1191.28	92.45	972.29	2483.8	151.59	0.68	0.05	270.75	401.11	970.01	617.28	44.09	1159.16	374.78	11335.26	7374.2			374.34		7.2											4.87	15.69	2.06								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								94.25	94.25	26.68	0	76.98	0.15	0.15	35.41	62.82	29.74	43.99	38.49	38.49	38.49	11.55	23.09			76.98		0.15											94.25	0.15	0								9.36	0.73	2.16	-	0.97	0.1	0.01	0.8	2.1	2.4	2.26	0.14	3.72	1.2	10.91	14.19	-	-	2.4	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.42	-	-	-	-	-	-	-	-	57.02	0	17.05	9.36	0.73	2.16	-	0.97	0.1	0.01	0.8	2.1	2.4	2.26	0.14	3.72	1.2	10.91	14.19	-	-	2.4	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.42	-	-	-	-	-	-	-	-	57.02	5000																																																																																			-		0	9.36	0.73	2.16	-	0.97	0.1	0.01	0.8	2.1	2.4	2.26	0.14	3.72	1.2	10.91	14.19	-	-	2.4	-	1.11	-	-	-	-	-	-	-	-	-	-	0.04	2.42	-	-	-	-	-	-	-	-	57.02
H1804_276_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		197.82	9.9	937.12	2393.95	8.24	0.63	0.05	16.52	39.49	42.14	42.5	1.92	5.49	16.28	10925.23	7107.45			2.44		6.7											10.41	0.52	14.6	26.82							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							414.28	414.28	26.11	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.3	22.6			0.15		0.15											414.28	414.28	0.15	0.14							6.83	0.34	2.04	-	1.24	0.09	0.01	2.49	5.95	6.35	-	0.29	0.83	2.45	10.29	13.38	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.2	3.75	-	-	-	-	-	-	60.29	0	24.58	6.83	0.34	2.04	-	1.24	0.09	0.01	2.49	5.95	6.35	-	0.29	0.83	2.45	10.29	13.38	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.2	3.75	-	-	-	-	-	-	60.29	5000																																																																																			-		0	6.83	0.34	2.04	-	1.24	0.09	0.01	2.49	5.95	6.35	-	0.29	0.83	2.45	10.29	13.38	-	-	0.37	-	1.01	-	-	-	-	-	-	-	-	-	-	0.36	0.02	2.2	3.75	-	-	-	-	-	-	60.29
H1804_277_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		203.22	10.17	962.71	2459.33	8.68	0.66	0.05	17.41	41.6	44.4	43.66	2.02	5.78	17.15	11223.59	7301.54			2.57		7.06											10.7	0.54	15.39	28.25							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							409.68	409.68	25.82	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.17	22.35			0.15		0.15											409.68	409.68	0.15	0.14							6.94	0.35	2.07	-	1.29	0.1	0.01	2.59	6.2	6.61	-	0.3	0.86	2.56	10.45	13.6	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.29	3.91	-	-	-	-	-	-	61.95	0	26.48	6.94	0.35	2.07	-	1.29	0.1	0.01	2.59	6.2	6.61	-	0.3	0.86	2.56	10.45	13.6	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.29	3.91	-	-	-	-	-	-	61.95	5000																																																																																			-		0	6.94	0.35	2.07	-	1.29	0.1	0.01	2.59	6.2	6.61	-	0.3	0.86	2.56	10.45	13.6	-	-	0.38	-	1.05	-	-	-	-	-	-	-	-	-	-	0.37	0.02	2.29	3.91	-	-	-	-	-	-	61.95
H1804_801_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1141.4	88.58	465.79	2379.8	145.24	0.62	0.05	212.72	384.31	211.22	633.67	42.24	1110.62	359.08	10860.62	7065.41			358.66		6.64											60.07	4.66	14.46								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.41	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.1	17.66	-	-	1.49	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.89	-	-	-	-	-	-	-	75.27	0	0	19.41	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.1	17.66	-	-	1.49	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.89	-	-	-	-	-	-	-	75.27																																																																																				-		0	19.41	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.1	17.66	-	-	1.49	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.89	-	-	-	-	-	-	-	75.27
H1804_804_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1141.47	88.59	465.82	2379.95	145.25	0.62	0.05	212.73	384.34	211.24	633.71	42.25	1110.69	359.1	10861.3	7065.86			358.69		6.64											60.08	4.66	14.46								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.41	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.1	17.66	-	-	1.49	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.89	-	-	-	-	-	-	-	75.28	0	0	19.41	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.1	17.66	-	-	1.49	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.89	-	-	-	-	-	-	-	75.28																																																																																				-		0	19.41	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.1	17.66	-	-	1.49	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.89	-	-	-	-	-	-	-	75.28
H1804_805_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1142.57	88.67	466.27	2382.23	145.39	0.62	0.05	212.94	384.71	211.44	634.32	42.29	1111.75	359.45	10871.72	7072.64			359.03		6.66											60.14	4.67	14.5								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.43	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.12	17.68	-	-	1.5	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.9	-	-	-	-	-	-	-	75.36	0	0	19.43	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.12	17.68	-	-	1.5	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.9	-	-	-	-	-	-	-	75.36																																																																																				-		0	19.43	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.12	17.68	-	-	1.5	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.9	-	-	-	-	-	-	-	75.36
H1804_806_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1142.62	88.68	466.29	2382.35	145.4	0.62	0.05	212.95	384.72	211.45	634.35	42.29	1111.81	359.47	10872.25	7072.98			359.05		6.66											60.14	4.67	14.51								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.43	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.12	17.68	-	-	1.5	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.9	-	-	-	-	-	-	-	75.36	0	0	19.43	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.12	17.68	-	-	1.5	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.9	-	-	-	-	-	-	-	75.36																																																																																				-		0	19.43	1.51	0.68	-	1.21	0.16	0.01	0.88	3.19	0.88	3.08	0.35	-	1.34	18.12	17.68	-	-	1.5	-	1.33	-	-	-	-	-	-	-	-	-	-	1.02	0.08	2.9	-	-	-	-	-	-	-	75.36
H1806_001_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1229.05	8.97	440.92	2103.72	122.67	0.68	0.05	199.05	433.9	800.18	545.57	36.37	372.98	309.16	7032.21	8341.47			307.6		9.44											64.69	0.47	15.36								175/day (1-5)	175/day (1-5)	0/day (1-13) 75/day (14-100)	15/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125-175/ Visit	0-75/ Visit	50-75/ Visit	50/ Visit	0/ Procedure	35-75/ Visit	15/ Visit	35/ Visit			50/ Visit		20 Coins											175/day (1-5)	175/day (1-5)	20 Coins								119.04	119.04	11.79	15	100	0.2	0.2	49.63	141.5	57.95	54.17	50	0	42.06	15	35			50		0.2											119.04	119.04	0.2								12.19	0.09	0.43	2.63	1.02	0.14	0.01	0.82	5.12	3.86	2.46	0.15	-	1.08	8.79	24.33	-	-	1.28	-	1.89	-	-	-	-	-	-	-	-	-	-	0.64	0	3.07	-	-	-	-	-	-	-	70.02	0	0	12.19	0.09	0.43	2.63	1.02	0.14	0.01	0.82	5.12	3.86	2.46	0.15	-	1.08	8.79	24.33	-	-	1.28	-	1.89	-	-	-	-	-	-	-	-	-	-	0.64	0	3.07	-	-	-	-	-	-	-	70.02		25 Coins	25 Coins	25 Coins	25 Coins	100/Trip	25 Coins		50/Visit	25 Coins	25 Coins			0/Procedure		25 Coins	25 Coins					20 Coins													25 Coins								7.61	0.03	0.25	0.35	0.28	0.02		0.27	3.14	3.71			0		2.35	2.83					0.61													0.81								22.27	250	0.53	19.8	0.12	0.69	2.97	1.3	0.16	0.01	1.1	8.26	7.58	2.46	0.15	-	1.08	11.14	27.16	-	-	1.28	-	2.5	-	-	-	-	-	-	-	-	-	-	0.64	0	3.88	-	-	-	-	-	-	-	92.29
H1806_002_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1212.22	8.85	434.88	2074.91	120.99	0.66	0.05	196.32	427.95	789.22	538.1	35.87	367.87	304.92	6935.9	8227.23			303.38		9.19											63.8	0.47	14.95								150/day (1-5)	150/day (1-5)	0/day (1-13) 75/day (14-100)	15/Visit	75/ Trip	20 Coins	20 Coins	35-50/ Visit	125-175/ Visit	0-75/ Visit	50-75/ Visit	50/ Visit	0/ Procedure	35-75/ Visit	15/ Visit	35/ Visit			50/ Visit		20 Coins											150/day (1-5)	150/day (1-5)	20 Coins								102.03	102.03	11.79	15	75	0.2	0.2	49.63	141.5	57.95	54.17	50	0	42.06	15	35			50		0.2											102.03	102.03	0.2								10.31	0.08	0.43	2.59	0.76	0.13	0.01	0.81	5.05	3.81	2.43	0.15	-	1.07	8.67	24	-	-	1.26	-	1.84	-	-	-	-	-	-	-	-	-	-	0.54	0	2.99	-	-	-	-	-	-	-	66.92	0	0	10.31	0.08	0.43	2.59	0.76	0.13	0.01	0.81	5.05	3.81	2.43	0.15	-	1.07	8.67	24	-	-	1.26	-	1.84	-	-	-	-	-	-	-	-	-	-	0.54	0	2.99	-	-	-	-	-	-	-	66.92		25 Coins	25 Coins	25 Coins	25 Coins	75/Trip	25 Coins		50/Visit	25 Coins	25 Coins			0/Procedure		25 Coins	25 Coins					20 Coins													25 Coins								7.27	0.03	0.24	0.33	0.21	0.02		0.28	3	3.54			0		2.25	2.7					0.58													0.77								21.23	250	0	17.57	0.1	0.67	2.92	0.97	0.16	0.01	1.09	8.05	7.36	2.43	0.15	-	1.07	10.92	26.7	-	-	1.26	-	2.42	-	-	-	-	-	-	-	-	-	-	0.54	0	3.76	-	-	-	-	-	-	-	88.15
H1806_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		251.87	1.9	223.82	2135.8	124.54	0.7	0.05	246.45	440.51	812.38	553.89	36.93	378.67	313.87	7139.42	8468.65			312.29		9.73											13.26	0.1									600/admit	600/admit	100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35-50/ Visit		20 Coins											600/admit	600/admit									600	600	17.61	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			43.14		0.2											600	600									12.59	0.09	0.33	1.78	1.04	0.18	0.01	0.93	7.34	2.37	2.12	0.31	-	0.98	14.87	24.7	-	-	1.12	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.38	0	0	12.59	0.09	0.33	1.78	1.04	0.18	0.01	0.93	7.34	2.37	2.12	0.31	-	0.98	14.87	24.7	-	-	1.12	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.38		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.38	0.53	0.26	0.05		0.26	4.79	5.66			0		1.79	4.31					0.58																					20.86	0	0	14.83	0.11	0.71	2.31	1.3	0.22	0.01	1.18	12.13	8.02	2.12	0.31	-	0.98	16.67	29.01	-	-	1.12	-	2.53	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	94.24
H1806_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		247.99	1.87	440.75	2102.91	122.62	0.68	0.05	242.65	433.73	799.87	545.37	36.36	372.84	309.04	7029.51	8338.27			307.48		9.44											13.05	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.4	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.23	2.33	2.08	0.3	-	0.97	14.64	24.32	-	-	0.9	-	1.89	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	72.01	0	0	12.4	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.23	2.33	2.08	0.3	-	0.97	14.64	24.32	-	-	0.9	-	1.89	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	72.01		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.2	0.02	0.37	0.51	0.26	0.04		0.25	4.65	5.48			0		1.74	4.18					0.56																					20.27	0	0	14.6	0.11	0.7	2.26	1.28	0.21	0.01	1.17	11.87	7.82	2.08	0.3	-	0.97	16.38	28.5	-	-	0.9	-	2.45	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	92.28
H1806_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		251.87	1.9	223.82	2135.8	124.54	0.7	0.05	246.45	440.51	812.38	553.89	36.93	378.67	313.87	7139.42	8468.65			312.29		9.73											13.26	0.1									600/admit	600/admit	100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35-50/ Visit		20 Coins											600/admit	600/admit									600	600	17.61	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			43.14		0.2											600	600									12.59	0.09	0.33	1.78	1.04	0.18	0.01	0.93	7.34	2.37	2.12	0.31	-	0.98	14.87	24.7	-	-	1.12	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.38	0	0	12.59	0.09	0.33	1.78	1.04	0.18	0.01	0.93	7.34	2.37	2.12	0.31	-	0.98	14.87	24.7	-	-	1.12	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.38		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.38	0.53	0.26	0.05		0.26	4.79	5.66			0		1.79	4.31					0.58																					20.86	0	0	14.83	0.11	0.71	2.31	1.3	0.22	0.01	1.18	12.13	8.02	2.12	0.31	-	0.98	16.67	29.01	-	-	1.12	-	2.53	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	94.24
H1806_805_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		247.99	1.87	440.75	2102.91	122.62	0.68	0.05	242.65	433.73	799.87	545.37	36.36	372.84	309.04	7029.51	8338.27			307.48		9.44											13.05	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.4	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.23	2.33	2.08	0.3	-	0.97	14.64	24.32	-	-	0.9	-	1.89	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	72.01	0	0	12.4	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.23	2.33	2.08	0.3	-	0.97	14.64	24.32	-	-	0.9	-	1.89	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	72.01		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.2	0.02	0.37	0.51	0.26	0.04		0.25	4.65	5.48			0		1.74	4.18					0.56																					20.27	0	0	14.6	0.11	0.7	2.26	1.28	0.21	0.01	1.17	11.87	7.82	2.08	0.3	-	0.97	16.38	28.5	-	-	0.9	-	2.45	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	92.28
H1807_001_0	2007	3																					none											A	A	D	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	none	365.36	11.3	2283.34	0	16.11	40.43	3.52	26.97	36.06	5.14	22.66	0	0.2	29.46	51.05	129.21	6.15	2.29	26	6.94	27.65	22.32																				Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-40 0/day; days 41-100 100/day	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	20-50 coinsurance depending on APC	20-50 coinsurance depending on APC	0 coinsurance	20-50 coinsurance depending on APC	0 copay	20 coinsurance	20-50 coinsurance depending on APC	20 coinsurance	20 coinsurance	50 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				822.4	822.4	5.81	0	0.2	0.2	0.2	0.33	0.24	0	0.33	0	0.2	0.29	0.2	0.2	0.5	0.2	0.2	0.2	0.2	0.2																				25.04	0.77	1.11	-	3.28	8.23	0.72	8.84	8.57	0	7.43	-	0.04	8.61	10.26	26.3	3.07	0.47	5.29	1.41	5.63	4.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.56	0	0	25.04	0.77	1.11	-	3.28	8.23	0.72	8.84	8.57	0	7.43	-	0.04	8.61	10.26	26.3	3.07	0.47	5.29	1.41	5.63	4.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.56	none																																																																																			-	0	0	25.04	0.77	1.11	-	3.28	8.23	0.72	8.84	8.57	0	7.43	-	0.04	8.61	10.26	26.3	3.07	0.47	5.29	1.41	5.63	4.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.56
H1849_005_0	2007	8	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	390.63	7.28	585.07		316.31	12.32	4.15	354.95	452.91	928.05	1113	49.85	30.71	0.88	5809.3	1925.25	4.8	461.4			221.36				21.71		162					1062.17	21.46	82.81	393.31	116.41	0.04	874.26	2.48			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			404.73	456.87	68.25		68.25	0.18	0.18	45.5	159.24	46.46	54.22	159.24	31.5	22.75	9.1	22.75	22.75	22.75			27.5				22.75		22.75					22.75	45.5	22.75	22.75	9.1	0.18	22.75	22.75			13.17	0.28	3.33	-	1.8	2.24	0.76	1.35	6.01	3.59	5.03	0.66	0.08	0	4.41	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.85		5.23	13.17	0.28	3.33	-	1.8	2.24	0.76	1.35	6.01	3.59	5.03	0.66	0.08	0	4.41	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.85	2750																																																																																			-			13.17	0.28	3.33	-	1.8	2.24	0.76	1.35	6.01	3.59	5.03	0.66	0.08	0	4.41	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.85
H1849_014_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	2251.53	56.43	585.07		316.31	12.32	4.15	354.95	452.91	928.05	1113	49.85	30.71	0.88	5809.3	1925.25	4.8	461.4			221.36				21.71		162					1062.17	21.46	82.81	393.31	116.41	0.04	874.26	2.48			150/day with 1500 yearly max	150/day with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			88.26	89.94	68.55		68.55	0.18	0.18	45.7	137.1	46.67	54.47	137.1	31.64	22.85	9.14	22.85	22.85	22.85			27.63				22.85		22.85					22.85	45.7	22.85	22.85	9.14	0.18	22.85	22.85			16.56	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.67	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.6		5.23	16.56	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.67	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.6	2750																																																																																			-			16.56	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.67	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.6
H1849_801_0	2007	4	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	374.34	4.96	316.31		0.25	13.55	6.15	301.38	541.03	953.99	1240.13	42.77	10.66	0	6593.1	2236.98	2.76	736.56			252.47				31.1		162					1128.18	24.67	146.65	479.53	159.42	0.05	1013.93	3.16			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			406.57	423.82	68.36		68.36	0.18	0.18	45.57	159.5	46.74	55.15	159.5	31.9	22.79	9.11	22.79	22.79	22.79			34.36				22.79		22.79					22.79	45.57	22.79	22.79	9.11	0.18	22.79	22.79			12.68	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.83		5.23	12.68	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.83	2750																																																																																			-			12.68	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.83
H1849_803_0	2007	2	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	374.34	4.96	316.31		0.25	13.55	6.15	301.38	541.03	953.99	1240.13	42.77	10.66	0	6593.1	2236.98	2.76	736.56			252.47				31.1		162					1128.18	24.67	146.65	479.53	159.42	0.05	1013.93	3.16			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			406.57	423.82	68.36		68.36	0.18	0.18	45.57	159.5	46.74	55.15	159.5	31.9	22.79	9.11	22.79	22.79	22.79			34.36				22.79		22.79					22.79	45.57	22.79	22.79	9.11	0.18	22.79	22.79			12.68	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.83		5.23	12.68	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.83	2750																																																																																			-			12.68	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.83
H1850_001_0	2007	3																																D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		2003.39	219.23	1813.44		242.14	14.53	17.61	534.99	38.19		538.85	30.85		375.13	4364.8	5255.92	747.25	240.85		1.88	27.06				136.81		232.08															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											42.65	75.45	28.87		45	0.2	0.17	44.99	0.17		75	50		29.24	20	21.85	19.5	29.16		0	0.2				30		30															7.12	1.38	4.36	-	0.91	2.91	2.93	2.01	6.56	-	3.37	0.13	-	0.91	7.27	9.57	1.21	0.59	-	0	5.41	-	-	-	0.34	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.56		0	7.12	1.38	4.36	-	0.91	2.91	2.93	2.01	6.56	-	3.37	0.13	-	0.91	7.27	9.57	1.21	0.59	-	0	5.41	-	-	-	0.34	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.56		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	7.12	1.38	4.36	-	0.91	2.91	2.93	2.01	6.56	-	3.37	0.13	-	0.91	7.27	9.57	1.21	0.59	-	0	5.41	-	-	-	0.34	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.56
H1850_002_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		2003.39	219.23	1813.44		242.14	14.53	17.61	534.99	38.19		538.85	30.85		375.13	4364.8	5255.92	747.25	240.85		1.88	27.06				136.81		232.08															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											42.65	75.45	28.87		45	0.2	0.17	44.99	0.17		75	50		29.24	20	21.85	19.5	29.16		0	0.2				30		30															7.12	1.38	4.36	-	0.91	2.91	2.93	2.01	6.56	-	3.37	0.13	-	0.91	7.27	9.57	1.21	0.59	-	0	5.41	-	-	-	0.34	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.56		0	7.12	1.38	4.36	-	0.91	2.91	2.93	2.01	6.56	-	3.37	0.13	-	0.91	7.27	9.57	1.21	0.59	-	0	5.41	-	-	-	0.34	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.56		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	7.12	1.38	4.36	-	0.91	2.91	2.93	2.01	6.56	-	3.37	0.13	-	0.91	7.27	9.57	1.21	0.59	-	0	5.41	-	-	-	0.34	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.56
H1903_001_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1785.3	34.05	427.85	1556.88	282.46	11.21	1.98	413.01	400.17	2744.53	1356.76	0	764.04	819.11	2830.24	5250.88	117.56	506.9	2760.68	15445.6	6.4	2101.5	0	381	175.2	129.07	85.13	3.41	0	113.93	843.2											25  days 1 - 5	25  days 1 - 5	25  days 8 - 100	0	100	20	20	50	25-ASC/ 25-OP/ 0-Non Surg	0	0 - 75		0 - 20	20 to 0	5	0 to 20	10 to 20	20	0 - 75	0 to 5	0 -20	0	0	5 to 20	5	5	5	0		0	0 to 0											15.95	15.95	15.2	0	100	0.2	0.2	50	22.5	0	18.75	0	13.33	10.33	4.04	20	12.5	20	7.53	1.07	0.13	0	0	15	5	5	5	0	0	0	0											2.37	0.05	0.54	-	2.35	2.24	0.4	1.72	0.75	-	2.12	-	0.85	0.71	0.95	8.75	0.12	0.84	1.73	1.37	0.86	-	-	0.48	0.07	0.05	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.37		0	2.37	0.05	0.54	-	2.35	2.24	0.4	1.72	0.75	-	2.12	-	0.85	0.71	0.95	8.75	0.12	0.84	1.73	1.37	0.86	-	-	0.48	0.07	0.05	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.37	0																																																																																			-		0	2.37	0.05	0.54	-	2.35	2.24	0.4	1.72	0.75	-	2.12	-	0.85	0.71	0.95	8.75	0.12	0.84	1.73	1.37	0.86	-	-	0.48	0.07	0.05	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.37
H1903_005_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1678.31	31.95	883.54	3543.68	489.15	23.35	4.15	320.75	316.49	2044.13	1011.44	0	570.45	611.43	5173.09	9829.54	222.84	982.6	4678.28	26206.64	9.07	5597.14	0	381	464.87	338.86	199.23	7.89	0	305.07	2331.2											0  Unlimited	0  Unlimited	0  days 8 - 100	0	100	20	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 5	0 -20	0	0	5 to 20	5	5	5	0		0	0 to 0											0	0	0	0	100	0.2	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.02	1.1	0.13	0	0	15	5	5	5	0	0	0	0											-	-	-	-	4.08	4.67	0.83	1.34	-	-	1.05	-	-	-	-	-	-	-	1.96	2.41	1.22	-	-	0.48	0.19	0.14	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.44		0	-	-	-	-	4.08	4.67	0.83	1.34	-	-	1.05	-	-	-	-	-	-	-	1.96	2.41	1.22	-	-	0.48	0.19	0.14	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.44	0																																																																																			-		0	-	-	-	-	4.08	4.67	0.83	1.34	-	-	1.05	-	-	-	-	-	-	-	1.96	2.41	1.22	-	-	0.48	0.19	0.14	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.44
H1903_011_0	2007	6																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2396.56	47.53	1132.45	5082.58	12.23	32.49	5.52	6.94	36.38	2823.36	37.03	0	11	23.86	6172.13	64.94	2.19	2.67	6385.05	170.7	11.85	7432.34	0	381	599.54	428.72	256.95	9.98	0	370	2331.2											952 Deductible; 238 (61-90); 476 (91+)  0	952 Deductible; 238 (61-90); 476 (91+) - 238  0	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0	0	0	0	0	0	0		0	0 to 0											142.91	121.03	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.13	0.2	0	0.2	0.2	0.2	2.1	0.08	0.13	0	0	0	0	0	0	0	0	0	0											28.54	0.48	2.55	-	2.45	-	-	1.39	7.28	-	1.85	-	1.47	4.77	-	12.99	0.44	0.53	1.12	13.24	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.67		0	28.54	0.48	2.55	-	2.45	-	-	1.39	7.28	-	1.85	-	1.47	4.77	-	12.99	0.44	0.53	1.12	13.24	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.67	0																																																																																			-		0	28.54	0.48	2.55	-	2.45	-	-	1.39	7.28	-	1.85	-	1.47	4.77	-	12.99	0.44	0.53	1.12	13.24	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.67
H1903_014_0	2007	2																					0											D	D	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2283.81	43.25	1217.78	4775.06	667.6	31.86	5.71	441.94	435.55	2805.71	1390.62	0	786.56	842.68	7112.25	13468.57	305.41	1348	6376.15	35841.4	12.56	7687.27	1200	381	639.47	467.37	274.06	10.88	0	422.52	2331.2											0  unlimited	0  unlimited	0  days 1 - 100	0	50	0	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 5	0 -20	0	24 One-way trips per year	5 to 20	5	5	5	0		0	0 to 0											0	0	0	0	50	0	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.02	1.34	0.13	0	0	15	5	5	5	0	0	0	0											-	-	-	-	2.78	-	1.14	1.84	-	-	1.45	-	-	-	-	-	-	-	2.67	4	1.68	-	-	0.48	0.27	0.19	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.62		0	-	-	-	-	2.78	-	1.14	1.84	-	-	1.45	-	-	-	-	-	-	-	2.67	4	1.68	-	-	0.48	0.27	0.19	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.62	0																																																																																			-		0	-	-	-	-	2.78	-	1.14	1.84	-	-	1.45	-	-	-	-	-	-	-	2.67	4	1.68	-	-	0.48	0.27	0.19	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.62
H1903_018_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1765.36	33.33	943.83	3713.03	517.71	24.68	4.43	342.29	337.06	2167.12	1075.41	0	609.53	652.81	5538.66	10460.48	236.91	1046.29	4957.53	27863.61	9.72	5445.61	0	381	498.13	364.31	213.48	8.48	0	330.29	843.2											0  unlimited	0  unlimited	0  days 8 - 100	0	50	20	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 0	0 to 0	0	0 - 50	0 to 5	0 -20	5	0	5 to 20	5	5	5	0		0	0 to 0											0	0	0	0	50	0.2	0.2	50	0	0	12.5	0	0	0	0	0	0	0	5.03	1.11	0.13	5	0	15	5	5	5	0	0	0	0											-	-	-	-	2.16	4.94	0.89	1.43	-	-	1.12	-	-	-	-	-	-	-	2.08	2.59	1.3	2.27	-	0.48	0.21	0.15	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.68		0	-	-	-	-	2.16	4.94	0.89	1.43	-	-	1.12	-	-	-	-	-	-	-	2.08	2.59	1.3	2.27	-	0.48	0.21	0.15	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.68	0																																																																																			-		0	-	-	-	-	2.16	4.94	0.89	1.43	-	-	1.12	-	-	-	-	-	-	-	2.08	2.59	1.3	2.27	-	0.48	0.21	0.15	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.68
H1906_001_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		210.56	10.54	997.47	2548.13	9.32	0.71	0.05	18.7	44.69	47.69	45.23	2.17	6.21	18.43	11628.82	7565.17			2.77		7.59											0.55	16.53	30.35								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								404.03	404.03	25.46	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.02	22.04			0.15		0.15											404.03	0.15	0.14								7.09	0.35	2.12	-	1.37	0.1	0.01	2.75	6.57	7.01	-	0.32	0.91	2.71	10.68	13.89	-	-	0.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.02	2.43	4.14	-	-	-	-	-	-	-	63.98	0	29	7.09	0.35	2.12	-	1.37	0.1	0.01	2.75	6.57	7.01	-	0.32	0.91	2.71	10.68	13.89	-	-	0.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.02	2.43	4.14	-	-	-	-	-	-	-	63.98	5000																																																																																			-		0	7.09	0.35	2.12	-	1.37	0.1	0.01	2.75	6.57	7.01	-	0.32	0.91	2.71	10.68	13.89	-	-	0.41	-	1.11	-	-	-	-	-	-	-	-	-	-	0.02	2.43	4.14	-	-	-	-	-	-	-	63.98
H1906_002_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		228.91	11.46	1084.44	2770.29	11.02	0.84	0.06	22.1	52.82	56.36	49.18	2.56	7.34	21.78	12642.71	8224.76			3.27		8.97											0.6	19.53	35.87								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								388.53	388.53	24.49	0	0.14	0.14	0.14	0.14	0.14	0.14	0	0.14	0.14	0.14	10.6	21.19			0.14		0.14											388.53	0.14	0.13								7.41	0.37	2.21	-	1.56	0.12	0.01	3.12	7.46	7.96	-	0.36	1.04	3.08	11.16	14.53	-	-	0.46	-	1.27	-	-	-	-	-	-	-	-	-	-	0.02	2.76	4.71	-	-	-	-	-	-	-	69.61	0	36.62	7.41	0.37	2.21	-	1.56	0.12	0.01	3.12	7.46	7.96	-	0.36	1.04	3.08	11.16	14.53	-	-	0.46	-	1.27	-	-	-	-	-	-	-	-	-	-	0.02	2.76	4.71	-	-	-	-	-	-	-	69.61	5000																																																																																			-		0	7.41	0.37	2.21	-	1.56	0.12	0.01	3.12	7.46	7.96	-	0.36	1.04	3.08	11.16	14.53	-	-	0.46	-	1.27	-	-	-	-	-	-	-	-	-	-	0.02	2.76	4.71	-	-	-	-	-	-	-	69.61
H1906_003_0	2007	3	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin									Coin		A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		229.01	11.46	1084.91	2771.49	11.04	0.84	0.06	22.14	52.91	56.46	49.2	2.57	7.36	21.81	12648.16	8228.3			3.27		8.98											0.6	19.57	35.93								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								388.38	388.38	24.48	0	0.14	0.14	0.14	0.14	0.14	0.14	0	0.14	0.14	0.14	10.59	21.18			0.14		0.14											388.38	0.14	0.13								7.41	0.37	2.21	-	1.56	0.12	0.01	3.13	7.47	7.97	-	0.36	1.04	3.08	11.16	14.53	-	-	0.46	-	1.27	-	-	-	-	-	-	-	-	-	-	0.02	2.76	4.71	-	-	-	-	-	-	-	69.65	0	36.7	7.41	0.37	2.21	-	1.56	0.12	0.01	3.13	7.47	7.97	-	0.36	1.04	3.08	11.16	14.53	-	-	0.46	-	1.27	-	-	-	-	-	-	-	-	-	-	0.02	2.76	4.71	-	-	-	-	-	-	-	69.65	5000																																																																																			-		0	7.41	0.37	2.21	-	1.56	0.12	0.01	3.13	7.47	7.97	-	0.36	1.04	3.08	11.16	14.53	-	-	0.46	-	1.27	-	-	-	-	-	-	-	-	-	-	0.02	2.76	4.71	-	-	-	-	-	-	-	69.65
H1906_006_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1234.29	95.79	1007.39	2573.47	157.06	0.73	0.05	280.52	415.59	1005.02	639.56	45.68	1201	388.31	11744.47	7640.41			387.85		7.74											5.04	16.86	2.21								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								93.27	93.27	26.41	0	76.18	0.15	0.15	35.04	62.16	29.43	43.53	38.09	38.09	38.09	11.43	22.85			76.18		0.15											93.27	0.15	0								9.59	0.74	2.22	-	1	0.11	0.01	0.82	2.15	2.46	2.32	0.14	3.81	1.23	11.18	14.55	-	-	2.46	-	1.18	-	-	-	-	-	-	-	-	-	-	0.04	2.57	-	-	-	-	-	-	-	-	58.6	0	18.33	9.59	0.74	2.22	-	1	0.11	0.01	0.82	2.15	2.46	2.32	0.14	3.81	1.23	11.18	14.55	-	-	2.46	-	1.18	-	-	-	-	-	-	-	-	-	-	0.04	2.57	-	-	-	-	-	-	-	-	58.6	5000																																																																																			-		0	9.59	0.74	2.22	-	1	0.11	0.01	0.82	2.15	2.46	2.32	0.14	3.81	1.23	11.18	14.55	-	-	2.46	-	1.18	-	-	-	-	-	-	-	-	-	-	0.04	2.57	-	-	-	-	-	-	-	-	58.6
H1906_007_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1341.88	104.14	1095.2	2797.79	170.76	0.86	0.06	304.98	451.82	1092.63	695.31	49.67	1305.69	422.15	12768.21	8306.41			421.66		9.15											5.48	19.92	2.61								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								90.89	90.89	25.73	0	74.24	0.15	0.15	34.15	60.58	28.68	42.42	37.12	37.12	37.12	11.14	22.27			74.24		0.15											90.89	0.15	0								10.16	0.79	2.35	-	1.06	0.13	0.01	0.87	2.28	2.61	2.46	0.15	4.04	1.31	11.85	15.42	-	-	2.61	-	1.36	-	-	-	-	-	-	-	-	-	-	0.04	2.96	-	-	-	-	-	-	-	-	62.44	0	21.67	10.16	0.79	2.35	-	1.06	0.13	0.01	0.87	2.28	2.61	2.46	0.15	4.04	1.31	11.85	15.42	-	-	2.61	-	1.36	-	-	-	-	-	-	-	-	-	-	0.04	2.96	-	-	-	-	-	-	-	-	62.44	5000																																																																																			-		0	10.16	0.79	2.35	-	1.06	0.13	0.01	0.87	2.28	2.61	2.46	0.15	4.04	1.31	11.85	15.42	-	-	2.61	-	1.36	-	-	-	-	-	-	-	-	-	-	0.04	2.96	-	-	-	-	-	-	-	-	62.44
H1906_008_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	Coin	Coins								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1342.53	104.19	1095.73	2799.15	170.84	0.86	0.06	305.12	452.03	1093.16	695.65	49.69	1306.32	422.36	12774.39	8310.43			421.87		9.16											5.48	19.96	2.62								180/day (1-5)	180/day (1-5)	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	50/ Procedure	50/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins											180/day (1-5)	20 Coins	0 Coins								90.88	90.88	25.73	0	74.22	0.15	0.15	34.14	60.57	28.68	42.41	37.11	37.11	37.11	11.13	22.27			74.22		0.15											90.88	0.15	0								10.17	0.79	2.35	-	1.06	0.13	0.01	0.87	2.28	2.61	2.46	0.15	4.04	1.31	11.85	15.42	-	-	2.61	-	1.36	-	-	-	-	-	-	-	-	-	-	0.04	2.96	-	-	-	-	-	-	-	-	62.47	0	21.69	10.17	0.79	2.35	-	1.06	0.13	0.01	0.87	2.28	2.61	2.46	0.15	4.04	1.31	11.85	15.42	-	-	2.61	-	1.36	-	-	-	-	-	-	-	-	-	-	0.04	2.96	-	-	-	-	-	-	-	-	62.47	5000																																																																																			-		0	10.17	0.79	2.35	-	1.06	0.13	0.01	0.87	2.28	2.61	2.46	0.15	4.04	1.31	11.85	15.42	-	-	2.61	-	1.36	-	-	-	-	-	-	-	-	-	-	0.04	2.96	-	-	-	-	-	-	-	-	62.47
H1906_801_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1251.95	97.16	510.9	2610.29	159.31	0.75	0.06	233.32	421.54	231.68	695.05	46.34	1218.18	393.86	11912.51	7749.72			393.4		8											65.89	5.11	17.42								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								21.29	1.65	0.75	-	1.33	0.19	0.01	0.96	3.5	0.97	3.38	0.39	-	1.47	19.85	19.37	-	-	1.64	-	1.6	-	-	-	-	-	-	-	-	-	-	1.12	0.09	3.48	-	-	-	-	-	-	-	83.04	0	0	21.29	1.65	0.75	-	1.33	0.19	0.01	0.96	3.5	0.97	3.38	0.39	-	1.47	19.85	19.37	-	-	1.64	-	1.6	-	-	-	-	-	-	-	-	-	-	1.12	0.09	3.48	-	-	-	-	-	-	-	83.04																																																																																				-		0	21.29	1.65	0.75	-	1.33	0.19	0.01	0.96	3.5	0.97	3.38	0.39	-	1.47	19.85	19.37	-	-	1.64	-	1.6	-	-	-	-	-	-	-	-	-	-	1.12	0.09	3.48	-	-	-	-	-	-	-	83.04
H1906_802_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1201.54	93.25	490.33	2505.17	152.9	0.69	0.05	223.92	404.56	222.35	667.06	44.47	1169.13	378	11432.8	7437.65			377.56		7.39											63.24	4.91	16.09								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5	0	0	20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5																																																																																				-		0	20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5
H1906_803_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1201.54	93.25	490.33	2505.17	152.9	0.69	0.05	223.92	404.56	222.35	667.06	44.47	1169.13	378	11432.8	7437.65			377.56		7.39											63.24	4.91	16.09								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5	0	0	20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5																																																																																				-		0	20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5
H1906_804_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1201.54	93.25	490.33	2505.17	152.9	0.69	0.05	223.92	404.56	222.35	667.06	44.47	1169.13	378	11432.8	7437.65			377.56		7.39											63.24	4.91	16.09								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5	0	0	20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5																																																																																				-		0	20.43	1.59	0.72	-	1.27	0.17	0.01	0.92	3.35	0.93	3.24	0.37	-	1.41	19.05	18.59	-	-	1.57	-	1.48	-	-	-	-	-	-	-	-	-	-	1.08	0.08	3.22	-	-	-	-	-	-	-	79.5
H1951_001_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin				Coin							D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0							0	0	0								-		1996.59	44.34	816.13	2613.9	253.07	0.71	0.05	442.93	487.56	284.64	194.07	12.94	52.04	109.97	7507.75	6783.48			285.94		9.5				0							105.08	2.33	14.76								45/day (1-7)	45/day (1-7)	0/day (1-6) 25/day (7-100)	0/Visit	150/ Trip	20 Coins	20 Coins	10-50/ Visit	100/ Visit	0-50/ Visit	0-150/ Visit	25/ Visit	0/ Procedure	10-150/ Visit	10/ Visit	25/ Visit			150/ Visit		20 Coins				0							45/day (1-7)	45/day (1-7)	20 Coins								35.08	35.08	7.27	0	150	0.2	0.2	42.65	100	38.64	30	25	0	21.47	10	25			150		0.2				0							35.08	35.08	0.2								5.84	0.13	0.49	-	3.16	0.14	0.01	1.57	4.06	0.92	0.49	0.03	-	0.2	6.26	14.13	-	-	3.57	-	1.9	-	-	-	-	-	-	-	-	-	-	0.31	0.01	2.95	-	-	-	-	-	-	-	46.17	0	0	5.84	0.13	0.49	-	3.16	0.14	0.01	1.57	4.06	0.92	0.49	0.03	-	0.2	6.26	14.13	-	-	3.57	-	1.9	-	-	-	-	-	-	-	-	-	-	0.31	0.01	2.95	-	-	-	-	-	-	-	46.17																																																																																				-			5.84	0.13	0.49	-	3.16	0.14	0.01	1.57	4.06	0.92	0.49	0.03	-	0.2	6.26	14.13	-	-	3.57	-	1.9	-	-	-	-	-	-	-	-	-	-	0.31	0.01	2.95	-	-	-	-	-	-	-	46.17
H1951_005_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin					D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0	0								-		1903.37	42.27	778.02	2491.86	241.25	0.65	0.05	422.25	464.8	271.35	185.01	12.33	49.61	104.84	7157.22	6466.77			272.59		8.59			2.15	0		0					100.18	2.22	13.36								25/day (1-5)	25/day (1-5)	0/day (1-20) 25/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	10-50/ Visit	100/ Visit	0-50/ Visit	0-100/ Visit	25/ Visit	0/ Procedure	5-100/ Visit	5/ Visit	20/ Visit			100/ Visit		20 Coins			0 to 0	Vision capitated - see PBP		Hearing capitated benefit-see PBP					25/day (1-5)	25/day (1-5)	20 Coins								17.01	17.01	2.2	0	100	0.2	0.2	42.65	100	38.64	20	25	0	15.59	5	20			100		0.2			0	0		0					17.01	17.01	0.2								2.7	0.06	0.14	-	2.01	0.13	0.01	1.5	3.87	0.87	0.31	0.03	-	0.14	2.98	10.78	-	-	2.27	-	1.72	-	-	-	-	-	-	-	-	-	-	0.14	0	2.67	-	-	-	-	-	-	-	32.33	0	0	2.7	0.06	0.14	-	2.01	0.13	0.01	1.5	3.87	0.87	0.31	0.03	-	0.14	2.98	10.78	-	-	2.27	-	1.72	-	-	-	-	-	-	-	-	-	-	0.14	0	2.67	-	-	-	-	-	-	-	32.33																																																																																				-			2.7	0.06	0.14	-	2.01	0.13	0.01	1.5	3.87	0.87	0.31	0.03	-	0.14	2.98	10.78	-	-	2.27	-	1.72	-	-	-	-	-	-	-	-	-	-	0.14	0	2.67	-	-	-	-	-	-	-	32.33
H1951_013_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin				Coin		Coin					A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0		0					0	0	0								-		316.83	2.41	744.33	2383.95	230.8	0.59	0.04	412.21	444.67	259.59	177	11.8	47.46	100.3	6847.27	6186.72			260.78		7.87				0		0					16.68	0.13	12.22								580/admit	580/admit	0/day (1-6) 125/day (7-100)	0/Visit	150/ Trip	20 Coins	20 Coins	10-50/ Visit	150/ Visit	0-150/ Visit	0-150/ Visit	150/ Visit	0/ Procedure	10-150/ Visit	15/ Visit	30/ Visit			150/ Visit		20 Coins				0		0					580/admit	580/admit	20 Coins								580	580	36.36	0	150	0.2	0.2	42.3	150	115.91	30	150	0	20.59	15	30			150		0.2				0		0					580	580	0.2								15.31	0.12	2.26	-	2.89	0.12	0.01	1.45	5.56	2.51	0.44	0.15	-	0.17	8.56	15.47	-	-	3.26	-	1.57	-	-	-	-	-	-	-	-	-	-	0.81	0.01	2.44	-	-	-	-	-	-	-	63.09	0	0	15.31	0.12	2.26	-	2.89	0.12	0.01	1.45	5.56	2.51	0.44	0.15	-	0.17	8.56	15.47	-	-	3.26	-	1.57	-	-	-	-	-	-	-	-	-	-	0.81	0.01	2.44	-	-	-	-	-	-	-	63.09																																																																																				-			15.31	0.12	2.26	-	2.89	0.12	0.01	1.45	5.56	2.51	0.44	0.15	-	0.17	8.56	15.47	-	-	3.26	-	1.57	-	-	-	-	-	-	-	-	-	-	0.81	0.01	2.44	-	-	-	-	-	-	-	63.09
H1951_801_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0									-		1964.6	43.63	803.05	2572.02	249.01	0.69	0.05	435.84	479.75	280.07	44.56	12.73	51.21	108.21	7387.45	6674.78			281.36		9.15			0	0		0					103.4	2.3									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									33.41	0.74	0.74	-	2.08	0.14	0.01	1.72	8	1.99	0.3	0.11	-	0.42	12.31	19.47	-	-	3.52	-	1.83	-	-	-	-	-	-	-	-	-	-	1.76	0.04	-	-	-	-	-	-	-	-	88.56	0	0	33.41	0.74	0.74	-	2.08	0.14	0.01	1.72	8	1.99	0.3	0.11	-	0.42	12.31	19.47	-	-	3.52	-	1.83	-	-	-	-	-	-	-	-	-	-	1.76	0.04	-	-	-	-	-	-	-	-	88.56																																																																																				-			33.41	0.74	0.74	-	2.08	0.14	0.01	1.72	8	1.99	0.3	0.11	-	0.42	12.31	19.47	-	-	3.52	-	1.83	-	-	-	-	-	-	-	-	-	-	1.76	0.04	-	-	-	-	-	-	-	-	88.56
H1951_804_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1935	42.98	790.95	2533.26	245.26	0.67	0.05	429.27	472.52	275.85	43.89	12.54	50.44	106.58	7276.14	6574.22			277.12		8.88											101.84	2.26									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									32.9	0.73	0.73	-	2.04	0.13	0.01	1.69	7.88	1.96	0.3	0.1	-	0.41	12.13	19.17	-	-	3.46	-	1.78	-	-	-	-	-	-	-	-	-	-	1.73	0.04	-	-	-	-	-	-	-	-	87.2	0	0	32.9	0.73	0.73	-	2.04	0.13	0.01	1.69	7.88	1.96	0.3	0.1	-	0.41	12.13	19.17	-	-	3.46	-	1.78	-	-	-	-	-	-	-	-	-	-	1.73	0.04	-	-	-	-	-	-	-	-	87.2																																																																																				-			32.9	0.73	0.73	-	2.04	0.13	0.01	1.69	7.88	1.96	0.3	0.1	-	0.41	12.13	19.17	-	-	3.46	-	1.78	-	-	-	-	-	-	-	-	-	-	1.73	0.04	-	-	-	-	-	-	-	-	87.2
H1951_805_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0									-		1964.6	43.63	803.05	2572.02	249.01	0.69	0.05	435.84	479.75	280.07	44.56	12.73	51.21	108.21	7387.45	6674.78			281.36		9.15			0	0		0					103.4	2.3									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									33.41	0.74	0.74	-	2.08	0.14	0.01	1.72	8	1.99	0.3	0.11	-	0.42	12.31	19.47	-	-	3.52	-	1.83	-	-	-	-	-	-	-	-	-	-	1.76	0.04	-	-	-	-	-	-	-	-	88.56	0	0	33.41	0.74	0.74	-	2.08	0.14	0.01	1.72	8	1.99	0.3	0.11	-	0.42	12.31	19.47	-	-	3.52	-	1.83	-	-	-	-	-	-	-	-	-	-	1.76	0.04	-	-	-	-	-	-	-	-	88.56																																																																																				-			33.41	0.74	0.74	-	2.08	0.14	0.01	1.72	8	1.99	0.3	0.11	-	0.42	12.31	19.47	-	-	3.52	-	1.83	-	-	-	-	-	-	-	-	-	-	1.76	0.04	-	-	-	-	-	-	-	-	88.56
H1951_806_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1935	42.98	790.95	2533.26	245.26	0.67	0.05	429.27	472.52	275.85	43.89	12.54	50.44	106.58	7276.14	6574.22			277.12		8.88											101.84	2.26									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									32.9	0.73	0.73	-	2.04	0.13	0.01	1.69	7.88	1.96	0.3	0.1	-	0.41	12.13	19.17	-	-	3.46	-	1.78	-	-	-	-	-	-	-	-	-	-	1.73	0.04	-	-	-	-	-	-	-	-	87.2	0	0	32.9	0.73	0.73	-	2.04	0.13	0.01	1.69	7.88	1.96	0.3	0.1	-	0.41	12.13	19.17	-	-	3.46	-	1.78	-	-	-	-	-	-	-	-	-	-	1.73	0.04	-	-	-	-	-	-	-	-	87.2																																																																																				-			32.9	0.73	0.73	-	2.04	0.13	0.01	1.69	7.88	1.96	0.3	0.1	-	0.41	12.13	19.17	-	-	3.46	-	1.78	-	-	-	-	-	-	-	-	-	-	1.73	0.04	-	-	-	-	-	-	-	-	87.2
H1961_001_0	2007	2	i.1.	i.2.	i.6.	k.							Professional	Professional	Professional	Other Medicare Part B								PCP - Non Office Visits	Specialist excl. MH	Other	Blood							D	D	D	P	T	Coin	Coin	V	V	P	P	P	Coin	V	V	V	V	V	V	V	S	P	T	V	P	P	P	P	O	O	O	V	V	V	O																																																-		1722.44	29.6	724.89	1369.95	770.13	8.39	15.67	386.03	287.66	333.02	1112.44	0	0.48	1640.59	4415.46	4700.44	237.12	305.76	4623.99	6846.75	97.74	3.71	630	0	1055.55	243.72	0	0	0	0	444.39	3130.95	16423.93	805.06	9.7							Choice 1: 0 Choice 2: 150 copay days 1-3 0 Copay afterwards		0 Copay days 1-20 50 Copay 21+	Choice 2: 10 for MC services 500 max OOP		5 of MA	Choice 1: 0 for Infusion Supplies 5 otherwise; Choice 2: 0 for Infusion Supplies 20 otherwise	50 Copay MC & WW	Choice 2: 150 Copay per visit				20 Coins for OOA services		Office Visit:  Choice 1: 5 Copay Choice 2: 25 Copay Urgent Care: 25 Copay Worldwide: 50 Copay Routine Physical Choice 1: 10 Copay Choice 2: NA	Office Visit:  Choice 1: 10 Copay Choice 2: 25 Copay Urgent Care: 25 Copay WorldWide: 50 Copay	10 Copay Days 1-20 50 coins after					Vision Exams: 10 Copay	5 Copay 12 one-way trips		10 Copay 1 Exam per BP									Chiropractor & Podiatrist: Choice 1: 10 Copay Choice 2: 25 Copay Hearing Exams: 10 Copay								10.03	0	8.37	0.23	0	0.05	0.07	50	23.81	0	0	0	0	0	7.87	12.38	10	0	0	0	0	10	4.76	0	10	0	0	0	0	0	0	0	0	12.06	0							1.44	-	0.51	0.03	-	0.42	1.16	1.61	0.57	-	-	-	0	-	2.9	4.85	0.2	-	-	-	-	0	0.25	-	0.88	-	-	-	-	-	-	-	-	0.81	-	-	-	-	-	-	-	15.62			1.44	-	0.51	0.03	-	0.42	1.16	1.61	0.57	-	-	-	0	-	2.9	4.85	0.2	-	-	-	-	0	0.25	-	0.88	-	-	-	-	-	-	-	-	0.81	-	-	-	-	-	-	-	15.62																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0							-			1.44	-	0.51	0.03	-	0.42	1.16	1.61	0.57	-	-	-	0	-	2.9	4.85	0.2	-	-	-	-	0	0.25	-	0.88	-	-	-	-	-	-	-	-	0.81	-	-	-	-	-	-	-	15.62
H1961_002_0	2007	4	i.1.	i.2.	i.6.	k.							Professional	Professional	Professional	Other Medicare Part B								PCP - Non Office Visits	Specialist excl. MH	Other	Blood							D	D	D	P	T	Coin	Coin	V	V	P	P	P	Coin	V	V	V	V	V	V	V	S	P	T	V	P	P	P	P	O	O	O	V	V	V	O																																																-		1470.77	26.05	617.81	1167.58	656.37	7.15	13.36	329	245.17	283.82	952.73	0	0.41	1398.23	3814.03	4013.01	208.67	274.52	3940.92	5835.33	83.3	3.16	295.78	0	927.27	214.46	0	0	0	0	378.74	2668.43	13997.73	687.42	8.27							Choice 1: 0 Choice 2: 150 copay days 1-3 0 Copay afterwards		0 Copay days 1-20 50 Copay 21+	Choice 2: 10 for MC services 500 max OOP		5 of MA	Choice 1: 0 for Infusion Supplies 5 otherwise; Choice 2: 0 for Infusion Supplies 20 otherwise	50 Copay MC & WW	Choice 2: 150 Copay per visit				Choice 2: 20 Coins		Office Visit:  Choice 1: 5 Copay Choice 2: 25 Copay Urgent Care: 25 Copay Worldwide: 50 Copay Routine Physical Choice 1: 10 Copay Choice 2: NA	Office Visit:  Choice 1: 10 Copay Choice 2: 25 Copay Urgent Care: 25 Copay WorldWide: 50 Copay	10 Copay days 1 - 20 50 coins afterwards					Vision Exams: 10 Copay	5 Copay 12 one-way trips		10 Copay 1 Exam per BP									Chiropractor & Podiatrist: Choice 1: 10 Copay Choice 2: 25 Copay Hearing Exams: 10 Copay								9.48	0	8.37	0.22	0	0.05	0.07	50	22.5	0	0	0	0.03	0	7.71	12.25	10	0	0	0	0	10	5	0	10	0	0	0	0	0	0	0	0	11.95	0							1.16	-	0.43	0.02	-	0.36	0.96	1.37	0.46	-	-	-	0.01	-	2.45	4.1	0.17	-	-	-	-	0	0.12	-	0.77	-	-	-	-	-	-	-	-	0.68	-	-	-	-	-	-	-	13.08			1.16	-	0.43	0.02	-	0.36	0.96	1.37	0.46	-	-	-	0.01	-	2.45	4.1	0.17	-	-	-	-	0	0.12	-	0.77	-	-	-	-	-	-	-	-	0.68	-	-	-	-	-	-	-	13.08		Medicare FFS Cost Sharing		20 of MC services 100 day limit	20 of MC services		20 of MC services	20 of MC services	50 Copay MC & WW	20 of MC services	20 of MC services	20 of MC services		20 of MC services	20 of MC services	20 of MC services	20 of MC services		20 of MC services	20 of MC services	20 of MC services		20 of MC services										10 Copay MC visits 50 Copay WW Coverage 5000 Annual Max for WW.	10 Copay MC visits 50 Copay WW Coverage 5000 Annual Max for WW.									3.3	0	0.52	0.4	0	0.2	0.36	0.19	0.68	0.03	0.55	0	0.01	0.55	0.85	2.79	0	0.02	0.61	0.73	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0							11.78			4.46	-	0.96	0.42	-	0.55	1.33	1.56	1.14	0.03	0.55	-	0.02	0.55	3.3	6.89	0.17	0.02	0.61	0.73	-	0	0.12	-	0.77	-	-	-	-	-	-	0	0	0.68	-	-	-	-	-	-	-	24.87
H1961_003_0	2007	4	i.1.	i.2.	i.6.	k.							Professional	Professional	Professional	Other Medicare Part B								PCP - Non Office Visits	Specialist excl. MH	Other	Blood							D	D	D	P	T	Coin	Coin	V	V	P	P	P	P	V	V	V	V	V	V	V	S	P	T	V	P	P	P	P	O	O	O	V	V	V	O																																																-		2349.83	41.05	1010.96	2140.36	1067.95	12.8	23.91	535.31	398.9	461.8	1552.47	0	11.66	2275	6218.76	7014.3	328.81	453.51	6412.09	9494.38	135.54	5.69	423.5	0	1086.66	243.93	0	0	0	0	616.23	4701.83	22775.05	1224.76	13.46							Choice 1: 0 Choice 2: 150 copay days 1-3 0 Copay afterwards		Choice 2: 0 Copay days 1-20 50 Copay 21+	Choice 2: 10 for MC services 500 max OOP		Choice 2: 5 of MA	Choice 2: 0 for Infusion Supplies 5 otherwise	50 Copay MC & WW	Choice 2: 150 Copay per visit						Office Visit:  Choice 2: 25 Copay Urgent Care: 25 Copay Worldwide: 50 Copay	Office Visit:  Choice 2: 25 Copay Urgent Care: 25 Copay WorldWide: 50 Copay	10 Copay Days 1-20 50 coins after					Vision Exams: Choice 2: 10 Copay			Choice 2: 10 Copay 1 Exam per BP									Chiropractor & Podiatrist: Choice 2: 25 Copay Hearing Exams: Choice 2: 10 Copay								10.03	0	1.33	0.23	0	0.01	0.01	50	23.81	0	0	0	0	0	3.97	3.97	10	0	0	0	0	1.59	0	0	1.59	0	0	0	0	0	0	0	0	3.64	0							1.96	-	0.11	0.04	-	0.1	0.18	2.23	0.79	-	-	-	-	-	2.06	2.32	0.27	-	-	-	-	0	-	-	0.14	-	-	-	-	-	-	-	-	0.37	-	-	-	-	-	-	-	10.59			1.96	-	0.11	0.04	-	0.1	0.18	2.23	0.79	-	-	-	-	-	2.06	2.32	0.27	-	-	-	-	0	-	-	0.14	-	-	-	-	-	-	-	-	0.37	-	-	-	-	-	-	-	10.59																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0							-			1.96	-	0.11	0.04	-	0.1	0.18	2.23	0.79	-	-	-	-	-	2.06	2.32	0.27	-	-	-	-	0	-	-	0.14	-	-	-	-	-	-	-	-	0.37	-	-	-	-	-	-	-	10.59
H2001_001_0	2007	7																					3200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1746.06	152.1	831.05	0	235.03	12.16	5.25	434.73	26.97	6267.02	37.53	0	0.18	20.52	2874.04	3367.79	578.07	1.57	0	0	18.83	585.61	0	0	131.89	0	182.75	0	0	0	0											295 (1a)	295 (1b)	175 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											173.73	173.73	103.06	0	103.06	0.18	0.2	29.45	0.12	1.18	0.09	0	0.18	0.12	15	25	37.5	0.12	0	0	0.18	25	0	0	25	0	25	0	0	0	0											25.28	2.2	7.14	-	2.02	2.15	1.05	1.07	3.18	0.62	3.41	-	0.03	2.42	3.59	7.02	1.81	0.18	-	-	3.33	1.22	-	-	0.27	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.35		37.53	25.28	2.2	7.14	-	2.02	2.15	1.05	1.07	3.18	0.62	3.41	-	0.03	2.42	3.59	7.02	1.81	0.18	-	-	3.33	1.22	-	-	0.27	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.35		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											5.67	0.2	0.66	0.5	0.75	0.8	0.35	0.4	1.78	0.92	1.91	0	0.01	1.35	1.6	2.16	0.45	0.1	0	0	1.24	0.38	0	0	0.08	0	0.12	0	0	0	0											21.41		0	30.95	2.4	7.79	0.5	2.77	2.95	1.39	1.46	4.95	1.53	5.31	-	0.04	3.77	5.19	9.17	2.26	0.29	-	-	4.57	1.6	-	-	0.36	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.76
H2001_003_0	2007	6																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1832.93	159.67	872.39	0	246.72	12.77	5.51	456.36	28.31	0	39.38	0	0.19	21.54	3017.04	3535.35	606.83	1.65	0	0	19.76	614.75	0	0	138.45	0	191.85	0	0	0	0											150 (1a)	150 (1b)	75 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	15 (9b)	0 (8a 8b)	15/15 (8a 8b)	15 (incl in h5)	30 (12)	15 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	15 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											93.86	93.86	46.93	0	109.51	0.19	0.21	31.29	0.09	0	0.07	0	0.19	0.09	10	20	37.5	0.09	0	0	0.19	20	0	0	20	0	20	0	0	0	0											14.34	1.25	3.41	-	2.25	2.4	1.15	1.19	2.66	-	2.94	-	0.04	2.03	2.51	5.89	1.9	0.15	-	-	3.71	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.39		22.25	14.34	1.25	3.41	-	2.25	2.4	1.15	1.19	2.66	-	2.94	-	0.04	2.03	2.51	5.89	1.9	0.15	-	-	3.71	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.39		250 (1a)	250 (1b)	125 (2a)	25 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	20 (8a 8b)	20/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 25 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	25 (7c 7i)	25 (incl in h2)	25 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 25 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.32	0.29	0.79	0.44	0.79	0.84	0.36	0.42	1.55	0.96	1.72	0	0.01	1.18	1.35	2.26	0.47	0.09	0	0	1.3	0.39	0	0	0.09	0	0.12	0	0	0	0											18.77		0	17.66	1.54	4.2	0.44	3.04	3.24	1.51	1.61	4.21	0.96	4.66	-	0.05	3.21	3.87	8.16	2.37	0.24	-	-	5.01	1.42	-	-	0.32	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.15
H2001_005_0	2007	5																					2600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1746.06	152.1	831.05	0	235.03	12.16	5.25	434.73	26.97	6267.02	37.53	0	0.18	20.52	2874.04	3367.79	578.07	1.57	0	0	18.83	585.61	0	0	131.89	0	182.75	0	0	0	0											295 (1a)	295 (1b)	175 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											157.13	157.13	93.21	0	93.21	0.16	0.19	26.63	0.11	3.2	0.08	0	0.16	0.11	15	25	37.5	0.11	0	0	0.16	25	0	0	25	0	25	0	0	0	0											22.86	1.99	6.46	-	1.83	1.94	0.98	0.96	2.87	1.67	3.08	-	0.03	2.19	3.59	7.02	1.81	0.17	-	-	3.01	1.22	-	-	0.27	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.33		43.65	22.86	1.99	6.46	-	1.83	1.94	0.98	0.96	2.87	1.67	3.08	-	0.03	2.19	3.59	7.02	1.81	0.17	-	-	3.01	1.22	-	-	0.27	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.33		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											5.67	0.2	0.66	0.5	0.75	0.8	0.35	0.4	1.78	0.92	1.91	0	0.01	1.35	1.6	2.16	0.45	0.1	0	0	1.24	0.38	0	0	0.08	0	0.12	0	0	0	0											21.41		0	28.53	2.19	7.11	0.5	2.58	2.74	1.32	1.36	4.65	2.59	4.99	-	0.04	3.54	5.19	9.17	2.26	0.27	-	-	4.25	1.6	-	-	0.36	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.74
H2001_006_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1832.93	159.67	872.39	0	246.72	12.77	5.51	456.36	28.31	6578.83	39.38	0	0.19	21.54	3017.04	3535.35	606.83	1.65	0	0	19.76	614.75	0	0	138.45	0	191.85	0	0	0	0											150 (1a)	150 (1b)	75 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	15 (9b)	15 (8a 8b)	15/15 (8a 8b)	15 (incl in h5)	30 (12)	15 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	15 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											84.98	84.98	42.49	0	99.14	0.17	0.19	28.33	0.08	3.4	0.07	0	0.17	0.09	10	20	37.5	0.08	0	0	0.17	20	0	0	20	0	20	0	0	0	0											12.98	1.13	3.09	-	2.04	2.17	1.07	1.08	2.41	1.86	2.66	-	0.03	1.84	2.51	5.89	1.9	0.14	-	-	3.36	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.73		27.19	12.98	1.13	3.09	-	2.04	2.17	1.07	1.08	2.41	1.86	2.66	-	0.03	1.84	2.51	5.89	1.9	0.14	-	-	3.36	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.73		250 (1a)	250 (1b)	125 (2a)	25 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	20 (8a 8b)	20/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 25 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	25 (7c 7i)	25 (incl in h2)	25 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 25 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.32	0.29	0.79	0.44	0.79	0.84	0.36	0.42	1.55	0.96	1.72	0	0.01	1.18	1.35	2.26	0.47	0.09	0	0	1.3	0.39	0	0	0.09	0	0.12	0	0	0	0											18.77		0	16.3	1.42	3.88	0.44	2.83	3.01	1.43	1.49	3.96	2.83	4.38	-	0.05	3.02	3.87	8.16	2.37	0.23	-	-	4.66	1.42	-	-	0.32	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.5
H2001_007_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2182.18	345.29	1115.58		250.25	24.27	21.02	842.93	365.49	1917.55	899.63	62.26	2.91	1892.96		3453.38		516.57		803.81												269.84		153.54	228.42							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							37	37	18		37	10	10	18	12	5	5	12	10	12		5		5		5												5		5	5							6.64	1.05	1.63	-	0.76	2.36	2.05	1.23	0.37	0.78	0.37	0.06	0.28	1.92	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.71		22.87	6.64	1.05	1.63	-	0.76	2.36	2.05	1.23	0.37	0.78	0.37	0.06	0.28	1.92	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.71		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							1.98	0.14	0.26	0.33	0.06	0.15	0.13	0.04	0.17	0.12	0.12	0.01	0.02	0.19	0.33	0.19	0.04	0.03	0.13	0.62	0.12	0																				5.2		0	8.62	1.19	1.89	0.33	0.82	2.51	2.18	1.28	0.54	0.9	0.48	0.08	0.3	2.11	0.33	1.59	0.04	0.24	0.13	0.94	0.12	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	26.91
H2001_801_0	2007	5																					3800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1833.23	159.7	872.54	0	246.76	12.77	5.51	456.44	28.32	6579.91	39.4	0	0.19	21.55	3017.53	3535.93	606.93	1.65	0	0	19.76	614.85	0	0	138.48	0	191.88	0	0	0	0											340 (1a)	340 (1b)	175 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											202.67	202.67	104.31	0	104.31	0.18	0.2	29.8	0.12	3.58	0.09	0	0.18	0.12	15	25	37.5	0.12	0	0	0.18	25	0	0	25	0	25	0	0	0	0											30.96	2.7	7.58	-	2.15	2.28	1.11	1.13	3.38	1.96	3.51	-	0.03	2.57	3.77	7.37	1.9	0.2	-	-	3.53	1.28	-	-	0.29	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.1		42.54	30.96	2.7	7.58	-	2.15	2.28	1.11	1.13	3.38	1.96	3.51	-	0.03	2.57	3.77	7.37	1.9	0.2	-	-	3.53	1.28	-	-	0.29	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.1		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											5.95	0.21	0.69	0.53	0.79	0.84	0.36	0.42	1.86	0.96	1.94	0	0.01	1.42	1.68	2.26	0.47	0.11	0	0	1.3	0.39	0	0	0.09	0	0.12	0	0	0	0											22.41		0	36.91	2.9	8.27	0.53	2.93	3.12	1.47	1.55	5.24	2.92	5.44	-	0.05	3.99	5.45	9.63	2.37	0.3	-	-	4.84	1.67	-	-	0.38	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.51
H2003_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1000	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1574.98	146.65	8084.53	151.52	568.67	1279.07	6216.39	163.54	108.58	3378.17	150.18	29.7	3.89	252.5	113.14	1133.14	1472.01	17.39		236.6	239.73	1157.01	1140		133.19	157.7		51.87				96.44	0.24	0.06	285	280.44						(1a) 125/day	(1b) 125/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						111	111			66			44	22			22		22		9				9		9										9		22								14.55	1.35	-	-	3.15	-	-	0.6	0.2	-	-	0.05	-	0.47	-	0.84	-	-	-	0.17	-	0.85	-	-	-	-	-	-	-	-	-	0.07	-	0	-	-	-	-	-	-	-	22.32		2.85	14.55	1.35	-	-	3.15	-	-	0.6	0.2	-	-	0.05	-	0.47	-	0.84	-	-	-	0.17	-	0.85	-	-	-	-	-	-	-	-	-	0.07	-	0	-	-	-	-	-	-	-	22.32		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						1.95	0.05	0.73	0.07	0.33	0.28	0.09	0.04	0.18	0.53	0.59	0.03	0	0.1	0.01	1.54	0.14	0		0.15		0.11	0.06		0.02							0	0	0	0.02	0.02						7.04		0	16.49	1.41	0.73	0.07	3.48	0.28	0.09	0.64	0.38	0.53	0.59	0.09	0	0.57	0.01	2.38	0.14	0	-	0.33	-	0.96	0.06	-	0.02	-	-	-	-	-	-	0.08	0	0	0.02	0.02	-	-	-	-	-	29.36
H2003_002_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V																																															-		2329.69	211.37	974.96		202.86	20.95	24.19	562.52	437.28	2194.8	928.82	70.04	1.12	1320.21		5120.32		478.4		947.8												256.36		264.21	267.91							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						43	43	21		43	9	12	21	14	3	6	14	12	14		6		6		6												6		6	6							8.38	0.76	1.68	-	0.73	1.81	2.78	0.97	0.52	0.53	0.45	0.08	0.13	1.58	-	2.46	-	0.23	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.13	0.13	-	-	-	-	-	-	23.93		17.65	8.38	0.76	1.68	-	0.73	1.81	2.78	0.97	0.52	0.53	0.45	0.08	0.13	1.58	-	2.46	-	0.23	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.13	0.13	-	-	-	-	-	-	23.93		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.36	0.09	0.24	0.29	0.05	0.13	0.15	0.03	0.26	0.16	0.16	0.02	0.01	0.18	0.35	0.27	0.03	0.03	0.18	0.79	0.17	0	0.04		0.01		0.01															6		0	10.74	0.85	1.92	0.29	0.78	1.94	2.93	1.01	0.78	0.69	0.61	0.1	0.14	1.76	0.35	2.73	0.03	0.26	0.18	1.25	0.17	0	0.04	-	0.01	-	0.01	-	-	-	-	0.12	-	0.13	0.13	-	-	-	-	-	-	29.92
H2108_001_0	2007	5																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	Coin	P	V	P	O	O	V																																																				-		504.58	17.68			14.75	21.26	8.92	262.63	33.53	11.79	24.83	0.12	4.23	18.65	6.33	166.25	4.79	8.69	21.5	5.19	14.95	0.05																				#1A 0/day days 1-60 238/day days 61-90	#1B 0/day days 1-60 238/day days 61-90	#2 0	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 50	#9A 20 #9B 20	#8A 0-clin/diag lab 20-all other	#8A 20 #8B 20	20	#12 20	#3 20 #5 20 #9C 20 #9D 20	#7A 20 #14B 20 #14C 0 #14D 0-pap smears 20-pelvic exams #14E 20 #14F 20 #14G 20 #14H 20	#7B 20 #7D 20 #7F 20 #7G 20	#7E 20 #7H 50	#7C 20 #7I 20	20	#14I 20	#15 20	20	#10B 0	#16A 0 #16B 0	#17A 0	#17B 0	#18A 0	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											0.06	0.06			0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				30.45	1.07	-	-	3.48	5.02	2.1	1.09	7.91	2.78	5.86	0.03	1	4.4	1.49	39.24	1.13	2.05	5.08	1.23	3.53	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.95	138	0	30.45	1.07	-	-	3.48	5.02	2.1	1.09	7.91	2.78	5.86	0.03	1	4.4	1.49	39.24	1.13	2.05	5.08	1.23	3.53	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.95																																																																																				-		0	30.45	1.07	-	-	3.48	5.02	2.1	1.09	7.91	2.78	5.86	0.03	1	4.4	1.49	39.24	1.13	2.05	5.08	1.23	3.53	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.95
H2108_002_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	P	P	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V																																																				-		2285.25	109.11	1379.62		269.68	6.85	5.06	186.29	114.9		1027.54		1.89	0.41	1040.5	6507.47	153.92	788.63			15.29				299.89																	#1A 50/day days 1-6 0/day days 7-90	#1B 50/day days 1-6 0/day days 7-90	#2 0/day days 1-20; 125/day days 21-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 35	#9A 150 #9B 50	0 diag lab	#8A 50-CAT & MRI 100-PET 25-Other #8B 15		#12 20	#3 20 #5 20 #9C 20 #9D 20	#7A 10 #14B 0 n/c #14C 0 #14D 0 n/c #14E 0 n/c #14F 0 n/c #14G 0 n/c #14H 0 n/c	#7B 20 #7D 20 #7F 20 #7G 20	#7E 20 #7H 20	#7C 20 #7I 20		#14I 0	#15 20	#13A 0	#10B 0	#16A 0 #16B 0	#17A 20	#17B 0	#18A 0	#18B 0 n/c	#19 0 n/c	#14A 0 n/c	#13B 0 n/c											36.14	36.14	60.11		50	0.2	0.2	50	140		33.14		0.2	0.34	10	17.1	20	20			0.2				18.92																	6.88	0.33	6.91	-	1.12	1.37	1.01	0.78	1.34	-	2.84	-	0.38	0.14	0.87	9.27	0.26	1.31	-	-	3.06	-	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.34	0	0	6.88	0.33	6.91	-	1.12	1.37	1.01	0.78	1.34	-	2.84	-	0.38	0.14	0.87	9.27	0.26	1.31	-	-	3.06	-	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.34																																																																																				-		0	6.88	0.33	6.91	-	1.12	1.37	1.01	0.78	1.34	-	2.84	-	0.38	0.14	0.87	9.27	0.26	1.31	-	-	3.06	-	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.34
H2108_018_0	2007	7																																D	D	D	V	T	Coin	Coin	V	V	P	P	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V	P	P	P	P	P	P	P	P	P	P																																										-		1371.91	69.81	833.05		48.89	6.54	9.29	278.25	212.08		462.21		0.5	19.84	3498.73	5914.16	430.35	665.15			24.93				129.09																	#1A 25/day days 1-6 0/day days 7-90	#1B 25/day days 1-6 0/day days 7-90	#2 0/day days 1-20; 125/day days 21-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 25	#9A 100 #9B 0	#8A 0 diag lab	#8A 25-CAT & MRI 50-PET 15-other #8B 10		#12 20	#3 20 #5 20 #9C 20 #9D 10	#7A5 #14B 0 n/c #14C 0 #14D 0 n/c #14E 0 n/c #14F 0 n/c #14G 0 n/c #14H 0 n/c	#7B10 #7D10 #7F10 #7G10	#7E10 #7H10	#7C10 #7I10		#14I 0	#15 20	#13A 0	#10B 0 n/c	#16A 0 #16B 0	#17A 10	#17B 0	#18A 0 n/c	#18B 0 n/c	#19 0 n/c	#14A 0	#13B 0 n/c											18.07	18.07	68.83		50	0.2	0.2	47.5	100		15		0.2	0.06	5	10	9.93	10			0.2				10																	2.07	0.11	4.78	-	0.2	1.31	1.86	1.1	1.77	-	0.58	-	0.1	1.26	1.46	4.93	0.36	0.55	-	-	4.99	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.52		0	2.07	0.11	4.78	-	0.2	1.31	1.86	1.1	1.77	-	0.58	-	0.1	1.26	1.46	4.93	0.36	0.55	-	-	4.99	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.52		.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.																																										-		0	2.07	0.11	4.78	-	0.2	1.31	1.86	1.1	1.77	-	0.58	-	0.1	1.26	1.46	4.93	0.36	0.55	-	-	4.99	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.52
H2111_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1837.16	118.34	7947	120.68	546.22	1505.66	1893.1	147.58	163.64	5880.3	153.18	1.49	4.48	236.59	28880.97	1461.19	2542.04	21.85		73.06	120.43	622.81	1014.73		37.96	315.4		51.87				85.18		0.37	74.13	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)		(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						64	64			64			43	21			21		21																		9										9.79	0.63	-	-	2.91	-	-	0.52	0.29	-	-	0	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	14.63		2.53	9.79	0.63	-	-	2.91	-	-	0.52	0.29	-	-	0	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	14.63		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10		30	30	30						2.92	0.07	0.95	0.08	0.25	0.34	0.04	0.03	0.37	0.56	0.74	0	0.01	0.13	0.01	2.25	0.25	0		0.31		0.09	0.06		0							0		0	0.01	0.02						9.52		0	12.71	0.71	0.95	0.08	3.16	0.34	0.04	0.56	0.66	0.56	0.74	0	0.01	0.56	0.01	2.25	0.25	0	-	0.31	-	0.09	0.06	-	0	-	-	-	-	-	-	0.06	-	0	0.01	0.02	-	-	-	-	-	24.15
H2111_002_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2194.13	141.33	7911.12	120.13	543.76	1498.86	1884.55	146.91	162.9	5853.75	152.49	1.49	4.46	235.52	28750.58	1454.6	2530.57	21.75		72.73	119.89	620	2137.5		133.19	315.4		51.87				84.8		0.37	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)		(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						62	62			62			41	21			21		21																		8										11.33	0.73	-	-	2.81	-	-	0.51	0.28	-	-	0	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	16.11		3.4	11.33	0.73	-	-	2.81	-	-	0.51	0.28	-	-	0	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	16.11		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10		30	30	30						3.47	0.09	0.94	0.08	0.24	0.33	0.04	0.03	0.37	0.55	0.74	0	0.01	0.13	0.01	2.24	0.25	0		0.3		0.09	0.11		0.02							0		0	0.02	0.02						10.1		0	14.8	0.82	0.94	0.08	3.05	0.33	0.04	0.54	0.65	0.55	0.74	0	0.01	0.54	0.01	2.24	0.25	0	-	0.3	-	0.09	0.11	-	0.02	-	-	-	-	-	-	0.06	-	0	0.02	0.02	-	-	-	-	-	26.22
H2111_003_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1914.05	123.29	7417.7	112.64	509.84	1405.38	1767.01	137.75	152.74	5488.64	142.98	1.39	4.18	220.83	26957.38	1363.87	2372.73	20.39		68.19	112.41	581.33	2137.5		133.19	315.4		51.87				79.51		0.35	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)		(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						64	64			64			43	21			21		21																		9										10.18	0.66	-	-	2.71	-	-	0.49	0.27	-	-	0	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	14.75		2.59	10.18	0.66	-	-	2.71	-	-	0.49	0.27	-	-	0	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	14.75		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10		30	30	30						2.84	0.07	0.82	0.07	0.21	0.29	0.04	0.03	0.33	0.48	0.65	0	0.01	0.12	0.01	1.97	0.22	0		0.27		0.08	0.11		0.02							0		0	0.02	0.02						8.69		0	13.02	0.73	0.82	0.07	2.92	0.29	0.04	0.52	0.6	0.48	0.65	0	0.01	0.51	0.01	1.97	0.22	0	-	0.27	-	0.08	0.11	-	0.02	-	-	-	-	-	-	0.06	-	0	0.02	0.02	-	-	-	-	-	23.44
H2112_001_0	2007	2																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1813.79		312.95	530.32	43.64	25.62		468.22	223.9	131.86	1435.44	0	0	140.98	1187.09	989.69	0	323.55	0	0	251.55				480.41		49.66															800 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	31.4 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															130.5		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	31.4	35	35	35	35	45				0		0															19.73	-	1.77	0.88	0.36	5.12	-	1.87	3.73	0.38	7.87	-	-	0.41	1.98	2.59	-	0.94	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.59			19.73	-	1.77	0.88	0.36	5.12	-	1.87	3.73	0.38	7.87	-	-	0.41	1.98	2.59	-	0.94	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.59																																																																																				-			19.73	-	1.77	0.88	0.36	5.12	-	1.87	3.73	0.38	7.87	-	-	0.41	1.98	2.59	-	0.94	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.59
H2112_002_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1851.42		319.44	541.32	44.54	26.15		477.93	228.55	134.6	1465.22	0	0	143.9	1211.71	1010.22	0	330.27	0	0	256.77				490.38		50.69															350 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 125 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															57.09		67.84	20	100	0.2		48	200	25	59.2	25	25	25	10	25	25	25	25	25	45				0		0															8.81	-	1.81	0.9	0.37	5.23	-	1.91	3.81	0.28	7.23	-	-	0.3	1.01	2.1	-	0.69	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.41			8.81	-	1.81	0.9	0.37	5.23	-	1.91	3.81	0.28	7.23	-	-	0.3	1.01	2.1	-	0.69	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.41																																																																																				-			8.81	-	1.81	0.9	0.37	5.23	-	1.91	3.81	0.28	7.23	-	-	0.3	1.01	2.1	-	0.69	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.41
H2112_003_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S		T	V	V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0	0		0															-		2054.49		354.48	600.7	49.43	29.02		530.35	253.62	149.36	1625.92	0	0	159.68	1344.62	1121.02	0	366.49	0	0	284.93		0	3795.51	544.16		56.25															992/admission		0 days 1-20 100 21-100	0 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	400 per procedure	30 per visit	30 X-ray; 100 CATPETMRI	50 per visit	30 per visit	30 per visit	0 per visit	50 per visit; 30 per dialysis visit	50 per visit	50 per visit	50 per visit	50 per visit	45 per script		40 one way trips per year	5 per visit	0 per visit		0 per visit															161.82		40.15	0	100	0.2		48	400	30	67.1	50	30	50	0	37.14	50	50	50	50	45		0	5	0		0															27.7	-	1.19	-	0.41	5.8	-	2.12	8.45	0.37	9.09	-	-	0.67	-	3.47	-	1.53	-	-	1.07	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.46			27.7	-	1.19	-	0.41	5.8	-	2.12	8.45	0.37	9.09	-	-	0.67	-	3.47	-	1.53	-	-	1.07	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.46																																																																																				-			27.7	-	1.19	-	0.41	5.8	-	2.12	8.45	0.37	9.09	-	-	0.67	-	3.47	-	1.53	-	-	1.07	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.46
H2112_007_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1813.76		312.94	530.31	43.64	25.62		468.21	223.9	131.86	1435.41	0	0	140.97	1187.06	989.67	0	323.55	0	0	251.55				480.4		49.66															800 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	31.4 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															130.5		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	31.4	35	35	35	35	45				0		0															19.72	-	1.77	0.88	0.36	5.12	-	1.87	3.73	0.38	7.87	-	-	0.41	1.98	2.59	-	0.94	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.59			19.72	-	1.77	0.88	0.36	5.12	-	1.87	3.73	0.38	7.87	-	-	0.41	1.98	2.59	-	0.94	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.59																																																																																				-			19.72	-	1.77	0.88	0.36	5.12	-	1.87	3.73	0.38	7.87	-	-	0.41	1.98	2.59	-	0.94	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.59
H2112_008_0	2007	2																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1896.09		327.15	554.38	45.62	26.8		489.46	234.06	137.84	1500.56	0	0	147.37	1240.95	1034.59	0	338.24	0	0	262.97				502.21		51.91															50/day 1-8		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	20 per visit	20 X-ray; 100 CATPETMRI	20 per visit	20 per visit	20 per visit	0 per visit	20 per visit	20 per visit	20 per visit	20 per visit	20 per visit	45 per script				0 per visit		0 per visit															37.9		67.84	20	100	0.2		48	200	20	47.36	20	20	20	0	20	20	20	20	20	45				0		0															5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.56	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03			5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.56	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03																																																																																				-			5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.56	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03
H2112_009_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1895.37		327.03	554.17	45.6	26.79		489.28	233.97	137.79	1499.99	0	0	147.32	1240.47	1034.2	0	338.11	0	0	262.86				502.01		51.89															50/day 1-8		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	20 per visit	20 X-ray; 100 CATPETMRI	20 per visit	20 per visit	20 per visit	0 per visit	20 per visit	10 per visit	10 per visit	20 per visit	20 per visit	45 per script				0 per visit		0 per visit															37.9		67.84	20	100	0.2		48	200	20	47.36	20	20	20	0	20	10	10	20	20	45				0		0															5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.28	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.74			5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.28	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.74																																																																																				-			5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.28	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.74
H2112_011_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1896.09		327.15	554.38	45.62	26.8		489.46	234.06	137.84	1500.56	0	0	147.37	1240.95	1034.59	0	338.24	0	0	262.97				502.21		51.91															50/day 1-8		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	20 per visit	20 X-ray; 100 CATPETMRI	20 per visit	20 per visit	20 per visit	0 per visit	20 per visit	20 per visit	20 per visit	20 per visit	20 per visit	45 per script				0 per visit		0 per visit															37.9		67.84	20	100	0.2		48	200	20	47.36	20	20	20	0	20	20	20	20	20	45				0		0															5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.56	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03			5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.56	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03																																																																																				-			5.99	-	1.85	0.92	0.38	5.36	-	1.96	3.9	0.23	5.92	-	-	0.25	-	1.72	-	0.56	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03
H2112_012_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S	P	T	V	V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0	0		0															-		1968.9		339.71	575.67	47.37	27.83		508.26	243.05	143.14	1558.19	0	0	153.03	1288.6	1074.32	0	351.22	0	0	273.06		0	3795.51	521.49		53.91															992/admission		0 days 1-20 100 21-100	0 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	400 per procedure	36.64 per visit	36.64 X-ray; 100 CATPETMRI	36.64 per visit	30 per visit	30 per visit	0 per visit	50 per visit; 30 per dialysis visit	50 per visit	50 per visit	50 per visit	50 per visit	45 per script		40 one way trips per year	5 per visit	0 per visit		0 per visit															161.82		40.15	0	100	0.2		48	400	36.64	67.1	36.64	30	50	0	36.64	50	50	50	50	45		0	5	0		0															26.55	-	1.14	-	0.39	5.57	-	2.03	8.1	0.44	8.71	-	-	0.64	-	3.28	-	1.46	-	-	1.02	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.92			26.55	-	1.14	-	0.39	5.57	-	2.03	8.1	0.44	8.71	-	-	0.64	-	3.28	-	1.46	-	-	1.02	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.92																																																																																				-			26.55	-	1.14	-	0.39	5.57	-	2.03	8.1	0.44	8.71	-	-	0.64	-	3.28	-	1.46	-	-	1.02	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.92
H2112_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H2112_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H2174_001_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		189.25	189.25	46.91	52.7	8.88	15.4	15.4	7.67	35.68	17.17	17.17	17.17	17.17	17.17	62.28	62.28	62.28	62.28	62.28	62.28	10.46	9.77	-	-	-	-	-	-	-	-	-											7.5	7.5	13.6	0	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	0	0	0	0	0	0	0	0	0											7.5	7.5	13.6	0	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	23.6	0	0	0	0	0	0	0	0	0											14.1	14.1	6.37	-	2.1	3.63	3.63	1.81	8.42	4.05	4.05	4.05	4.05	4.05	14.7	14.7	14.7	14.7	14.7	14.7	2.47	2.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	167.38			14.1	14.1	6.37	-	2.1	3.63	3.63	1.81	8.42	4.05	4.05	4.05	4.05	4.05	14.7	14.7	14.7	14.7	14.7	14.7	2.47	2.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	167.38																																																																																				-			14.1	14.1	6.37	-	2.1	3.63	3.63	1.81	8.42	4.05	4.05	4.05	4.05	4.05	14.7	14.7	14.7	14.7	14.7	14.7	2.47	2.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	167.38
H2174_002_0	2007	11																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	V	V	V	V	V	V																																																				-		680	10	-	-	177	11.56	7.42	372	254	-	-	-	-	271	4381	3838	163	1349	-	1039	7	698	-	-	-	-	-	-	-	-	-											100	100	-	-	50	20	17	41.31	50	-	-	-	-	20	20	20	22.5	20	-	20	-	20	-	-	-	-	-	-	-	-	-											100	100	-	-	50	20	17	41.31	50	-	-	-	-	20	20	20	22.5	20	-	20	-	20	-	-	-	-	-	-	-	-	-											5.67	0.08	-	-	0.74	2.31	1.25	1.28	1.06	-	-	-	-	0.45	7.3	6.4	0.3	2.25	-	1.73	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.98			5.67	0.08	-	-	0.74	2.31	1.25	1.28	1.06	-	-	-	-	0.45	7.3	6.4	0.3	2.25	-	1.73	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.98																																																																																				-			5.67	0.08	-	-	0.74	2.31	1.25	1.28	1.06	-	-	-	-	0.45	7.3	6.4	0.3	2.25	-	1.73	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.98
H2224_001_0	2007	4																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	357.95	6.01	105.35	101.08	16.35	38.71	22.94	18.18	17.82	13.88	31.52	0.97	1.48	40.98	51.17	99.77	1.99	5.23	22.79	38.21	10.13	4.3	0	0	0	0	0	0	0	0	0											6.52 Medicare equivalent coinsurance	6.53 Medicare equivalent coinsurance	17.10 Medicare equivalent coinsurance	0	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	PBP 10B 0 coinsurance	0	PBP 17A 0 coinsurance	PBP 17B 0 coinsurance	0	0	0	0	PBP 13C Adult Day Care 0 coinsurance											0.07	0.07	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											23.34	0.39	18.02	-	3.86	9.14	5.42	4.29	4.21	3.28	7.44	0.23	0.35	9.67	12.08	23.54	0.47	1.23	5.38	9.02	2.39	1.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.73	0	0	23.34	0.39	18.02	-	3.86	9.14	5.42	4.29	4.21	3.28	7.44	0.23	0.35	9.67	12.08	23.54	0.47	1.23	5.38	9.02	2.39	1.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.73	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	23.34	0.39	18.02	-	3.86	9.14	5.42	4.29	4.21	3.28	7.44	0.23	0.35	9.67	12.08	23.54	0.47	1.23	5.38	9.02	2.39	1.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.73
H2225_001_0	2007	4																																Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin						Coin	Coin																																																													-		513.16		133.12		32.96	45.5		14.22	19.7	129.19					385.01						10.31	12.82																				Medicare FFS		Medicare FFS		Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS					Medicare FFS						Medicare FFS	Medicare FFS																				0.07		0.18		0.24	0.24		0.24	0.24	0.24					0.24						0.24	0.24																				33.75	-	23.9	-	7.78	10.74	-	3.36	4.65	30.49	-	-	-	-	90.86	-	-	-	-	-	2.43	3.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	210.99			33.75	-	23.9	-	7.78	10.74	-	3.36	4.65	30.49	-	-	-	-	90.86	-	-	-	-	-	2.43	3.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	210.99																																																																																				-			33.75	-	23.9	-	7.78	10.74	-	3.36	4.65	30.49	-	-	-	-	90.86	-	-	-	-	-	2.43	3.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	210.99
H2226_001_0	2007	3	H.5	H.5	I.4	I.3	I.2						OP Facility - Other	OP Facility - Other	Professional	Professional	Professional						0	Rehab	MH/SA	Chiropractic	MH (non-MD)	Podiatry						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin										Coin	Coin	Coin	Coin	Coin	Coin																																															-		346.7	9.46	72.86		17.13	29.36	34.26	23.77	39.44	28.44	26.87	3.47	4.75	23.19	61.63	42.47	3.91	9.39	31.93	143.92	25.78										1.28	19.95	3.14	1.14	1.98	1.74						1000 for days 1-60; 250 per day for days 61-90; 500 per day for days 91+	1000 for days 1-60; 250 per day for days 61-90; 500 per day for days 91+	125 per day for days 21-100	0	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible										20	20 after deductible	20 after deductible	20 after deductible	20 after deductible	20 after deductible						7	7	17		24	24	24	24	24	24	24	24	24	24	24	24	24	24	24	24	24										20	24	24	24	24	24						22.64	0.62	12.57	-	4.04	6.93	8.09	5.61	9.31	6.71	6.34	0.82	1.12	5.47	14.55	10.02	0.92	2.22	7.54	33.97	6.08	-	-	-	-	-	-	-	-	-	0.26	4.71	0.74	0.27	0.47	0.41	-	-	-	-	-	172.41	138	0	22.64	0.62	12.57	-	4.04	6.93	8.09	5.61	9.31	6.71	6.34	0.82	1.12	5.47	14.55	10.02	0.92	2.22	7.54	33.97	6.08	-	-	-	-	-	-	-	-	-	0.26	4.71	0.74	0.27	0.47	0.41	-	-	-	-	-	172.41																																																																																				-		0	22.64	0.62	12.57	-	4.04	6.93	8.09	5.61	9.31	6.71	6.34	0.82	1.12	5.47	14.55	10.02	0.92	2.22	7.54	33.97	6.08	-	-	-	-	-	-	-	-	-	0.26	4.71	0.74	0.27	0.47	0.41	-	-	-	-	-	172.41
H2228_001_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1750	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		1650.69	200.48	10201.05	348.03	647.64	30.14	12.08	229.37	117.92	3936.84	223.09	48.24	4.99	357.24	24231.87	1220.87	1723.63	1.77		402.18	567.53	2139.02	2591.85		8.5	157.64						191.48	0.55		266.52	280.44						(1a) 250/day	(1b) 250/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 35/visit	(8a) 0/visit	(8b) 0/visit	(9a) 35/visit	(12) 0/proc	(9a) 35/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 15/visit	(7e/7h) 32.5/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 15/visit	(15) 0/proc	(16b/17a) 15/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc						(4b) 35/visit (waived if admitted)	(9c) 32.5/visit 75/25 Ind/Grp Blended Copay		(7f1) 0/visit	(18a1) 0/visit						204	204			61	16	16	41	29			29		29		12	27			12		12										29	27									28.05	3.41	-	-	3.3	4.92	1.97	0.78	0.28	-	-	0.11	-	0.85	-	1.24	3.81	-	-	0.41	-	2.18	-	-	-	-	-	-	-	-	-	0.46	0	-	-	-	-	-	-	-	-	51.76		11.71	28.05	3.41	-	-	3.3	4.92	1.97	0.78	0.28	-	-	0.11	-	0.85	-	1.24	3.81	-	-	0.41	-	2.18	-	-	-	-	-	-	-	-	-	0.46	0	-	-	-	-	-	-	-	-	51.76		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30		30	30						2.03	0.08	1.09	0.2	0.57	0.48	0.19	0.05	0.15	0.9	0.84	0.07	0.01	0.19	0.01	1.63	0.19	0		0.16		0.2	0.17		0							0.03	0		0.04	0.02						9.31		0	30.07	3.48	1.09	0.2	3.87	5.39	2.16	0.83	0.43	0.9	0.84	0.19	0.01	1.04	0.01	2.88	4	0	-	0.57	-	2.39	0.17	-	0	-	-	-	-	-	-	0.48	0	-	0.04	0.02	-	-	-	-	-	61.08
H2228_002_0	2007	6	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1000	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1796.59	106.44	10974.77	233.11	729.12	1722.56	15817.42	300.14	93.91	1900.97	183.08	29.42	2.36	267.63	20467.39	1256.77	1192.82	0.84		378.07	306.74	1454.21	631.88		69.57	225.65		51.87				109.1	0.26		350.02	280.44						(1a) 125/day	(1b) 125/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay		(7f1) 0/visit	(18a1) 0/visit						108	108			65			43	22			22		22		9				9		9										9										16.11	0.95	-	-	3.92	-	-	1.08	0.17	-	-	0.05	-	0.48	-	0.9	-	-	-	0.27	-	1.04	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	25.06		4.05	16.11	0.95	-	-	3.92	-	-	1.08	0.17	-	-	0.05	-	0.48	-	0.9	-	-	-	0.27	-	1.04	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	25.06		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30		30	30						1.75	0.04	0.97	0.12	0.62	0.31	0.36	0.07	0.17	0.63	0.81	0.04	0	0.17	0.01	1.45	0.11	0		0.11		0.13	0.04		0.01							0	0		0.03	0.02						7.97		0	17.86	0.99	0.97	0.12	4.54	0.31	0.36	1.14	0.34	0.63	0.81	0.09	0	0.65	0.01	2.36	0.11	0	-	0.38	-	1.18	0.04	-	0.01	-	-	-	-	-	-	0.08	0	-	0.03	0.02	-	-	-	-	-	33.03
H2228_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V		V	V																																																-		2516.53	361.26	1710.82		334.91	31.78	26.52	989.62	401.7	2369.63	986.5	70.54	3.6	2188.62		3604.53		529.53		830.72												347.64		147.8	250.98							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							33	33	16		33	9	9	16	11	4	4	11	9	11		4		4		4												4		4	4							6.99	1	2.28	-	0.93	2.82	2.36	1.32	0.37	0.88	0.37	0.07	0.32	2.03	-	1.33	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.05	0.09	-	-	-	-	-	-	23.84		29.82	6.99	1	2.28	-	0.93	2.82	2.36	1.32	0.37	0.88	0.37	0.07	0.32	2.03	-	1.33	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.05	0.09	-	-	-	-	-	-	23.84		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 per Visit	30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.69	0.18	0.5	0.5	0.09	0.19	0.16	0.05	0.21	0.16	0.14	0.02	0.02	0.26	0.35	0.24	0.05	0.03	0.16	0.8	0.16	0																				6.97		0	9.68	1.18	2.78	0.5	1.02	3.02	2.52	1.37	0.58	1.03	0.51	0.08	0.34	2.29	0.35	1.58	0.05	0.23	0.16	1.11	0.16	0	-	-	-	-	-	-	-	-	-	0.13	-	0.05	0.09	-	-	-	-	-	-	30.8
H2228_006_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		3600.85	133.96	1397.47		320.54	32.86	38	731.06	547.19	3112.9	1115.76	100.18	2.67	1635.71		6701.61		576.19		1206.42												320.88		274.34	309.56							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						36	36	17		36	7	9	17	12	2	5	12	9	12		5		5		5												5		5	5							10.67	0.4	1.99	-	0.95	2.34	3.6	1.04	0.54	0.61	0.44	0.1	0.25	1.62	-	2.65	-	0.23	-	0.48	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.11	0.12	-	-	-	-	-	-	28.25		31.35	10.67	0.4	1.99	-	0.95	2.34	3.6	1.04	0.54	0.61	0.44	0.1	0.25	1.62	-	2.65	-	0.23	-	0.48	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.11	0.12	-	-	-	-	-	-	28.25		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	(16a/16b) 0 per Visit	30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						4.39	0.07	0.41	0.54	0.09	0.2	0.23	0.04	0.4	0.25	0.22	0.03	0.02	0.25	0.4	0.43	0.02	0.04	0.28	1.33	0.24	0	0.04		0.01		0.01															9.93		0	15.05	0.47	2.4	0.54	1.04	2.54	3.83	1.08	0.94	0.86	0.66	0.13	0.27	1.87	0.4	3.07	0.02	0.27	0.28	1.8	0.24	0	0.04	-	0.01	-	0.01	-	-	-	-	0.13	-	0.11	0.12	-	-	-	-	-	-	38.18
H2228_007_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		2724.28	140.86	1052.11		239.9	26.72	38.03	629.71	522.97	2751.92	1041.55	87.33	2.59	1642.2		5653.02		558.48		1040.92												299.53		271.44	376.39							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						39	39	19		39	8	10	19	13	3	5	13	10	13		5		5		5												5		5	5							8.89	0.46	1.65	-	0.78	2.09	3.97	0.99	0.57	0.6	0.45	0.09	0.27	1.79	-	2.46	-	0.24	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.16	-	-	-	-	-	-	26.16		23.96	8.89	0.46	1.65	-	0.78	2.09	3.97	0.99	0.57	0.6	0.45	0.09	0.27	1.79	-	2.46	-	0.24	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.16	-	-	-	-	-	-	26.16		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	(16a/16b) 0 per Visit	30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						3.28	0.07	0.31	0.45	0.07	0.16	0.23	0.04	0.35	0.24	0.2	0.03	0.02	0.23	0.4	0.37	0.02	0.04	0.24	1.1	0.21	0	0.04		0.01		0.01															8.11		0	12.17	0.53	1.96	0.45	0.85	2.26	4.2	1.02	0.91	0.84	0.65	0.12	0.29	2.02	0.4	2.83	0.02	0.28	0.24	1.55	0.21	0	0.04	-	0.01	-	0.01	-	-	-	-	0.13	-	0.12	0.16	-	-	-	-	-	-	34.27
H2228_008_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		5699.41	339	2028.94		535.16	64.26	77.3	1096.52	600.13	3578.19	1293.67	130.12	4.43	2032.96		7899.51		680.6		1729.58												384.5		238.39	393.51							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						27	27	13		27	5	7	13	9	2	4	9	7	9		4		4		4												4		4	4							12.86	0.76	2.2	-	1.21	3.48	5.58	1.19	0.45	0.54	0.39	0.1	0.32	1.53	-	2.38	-	0.2	-	0.52	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.07	0.12	-	-	-	-	-	-	34.01		60.2	12.86	0.76	2.2	-	1.21	3.48	5.58	1.19	0.45	0.54	0.39	0.1	0.32	1.53	-	2.38	-	0.2	-	0.52	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.07	0.12	-	-	-	-	-	-	34.01		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	(16a/16b) 0 per Visit	30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						6.47	0.18	0.59	0.85	0.15	0.39	0.47	0.07	0.43	0.29	0.25	0.04	0.03	0.34	0.45	0.51	0.04	0.05	0.32	1.76	0.28	0	0.04		0.01		0.01															14.01		0	19.32	0.94	2.79	0.85	1.36	3.87	6.05	1.25	0.88	0.83	0.64	0.14	0.35	1.87	0.45	2.89	0.04	0.25	0.32	2.28	0.28	0	0.04	-	0.01	-	0.01	-	-	-	-	0.12	-	0.07	0.12	-	-	-	-	-	-	48.02
H2229_001_1	2007	2																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	928.81	0	1041.54	0	0	0	0	453.14	26.37	0	0	0	0	0	3252.3	4584.65	156.39	0	0	0	4.22	0	0	0	322.18	0	138.08	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												91.71	0	22.98	0	0	0	0	45.88	0.18	0	0	0	0	0	13.79	18.38	18.37	0	0	0	0.18	0	0	0	18.39	0	18.39	0	0	0	0											7.1	-	1.99	-	-	-	-	1.73	4.8	-	-	-	-	-	3.74	7.02	0.24	-	-	-	0.77	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.1	0	2.51	7.1	-	1.99	-	-	-	-	1.73	4.8	-	-	-	-	-	3.74	7.02	0.24	-	-	-	0.77	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.1	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.37	0	0.33	0.68	0	0.29	0.01	0.14	0.4	0.11	0.31	0	0	0.41	0.64	0.87	0.03	0.06	0.32	0.09	0.26	0	0	0	0.06	0	0.03	0	0	0	0											6.41	0	2.99	8.47	-	2.32	0.68	-	0.29	0.01	1.88	5.19	0.11	0.31	-	-	0.41	4.37	7.89	0.27	0.06	0.32	0.09	1.03	-	-	-	0.55	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.51
H2229_001_2	2007	2																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	832.96	0	917	0	0	0	0	331.33	21.21	0	0	0	0	0	3279.11	4710.3	172.38	0	0	0	4.41	0	0	0	320.84	0	137.5	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												93.08	0	23.27	0	0	0	0	46.55	0.18	0	0	0	0	0	13.96	18.61	18.61	0	0	0	0.19	0	0	0	18.62	0	18.62	0	0	0	0											6.46	-	1.78	-	-	-	-	1.29	3.81	-	-	-	-	-	3.81	7.31	0.27	-	-	-	0.82	-	-	-	0.5	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.25	0	1.95	6.46	-	1.78	-	-	-	-	1.29	3.81	-	-	-	-	-	3.81	7.31	0.27	-	-	-	0.82	-	-	-	0.5	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.25	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.34	0	0.3	0.55	0	0.31	0.01	0.11	0.33	0.1	0.26	0	0	0.34	0.66	0.92	0.03	0.06	0.34	0.11	0.28	0	0	0	0.06	0	0.03	0	0	0	0											6.14	0	2.59	7.8	-	2.08	0.55	-	0.31	0.01	1.39	4.14	0.1	0.26	-	-	0.34	4.47	8.23	0.3	0.06	0.34	0.11	1.1	-	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.39
H2229_010_1	2007	3																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	928.81	0	1041.54	0	0	0	0	453.14	26.37	0	0	0	0	0	3252.3	4584.65	156.39	0	0	0	4.22	0	0	0	322.18	0	138.08	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												91.71	0	22.98	0	0	0	0	45.88	0.18	0	0	0	0	0	13.79	18.38	18.37	0	0	0	0.18	0	0	0	18.39	0	18.39	0	0	0	0											7.1	-	1.99	-	-	-	-	1.73	4.8	-	-	-	-	-	3.74	7.02	0.24	-	-	-	0.77	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.1	0	2.51	7.1	-	1.99	-	-	-	-	1.73	4.8	-	-	-	-	-	3.74	7.02	0.24	-	-	-	0.77	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.1	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.37	0	0.33	0.68	0	0.29	0.01	0.14	0.4	0.11	0.31	0	0	0.41	0.64	0.87	0.03	0.06	0.32	0.09	0.26	0	0	0	0.06	0	0.03	0	0	0	0											6.41	0	2.99	8.47	-	2.32	0.68	-	0.29	0.01	1.88	5.19	0.11	0.31	-	-	0.41	4.37	7.89	0.27	0.06	0.32	0.09	1.03	-	-	-	0.55	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.51
H2229_010_2	2007	3																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	832.96	0	917	0	0	0	0	331.33	21.21	0	0	0	0	0	3279.11	4710.3	172.38	0	0	0	4.41	0	0	0	320.84	0	137.5	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												93.08	0	23.27	0	0	0	0	46.55	0.18	0	0	0	0	0	13.96	18.61	18.61	0	0	0	0.19	0	0	0	18.62	0	18.62	0	0	0	0											6.46	-	1.78	-	-	-	-	1.29	3.81	-	-	-	-	-	3.81	7.31	0.27	-	-	-	0.82	-	-	-	0.5	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.25	0	1.95	6.46	-	1.78	-	-	-	-	1.29	3.81	-	-	-	-	-	3.81	7.31	0.27	-	-	-	0.82	-	-	-	0.5	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.25	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.34	0	0.3	0.55	0	0.31	0.01	0.11	0.33	0.1	0.26	0	0	0.34	0.66	0.92	0.03	0.06	0.34	0.11	0.28	0	0	0	0.06	0	0.03	0	0	0	0											6.14	0	2.59	7.8	-	2.08	0.55	-	0.31	0.01	1.39	4.14	0.1	0.26	-	-	0.34	4.47	8.23	0.3	0.06	0.34	0.11	1.1	-	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.39
H2229_011_1	2007	3																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	928.81	0	1041.54	0	0	0	0	453.14	26.37	0	0	0	0	0	3252.3	4584.65	156.39	0	0	0	4.22	0	0	0	322.18	0	138.08	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												91.71	0	22.98	0	0	0	0	45.88	0.18	0	0	0	0	0	13.79	18.38	18.37	0	0	0	0.18	0	0	0	18.39	0	18.39	0	0	0	0											7.1	-	1.99	-	-	-	-	1.73	4.8	-	-	-	-	-	3.74	7.02	0.24	-	-	-	0.77	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.1	0	2.51	7.1	-	1.99	-	-	-	-	1.73	4.8	-	-	-	-	-	3.74	7.02	0.24	-	-	-	0.77	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.1	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.37	0	0.33	0.68	0	0.29	0.01	0.14	0.4	0.11	0.31	0	0	0.41	0.64	0.87	0.03	0.06	0.32	0.09	0.26	0	0	0	0.06	0	0.03	0	0	0	0											6.41	0	2.99	8.47	-	2.32	0.68	-	0.29	0.01	1.88	5.19	0.11	0.31	-	-	0.41	4.37	7.89	0.27	0.06	0.32	0.09	1.03	-	-	-	0.55	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.51
H2229_011_2	2007	3																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	832.96	0	917	0	0	0	0	331.33	21.21	0	0	0	0	0	3279.11	4710.3	172.38	0	0	0	4.41	0	0	0	320.84	0	137.5	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												93.08	0	23.27	0	0	0	0	46.55	0.18	0	0	0	0	0	13.96	18.61	18.61	0	0	0	0.19	0	0	0	18.62	0	18.62	0	0	0	0											6.46	-	1.78	-	-	-	-	1.29	3.81	-	-	-	-	-	3.81	7.31	0.27	-	-	-	0.82	-	-	-	0.5	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.25	0	1.95	6.46	-	1.78	-	-	-	-	1.29	3.81	-	-	-	-	-	3.81	7.31	0.27	-	-	-	0.82	-	-	-	0.5	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.25	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.34	0	0.3	0.55	0	0.31	0.01	0.11	0.33	0.1	0.26	0	0	0.34	0.66	0.92	0.03	0.06	0.34	0.11	0.28	0	0	0	0.06	0	0.03	0	0	0	0											6.14	0	2.59	7.8	-	2.08	0.55	-	0.31	0.01	1.39	4.14	0.1	0.26	-	-	0.34	4.47	8.23	0.3	0.06	0.34	0.11	1.1	-	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.39
H2229_801_0	2007	2																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	914.49	0	1022.94	0	0	0	0	434.94	25.59	0	0	0	0	0	3256.3	4603.42	158.78	0	0	0	4.24	0	0	0	321.98	0	137.99	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												92.18	0	23.05	0	0	0	0	46.09	0.18	0	0	0	0	0	13.83	18.44	18.44	0	0	0	0.18	0	0	0	18.44	0	18.44	0	0	0	0											7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	0	2.37	7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.37	0	0.32	0.66	0	0.29	0.01	0.14	0.39	0.11	0.31	0	0	0.41	0.64	0.88	0.03	0.06	0.32	0.09	0.26	0	0	0	0.06	0	0.03	0	0	0	0											6.39	0	2.92	8.4	-	2.29	0.66	-	0.29	0.01	1.81	5.11	0.11	0.31	-	-	0.41	4.39	7.95	0.27	0.06	0.32	0.09	1.04	-	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.32
H2229_802_0	2007	2																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	914.49	0	1022.94	0	0	0	0	434.94	25.59	0	0	0	0	0	3256.3	4603.42	158.78	0	0	0	4.24	0	0	0	321.98	0	137.99	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												92.18	0	23.05	0	0	0	0	46.09	0.18	0	0	0	0	0	13.83	18.44	18.44	0	0	0	0.18	0	0	0	18.44	0	18.44	0	0	0	0											7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	0	2.37	7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.37	0	0.32	0.66	0	0.29	0.01	0.14	0.39	0.11	0.31	0	0	0.41	0.64	0.88	0.03	0.06	0.32	0.09	0.26	0	0	0	0.06	0	0.03	0	0	0	0											6.39	0	2.92	8.4	-	2.29	0.66	-	0.29	0.01	1.81	5.11	0.11	0.31	-	-	0.41	4.39	7.95	0.27	0.06	0.32	0.09	1.04	-	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.32
H2229_803_0	2007	2																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	914.49	0	1022.94	0	0	0	0	434.94	25.59	0	0	0	0	0	3256.3	4603.42	158.78	0	0	0	4.24	0	0	0	321.98	0	137.99	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												92.18	0	23.05	0	0	0	0	46.09	0.18	0	0	0	0	0	13.83	18.44	18.44	0	0	0	0.18	0	0	0	18.44	0	18.44	0	0	0	0											7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	0	2.37	7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.37	0	0.32	0.66	0	0.29	0.01	0.14	0.39	0.11	0.31	0	0	0.41	0.64	0.88	0.03	0.06	0.32	0.09	0.26	0	0	0	0.06	0	0.03	0	0	0	0											6.39	0	2.92	8.4	-	2.29	0.66	-	0.29	0.01	1.81	5.11	0.11	0.31	-	-	0.41	4.39	7.95	0.27	0.06	0.32	0.09	1.04	-	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.32
H2229_804_0	2007	2																					3000											D		D					V	Coin						V	V	V				Coin				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	914.49	0	1022.94	0	0	0	0	434.94	25.59	0	0	0	0	0	3256.3	4603.42	158.78	0	0	0	4.24	0	0	0	321.98	0	137.99	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												92.18	0	23.05	0	0	0	0	46.09	0.18	0	0	0	0	0	13.83	18.44	18.44	0	0	0	0.18	0	0	0	18.44	0	18.44	0	0	0	0											7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	0	2.37	7.03	-	1.96	-	-	-	-	1.67	4.72	-	-	-	-	-	3.75	7.07	0.24	-	-	-	0.78	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.94	3000	PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.37	0	0.32	0.66	0	0.29	0.01	0.14	0.39	0.11	0.31	0	0	0.41	0.64	0.88	0.03	0.06	0.32	0.09	0.26	0	0	0	0.06	0	0.03	0	0	0	0											6.39	0	2.92	8.4	-	2.29	0.66	-	0.29	0.01	1.81	5.11	0.11	0.31	-	-	0.41	4.39	7.95	0.27	0.06	0.32	0.09	1.04	-	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.32
H2230_002_0	2007	5																					2000											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	V	V	V																																																				-	4500	1632.99	105.3	2895.7		613.1	1266.3	388.59	1053.99	385.95					2447.76	4401.09	5280.96	326.94	1016.62		8206.53		39.33		291.61	607.11						412.02											100 days 1 - 5 0 days 6+ (500 annual max)	100 days 1 - 5 0 days 6+ (500 annual max)	10/day days 1-20 per benefit period (200 calendar year max)	0	100/day	10 each item	10 each item	0 - 50/visit	0 - 100/visit	0	0	0	0	0 - 100 per visit	15  (POC) 25 (non POC) per visit	15 - 25 per visit	15/Visit 1-10 25/visit 11-beyond	10 per visit	0	0 - 25 per visit	0			25 visit every six months	25 one exam per calendar year		0				misc. 0 to 100											47.44	30.88	4.53		25.3	12.08	8.1	45.78	89.85					3.35	18.16	23.28	17.45	6.83		1.88		0		25	25						49.75											6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07		0.02	6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07	6500	20  per stay	20  per stay	20  per day	20  per day	100 per day	20 each item	20 each item	40 per visit urgent care	0	0	20	20	20	0	40 one exam calendar year	20	0	0	20	20				20	20		0															1.45	0.04	0.14	0.07	0.07	0.28	0.08	1.73	0.48	0.35	0.59	0.09	0.05	0.35	0.72	0.41	0.02	0.04	0.12	0.11				0.03	0.16		0															7.39	500	7.57	7.9	0.31	1.23	0.07	1.36	1.55	0.34	5.75	3.37	0.35	0.59	0.09	0.05	1.03	7.38	10.66	0.49	0.61	0.12	1.4	-	-	-	0.64	1.42	-	0	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	48.46
H2230_006_0	2007	5																					2000											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	V	V	V																																																				-	4500	1632.99	105.3	2895.7		613.1	1266.3	388.59	1053.99	385.95					2447.76	4401.09	5280.96	326.94	1016.62		8206.53		39.33		291.61	607.11						412.02											100 days 1 - 5 0 days 6+ (500 annual max)	100 days 1 - 5 0 days 6+ (500 annual max)	10/day days 1-20 per benefit period (200 calendar year max)	0	100/day	10 each item	10 each item	0 - 50/visit	0 - 100/visit	0	0	0	0	0 - 100 per visit	15  (POC) 25 (non POC) per visit	15 - 25 per visit	15/Visit 1-10 25/visit 11-beyond	10 per visit	0	0 - 25 per visit	0			25 visit every six months	25 one exam per calendar year		0				misc. 0 to 100											47.44	30.88	4.53		25.3	12.08	8.1	45.78	89.85					3.35	18.16	23.28	17.45	6.83		1.88		0		25	25						49.75											6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07		0.02	6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07	6500	20  per stay	20  per stay	20  per day	20  per day	100 per day	20 each item	20 each item	40 per visit urgent care	0	0	20	20	20	0	40 one exam calendar year	20	0	0	20	20				20	20		0															1.45	0.04	0.14	0.07	0.07	0.28	0.08	1.73	0.48	0.35	0.59	0.09	0.05	0.35	0.72	0.41	0.02	0.04	0.12	0.11				0.03	0.16		0															7.39	500	7.57	7.9	0.31	1.23	0.07	1.36	1.55	0.34	5.75	3.37	0.35	0.59	0.09	0.05	1.03	7.38	10.66	0.49	0.61	0.12	1.4	-	-	-	0.64	1.42	-	0	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	48.46
H2230_010_0	2007	2																					2000											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	V	V	V																																																				-	4500	1632.99	105.3	2895.7		613.1	1266.3	388.59	1053.99	385.95					2447.76	4401.09	5280.96	326.94	1016.62		8206.53		39.33		291.61	607.11						412.02											100 days 1 - 5 0 days 6+ (500 annual max)	100 days 1 - 5 0 days 6+ (500 annual max)	10/day days 1-20 per benefit period (200 calendar year max)	0	100/day	10 each item	10 each item	0 - 50/visit	0 - 100/visit	0	0	0	0	0 - 100 per visit	15  (POC) 25 (non POC) per visit	15 - 25 per visit	15/Visit 1-10 25/visit 11-beyond	10 per visit	0	0 - 25 per visit	0			25 visit every six months	25 one exam per calendar year		0				misc. 0 to 100											47.44	30.88	4.53		25.3	12.08	8.1	45.78	89.85					3.35	18.16	23.28	17.45	6.83		1.88		0		25	25						49.75											6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07		0.02	6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07	6500	20  per stay	20  per stay	20  per day	20  per day	100 per day	20 each item	20 each item	40 per visit urgent care	0	0	20	20	20	0	40 one exam calendar year	20	0	0	20	20				20	20		0															1.45	0.04	0.14	0.07	0.07	0.28	0.08	1.73	0.48	0.35	0.59	0.09	0.05	0.35	0.72	0.41	0.02	0.04	0.12	0.11				0.03	0.16		0															7.39	500	7.57	7.9	0.31	1.23	0.07	1.36	1.55	0.34	5.75	3.37	0.35	0.59	0.09	0.05	1.03	7.38	10.66	0.49	0.61	0.12	1.4	-	-	-	0.64	1.42	-	0	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	48.46
H2230_801_0	2007	4																					2000											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	V	V	V																																																				-	4500	1632.99	105.3	2895.7		613.1	1266.3	388.59	1053.99	385.95					2447.76	4401.09	5280.96	326.94	1016.62		8206.53		39.33		291.61	607.11						412.02											100 days 1 - 5 0 days 6+ (500 annual max)	100 days 1 - 5 0 days 6+ (500 annual max)	10/day days 1-20 per benefit period (200 calendar year max)	0	100/day	10 each item	10 each item	0 - 50/visit	0 - 100/visit	0	0	0	0	0 - 100 per visit	15  (POC) 25 (non POC) per visit	15 - 25 per visit	15/Visit 1-10 25/visit 11-beyond	10 per visit	0	0 - 25 per visit	0			25 visit every six months	25 one exam per calendar year		0				misc. 0 to 100											47.44	30.88	4.53		25.3	12.08	8.1	45.78	89.85					3.35	18.16	23.28	17.45	6.83		1.88		0		25	25						49.75											6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07		0.02	6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07	6500	20  per stay	20  per stay	20  per day	20  per day	100 per day	20 each item	20 each item	40 per visit urgent care	0	0	20	20	20	0	40 one exam calendar year	20	0	0	20	20				20	20		0															1.45	0.04	0.14	0.07	0.07	0.28	0.08	1.73	0.48	0.35	0.59	0.09	0.05	0.35	0.72	0.41	0.02	0.04	0.12	0.11				0.03	0.16		0															7.39	500	7.57	7.9	0.31	1.23	0.07	1.36	1.55	0.34	5.75	3.37	0.35	0.59	0.09	0.05	1.03	7.38	10.66	0.49	0.61	0.12	1.4	-	-	-	0.64	1.42	-	0	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	48.46
H2230_809_0	2007	2																					2000											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	V	V	V																																																				-	4500	1632.99	105.3	2895.7		613.1	1266.3	388.59	1053.99	385.95					2447.76	4401.09	5280.96	326.94	1016.62		8206.53				291.61	607.11						412.02											100 days 1 - 5 0 days 6+ (500 annual max)	100 days 1 - 5 0 days 6+ (500 annual max)	10/day days 1-20 per benefit period (200 calendar year max)	0	100/day	10 each item	10 each item	0 - 50/visit	0 - 100/visit	0	0	0	0	0 - 100 per visit	15  (POC) 25 (non POC) per visit	15 - 25 per visit	15/Visit 1-10 25/visit 11-beyond	10 per visit	0	0 - 25 per visit	0			25 visit every six months	25 one exam per calendar year		0				misc. 0 to 100											47.44	30.88	4.53		25.3	12.08	8.1	45.78	89.85					3.35	18.16	23.28	17.45	6.83		1.88				25	25						49.75											6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07		0.02	6.46	0.27	1.09	-	1.29	1.28	0.26	4.02	2.89	-	-	-	-	0.68	6.66	10.25	0.48	0.58	-	1.29	-	-	-	0.61	1.26	-	-	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	41.07	6500	20  per stay	20  per stay	20  per day	20  per day	100 per day	20 each item	20 each item	40 per visit urgent care	0	0	20	20	20	0	40 one exam calendar year	20	0	0	20	20				20	20		0															1.45	0.04	0.14	0.07	0.07	0.28	0.08	1.73	0.48	0.35	0.59	0.09	0.05	0.35	0.72	0.41	0.02	0.04	0.12	0.11				0.03	0.16		0															7.39	500	7.57	7.9	0.31	1.23	0.07	1.36	1.55	0.34	5.75	3.37	0.35	0.59	0.09	0.05	1.03	7.38	10.66	0.49	0.61	0.12	1.4	-	-	-	0.64	1.42	-	0	-	-	-	1.71	-	-	-	-	-	-	-	-	-	-	48.46
H2237_001_0	2007	8																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	383.77	29.63	80.91	0	12.86	29.92	19.63	718.44	23.93	16.3	32.79	1.12	1.29	46.82	53.27	103.91	8.08	4.24	21.72	35.1	10.89	3.32	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 7.2 Medicare equivalent coinsurance	1B IP Psych: 7.2 Medicare equivalent coinsurance	2 SNF: 17.5 Medicare equivalent coinsurance	6 Home Health: 0	10A Ambulance: 23.6 Medicare equivalent coinsurance	11A DME: 23.6 Medicare equivalent coinsurance	11B Prosthetic Medical Supplies and 11C Diabetes Monitoring Supplies :  23.6 Medicare equivalent coinsurance	4A ER: 50 ER copay 4B Urgent Care:  23.6 Urgent Care equivalent coins	9A OP Hospital and 9B ASC Services:  23.6 Medicare equivalent coinsurance	8A OP C/D/T:  23.6 Medicare equivalent coinsurance	8B OP X-Ray: 23.6 Medicare equivalent coinsurance	5 Partial Hosp:  23.6 Medicare equivalent coinsurance	12 Renal Dialysis: 23.6 Medicare equivalent coinsurance	3 CORF 9C OP Substance Abuse & 9D Cardiac Rehab:  23.6 Medicare equivalent coinsurance	7A PCP 14D Pap Smears 14D Pelvic Exams 14E Prostate Screening 14F Colorectal Screening 14G Bone Mass Measurement 14H Mammography & 14I Diabetes Monitoring:  138 Ded and 20 Coinsurance  14B Immunizations: 0  14C Routine Physical Exam:  Not covered	7D Physician Specialist:  22.7 Medicare equivalent coinsurance	7E Mental Health & 7H Psych:  23.6 Medicare equivalent coinsurance	7C Occupational Therapy & 7I Physical and Speech Therapy:  23.6 Medicare equivalent coinsurance	7D Physician Specialist: 23.6 Medicare equivalent coinsurance	7B Chiropractic 7F Podiatry 7G Other Health Care & 18A Medicare Covered Hearing Exams:  23.6 Medicare equivalent coinsurance	15 Part B Drugs:  23.6 Medicare equivalent coinsurance	13A Blood 17A Medicare Covered Eye Exams & 16B Comprehensive Dental Services: 23.6 Medicare equivalent coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered  16B Comprehensive Dental Services:  Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0.07	0.07	0.17	0	0.24	0.24	0.24	48.79	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											27.59	2.13	14.13	-	3.03	7.06	4.63	2.92	5.65	3.85	7.74	0.26	0.3	11.05	12.16	23.63	1.91	1	5.13	8.28	2.57	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	145.81	0	0	27.59	2.13	14.13	-	3.03	7.06	4.63	2.92	5.65	3.85	7.74	0.26	0.3	11.05	12.16	23.63	1.91	1	5.13	8.28	2.57	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	145.81	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	27.59	2.13	14.13	-	3.03	7.06	4.63	2.92	5.65	3.85	7.74	0.26	0.3	11.05	12.16	23.63	1.91	1	5.13	8.28	2.57	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	145.81
H2237_002_0	2007	8																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	347	28.16	70.18	0	12.74	29.97	19.39	834.55	26.51	18.44	36.88	1.22	1.41	51.32	51.63	98.65	7.91	4.11	20.5	33.56	12	3.29	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 7.8 Medicare equivalent coinsurance	1B IP Psych: 7.8 Medicare equivalent coinsurance	2 SNF: 17.1 Medicare equivalent coinsurance	6 Home Health: 0	10A Ambulance: 23.6 Medicare equivalent coinsurance	11A DME: 23.6 Medicare equivalent coinsurance	11B Prosthetic Medical Supplies and 11C Diabetes Monitoring Supplies :  23.6 Medicare equivalent coinsurance	4A ER: 50 ER copay 4B Urgent Care:  23.6 Urgent Care equivalent coins	9A OP Hospital and 9B ASC Services:  23.6 Medicare equivalent coinsurance	8A OP C/D/T:  23.6 Medicare equivalent coinsurance	8B OP X-Ray: 23.6 Medicare equivalent coinsurance	5 Partial Hosp:  23.6 Medicare equivalent coinsurance	12 Renal Dialysis: 23.6 Medicare equivalent coinsurance	3 CORF 9C OP Substance Abuse & 9D Cardiac Rehab:  23.6 Medicare equivalent coinsurance	7A PCP 14D Pap Smears 14D Pelvic Exams 14E Prostate Screening 14F Colorectal Screening 14G Bone Mass Measurement 14H Mammography & 14I Diabetes Monitoring:  138 Ded and 20 Coinsurance  14B Immunizations: 0  14C Routine Physical Exam:  Not covered	7D Physician Specialist:  22.8 Medicare equivalent coinsurance	7E Mental Health & 7H Psych:  23.6 Medicare equivalent coinsurance	7C Occupational Therapy & 7I Physical and Speech Therapy:  23.6 Medicare equivalent coinsurance	7D Physician Specialist: 23.6 Medicare equivalent coinsurance	7B Chiropractic 7F Podiatry 7G Other Health Care & 18A Medicare Covered Hearing Exams:  23.6 Medicare equivalent coinsurance	15 Part B Drugs:  23.6 Medicare equivalent coinsurance	13A Blood 17A Medicare Covered Eye Exams & 16B Comprehensive Dental Services: 23.6 Medicare equivalent coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered  16B Comprehensive Dental Services:  Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0.08	0.08	0.17	0	0.24	0.24	0.24	49.05	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											27.14	2.2	11.98	-	3.01	7.07	4.58	3.41	6.26	4.35	8.7	0.29	0.33	12.11	11.76	22.3	1.87	0.97	4.84	7.92	2.83	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.69	0	0	27.14	2.2	11.98	-	3.01	7.07	4.58	3.41	6.26	4.35	8.7	0.29	0.33	12.11	11.76	22.3	1.87	0.97	4.84	7.92	2.83	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.69	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	27.14	2.2	11.98	-	3.01	7.07	4.58	3.41	6.26	4.35	8.7	0.29	0.33	12.11	11.76	22.3	1.87	0.97	4.84	7.92	2.83	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.69
H2256_001_1	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		209.51	0						377.29	413.26						2715.23	2713.05	109.26	0	0	41.7								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43			3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43																																																																																				-			3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43
H2256_001_2	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		216	0						288.47	416.04						2574.2	2580.96	115.67	0	0	18.63								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87			3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87																																																																																				-			3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87
H2256_001_3	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		166.14	0						330.52	410.97						2717.89	2735.34	115.5	0	0	15.98								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51			2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51																																																																																				-			2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51
H2256_001_4	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		144.72	0						350.85	491.45						2591.72	2585.31	142.84	0	0	5.59								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25			2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25																																																																																				-			2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25
H2256_001_5	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		205.5	0						312.19	417.19						2613.73	2612.84	128.45	0	0	15.67								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89			3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89																																																																																				-			3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89
H2256_015_1	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		209.51	0						377.29	413.26						2715.23	2713.05	109.26	0	0	41.7								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43			3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43																																																																																				-			3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43
H2256_015_2	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		216	0						288.47	416.04						2574.2	2580.96	115.67	0	0	18.63								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87			3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87																																																																																				-			3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87
H2256_015_3	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		166.14	0						330.52	410.97						2717.89	2735.34	115.5	0	0	15.98								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51			2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51																																																																																				-			2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51
H2256_015_4	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		144.72	0						350.85	491.45						2591.72	2585.31	142.84	0	0	5.59								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25			2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25																																																																																				-			2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25
H2256_015_5	2007	4																																D	D						P	P	P					P	P	P	P	P	P																																																															-		205.5	0						312.19	417.19						2613.73	2612.84	128.45	0	0	15.67								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89			3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89																																																																																				-			3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89
H2256_016_1	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		209.51	0						377.29	413.26						2715.23	2713.05	109.26	0	0	41.7								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43			3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43																																																																																				-			3.49	-	-	-	-	-	-	1.57	1.48	-	-	-	-	-	2.26	3.39	0.14	-	-	0.05	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	12.43
H2256_016_2	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		216	0						288.47	416.04						2574.2	2580.96	115.67	0	0	18.63								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87			3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87																																																																																				-			3.6	-	-	-	-	-	-	1.2	1.49	-	-	-	-	-	2.15	3.23	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87
H2256_016_3	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		166.14	0						330.52	410.97						2717.89	2735.34	115.5	0	0	15.98								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51			2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51																																																																																				-			2.77	-	-	-	-	-	-	1.38	1.47	-	-	-	-	-	2.26	3.42	0.14	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51
H2256_016_4	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		144.72	0						350.85	491.45						2591.72	2585.31	142.84	0	0	5.59								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25			2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25																																																																																				-			2.41	-	-	-	-	-	-	1.46	1.76	-	-	-	-	-	2.16	3.23	0.18	-	-	0.01	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.25
H2256_016_5	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		205.5	0						312.19	417.19						2613.73	2612.84	128.45	0	0	15.67								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	200						50	43						10	15	15	0	0	15								15														3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89			3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89																																																																																				-			3.43	-	-	-	-	-	-	1.3	1.49	-	-	-	-	-	2.18	3.27	0.16	-	-	0.02	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.89
H2256_017_1	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		1009.87	27.13	829.47					366.79	313.34						2415.36	2721.53	123.98	0	0	20.67	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61			8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61																																																																																				-			8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61
H2256_017_2	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		1025.95	27.57	829.47					288.47	309.86						2361.38	2660.71	121.21	0	0	20.21	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2			8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2																																																																																				-			8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2
H2256_017_3	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		806.93	21.68	829.47					328.41	319.81						2422.01	2729.03	124.32	0	0	20.72	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82			6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82																																																																																				-			6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82
H2256_017_4	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		979.21	26.31	829.47					318.12	310.71						2403.55	2708.22	123.37	0	0	20.57	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07			8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07																																																																																				-			8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07
H2256_018_1	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		1009.87	27.13	829.47					366.79	313.34						2415.36	2721.53	123.98	0	0	20.67	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61			8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61																																																																																				-			8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61
H2256_018_2	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		1025.95	27.57	829.47					288.47	309.86						2361.38	2660.71	121.21	0	0	20.21	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2			8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2																																																																																				-			8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2
H2256_018_3	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		806.93	21.68	829.47					328.41	319.81						2422.01	2729.03	124.32	0	0	20.72	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82			6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82																																																																																				-			6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82
H2256_018_4	2007	4																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		979.21	26.31	829.47					318.12	310.71						2403.55	2708.22	123.37	0	0	20.57	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07			8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07																																																																																				-			8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07
H2256_019_1	2007	3																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		1009.87	27.13	829.47					366.79	313.34						2415.36	2721.53	123.98	0	0	20.67	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61			8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61																																																																																				-			8.42	0.23	1.73	-	-	-	-	1.53	3.92	-	-	-	-	-	3.02	4.54	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.61
H2256_019_2	2007	3																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		1025.95	27.57	829.47					288.47	309.86						2361.38	2660.71	121.21	0	0	20.21	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2			8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2																																																																																				-			8.55	0.23	1.73	-	-	-	-	1.2	3.87	-	-	-	-	-	2.95	4.43	0.2	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.2
H2256_019_3	2007	3																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		806.93	21.68	829.47					328.41	319.81						2422.01	2729.03	124.32	0	0	20.72	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82			6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82																																																																																				-			6.72	0.18	1.73	-	-	-	-	1.37	4	-	-	-	-	-	3.03	4.55	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82
H2256_019_4	2007	3																																D	D	P	P	O	P	P	O	P	O				V	P		O	O		V																																																															-		979.21	26.31	829.47					318.12	310.71						2403.55	2708.22	123.37	0	0	20.57	0	0																				100 each day for day(s) 1-5	100 each day for day(s) 1-6	25 per day for day(s) 11-100					50/ ER visit	20 if applicable Max 150						15/visit	20/visit	20/visit	20/visit	20/visit	20/visit					15/exam		15/test															100	100	25	0	0	0	0	50	150	20	0	0	0	0	15	20	20	0	0	20	20	0		0	15	0	15	0	0	0	0	0	0	0	0	0	0	0	0	0	0	8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07			8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07																																																																																				-			8.16	0.22	1.73	-	-	-	-	1.33	3.88	-	-	-	-	-	3	4.51	0.21	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.07
H2256_801_0	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		160.72	0						271.73	400.33	4.62				0.94	256.7	4318.83	188.97			25.77								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	0						50	43	20				0	10	15	15	0	0	20	20				15	0		15														2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18																																																																																				-			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18
H2256_802_0	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		160.72	0						271.73	400.33	4.62				0.94	256.7	4318.83	188.97			25.77								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	0						50	43	20				0	10	15	15	0	0	20	20				15	0		15														2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18																																																																																				-			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18
H2256_803_0	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		160.72	0						271.73	400.33	4.62				0.94	256.7	4318.83	188.97			25.77								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	0						50	43	20				0	10	15	15	0	0	20	20				15	0		15														2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18																																																																																				-			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18
H2256_804_0	2007	3																																D	D						P	P	P					P	P	P	P	P	P																																																															-		160.72	0						271.73	400.33	4.62				0.94	256.7	4318.83	188.97			25.77								32														200 deductible	200 deductible						50 per visit	0-50 per visit max 20						10 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit								15 per visit														200	0						50	43	20				0	10	15	15	0	0	20	20				15	0		15														2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18																																																																																				-			2.68	-	-	-	-	-	-	1.13	1.43	0.01	-	-	-	-	0.21	5.4	0.24	-	-	0.04	-	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	11.18
H2261_005_0	2007	6																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S			V	V	V	V	V		V	V																																																				-		1672.93	107.88	2966.52		468.6			1079.77	395.39					2507.63	8097.02	11204.57	334.94	1041.48		8407.25		40.3		312.18	1270.8	336.77					433.71											100 days 1 - 5 0 days 6+	100 days 1 - 5 0 days 6+	10/day days 1-20 200 max per calendar year		0 - 50/day			0 - 50/visit	0 - 50/visit					0 - 30 per visit	0 -10 per visit no cost for immunization	0 - 20 per visit	20/Visit 1-10 30/visit 11-beyond	0 - 15 per visit		0 - 30 per visit		10 - 20 per visit		20 visit every six months	20  exam per calendar year	0 - 57 contact lenses every 24 mos.					0 - 20 per visit											46.98	27.34	5		12.65			12.48	32.03					3.29	5.38	8.98	12.28	8.75		0.02		0		19.04	13.88	40.7					10.89											6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03																																																																																				-			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03
H2261_011_0	2007	6																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S			V	V	V	V	V		V	V																																																				-		1672.93	107.88	2966.52	2703.81	468.6	1297.27	398.09	1079.77	395.39					2507.63	8097.02	11204.57	334.94	1041.48		8407.25		40.3		312.18	1270.8	336.77					433.71											100 days 1 - 5 0 days 6+	100 days 1 - 5 0 days 6+	10/day days 1-20 200 max per calendar year		0 - 50/day			0 - 50/visit	0 - 50/visit					0 - 30 per visit	0 -10 per visit no cost for immunization	0 - 20 per visit	20/Visit 1-10 30/visit 11-beyond	0 - 15 per visit		0 - 30 per visit		10 - 20 per visit		20 visit every six months	20  exam per calendar year	0 - 57 contact lenses every 24 mos.					0 - 20 per visit											46.98	27.34	5		12.65			12.48	32.03					3.29	5.38	8.98	12.28	8.75		0.02		0		19.04	13.88	40.7					10.89											6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03																																																																																				-			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03
H2261_015_0	2007	4																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S			V	V	V	V	V		V	V																																																				-		1672.93	107.88	2966.52		468.6			1079.77	395.39					2507.63	8097.02	11204.57	334.94	1041.48		8407.25		40.3		312.18	1270.8	336.77					433.71											100 days 1 - 5 0 days 6+	100 days 1 - 5 0 days 6+	10/day days 1-20 200 max per calendar year		0 - 50/day			0 - 50/visit	0 - 50/visit					0 - 30 per visit	0 -10 per visit no cost for immunization	0 - 20 per visit	20/Visit 1-10 30/visit 11-beyond	0 - 15 per visit		0 - 30 per visit		10 - 20 per visit		20 visit every six months	20  exam per calendar year	0 - 57 contact lenses every 24 mos.					0 - 20 per visit											46.98	27.34	5		12.65			12.48	32.03					3.29	5.38	8.98	12.28	8.75		0.02		0		19.04	13.88	40.7					10.89											6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03																																																																																				-			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03
H2261_801_0	2007	3																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S			V	V	V	V	V		V	V																																																				-		1672.93	107.88	2966.52		468.6			1079.77	395.39					2507.63	8097.02	11204.57	334.94	1041.48		8407.25		40.3		312.18	1270.8	336.77					433.71											100 days 1 - 5 0 days 6+	100 days 1 - 5 0 days 6+	10/day days 1-20 200 max per calendar year		0 - 50/day			0 - 50/visit	0 - 50/visit					0 - 30 per visit	0 -10 per visit no cost for immunization	0 - 20 per visit	20/Visit 1-10 30/visit 11-beyond	0 - 15 per visit		0 - 30 per visit		10 - 20 per visit		20 visit every six months	20  exam per calendar year	0 - 57 contact lenses every 24 mos.					0 - 20 per visit											46.98	27.34	5		12.65			12.48	32.03					3.29	5.38	8.98	12.28	8.75		0.02		0		19.04	13.88	40.7					10.89											6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03																																																																																				-			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03
H2261_809_0	2007	3																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S			V	V	V	V	V		V	V																																																				-		1672.93	107.88	2966.52	2703.81	468.6	1297.27		1079.77	395.39					2507.63	8097.02	11204.57	334.94	1041.48		8407.25		40.3		312.18	1270.8	336.77					433.71											Inpat/Mental Health 100 1st 5	days 0 day 6 - 999	10/day 1-20 max 200 per year		0 - 50/day			0 - 50/visit	0 - 50/visit					0 - 30 per visit	0 -10 per visit no cost for immunization	0 - 20 per visit	0 - 30 per visit	0 - 15 per visit		0 - 30 per visit		10 - 20 per visit		20 visit every six months	20  exam per calendar year	37 - 57 contact lenses every 24 mos.					0 - 20 per visit											46.98	27.34	5		12.65			12.48	32.03					3.29	5.38	8.98	12.28	8.75		0.02		0		19.04	13.88	40.7					10.89											6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03																																																																																				-			6.55	0.25	1.24	-	0.49	-	-	1.12	1.06	-	-	-	-	0.69	3.63	8.39	0.34	0.76	-	0.01	-	-	-	0.5	1.47	1.14	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	28.03
H2312_004_0	2007	5																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	300.52	4.13	1224.2	0	0	15.92	0	731.56	0	0	0	0	0	0	3095.58	5632.04	212.36	35.05	0	74.43	0	1153.51	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.26	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01	0	0	6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01
H2312_006_0	2007	3																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	300.52	4.13	1224.2	0	0	15.92	0	731.56	0	0	0	0	0	0	3095.58	5632.04	212.36	35.05	0	74.43	0	1153.51	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.26	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01	0	0	6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01
H2312_007_0	2007	5																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	311.8	4.29	1328.67	0	0	17.2	10.48	432.51	0	0	0	0	0	0	5944.39	6898.45	210.82	3775.92	0	1957.96	0	736.99	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.24	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79	0	0	6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79
H2312_008_0	2007	3																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	311.8	4.29	1328.67	0	0	17.2	10.48	432.51	0	0	0	0	0	0	5944.39	6898.45	210.82	3775.92	0	1957.96	0	736.99	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.24	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79	0	0	6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79
H2312_009_0	2007	7																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	300.52	4.13	1224.2	0	0	15.92	0	731.56	0	0	0	0	0	0	3095.58	5632.04	212.36	35.05	0	74.43	0	1153.51	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.26	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01	0	0	6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.26	0.09	5.83	-	-	3.18	-	3	-	-	-	-	-	-	3.87	11.73	0.44	0.04	-	0.16	-	2.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.01
H2312_010_0	2007	7																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	311.8	4.29	1328.67	0	0	17.2	10.48	432.51	0	0	0	0	0	0	5944.39	6898.45	210.82	3775.92	0	1957.96	0	736.99	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.24	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79	0	0	6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.5	0.09	6.32	-	-	3.44	2.09	1.77	-	-	-	-	-	-	7.43	14.37	0.44	4.72	-	4.08	-	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.79
H2312_801_0	2007	3																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	276.74	1.89	34.61	11.17	12.74	14.82	0	44.13	26.48	2.75	26.17	0	0	152.35	20.88	82.37	1.44	0.08	0	54.24	20.04	5.43																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63
H2312_802_0	2007	3																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	276.74	1.89	34.61	11.17	12.74	14.82	0	44.13	26.48	2.75	26.17	0	0	152.35	20.88	82.37	1.44	0.08	0	54.24	20.04	5.43																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63
H2312_803_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	276.74	1.89	34.61	11.17	12.74	14.82	0	44.13	26.48	2.75	26.17	0	0	152.35	20.88	82.37	1.44	0.08	0	54.24	20.04	5.43																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63
H2312_804_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	276.74	1.89	34.61	11.17	12.74	14.82	0	44.13	26.48	2.75	26.17	0	0	152.35	20.88	82.37	1.44	0.08	0	54.24	20.04	5.43																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	17.68	0.12	6.5	-	3.01	3.5	-	10.25	6.25	0.65	6.18	-	-	35.96	4.93	19.44	0.34	0.02	-	12.8	4.73	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.63
H2312_805_0	2007	3																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	294.91	2.94	47.12	0	7.75	17.23	10.5	6.92	31.88	13.63	37.05	0.95	0.12	34.83	54.42	130.32	1.91	5.7	41.66	57.83	10.37	7.36																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72
H2312_806_0	2007	3																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	294.91	2.94	47.12	0	7.75	17.23	10.5	6.92	31.88	13.63	37.05	0.95	0.12	34.83	54.42	130.32	1.91	5.7	41.66	57.83	10.37	7.36																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72
H2312_807_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	294.91	2.94	47.12	0	7.75	17.23	10.5	6.92	31.88	13.63	37.05	0.95	0.12	34.83	54.42	130.32	1.91	5.7	41.66	57.83	10.37	7.36																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72
H2312_808_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	294.91	2.94	47.12	0	7.75	17.23	10.5	6.92	31.88	13.63	37.05	0.95	0.12	34.83	54.42	130.32	1.91	5.7	41.66	57.83	10.37	7.36																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	0	18.8	0.19	8.74	-	1.83	4.07	2.48	1.61	7.52	3.22	8.74	0.22	0.03	8.22	12.84	30.76	0.45	1.34	9.83	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.72
H2319_008_3	2007	4																																D	D	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	704.71	14.88	621.85	0	0	13.16	0.94	540.71	513.41	0	1087.84	0	0	320.4	2969.67	3435.37	125.3	367.57	765.94	1436.42	0	0	0	0	0	0	0	0	0	0	0											150 copay for days 1-5 (PBP Section B-01 #1a)	150 copay for days 1-5 (PBP Section B-01#1b)	85 for days 6-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	0 no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	100 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	20 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	20 copay (PBP Section B-12 #12)	20 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	20 copay (PBP Section B-07#7a;B-14#14b & #14c)	20 copay (PBP Section B-07#7b #7d & #7f)	20 copay (PBP Section B-07#7e & #7h)	20 copay (PBP Section B-07#7c & #7i)	20 copay (PBP Section B-07#7d)	20 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											144.45	144.45	81.86	0	0	0.01	0	46.84	96.3	0	19.26	0	0	19.26	19.26	19.26	19.26	19.26	19.26	19.26	0	0	0	0	0	0	0	0	0	0	0											8.48	0.18	4.24	-	-	0.19	-	2.11	4.12	-	1.75	-	-	0.51	4.77	5.51	0.2	0.59	1.23	2.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.19	0	1.39	8.48	0.18	4.24	-	-	0.19	-	2.11	4.12	-	1.75	-	-	0.51	4.77	5.51	0.2	0.59	1.23	2.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.19	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.48	0.18	4.24	-	-	0.19	-	2.11	4.12	-	1.75	-	-	0.51	4.77	5.51	0.2	0.59	1.23	2.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.19
H2319_008_4	2007	3																																D	D	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	832.23	17.57	852.77	0	0	12.89	0.92	468.82	437.62	0	927.25	0	0	273.1	3491.23	4067.99	151.69	444.97	819.85	1738.87	0	0	0	0	0	0	0	0	0	0	0											150 copay for days 1-5 (PBP Section B-01 #1a)	150 copay for days 1-5 (PBP Section B-01#1b)	85 for days 6-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	0 no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	100 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	20 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	20 copay (PBP Section B-12 #12)	20 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	20 copay (PBP Section B-07#7a;B-14#14b & #14c)	20 copay (PBP Section B-07#7b #7d & #7f)	20 copay (PBP Section B-07#7e & #7h)	20 copay (PBP Section B-07#7c & #7i)	20 copay (PBP Section B-07#7d)	20 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											142.86	142.86	80.95	0	0	0.01	0	45.86	95.24	0	19.05	0	0	19.05	19.05	19.05	19.05	19.05	19.05	19.05	0	0	0	0	0	0	0	0	0	0	0											9.91	0.21	5.75	-	-	0.18	-	1.79	3.47	-	1.47	-	-	0.43	5.54	6.46	0.24	0.71	1.3	2.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.23	0	2.01	9.91	0.21	5.75	-	-	0.18	-	1.79	3.47	-	1.47	-	-	0.43	5.54	6.46	0.24	0.71	1.3	2.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.23	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.91	0.21	5.75	-	-	0.18	-	1.79	3.47	-	1.47	-	-	0.43	5.54	6.46	0.24	0.71	1.3	2.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.23
H2319_008_5	2007	3																																D	D	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	836.67	17.66	684.88	0	0	15.04	1.07	533.42	500.29	0	1060.04	0	0	312.21	3683.93	4296.85	160.71	471.43	939.69	1842.26	0	0	0	0	0	0	0	0	0	0	0											150 copay for days 1-5 (PBP Section B-01 #1a)	150 copay for days 1-5 (PBP Section B-01#1b)	85 for days 6-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	0 no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	100 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	20 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	20 copay (PBP Section B-12 #12)	20 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	20 copay (PBP Section B-07#7a;B-14#14b & #14c)	20 copay (PBP Section B-07#7b #7d & #7f)	20 copay (PBP Section B-07#7e & #7h)	20 copay (PBP Section B-07#7c & #7i)	20 copay (PBP Section B-07#7d)	20 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											142.53	142.53	80.77	0	0	0.01	0	45.89	95.02	0	19	0	0	19	19	19	19	19	19	19	0	0	0	0	0	0	0	0	0	0	0											9.94	0.21	4.61	-	-	0.21	-	2.04	3.96	-	1.68	-	-	0.49	5.83	6.8	0.25	0.75	1.49	2.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.19	0	2.16	9.94	0.21	4.61	-	-	0.21	-	2.04	3.96	-	1.68	-	-	0.49	5.83	6.8	0.25	0.75	1.49	2.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.19	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.94	0.21	4.61	-	-	0.21	-	2.04	3.96	-	1.68	-	-	0.49	5.83	6.8	0.25	0.75	1.49	2.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.19
H2319_008_7	2007	3																																D	D	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	1206.99	25.48	989.68	0	0	15.97	1.14	465.39	422.98	0	896.23	0	0	263.96	4859.64	5877.1	243.25	713.56	1180.91	2788.46	0	0	0	0	0	0	0	0	0	0	0											150 copay for days 1-5 (PBP Section B-01 #1a)	150 copay for days 1-5 (PBP Section B-01#1b)	85 for days 6-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	0 no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	100 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	20 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	20 copay (PBP Section B-12 #12)	20 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	20 copay (PBP Section B-07#7a;B-14#14b & #14c)	20 copay (PBP Section B-07#7b #7d & #7f)	20 copay (PBP Section B-07#7e & #7h)	20 copay (PBP Section B-07#7c & #7i)	20 copay (PBP Section B-07#7d)	20 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											137.68	137.68	78.02	0	0	0.01	0	43.52	91.79	0	18.36	0	0	18.36	18.36	18.36	18.36	18.36	18.36	18.36	0	0	0	0	0	0	0	0	0	0	0											13.85	0.29	6.43	-	-	0.22	-	1.69	3.24	-	1.37	-	-	0.4	7.43	8.99	0.37	1.09	1.81	4.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.46	0	4.6	13.85	0.29	6.43	-	-	0.22	-	1.69	3.24	-	1.37	-	-	0.4	7.43	8.99	0.37	1.09	1.81	4.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.46	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	13.85	0.29	6.43	-	-	0.22	-	1.69	3.24	-	1.37	-	-	0.4	7.43	8.99	0.37	1.09	1.81	4.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.46
H2319_008_8	2007	3																																D	D	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	709.76	14.98	705.57	0	0	13.06	0.93	457.12	425.68	0	901.95	0	0	265.65	3528.16	4112.41	153.5	450.29	822.7	1759.65	0	0	0	0	0	0	0	0	0	0	0											150 copay for days 1-5 (PBP Section B-01 #1a)	150 copay for days 1-5 (PBP Section B-01#1b)	85 for days 6-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	0 no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	100 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	20 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	20 copay (PBP Section B-12 #12)	20 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	20 copay (PBP Section B-07#7a;B-14#14b & #14c)	20 copay (PBP Section B-07#7b #7d & #7f)	20 copay (PBP Section B-07#7e & #7h)	20 copay (PBP Section B-07#7c & #7i)	20 copay (PBP Section B-07#7d)	20 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											143.71	143.71	81.44	0	0	0.01	0	46.07	95.81	0	19.16	0	0	19.16	19.16	19.16	19.16	19.16	19.16	19.16	0	0	0	0	0	0	0	0	0	0	0											8.5	0.18	4.79	-	-	0.19	-	1.75	3.4	-	1.44	-	-	0.42	5.63	6.57	0.25	0.72	1.31	2.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.96	0	1.66	8.5	0.18	4.79	-	-	0.19	-	1.75	3.4	-	1.44	-	-	0.42	5.63	6.57	0.25	0.72	1.31	2.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.96	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.5	0.18	4.79	-	-	0.19	-	1.75	3.4	-	1.44	-	-	0.42	5.63	6.57	0.25	0.72	1.31	2.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.96
H2319_009_1	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	679.04	0	0	14.95	1.07	508.55	479.42	0	1024.01	0	0	295.27	4274.44	5038.68	194.27	569.87	962.91	2154.42	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	75  for days 11-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	75	0	0	0.02	0	47.22	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	4.24	-	-	0.22	-	2	0.4	-	0.85	-	-	0.25	3.56	4.2	0.16	0.47	0.8	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.96	0	0	-	-	4.24	-	-	0.22	-	2	0.4	-	0.85	-	-	0.25	3.56	4.2	0.16	0.47	0.8	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.96	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	4.24	-	-	0.22	-	2	0.4	-	0.85	-	-	0.25	3.56	4.2	0.16	0.47	0.8	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.96
H2319_009_2	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	703.67	0	0	14.75	1.05	576.97	546.56	0	1167.43	0	0	336.62	4533.5	5138.86	175.56	515.01	1012.68	1947.02	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	75  for days 11-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	75	0	0	0.02	0	47.4	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	4.4	-	-	0.22	-	2.28	0.46	-	0.97	-	-	0.28	3.78	4.28	0.15	0.43	0.84	1.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.71	0	0	-	-	4.4	-	-	0.22	-	2.28	0.46	-	0.97	-	-	0.28	3.78	4.28	0.15	0.43	0.84	1.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.71	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	4.4	-	-	0.22	-	2.28	0.46	-	0.97	-	-	0.28	3.78	4.28	0.15	0.43	0.84	1.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.71
H2319_009_3	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	565.85	0	0	14.09	1.01	577.73	556.91	0	1189.52	0	0	342.99	3389.42	3921.4	143.05	419.63	841.58	1586.43	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	75  for days 11-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	75	0	0	0.02	0	48.06	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	3.54	-	-	0.21	-	2.31	0.46	-	0.99	-	-	0.29	2.82	3.27	0.12	0.35	0.7	1.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.39	0	0	-	-	3.54	-	-	0.21	-	2.31	0.46	-	0.99	-	-	0.29	2.82	3.27	0.12	0.35	0.7	1.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.39	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	3.54	-	-	0.21	-	2.31	0.46	-	0.99	-	-	0.29	2.82	3.27	0.12	0.35	0.7	1.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.39
H2319_009_4	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	883.18	0	0	15.53	1.11	555.29	525.13	0	1121.66	0	0	323.42	4469.34	5193.11	191.94	563.04	1002.5	2128.6	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	75  for days 11-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	75	0	0	0.02	0	47.34	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	5.52	-	-	0.23	-	2.19	0.44	-	0.93	-	-	0.27	3.72	4.33	0.16	0.47	0.84	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.88	0	0	-	-	5.52	-	-	0.23	-	2.19	0.44	-	0.93	-	-	0.27	3.72	4.33	0.16	0.47	0.84	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.88	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	5.52	-	-	0.23	-	2.19	0.44	-	0.93	-	-	0.27	3.72	4.33	0.16	0.47	0.84	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.88
H2319_009_5	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	683.51	0	0	17.68	1.26	599.13	567.99	0	1213.19	0	0	349.82	4655.5	5449.92	205.95	604.14	1148.76	2283.97	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	75  for days 11-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	75	0	0	0.02	0	47.43	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	4.27	-	-	0.27	-	2.37	0.47	-	1.01	-	-	0.29	3.88	4.54	0.17	0.5	0.96	1.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.64	0	0	-	-	4.27	-	-	0.27	-	2.37	0.47	-	1.01	-	-	0.29	3.88	4.54	0.17	0.5	0.96	1.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.64	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	4.27	-	-	0.27	-	2.37	0.47	-	1.01	-	-	0.29	3.88	4.54	0.17	0.5	0.96	1.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.64
H2319_009_6	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	997.37	0	0	19	1.36	554.95	510.71	0	1090.86	0	0	314.54	6152.08	7447.48	308.63	905.35	1440.19	3422.69	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	75  for days 11-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	75	0	0	0.02	0	46.34	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	6.23	-	-	0.28	-	2.14	0.43	-	0.91	-	-	0.26	5.13	6.21	0.26	0.75	1.2	2.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.66	0	0	-	-	6.23	-	-	0.28	-	2.14	0.43	-	0.91	-	-	0.26	5.13	6.21	0.26	0.75	1.2	2.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.66	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	6.23	-	-	0.28	-	2.14	0.43	-	0.91	-	-	0.26	5.13	6.21	0.26	0.75	1.2	2.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.66
H2319_010_1	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	450.22	0	0	15.11	1.08	513.69	484.27	0	1034.37	0	0	298.26	4317.48	5089.41	196.22	575.61	972.61	2176.1	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	50  for days 21-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	50	0	0	0.02	0	47.22	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	1.88	-	-	0.23	-	2.02	0.4	-	0.86	-	-	0.25	3.6	4.24	0.16	0.48	0.81	1.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.74	0	0	-	-	1.88	-	-	0.23	-	2.02	0.4	-	0.86	-	-	0.25	3.6	4.24	0.16	0.48	0.81	1.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.74	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	1.88	-	-	0.23	-	2.02	0.4	-	0.86	-	-	0.25	3.6	4.24	0.16	0.48	0.81	1.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.74
H2319_010_2	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	466.51	0	0	14.9	1.06	582.8	552.08	0	1179.22	0	0	340.02	4579.3	5190.62	177.32	520.15	1022.88	1966.45	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	50  for days 21-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	50	0	0	0.02	0	47.4	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	1.94	-	-	0.22	-	2.3	0.46	-	0.98	-	-	0.28	3.82	4.33	0.15	0.43	0.85	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.41	0	0	-	-	1.94	-	-	0.22	-	2.3	0.46	-	0.98	-	-	0.28	3.82	4.33	0.15	0.43	0.85	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.41	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	1.94	-	-	0.22	-	2.3	0.46	-	0.98	-	-	0.28	3.82	4.33	0.15	0.43	0.85	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.41
H2319_010_3	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	376.12	0	0	14.22	1.02	583.54	562.52	0	1201.51	0	0	346.45	3422.15	3959.27	144.43	423.69	849.7	1601.75	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	50  for days 21-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	50	0	0	0.02	0	48.06	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	1.57	-	-	0.21	-	2.34	0.47	-	1	-	-	0.29	2.85	3.3	0.12	0.35	0.71	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54	0	0	-	-	1.57	-	-	0.21	-	2.34	0.47	-	1	-	-	0.29	2.85	3.3	0.12	0.35	0.71	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	1.57	-	-	0.21	-	2.34	0.47	-	1	-	-	0.29	2.85	3.3	0.12	0.35	0.71	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54
H2319_010_4	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	585.27	0	0	15.68	1.12	560.65	530.21	0	1132.5	0	0	326.55	4512.34	5243.38	193.83	568.6	1012.27	2149.59	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	50  for days 21-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	50	0	0	0.02	0	47.34	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	2.44	-	-	0.24	-	2.21	0.44	-	0.94	-	-	0.27	3.76	4.37	0.16	0.47	0.84	1.79	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.94	0	0	-	-	2.44	-	-	0.24	-	2.21	0.44	-	0.94	-	-	0.27	3.76	4.37	0.16	0.47	0.84	1.79	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.94	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	2.44	-	-	0.24	-	2.21	0.44	-	0.94	-	-	0.27	3.76	4.37	0.16	0.47	0.84	1.79	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.94
H2319_010_5	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	453.67	0	0	17.84	1.27	604.96	573.52	0	1225	0	0	353.22	4700.9	5503.41	208.01	610.19	1159.95	2306.82	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	50  for days 21-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	50	0	0	0.02	0	47.43	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	1.89	-	-	0.27	-	2.39	0.48	-	1.02	-	-	0.29	3.92	4.59	0.17	0.51	0.97	1.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.42	0	0	-	-	1.89	-	-	0.27	-	2.39	0.48	-	1.02	-	-	0.29	3.92	4.59	0.17	0.51	0.97	1.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.42	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	1.89	-	-	0.27	-	2.39	0.48	-	1.02	-	-	0.29	3.92	4.59	0.17	0.51	0.97	1.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.42
H2319_010_6	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	661.23	0	0	19.19	1.37	560.5	515.82	0	1101.77	0	0	317.69	6213.55	7521.7	311.68	914.31	1454.55	3456.57	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing  (PBP Section B-01#1b)	50  for days 21-100 (PBP Section B-02#2)	no cost sharing  (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	50 copay waived if admitted (PBP Section B-04#4a)	10 copay (PBP Section B-09#9a & #9b)	0 copay (PBP Section B-08#8a)	10 copay (PBP Section B-08#8b)	0 copay (PBP Section B-05#5)	10 copay (PBP Section B-12 #12)	10 copay (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	10 copay (PBP Section B-07#7a;B-14#14b & #14c)	10 copay (PBP Section B-07#7b #7d & #7f)	10 copay (PBP Section B-07#7e & #7h)	10 copay (PBP Section B-07#7c & #7i)	10 copay (PBP Section B-07#7d)	10 copay (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) cost sharing included in net allowed PMPM											0	0	50	0	0	0.02	0	46.34	10	0	10	0	0	10	10	10	10	10	10	10	0	0	0	0	0	0	0	0	0	0	0											-	-	2.76	-	-	0.29	-	2.16	0.43	-	0.92	-	-	0.26	5.18	6.27	0.26	0.76	1.21	2.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.38	0	0	-	-	2.76	-	-	0.29	-	2.16	0.43	-	0.92	-	-	0.26	5.18	6.27	0.26	0.76	1.21	2.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.38	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	2.76	-	-	0.29	-	2.16	0.43	-	0.92	-	-	0.26	5.18	6.27	0.26	0.76	1.21	2.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.38
H2319_011_1	2007	3																																A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	0	0	0	15.41	1.1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing (PBP Section B-01#1b)	no cost sharing (PBP Section B-02#2)	no cost sharing (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	no cost sharing (PBP Section B-04#4a)	no cost sharing (PBP Section B-09#9a & #9b)	no cost sharing (PBP Section B-08#8a)	no cost sharing (PBP Section B-08#8b)	no cost sharing (PBP Section B-05#5)	no cost sharing (PBP Section B-12 #12)	no cost sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	no cost sharing (PBP Section B-07#7a;B-14#14b & #14c)	no cost sharing (PBP Section B-07#7b #7d & #7f)	no cost sharing (PBP Section B-07#7e & #7h)	no cost sharing (PBP Section B-07#7c & #7i)	no cost sharing (PBP Section B-07#7d)	no cost sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) - included in net allowed PMPM											0	0	0	0	0	0.02	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.23	0	0	-	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.23	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.23
H2319_011_2	2007	3																					5000											A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	0	0	0	15.2	1.09	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing (PBP Section B-01#1b)	no cost sharing (PBP Section B-02#2)	no cost sharing (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	no cost sharing (PBP Section B-04#4a)	no cost sharing (PBP Section B-09#9a & #9b)	no cost sharing (PBP Section B-08#8a)	no cost sharing (PBP Section B-08#8b)	no cost sharing (PBP Section B-05#5)	no cost sharing (PBP Section B-12 #12)	no cost sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	no cost sharing (PBP Section B-07#7a;B-14#14b & #14c)	no cost sharing (PBP Section B-07#7b #7d & #7f)	no cost sharing (PBP Section B-07#7e & #7h)	no cost sharing (PBP Section B-07#7c & #7i)	no cost sharing (PBP Section B-07#7d)	no cost sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) - included in net allowed PMPM											0	0	0	0	0	0.02	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.23	0	0	-	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.23	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.23
H2319_011_3	2007	3																					5000											A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	0	0	0	14.51	1.04	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing (PBP Section B-01#1b)	no cost sharing (PBP Section B-02#2)	no cost sharing (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	no cost sharing (PBP Section B-04#4a)	no cost sharing (PBP Section B-09#9a & #9b)	no cost sharing (PBP Section B-08#8a)	no cost sharing (PBP Section B-08#8b)	no cost sharing (PBP Section B-05#5)	no cost sharing (PBP Section B-12 #12)	no cost sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	no cost sharing (PBP Section B-07#7a;B-14#14b & #14c)	no cost sharing (PBP Section B-07#7b #7d & #7f)	no cost sharing (PBP Section B-07#7e & #7h)	no cost sharing (PBP Section B-07#7c & #7i)	no cost sharing (PBP Section B-07#7d)	no cost sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) - included in net allowed PMPM											0	0	0	0	0	0.02	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.22	0	0	-	-	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.22	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.22
H2319_011_4	2007	3																					5000											A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	0	0	0	16	1.14	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing (PBP Section B-01#1b)	no cost sharing (PBP Section B-02#2)	no cost sharing (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	no cost sharing (PBP Section B-04#4a)	no cost sharing (PBP Section B-09#9a & #9b)	no cost sharing (PBP Section B-08#8a)	no cost sharing (PBP Section B-08#8b)	no cost sharing (PBP Section B-05#5)	no cost sharing (PBP Section B-12 #12)	no cost sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	no cost sharing (PBP Section B-07#7a;B-14#14b & #14c)	no cost sharing (PBP Section B-07#7b #7d & #7f)	no cost sharing (PBP Section B-07#7e & #7h)	no cost sharing (PBP Section B-07#7c & #7i)	no cost sharing (PBP Section B-07#7d)	no cost sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) - included in net allowed PMPM											0	0	0	0	0	0.02	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.24	0	0	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.24	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.24
H2319_011_5	2007	3																					5000											A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	0	0	0	18.1	1.29	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing (PBP Section B-01#1b)	no cost sharing (PBP Section B-02#2)	no cost sharing (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	no cost sharing (PBP Section B-04#4a)	no cost sharing (PBP Section B-09#9a & #9b)	no cost sharing (PBP Section B-08#8a)	no cost sharing (PBP Section B-08#8b)	no cost sharing (PBP Section B-05#5)	no cost sharing (PBP Section B-12 #12)	no cost sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	no cost sharing (PBP Section B-07#7a;B-14#14b & #14c)	no cost sharing (PBP Section B-07#7b #7d & #7f)	no cost sharing (PBP Section B-07#7e & #7h)	no cost sharing (PBP Section B-07#7c & #7i)	no cost sharing (PBP Section B-07#7d)	no cost sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) - included in net allowed PMPM											0	0	0	0	0	0.02	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.27	0	0	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.27	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.27
H2319_011_6	2007	3																					5000											A	A	D			Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V											V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	0	0	0	19.57	1.4	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											no cost sharing (PBP Section B-01 #1a)	no cost sharing (PBP Section B-01#1b)	no cost sharing (PBP Section B-02#2)	no cost sharing (PBP Section B-06#6)	no cost sharing (PBP Section B-10#10a)	50 on non-contracted DME (PBP Section B-11#11a)	50 on non-contracted DME (PBP Section B-11#11b & #11c)	no cost sharing (PBP Section B-04#4a)	no cost sharing (PBP Section B-09#9a & #9b)	no cost sharing (PBP Section B-08#8a)	no cost sharing (PBP Section B-08#8b)	no cost sharing (PBP Section B-05#5)	no cost sharing (PBP Section B-12 #12)	no cost sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	no cost sharing (PBP Section B-07#7a;B-14#14b & #14c)	no cost sharing (PBP Section B-07#7b #7d & #7f)	no cost sharing (PBP Section B-07#7e & #7h)	no cost sharing (PBP Section B-07#7c & #7i)	no cost sharing (PBP Section B-07#7d)	no cost sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	no cost sharing (PBP B-15 #15)	no cost sharing (PBP B-15 #13a)	not covered (PBP B-10 #10b)	not covered (PBP B-16 #16a & #16b)	not covered (PBP B-17 #17a)	not covered (PBP B-17 #17b)	not covered (PBP B-18 #18a)	not covered (PBP B-18 #18b)	not covered (PBP B-19 #19)	not covered (PBP B-14 #14a)	foreign travel: 250 deductible 20 coins. 50000 lifetime max (PBP Section A-3 Notes) - included in net allowed PMPM											0	0	0	0	0	0.02	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.29	0	0	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.29
H2319_801_0	2007	4																					n/a											Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	263.14	2.82	37.26	0	7.46	20.51	1.17	6.3	30.88	12.07	32.81	0	9.15	32.5	26.47	40.82	1.66	4.61	31.99	118.9	22.6	2.96	0	0	0	0	0	0	0	0	0											Medicare FFS Cost Sharing (PBP Section B-01 #1a)	Medicare FFS Cost Sharing (PBP Section B-01#1b)	Medicare FFS Cost Sharing (PBP Section B-02#2)	Medicare FFS Cost Sharing (PBP Section B-06#6)	Medicare FFS Cost Sharing (PBP Section B-10#10a)	Medicare FFS Cost Sharing (PBP Section B-11#11a)	Medicare FFS Cost Sharing (PBP Section B-11#11b & #11c)	Medicare FFS Cost Sharing (PBP Section B-04#4a)	Medicare FFS Cost Sharing (PBP Section B-09#9a & #9b)	Medicare FFS Cost Sharing (PBP Section B-08#8a)	Medicare FFS Cost Sharing (PBP Section B-08#8b)	Medicare FFS Cost Sharing (PBP Section B-05#5)	Medicare FFS Cost Sharing (PBP Section B-12 #12)	Medicare FFS Cost Sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	Medicare FFS Cost Sharing (PBP Section B-07#7a;B-14#14b & #14c)	Medicare FFS Cost Sharing (PBP Section B-07#7b #7d & #7f)	Medicare FFS Cost Sharing (PBP Section B-07#7e & #7h)	Medicare FFS Cost Sharing (PBP Section B-07#7c & #7i)	Medicare FFS Cost Sharing (PBP Section B-07#7d)	Medicare FFS Cost Sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	Medicare FFS Cost Sharing (PBP B-15 #15)	Medicare FFS Cost Sharing (PBP B-15 #13a)	Medicare FFS Cost Sharing (PBP B-10 #10b)	Medicare FFS Cost Sharing (PBP B-16 #16a & #16b)	Medicare FFS Cost Sharing (PBP B-17 #17a)	Medicare FFS Cost Sharing (PBP B-17 #17b)	Medicare FFS Cost Sharing (PBP B-18 #18a)	Medicare FFS Cost Sharing (PBP B-18 #18b)	Medicare FFS Cost Sharing (PBP B-19 #19)	Medicare FFS Cost Sharing (PBP B-14 #14b)	Medicare FFS Cost Sharing (PBP Section B-13 #13b)											0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.2	0.2	6.99	-	1.76	4.84	0.28	1.49	7.29	2.85	7.74	-	2.16	7.67	6.25	9.63	0.39	1.09	7.55	28.06	5.33	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.46	0	0	18.2	0.2	6.99	-	1.76	4.84	0.28	1.49	7.29	2.85	7.74	-	2.16	7.67	6.25	9.63	0.39	1.09	7.55	28.06	5.33	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.46	n/a																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	18.2	0.2	6.99	-	1.76	4.84	0.28	1.49	7.29	2.85	7.74	-	2.16	7.67	6.25	9.63	0.39	1.09	7.55	28.06	5.33	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.46
H2319_802_0	2007	4																					n/a											Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	271.65	2.92	40.05	0	7.65	21.03	1.2	6.04	29.43	11.5	31.26	0	8.72	30.96	28.96	44.56	1.79	4.97	36.72	129.54	24.39	3.2	0	0	0	0	0	0	0	0	0											Medicare FFS Cost Sharing (PBP Section B-01 #1a)	Medicare FFS Cost Sharing (PBP Section B-01#1b)	Medicare FFS Cost Sharing (PBP Section B-02#2)	Medicare FFS Cost Sharing (PBP Section B-06#6)	Medicare FFS Cost Sharing (PBP Section B-10#10a)	Medicare FFS Cost Sharing (PBP Section B-11#11a)	Medicare FFS Cost Sharing (PBP Section B-11#11b & #11c)	Medicare FFS Cost Sharing (PBP Section B-04#4a)	Medicare FFS Cost Sharing (PBP Section B-09#9a & #9b)	Medicare FFS Cost Sharing (PBP Section B-08#8a)	Medicare FFS Cost Sharing (PBP Section B-08#8b)	Medicare FFS Cost Sharing (PBP Section B-05#5)	Medicare FFS Cost Sharing (PBP Section B-12 #12)	Medicare FFS Cost Sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	Medicare FFS Cost Sharing (PBP Section B-07#7a;B-14#14b & #14c)	Medicare FFS Cost Sharing (PBP Section B-07#7b #7d & #7f)	Medicare FFS Cost Sharing (PBP Section B-07#7e & #7h)	Medicare FFS Cost Sharing (PBP Section B-07#7c & #7i)	Medicare FFS Cost Sharing (PBP Section B-07#7d)	Medicare FFS Cost Sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	Medicare FFS Cost Sharing (PBP B-15 #15)	Medicare FFS Cost Sharing (PBP B-15 #13a)	Medicare FFS Cost Sharing (PBP B-10 #10b)	Medicare FFS Cost Sharing (PBP B-16 #16a & #16b)	Medicare FFS Cost Sharing (PBP B-17 #17a)	Medicare FFS Cost Sharing (PBP B-17 #17b)	Medicare FFS Cost Sharing (PBP B-18 #18a)	Medicare FFS Cost Sharing (PBP B-18 #18b)	Medicare FFS Cost Sharing (PBP B-19 #19)	Medicare FFS Cost Sharing (PBP B-14 #14b)	Medicare FFS Cost Sharing (PBP Section B-13 #13b)											0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.94	0.2	7.46	-	1.81	4.96	0.28	1.42	6.94	2.71	7.38	-	2.06	7.31	6.83	10.52	0.42	1.17	8.67	30.57	5.76	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.17	0	0	18.94	0.2	7.46	-	1.81	4.96	0.28	1.42	6.94	2.71	7.38	-	2.06	7.31	6.83	10.52	0.42	1.17	8.67	30.57	5.76	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.17	n/a																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	18.94	0.2	7.46	-	1.81	4.96	0.28	1.42	6.94	2.71	7.38	-	2.06	7.31	6.83	10.52	0.42	1.17	8.67	30.57	5.76	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.17
H2319_803_0	2007	4																					n/a											Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	242.69	2.61	34.58	0	7.35	20.22	1.16	5.66	27.8	10.87	29.54	0	8.24	29.25	22.45	34.2	1.3	3.62	24.67	100.37	17.76	2.35	0	0	0	0	0	0	0	0	0											Medicare FFS Cost Sharing (PBP Section B-01 #1a)	Medicare FFS Cost Sharing (PBP Section B-01#1b)	Medicare FFS Cost Sharing (PBP Section B-02#2)	Medicare FFS Cost Sharing (PBP Section B-06#6)	Medicare FFS Cost Sharing (PBP Section B-10#10a)	Medicare FFS Cost Sharing (PBP Section B-11#11a)	Medicare FFS Cost Sharing (PBP Section B-11#11b & #11c)	Medicare FFS Cost Sharing (PBP Section B-04#4a)	Medicare FFS Cost Sharing (PBP Section B-09#9a & #9b)	Medicare FFS Cost Sharing (PBP Section B-08#8a)	Medicare FFS Cost Sharing (PBP Section B-08#8b)	Medicare FFS Cost Sharing (PBP Section B-05#5)	Medicare FFS Cost Sharing (PBP Section B-12 #12)	Medicare FFS Cost Sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	Medicare FFS Cost Sharing (PBP Section B-07#7a;B-14#14b & #14c)	Medicare FFS Cost Sharing (PBP Section B-07#7b #7d & #7f)	Medicare FFS Cost Sharing (PBP Section B-07#7e & #7h)	Medicare FFS Cost Sharing (PBP Section B-07#7c & #7i)	Medicare FFS Cost Sharing (PBP Section B-07#7d)	Medicare FFS Cost Sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	Medicare FFS Cost Sharing (PBP B-15 #15)	Medicare FFS Cost Sharing (PBP B-15 #13a)	Medicare FFS Cost Sharing (PBP B-10 #10b)	Medicare FFS Cost Sharing (PBP B-16 #16a & #16b)	Medicare FFS Cost Sharing (PBP B-17 #17a)	Medicare FFS Cost Sharing (PBP B-17 #17b)	Medicare FFS Cost Sharing (PBP B-18 #18a)	Medicare FFS Cost Sharing (PBP B-18 #18b)	Medicare FFS Cost Sharing (PBP B-19 #19)	Medicare FFS Cost Sharing (PBP B-14 #14b)	Medicare FFS Cost Sharing (PBP Section B-13 #13b)											0.08	0.08	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.66	0.2	6.35	-	1.74	4.77	0.27	1.34	6.56	2.56	6.97	-	1.94	6.9	5.3	8.07	0.31	0.85	5.82	23.69	4.19	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.06	0	0	18.66	0.2	6.35	-	1.74	4.77	0.27	1.34	6.56	2.56	6.97	-	1.94	6.9	5.3	8.07	0.31	0.85	5.82	23.69	4.19	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.06	n/a																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	18.66	0.2	6.35	-	1.74	4.77	0.27	1.34	6.56	2.56	6.97	-	1.94	6.9	5.3	8.07	0.31	0.85	5.82	23.69	4.19	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.06
H2319_804_0	2007	4																					n/a											Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	253.84	2.72	34.79	0	7.35	20.22	1.16	6.23	30.58	11.96	32.49	0	9.06	32.18	25.33	38.79	1.52	4.22	29.79	112.62	20.7	2.73	0	0	0	0	0	0	0	0	0											Medicare FFS Cost Sharing (PBP Section B-01 #1a)	Medicare FFS Cost Sharing (PBP Section B-01#1b)	Medicare FFS Cost Sharing (PBP Section B-02#2)	Medicare FFS Cost Sharing (PBP Section B-06#6)	Medicare FFS Cost Sharing (PBP Section B-10#10a)	Medicare FFS Cost Sharing (PBP Section B-11#11a)	Medicare FFS Cost Sharing (PBP Section B-11#11b & #11c)	Medicare FFS Cost Sharing (PBP Section B-04#4a)	Medicare FFS Cost Sharing (PBP Section B-09#9a & #9b)	Medicare FFS Cost Sharing (PBP Section B-08#8a)	Medicare FFS Cost Sharing (PBP Section B-08#8b)	Medicare FFS Cost Sharing (PBP Section B-05#5)	Medicare FFS Cost Sharing (PBP Section B-12 #12)	Medicare FFS Cost Sharing (PBP Sections B-04 #4b; B-03 #3; B-09 #9c & #9d)	Medicare FFS Cost Sharing (PBP Section B-07#7a;B-14#14b & #14c)	Medicare FFS Cost Sharing (PBP Section B-07#7b #7d & #7f)	Medicare FFS Cost Sharing (PBP Section B-07#7e & #7h)	Medicare FFS Cost Sharing (PBP Section B-07#7c & #7i)	Medicare FFS Cost Sharing (PBP Section B-07#7d)	Medicare FFS Cost Sharing (PBP Section B-07#7g); 0 copay (PBP Section-14 #14d #14e #14f #14g #14h & #14i)	Medicare FFS Cost Sharing (PBP B-15 #15)	Medicare FFS Cost Sharing (PBP B-15 #13a)	Medicare FFS Cost Sharing (PBP B-10 #10b)	Medicare FFS Cost Sharing (PBP B-16 #16a & #16b)	Medicare FFS Cost Sharing (PBP B-17 #17a)	Medicare FFS Cost Sharing (PBP B-17 #17b)	Medicare FFS Cost Sharing (PBP B-18 #18a)	Medicare FFS Cost Sharing (PBP B-18 #18b)	Medicare FFS Cost Sharing (PBP B-19 #19)	Medicare FFS Cost Sharing (PBP B-14 #14b)	Medicare FFS Cost Sharing (PBP Section B-13 #13b)											0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.09	0.19	6.58	-	1.74	4.77	0.27	1.47	7.22	2.82	7.67	-	2.14	7.59	5.98	9.15	0.36	1	7.03	26.58	4.89	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.18	0	0	18.09	0.19	6.58	-	1.74	4.77	0.27	1.47	7.22	2.82	7.67	-	2.14	7.59	5.98	9.15	0.36	1	7.03	26.58	4.89	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.18	n/a																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	18.09	0.19	6.58	-	1.74	4.77	0.27	1.47	7.22	2.82	7.67	-	2.14	7.59	5.98	9.15	0.36	1	7.03	26.58	4.89	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.18
H2320_004_1	2007	3																					2000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2000	694.6	14.66	536.43	0	175.41	44099.36	45.54	416.27	391.19	0	778.74	0	0	0	3530.16	4145.87	142.06	431.43	721.71	0	843.41	0	0	0	0	0	119.81	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												47.46	47.46	23.73	0	94.92	0.9	40.03	45.93	47.46	0	23.73	0	0	0	9.49	23.73	40.15	23.73	23.73	0	9.49	0	0	0	0	0	23.73	0	0	0	0											2.75	0.06	1.06	-	1.39	3.32	0.15	1.59	1.55	-	1.54	-	-	-	2.79	8.2	0.48	0.85	1.43	-	0.67	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.06	0	1.5	2.75	0.06	1.06	-	1.39	3.32	0.15	1.59	1.55	-	1.54	-	-	-	2.79	8.2	0.48	0.85	1.43	-	0.67	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.06	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												2.88	0.03	0.44	0.43	0.11	0.31	0.01	0.11	0.36	0.14	0.36	0	0.11	0.39	0.29	0.42	0.03	0.05	0.27	1.31	0.25	0.03	0	0	0	0.01	0	0	0	0	0											8.35	500	6.9	5.62	0.09	1.5	0.43	1.5	3.63	0.17	1.7	1.91	0.14	1.9	-	0.11	0.39	3.09	8.61	0.5	0.9	1.7	1.31	0.92	0.03	-	-	-	0.01	0.24	0	-	-	-	-	-	-	-	-	-	-	-	-	-	36.41
H2320_004_2	2007	3																					2000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2000	779.61	16.46	465.18	0	214.29	53872.74	55.63	580.57	555.19	0	1105.22	0	0	0	3667.69	4120.57	120.59	366.22	747.24	0	715.95	0	0	0	0	0	124.48	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												47.09	47.09	23.55	0	94.18	0.85	37.49	45.96	47.09	0	23.55	0	0	0	9.42	23.55	42.67	23.55	23.55	0	9.42	0	0	0	0	0	23.55	0	0	0	0											3.06	0.06	0.91	-	1.68	3.8	0.17	2.22	2.18	-	2.17	-	-	-	2.88	8.09	0.43	0.72	1.47	-	0.56	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.65	0	1.89	3.06	0.06	0.91	-	1.68	3.8	0.17	2.22	2.18	-	2.17	-	-	-	2.88	8.09	0.43	0.72	1.47	-	0.56	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.65	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												2.95	0.03	0.35	0.41	0.12	0.33	0.02	0.14	0.49	0.19	0.49	0	0.15	0.52	0.3	0.42	0.03	0.04	0.26	1.18	0.21	0.03	0	0	0	0.01	0.01	0	0	0	0											8.67	500	8.12	6.01	0.1	1.26	0.41	1.81	4.13	0.19	2.36	2.67	0.19	2.66	-	0.15	0.52	3.18	8.5	0.45	0.76	1.72	1.18	0.77	0.03	-	-	-	0.01	0.25	0	-	-	-	-	-	-	-	-	-	-	-	-	-	39.32
H2320_004_3	2007	3																					2000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2000	713.58	15.06	632.24	0	218.13	54839.28	56.63	546.96	522.25	0	1039.64	0	0	0	3560.58	4110.46	133	403.92	799.72	0	789.64	0	0	0	0	0	120.85	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												47.09	47.09	23.55	0	94.19	0.86	37.94	45.93	47.09	0	23.55	0	0	0	9.42	23.55	41.39	23.55	23.55	0	9.42	0	0	0	0	0	23.55	0	0	0	0											2.8	0.06	1.24	-	1.71	3.92	0.18	2.09	2.05	-	2.04	-	-	-	2.79	8.07	0.46	0.79	1.57	-	0.62	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.63	0	1.89	2.8	0.06	1.24	-	1.71	3.92	0.18	2.09	2.05	-	2.04	-	-	-	2.79	8.07	0.46	0.79	1.57	-	0.62	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.63	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												2.85	0.03	0.47	0.35	0.13	0.35	0.02	0.13	0.44	0.17	0.44	0	0.13	0.47	0.29	0.41	0.03	0.04	0.3	1.28	0.23	0.03	0	0	0	0.01	0	0	0	0	0											8.6	500	7.8	5.65	0.09	1.71	0.35	1.84	4.26	0.19	2.23	2.49	0.17	2.48	-	0.13	0.47	3.09	8.47	0.49	0.83	1.87	1.28	0.85	0.03	-	-	-	0.01	0.24	0	-	-	-	-	-	-	-	-	-	-	-	-	-	39.22
H2320_005_1	2007	3																					2000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2000	694.6	14.66	536.43	0	175.41	44099.36	45.54	416.27	391.19	0	778.74	0	0	0	3530.16	4145.87	142.06	431.43	721.71	0	843.41	0	0	0	0	0	119.81	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												47.46	47.46	23.73	0	94.92	0.9	40.03	45.93	47.46	0	23.73	0	0	0	9.49	23.73	40.15	23.73	23.73	0	9.49	0	0	0	0	0	23.73	0	0	0	0											2.75	0.06	1.06	-	1.39	3.32	0.15	1.59	1.55	-	1.54	-	-	-	2.79	8.2	0.48	0.85	1.43	-	0.67	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.06	0	1.5	2.75	0.06	1.06	-	1.39	3.32	0.15	1.59	1.55	-	1.54	-	-	-	2.79	8.2	0.48	0.85	1.43	-	0.67	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.06	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												2.88	0.03	0.44	0.43	0.11	0.31	0.01	0.11	0.36	0.14	0.36	0	0.11	0.39	0.29	0.42	0.03	0.05	0.27	1.31	0.25	0.03	0	0	0	0.01	0	0	0	0	0											8.35	500	6.9	5.62	0.09	1.5	0.43	1.5	3.63	0.17	1.7	1.91	0.14	1.9	-	0.11	0.39	3.09	8.61	0.5	0.9	1.7	1.31	0.92	0.03	-	-	-	0.01	0.24	0	-	-	-	-	-	-	-	-	-	-	-	-	-	36.41
H2320_005_2	2007	3																					2000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2000	779.61	16.46	465.18	0	214.29	53872.74	55.63	580.57	555.19	0	1105.22	0	0	0	3667.69	4120.57	120.59	366.22	747.24	0	715.95	0	0	0	0	0	124.48	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												47.09	47.09	23.55	0	94.18	0.85	37.49	45.96	47.09	0	23.55	0	0	0	9.42	23.55	42.67	23.55	23.55	0	9.42	0	0	0	0	0	23.55	0	0	0	0											3.06	0.06	0.91	-	1.68	3.8	0.17	2.22	2.18	-	2.17	-	-	-	2.88	8.09	0.43	0.72	1.47	-	0.56	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.65	0	1.89	3.06	0.06	0.91	-	1.68	3.8	0.17	2.22	2.18	-	2.17	-	-	-	2.88	8.09	0.43	0.72	1.47	-	0.56	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.65	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												2.95	0.03	0.35	0.41	0.12	0.33	0.02	0.14	0.49	0.19	0.49	0	0.15	0.52	0.3	0.42	0.03	0.04	0.26	1.18	0.21	0.03	0	0	0	0.01	0.01	0	0	0	0											8.67	500	8.12	6.01	0.1	1.26	0.41	1.81	4.13	0.19	2.36	2.67	0.19	2.66	-	0.15	0.52	3.18	8.5	0.45	0.76	1.72	1.18	0.77	0.03	-	-	-	0.01	0.25	0	-	-	-	-	-	-	-	-	-	-	-	-	-	39.32
H2320_005_3	2007	3																					2000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2000	713.58	15.06	632.24	0	218.13	54839.28	56.63	546.96	522.25	0	1039.64	0	0	0	3560.58	4110.46	133	403.92	799.72	0	789.64	0	0	0	0	0	120.85	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												47.09	47.09	23.55	0	94.19	0.86	37.94	45.93	47.09	0	23.55	0	0	0	9.42	23.55	41.39	23.55	23.55	0	9.42	0	0	0	0	0	23.55	0	0	0	0											2.8	0.06	1.24	-	1.71	3.92	0.18	2.09	2.05	-	2.04	-	-	-	2.79	8.07	0.46	0.79	1.57	-	0.62	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.63	0	1.89	2.8	0.06	1.24	-	1.71	3.92	0.18	2.09	2.05	-	2.04	-	-	-	2.79	8.07	0.46	0.79	1.57	-	0.62	-	-	-	-	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.63	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												2.85	0.03	0.47	0.35	0.13	0.35	0.02	0.13	0.44	0.17	0.44	0	0.13	0.47	0.29	0.41	0.03	0.04	0.3	1.28	0.23	0.03	0	0	0	0.01	0	0	0	0	0											8.6	500	7.8	5.65	0.09	1.71	0.35	1.84	4.26	0.19	2.23	2.49	0.17	2.48	-	0.13	0.47	3.09	8.47	0.49	0.83	1.87	1.28	0.85	0.03	-	-	-	0.01	0.24	0	-	-	-	-	-	-	-	-	-	-	-	-	-	39.22
H2320_802_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1143.73	24.14	941.52	0	206.68	50919.74	52.58	568.57	481.44	3148.32	1526.25	0	821.57	2573	4866.89	5404.52	167.74	1476.2	4453.51	21826.45	872.71	496.82	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29	138	0	13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.78	0.01	0.3	0	0.08	0.29	0.01	0.08	0.37	0.14	0.39	0	0.11	0.39	0.27	0.41	0.02	0.04	0.26	1.18	0.22	0.03	0	0	0	0	0	0	0	0	0											5.37	0	0	14.58	0.16	5.59	-	1.45	4.96	0.23	1.47	6.82	2.67	6.95	-	2.02	7.18	5.09	7.77	0.3	0.84	4.66	22.31	4.11	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.66
H2320_803_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1143.73	24.14	941.52	0	206.68	50919.74	52.58	568.57	481.44	3148.32	1526.25	0	821.57	2573	4866.89	5404.52	167.74	1476.2	4453.51	21826.45	872.71	496.82	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29	138	0	13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.78	0.01	0.3	0	0.08	0.29	0.01	0.08	0.37	0.14	0.39	0	0.11	0.39	0.27	0.41	0.02	0.04	0.26	1.18	0.22	0.03	0	0	0	0	0	0	0	0	0											5.37	0	0	14.58	0.16	5.59	-	1.45	4.96	0.23	1.47	6.82	2.67	6.95	-	2.02	7.18	5.09	7.77	0.3	0.84	4.66	22.31	4.11	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.66
H2320_804_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1203.92	25.41	991.07	0	217.56	53599.73	55.35	598.5	506.77	3314.02	1606.57	0	864.81	2708.42	5123.04	5688.97	176.57	1553.89	4687.9	22975.21	918.64	522.97	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26	138	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26
H2320_805_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1203.92	25.41	991.07	0	217.56	53599.73	55.35	598.5	506.77	3314.02	1606.57	0	864.81	2708.42	5123.04	5688.97	176.57	1553.89	4687.9	22975.21	918.64	522.97	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26	138	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26
H2320_806_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1143.73	24.14	941.52	0	206.68	50919.74	52.58	568.57	481.44	3148.32	1526.25	0	821.57	2573	4866.89	5404.52	167.74	1476.2	4453.51	21826.45	872.71	496.82	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29	138	0	13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.78	0.01	0.3	0	0.08	0.29	0.01	0.08	0.37	0.14	0.39	0	0.11	0.39	0.27	0.41	0.02	0.04	0.26	1.18	0.22	0.03	0	0	0	0	0	0	0	0	0											5.37	0	0	14.58	0.16	5.59	-	1.45	4.96	0.23	1.47	6.82	2.67	6.95	-	2.02	7.18	5.09	7.77	0.3	0.84	4.66	22.31	4.11	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.66
H2320_807_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1143.73	24.14	941.52	0	206.68	50919.74	52.58	568.57	481.44	3148.32	1526.25	0	821.57	2573	4866.89	5404.52	167.74	1476.2	4453.51	21826.45	872.71	496.82	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29	138	0	13.8	0.15	5.28	-	1.36	4.67	0.21	1.39	6.45	2.52	6.56	-	1.91	6.79	4.82	7.36	0.29	0.79	4.4	21.14	3.89	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.29		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.78	0.01	0.3	0	0.08	0.29	0.01	0.08	0.37	0.14	0.39	0	0.11	0.39	0.27	0.41	0.02	0.04	0.26	1.18	0.22	0.03	0	0	0	0	0	0	0	0	0											5.37	0	0	14.58	0.16	5.59	-	1.45	4.96	0.23	1.47	6.82	2.67	6.95	-	2.02	7.18	5.09	7.77	0.3	0.84	4.66	22.31	4.11	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.66
H2320_808_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1203.92	25.41	991.07	0	217.56	53599.73	55.35	598.5	506.77	3314.02	1606.57	0	864.81	2708.42	5123.04	5688.97	176.57	1553.89	4687.9	22975.21	918.64	522.97	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26	138	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26
H2320_809_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1203.92	25.41	991.07	0	217.56	53599.73	55.35	598.5	506.77	3314.02	1606.57	0	864.81	2708.42	5123.04	5688.97	176.57	1553.89	4687.9	22975.21	918.64	522.97	0	0	0	0	0	0	0	0	0											Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				144.82	73.65	67.36	0	79.17	1.1	48.7	29.27	160.84	9.62	51.57	0	27.93	31.67	11.88	16.35	20.44	6.44	11.84	11.62	53.48	12.31	0	0	0	0	0	0	0	0	0											14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26	138	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	14.53	0.16	5.56	-	1.44	4.91	0.22	1.46	6.79	2.66	6.9	-	2.01	7.15	5.07	7.75	0.3	0.83	4.63	22.25	4.09	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.26
H2322_001_0	2007	6																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	307.56	4.37	1326.38	0	0	15.48	9.43	431.97	0	0	0	0	0	0	5349.95	6208.61	206.42	3398.33	0	1762.16	0	663.29	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.32	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.41	0.09	6.31	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.92	0	0	6.41	0.09	6.31	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.92	0	500 Copay per Admit	500 Copay per Admit	100 Copay for days 0-20 119 Copay for days 21-100	20 Coinsurance	0	50 Coinsurance	50 Coinsurance	50 Copay emergency care/10 Copay urgent care	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	20 Coinsurance	20 Coinsurance	0	0	0	0	0											7.97	0.09	1.4	0.9	0.15	0.86	0.53	0.21	0.68	0.27	0.73	0.02	0	0.68	1.1	2.59	0.04	0.11	0.82	1.13	0.2	0.14	0	0	0.07	0.03	0	0	0	0	0											20.73	0	0	14.37	0.18	7.71	0.9	0.15	3.96	2.41	1.99	0.68	0.27	0.73	0.02	0	0.68	7.78	15.52	0.47	4.36	0.82	4.8	0.2	1.53	-	-	0.07	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.64
H2322_003_0	2007	4																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	307.56	4.37	1326.38	0	0	15.48	9.43	431.97	0	0	0	0	0	0	5349.95	6208.61	206.42	3398.33	0	1762.16	0	663.29	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.32	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.41	0.09	6.31	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.92	0	0	6.41	0.09	6.31	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.92	0	500 Copay per Admit	500 Copay per Admit	100 Copay for days 0-20 119 Copay for days 21-100	20 Coinsurance	0	50 Coinsurance	50 Coinsurance	50 Copay emergency care/10 Copay urgent care	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	20 Coinsurance	20 Coinsurance	0	0	0	0	0											7.97	0.09	1.4	0.9	0.15	0.86	0.53	0.21	0.68	0.27	0.73	0.02	0	0.68	1.1	2.59	0.04	0.11	0.82	1.13	0.2	0.14	0	0	0.07	0.03	0	0	0	0	0											20.73	0	0	14.37	0.18	7.71	0.9	0.15	3.96	2.41	1.99	0.68	0.27	0.73	0.02	0	0.68	7.78	15.52	0.47	4.36	0.82	4.8	0.2	1.53	-	-	0.07	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.64
H2322_004_0	2007	8																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	307.56	4.37	1326.38	0	0	15.48	9.43	431.97	0	0	0	0	0	0	5349.95	6208.61	206.42	3398.33	0	1762.16	0	663.29	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.2	0.2	49.32	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.41	0.09	6.31	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.92	0	0	6.41	0.09	6.31	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.92	0	500 Copay per Admit	500 Copay per Admit	100 Copay for days 0-20 119 Copay for days 21-100	20 Coinsurance	0	50 Coinsurance	50 Coinsurance	50 Copay emergency care/10 Copay urgent care	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	20 Coinsurance	20 Coinsurance	0	0	0	0	0											7.97	0.09	1.4	0.9	0.15	0.86	0.53	0.21	0.68	0.27	0.73	0.02	0	0.68	1.1	2.59	0.04	0.11	0.82	1.13	0.2	0.14	0	0	0.07	0.03	0	0	0	0	0											20.73	0	0	14.37	0.18	7.71	0.9	0.15	3.96	2.41	1.99	0.68	0.27	0.73	0.02	0	0.68	7.78	15.52	0.47	4.36	0.82	4.8	0.2	1.53	-	-	0.07	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.64
H2322_005_0	2007	4																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											12.97	0.14	1.67	1.8	0.31	0.55	0.34	0.01	1.36	0.55	1.49	0.04	0	1.38	1.74	4.46	0.06	0.03	1.59	1.9	0.42	0.2	0	0	0.11	0.07	0	0	0	0	0											33.17	0	308.37	4.4	1330.32	0	0	14.93	9.09	433.26	0	0	0	0	0	0	5349.95	6208.61	206.93	3398.33	0	1762.16	0	663.29	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.21	0.21	49.32	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.42	0.09	6.33	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.96	500	0	19.39	0.23	8	1.8	0.31	3.65	2.22	1.79	1.36	0.55	1.49	0.04	0	1.38	8.43	17.39	0.49	4.28	1.59	5.57	0.42	1.58	-	-	0.11	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.12	0	500 Copay per Admit	500 Copay per Admit	100 Copay for days 0-20 119 Copay for days 21-100	20 Coinsurance	0	50 Coinsurance	50 Coinsurance	50 Copay emergency care/10 Copay urgent care	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	20 Coinsurance	20 Coinsurance	0	0	0	0	0											8.84	0.1	1.4	1.03	0.17	0.86	0.53	0.21	0.78	0.3	0.83	0.02	0	0.78	1.25	2.95	0.05	0.13	0.94	1.29	0.23	0.16	0	0	0.08	0.04	0	0	0	0	0											22.97	500	0	28.23	0.33	9.4	2.83	0.48	4.51	2.74	2	2.14	0.85	2.32	0.06	0.01	2.15	9.68	20.34	0.54	4.41	2.53	6.86	0.65	1.75	-	-	0.19	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.09
H2322_006_0	2007	6																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											12.97	0.14	1.67	1.8	0.31	0.55	0.34	0.01	1.36	0.55	1.49	0.04	0	1.38	1.74	4.46	0.06	0.03	1.59	1.9	0.42	0.2	0	0	0.11	0.07	0	0	0	0	0											33.17	0	308.37	4.4	1330.32	0	0	14.93	9.09	433.26	0	0	0	0	0	0	5349.95	6208.61	206.93	3398.33	0	1762.16	0	663.29	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.21	0.21	49.32	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.42	0.09	6.33	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.96	500	0	19.39	0.23	8	1.8	0.31	3.65	2.22	1.79	1.36	0.55	1.49	0.04	0	1.38	8.43	17.39	0.49	4.28	1.59	5.57	0.42	1.58	-	-	0.11	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.12	0	500 Copay per Admit	500 Copay per Admit	100 Copay for days 0-20 119 Copay for days 21-100	20 Coinsurance	0	50 Coinsurance	50 Coinsurance	50 Copay emergency care/10 Copay urgent care	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	20 Coinsurance	20 Coinsurance	0	0	0	0	0											8.84	0.1	1.4	1.03	0.17	0.86	0.53	0.21	0.78	0.3	0.83	0.02	0	0.78	1.25	2.95	0.05	0.13	0.94	1.29	0.23	0.16	0	0	0.08	0.04	0	0	0	0	0											22.97	500	0	28.23	0.33	9.4	2.83	0.48	4.51	2.74	2	2.14	0.85	2.32	0.06	0.01	2.15	9.68	20.34	0.54	4.41	2.53	6.86	0.65	1.75	-	-	0.19	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.09
H2322_007_0	2007	8																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											12.97	0.14	1.67	1.8	0.31	0.55	0.34	0.01	1.36	0.55	1.49	0.04	0	1.38	1.74	4.46	0.06	0.03	1.59	1.9	0.42	0.2	0	0	0.11	0.07	0	0	0	0	0											33.17	0	308.37	4.4	1330.32	0	0	14.93	9.09	433.26	0	0	0	0	0	0	5349.95	6208.61	206.93	3398.33	0	1762.16	0	663.29	0	0	0	0	0	0	0	0	0											1A IP Acute: 250 Copay per Admit	1B IP Psych: 250 Copay per Admit	2 SNF: 119 Copay for Days 21-100	6 Home Health: 0	10A Ambulance: 0	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25 9C Outpatient Sub Abuse: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 0 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 0	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	57.11	0	0	0.21	0.21	49.32	0	0	0	0	0	0	15	25	25	15	0	25	0	25	0	0	0	0	0	0	0	0	0											6.42	0.09	6.33	-	-	3.1	1.88	1.78	-	-	-	-	-	-	6.69	12.93	0.43	4.25	-	3.67	-	1.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.96	500	0	19.39	0.23	8	1.8	0.31	3.65	2.22	1.79	1.36	0.55	1.49	0.04	0	1.38	8.43	17.39	0.49	4.28	1.59	5.57	0.42	1.58	-	-	0.11	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.12	0	500 Copay per Admit	500 Copay per Admit	100 Copay for days 0-20 119 Copay for days 21-100	20 Coinsurance	0	50 Coinsurance	50 Coinsurance	50 Copay emergency care/10 Copay urgent care	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	20 Coinsurance	20 Coinsurance	0	0	0	0	0											8.84	0.1	1.4	1.03	0.17	0.86	0.53	0.21	0.78	0.3	0.83	0.02	0	0.78	1.25	2.95	0.05	0.13	0.94	1.29	0.23	0.16	0	0	0.08	0.04	0	0	0	0	0											22.97	500	0	28.23	0.33	9.4	2.83	0.48	4.51	2.74	2	2.14	0.85	2.32	0.06	0.01	2.15	9.68	20.34	0.54	4.41	2.53	6.86	0.65	1.75	-	-	0.19	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.09
H2322_801_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	273.42	2.77	43.45	0	6.98	15.51	9.45	6.34	29.23	12.27	33.35	0.86	0.11	31.35	49.44	118.49	1.77	5.13	37.58	52.05	9.33	6.62																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent  coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				1.94	0.02	0.9	0	0.18	0.41	0.25	0.16	0.77	0.32	0.87	0.02	0	0.82	1.3	3.11	0.05	0.13	0.99	1.36	0.24	0.17																				14.02	0	0	19.37	0.2	8.95	-	1.83	4.07	2.48	1.64	7.67	3.22	8.74	0.22	0.03	8.22	12.96	31.07	0.46	1.34	9.85	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	140.16
H2322_802_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	273.42	2.77	43.45	0	6.98	15.51	9.45	6.34	29.23	12.27	33.35	0.86	0.11	31.35	49.44	118.49	1.77	5.13	37.58	52.05	9.33	6.62																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent  coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				1.94	0.02	0.9	0	0.18	0.41	0.25	0.16	0.77	0.32	0.87	0.02	0	0.82	1.3	3.11	0.05	0.13	0.99	1.36	0.24	0.17																				14.02	0	0	19.37	0.2	8.95	-	1.83	4.07	2.48	1.64	7.67	3.22	8.74	0.22	0.03	8.22	12.96	31.07	0.46	1.34	9.85	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	140.16
H2322_803_0	2007	6																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	273.42	2.77	43.45	0	6.98	15.51	9.45	6.34	29.23	12.27	33.35	0.86	0.11	31.35	49.44	118.49	1.77	5.13	37.58	52.05	9.33	6.62																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent  coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				1.94	0.02	0.9	0	0.18	0.41	0.25	0.16	0.77	0.32	0.87	0.02	0	0.82	1.3	3.11	0.05	0.13	0.99	1.36	0.24	0.17																				14.02	0	0	19.37	0.2	8.95	-	1.83	4.07	2.48	1.64	7.67	3.22	8.74	0.22	0.03	8.22	12.96	31.07	0.46	1.34	9.85	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	140.16
H2322_804_0	2007	6																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	273.42	2.77	43.45	0	6.98	15.51	9.45	6.34	29.23	12.27	33.35	0.86	0.11	31.35	49.44	118.49	1.77	5.13	37.58	52.05	9.33	6.62																				6.38 Medicare equivalent coinsurance	6.37 Medicare equivalent coinsurance	18.55 Medicare equivalent coinsurance	0	23.61 Medicare equivalent  coinsurance	23.60 Medicare equivalent coinsurance	23.51 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.61 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	17.43	0.18	8.06	-	1.65	3.66	2.23	1.47	6.9	2.9	7.87	0.2	0.03	7.4	11.67	27.96	0.42	1.21	8.87	12.28	2.2	1.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.14	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				1.94	0.02	0.9	0	0.18	0.41	0.25	0.16	0.77	0.32	0.87	0.02	0	0.82	1.3	3.11	0.05	0.13	0.99	1.36	0.24	0.17																				14.02	0	0	19.37	0.2	8.95	-	1.83	4.07	2.48	1.64	7.67	3.22	8.74	0.22	0.03	8.22	12.96	31.07	0.46	1.34	9.85	13.65	2.45	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	140.16
H2323_001_0	2007	19																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		522.58	9.99	323.44	0	21.34	3.97	12.93	13.44	12.46	19.64	20.6	0.8	1.2	113.85	0	147.14	8.21	1.54	33.17	56.13	4.81	5.51	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9A OP Hospital:  138 Ded and 20 Coinsurance   9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	5 Partial Hosp:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 0 14B Immunizations: 0 14C Routine Physical Exam: 0  14D Pap Smears:  0 14D Pelvic Exams:  0 14E Prostate Screening:  0 14F Colorectal Screening:  0 14G Bone Mass Measurement:  0 14H Mammography:  0 14I Diabetes Monitoring:  0	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance   9C OP Substance Abuse:  138 Ded and 20 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance for Radiology Services	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 0 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: 12 Trips Per Year	16A Preventive Dental Services: Not Covered  16B Comprehensive Dental Services:  Not Covered	17A Routine Eye Exams: 0 Copay	17B Eye Wear: 1 Pair of Glasses or Contacts Per Year	18A Routine Hearing Exams: 20 Coinsurance	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0.06	0.06	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.22	0.24	0.24	0.24	0.23	0.24	0.24	0	0	0	0	0	0	0	0	0											33.45	0.64	60.47	-	5.04	0.94	3.05	3.17	2.94	4.64	4.86	0.19	0.28	26.87	-	32.67	1.94	0.36	7.83	12.84	1.14	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	204.6	0	0	33.45	0.64	60.47	-	5.04	0.94	3.05	3.17	2.94	4.64	4.86	0.19	0.28	26.87	-	32.67	1.94	0.36	7.83	12.84	1.14	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	204.6																																																																																				-			33.45	0.64	60.47	-	5.04	0.94	3.05	3.17	2.94	4.64	4.86	0.19	0.28	26.87	-	32.67	1.94	0.36	7.83	12.84	1.14	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	204.6
H2323_002_0	2007	22																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 0 copay  4B Urgent Care: 0 copay	9A Outpatient Hospital: 0 copay   9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay	5  Partial Hosp:  0 copay	12 Renal Dialysis: 0 copay	3 CORF: 0 copay  9D Cardiac Rehab: 0 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 0 copay	7E Mental Health:   0 copay 7H Psychiatric:   0 copay   9C OP Substance Abuse: 0 copay	7C Occupational Therapy:  0 copay 7I Physical and Speech Therapy:  0 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  0 copay 7F Podiatry:  0 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  0 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay	10B Transportation: 12 Trips Per Year	16A Preventive Dental Services: Not covered  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 0 copay	17B Eye Wear: 1 Pair of Glasses or Contacts Per Year	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H2354_001_0	2007	4																					0											D	D	D	V	T	Coin	O	V	P	P	P	P	P	P	V	V	V	V	V	V	S	P	T	P	V	P	V	P	O	O	O																																																				-	0	2049.08	44.94	915.34			17.5		224.72							5199.58	2332.08	180.17			566.13					573.39		2.18															1A IP Acute: 65 per day (days 1-10)	1B IP Psych: 65 per day (days 1-10)	2 SNF: 0 per day for days 1-20 plus 75 per day for days 21-100			11A DME: 20 11B Prosthetics/Supplies: 20		4A ER: 50 4B Urgent Care: 30							7A PCP: 20 14C Routine Physical Exams: 20	7B Chiropractic: 20 7D Physician Specialist: 20 7F Podiatry: 20 17A Medicare Covered Eye Exams: 20 18A Medicare Covered Hearing Exams: 20	7E Mental Health: 20 7H Psychiatric: 20 9C Outpatient Substance Abuse: 20			7G Other Health Care: 20					17A Routine Eye Exams: 20		18A Routine Hearing Exams: 20															44.11	44.11	35.99			0.2		48							20	20	20			20					20		20															7.53	0.17	2.75	-	-	3.5	-	0.9	-	-	-	-	-	-	8.67	3.89	0.3	-	-	0.94	-	-	-	-	0.96	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.6	0	0	7.53	0.17	2.75	-	-	3.5	-	0.9	-	-	-	-	-	-	8.67	3.89	0.3	-	-	0.94	-	-	-	-	0.96	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.6	0																																																																																			-	0	0	7.53	0.17	2.75	-	-	3.5	-	0.9	-	-	-	-	-	-	8.67	3.89	0.3	-	-	0.94	-	-	-	-	0.96	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.6
H2354_013_0	2007	4																					0											D	D	D	V	T	Coin	O	V	P	P	P	P	P	P	V	V	V	V	V	V	S	P	T	P	V	P	V	P	O	O	O																																																				-	0	2095.53	45.96	952.1			17.85		229.21							5480.36	2458.02	189.89			596.7					604.36		2.29															1A IP Acute: 50 per day (days 1-10)	1B IP Psych: 50 per day (days 1-10)	2 SNF: 0 per day for days 1-20 plus 25 per day for days 21-100			11A DME: 20 11B Prosthetics/Supplies: 20		4A ER: 50 4B Urgent Care: 25							7A PCP: 15 14C Routine Physical Exams: 15	7B Chiropractic: 15 7D Physician Specialist: 15 7F Podiatry: 15 17A Medicare Covered Eye Exams: 15 18A Medicare Covered Hearing Exams: 15	7E Mental Health: 15 7H Psychiatric: 15 9C Outpatient Substance Abuse: 15			7G Other Health Care: 15					17A Routine Eye Exams: 15		18A Routine Hearing Exams: 15															33.93	33.93	12			0.2		47.5							15	15	15			15					15		15															5.93	0.13	0.95	-	-	3.57	-	0.91	-	-	-	-	-	-	6.85	3.07	0.24	-	-	0.75	-	-	-	-	0.76	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.15	0	0	5.93	0.13	0.95	-	-	3.57	-	0.91	-	-	-	-	-	-	6.85	3.07	0.24	-	-	0.75	-	-	-	-	0.76	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.15	0																																																																																			-	0	0	5.93	0.13	0.95	-	-	3.57	-	0.91	-	-	-	-	-	-	6.85	3.07	0.24	-	-	0.75	-	-	-	-	0.76	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.15
H2354_014_0	2007	6																					0											D	D	D	V	T	Coin	O	V	P	P	P	P	P	P	V	V	V	V	V	V	S	P	T	P	V	P	V	P	O	O	O																																																				-	0	0	0	971.14			18.21		233.8							5589.96	2507.18	193.69			608.64					616.44		2.34																	2 SNF: 0 per day for days 1-20 plus 25 per day for days 21-100			11A DME: 20 11B Prosthetics/Supplies: 20		4A ER: 50 4B Urgent Care: 25							7A PCP: 15 14C Routine Physical Exams: 15	7B Chiropractic: 15 7D Physician Specialist: 15 7F Podiatry: 15 17A Medicare Covered Eye Exams: 15 18A Medicare Covered Hearing Exams: 15	7E Mental Health: 15 7H Psychiatric: 15 9C Outpatient Substance Abuse: 15			7G Other Health Care: 15					17A Routine Eye Exams: 15		18A Routine Hearing Exams: 15															0	0	12			0.2		47.5							15	15	15			15					15		15															-	-	0.97	-	-	3.64	-	0.93	-	-	-	-	-	-	6.99	3.13	0.24	-	-	0.76	-	-	-	-	0.77	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.44	0	0	-	-	0.97	-	-	3.64	-	0.93	-	-	-	-	-	-	6.99	3.13	0.24	-	-	0.76	-	-	-	-	0.77	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.44	0																																																																																			-	0	0	-	-	0.97	-	-	3.64	-	0.93	-	-	-	-	-	-	6.99	3.13	0.24	-	-	0.76	-	-	-	-	0.77	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.44
H2354_801_0	2007	1																					0											Coin	Coin	Coin		Coin	Coin		V	Coin	Coin				Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin																				0	0	0		0	0		0	0	0				0	0	0	0	0		0	0	0																				-	0	255.91	1.27	8.07		4.29	17.64		242.32	59.78	3.59				29.25	24.37	14.06	1.37	2.48		180.54	17.45	22.62																				Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits	Medicare Benefits		4A: 50 Copay for ER Visit 4B: 0 Copay Urgent Care (worldwide coverage)	Medicare Benefits	Medicare Benefits				Medicare Benefits	Medicare Benefits (immunizations covered in full)	Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits	Medicare Benefits	Medicare Benefits																				0.06	0.06	0.18		0.24	0.24		50	0.24	0.24				0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24																				15.49	0.08	1.47	-	1.01	4.16	-	1.01	14.11	0.85	-	-	-	6.9	5.73	3.32	0.32	0.59	-	42.61	4.12	5.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.09	0	0	15.49	0.08	1.47	-	1.01	4.16	-	1.01	14.11	0.85	-	-	-	6.9	5.73	3.32	0.32	0.59	-	42.61	4.12	5.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.09	0																																																																																			-	0	0	15.49	0.08	1.47	-	1.01	4.16	-	1.01	14.11	0.85	-	-	-	6.9	5.73	3.32	0.32	0.59	-	42.61	4.12	5.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.09
H2354_802_0	2007	2																					0											Coin	Coin	Coin		Coin	Coin		V	Coin	Coin				Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin																				0	0	0		0	0		0	0	0				0	0	0	0	0		0	0	0																				-	0	255.91	1.27	8.07		4.29	17.64		242.32	59.78	3.59				29.25	24.37	14.06	1.37	2.48		180.54	17.45	22.62																				Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits	Medicare Benefits		4A: 50 Copay for ER Visit 4B: 0 Copay Urgent Care (worldwide coverage)	Medicare Benefits	Medicare Benefits				Medicare Benefits	Medicare Benefits (immunizations covered in full)	Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits	Medicare Benefits	Medicare Benefits																				0.06	0.06	0.18		0.24	0.24		50	0.24	0.24				0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24																				15.49	0.08	1.47	-	1.01	4.16	-	1.01	14.11	0.85	-	-	-	6.9	5.73	3.32	0.32	0.59	-	42.61	4.12	5.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.09	0	0	15.49	0.08	1.47	-	1.01	4.16	-	1.01	14.11	0.85	-	-	-	6.9	5.73	3.32	0.32	0.59	-	42.61	4.12	5.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.09	0																																																																																			-	0	0	15.49	0.08	1.47	-	1.01	4.16	-	1.01	14.11	0.85	-	-	-	6.9	5.73	3.32	0.32	0.59	-	42.61	4.12	5.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.09
H2406_001_0	2007	6	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2164.18	125.54	7979.5	256.48	946.61	15.7	7.53	252.08	208.58	567.95	301.43	94.21	14.14	295.69	35003.07	1766.53	1322.12	1.84		29.03	155.96	955.59	2195.63		53.77	157.7		51.87				197.77	0.01	0	27.88	280.44						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						131	131			66	17	17	44	22			22		22		9				9		9										31		22								23.66	1.37	-	-	5.17	2.75	1.32	0.92	0.38	-	-	0.17	-	0.54	-	1.29	-	-	-	0.02	-	0.7	-	-	-	-	-	-	-	-	-	0.5	-	0	-	-	-	-	-	-	-	38.79		5.56	23.66	1.37	-	-	5.17	2.75	1.32	0.92	0.38	-	-	0.17	-	0.54	-	1.29	-	-	-	0.02	-	0.7	-	-	-	-	-	-	-	-	-	0.5	-	0	-	-	-	-	-	-	-	38.79		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						2.62	0.07	0.81	0.08	0.52	0.25	0.12	0.06	0.62	0.53	0.62	0.11	0.01	0.13	0.02	2.4	0.13	0		0.11		0.1	0.08		0							0.03	0	0	0	0.02						9.44		0	26.28	1.44	0.81	0.08	5.69	2.99	1.44	0.97	1	0.53	0.62	0.28	0.01	0.67	0.02	3.69	0.13	0	-	0.13	-	0.8	0.08	-	0	-	-	-	-	-	-	0.53	0	0	0	0.02	-	-	-	-	-	48.23
H2407_001_0	2007	6																																Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin						Coin																																																														-		1		1		1	1		1	1	1					1						1																																																														36.92		22.19		5.85	26.94		7.2	21.58	7.93					124.56						8.39																					36.92	-	22.19	-	5.85	26.94	-	7.2	21.58	7.93	-	-	-	-	124.56	-	-	-	-	-	8.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	261.57	0	0	36.92	-	22.19	-	5.85	26.94	-	7.2	21.58	7.93	-	-	-	-	124.56	-	-	-	-	-	8.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	261.57																																																																																				-	0	0	36.92	-	22.19	-	5.85	26.94	-	7.2	21.58	7.93	-	-	-	-	124.56	-	-	-	-	-	8.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	261.57
H2408_001_0	2007	4																					2950											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1438.4	87.07	503.53	0	93.44	12.62	7.77	566.82	32.43	9975.25	37.61	0	0	29.89	3947.49	5253.64	406.9	2.74	0	0	22.06	1129.48	0	0	96.63	0	212.35	0	0	0	0											275 (1a)	275 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	14 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											174.34	174.34	85.59	0	110.95	0.19	0.21	31.7	0.13	3.55	0.1	0	0.19	0.13	10	25	37.5	0.13	0	0	0.19	25	0	0	25	0	25	0	0	0	0											20.9	1.27	3.59	-	0.86	2.4	1.66	1.5	4.11	2.95	3.78	-	0	3.79	3.29	10.95	1.27	0.35	-	-	4.2	2.35	-	-	0.2	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.86		29.36	20.9	1.27	3.59	-	0.86	2.4	1.66	1.5	4.11	2.95	3.78	-	0	3.79	3.29	10.95	1.27	0.35	-	-	4.2	2.35	-	-	0.2	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.86																																																																																				-			20.9	1.27	3.59	-	0.86	2.4	1.66	1.5	4.11	2.95	3.78	-	0	3.79	3.29	10.95	1.27	0.35	-	-	4.2	2.35	-	-	0.2	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.86
H2408_011_0	2007	4																					3950											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1652.98	92.83	557.75	0	146.94	11.9	7.52	828.78	30.7	10446.04	42.83	0	0.01	32.01	4560.76	5642.65	404.96	2.56	0	0	21.35	1152.76	0	0	105.18	0	212.14	0	0	0	0											325 (1a)	325 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	10 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											215.59	215.59	106.14	0	116.09	0.2	0.22	33.17	0.13	2.65	0.11	0	0.2	0.13	10	25	37.5	0.13	0	0	0.2	25	0	0	25	0	25	0	0	0	0											29.7	1.67	4.93	-	1.42	2.37	1.64	2.29	4.07	2.31	4.51	-	0	4.25	3.8	11.76	1.27	0.34	-	-	4.25	2.4	-	-	0.22	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.63		32.14	29.7	1.67	4.93	-	1.42	2.37	1.64	2.29	4.07	2.31	4.51	-	0	4.25	3.8	11.76	1.27	0.34	-	-	4.25	2.4	-	-	0.22	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.63																																																																																				-			29.7	1.67	4.93	-	1.42	2.37	1.64	2.29	4.07	2.31	4.51	-	0	4.25	3.8	11.76	1.27	0.34	-	-	4.25	2.4	-	-	0.22	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.63
H2408_013_0	2007	8																					3900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1754.31	143.98	438.53	0	91.68	16.37	6.78	627.77	32.04	10864.82	45.25	0	0	28.08	5038.59	5772.45	388.85	2.52	0	0	22.62	1164.28	0	0	193.45	0	216.08	0	0	0	0											375 (1a)	375 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	8 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											230.17	230.17	98.21	0	107.41	0.18	0.21	30.69	0.18	1.96	0.15	0	0.18	0.18	15	30	37.5	0.18	0	0	0.18	30	0	0	30	0	30	0	0	0	0											33.65	2.76	3.59	-	0.82	3.01	1.41	1.61	5.9	1.78	6.61	-	0	5.17	6.3	14.43	1.22	0.46	-	-	4.17	2.91	-	-	0.48	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.82		44.37	33.65	2.76	3.59	-	0.82	3.01	1.41	1.61	5.9	1.78	6.61	-	0	5.17	6.3	14.43	1.22	0.46	-	-	4.17	2.91	-	-	0.48	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.82																																																																																				-			33.65	2.76	3.59	-	0.82	3.01	1.41	1.61	5.9	1.78	6.61	-	0	5.17	6.3	14.43	1.22	0.46	-	-	4.17	2.91	-	-	0.48	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.82
H2408_015_0	2007	5																					4400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1830.17	142.6	461	0	111.79	17.11	9.95	727.51	25.65	10069.73	40.28	0	0.06	31	4438.39	5550.45	402.6	2.81	0	0	27.62	1151.14	0	0	94.23	0	217.2	0	0	0	0											325 (1a)	325 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	8 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											217.08	217.08	106.87	0	116.89	0.17	0.18	33.4	0.17	2.14	0.13	0	0.2	0.17	15	30	37.5	0.17	0	0	0.2	30	0	0	30	0	30	0	0	0	0											33.11	2.58	4.11	-	1.09	2.86	1.76	2.02	4.28	1.79	5.33	-	0.01	5.18	5.55	13.88	1.26	0.47	-	-	5.53	2.88	-	-	0.24	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.46		34.71	33.11	2.58	4.11	-	1.09	2.86	1.76	2.02	4.28	1.79	5.33	-	0.01	5.18	5.55	13.88	1.26	0.47	-	-	5.53	2.88	-	-	0.24	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.46																																																																																				-			33.11	2.58	4.11	-	1.09	2.86	1.76	2.02	4.28	1.79	5.33	-	0.01	5.18	5.55	13.88	1.26	0.47	-	-	5.53	2.88	-	-	0.24	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.46
H2408_801_0	2007	2																					4500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1583.6	97.68	500.12	0	103.36	14.17	7.94	584.05	32.24	10204.84	39.95	0	0.01	29.58	4098.22	5301.71	407.11	2.5	0	0	24.03	1111.58	0	0	113.13	0	213.5	0	0	0	0											350 (1a)	350 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											238.35	238.35	108.96	0	119.17	0.17	0.19	34.05	0.17	4.09	0.14	0	0.2	0.17	25	35	37.5	0.17	0	0	0.2	35	0	0	35	0	35	0	0	0	0											31.45	1.94	4.54	-	1.03	2.41	1.48	1.66	5.49	3.47	5.39	-	0	5.04	8.54	15.46	1.27	0.42	-	-	4.91	3.24	-	-	0.33	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.71		32.25	31.45	1.94	4.54	-	1.03	2.41	1.48	1.66	5.49	3.47	5.39	-	0	5.04	8.54	15.46	1.27	0.42	-	-	4.91	3.24	-	-	0.33	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.71																																																																																				-			31.45	1.94	4.54	-	1.03	2.41	1.48	1.66	5.49	3.47	5.39	-	0	5.04	8.54	15.46	1.27	0.42	-	-	4.91	3.24	-	-	0.33	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.71
H2408_802_0	2007	1																					4500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1583.6	97.68	500.12	0	103.36	14.17	7.94	584.05	32.24	10204.84	39.95	0	0.01	29.58	4098.22	5301.71	407.11	2.5	0	0	24.03	1111.58	0	0	113.13	0	213.5	0	0	0	0											350 (1a)	350 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											238.35	238.35	108.96	0	119.17	0.17	0.19	34.05	0.17	4.09	0.14	0	0.2	0.17	25	35	37.5	0.17	0	0	0.2	35	0	0	35	0	35	0	0	0	0											31.45	1.94	4.54	-	1.03	2.41	1.48	1.66	5.49	3.47	5.39	-	0	5.04	8.54	15.46	1.27	0.42	-	-	4.91	3.24	-	-	0.33	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.71		32.25	31.45	1.94	4.54	-	1.03	2.41	1.48	1.66	5.49	3.47	5.39	-	0	5.04	8.54	15.46	1.27	0.42	-	-	4.91	3.24	-	-	0.33	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.71																																																																																				-			31.45	1.94	4.54	-	1.03	2.41	1.48	1.66	5.49	3.47	5.39	-	0	5.04	8.54	15.46	1.27	0.42	-	-	4.91	3.24	-	-	0.33	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.71
H2409_003_0	2007	4																					5000											D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			Coin	Coin					P																																																								-		1284.75	51.84	857.55	0	105.94	6.7	8.73	305.83	379.99	1708.69	811.83	65.35	1.44	1601.66	3573.26	4831.11	228.46	267.95	0	0	22.58	0.17	0	0	0	0	231.99	0	0	0	0											150 days 1-7	150 days 1-7	75 days 8+		100	30	30	Oct-50	75	75	75	75	75	75	10	10	20	10			20	30					10															103.12	103.12	34.74	0	87.68	0.26	0.26	42.09	65.76	59.18	63.91	65.76	65.76	65.76	8.62	3.38	8.77	8.77	0	0	0.18	0.26	0	0	0	0	10	0	0	0	0											11.04	0.45	2.48	-	0.77	1.76	2.3	1.07	2.08	8.43	4.32	0.36	0.01	8.78	2.57	1.36	0.17	0.2	-	-	3.96	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.34	140	7.59	11.04	0.45	2.48	-	0.77	1.76	2.3	1.07	2.08	8.43	4.32	0.36	0.01	8.78	2.57	1.36	0.17	0.2	-	-	3.96	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.34																																																																																				-			11.04	0.45	2.48	-	0.77	1.76	2.3	1.07	2.08	8.43	4.32	0.36	0.01	8.78	2.57	1.36	0.17	0.2	-	-	3.96	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.34
H2409_006_0	2007	3																					5000											D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			Coin	Coin					P																																																								-		1284.75	51.84	857.55	0	105.94	6.7	8.73	305.83	379.99	1708.69	811.83	65.35	1.44	1601.66	3573.26	4831.11	228.46	267.95	0	0	22.58	0.17	0	0	0	0	231.99	0	0	0	0											150 days 1-7	150 days 1-7	75 days 8+		100	30	30	Oct-50	75	75	75	75	75	75	10	10	20	10			20	30					10															103.12	103.12	34.74	0	87.68	0.26	0.26	42.09	65.76	59.18	63.91	65.76	65.76	65.76	8.62	3.38	8.77	8.77	0	0	0.18	0.26	0	0	0	0	10	0	0	0	0											11.04	0.45	2.48	-	0.77	1.76	2.3	1.07	2.08	8.43	4.32	0.36	0.01	8.78	2.57	1.36	0.17	0.2	-	-	3.96	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.34	140	7.59	11.04	0.45	2.48	-	0.77	1.76	2.3	1.07	2.08	8.43	4.32	0.36	0.01	8.78	2.57	1.36	0.17	0.2	-	-	3.96	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.34																																																																																				-			11.04	0.45	2.48	-	0.77	1.76	2.3	1.07	2.08	8.43	4.32	0.36	0.01	8.78	2.57	1.36	0.17	0.2	-	-	3.96	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.34
H2409_801_0	2007	4																																Coin	Coin	Coin		Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		231.84	3.75	30.36	0	3.61	6.74	8.79	308.45	37.51	21.98	27.32	3.95	0.18	25.71	21.47	27.46	1.62	2.28	22.13	84.11	22.74	0.17	0	0	0	0	0	0	0	0	0											mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	50	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06	140		18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06																																																																																				-			18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06
H2409_802_0	2007	4																																Coin	Coin	Coin		Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		231.84	3.75	30.36	0	3.61	6.74	8.79	308.45	37.51	21.98	27.32	3.95	0.18	25.71	21.47	27.46	1.62	2.28	22.13	84.11	22.74	0.17	0	0	0	0	0	0	0	0	0											mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	50	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06	140		18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06																																																																																				-			18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06
H2409_803_0	2007	3																																Coin	Coin	Coin		Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		231.84	3.75	30.36	0	3.61	6.74	8.79	308.45	37.51	21.98	27.32	3.95	0.18	25.71	21.47	27.46	1.62	2.28	22.13	84.11	22.74	0.17	0	0	0	0	0	0	0	0	0											mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	50	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06	140		18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06																																																																																				-			18.47	0.3	5.02	-	0.85	1.59	2.07	1.29	8.85	5.19	6.45	0.93	0.04	6.07	5.07	6.48	0.38	0.54	5.22	19.85	5.37	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.06
H2410_001_0	2007	3																					5000											D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			Coin	Coin					P																																																								-		1296.7	52.32	865.53	0	105.3	6.72	8.76	304	377.71	1698.46	806.97	64.96	1.43	1592.07	3551.86	4802.17	227.09	266.35	0	0	22.65	0.17	0	0	0	0	231.99	0	0	0	0											150 days 1-7	150 days 1-7	75 days 8+		100	30	30	Oct-50	75	75	75	75	75	75	10	10	20	10			20	30					10															103.11	103.11	34.74	0	87.67	0.26	0.26	42.08	65.75	59.18	63.91	65.75	65.75	65.75	8.62	3.38	8.77	8.77	0	0	0.18	0.26	0	0	0	0	10	0	0	0	0											11.14	0.45	2.51	-	0.77	1.77	2.3	1.07	2.07	8.38	4.3	0.36	0.01	8.72	2.55	1.35	0.17	0.19	-	-	3.97	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.31	140	7.6	11.14	0.45	2.51	-	0.77	1.77	2.3	1.07	2.07	8.38	4.3	0.36	0.01	8.72	2.55	1.35	0.17	0.19	-	-	3.97	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.31																																																																																				-			11.14	0.45	2.51	-	0.77	1.77	2.3	1.07	2.07	8.38	4.3	0.36	0.01	8.72	2.55	1.35	0.17	0.19	-	-	3.97	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.31
H2410_009_0	2007	4																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		422.01	31.25	121.85	0	12.43	20.12	22.32	28.95	40.85	34.55	35.48	6.82	2.88	61.55	29.58	29.03	10.21	2.32	24.31	121.81	26.73	0.15	0	0	0	0	0	0	0	0	0											mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.15		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				32.12	2.38	18.37	-	2.93	4.75	5.27	6.83	9.64	8.15	8.37	1.61	0.68	14.53	6.98	6.85	2.41	0.55	5.74	28.75	6.31	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	173.25	140		32.12	2.38	18.37	-	2.93	4.75	5.27	6.83	9.64	8.15	8.37	1.61	0.68	14.53	6.98	6.85	2.41	0.55	5.74	28.75	6.31	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	173.25																																																																																				-			32.12	2.38	18.37	-	2.93	4.75	5.27	6.83	9.64	8.15	8.37	1.61	0.68	14.53	6.98	6.85	2.41	0.55	5.74	28.75	6.31	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	173.25
H2410_015_0	2007	4																					5000											D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			Coin	Coin					P																																																								-		1296.7	52.32	865.53	0	105.3	6.72	8.76	304	377.71	1698.46	806.97	64.96	1.43	1592.07	3551.86	4802.17	227.09	266.35	0	0	22.65	0.17	0	0	0	0	231.99	0	0	0	0											150 days 1-7	150 days 1-7	75 days 8+		100	30	30	Oct-50	75	75	75	75	75	75	10	10	20	10			20	30					10															103.11	103.11	34.74	0	87.67	0.26	0.26	42.08	65.75	59.18	63.91	65.75	65.75	65.75	8.62	3.38	8.77	8.77	0	0	0.18	0.26	0	0	0	0	10	0	0	0	0											11.14	0.45	2.51	-	0.77	1.77	2.3	1.07	2.07	8.38	4.3	0.36	0.01	8.72	2.55	1.35	0.17	0.19	-	-	3.97	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.31	140	7.6	11.14	0.45	2.51	-	0.77	1.77	2.3	1.07	2.07	8.38	4.3	0.36	0.01	8.72	2.55	1.35	0.17	0.19	-	-	3.97	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.31																																																																																				-			11.14	0.45	2.51	-	0.77	1.77	2.3	1.07	2.07	8.38	4.3	0.36	0.01	8.72	2.55	1.35	0.17	0.19	-	-	3.97	0.05	-	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.31
H2410_801_0	2007	3																																Coin	Coin	Coin		Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		256.71	4.15	33.62	0	4	7.47	9.74	324.58	41.53	24.34	30.25	4.37	0.2	28.47	23.78	30.41	1.79	2.52	24.5	93.14	25.17	0.19	0	0	0	0	0	0	0	0	0											mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	50	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73	140		20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73																																																																																				-			20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73
H2410_802_0	2007	3																																Coin	Coin	Coin		Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		256.71	4.15	33.62	0	4	7.47	9.74	324.58	41.53	24.34	30.25	4.37	0.2	28.47	23.78	30.41	1.79	2.52	24.5	93.14	25.17	0.19	0	0	0	0	0	0	0	0	0											mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	50	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73	140		20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73																																																																																				-			20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73
H2410_803_0	2007	2																																Coin	Coin	Coin		Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		256.71	4.15	33.62	0	4	7.47	9.74	324.58	41.53	24.34	30.25	4.37	0.2	28.47	23.78	30.41	1.79	2.52	24.5	93.14	25.17	0.19	0	0	0	0	0	0	0	0	0											mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	50	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73	140		20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73																																																																																				-			20.45	0.33	5.56	-	0.94	1.76	2.3	1.35	9.8	5.74	7.14	1.03	0.05	6.72	5.61	7.18	0.42	0.6	5.78	21.98	5.94	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.73
H2411_002_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	255.13	3.12	72.5	0	311.7	0	0	1148.79	0	0	899.6	0	0	0	9154.42	2445.58	282.19	582.63	0	44.76	696.84	24.52	0	0	1146.77	0	0	0	0	384.54	0											PBP: 1A IP Acute: 250 per admit 750 annual OOP Max	1B IP Psych: 250 per admit 750 annual OOP Max	2 SNF: 250 per admit 750 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 15	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 15	7B Chiropractic: 15 7D Physician Specialist: 15 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 15 9C OP Substance Abuse: 15	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-15 17A Medicare Covered Eye Exams: 15	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non-Medicare Covered Comprehensive Dental Services: Not Covered	17A Routine Eye Exams: 15	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 15	13B Acupuncture: Not Covered											248.75	248.75	248.75	0	49.75	0	0	47.63	0	0	49.75	0	0	0	14.76	14.93	14.93	14.93	0	14.93	12.37	8.62	0	0	14.93	0	0	0	0	14.93	0											5.29	0.06	1.5	-	1.29	-	-	4.56	-	-	3.73	-	-	-	11.26	3.04	0.35	0.72	-	0.06	0.72	0.02	-	-	1.43	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	34.51	0	0.17	5.29	0.06	1.5	-	1.29	-	-	4.56	-	-	3.73	-	-	-	11.26	3.04	0.35	0.72	-	0.06	0.72	0.02	-	-	1.43	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	34.51	10600	0.2	0.2	0.2	0.2	50	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0.2	15	0.2											8.07	0.1	1.81	1.01	0.23	0.43	0.24	0.7	1.08	1.82	0.9	1.38	0.05	0.07	1.89	0.76	0.19	0.15	0	0.01	0.1	0.08	0	0.02	0.25	0	0	0	0	0.07	0.06											21.48	500	1.44	13.36	0.17	3.31	1.01	1.52	0.43	0.24	5.26	1.08	1.82	4.63	1.38	0.05	0.07	13.15	3.8	0.54	0.88	-	0.07	0.82	0.1	-	0.02	1.68	0	-	-	-	0.55	0.06	-	-	-	-	-	-	-	-	-	-	55.99
H2411_801_0	2007	3																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.24	1.35	58.7	0	241.74	0	0	935.2	443.57	0	801.85	0	0	0	8113.24	2195.32	214.24	631.58	0	52.31	623.76	63.5	0	0	1006.66	0	0	0	0	664.6	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit	2 SNF: 450 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 20	9A OP Hospital and 9B ASC Services: 225	8A OP C/D/T: 0	8B OP X-Ray: 50	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 20	7B Chiropractic: 20 7D Physician Specialist: 25 7F Podiatry: 20	7E Mental Health: 20 7H Psychiatric: 25 9C OP Substance Abuse: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	Included in i.2.	7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 20-25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non-Medicare Covered Comprehensive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 20	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.48	223.88	0	49.75	0	0	0	19.66	23.59	19.9	19.9	0	19.9	11.83	18.62	0	0	19.9	0	0	0	0	19.9	0											7.51	0.05	2.19	-	1	-	-	3.7	8.28	-	3.32	-	-	-	13.29	4.32	0.36	1.05	-	0.09	0.61	0.1	-	-	1.67	-	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	-	48.63	0	0.24	7.51	0.05	2.19	-	1	-	-	3.7	8.28	-	3.32	-	-	-	13.29	4.32	0.36	1.05	-	0.09	0.61	0.1	-	-	1.67	-	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	-	48.63	10600	0.2	0.2	0.2	0.2	50	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0.2	15	0.2											6.87	0.06	1.54	0.71	0.2	0.37	0.2	0.47	1.15	1.51	0.86	1.33	0.02	0.04	1.78	0.62	0.19	0.11	0	0.01	0.12	0.04	0	0.02	0.24	0.01	0	0	0	0.11	0.06											18.63	500	1.21	14.37	0.11	3.73	0.71	1.2	0.37	0.2	4.17	9.42	1.51	4.18	1.33	0.02	0.04	15.07	4.94	0.54	1.15	-	0.1	0.73	0.14	-	0.02	1.91	0.01	-	-	-	1.21	0.06	-	-	-	-	-	-	-	-	-	-	67.26
H2411_802_0	2007	4																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.24	1.35	58.7	0	241.74	0	0	935.2	443.57	0	801.85	0	0	0	8113.24	2195.32	214.24	631.58	0	52.31	623.76	63.5	0	0	1006.66	0	0	0	0	664.6	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit	2 SNF: 450 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 20	9A OP Hospital and 9B ASC Services: 225	8A OP C/D/T: 0	8B OP X-Ray: 50	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 20	7B Chiropractic: 20 7D Physician Specialist: 25 7F Podiatry: 20	7E Mental Health: 20 7H Psychiatric: 25 9C OP Substance Abuse: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	Included in i.2.	7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 20-25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non-Medicare Covered Comprehensive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 20	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.48	223.88	0	49.75	0	0	0	19.66	23.59	19.9	19.9	0	19.9	11.83	18.62	0	0	19.9	0	0	0	0	19.9	0											7.51	0.05	2.19	-	1	-	-	3.7	8.28	-	3.32	-	-	-	13.29	4.32	0.36	1.05	-	0.09	0.61	0.1	-	-	1.67	-	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	-	48.63	0	0.24	7.51	0.05	2.19	-	1	-	-	3.7	8.28	-	3.32	-	-	-	13.29	4.32	0.36	1.05	-	0.09	0.61	0.1	-	-	1.67	-	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	-	48.63	10600	0.2	0.2	0.2	0.2	50	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0.2	15	0.2											6.87	0.06	1.54	0.71	0.2	0.37	0.2	0.47	1.15	1.51	0.86	1.33	0.02	0.04	1.78	0.62	0.19	0.11	0	0.01	0.12	0.04	0	0.02	0.24	0.01	0	0	0	0.11	0.06											18.63	500	1.21	14.37	0.11	3.73	0.71	1.2	0.37	0.2	4.17	9.42	1.51	4.18	1.33	0.02	0.04	15.07	4.94	0.54	1.15	-	0.1	0.73	0.14	-	0.02	1.91	0.01	-	-	-	1.21	0.06	-	-	-	-	-	-	-	-	-	-	67.26
H2411_803_0	2007	4																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.24	1.35	58.7	0	241.74	0	0	935.2	443.57	0	801.85	0	0	0	8113.24	2195.32	214.24	631.58	0	52.31	623.76	63.5	0	0	1006.66	0	0	0	0	664.6	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit	2 SNF: 450 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 20	9A OP Hospital and 9B ASC Services: 225	8A OP C/D/T: 0	8B OP X-Ray: 50	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 20	7B Chiropractic: 20 7D Physician Specialist: 25 7F Podiatry: 20	7E Mental Health: 20 7H Psychiatric: 25 9C OP Substance Abuse: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	Included in i.2.	7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 20-25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non-Medicare Covered Comprehensive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 20	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.48	223.88	0	49.75	0	0	0	19.66	23.59	19.9	19.9	0	19.9	11.83	18.62	0	0	19.9	0	0	0	0	19.9	0											7.51	0.05	2.19	-	1	-	-	3.7	8.28	-	3.32	-	-	-	13.29	4.32	0.36	1.05	-	0.09	0.61	0.1	-	-	1.67	-	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	-	48.63	0	0.24	7.51	0.05	2.19	-	1	-	-	3.7	8.28	-	3.32	-	-	-	13.29	4.32	0.36	1.05	-	0.09	0.61	0.1	-	-	1.67	-	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	-	48.63	10600	0.2	0.2	0.2	0.2	50	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0.2	15	0.2											6.87	0.06	1.54	0.71	0.2	0.37	0.2	0.47	1.15	1.51	0.86	1.33	0.02	0.04	1.78	0.62	0.19	0.11	0	0.01	0.12	0.04	0	0.02	0.24	0.01	0	0	0	0.11	0.06											18.63	500	1.21	14.37	0.11	3.73	0.71	1.2	0.37	0.2	4.17	9.42	1.51	4.18	1.33	0.02	0.04	15.07	4.94	0.54	1.15	-	0.1	0.73	0.14	-	0.02	1.91	0.01	-	-	-	1.21	0.06	-	-	-	-	-	-	-	-	-	-	67.26
H2416_001_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		454.21		80.32	40.1	10.16	48.65		28.51	105.61	149.84					291.29							1.28																				same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare																				0.08		0.17		0.24	0.24		0.24	0.24	0.24					0.24							0.24																				35.97	-	13.86	-	2.4	11.48	-	6.73	24.92	35.36	-	-	-	-	68.74	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	199.78			35.97	-	13.86	-	2.4	11.48	-	6.73	24.92	35.36	-	-	-	-	68.74	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	199.78																																																																																				-			35.97	-	13.86	-	2.4	11.48	-	6.73	24.92	35.36	-	-	-	-	68.74	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	199.78
H2417_001_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		440.89		77.96		9.86	47.22		27.67	102.52	145.43					282.77							1.24																				same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare																				0.08		0.17		0.24	0.24		0.24	0.24	0.24					0.24							0.24																				34.92	-	13.46	-	2.33	11.14	-	6.53	24.19	34.32	-	-	-	-	66.73	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	193.92			34.92	-	13.46	-	2.33	11.14	-	6.53	24.19	34.32	-	-	-	-	66.73	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	193.92																																																																																				-			34.92	-	13.46	-	2.33	11.14	-	6.53	24.19	34.32	-	-	-	-	66.73	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	193.92
H2419_001_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		393.32	20.15	324.45		31.29	9.91	13.34	18.14	14.42	30.2	9.58	1.49	2.76	91.95	8.56	23.38	16.46	1.95	19.87	155.7	28.54	0.07																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co																				0.08	0.08	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				31.15	1.6	56	-	7.38	2.34	3.15	4.28	3.4	7.13	2.26	0.35	0.65	21.7	2.02	5.52	3.88	0.46	4.69	36.75	6.74	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	201.46	138	0	31.15	1.6	56	-	7.38	2.34	3.15	4.28	3.4	7.13	2.26	0.35	0.65	21.7	2.02	5.52	3.88	0.46	4.69	36.75	6.74	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	201.46																																																																																				-		0	31.15	1.6	56	-	7.38	2.34	3.15	4.28	3.4	7.13	2.26	0.35	0.65	21.7	2.02	5.52	3.88	0.46	4.69	36.75	6.74	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	201.46
H2422_002_0	2007	8																																Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																							-		472.46		109.16	13.31	44.53	30.3		28.72	33.24	160.28					278.03						3.32										6.97											1a: First 60 days  all but 952 Day 61-90 238 per day Day 90-150 (lifetime days) 476 per day Beyond 150  no coverage	1b: First 60 days  all but 952 Day 61-90 238 per day Day 90-150 476 per day 190 days lifetime	2: Days 1-20  no copay Days 21-100 119 per day No coverage after day 100	6: No member cost sharing	10a: 20 coinsurance	11a: 20 coinsurance	11b 11c: 20 coinsurance	4a 4b: 20 coinsurance up to 50	9a 9b: 20 coinsurance	8a: 20 coinsurance	8b: 20 coinsurance	5: 20 coinsurance	12: 20 coinsurance	3 9c 9d: 20 coinsurance	7a: 20 coins; 14b:No co-pay for flu or pneumonia vaccines;14c:1 exam covered within 6 months of enrollment	7b: 20 coinsurance on Medicare approved amounts 100 coinsurance on routine care;7d:20 coinsurance;7f:20 coinsurance 100 coinsurance for routine care	7e 7h: 50 coinsurance	7c 7i: 20 coinsurance	7d: 20 coinsurance	7g 14e 14f 14g 14h 14i: 20 coins; 14d: 0 coins	15: No member cost sharing	13a: No member cost sharing	10b: 100 coinsurance	16a 16b: 0 coins up to 1000	17a: No member cost sharing	17b No member cost sharing	18a: 100 coinsurance	18b: 100 coinsurance		14a: Not Covered	13b:  Dental Crowns (not including full cast high noble) no cost sharing up to 1000 in benefits.											0.08	0	0.15	0	0.24	0.24		0.24	0.24	0.24					0.24						0.24										0											35.81	-	16.17	-	10.51	7.15	-	6.78	7.84	37.83	-	-	-	-	65.61	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	188.48			35.81	-	16.17	-	10.51	7.15	-	6.78	7.84	37.83	-	-	-	-	65.61	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	188.48																																																																																				-			35.81	-	16.17	-	10.51	7.15	-	6.78	7.84	37.83	-	-	-	-	65.61	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	188.48
H2424_001_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		403.87	12.22	147.49	72.26	17.23	24.65	29.17	529.21	31.79	19.03	11.41	5.06	4.4	76.55	69.35	124.73	6.07	3.47	29.73	42.91	25.21	0	0	0	0	0	0	0	0	0	7.6											ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14B Immunizations. PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture. No member cost sharing for other services.											0.08	0.08	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0.24	0	0											31.99	0.97	25.46	-	4.07	5.82	6.88	2.21	7.5	4.49	2.69	1.19	1.04	18.06	16.37	29.44	1.43	0.82	7.02	10.13	5.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	183.51	126		31.99	0.97	25.46	-	4.07	5.82	6.88	2.21	7.5	4.49	2.69	1.19	1.04	18.06	16.37	29.44	1.43	0.82	7.02	10.13	5.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	183.51																																																																																				-			31.99	0.97	25.46	-	4.07	5.82	6.88	2.21	7.5	4.49	2.69	1.19	1.04	18.06	16.37	29.44	1.43	0.82	7.02	10.13	5.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	183.51
H2425_001_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		379.88	11.5	138.72	67.96	16.21	23.19	27.43	532.67	29.9	17.9	10.74	4.75	4.14	72	65.23	117.32	5.71	3.26	27.96	40.36	23.71	0	0	0	0	0	0	0	0	0	7.84											ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14B Immunizations. PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture. No member cost sharing for other services.											0.08	0.08	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0.24	0	0											29.83	0.9	23.36	-	3.82	5.47	6.47	2.22	7.06	4.22	2.53	1.12	0.98	16.99	15.39	27.69	1.35	0.77	6.6	9.52	5.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.9	126		29.83	0.9	23.36	-	3.82	5.47	6.47	2.22	7.06	4.22	2.53	1.12	0.98	16.99	15.39	27.69	1.35	0.77	6.6	9.52	5.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.9																																																																																				-			29.83	0.9	23.36	-	3.82	5.47	6.47	2.22	7.06	4.22	2.53	1.12	0.98	16.99	15.39	27.69	1.35	0.77	6.6	9.52	5.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.9
H2456_002_0	2007	7																																Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin						Coin																																																														-		1		1		1	1		1	1	1					1						1																																																														25.94		19.02		4.02	15.79		5.21	13.94	5.65					96.27						3.96																					25.94	-	19.02	-	4.02	15.79	-	5.21	13.94	5.65	-	-	-	-	96.27	-	-	-	-	-	3.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	189.81	0	0	25.94	-	19.02	-	4.02	15.79	-	5.21	13.94	5.65	-	-	-	-	96.27	-	-	-	-	-	3.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	189.81																																																																																				-	0	0	25.94	-	19.02	-	4.02	15.79	-	5.21	13.94	5.65	-	-	-	-	96.27	-	-	-	-	-	3.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	189.81
H2457_002_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		599.19		83.94	41.91	10.62	50.85		29.8	110.37	156.57					304.44							1.34																				same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare	same as Medicare											0.08		0.15	0	0.24	0.24		0.24	0.24	0.24					0.24							0.24																				45.54	-	12.57	-	2.51	12	-	7.03	26.05	36.95	-	-	-	-	71.85	-	-	-	-	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	214.81			45.54	-	12.57	-	2.51	12	-	7.03	26.05	36.95	-	-	-	-	71.85	-	-	-	-	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	214.81																																																																																				-			45.54	-	12.57	-	2.51	12	-	7.03	26.05	36.95	-	-	-	-	71.85	-	-	-	-	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	214.81
H2458_002_0	2007	3																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		265.31	18.26	110.82		10.37	9.88	0	0	0	0	0	0	3.54	402.48	24.39	343.49	8.84	3.14	0	0.02	11.26	4.45																				mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin		mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin	mcare ffs ded/coin																				0.08	0.08	0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.46	1.41	17.58	-	2.45	2.33	-	-	-	-	-	-	0.84	94.99	5.76	81.06	2.09	0.74	-	0	2.66	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	233.41	140		20.46	1.41	17.58	-	2.45	2.33	-	-	-	-	-	-	0.84	94.99	5.76	81.06	2.09	0.74	-	0	2.66	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	233.41																																																																																				-			20.46	1.41	17.58	-	2.45	2.33	-	-	-	-	-	-	0.84	94.99	5.76	81.06	2.09	0.74	-	0	2.66	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	233.41
H2459_001_0	2007	3																					3100											A	A	D		T	Coin		V	P	V	V			V		V	V	V		V									Coin																																																						-	0	295.49	4.96	395.59		194.54	11.09		151.06	475.22	1318.3	373.51			1617.47		1553.3	121.97	494.95		1081.73									1.51													250 Per Admit	250 Per Admit	50 days 21 to 100		100 per Trip	20 Coinsurance DME & Prosthetics & 10 for supplies.		50 per ER Visit	100 per Surgery/Procedure	25 per visit	25 per visit			25 per UC visit and 25 per OP Facility Other		25 per visit	25 per visit	25 per PT and ST visit		25 per podiatry visit and 15 per Medicare covered hearing and vision exams.									20 Coinsurance													249.25	249.25	49.85		99.7	0.2		49.85	99.7	24.93	24.93			24.93		24.93	24.93	24.93		16.52									0.2													6.14	0.1	1.64	-	1.62	2.17	-	0.63	3.95	2.74	0.78	-	-	3.36	-	3.23	0.25	1.03	-	1.49	-	-	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	29.42	0	0.09	6.14	0.1	1.64	-	1.62	2.17	-	0.63	3.95	2.74	0.78	-	-	3.36	-	3.23	0.25	1.03	-	1.49	-	-	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	29.42	3100																																																																																			-	0	0	6.14	0.1	1.64	-	1.62	2.17	-	0.63	3.95	2.74	0.78	-	-	3.36	-	3.23	0.25	1.03	-	1.49	-	-	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	29.42
H2459_002_0	2007	4																					3100											A	A			T	Coin		V						V		V	V	V		V									Coin																																																						-	0	360.69	6.06			237.46	13.54		184.39						125.38		1896.01	148.89	604.15		1320.41									2.58													100 Per Admit	100 Per Admit			100 per Trip	20 Coinsurance DME & 10 Prosthetics and Supplies		50 per Visit						20 per UC visit		10 per visit	10 per visit	10 per PT and ST visit		10 per Podiatry and Medicare covered hearing and vision exams									20 Coinsurance per													99.9	99.9			99.9	0.18		49.95						19.7		9.99	9.99	9.99		9.99									0.2													3	0.05	-	-	1.98	2.49	-	0.77	-	-	-	-	-	0.21	-	1.58	0.12	0.5	-	1.1	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	12.32	0	0.01	3	0.05	-	-	1.98	2.49	-	0.77	-	-	-	-	-	0.21	-	1.58	0.12	0.5	-	1.1	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	12.32	3100																																																																																			-	0	0	3	0.05	-	-	1.98	2.49	-	0.77	-	-	-	-	-	0.21	-	1.58	0.12	0.5	-	1.1	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	12.32
H2459_005_0	2007	3																					3100											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	P	P	Coin	P	T	P	V	P	V	P	Coin	P	P	P	P	P	P	P	P	P	P	P	P																																										-		251.14	6.94	953.01		69.28	6.49	8.04	286.8	281.5	1589.58	692.35	31.17		1622.39		2241.16	154.89	136.08							129.09		231.11		1.51													#1A 250	#1B 250	#2 0/day days 1-20 50/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20/10 #11C 0	#4A 50 #4B 25	#9A 50 #9B 50	#8A 25	#8A 25 #8B 25		#12 0	#3 0 #5 0 #9A 50 #9C 25 #9D 25	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 0 #7D 25 #7F 25 #7G 0	#7E 25 #7H 25	#7C 0 #7I 25		#14I 0	#15 0	#13A 0	#10B 0 n/c	#16A 0 n/c #16B 0 n/c	#16B 15	#17B 0 n/c	#18A 15	#18B 0 n/c	#19 20	#14A 0	#13B 0 n/c											250	250	14.1		100	0.2	0.2	39.99	100	25	25	25		24.84		21.76	25	25							15		15		0.2													5.23	0.14	1.12	-	0.58	1.3	1.61	0.96	2.35	3.31	1.44	0.06	-	3.36	-	4.06	0.32	0.28	-	-	-	-	-	-	0.16	-	0.29	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	26.88		0	5.23	0.14	1.12	-	0.58	1.3	1.61	0.96	2.35	3.31	1.44	0.06	-	3.36	-	4.06	0.32	0.28	-	-	-	-	-	-	0.16	-	0.29	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	26.88																																																																																				-		0	5.23	0.14	1.12	-	0.58	1.3	1.61	0.96	2.35	3.31	1.44	0.06	-	3.36	-	4.06	0.32	0.28	-	-	-	-	-	-	0.16	-	0.29	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	26.88
H2459_006_0	2007	6																					3100											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	P	P	Coin	P	T	P	V	P	V	P	Coin	P	P	P	P	P	P	P	P	P	P	P	P																																										-		307.94	8.5			84.95	7.88	9.76	351.54						241.75		3231.4	202.04	177.5							129.09		231.11		2.58													#1A 100	#1B 100	#2 0	#6 0	#10A 100	#11A 20	#11B 10 #11C 0	#4A 50 #4B 20	#9A 0 #9B 0	#8A 0	#8B 0		#12 0	#3 0 #5 0 #9A 0 #9C 0 #9D 0	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 0 #7D 10 #7F 10 #7G 0	#7E 10 #7H 10	#7C 0 #7I 10		#14I 0	#15 0	#13A 0	#10B 0 n/c	#16A 0 #16B 20/50	#17A 10	#17B 0	#18A 10/0	#18B 0	#19 20	#14A 0	#13B 0 n/c											100	100			100	0.2	0.1	37.99						9.51		10	10	10							10		10		0.2													2.57	0.07	-	-	0.71	1.58	0.98	1.11	-	-	-	-	-	0.19	-	2.69	0.17	0.15	-	-	-	-	-	-	0.11	-	0.19	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	11.03		0	2.57	0.07	-	-	0.71	1.58	0.98	1.11	-	-	-	-	-	0.19	-	2.69	0.17	0.15	-	-	-	-	-	-	0.11	-	0.19	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	11.03																																																																																				-		0	2.57	0.07	-	-	0.71	1.58	0.98	1.11	-	-	-	-	-	0.19	-	2.69	0.17	0.15	-	-	-	-	-	-	0.11	-	0.19	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	11.03
H2459_013_0	2007	4																					3100											A	A	D		T	Coin		V	P	V	V			V		V	V	V		V									Coin																																																						-	0	333.27	5.6	465.33		219.41	12.51		170.38	535.98	1486.85	421.27			1824.27		1751.9	137.57	558.23		1220.04									1.78													250 per Admit	250 per Admit	50 days 21 to 100		100 per Trip	20 Coinsurance DME & Prosthetics & 10 for supplies.		50 per ER Visit	100 per Surgery/Procedure	25 per visit	25 per visit			25 per UC visit and 25 per OP Facility Other		25 per visit	25 per visit	25 per PT and SP visit		25 per podiatry visit and 15 per Medicare covered hearing and vision exams.									20 Coinsurance													249.25	249.25	49.85		99.7	0.2		49.85	99.7	24.93	24.93			24.93		24.93	24.93	24.93		16.52									0.2													6.92	0.12	1.93	-	1.82	2.44	-	0.71	4.45	3.09	0.88	-	-	3.79	-	3.64	0.29	1.16	-	1.68	-	-	-	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	33.27	0	0.1	6.92	0.12	1.93	-	1.82	2.44	-	0.71	4.45	3.09	0.88	-	-	3.79	-	3.64	0.29	1.16	-	1.68	-	-	-	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	33.27	3100																																																																																			-	0	0	6.92	0.12	1.93	-	1.82	2.44	-	0.71	4.45	3.09	0.88	-	-	3.79	-	3.64	0.29	1.16	-	1.68	-	-	-	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	33.27
H2459_014_0	2007	6																					3100											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	P	P	Coin	P	T	P	V	P	V	P	Coin	P	P	P	P	P	P	P	P	P	P	P	P																																										-		305.79	8.44	1160.37		84.36	7.89	9.78	349.08	342.75	1935.44	842.99	37.95		1975.39		2728.79	188.59	165.69							129.09		231.11		1.78													#1A 250	#1B 250	#2 0/day days 1-20 50/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20/10 #11C 0	#4A 50 #4B 25	#9A 100 #9B 50	#8A 25	#8A 25 #8B 25		#12 0	#3 0 #5 0 #9A 100 #9C 25 #9D 25	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 0 #7D 25 #7F 25 #7G 0	#7E 25 #7H 25	#7C 0 #7I 25		#14I 0	#15 0	#13A 0	#10B 0 n/c	#16A 0 n/c #16B 0 n/c	#16B 15	#17B 0 n/c	#18A 15	#18B 0 n/c	#19 20	#14A 0	#13B 0 n/c											250	250	14.1		100	0.2	0.2	40	100	25	25	25		24.84		21.76	25	25							15		15		0.2													6.37	0.18	1.36	-	0.7	1.58	1.96	1.16	2.86	4.03	1.76	0.08	-	4.09	-	4.95	0.39	0.35	-	-	-	-	-	-	0.16	-	0.29	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	32.62		0	6.37	0.18	1.36	-	0.7	1.58	1.96	1.16	2.86	4.03	1.76	0.08	-	4.09	-	4.95	0.39	0.35	-	-	-	-	-	-	0.16	-	0.29	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	32.62																																																																																				-		0	6.37	0.18	1.36	-	0.7	1.58	1.96	1.16	2.86	4.03	1.76	0.08	-	4.09	-	4.95	0.39	0.35	-	-	-	-	-	-	0.16	-	0.29	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	32.62
H2459_016_0	2007	6																																Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin						Coin																																																														-		1		1		1	1		1	1	1					1						1																																																														34.77		23.3		5.27	24.28		6.49	19.45	7.15					101.64						7.56																					34.77	-	23.3	-	5.27	24.28	-	6.49	19.45	7.15	-	-	-	-	101.64	-	-	-	-	-	7.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	229.92	0	0	34.77	-	23.3	-	5.27	24.28	-	6.49	19.45	7.15	-	-	-	-	101.64	-	-	-	-	-	7.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	229.92																																																																																				-	0	0	34.77	-	23.3	-	5.27	24.28	-	6.49	19.45	7.15	-	-	-	-	101.64	-	-	-	-	-	7.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	229.92
H2459_801_0	2007	1																					3100											A	A	D		T	Coin		V	P	V	V			V	V	V	V	V		V									Coin																																																						-	0	183.66	2.7	295.14		160.32	10.7		173.94	730.91	1409.7	464.44			2373.71	2279.28	2267.45	203.73	932.97		1363.99									3.89													250 per Admission	250 per Admission	50 days 21 to 100		100 per Trip	20 Coinsurance DME & Prosthetics and 10 supplies		50 per Visit	100 per surgery/procedure	25 per visit	25 per visit			25 per UC visit	25 per visit	25 per visit	25 per visit	25 per PT and ST visit		25 per podiatry visit and 15 per Medicare hearing and vision.									20 Coinsurance													249.25	249.25	49.85		99.7	0.2		49.85	99.7	24.93	24.93			24.93	24.93	24.93	24.93	24.93		15.72									0.2													3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51	0	0.12	3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51	3100																																																																																			-	0	0	3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51
H2459_802_0	2007	1																					3100											A	A	D		T	Coin		V	P	V	V			V	V	V	V	V		V									Coin																																																						-	0	183.66	2.7	295.14		160.32	10.7		173.94	730.91	1409.7	464.44			2373.71	2279.28	2267.45	203.73	932.97		1363.99									3.89													250 per Admission	250 per Admission	50 days 21 to 100		100 per Trip	20 Coinsurance DME & Prosthetics and 10 supplies		50 per Visit	100 per surgery/procedure	25 per visit	25 per visit			25 per UC visit	25 per visit	25 per visit	25 per visit	25 per PT and ST visit		25 per podiatry visit and 15 per Medicare hearing and vision.									20 Coinsurance													249.25	249.25	49.85		99.7	0.2		49.85	99.7	24.93	24.93			24.93	24.93	24.93	24.93	24.93		15.72									0.2													3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51	0	0.12	3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51	3100																																																																																			-	0	0	3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51
H2459_803_0	2007	1																					3100											A	A	D		T	Coin		V	P	V	V			V	V	V	V	V		V									Coin																																																						-	0	183.66	2.7	295.14		160.32	10.7		173.94	730.91	1409.7	464.44			2373.71	2279.28	2267.45	203.73	932.97		1363.99									3.89													250 per Admission	250 per Admission	50 days 21 to 100		100 per Trip	20 Coinsurance DME & Prosthetics and 10 supplies		50 per Visit	100 per surgery/procedure	25 per visit	25 per visit			25 per UC visit	25 per visit	25 per visit	25 per visit	25 per PT and ST visit		25 per podiatry visit and 15 per Medicare hearing and vision.									20 Coinsurance													249.25	249.25	49.85		99.7	0.2		49.85	99.7	24.93	24.93			24.93	24.93	24.93	24.93	24.93		15.72									0.2													3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51	0	0.12	3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51	3100																																																																																			-	0	0	3.81	0.06	1.23	-	1.33	2.09	-	0.72	6.07	2.93	0.96	-	-	4.93	4.73	4.71	0.42	1.94	-	1.79	-	-	-	-	-	-	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	38.51
H2610_005_0	2007	4																					900											D	D	D	V	P	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	V	Coin	V	T	V	V	P	V	V	V	V	V																																																				-		925.76	45.64	541.5		320.25	6.13	2.45	241.61	264.63	2.13	15.74	43.77	0	919.26	5814.14	3560.2	55.99	1236.03			19.65			774.03	129.97	296	232.59															1a: 150	1b: 275	2: 100 days 4-13	6:00	10a: 150	11a: 20	11b 11c: 20	4a: 50 4b: 25	9b: 200	8a: 20	8b: 20 / 15	9a:  20	12:20	9a:  20	7a 14c: 5 14b 14d 14e 14f 14g 14h 14i:  0	7b 7d 7f 17a 18a:  20;  16b: 0	7e 7h: 25/35	7b 7c 7i: 20	0 (incl in i.2.)	7g: 20	15:20	13a: 0; 17b: 20 up to 100	10b: 0	16a: 20	17a: 20	17b: 20	18a: 25	18b: 0		14a:  0												79.64	146.01	20.31		83.26	0.1	0.09	25.81	106.19	0.11	0.2	93.5	0.11	35.23	5	19.44	30	20			0.2			20	20	20	20															6.14	0.56	0.92	-	2.22	0.59	0.23	0.52	2.34	0.23	3.07	0.34	0	2.7	2.42	5.77	0.14	2.06	-	-	3.93	-	-	1.29	0.22	0.49	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.57		14.2	6.14	0.56	0.92	-	2.22	0.59	0.23	0.52	2.34	0.23	3.07	0.34	0	2.7	2.42	5.77	0.14	2.06	-	-	3.93	-	-	1.29	0.22	0.49	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.57																																																																																				-		0	6.14	0.56	0.92	-	2.22	0.59	0.23	0.52	2.34	0.23	3.07	0.34	0	2.7	2.42	5.77	0.14	2.06	-	-	3.93	-	-	1.29	0.22	0.49	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.57
H2610_006_0	2007	4																					600											D	D	D	V	P	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	V	Coin	V	T	V	V	P	V	V	V	V	V																																																				-		942.15	46.51	555.74		335.45	6.56	2.68	246.78	270.14	2.06	16.22	44.78	0	931.82	6117.55	3754.75	58.51	1294.75			20.83			774.03	129.98	296	232.59															1a: 150	1b: 275	2: 100 days 4-13	6:00	10a: 150	11a: 20	11b 11c: 20	4a: 50 4b: 20	9b: 200	8a: 20	8b: 20 / 15	9a:  200	12:20	9a:  200	7a 14c: 5 14b 14d 14e 14f 14g 14h 14i:  0	7b 7d 7f 17a 18a:  20;  16b: 0	7e 7h: 25/35	7b 7c 7i: 20	0 (incl in i.2.)	7g: 20	15:20	13a: 0; 17b: 20 up to 100	10b: 0	16a: 20	17a: 20	17b: 20	18a: 25	18b: 0		14a:  0												41.33	113.65	15.81		66.51	0.07	0.07	19.96	82.65	0.09	0.2	82.65	0.08	57.18	5	14.96	30	15			0.2			20	20	20	20															3.24	0.44	0.73	-	1.86	0.49	0.2	0.41	1.86	0.18	3.18	0.31	0	4.44	2.55	4.68	0.15	1.62	-	-	4.17	-	-	1.29	0.22	0.49	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.89		19.22	3.24	0.44	0.73	-	1.86	0.49	0.2	0.41	1.86	0.18	3.18	0.31	0	4.44	2.55	4.68	0.15	1.62	-	-	4.17	-	-	1.29	0.22	0.49	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.89																																																																																				-		0	3.24	0.44	0.73	-	1.86	0.49	0.2	0.41	1.86	0.18	3.18	0.31	0	4.44	2.55	4.68	0.15	1.62	-	-	4.17	-	-	1.29	0.22	0.49	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.89
H2610_803_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		199.43	1.78	16.24		4.98	6.53	2.61	8.12	22.79	19.13	16.77	3.42	0	28.03	38.2	31.77	0.26	3.05	30.63	106.96	25.87	0.02																				Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing																				0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.05	0.13	3.11	-	1.17	1.54	0.62	1.92	5.38	4.51	3.96	0.81	0	6.61	9.02	7.67	0.06	0.72	7.23	25.24	6.11	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.86	138		15.05	0.13	3.11	-	1.17	1.54	0.62	1.92	5.38	4.51	3.96	0.81	0	6.61	9.02	7.67	0.06	0.72	7.23	25.24	6.11	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.86																																																																																				-		0	15.05	0.13	3.11	-	1.17	1.54	0.62	1.92	5.38	4.51	3.96	0.81	0	6.61	9.02	7.67	0.06	0.72	7.23	25.24	6.11	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.86
H2611_001_0	2007	7	h.6.										OP Facility - Other										None	Other Coin										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	V	Coin	Coin	Coin	P	P	P	P	P	Coin	Coin	Coin	Coin										35.6	1.68	0.82	1.41	0.8	1.26	0.53	1.59	1.69	0.85	0.16	0.28	0	0.72	0	1.91	0.21	0	5.74	20.67	0.52	0	0.02	0	0.05	0	0.01	0	0	0	0	1.08										77.6	None	532.5	20.35	30.57	12.09	448.67	10.78	4.51	2647.21	357.63	5599.64	1.38	2.42	0	701.47	3658.93	2972.15	263.28	0	49.18	28179.43	33.9	0	9.95	0	44.26	0	15.55	0	0	0	0	9.27										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	30 Copay PBP Section B: #7D	30 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	30 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	30 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	30 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	0.73	15	30	30	0	0.1	1.38	0.2	0	0	0	30	0	30	0	0	0	0	0										-	-	-	-	-	-	-	1.32	-	-	0.28	-	-	0.04	4.57	7.43	0.66	-	4.67	3.25	6.78	-	-	-	0.11	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.16	1200	0	35.6	1.68	0.82	1.41	0.8	1.26	0.53	2.91	1.69	0.85	0.44	0.28	-	0.76	4.57	9.34	0.87	-	10.42	23.92	7.3	-	0.02	-	0.16	-	0.05	-	-	-	-	1.08	-	-	-	-	-	-	-	-	-	106.76	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										2.61	0.14	0.07	0.12	0.01	0.1	0.04	0.02	0.02	0.07	0.01	0.02	0	0.06	0.2	0.16	0.02	0	0.24	1.69	0.32	0	0	0	0	0	0	0	0	0	0	0.09										6.02	1200	0	38.22	1.82	0.89	1.53	0.81	1.36	0.57	2.93	1.71	0.92	0.45	0.31	-	0.82	4.77	9.5	0.88	-	10.66	25.61	7.62	-	0.02	-	0.16	-	0.05	-	-	-	-	1.17	-	-	-	-	-	-	-	-	-	112.78
H2611_002_0	2007	7	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										32.56	2.29	0.6	1.35	0.95	1.62	3.41	3.34	0.6	0.23	0.19	0.28	0	3.15	0	1.36	0.16	0	8.42	25.11	2.72	0	0.37	0	0.01	0	0	0	0	0	0	0.94										89.66	None	358.66	19.95	27	9.01	283.83	10.88	22.87	3714.03	54.79	857.32	1.27	1.9	0	1673.58	4343.68	2110.79	149.36	0	56.39	31917.43	24.77	0	125.28	0	2.68	0	0	0	0	0	0	6.33										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	25 Copay PBP Section B: #7A	30 Copay PBP Section B: #7D	30 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	30 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	30 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	30 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	25	30	30	0	0.1	0.46	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.86	-	-	0.25	-	-	0.15	9.05	5.28	0.37	-	5.63	1.22	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.76	1475	0	32.56	2.29	0.6	1.35	0.95	1.62	3.41	5.2	0.6	0.23	0.44	0.28	-	3.3	9.05	6.64	0.53	-	14.04	26.33	7.67	-	0.37	-	0.01	-	-	-	-	-	-	0.94	-	-	-	-	-	-	-	-	-	118.42	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.85	0.15	0.04	0.09	0.01	0.1	0.22	0.03	0.01	0.01	0.01	0.02	0	0.2	0.2	0.09	0.01	0	0.29	1.59	0.23	0	0.02	0	0	0	0	0	0	0	0	0.06										5.21	1475	0	34.4	2.43	0.63	1.43	0.96	1.73	3.63	5.22	0.62	0.24	0.45	0.3	-	3.5	9.24	6.72	0.54	-	14.33	27.93	7.91	-	0.39	-	0.01	-	-	-	-	-	-	1	-	-	-	-	-	-	-	-	-	123.63
H2611_003_0	2007	7	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										31.6	2.22	0.58	1.31	0.93	1.58	3.31	3.24	0.58	0.22	0.18	0.28	0	3.06	0	1.32	0.15	0	8.17	24.42	2.64	0	0.36	0	0.01	0	0	0	0	0	0	0.92										87.08	None	333.55	18.56	25.11	8.38	263.97	10.12	21.27	3454.05	50.95	797.31	1.18	1.77	0	1556.43	4080.84	1963.03	138.91	0	52.47	29817.76	23.03	0	116.51	0	2.49	0	0	0	0	0	0	5.88										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	20 Copay PBP Section B: #7A	30 Copay PBP Section B: #7D	30 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	30 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	30 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	30 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	20	30	30	0	0.1	0.46	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.73	-	-	0.24	-	-	0.14	6.8	4.91	0.35	-	5.24	1.13	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.14	1450	0	31.6	2.22	0.58	1.31	0.93	1.58	3.31	4.97	0.58	0.22	0.42	0.28	-	3.2	6.8	6.23	0.5	-	13.41	25.55	7.25	-	0.36	-	0.01	-	-	-	-	-	-	0.92	-	-	-	-	-	-	-	-	-	112.21	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.72	0.14	0.04	0.08	0.01	0.1	0.2	0.02	0.01	0.01	0.01	0.02	0	0.18	0.18	0.08	0.01	0	0.27	1.48	0.22	0	0.02	0	0	0	0	0	0	0	0	0.06										4.85	1450	0	33.32	2.36	0.61	1.39	0.93	1.67	3.52	4.99	0.6	0.24	0.43	0.29	-	3.38	6.98	6.31	0.51	-	13.68	27.03	7.46	-	0.38	-	0.01	-	-	-	-	-	-	0.97	-	-	-	-	-	-	-	-	-	117.07
H2611_004_0	2007	3	h.6.										OP Facility - Other										None	Other Coin										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	V	Coin	Coin	Coin	P	P	P	P	P	Coin	Coin	Coin	Coin										30.45	1.44	0.7	1.21	0.69	1.08	0.45	1.36	1.44	0.73	0.14	0.24	0	0.62	0	1.67	0.18	0	5.04	17.91	0.44	0	0.02	0	0.04	0	0.01	0	0	0	0	0.93										66.77	None	532.5	20.35	30.57	12.09	448.67	10.78	4.51	2647.21	357.63	5599.64	1.38	2.42	0	701.47	3695.52	3035.39	263.28	0	50.49	28483.8	33.9	0	9.95	0	44.26	0	15.55	0	0	0	0	9.27										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	10 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	0.73	10	25	25	0	0.1	1.14	0.2	0	0	0	25	0	25	0	0	0	0	0										-	-	-	-	-	-	-	1.32	-	-	0.28	-	-	0.04	3.08	6.32	0.55	-	4.8	2.71	6.78	-	-	-	0.09	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.01	1000	0	30.45	1.44	0.7	1.21	0.69	1.08	0.45	2.68	1.44	0.73	0.41	0.24	-	0.66	3.08	7.99	0.73	-	9.84	20.62	7.22	-	0.02	-	0.13	-	0.04	-	-	-	-	0.93	-	-	-	-	-	-	-	-	-	92.78	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										2.61	0.14	0.07	0.12	0.01	0.1	0.04	0.02	0.02	0.07	0.01	0.02	0	0.06	0.2	0.16	0.02	0	0.25	1.71	0.32	0	0	0	0	0	0	0	0	0	0	0.09										6.05	1000	0	33.06	1.57	0.77	1.32	0.69	1.18	0.49	2.7	1.47	0.8	0.43	0.26	-	0.71	3.28	8.15	0.74	-	10.09	22.33	7.55	-	0.02	-	0.13	-	0.04	-	-	-	-	1.01	-	-	-	-	-	-	-	-	-	98.82
H2611_005_0	2007	4	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										30.78	2.16	0.56	1.27	0.9	1.54	3.23	3.16	0.57	0.22	0.18	0.27	0	2.98	0	1.29	0.15	0	7.97	23.82	2.57	0	0.35	0	0.01	0	0	0	0	0	0	0.89										84.85	None	358.66	19.95	27	9.65	283.83	11.64	24.47	3714.03	54.79	857.32	1.35	2.03	0	1673.58	4432.33	2110.79	149.36	0	60.41	32206.79	26.5	0	125.28	0	2.68	0	0	0	0	0	0	6.77										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	30	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.86	-	-	0.27	-	-	0.15	5.54	5.28	0.31	-	6.03	1.01	5.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.75	1350	0	30.78	2.16	0.56	1.27	0.9	1.54	3.23	5.02	0.57	0.22	0.45	0.27	-	3.13	5.54	6.56	0.46	-	14	24.83	7.87	-	0.35	-	0.01	-	-	-	-	-	-	0.89	-	-	-	-	-	-	-	-	-	110.61	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.98	0.16	0.04	0.09	0.01	0.11	0.23	0.03	0.02	0.02	0.01	0.02	0	0.21	0.21	0.09	0.01	0	0.31	1.71	0.25	0	0.02	0	0	0	0	0	0	0	0	0.06										5.59	1350	0	32.75	2.32	0.6	1.36	0.91	1.65	3.46	5.04	0.58	0.23	0.46	0.29	-	3.34	5.75	6.66	0.47	-	14.31	26.55	8.12	-	0.37	-	0.01	-	-	-	-	-	-	0.96	-	-	-	-	-	-	-	-	-	116.2
H2611_006_0	2007	4	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										32.47	2.28	0.59	1.34	0.95	1.62	3.4	3.33	0.6	0.23	0.19	0.28	0	3.14	0	1.39	0.16	0	8.62	25.4	2.71	0	0.37	0	0.01	0	0	0	0	0	0	0.94										90.03	None	333.55	18.56	25.11	9.12	263.97	11.01	23.13	3454.05	50.95	797.31	1.28	1.92	0	1556.43	4122.07	2004.8	138.91	0	58.54	30127.73	25.05	0	116.51	0	2.49	0	0	0	0	0	0	6.4										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	25	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.73	-	-	0.26	-	-	0.14	5.15	4.18	0.29	-	5.65	0.94	5.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.34	1475	0	32.47	2.28	0.59	1.34	0.95	1.62	3.4	5.06	0.6	0.23	0.44	0.28	-	3.28	5.15	5.56	0.45	-	14.26	26.35	7.72	-	0.37	-	0.01	-	-	-	-	-	-	0.94	-	-	-	-	-	-	-	-	-	113.37	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.87	0.15	0.04	0.09	0.01	0.1	0.22	0.03	0.01	0.01	0.01	0.02	0	0.2	0.2	0.09	0.01	0	0.3	1.64	0.24	0	0.02	0	0	0	0	0	0	0	0	0.06										5.31	1475	0	34.34	2.43	0.63	1.43	0.96	1.72	3.62	5.09	0.61	0.24	0.46	0.3	-	3.48	5.35	5.65	0.46	-	14.56	27.98	7.96	-	0.39	-	0.01	-	-	-	-	-	-	1	-	-	-	-	-	-	-	-	-	118.68
H2611_007_0	2007	7	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										32.56	2.29	0.6	1.35	0.95	1.62	3.41	3.34	0.6	0.23	0.19	0.28	0	3.15	0	1.36	0.16	0	8.42	25.11	2.72	0	0.37	0	0.01	0	0	0	0	0	0	0.94										89.66	None	358.66	19.95	27	9.01	283.83	10.88	22.87	3714.03	54.79	857.32	1.27	1.9	0	1673.58	4343.68	2110.79	149.36	0	56.39	31917.43	24.77	0	125.28	0	2.68	0	0	0	0	0	0	6.33										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	25 Copay PBP Section B: #7A	30 Copay PBP Section B: #7D	30 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	30 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	30 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	30 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	25	30	30	0	0.1	0.46	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.86	-	-	0.25	-	-	0.15	9.05	5.28	0.37	-	5.63	1.22	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.76	1475	0	32.56	2.29	0.6	1.35	0.95	1.62	3.41	5.2	0.6	0.23	0.44	0.28	-	3.3	9.05	6.64	0.53	-	14.04	26.33	7.67	-	0.37	-	0.01	-	-	-	-	-	-	0.94	-	-	-	-	-	-	-	-	-	118.42	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.85	0.15	0.04	0.09	0.01	0.1	0.22	0.03	0.01	0.01	0.01	0.02	0	0.2	0.2	0.09	0.01	0	0.29	1.59	0.23	0	0.02	0	0	0	0	0	0	0	0	0.06										5.21	1475	0	34.4	2.43	0.63	1.43	0.96	1.73	3.63	5.22	0.62	0.24	0.45	0.3	-	3.5	9.24	6.72	0.54	-	14.33	27.93	7.91	-	0.39	-	0.01	-	-	-	-	-	-	1	-	-	-	-	-	-	-	-	-	123.63
H2611_801_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	V	Coin	Coin	Coin	P	P	P	P	P	Coin	Coin	Coin	Coin										7.72	0.36	0.18	0.31	0.17	0.27	0.11	0.34	0.37	0.18	0.04	0.06	0	0.16	0	0.42	0.05	0	1.28	4.53	0.11	0	0	0	0.01	0	0	0	0	0	0	0.23										16.92	None	532.5	20.35	30.57	12.09	448.67	10.78	4.51	2647.21	357.63	5599.64	1.38	2.42	0	701.47	3658.93	3035.39	263.28	0	50.48	28426.97	33.9	0	9.95	0	44.26	0	15.55	0	0	0	0	9.27										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	0.73	15	25	25	0	0.1	1.14	0.2	0	0	0	25	0	25	0	0	0	0	0										-	-	-	-	-	-	-	1.32	-	-	0.28	-	-	0.04	4.57	6.32	0.55	-	4.8	2.71	6.78	-	-	-	0.09	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.5	225	0	7.72	0.36	0.18	0.31	0.17	0.27	0.11	1.67	0.37	0.18	0.31	0.06	-	0.2	4.57	6.75	0.59	-	6.08	7.24	6.89	-	0	-	0.1	-	0.03	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	44.42	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										2.61	0.14	0.07	0.12	0.01	0.1	0.04	0.02	0.02	0.07	0.01	0.02	0	0.06	0.2	0.16	0.02	0	0.25	1.71	0.32	0	0	0	0	0	0	0	0	0	0	0.09										6.05	225	0	10.33	0.5	0.24	0.42	0.18	0.38	0.16	1.68	0.39	0.25	0.32	0.08	-	0.26	4.77	6.91	0.61	-	6.33	8.96	7.22	-	0.01	-	0.11	-	0.03	-	-	-	-	0.32	-	-	-	-	-	-	-	-	-	50.47
H2611_802_0	2007	2	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.56	1.23	0.32	0.73	0.52	0.88	1.84	1.8	0.32	0.12	0.1	0.15	0	1.7	0	0.73	0.09	0	4.55	13.59	1.47	0	0.2	0	0	0	0	0	0	0	0	0.51										48.42	None	358.66	19.95	27	9.01	283.83	10.88	22.87	3714.03	54.79	857.32	1.27	1.9	0	1673.58	4432.33	2110.79	149.36	0	56.46	32206.79	24.77	0	125.28	0	2.68	0	0	0	0	0	0	6.33										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	30	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.86	-	-	0.25	-	-	0.15	5.54	5.28	0.31	-	5.64	1.01	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25	700	0	17.56	1.23	0.32	0.73	0.52	0.88	1.84	3.66	0.32	0.12	0.36	0.15	-	1.85	5.54	6.01	0.4	-	10.18	14.61	6.42	-	0.2	-	0	-	-	-	-	-	-	0.51	-	-	-	-	-	-	-	-	-	73.41	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.85	0.15	0.04	0.09	0.01	0.1	0.22	0.03	0.01	0.01	0.01	0.02	0	0.2	0.2	0.09	0.01	0	0.29	1.6	0.23	0	0.02	0	0	0	0	0	0	0	0	0.06										5.22	700	0	19.41	1.38	0.36	0.81	0.52	0.98	2.06	3.68	0.34	0.14	0.37	0.17	-	2.05	5.74	6.1	0.41	-	10.47	16.2	6.65	-	0.22	-	0	-	-	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	78.63
H2611_803_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.31	1.22	0.32	0.72	0.51	0.86	1.81	1.78	0.32	0.12	0.1	0.15	0	1.68	0	0.74	0.08	0	4.59	13.54	1.45	0	0.2	0	0	0	0	0	0	0	0	0.5										48	None	333.55	18.56	25.11	8.38	263.97	10.12	21.27	3454.05	50.95	797.31	1.18	1.77	0	1556.43	4122.07	2004.8	138.91	0	53.83	30127.73	23.03	0	116.51	0	2.49	0	0	0	0	0	0	5.88										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	25	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.73	-	-	0.24	-	-	0.14	5.15	4.18	0.29	-	5.19	0.94	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.46	700	0	17.31	1.22	0.32	0.72	0.51	0.86	1.81	3.5	0.32	0.12	0.34	0.15	-	1.82	5.15	4.92	0.37	-	9.79	14.49	6.05	-	0.2	-	0	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	70.46	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.72	0.14	0.04	0.08	0.01	0.1	0.2	0.02	0.01	0.01	0.01	0.02	0	0.18	0.19	0.08	0.01	0	0.27	1.5	0.22	0	0.02	0	0	0	0	0	0	0	0	0.06										4.88	700	0	19.03	1.35	0.35	0.79	0.51	0.96	2.02	3.53	0.33	0.14	0.35	0.17	-	2	5.34	5	0.38	-	10.06	15.99	6.27	-	0.22	-	0	-	-	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	75.34
H2611_804_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	V	Coin	Coin	Coin	P	P	P	P	P	Coin	Coin	Coin	Coin										7.72	0.36	0.18	0.31	0.17	0.27	0.11	0.34	0.37	0.18	0.04	0.06	0	0.16	0	0.42	0.05	0	1.28	4.53	0.11	0	0	0	0.01	0	0	0	0	0	0	0.23										16.92	None	532.5	20.35	30.57	12.09	448.67	10.78	4.51	2647.21	357.63	5599.64	1.38	2.42	0	701.47	3658.93	3035.39	263.28	0	50.48	28426.97	33.9	0	9.95	0	44.26	0	15.55	0	0	0	0	9.27										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	0.73	15	25	25	0	0.1	1.14	0.2	0	0	0	25	0	25	0	0	0	0	0										-	-	-	-	-	-	-	1.32	-	-	0.28	-	-	0.04	4.57	6.32	0.55	-	4.8	2.71	6.78	-	-	-	0.09	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.5	225	0	7.72	0.36	0.18	0.31	0.17	0.27	0.11	1.67	0.37	0.18	0.31	0.06	-	0.2	4.57	6.75	0.59	-	6.08	7.24	6.89	-	0	-	0.1	-	0.03	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	44.42	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										2.61	0.14	0.07	0.12	0.01	0.1	0.04	0.02	0.02	0.07	0.01	0.02	0	0.06	0.2	0.16	0.02	0	0.25	1.71	0.32	0	0	0	0	0	0	0	0	0	0	0.09										6.05	225	0	10.33	0.5	0.24	0.42	0.18	0.38	0.16	1.68	0.39	0.25	0.32	0.08	-	0.26	4.77	6.91	0.61	-	6.33	8.96	7.22	-	0.01	-	0.11	-	0.03	-	-	-	-	0.32	-	-	-	-	-	-	-	-	-	50.47
H2611_805_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.56	1.23	0.32	0.73	0.52	0.88	1.84	1.8	0.32	0.12	0.1	0.15	0	1.7	0	0.73	0.09	0	4.55	13.59	1.47	0	0.2	0	0	0	0	0	0	0	0	0.51										48.42	None	358.66	19.95	27	9.01	283.83	10.88	22.87	3714.03	54.79	857.32	1.27	1.9	0	1673.58	4432.33	2110.79	149.36	0	56.46	32206.79	24.77	0	125.28	0	2.68	0	0	0	0	0	0	6.33										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	30	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.86	-	-	0.25	-	-	0.15	5.54	5.28	0.31	-	5.64	1.01	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25	700	0	17.56	1.23	0.32	0.73	0.52	0.88	1.84	3.66	0.32	0.12	0.36	0.15	-	1.85	5.54	6.01	0.4	-	10.18	14.61	6.42	-	0.2	-	0	-	-	-	-	-	-	0.51	-	-	-	-	-	-	-	-	-	73.41	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.85	0.15	0.04	0.09	0.01	0.1	0.22	0.03	0.01	0.01	0.01	0.02	0	0.2	0.2	0.09	0.01	0	0.29	1.6	0.23	0	0.02	0	0	0	0	0	0	0	0	0.06										5.22	700	0	19.41	1.38	0.36	0.81	0.52	0.98	2.06	3.68	0.34	0.14	0.37	0.17	-	2.05	5.74	6.1	0.41	-	10.47	16.2	6.65	-	0.22	-	0	-	-	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	78.63
H2611_806_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.31	1.22	0.32	0.72	0.51	0.86	1.81	1.78	0.32	0.12	0.1	0.15	0	1.68	0	0.74	0.08	0	4.59	13.54	1.45	0	0.2	0	0	0	0	0	0	0	0	0.5										48	None	333.55	18.56	25.11	8.38	263.97	10.12	21.27	3454.05	50.95	797.31	1.18	1.77	0	1556.43	4122.07	2004.8	138.91	0	53.83	30127.73	23.03	0	116.51	0	2.49	0	0	0	0	0	0	5.88										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	25	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.73	-	-	0.24	-	-	0.14	5.15	4.18	0.29	-	5.19	0.94	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.46	700	0	17.31	1.22	0.32	0.72	0.51	0.86	1.81	3.5	0.32	0.12	0.34	0.15	-	1.82	5.15	4.92	0.37	-	9.79	14.49	6.05	-	0.2	-	0	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	70.46	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.72	0.14	0.04	0.08	0.01	0.1	0.2	0.02	0.01	0.01	0.01	0.02	0	0.18	0.19	0.08	0.01	0	0.27	1.5	0.22	0	0.02	0	0	0	0	0	0	0	0	0.06										4.88	700	0	19.03	1.35	0.35	0.79	0.51	0.96	2.02	3.53	0.33	0.14	0.35	0.17	-	2	5.34	5	0.38	-	10.06	15.99	6.27	-	0.22	-	0	-	-	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	75.34
H2611_807_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	V	Coin	Coin	Coin	P	P	P	P	P	Coin	Coin	Coin	Coin										7.72	0.36	0.18	0.31	0.17	0.27	0.11	0.34	0.37	0.18	0.04	0.06	0	0.16	0	0.42	0.05	0	1.28	4.53	0.11	0	0	0	0.01	0	0	0	0	0	0	0.23										16.92	None	532.5	20.35	30.57	12.09	448.67	10.78	4.51	2647.21	357.63	5599.64	1.38	2.42	0	701.47	3658.93	3035.39	263.28	0	50.48	28426.97	33.9	0	9.95	0	44.26	0	15.55	0	0	0	0	9.27										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	0.73	15	25	25	0	0.1	1.14	0.2	0	0	0	25	0	25	0	0	0	0	0										-	-	-	-	-	-	-	1.32	-	-	0.28	-	-	0.04	4.57	6.32	0.55	-	4.8	2.71	6.78	-	-	-	0.09	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.5	225	0	7.72	0.36	0.18	0.31	0.17	0.27	0.11	1.67	0.37	0.18	0.31	0.06	-	0.2	4.57	6.75	0.59	-	6.08	7.24	6.89	-	0	-	0.1	-	0.03	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	44.42	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										2.61	0.14	0.07	0.12	0.01	0.1	0.04	0.02	0.02	0.07	0.01	0.02	0	0.06	0.2	0.16	0.02	0	0.25	1.71	0.32	0	0	0	0	0	0	0	0	0	0	0.09										6.05	225	0	10.33	0.5	0.24	0.42	0.18	0.38	0.16	1.68	0.39	0.25	0.32	0.08	-	0.26	4.77	6.91	0.61	-	6.33	8.96	7.22	-	0.01	-	0.11	-	0.03	-	-	-	-	0.32	-	-	-	-	-	-	-	-	-	50.47
H2611_808_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	V	Coin	Coin	Coin	P	P	P	P	P	Coin	Coin	Coin	Coin										7.72	0.36	0.18	0.31	0.17	0.27	0.11	0.34	0.37	0.18	0.04	0.06	0	0.16	0	0.42	0.05	0	1.28	4.53	0.11	0	0	0	0.01	0	0	0	0	0	0	0.23										16.92	None	532.5	20.35	30.57	12.09	448.67	10.78	4.51	2647.21	357.63	5599.64	1.38	2.42	0	701.47	3658.93	3035.39	263.28	0	50.48	28426.97	33.9	0	9.95	0	44.26	0	15.55	0	0	0	0	9.27										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	0.73	15	25	25	0	0.1	1.14	0.2	0	0	0	25	0	25	0	0	0	0	0										-	-	-	-	-	-	-	1.32	-	-	0.28	-	-	0.04	4.57	6.32	0.55	-	4.8	2.71	6.78	-	-	-	0.09	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.5	225	0	7.72	0.36	0.18	0.31	0.17	0.27	0.11	1.67	0.37	0.18	0.31	0.06	-	0.2	4.57	6.75	0.59	-	6.08	7.24	6.89	-	0	-	0.1	-	0.03	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	44.42	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										2.61	0.14	0.07	0.12	0.01	0.1	0.04	0.02	0.02	0.07	0.01	0.02	0	0.06	0.2	0.16	0.02	0	0.25	1.71	0.32	0	0	0	0	0	0	0	0	0	0	0.09										6.05	225	0	10.33	0.5	0.24	0.42	0.18	0.38	0.16	1.68	0.39	0.25	0.32	0.08	-	0.26	4.77	6.91	0.61	-	6.33	8.96	7.22	-	0.01	-	0.11	-	0.03	-	-	-	-	0.32	-	-	-	-	-	-	-	-	-	50.47
H2611_809_0	2007	2	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.56	1.23	0.32	0.73	0.52	0.88	1.84	1.8	0.32	0.12	0.1	0.15	0	1.7	0	0.73	0.09	0	4.55	13.59	1.47	0	0.2	0	0	0	0	0	0	0	0	0.51										48.42	None	358.66	19.95	27	9.01	283.83	10.88	22.87	3714.03	54.79	857.32	1.27	1.9	0	1673.58	4432.33	2110.79	149.36	0	56.46	32206.79	24.77	0	125.28	0	2.68	0	0	0	0	0	0	6.33										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	30	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.86	-	-	0.25	-	-	0.15	5.54	5.28	0.31	-	5.64	1.01	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25	700	0	17.56	1.23	0.32	0.73	0.52	0.88	1.84	3.66	0.32	0.12	0.36	0.15	-	1.85	5.54	6.01	0.4	-	10.18	14.61	6.42	-	0.2	-	0	-	-	-	-	-	-	0.51	-	-	-	-	-	-	-	-	-	73.41	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.85	0.15	0.04	0.09	0.01	0.1	0.22	0.03	0.01	0.01	0.01	0.02	0	0.2	0.2	0.09	0.01	0	0.29	1.6	0.23	0	0.02	0	0	0	0	0	0	0	0	0.06										5.22	700	0	19.41	1.38	0.36	0.81	0.52	0.98	2.06	3.68	0.34	0.14	0.37	0.17	-	2.05	5.74	6.1	0.41	-	10.47	16.2	6.65	-	0.22	-	0	-	-	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	78.63
H2611_810_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.56	1.23	0.32	0.73	0.52	0.88	1.84	1.8	0.32	0.12	0.1	0.15	0	1.7	0	0.73	0.09	0	4.55	13.59	1.47	0	0.2	0	0	0	0	0	0	0	0	0.51										48.42	None	358.66	19.95	27	9.01	283.83	10.88	22.87	3714.03	54.79	857.32	1.27	1.9	0	1673.58	4432.33	2110.79	149.36	0	56.46	32206.79	24.77	0	125.28	0	2.68	0	0	0	0	0	0	6.33										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	30	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.86	-	-	0.25	-	-	0.15	5.54	5.28	0.31	-	5.64	1.01	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25	700	0	17.56	1.23	0.32	0.73	0.52	0.88	1.84	3.66	0.32	0.12	0.36	0.15	-	1.85	5.54	6.01	0.4	-	10.18	14.61	6.42	-	0.2	-	0	-	-	-	-	-	-	0.51	-	-	-	-	-	-	-	-	-	73.41	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.85	0.15	0.04	0.09	0.01	0.1	0.22	0.03	0.01	0.01	0.01	0.02	0	0.2	0.2	0.09	0.01	0	0.29	1.6	0.23	0	0.02	0	0	0	0	0	0	0	0	0.06										5.22	700	0	19.41	1.38	0.36	0.81	0.52	0.98	2.06	3.68	0.34	0.14	0.37	0.17	-	2.05	5.74	6.1	0.41	-	10.47	16.2	6.65	-	0.22	-	0	-	-	-	-	-	-	0.57	-	-	-	-	-	-	-	-	-	78.63
H2611_811_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.31	1.22	0.32	0.72	0.51	0.86	1.81	1.78	0.32	0.12	0.1	0.15	0	1.68	0	0.74	0.08	0	4.59	13.54	1.45	0	0.2	0	0	0	0	0	0	0	0	0.5										48	None	333.55	18.56	25.11	8.38	263.97	10.12	21.27	3454.05	50.95	797.31	1.18	1.77	0	1556.43	4122.07	2004.8	138.91	0	53.83	30127.73	23.03	0	116.51	0	2.49	0	0	0	0	0	0	5.88										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	25	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.73	-	-	0.24	-	-	0.14	5.15	4.18	0.29	-	5.19	0.94	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.46	700	0	17.31	1.22	0.32	0.72	0.51	0.86	1.81	3.5	0.32	0.12	0.34	0.15	-	1.82	5.15	4.92	0.37	-	9.79	14.49	6.05	-	0.2	-	0	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	70.46	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.72	0.14	0.04	0.08	0.01	0.1	0.2	0.02	0.01	0.01	0.01	0.02	0	0.18	0.19	0.08	0.01	0	0.27	1.5	0.22	0	0.02	0	0	0	0	0	0	0	0	0.06										4.88	700	0	19.03	1.35	0.35	0.79	0.51	0.96	2.02	3.53	0.33	0.14	0.35	0.17	-	2	5.34	5	0.38	-	10.06	15.99	6.27	-	0.22	-	0	-	-	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	75.34
H2611_812_0	2007	1	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										17.31	1.22	0.32	0.72	0.51	0.86	1.81	1.78	0.32	0.12	0.1	0.15	0	1.68	0	0.74	0.08	0	4.59	13.54	1.45	0	0.2	0	0	0	0	0	0	0	0	0.5										48	None	333.55	18.56	25.11	8.38	263.97	10.12	21.27	3454.05	50.95	797.31	1.18	1.77	0	1556.43	4122.07	2004.8	138.91	0	53.83	30127.73	23.03	0	116.51	0	2.49	0	0	0	0	0	0	5.88										0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	50 Copay - Waived if Admitted - PBP Section B: #4A	0 Coinsurance	0 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Urgent Care Copay - Waived if admitted - PBP Section B: #4B;  0 Coinsurance on all other benefits	15 Copay PBP Section B: #7A	25 Copay PBP Section B: #7D	25 Copay PBP Section B: #7E	0 Coinsurance	20 Coinsurance - Coinsurance may not apply if Specialist Copay applies	25 Chiropractor and Podiatrist Copay PBP Section B: #7B and #7F; 0 Coinsurance on all other benefits	20 Coinsurance	20 Coinsurance	0 Coinsurance	0 Coinsurance	25 Copay Routine Eye Exam - PBP Section B: #17A	150 maximum benefit every two years for eye glasses; PBP Section B: 17B	25 Copay Routine Hearing Test - PBP Section B: #18A	Not Cover Benefit	Not Cover Benefit	0 Coinsurance - PBP Section B: #14A	Not Cover Benefit	0 Coinsurance										0	0	0	0	0	0	0	6	0	0	0.2	0	0	1.07	15	25	25	0	0.1	0.38	0.2	0	0	0	0	0	0	0	0	0	0	0										-	-	-	-	-	-	-	1.73	-	-	0.24	-	-	0.14	5.15	4.18	0.29	-	5.19	0.94	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.46	700	0	17.31	1.22	0.32	0.72	0.51	0.86	1.81	3.5	0.32	0.12	0.34	0.15	-	1.82	5.15	4.92	0.37	-	9.79	14.49	6.05	-	0.2	-	0	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	70.46	None	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance										1.72	0.14	0.04	0.08	0.01	0.1	0.2	0.02	0.01	0.01	0.01	0.02	0	0.18	0.19	0.08	0.01	0	0.27	1.5	0.22	0	0.02	0	0	0	0	0	0	0	0	0.06										4.88	700	0	19.03	1.35	0.35	0.79	0.51	0.96	2.02	3.53	0.33	0.14	0.35	0.17	-	2	5.34	5	0.38	-	10.06	15.99	6.27	-	0.22	-	0	-	-	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	75.34
H2613_001_0	2007	2	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12	F.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	OP Facility - Emergency			Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Urgent Care		D	A	D		T	Coin	Coin	V	V		V	V	V	V	V	V	Coin	V			Coin				V		V					V	V	V	V	V	V	Coin	V	V																																											-		2041.35	6.52	517.96		260.38	10.2	3.43	313.04	402.79		989.32	44.32	28.15	0.79	5314.23	1759.83	0.07	423.98			5.22				19.77		162					970.48	19.65	76.17	360.43	106.38	11.14	12.69	2.25	2.7		150/day with 750 yearly max	300/admit with NO yearly max	25/day for days 21 to 100		100 copay	30 coinsurance	30 coinsurance	50 copay	100 copay		25 copay for Lower/Higher Tier	100 copay	25 copay for in-home/facility	10 copay	10 copay	10 copay	50 coinsurance	10 copay			0 coinsurance				10 copay		10 copay					10 copay	0 copay	10 copay	10 copay	10 copay	10 copay	50 coinsurance	10 copay	10 copay		65.5	300	25		100	0.3	0.3	50	100		25	100	25	10	10	10	0.5	10			0				10		10					10	0	10	10	10	10	0.5	10	10		11.14	0.16	1.08	-	2.17	3.06	1.03	1.3	3.36	-	2.06	0.37	0.06	0	4.43	1.47	0.03	0.35	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.81	-	0.06	0.3	0.09	0.01	6.35	0	0	-	39.85			11.14	0.16	1.08	-	2.17	3.06	1.03	1.3	3.36	-	2.06	0.37	0.06	0	4.43	1.47	0.03	0.35	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.81	-	0.06	0.3	0.09	0.01	6.35	0	0	-	39.85																																																																																				-			11.14	0.16	1.08	-	2.17	3.06	1.03	1.3	3.36	-	2.06	0.37	0.06	0	4.43	1.47	0.03	0.35	-	-	-	-	-	-	0.02	-	0.14	-	-	-	-	0.81	-	0.06	0.3	0.09	0.01	6.35	0	0	-	39.85
H2613_004_0	2007	7	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12	F.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	OP Facility - Emergency			Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Urgent Care		D	A	D		T	Coin	Coin	V	V		Coin	V	V	V	V	V	Coin	V			Coin				V		V					V	V	V	V	V	V	Coin	V	V																																											-		2020.93	6.45	515.2		249.82	10.2	3.43	313.04	419.81		18.4	44.32	28.15	0.79	5160.16	1708.81	0.07	411.69			5.24				19.2		162					942.35	19.08	73.97	349.98	103.3	10.82	12.38	2.19	2.62		200/day with 1000 yearly max	900/admit with NO yearly max	100/day for days 21 to 100		150 copay	30 coinsurance	30 coinsurance	50 copay	100 copay		20 coinsurance	100 copay	25 copay for in-home/facility	25 copay	10 copay	25 copay	50 coinsurance	25 copay			20 coinsurance				25 copay		25 copay					25 copay	0 copay	25 copay	25 copay	10 copay	10 copay	50 coinsurance	25 copay	25 copay		87.34	900	100		150	0.3	0.3	50	100		0.2	100	25	25	10	25	0.5	25			0.2				25		25					25	0	25	25	10	10	0.5	25	25		14.71	0.48	4.29	-	3.12	3.06	1.03	1.3	3.5	-	3.68	0.37	0.06	0	4.3	3.56	0.03	0.86	-	-	1.05	-	-	-	0.04	-	0.34	-	-	-	-	1.96	-	0.15	0.73	0.09	0.01	6.19	0	0.01	-	54.93			14.71	0.48	4.29	-	3.12	3.06	1.03	1.3	3.5	-	3.68	0.37	0.06	0	4.3	3.56	0.03	0.86	-	-	1.05	-	-	-	0.04	-	0.34	-	-	-	-	1.96	-	0.15	0.73	0.09	0.01	6.19	0	0.01	-	54.93																																																																																				-			14.71	0.48	4.29	-	3.12	3.06	1.03	1.3	3.5	-	3.68	0.37	0.06	0	4.3	3.56	0.03	0.86	-	-	1.05	-	-	-	0.04	-	0.34	-	-	-	-	1.96	-	0.15	0.73	0.09	0.01	6.19	0	0.01	-	54.93
H2613_803_0	2007	6																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H2613_804_0	2007	2																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H2613_805_0	2007	6																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H2649_004_0	2007	4	s.	t.									Inpatient Facility	Professional									3900	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin						Coin					D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0						0					0	0									-		1564.99	44.18	956.59	2570.37	210.64	0.34	0.03	298.77	194.24	475.13	323.95	21.6	99.71	183.57	7298.79	4338.68			232.84		7.08						230					2.33	7.99									220/day (1-5)	220/day (1-5)	0/day (1-7) 100/day (8-100)	5/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	175/ Visit	5-50/ Visit	0-100/ Visit	50/ Visit	0/ Procedure	0-50/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins						0					220/day (1-5)	20 Coins									116.25	116.25	20.63	3.88	77.68	0.16	0.16	36.51	135.94	30.9	25.89	38.84	0	25.59	7.77	27.19			77.68		0.16						0					116.25	0.16									15.16	0.43	1.64	0.83	1.36	0.05	0	0.91	2.2	1.22	0.7	0.07	-	0.39	4.72	9.83	-	-	1.51	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.24	-	-	-	-	-	-	-	-	43.41	0	12.47	15.16	0.43	1.64	0.83	1.36	0.05	0	0.91	2.2	1.22	0.7	0.07	-	0.39	4.72	9.83	-	-	1.51	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.24	-	-	-	-	-	-	-	-	43.41	3900																																																																																			-			15.16	0.43	1.64	0.83	1.36	0.05	0	0.91	2.2	1.22	0.7	0.07	-	0.39	4.72	9.83	-	-	1.51	-	1.1	-	-	-	-	-	-	-	-	-	-	0.02	1.24	-	-	-	-	-	-	-	-	43.41
H2649_011_0	2007	4	s.	t.									Inpatient Facility	Professional									3900	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin						Coin					D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0						0					0	0									-		1636.03	46.18	1000.01	2687.03	220.2	0.37	0.03	312.33	203.06	496.7	338.66	22.58	104.24	191.91	7630.08	4535.61			243.41		7.74						230					2.43	8.74									220/day (1-5)	220/day (1-5)	0/day (1-7) 100/day (8-100)	5/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	175/ Visit	5-50/ Visit	0-100/ Visit	50/ Visit	0/ Procedure	0-50/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins						0					220/day (1-5)	20 Coins									114.77	114.77	20.37	3.83	76.7	0.15	0.15	36.05	134.22	30.5	25.57	38.35	0	25.26	7.67	26.84			76.7		0.15						0					114.77	0.15									15.65	0.44	1.7	0.86	1.41	0.06	0	0.94	2.27	1.26	0.72	0.07	-	0.4	4.88	10.15	-	-	1.56	-	1.19	-	-	-	-	-	-	-	-	-	-	0.02	1.34	-	-	-	-	-	-	-	-	44.91	0	13.65	15.65	0.44	1.7	0.86	1.41	0.06	0	0.94	2.27	1.26	0.72	0.07	-	0.4	4.88	10.15	-	-	1.56	-	1.19	-	-	-	-	-	-	-	-	-	-	0.02	1.34	-	-	-	-	-	-	-	-	44.91	3900																																																																																			-			15.65	0.44	1.7	0.86	1.41	0.06	0	0.94	2.27	1.26	0.72	0.07	-	0.4	4.88	10.15	-	-	1.56	-	1.19	-	-	-	-	-	-	-	-	-	-	0.02	1.34	-	-	-	-	-	-	-	-	44.91
H2649_012_0	2007	7	s.	t.									Inpatient Facility	Professional									4000	Mental Health Level 2	Physician Administered Injectibles									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin				Coin							D	Coin									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0				0							0	0									-		1402.73	39.6	857.41	2303.86	188.8	0.27	0.02	267.79	174.1	425.87	290.36	19.36	89.37	164.54	6542.03	3888.83			208.7		5.69				356							2.08	6.42									285/day (1-5)	285/day (1-5)	0/day (1-13) 100/day (14-100)	5/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	5-50/ Visit	0-150/ Visit	100/ Visit	0/ Procedure	0-100/ Visit	0/ Visit	0/ Visit			150/ Visit		20 Coins				0							285/day (1-5)	20 Coins									164.35	164.35	13.33	4.24	84.78	0.17	0.17	39.85	169.55	33.72	53.69	84.78	0	27.93	0	0			127.16		0.17				0							164.35	0.17									19.21	0.54	0.95	0.81	1.33	0.05	0	0.89	2.46	1.2	1.3	0.14	-	0.38	-	-	-	-	2.21	-	0.96	-	-	-	0.41	-	-	-	-	-	-	0.03	1.09	-	-	-	-	-	-	-	-	33.97	0	6.03	19.21	0.54	0.95	0.81	1.33	0.05	0	0.89	2.46	1.2	1.3	0.14	-	0.38	-	-	-	-	2.21	-	0.96	-	-	-	0.41	-	-	-	-	-	-	0.03	1.09	-	-	-	-	-	-	-	-	33.97	4000																																																																																			-			19.21	0.54	0.95	0.81	1.33	0.05	0	0.89	2.46	1.2	1.3	0.14	-	0.38	-	-	-	-	2.21	-	0.96	-	-	-	0.41	-	-	-	-	-	-	0.03	1.09	-	-	-	-	-	-	-	-	33.97
H2649_801_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1606.42	45.35	981.91	2638.41	216.22	0.36	0.03	300.54	199.39	487.71	77.59	22.17	102.35	188.43	7492	4453.52			239.01		7.46											84.55	2.39									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									27.32	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.46	0.53	0.18	-	0.73	12.49	12.99	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.71	0	0	27.32	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.46	0.53	0.18	-	0.73	12.49	12.99	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.71																																																																																				-			27.32	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.46	0.53	0.18	-	0.73	12.49	12.99	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.71
H2649_802_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1607.24	45.37	982.41	2639.74	216.33	0.36	0.03	300.7	199.49	487.95	77.63	22.18	102.4	188.53	7495.8	4455.78			239.13		7.47											84.59	2.39									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75	0	0	27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75																																																																																				-			27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75
H2649_803_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1607.24	45.37	982.41	2639.74	216.33	0.36	0.03	300.7	199.49	487.95	77.63	22.18	102.4	188.53	7495.8	4455.78			239.13		7.47											84.59	2.39									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75	0	0	27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75																																																																																				-			27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75
H2649_804_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1607.24	45.37	982.41	2639.74	216.33	0.36	0.03	300.7	199.49	487.95	77.63	22.18	102.4	188.53	7495.8	4455.78			239.13		7.47											84.59	2.39									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75	0	0	27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75																																																																																				-			27.33	0.77	0.9	-	1.8	0.07	0.01	1.18	3.32	3.47	0.53	0.18	-	0.73	12.49	13	-	-	2.99	-	1.49	-	-	-	-	-	-	-	-	-	-	1.44	0.04	-	-	-	-	-	-	-	-	71.75
H2654_004_0	2007	12																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1576.12	106.55	558.04	0	264.37	11.13	6.25	334.98	26.76	7904.54	39.75	0	0.53	24.09	3854.12	2554.32	447.75	1.48	0	0	20.15	2034.78	0	0	213.26	339.89	220.84	0	0	0	0											285 (1a)	285 (1b)	85 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	10 5 (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											212.97	212.97	63.52	0	130.77	0.19	0.21	37.36	0.19	1.49	0.15	0	0.22	0.19	15	30	37.5	0.19	0	0	0.22	30	0	0	30	8.8	30	0	0	0	0											27.97	1.89	2.95	-	2.88	2.08	1.29	1.04	5	0.98	5.78	-	0.12	4.5	4.82	6.39	1.4	0.28	-	-	4.52	5.09	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.31		20.56	27.97	1.89	2.95	-	2.88	2.08	1.29	1.04	5	0.98	5.78	-	0.12	4.5	4.82	6.39	1.4	0.28	-	-	4.52	5.09	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.31																																																																																				-			27.97	1.89	2.95	-	2.88	2.08	1.29	1.04	5	0.98	5.78	-	0.12	4.5	4.82	6.39	1.4	0.28	-	-	4.52	5.09	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.31
H2654_010_0	2007	9																					3950											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1096.46	109.83	379.9	0	14.02	11.83	7.54	1623.52	19.13	6621.41	34.56	0	0.08	20.62	3218.17	2557.69	459.36	1.5	0	0	15.55	603.1	0	0	55.27	339.41	212.73	0	0	0	0											200 (1a)	200 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	14 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	10 5 (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											155.64	155.64	105.06	0	136.19	0.23	0.25	38.91	0.16	4.36	0.12	0	0.23	0.16	10	25	37.5	0.16	0	0	0.23	25	0	0	25	8.67	25	0	0	0	0											14.22	1.42	3.33	-	0.16	2.76	1.88	5.26	2.98	2.4	4.25	-	0.02	3.21	2.68	5.33	1.44	0.23	-	-	3.63	1.26	-	-	0.12	0.25	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.27		12.88	14.22	1.42	3.33	-	0.16	2.76	1.88	5.26	2.98	2.4	4.25	-	0.02	3.21	2.68	5.33	1.44	0.23	-	-	3.63	1.26	-	-	0.12	0.25	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.27																																																																																				-			14.22	1.42	3.33	-	0.16	2.76	1.88	5.26	2.98	2.4	4.25	-	0.02	3.21	2.68	5.33	1.44	0.23	-	-	3.63	1.26	-	-	0.12	0.25	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.27
H2654_013_0	2007	11																					3400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		943.52	102.61	312.35	0	200.72	7.58	4.77	303.21	18.55	5145.16	28.18	0	0.08	16.48	3462.28	2184.86	440.87	1.34	0	0	10.8	2008.74	0	0	210.15	334.79	218.2	0	0	0	0											200/265/285 (1a)	200 (1b)	85 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	10 5 (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											181.79	141.48	60.13	0	123.8	0.21	0.24	35.37	0.18	4.24	0.14	0	0.21	0.18	15	30	37.5	0.18	0	0	0.21	30	0	0	30	8.8	30	0	0	0	0											14.29	1.21	1.57	-	2.07	1.61	1.14	0.89	3.28	1.82	3.88	-	0.02	2.91	4.33	5.46	1.38	0.24	-	-	2.29	5.02	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.72		15.21	14.29	1.21	1.57	-	2.07	1.61	1.14	0.89	3.28	1.82	3.88	-	0.02	2.91	4.33	5.46	1.38	0.24	-	-	2.29	5.02	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.72		325 (1a)	0 n/c (1b)	0 n/c (2a)	0 n/c (6a)	0 n/c (10a)	0 n/c (11a)	0 n/c (11b 11c)	0 n/c (4a 4b)	35 (9b)	20 (8a 8b)	20/35 (8a 8b)	35 (incl in h5)	0 n/c (12)	35 (3 9d 9a); 0 n/c (5); 45/35 (9c)	0 n/c (7a 14c 14b 14d 14e 14f 14g 14h)	0 n/c (7b 7d 7f 7g)	45/35 (7e 7h)	35 (7c 7i)	35 (incl in h2)	0 n/c (14i)	0 n/c (15)	0 n/c (13a 17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	0 n/c (17a)	0 n/c (17b1-17b5)	0 n/c (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											1.14	0	0	0	0	0	0	0	0.12	0.06	0.13	0	0	0.11	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											1.57		16.84	15.44	1.21	1.57	-	2.07	1.61	1.14	0.89	3.4	1.88	4	-	0.02	3.02	4.33	5.46	1.38	0.24	-	-	2.29	5.02	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.29
H2654_020_0	2007	7																					4200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1576.12	106.55	558.04	0	264.37	11.13	6.25	334.98	26.76	7904.54	39.75	0	0.53	24.09	3854.12	2554.32	447.75	1.48	0	0	20.15	2034.78	0	0	213.26	339.89	220.84	0	0	0	0											285 (1a)	285 (1b)	85 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	10 5 (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											201.61	201.61	60.13	0	123.8	0.21	0.24	35.37	0.18	4.24	0.14	0	0.21	0.18	15	30	37.5	0.18	0	0	0.21	30	0	0	30	8.8	30	0	0	0	0											26.48	1.79	2.8	-	2.73	2.36	1.5	0.99	4.73	2.8	5.47	-	0.11	4.26	4.82	6.39	1.4	0.26	-	-	4.28	5.09	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.58		24.79	26.48	1.79	2.8	-	2.73	2.36	1.5	0.99	4.73	2.8	5.47	-	0.11	4.26	4.82	6.39	1.4	0.26	-	-	4.28	5.09	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.58																																																																																				-			26.48	1.79	2.8	-	2.73	2.36	1.5	0.99	4.73	2.8	5.47	-	0.11	4.26	4.82	6.39	1.4	0.26	-	-	4.28	5.09	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.58
H2654_021_0	2007	7																					3250											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1096.46	109.83	379.9	0	14.02	11.83	7.54	1623.52	19.13	6621.41	34.56	0	0.08	20.62	3218.17	2557.69	459.36	1.5	0	0	15.55	603.1	0	0	55.27	339.41	212.73	0	0	0	0											200 (1a)	200 (1b)	135 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	10 5 (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											146.91	146.91	99.17	0	128.55	0.22	0.24	36.73	0.15	4.41	0.12	0	0.22	0.15	10	25	37.5	0.15	0	0	0.22	25	0	0	25	8.67	25	0	0	0	0											13.42	1.34	3.14	-	0.15	2.61	1.81	4.97	2.81	2.43	4.01	-	0.02	3.03	2.68	5.33	1.44	0.22	-	-	3.43	1.26	-	-	0.12	0.25	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89		15.48	13.42	1.34	3.14	-	0.15	2.61	1.81	4.97	2.81	2.43	4.01	-	0.02	3.03	2.68	5.33	1.44	0.22	-	-	3.43	1.26	-	-	0.12	0.25	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89																																																																																				-			13.42	1.34	3.14	-	0.15	2.61	1.81	4.97	2.81	2.43	4.01	-	0.02	3.03	2.68	5.33	1.44	0.22	-	-	3.43	1.26	-	-	0.12	0.25	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89
H2654_022_0	2007	8																					2800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		943.52	102.61	312.35	0	200.72	7.58	4.77	303.21	18.55	5145.16	28.18	0	0.08	16.48	3462.28	2184.86	440.87	1.34	0	0	10.8	2008.74	0	0	210.15	334.79	218.2	0	0	0	0											200/265/285 (1a)	200 (1b)	85 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	10 5 (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											169.55	131.96	56.08	0	115.46	0.2	0.23	32.99	0.16	3.96	0.13	0	0.2	0.16	15	30	37.5	0.16	0	0	0.2	30	0	0	30	8.8	30	0	0	0	0											13.33	1.13	1.46	-	1.93	1.5	1.09	0.83	3.06	1.7	3.62	-	0.02	2.72	4.33	5.46	1.38	0.22	-	-	2.14	5.02	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.25		17.69	13.33	1.13	1.46	-	1.93	1.5	1.09	0.83	3.06	1.7	3.62	-	0.02	2.72	4.33	5.46	1.38	0.22	-	-	2.14	5.02	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.25		325 (1a)	0 n/c (1b)	0 n/c (2a)	0 n/c (6a)	0 n/c (10a)	0 n/c (11a)	0 n/c (11b 11c)	0 n/c (4a 4b)	35 (9b)	20 (8a 8b)	20/35 (8a 8b)	35 (incl in h5)	0 n/c (12)	35 (3 9d 9a); 0 n/c (5); 45/35 (9c)	0 n/c (7a 14c 14b 14d 14e 14f 14g 14h)	0 n/c (7b 7d 7f 7g)	45/35 (7e 7h)	35 (7c 7i)	35 (incl in h2)	0 n/c (14i)	0 n/c (15)	0 n/c (13a 17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	0 n/c (17a)	0 n/c (17b1-17b5)	0 n/c (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											1.14	0	0	0	0	0	0	0	0.12	0.06	0.13	0	0	0.11	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											1.57		16.84	14.48	1.13	1.46	-	1.93	1.5	1.09	0.83	3.18	1.76	3.74	-	0.02	2.82	4.33	5.46	1.38	0.22	-	-	2.14	5.02	-	-	0.53	0.25	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.81
H2654_023_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2133.73	337.62	1086.96		253.33	24.37	21.11	868.14	376.42	1974.92	926.54	64.13	2.98	1949.58		3364.79		510.78		783.19												277.91		149.6	222.56							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							37	37	18		37	10	10	18	12	5	5	12	10	12		5		5		5												5		5	5							6.57	1.04	1.61	-	0.78	2.4	2.08	1.28	0.39	0.81	0.38	0.07	0.29	2	-	1.38	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.87		22.54	6.57	1.04	1.61	-	0.78	2.4	2.08	1.28	0.39	0.81	0.38	0.07	0.29	2	-	1.38	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.87																																																																																				-		0	6.57	1.04	1.61	-	0.78	2.4	2.08	1.28	0.39	0.81	0.38	0.07	0.29	2	-	1.38	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.87
H2654_024_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2357.49	373.03	1200.95		279.9	29.75	25.77	959.18	415.9	2182.03	1023.71	70.85	3.63	2154.04		3717.65		564.34		865.33												307.06		165.29	245.9							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							6.84	1.08	1.67	-	0.81	2.76	2.39	1.34	0.4	0.84	0.4	0.07	0.34	2.08	-	1.44	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.1	-	-	-	-	-	-	23.29		26.9	6.84	1.08	1.67	-	0.81	2.76	2.39	1.34	0.4	0.84	0.4	0.07	0.34	2.08	-	1.44	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.1	-	-	-	-	-	-	23.29																																																																																				-		0	6.84	1.08	1.67	-	0.81	2.76	2.39	1.34	0.4	0.84	0.4	0.07	0.34	2.08	-	1.44	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.1	-	-	-	-	-	-	23.29
H2654_025_0	2007	6	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2323.39	367.63	1183.58		275.85	28.9	25.03	945.31	409.88	2150.46	1008.9	69.83	3.53	2122.88		3663.87		556.18		852.81												302.61		162.9	242.35							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							6.8	1.08	1.66	-	0.81	2.71	2.34	1.33	0.4	0.84	0.39	0.07	0.33	2.07	-	1.43	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.08		26.21	6.8	1.08	1.66	-	0.81	2.71	2.34	1.33	0.4	0.84	0.39	0.07	0.33	2.07	-	1.43	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.08																																																																																				-		0	6.8	1.08	1.66	-	0.81	2.71	2.34	1.33	0.4	0.84	0.39	0.07	0.33	2.07	-	1.43	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.08
H2654_801_0	2007	3																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1241.1	94.39	407.31	0	171.54	9.27	8.19	271.66	29.99	8296.16	43.1	0	0.18	32.15	3661.31	2714.4	394.3	1.89	0	0	28.14	1805.88	0	0	188.68	0	194.6	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	40 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	50 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 50 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	50 (17a)	0 n/c (17b1-17b5)	50 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											94.76	350	150	0	175	0.25	0.25	50	0.25	6	0.19	0	0.3	0.25	40	50	37.5	0.25	0	0	0.3	50	0	0	50	0	50	0	0	0	0											9.8	2.75	5.09	-	2.5	2.32	2.05	1.13	7.5	4.15	8.38	-	0.05	8.03	12.2	11.31	1.23	0.47	-	-	8.44	7.52	-	-	0.79	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.54		0	9.8	2.75	5.09	-	2.5	2.32	2.05	1.13	7.5	4.15	8.38	-	0.05	8.03	12.2	11.31	1.23	0.47	-	-	8.44	7.52	-	-	0.79	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.54																																																																																				-			9.8	2.75	5.09	-	2.5	2.32	2.05	1.13	7.5	4.15	8.38	-	0.05	8.03	12.2	11.31	1.23	0.47	-	-	8.44	7.52	-	-	0.79	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.54
H2654_802_0	2007	2																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1241.1	94.39	407.31	0	171.54	9.27	8.3	271.66	29.99	8296.16	43.1	0	0.18	32.15	3661.31	2714.4	394.3	1.89	0	0	28.14	1805.88	0	0	188.68	0	194.6	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	40 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	50 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 50 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	50 (17a)	0 n/c (17b1-17b5)	50 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											94.76	350	150	0	175	0.25	0.25	50	0.25	6	0.19	0	0.3	0.25	40	50	37.5	0.25	0	0	0.3	50	0	0	50	0	50	0	0	0	0											9.8	2.75	5.09	-	2.5	2.32	2.07	1.13	7.5	4.15	8.38	-	0.05	8.03	12.2	11.31	1.23	0.47	-	-	8.44	7.52	-	-	0.79	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.57		0	9.8	2.75	5.09	-	2.5	2.32	2.07	1.13	7.5	4.15	8.38	-	0.05	8.03	12.2	11.31	1.23	0.47	-	-	8.44	7.52	-	-	0.79	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.57																																																																																				-			9.8	2.75	5.09	-	2.5	2.32	2.07	1.13	7.5	4.15	8.38	-	0.05	8.03	12.2	11.31	1.23	0.47	-	-	8.44	7.52	-	-	0.79	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.57
H2654_803_0	2007	3																					5400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1307.23	120.83	449.72	0	12.12	13.27	10.13	1694.73	25.4	8316.8	42.05	0	0.81	32.34	3913.01	3327.27	514.73	1.98	0	0	25.72	795.65	0	0	61.47	0	239.04	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											258.84	258.84	110.93	0	129.42	0.18	0.2	36.98	0.18	4.44	0.14	0	0.22	0.18	25	35	37.5	0.18	0	0	0.22	35	0	0	35	0	35	0	0	0	0											28.2	2.61	4.16	-	0.13	2.45	2.04	5.22	4.7	3.08	5.98	-	0.18	5.98	8.15	9.7	1.61	0.37	-	-	5.71	2.32	-	-	0.18	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.45		24.7	28.2	2.61	4.16	-	0.13	2.45	2.04	5.22	4.7	3.08	5.98	-	0.18	5.98	8.15	9.7	1.61	0.37	-	-	5.71	2.32	-	-	0.18	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.45																																																																																				-			28.2	2.61	4.16	-	0.13	2.45	2.04	5.22	4.7	3.08	5.98	-	0.18	5.98	8.15	9.7	1.61	0.37	-	-	5.71	2.32	-	-	0.18	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.45
H2654_804_0	2007	2																					5400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1307.23	120.83	449.72	0	12.12	13.27	10.13	1694.73	25.4	8316.8	42.05	0	0.81	32.34	3913.01	3635.96	514.73	1.98	0	0	25.72	795.65	0	0	61.47	0	239.04	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											258.84	258.84	110.93	0	129.42	0.18	0.2	36.98	0.18	4.44	0.14	0	0.22	0.18	25	35	37.5	0.18	0	0	0.22	35	0	0	35	0	35	0	0	0	0											28.2	2.61	4.16	-	0.13	2.45	2.04	5.22	4.7	3.08	5.98	-	0.18	5.98	8.15	10.6	1.61	0.37	-	-	5.71	2.32	-	-	0.18	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.35		24.7	28.2	2.61	4.16	-	0.13	2.45	2.04	5.22	4.7	3.08	5.98	-	0.18	5.98	8.15	10.6	1.61	0.37	-	-	5.71	2.32	-	-	0.18	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.35																																																																																				-			28.2	2.61	4.16	-	0.13	2.45	2.04	5.22	4.7	3.08	5.98	-	0.18	5.98	8.15	10.6	1.61	0.37	-	-	5.71	2.32	-	-	0.18	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.35
H2663_002_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1500	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	Coin	Coin	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2747.97	53.73	1181.54		315.07	7.54	44.3	268.72	349.5		43.21	3.97	1.04	21.49	4510.39	5593.04	254.76	4.25	34.34	0.99	11.75				933.39	300.19	0.54				380.22	450.05	1100.71	23.73	9746.32	81.27						1a 175 days 1-5	1b 300 days 1-5	2 75 days 6-25		10a 100	11a 20	11b 20	4a 50	9a 2509b 250		8a 20	9a 20	12 20	9a 209d 20	14c 107a 10	17a 2517b 1518a 257b 257d 257f 258a 20	7h 309C 20	7c 207i 20	8a 20	7g 25	0.2				17a 25	17b 15	18a 25				7f 25	8b 15	8a 5	4b 50	8a 5	8b 15						61.09	165.18	32.12		60.23	0.12	0.12	30.12	150.59		0.12	0.12	0.12	0.12	10	23.97	38.23	0.12	0.2	25	0.2				25	15	25				24.99	9.04	2.23	30.12	1.75	9.04						13.99	0.74	3.16	-	1.58	0.91	5.34	0.67	4.39	-	5.21	0.48	0.12	2.59	3.76	11.17	0.81	0.51	6.87	0	2.35	-	-	-	1.94	0.38	0	-	-	-	0.79	0.34	0.2	0.06	1.42	0.06	-	-	-	-	-	69.85		27.09	13.99	0.74	3.16	-	1.58	0.91	5.34	0.67	4.39	-	5.21	0.48	0.12	2.59	3.76	11.17	0.81	0.51	6.87	0	2.35	-	-	-	1.94	0.38	0	-	-	-	0.79	0.34	0.2	0.06	1.42	0.06	-	-	-	-	-	69.85																																																																																				-			13.99	0.74	3.16	-	1.58	0.91	5.34	0.67	4.39	-	5.21	0.48	0.12	2.59	3.76	11.17	0.81	0.51	6.87	0	2.35	-	-	-	1.94	0.38	0	-	-	-	0.79	0.34	0.2	0.06	1.42	0.06	-	-	-	-	-	69.85
H2663_005_0	2007	5	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						2800	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	Coin	Coin	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		1694.51	50.55	685.23		177.72	5.65	20.47	219.74	258.69		31.06	5.46	0	17.27	3581.98	3636.72	247.84	4.47	12.71		11.82				600.68	299.85	0.3					260.19	926.63	27.2	9505.8	89.81						1a 325 days 1-5	1b 300 days 1-5	2 125 days 6-28		10a 150	11a 20	11b 20	4a 50	9a 2509b 150		8a 20	9a 20	12 20	9a 209d 20	14c 57a 5	17a 2517b 1518a 307b 307d 307f 308a 20	7h 309C 20	7c 207i 15	8a 20		0.2				17a 25	17b 15	18a 30					8b 15	8a 5	4b 25	8a 5	8b 15						165.83	165.18	78.25		132.06	0.18	0.18	44.02	159.16		0.18	0.18	0.18	0.18	5	27.95	40.81	0.18	0.2		0.2				25	15	5					13.21	3.05	22.01	2.51	13.21						23.42	0.7	4.47	-	1.96	0.99	3.6	0.81	3.43	-	5.47	0.96	0	3.04	1.49	8.47	0.84	0.79	2.54	-	2.36	-	-	-	1.25	0.37	0	-	-	-	-	0.29	0.24	0.05	1.99	0.1	-	-	-	-	-	69.63		7.01	23.42	0.7	4.47	-	1.96	0.99	3.6	0.81	3.43	-	5.47	0.96	0	3.04	1.49	8.47	0.84	0.79	2.54	-	2.36	-	-	-	1.25	0.37	0	-	-	-	-	0.29	0.24	0.05	1.99	0.1	-	-	-	-	-	69.63																																																																																				-			23.42	0.7	4.47	-	1.96	0.99	3.6	0.81	3.43	-	5.47	0.96	0	3.04	1.49	8.47	0.84	0.79	2.54	-	2.36	-	-	-	1.25	0.37	0	-	-	-	-	0.29	0.24	0.05	1.99	0.1	-	-	-	-	-	69.63
H2663_006_0	2007	4	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						4500	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	Coin	Coin	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2092.64	40.81	899.58		240.3	5.72	33.5	204.19	265.45		32.46	2.99	0.79	16.29	3431.33	4418.64	193.45	3.2	9.19	0.76	9.15				354.61	228.09	0.41				286.94	340.25	836.84	17.78	7405.15	62.44						1a 320 days 1-5	1b 300 days 1-5	2 100 days 6-50		10a 100	11a 20	11b 20	4a 50	9a 2509b 250		8a 20	9a 20	12 20	9a 209d 20	14c 107a 10	17a 2517b 1518a 307b 307d 307f 308a 20	7h 309C 20	7c 207i 20	8a 20	7g 30	0.2				17a 25	17b 15	18a 30				7f 30	8b 15	8a 5	4b 50	8a 5	8b 15						162.12	165.18	62.15		87.41	0.17	0.17	43.71	218.53		0.17	0.17	0.17	0.17	10	28	30	0.17	0.2	30	0.2				25	15	30				29.99	13.11	3.24	43.71	2.54	13.11						28.27	0.56	4.66	-	1.75	1	5.86	0.74	4.83	-	5.68	0.52	0.14	2.85	2.86	10.31	0.48	0.56	1.84	0	1.83	-	-	-	0.74	0.29	0	-	-	-	0.72	0.37	0.23	0.06	1.56	0.07	-	-	-	-	-	78.78		8.52	28.27	0.56	4.66	-	1.75	1	5.86	0.74	4.83	-	5.68	0.52	0.14	2.85	2.86	10.31	0.48	0.56	1.84	0	1.83	-	-	-	0.74	0.29	0	-	-	-	0.72	0.37	0.23	0.06	1.56	0.07	-	-	-	-	-	78.78																																																																																				-			28.27	0.56	4.66	-	1.75	1	5.86	0.74	4.83	-	5.68	0.52	0.14	2.85	2.86	10.31	0.48	0.56	1.84	0	1.83	-	-	-	0.74	0.29	0	-	-	-	0.72	0.37	0.23	0.06	1.56	0.07	-	-	-	-	-	78.78
H2663_007_0	2007	4	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1500	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	Coin	Coin	Coin	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2045.48	58.56	808.45		202	6.46	23.96	256.48	305.43		36.09	6.22	0	20.77	4101.9	4674.04	3.24	5.1	14.99	0.78	6.58				154.9	345.83	0.18					319.41	1092.75	32.64	10994.77	90.29						1a 175 days 1-5	1b 300 days 1-5	2 75 days 6-25		10a 100	11a 20	11b 20	4a 50	9a 2009b 150		8a 20	9a 20	12 20	9a 209d 15	14c 57a 58a 5	17a 2017b 1518a 157b 157d 157f 108a 20	7h 309C 20	7c 157i 15	8a 20	7g 15	0.2				17a 20	17b 15	18a 15					8b 15	8a 5	4b 25	8a 5	8b 15						71.49	165.18	37.59		70.48	0.14	0.14	35.24	116.7		0.14	0.14	0.14	0.14	5	16.24	0.31	0.11	0.2	5	0.2				20	15	5					10.57	2.46	17.62	2.01	10.57						12.19	0.81	2.53	-	1.19	0.91	3.38	0.75	2.97	-	5.09	0.88	0	2.92	1.71	6.32	1	0.54	3	0	1.32	-	-	-	0.26	0.43	0	-	-	-	-	0.28	0.22	0.05	1.84	0.08	-	-	-	-	-	50.66		15	12.19	0.81	2.53	-	1.19	0.91	3.38	0.75	2.97	-	5.09	0.88	0	2.92	1.71	6.32	1	0.54	3	0	1.32	-	-	-	0.26	0.43	0	-	-	-	-	0.28	0.22	0.05	1.84	0.08	-	-	-	-	-	50.66																																																																																				-			12.19	0.81	2.53	-	1.19	0.91	3.38	0.75	2.97	-	5.09	0.88	0	2.92	1.71	6.32	1	0.54	3	0	1.32	-	-	-	0.26	0.43	0	-	-	-	-	0.28	0.22	0.05	1.84	0.08	-	-	-	-	-	50.66
H2663_008_0	2007	5																					4500											D	D	D	V	T	Coin	Coin	V	V	V	Coin	Coin	Coin	V	V	V	V	Coin		V	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		3488.24	133.75	1396.69		221.33	18.37	28.71	355.99	341.29	12936.06	26.98	1.27	2.04	1072.68	4791.89	6596.35	400.65	3.49		11.22	34.8	24.56			1035.66	299.85	235.3															1a 320 days 1-5	1b 300 days 1-5	2 100 days 6-50		10a 100	11a 20	11b 20	4a 50	9b 250	8a 5	8a 20	9a 20	12 20	9a 2509d 20	14c 107a 10	17a 2517b 1518a 307b 307d 307f 308a 20	7h 309C 20	7c 207i 20		7g 30	0.2	17b 15			17a 25	17b 15	18a 30															138.73	165.18	53.19		74.8	0.15	0.15	37.4	187	3.74	0.14	0.15	0.15	45.67	10	27.61	27.44	0.15		17.01	0.13	15			25	15	30															40.33	1.84	6.19	-	1.38	2.75	4.2	1.11	5.32	4.03	3.76	0.19	0.31	4.08	3.99	15.18	0.92	0.52	-	0.02	4.69	0.03	-	-	2.16	0.37	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.95		24.77	40.33	1.84	6.19	-	1.38	2.75	4.2	1.11	5.32	4.03	3.76	0.19	0.31	4.08	3.99	15.18	0.92	0.52	-	0.02	4.69	0.03	-	-	2.16	0.37	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.95																																																																																				-			40.33	1.84	6.19	-	1.38	2.75	4.2	1.11	5.32	4.03	3.76	0.19	0.31	4.08	3.99	15.18	0.92	0.52	-	0.02	4.69	0.03	-	-	2.16	0.37	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.95
H2663_009_0	2007	4																					1500											D	D	D	V	T	Coin	Coin	V	V	V	Coin	Coin	Coin	V	V	V	V	Coin	Coin	V	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		3705.67	142.08	1483.73		228.13	18.93	29.59	366.9	351.77	13333.23	27.81	1.31	2.11	1105.61	4936.64	6793.93	412.95	3.6		11.56	35.87	25.32			1035.66	299.85	235.3															1a 175 days 1-5	1b 300 days 1-5	2 75 days 6-25		10a 100	11a 20	11b 20	4a 50	9b 250	8a 5	8a 20	9a 20	12 20	9a 2509d 20	14c 107a 10	17a 2517b 1518a 257b 257d 257f 108a 20	7h 309C 20	7c 207i 20	8a 20	7g 25	0.2				17a 25	17b 15	18a 25															55.59	165.18	29.23		54.81	0.11	0.11	27.4	137.02	2.74	0.1	0.11	0.11	35.34	10	23.86	27.44	0.11		15.26	0.13	15			25	15	25															17.17	1.96	3.61	-	1.04	2.08	3.17	0.84	4.02	3.04	2.84	0.14	0.23	3.26	4.11	13.51	0.94	0.39	-	0.01	4.83	0.03	-	-	2.16	0.37	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.25		33.96	17.17	1.96	3.61	-	1.04	2.08	3.17	0.84	4.02	3.04	2.84	0.14	0.23	3.26	4.11	13.51	0.94	0.39	-	0.01	4.83	0.03	-	-	2.16	0.37	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.25																																																																																				-			17.17	1.96	3.61	-	1.04	2.08	3.17	0.84	4.02	3.04	2.84	0.14	0.23	3.26	4.11	13.51	0.94	0.39	-	0.01	4.83	0.03	-	-	2.16	0.37	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.25
H2663_801_0	2007	2	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		339.24	2.02	21.06		7.29	8.98	43.12	7.09	40.79		51.16	4.14	0.62	22.41	26.95	95.31	1.56	6.21	46.34	1.46	24.5											1.92	2.34	0.46	7.94	0.22						MEDICARE FFS 8	MEDICARE FFS 8	MEDICARE FFS 19		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24											MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24						0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24											0.24	0.24	0.24	0.24	0.24						25.62	0.15	4.04	-	1.72	2.12	10.18	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.94	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.41			25.62	0.15	4.04	-	1.72	2.12	10.18	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.94	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.41																																																																																				-			25.62	0.15	4.04	-	1.72	2.12	10.18	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.94	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.41
H2663_802_0	2007	1	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		339.28	2.02	21.07		7.29	8.98	43.13	7.09	40.8		51.16	4.14	0.62	22.41	26.95	95.32	1.56	6.21	46.34	1.46	24.5											1.92	2.34	0.46	7.94	0.22						MEDICARE FFS 8	MEDICARE FFS 8	MEDICARE FFS 19		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24											MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24						0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24											0.24	0.24	0.24	0.24	0.24						25.62	0.15	4.04	-	1.72	2.12	10.18	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.5	0.37	1.47	10.94	0.35	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.42			25.62	0.15	4.04	-	1.72	2.12	10.18	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.5	0.37	1.47	10.94	0.35	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.42																																																																																				-			25.62	0.15	4.04	-	1.72	2.12	10.18	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.5	0.37	1.47	10.94	0.35	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.42
H2663_803_0	2007	1	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		339.19	2.02	21.06		7.29	8.97	43.11	7.09	40.79		51.16	4.14	0.62	22.41	26.95	95.3	1.56	6.21	46.32	1.46	24.49											1.92	2.34	0.46	7.94	0.22						MEDICARE FFS 8	MEDICARE FFS 8	MEDICARE FFS 19		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24											MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24						0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24											0.24	0.24	0.24	0.24	0.24						25.61	0.15	4.04	-	1.72	2.12	10.17	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.38			25.61	0.15	4.04	-	1.72	2.12	10.17	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.38																																																																																				-			25.61	0.15	4.04	-	1.72	2.12	10.17	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.38
H2663_804_0	2007	1	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		339.19	2.02	21.06		7.29	8.97	43.11	7.09	40.79		51.16	4.14	0.62	22.41	26.95	95.3	1.56	6.21	46.32	1.46	24.49											1.92	2.34	0.46	7.94	0.22						MEDICARE FFS 8	MEDICARE FFS 8	MEDICARE FFS 19		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24											MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24						0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24											0.24	0.24	0.24	0.24	0.24						25.61	0.15	4.04	-	1.72	2.12	10.17	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.38			25.61	0.15	4.04	-	1.72	2.12	10.17	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.38																																																																																				-			25.61	0.15	4.04	-	1.72	2.12	10.17	1.67	9.63	-	12.07	0.98	0.15	5.29	6.36	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.38
H2663_805_0	2007	1	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		339.04	2.02	21.04		7.29	8.97	43.07	7.09	40.77		51.14	4.14	0.61	22.4	26.98	95.28	1.56	6.21	46.33	1.46	24.5											1.92	2.34	0.46	7.95	0.22						MEDICARE FFS 8	MEDICARE FFS 8	MEDICARE FFS 19		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24											MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24						0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24											0.24	0.24	0.24	0.24	0.24						25.6	0.15	4.04	-	1.72	2.12	10.16	1.67	9.62	-	12.07	0.98	0.15	5.29	6.37	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.88	0.05	-	-	-	-	-	124.35			25.6	0.15	4.04	-	1.72	2.12	10.16	1.67	9.62	-	12.07	0.98	0.15	5.29	6.37	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.88	0.05	-	-	-	-	-	124.35																																																																																				-			25.6	0.15	4.04	-	1.72	2.12	10.16	1.67	9.62	-	12.07	0.98	0.15	5.29	6.37	22.49	0.37	1.47	10.93	0.34	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.88	0.05	-	-	-	-	-	124.35
H2663_806_0	2007	1	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Copay						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		340.13	2.01	21.15		7.3	9	43.34	7.09	40.89		51.22	4.15	0.62	22.44	26.8	95.43	1.56	6.21	46.35	1.46	24.48											1.92	2.34	0.46	7.91	0.22						MEDICARE FFS 8	MEDICARE FFS 8	MEDICARE FFS 19		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24		MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24											MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24	MEDICARE FFS 24						0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24											0.24	0.24	0.24	0.24	0.24						25.68	0.15	4.06	-	1.72	2.12	10.23	1.67	9.65	-	12.09	0.98	0.15	5.29	6.33	22.52	0.37	1.47	10.94	0.35	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.57			25.68	0.15	4.06	-	1.72	2.12	10.23	1.67	9.65	-	12.09	0.98	0.15	5.29	6.33	22.52	0.37	1.47	10.94	0.35	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.57																																																																																				-			25.68	0.15	4.06	-	1.72	2.12	10.23	1.67	9.65	-	12.09	0.98	0.15	5.29	6.33	22.52	0.37	1.47	10.94	0.35	5.78	-	-	-	-	-	-	-	-	-	-	0.45	0.55	0.11	1.87	0.05	-	-	-	-	-	124.57
H2667_001_0	2007	8	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	343.21	19.1	25.84	8.63	271.61	10.41	21.89	3554.1	52.43	820.4	1.21	1.82	0	1601.51	4241.46	2019.89	142.93	0	54.03	30819.89	23.7	0	119.89	0	2.56	0	0	0	0	0	0	6.05										150/day 750/admit	150/day 750/admit	125/day for days 11-100	Full Coverage	50 Copay	20 Coinsurance	20 Coinsurance	50 Copay - Waived if Admitted	150 Copay	Full Coverage	20 Coinsurance with a 2400 MOOP	20 Coinsurance	Full Coverage	25 Urgent Care Copay;  Full Coverage on all other benefits	15 Copay	30 Copay	30 Copay	20 Coinsurance	20 Coinsurance with a 2400 MOOP	30 Chiropractor and Podiatrist Copay; Full Coverage on all other benefits	20 Coinsurance	20 Coinsurance	Full Coverage	N/A	Full Coverage	N/A	N/A	N/A	N/A	N/A	N/A	Full Coverage on all other benefits										448.65	416.29	368.15	0	6	0.2	0.2	6	37.56	0	0.15	0.2	0	1.07	15	30	30	0	0.08	0.45	0.2	0	0	0	0	0	0	0	0	0	0	0										12.83	0.66	0.79	-	0.14	2.08	4.38	1.78	0.16	-	0.19	0.36	-	0.14	5.3	5.05	0.36	-	4.43	1.17	4.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.56	0	0	12.83	0.66	0.79	-	0.14	2.08	4.38	1.78	0.16	-	0.19	0.36	-	0.14	5.3	5.05	0.36	-	4.43	1.17	4.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.56	None																																																																																			-	0	0	12.83	0.66	0.79	-	0.14	2.08	4.38	1.78	0.16	-	0.19	0.36	-	0.14	5.3	5.05	0.36	-	4.43	1.17	4.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.56
H2667_003_0	2007	7	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	514.25	19.65	29.53	11.67	433.29	10.41	4.35	2556.46	345.37	5407.67	1.34	2.34	0	677.42	3568.83	2931.33	254.25	0	48.76	27496.57	32.74	0	9.61	0	42.74	0	15.02	0	0	0	0	8.95										185 per day	185 per day	100 per day	Full Coverage	100 Copay	20 Coinsurance	20 Coinsurance	50 Copay	200 Copay	Full Coverage	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	25 Copay	25 Copay	20 Coinsurance	20 Coinsurance	25 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	20 Coinsurance	Full Coverage	Full Coverage	Full Coverage	25 Copay	150 Maximum Benefit	25 Copay	NA	NA	Education Materials	NA	20 Coinsurance on PR/OT/ST										647.93	523.58	867.98	0	13.21	0.17	0.17	5.06	29.56	0	0.17	0.17	0	2	10	25	25	0	0.08	1.13	0.2	0	0	0	25	0	25	0	0	0	0	0.17										27.77	0.86	2.14	-	0.48	1.72	0.72	1.08	0.85	-	0.22	0.39	-	0.11	2.97	6.11	0.53	-	3.83	2.58	6.55	-	-	-	0.09	-	0.03	-	-	-	-	1.48	-	-	-	-	-	-	-	-	-	60.49	0	8.8	27.77	0.86	2.14	-	0.48	1.72	0.72	1.08	0.85	-	0.22	0.39	-	0.11	2.97	6.11	0.53	-	3.83	2.58	6.55	-	-	-	0.09	-	0.03	-	-	-	-	1.48	-	-	-	-	-	-	-	-	-	60.49	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	27.77	0.86	2.14	-	0.48	1.72	0.72	1.08	0.85	-	0.22	0.39	-	0.11	2.97	6.11	0.53	-	3.83	2.58	6.55	-	-	-	0.09	-	0.03	-	-	-	-	1.48	-	-	-	-	-	-	-	-	-	60.49
H2667_005_0	2007	6	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	561.35	16.96	50.11	13.4	660.66	13.69	5.5	3351.72	349.92	6678.06	0.95	2.86	0	676.94	3925.04	2645.8	248.39	0	56.88	25314.29	35.51	0	12.66	0	40.2	0	14.07	0	0	0	0	5.74										185 per day	185 per day	100 per day	Full Coverage	100 Copay	20 Coinsurance	20 Coinsurance	50 Copay	200 Copay	Full Coverage	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	30 Copay	30 Copay	20 Coinsurance	20 Coinsurance	30 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	20 Coinsurance	Full Coverage	Full Coverage	Full Coverage	30 Copay	150 Maximum Benefit every two years	30 Copay	NA	NA	Written health education materials nutrition training smoking cessation etc.	NA	20 Coinsurance on PR/OT/ST										585.32	489.63	811.7	0	12.36	0.15	0.15	4.73	25.86	0	0.15	0.15	0	1.59	10	30	30	0	0.07	1.21	0.2	0	0	0	30	0	30	0	0	0	0	0.15										27.38	0.69	3.39	-	0.68	2.11	0.85	1.32	0.75	-	0.15	0.44	-	0.09	3.27	6.61	0.62	-	4.2	2.55	7.1	-	-	-	0.1	-	0.04	-	-	-	-	0.89	-	-	-	-	-	-	-	-	-	63.24	0	12.69	27.38	0.69	3.39	-	0.68	2.11	0.85	1.32	0.75	-	0.15	0.44	-	0.09	3.27	6.61	0.62	-	4.2	2.55	7.1	-	-	-	0.1	-	0.04	-	-	-	-	0.89	-	-	-	-	-	-	-	-	-	63.24	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	27.38	0.69	3.39	-	0.68	2.11	0.85	1.32	0.75	-	0.15	0.44	-	0.09	3.27	6.61	0.62	-	4.2	2.55	7.1	-	-	-	0.1	-	0.04	-	-	-	-	0.89	-	-	-	-	-	-	-	-	-	63.24
H2667_012_0	2007	6	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	343.21	19.1	25.84	8.97	271.61	10.83	22.76	3554.1	52.43	820.4	1.26	1.89	0	1601.51	4241.46	2019.89	142.93	0	56.19	30819.89	24.65	0	119.89	0	2.56	0	0	0	0	0	0	6.3										150/day 750/admit	150/day 750/admit	125/day for days 11-100	Full Coverage	100 Copay	20 Coinsurance	20 Coinsurance	50 Copay - Waived if Admitted	150 Copay	Full Coverage	20 Coinsurance with a 2400 MOOP	20 Coinsurance	Full Coverage	25 Urgent Care Copay;  Full Coverage on all other benefits	15 Copay	30 Copay	30 Copay	20 Coinsurance	20 Coinsurance with a 2400 MOOP	30 Chiropractor and Podiatrist Copay; Full Coverage on all other benefits	20 Coinsurance	20 Coinsurance	Full Coverage	N/A	Full Coverage	N/A	N/A	N/A	N/A	N/A	N/A	20 Coinsurance on PT/OT/ST; Full Coverage on all other benefits										448.7	416.29	368.15	0	6	0.2	0.2	6	37.56	0	0.15	0.2	0	1.07	15	30	30	0	0.08	0.45	0.2	0	0	0	0	0	0	0	0	0	0	0										12.83	0.66	0.79	-	0.14	2.17	4.55	1.78	0.16	-	0.19	0.38	-	0.14	5.3	5.05	0.36	-	4.61	1.17	4.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.21	0	0	12.83	0.66	0.79	-	0.14	2.17	4.55	1.78	0.16	-	0.19	0.38	-	0.14	5.3	5.05	0.36	-	4.61	1.17	4.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.21	None																																																																																			-	0	0	12.83	0.66	0.79	-	0.14	2.17	4.55	1.78	0.16	-	0.19	0.38	-	0.14	5.3	5.05	0.36	-	4.61	1.17	4.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.21
H2667_013_0	2007	4	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	529.67	20.24	29.53	11.67	433.29	10.41	4.35	2556.46	345.37	5407.67	1.34	2.34	0	677.42	3568.83	2992.4	254.25	0	50.01	27740.98	32.74	0	9.61	0	42.74	0	15.02	0	0	0	0	8.95										185 per day	185 per day	100 per day	Full Coverage	100 Copay	20 Coinsurance	20 Coinsurance	50 Copay	200 Copay	Full Coverage	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	20 Coinsurance	20 Coinsurance	25 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	20 Coinsurance	Full Coverage	Full Coverage	Full Coverage	25 Copay	150 Maximum Benefit	25 Copay	NA	NA	Education Materials	NA	20 Coinsurance on PR/OT/ST										541.59	437.64	894.8	0	13.62	0.17	0.17	5.21	20.31	0	0.17	0.17	0	2.07	10	20	20	0	0.08	0.89	0.2	0	0	0	20	0	20	0	0	0	0	0.17										23.91	0.74	2.2	-	0.49	1.77	0.74	1.11	0.58	-	0.23	0.4	-	0.12	2.97	4.99	0.42	-	4.05	2.07	6.55	-	-	-	0.07	-	0.03	-	-	-	-	1.52	-	-	-	-	-	-	-	-	-	54.96	0	6.94	23.91	0.74	2.2	-	0.49	1.77	0.74	1.11	0.58	-	0.23	0.4	-	0.12	2.97	4.99	0.42	-	4.05	2.07	6.55	-	-	-	0.07	-	0.03	-	-	-	-	1.52	-	-	-	-	-	-	-	-	-	54.96	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	23.91	0.74	2.2	-	0.49	1.77	0.74	1.11	0.58	-	0.23	0.4	-	0.12	2.97	4.99	0.42	-	4.05	2.07	6.55	-	-	-	0.07	-	0.03	-	-	-	-	1.52	-	-	-	-	-	-	-	-	-	54.96
H2667_014_0	2007	4	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	561.35	16.96	50.11	13.87	660.66	14.11	5.68	3351.72	349.92	6678.06	1	2.96	0	676.94	3886.17	2645.38	248.39	0	59.13	25250.25	36.85	0	12.66	0	40.2	0	14.07	0	0	0	0	6.11										200 per day	200 per day	100 per day	Full Coverage	100 Copay	20 Coinsurance	20 Coinsurance	50 Copay	200 Copay	Full Coverage	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay for Urgent Care; 0 Copay for everything else	15 Copay	25 Copay	25 Copay	20 Coinsurance	20 Coinsurance	25 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	20 Coinsurance	Full Coverage	Full Coverage	Full Coverage	30 Copay	150 Maximum Benefit every two years	30 Copay	NA	NA	Written health education materials nutrition training smoking cessation etc.	NA	20 Coinsurance on PR/OT/ST										645.98	540.37	828.64	0	12.61	0.16	0.16	4.83	35.2	0	0.16	0.16	0	1.62	15	25	25	0	0.08	1.01	0.2	0	0	0	30	0	30	0	0	0	0	0.16										30.22	0.76	3.46	-	0.69	2.22	0.9	1.35	1.03	-	0.16	0.47	-	0.09	4.86	5.51	0.52	-	4.46	2.14	7.37	-	-	-	0.1	-	0.04	-	-	-	-	0.96	-	-	-	-	-	-	-	-	-	67.3	0	12.57	30.22	0.76	3.46	-	0.69	2.22	0.9	1.35	1.03	-	0.16	0.47	-	0.09	4.86	5.51	0.52	-	4.46	2.14	7.37	-	-	-	0.1	-	0.04	-	-	-	-	0.96	-	-	-	-	-	-	-	-	-	67.3	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	30.22	0.76	3.46	-	0.69	2.22	0.9	1.35	1.03	-	0.16	0.47	-	0.09	4.86	5.51	0.52	-	4.46	2.14	7.37	-	-	-	0.1	-	0.04	-	-	-	-	0.96	-	-	-	-	-	-	-	-	-	67.3
H2667_015_0	2007	7	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	343.21	19.1	25.84	8.63	271.61	10.41	21.89	3554.1	52.43	820.4	1.21	1.82	0	1601.51	4241.46	2019.89	142.93	0	54.03	30819.89	23.7	0	119.89	0	2.56	0	0	0	0	0	0	6.05										150/day 750/admit	150/day 750/admit	125/day for days 11-100	Full Coverage	50 Copay	20 Coinsurance	20 Coinsurance	50 Copay - Waived if Admitted	150 Copay	Full Coverage	20 Coinsurance with a 2400 MOOP	20 Coinsurance	Full Coverage	25 Urgent Care Copay;  Full Coverage on all other benefits	15 Copay	30 Copay	30 Copay	20 Coinsurance	20 Coinsurance with a 2400 MOOP	30 Chiropractor and Podiatrist Copay; Full Coverage on all other benefits	20 Coinsurance	20 Coinsurance	Full Coverage	N/A	Full Coverage	N/A	N/A	N/A	N/A	N/A	N/A	Full Coverage on all other benefits										448.65	416.29	368.15	0	6	0.2	0.2	6	37.56	0	0.15	0.2	0	1.07	15	30	30	0	0.08	0.45	0.2	0	0	0	0	0	0	0	0	0	0	0										12.83	0.66	0.79	-	0.14	2.08	4.38	1.78	0.16	-	0.19	0.36	-	0.14	5.3	5.05	0.36	-	4.43	1.17	4.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.56	0	0	12.83	0.66	0.79	-	0.14	2.08	4.38	1.78	0.16	-	0.19	0.36	-	0.14	5.3	5.05	0.36	-	4.43	1.17	4.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.56	None																																																																																			-	0	0	12.83	0.66	0.79	-	0.14	2.08	4.38	1.78	0.16	-	0.19	0.36	-	0.14	5.3	5.05	0.36	-	4.43	1.17	4.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.56
H2667_803_0	2007	3	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	289.89	20.15	23.2	7.36	234.17	10.13	21.4	2920.46	49.69	727.93	1.12	1.66	0	1505.8	4198.59	1941.02	147.84	0	58.4	31761.49	28.05	0	83.41	0	1.16	0	0	0	0	0	0	6.46										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	20 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage	NA	NA	NA	NA	Full Coverage										308.74	277.53	0	0	16	0	0	6.13	26.41	0	0	0	0	3.63	10	20	20	0	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0										7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	None																																																																																			-	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91
H2667_804_0	2007	4	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	367.37	20.72	13.63	7.22	292.97	10.43	4.88	2000.26	347.79	5432.69	1.39	2.61	0	630.01	3227.84	3608.39	264.57	0	56.09	29236.53	30.2	0	3.32	10.06	58.13	0	33.49	0	0	0	0	7.4										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	25 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage										302.81	272.3	0	0	15.7	0	0	6.01	22.49	0	0	0	0	1.87	10	20	20	0	0	0.92	0	0	0	0	0	0	0	0	0	0	0	0										9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	0	0.23	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27
H2667_805_0	2007	3	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	289.89	20.15	23.2	7.36	234.17	10.13	21.4	2920.46	49.69	727.93	1.12	1.66	0	1505.8	4198.59	1941.02	147.84	0	58.4	31761.49	28.05	0	83.41	0	1.16	0	0	0	0	0	0	6.46										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	20 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage	NA	NA	NA	NA	Full Coverage										308.74	277.53	0	0	16	0	0	6.13	26.41	0	0	0	0	3.63	10	20	20	0	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0										7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	None																																																																																			-	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91
H2667_806_0	2007	3	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	367.37	20.72	13.63	7.22	292.97	10.43	4.88	2000.26	347.79	5432.69	1.39	2.61	0	630.01	3227.84	3608.39	264.57	0	56.09	29236.53	30.2	0	3.32	10.06	58.13	0	33.49	0	0	0	0	7.4										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	25 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage										302.81	272.3	0	0	15.7	0	0	6.01	22.49	0	0	0	0	1.87	10	20	20	0	0	0.92	0	0	0	0	0	0	0	0	0	0	0	0										9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	0	0.23	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27
H2667_807_0	2007	4	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	289.89	20.15	23.2	7.36	234.17	10.13	21.4	2920.46	49.69	727.93	1.12	1.66	0	1505.8	4198.59	1941.02	147.84	0	58.4	31761.49	28.05	0	83.41	0	1.16	0	0	0	0	0	0	6.46										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	20 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage	NA	NA	NA	NA	Full Coverage										308.74	277.53	0	0	16	0	0	6.13	26.41	0	0	0	0	3.63	10	20	20	0	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0										7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	None																																																																																			-	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91
H2667_808_0	2007	4	h.6.										OP Facility - Other										None	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	289.89	20.15	23.2	7.36	234.17	10.13	21.4	2920.46	49.69	727.93	1.12	1.66	0	1505.8	4198.59	1941.02	147.84	0	58.4	31761.49	28.05	0	83.41	0	1.16	0	0	0	0	0	0	6.46										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	20 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage	NA	NA	NA	NA	Full Coverage										308.74	277.53	0	0	16	0	0	6.13	26.41	0	0	0	0	3.63	10	20	20	0	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0										7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91	None																																																																																			-	0	0	7.46	0.47	-	-	0.31	-	-	1.49	0.11	-	-	-	-	0.46	3.5	3.24	0.25	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.91
H2667_809_0	2007	4	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	367.37	20.72	13.63	7.22	292.97	10.43	4.88	2000.26	347.79	5432.69	1.39	2.61	0	630.01	3227.84	3608.39	264.57	0	56.09	29236.53	30.2	0	3.32	10.06	58.13	0	33.49	0	0	0	0	7.4										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	25 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage										302.81	272.3	0	0	15.7	0	0	6.01	22.49	0	0	0	0	1.87	10	20	20	0	0	0.92	0	0	0	0	0	0	0	0	0	0	0	0										9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	0	0.23	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27
H2667_810_0	2007	3	h.6.										OP Facility - Other										3200	Other Coin										A	A	A	Coin	P	Coin	Coin	P	P	P	Coin	Coin	Coin	P	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	None	367.37	20.72	13.63	7.22	292.97	10.43	4.88	2000.26	347.79	5432.69	1.39	2.61	0	630.01	3227.84	3608.39	264.57	0	56.09	29236.53	30.2	0	3.32	10.06	58.13	0	33.49	0	0	0	0	7.4										100 per day 500 per stay	100 per day 500 per stay	Full Coverage	Full Coverage	100 Copay	Full Coverage	Full Coverage	50 Copay	100 Copay	Full Coverage	Full Coverage	Full Coverage	Full Coverage	25 Copay for Urgent Care; 0 Copay for everything else	10 Copay	20 Copay	20 Copay	Full Coverage	Full Coverage	25 Copay for Chiropractic Mental Health Podiatrist; Full Coverage for everything else	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	Full Coverage	NA	NA	NA	Full Coverage										302.81	272.3	0	0	15.7	0	0	6.01	22.49	0	0	0	0	1.87	10	20	20	0	0	0.92	0	0	0	0	0	0	0	0	0	0	0	0										9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	0	0.23	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0	0	9.27	0.47	-	-	0.38	-	-	1	0.65	-	-	-	-	0.1	2.69	6.01	0.44	-	-	2.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.27
H2672_001_0	2007	6	H.6.	H.7.	H.8.	I.7.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							3000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V																																																-	0	1758.94	87.2	918.36		213.88	12.13	1.47	351.49	576.52		398.6			65.65	4482.49	4154.83	218.79	867.06	274.59		23.53				629.06						448.57			2.71								1a 180 days 1-7	1b 100 days 1-90	2 100 days 8-100		10a 100	11a 20	11b 20	4a 50	9a 1509b 150		8a 208b 100			9d 35	17a 107a 107f 10	17a 3518a 357b 357d 357f 35	7e 35	7c 357i 35	8a 208b 100		0.2				17a 35						14c 107f 35			4b 10								104.25	61.61	47.73		77.94	0.16	0.16	34.14	82.16		67.42			25.6	7.66	23.58	22.73	24.77	25.08		0.16				6.99						4.78			7.79								15.28	0.45	3.65	-	1.39	1.89	0.23	1	3.95	-	2.24	-	-	0.14	2.86	8.16	0.41	1.79	0.57	-	3.67	-	-	-	0.37	-	-	-	-	-	0.18	-	-	0	-	-	-	-	-	-	-	48.23		13.03	15.28	0.45	3.65	-	1.39	1.89	0.23	1	3.95	-	2.24	-	-	0.14	2.86	8.16	0.41	1.79	0.57	-	3.67	-	-	-	0.37	-	-	-	-	-	0.18	-	-	0	-	-	-	-	-	-	-	48.23																																																																																				-		0	15.28	0.45	3.65	-	1.39	1.89	0.23	1	3.95	-	2.24	-	-	0.14	2.86	8.16	0.41	1.79	0.57	-	3.67	-	-	-	0.37	-	-	-	-	-	0.18	-	-	0	-	-	-	-	-	-	-	48.23
H2672_003_0	2007	5	H.6.	H.7.	H.8.	I.7.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							5000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V																																																-	0	1755.99	76.76	852.03		210.9	11.63	1.46	350.74	573.79		401.76			67.6	4532.17	4215.52	218.12	857.07	278.95		22.87				623.86						448.26			2.03								1a 180 days 1-10	1b 180 days 1-10 max 3000	2 90 days 5-100		10a 150	11a 20	11b 20	4a 50	9a 2009b 200		8a 208b 100			9d 35	17a 157a 157f 15	17a 3518a 357b 357d 357f 35	7e 35	7c 357i 35	8a 208b 100		0.2				17a 35						14c 157f 35			4b 15								127.8	86.49	68.59		132.64	0.18	0.18	38.73	124.29		74.06			28.13	13.03	26.79	25.8	28.1	28.39		0.18				10.47						8.1			13.26								18.7	0.55	4.87	-	2.33	2.06	0.26	1.13	5.94	-	2.48	-	-	0.16	4.92	9.41	0.47	2.01	0.66	-	4.05	-	-	-	0.54	-	-	-	-	-	0.3	-	-	0	-	-	-	-	-	-	-	60.85		7.59	18.7	0.55	4.87	-	2.33	2.06	0.26	1.13	5.94	-	2.48	-	-	0.16	4.92	9.41	0.47	2.01	0.66	-	4.05	-	-	-	0.54	-	-	-	-	-	0.3	-	-	0	-	-	-	-	-	-	-	60.85																																																																																				-		0	18.7	0.55	4.87	-	2.33	2.06	0.26	1.13	5.94	-	2.48	-	-	0.16	4.92	9.41	0.47	2.01	0.66	-	4.05	-	-	-	0.54	-	-	-	-	-	0.3	-	-	0	-	-	-	-	-	-	-	60.85
H2672_007_0	2007	8	H.6.	H.7.	H.8.	I.7.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional								Radiology Copay	Lab Copay	Urgent Care	Lab Copay							D	D	D	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	V	P	V	P	P	P	P	V	V	Coin	V																																																-		1906.41	83.34	925.01		15.07	12.94	1.63	379.32	60.92		29.27	0.26		0.22	4865.62	4560.9	2.36	6.56	9.35	0.03	25.23				674.99		414.67				482.71			0.02								1a 300 days 1-7	1b 300 days 1-7 max 3000	2 100 days 8-100		10a 20	11a 20	11b 20	4a 50	9b 20		8a 20	9a 20		9d 20	17a 157a 157f 15	17a 3518a 357b 357d 357f 35	7e 20	7c 207i 20	8a 20	7e 207g 35	0.2				17a 35		18a 35				14c 157f 35			4b 20								223.04	136.92	61.25		0.2	0.2	0.2	43.8	0.2		0.2	0.2		0.2	14.74	30.3	0.2	0.2	0.2	0.2	0.2				10.47		12.12				9.15			0.2								35.43	0.95	4.72	-	3.01	2.59	0.33	1.38	12.18	-	5.85	0.05	-	0.04	5.97	11.52	0.47	1.31	1.87	0.01	5.05	-	-	-	0.59	-	0.42	-	-	-	0.37	-	-	0	-	-	-	-	-	-	-	94.13		0	35.43	0.95	4.72	-	3.01	2.59	0.33	1.38	12.18	-	5.85	0.05	-	0.04	5.97	11.52	0.47	1.31	1.87	0.01	5.05	-	-	-	0.59	-	0.42	-	-	-	0.37	-	-	0	-	-	-	-	-	-	-	94.13																																																																																				-		0	35.43	0.95	4.72	-	3.01	2.59	0.33	1.38	12.18	-	5.85	0.05	-	0.04	5.97	11.52	0.47	1.31	1.87	0.01	5.05	-	-	-	0.59	-	0.42	-	-	-	0.37	-	-	0	-	-	-	-	-	-	-	94.13
H2672_801_0	2007	3	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							0	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-	0	232.69	2.9	15.54		12.69	12.4	1.56	9.23	63.86	3.97	22.4	0.49	0.08	7.4	73.49	108.44	3.64	6.74	36.91	8.57	26.57	0.03												0.03	2.87							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43																																																																																				-		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43
H2672_802_0	2007	4	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							0	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-	0	232.69	2.9	15.54		12.69	12.4	1.56	9.23	63.86	3.97	22.4	0.49	0.08	7.4	73.49	108.44	3.64	6.74	36.91	8.57	26.57	0.03												0.03	2.87							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43																																																																																				-		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43
H2672_803_0	2007	2	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							0	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-	0	232.69	2.9	15.54		12.69	12.4	1.56	9.23	63.86	3.97	22.4	0.49	0.08	7.4	73.49	108.44	3.64	6.74	36.91	8.57	26.57	0.03												0.03	2.87							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43																																																																																				-		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43
H2672_804_0	2007	2	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							0	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-	0	232.69	2.9	15.54		12.69	12.4	1.56	9.23	63.86	3.97	22.4	0.49	0.08	7.4	73.49	108.44	3.64	6.74	36.91	8.57	26.57	0.03												0.03	2.87							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43																																																																																				-		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43
H2672_805_0	2007	3	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							0	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-	0	232.69	2.9	15.54		12.69	12.4	1.56	9.23	63.86	3.97	22.4	0.49	0.08	7.4	73.49	108.44	3.64	6.74	36.91	8.57	26.57	0.03												0.03	2.87							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43																																																																																				-		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43
H2672_806_0	2007	3	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							0	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-	0	232.69	2.9	15.54		12.69	12.4	1.56	9.23	63.86	3.97	22.4	0.49	0.08	7.4	73.49	108.44	3.64	6.74	36.91	8.57	26.57	0.03												0.03	2.87							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43																																																																																				-		0	18.7	0.23	2.78	-	2.99	2.93	0.37	2.18	15.07	0.94	5.29	0.12	0.02	1.75	17.34	25.59	0.86	1.59	8.71	2.02	6.27	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.68	-	-	-	-	-	-	116.43
H2701_001_0	2007	3																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	258.96	2.56	1095.39	0	238.19	20.45	0.96	530.32	520.09	3390.58	1719.07	0	0.16	2628.43	2993.87	3892.66	117.01	378.27	0	184.33	7.54	596.94	0	0	267.97	0	114.94	0	0	0	0											100 Per Admit	100 Per Admit	30 copay	0 copay	100 copay	20 coinsurance	20 coinsurance	50 ER / 25 UC	75 ASC / 75 OP	15 copay	15 copay	0 copay	15 copay	15 OP SA / 15 Cardiac Rehab	15 PCP	15 SCP / 15 Chiro / 15 Podiatrist	15 MH	15 Therapy	0 copay	15 Hearing / 15 Preventive	10 coinsurance	15 Vision		0	15 copay	0	15 copay				0											100	100	30	0	100	0.2	0.2	41.54	75	15	15	0	0.12	15	14.95	15.01	15	15	0	14.11	0.1	14.05	0	0	15	0	15	0	0	0	0											2.16	0.02	2.74	-	1.98	4.14	0.19	1.84	3.25	4.24	2.15	-	0.02	3.29	3.73	4.87	0.15	0.47	-	0.22	0.75	0.7	-	-	0.33	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39	0	0	2.16	0.02	2.74	-	1.98	4.14	0.19	1.84	3.25	4.24	2.15	-	0.02	3.29	3.73	4.87	0.15	0.47	-	0.22	0.75	0.7	-	-	0.33	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.39	none	150 Per Day: 1-4	150 Per Day: 1-4	30 copay	25 copay	100 copay	50 coinsurance	50 coinsurance	50 ER / 25 UC	150 ASC / 150 OP	25 copay	25 copay	0 copay	25 copay	25 OP SA / 25 Cardiac Rehab	25 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MH	25 Therapy	0 copay	25 Hearing / 25 Preventive	20 coinsurance	25 Vision		0	25 copay	0	25 copay				0											1.55	0.02	0.3	0.25	0.22	1.08	0.05	0.2	0.73	0.78	0.4	0	0	0.61	0.65	0.82	0.03	0.08	0	0.04	0.17	0.12	0	0	0.06	0	0.03	0	0	0	0											8.2	0	0	3.7	0.04	3.04	0.25	2.2	5.23	0.24	2.04	3.98	5.02	2.55	-	0.02	3.89	4.38	5.69	0.17	0.55	-	0.25	0.93	0.82	-	-	0.4	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.58
H2701_003_0	2007	5																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	810.09	12.15	1054.01	1100.1	231.95	20.01	0.94	516.04	509.71	3263.45	1686.36	0	0.16	2560.47	2765.84	3592.43	108.28	349.93	0	169.82	7.39	558.07	0	0	248.05	0	106	0	0	0	0											150 Per Day: 1-9	150 Per Day: 1-9	0 Per Day: 1-4; 75 Per Day: 5-100	25 copay	100 copay	20 coinsurance	20 coinsurance	50 ER / 25 UC	100 ASC / 100 OP	25 copay	25 copay	0 copay	25 copay	25 OP SA / 25 Cardiac Rehab	25 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MH	25 Therapy	0 copay	25 Hearing / 25 Preventive	20 coinsurance	25 Vision		0	25 copay	0	25 copay				0											150	150	56.74	25	100	0.22	0.2	41.54	100	25	25	0	0.2	25	24.91	25.02	25	25	0	23.42	0.2	23.93	0	0	25	0	25	0	0	0	0											10.13	0.15	4.98	2.29	1.93	4.44	0.19	1.79	4.25	6.8	3.51	-	0.03	5.33	5.74	7.49	0.23	0.73	-	0.33	1.48	1.11	-	-	0.52	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68	0	0	10.13	0.15	4.98	2.29	1.93	4.44	0.19	1.79	4.25	6.8	3.51	-	0.03	5.33	5.74	7.49	0.23	0.73	-	0.33	1.48	1.11	-	-	0.52	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68	none	225 Per Day: 1-9	225 Per Day: 1-9	0 Per Day: 1-4; 75 Per Day: 5-100	50 copay	100 copay	50 coinsurance	50 coinsurance	50 ER / 25 UC	200 ASC / 200 OP	50 copay	50 copay	0 copay	50 copay	50 OP SA / 50 Cardiac Rehab	50 PCP	50 SCP / 50 Chiro / 50 Podiatrist	50 MH	50 Therapy	0 copay	50 Hearing / 50 Preventive	30 coinsurance	50 Vision		0	50 copay	0	50 copay				0											1.72	0.03	0.55	0.48	0.21	1.16	0.05	0.2	0.95	1.17	0.76	0	0.01	1.1	1.16	1.33	0.05	0.09	0	0.06	0.25	0.23	0	0	0.11	0	0.05	0	0	0	0											11.73	0	0	11.85	0.18	5.54	2.77	2.15	5.6	0.24	1.99	5.2	7.97	4.28	-	0.04	6.43	6.9	8.82	0.27	0.82	-	0.39	1.73	1.34	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.4
H2701_805_0	2007	1																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	182.44	1.4	31.02	0	5.67	20.28	0.93	5.31	25.94	10.09	27.6	0	0.14	26.69	27.1	83.12	0.78	2.63	14.42	14	7.46	3.99	0	0	0	0	0	0	0	0	0											Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-20 0/day; days 21-100 125/day	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	20-50 coinsurance depending on APC	20-50 coinsurance depending on APC	0 coinsurance	20-50 coinsurance depending on APC	0 copay	20 coinsurance	20-50 coinsurance depending on APC	20 coinsurance	20 coinsurance	50 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		0	0	0	0				0											0.09	0.09	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.26	0.12	4.87	-	1.34	4.78	0.22	1.25	6.12	2.38	6.51	-	0.03	6.3	6.4	19.62	0.18	0.62	3.4	3.3	1.76	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.42	0	0	16.26	0.12	4.87	-	1.34	4.78	0.22	1.25	6.12	2.38	6.51	-	0.03	6.3	6.4	19.62	0.18	0.62	3.4	3.3	1.76	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.42	none	Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-20 0/day; days 21-100 125/day	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	20-50 coinsurance depending on APC	20-50 coinsurance depending on APC	0 coinsurance	20-50 coinsurance depending on APC	0 copay	20 coinsurance	20-50 coinsurance depending on APC	20 coinsurance	20 coinsurance	50 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		0	0	0	0				0											1.82	0.01	0.55	0	0.15	0.54	0.02	0.14	0.69	0.27	0.73	0	0	0.71	0.72	2.2	0.02	0.07	0.38	0.37	0.2	0.11	0	0	0	0	0	0	0	0	0											9.67	0	0	18.08	0.14	5.42	-	1.49	5.32	0.25	1.39	6.81	2.65	7.24	-	0.04	7	7.11	21.81	0.2	0.69	3.78	3.67	1.96	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.1
H2701_806_0	2007	1																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	182.44	1.4	31.02	0	5.67	20.28	0.93	5.31	25.94	10.09	27.6	0	0.14	26.69	27.1	83.12	0.78	2.63	14.42	14	7.46	3.99	0	0	0	0	0	0	0	0	0											Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-20 0/day; days 21-100 125/day	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	20-50 coinsurance depending on APC	20-50 coinsurance depending on APC	0 coinsurance	20-50 coinsurance depending on APC	0 copay	20 coinsurance	20-50 coinsurance depending on APC	20 coinsurance	20 coinsurance	50 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		0	0	0	0				0											0.09	0.09	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.26	0.12	4.87	-	1.34	4.78	0.22	1.25	6.12	2.38	6.51	-	0.03	6.3	6.4	19.62	0.18	0.62	3.4	3.3	1.76	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.42	0	0	16.26	0.12	4.87	-	1.34	4.78	0.22	1.25	6.12	2.38	6.51	-	0.03	6.3	6.4	19.62	0.18	0.62	3.4	3.3	1.76	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.42	none	Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-60 initial deductible of 1000; days 61-90 250/day; days 91-150 500/day	Days 1-20 0/day; days 21-100 125/day	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	20-50 coinsurance depending on APC	20-50 coinsurance depending on APC	0 coinsurance	20-50 coinsurance depending on APC	0 copay	20 coinsurance	20-50 coinsurance depending on APC	20 coinsurance	20 coinsurance	50 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		0	0	0	0				0											1.82	0.01	0.55	0	0.15	0.54	0.02	0.14	0.69	0.27	0.73	0	0	0.71	0.72	2.2	0.02	0.07	0.38	0.37	0.2	0.11	0	0	0	0	0	0	0	0	0											9.67	0	0	18.08	0.14	5.42	-	1.49	5.32	0.25	1.39	6.81	2.65	7.24	-	0.04	7	7.11	21.81	0.2	0.69	3.78	3.67	1.96	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.1
H2802_001_0	2007	13																					4600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2135.59	80.46	1290.29	0	118.11	15.46	9.75	448.74	30.29	9307.01	42.78	0	0.63	25.86	4250.34	4423.14	270.73	2.25	0	0	40.98	1430.12	0	0	18.75	724.81	221.26	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											191.91	191.91	97.58	0	113.84	0.16	0.19	31.39	0.16	1.3	0.13	0	0.2	0.16	20	30	37.5	0.16	0	0	0.2	30	0	0	30	15	30	0	0	0	0											34.15	1.29	10.49	-	1.12	2.51	1.81	1.17	4.93	1.01	5.47	-	0.12	4.2	7.08	11.06	0.85	0.37	-	-	8	3.58	-	-	0.05	0.91	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.71		40.83	34.15	1.29	10.49	-	1.12	2.51	1.81	1.17	4.93	1.01	5.47	-	0.12	4.2	7.08	11.06	0.85	0.37	-	-	8	3.58	-	-	0.05	0.91	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.71																																																																																				-			34.15	1.29	10.49	-	1.12	2.51	1.81	1.17	4.93	1.01	5.47	-	0.12	4.2	7.08	11.06	0.85	0.37	-	-	8	3.58	-	-	0.05	0.91	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.71
H2802_004_0	2007	8																					4200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2135.59	80.46	1290.29	0	118.11	15.46	9.75	448.74	30.29	9307.01	42.78	0	0.63	25.86	4250.34	4423.14	270.73	2.25	0	0	40.98	1430.12	0	0	18.75	724.81	221.26	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											182.81	182.81	92.95	0	108.44	0.19	0.22	29.9	0.15	3.72	0.12	0	0.19	0.15	20	30	37.5	0.15	0	0	0.19	30	0	0	30	15	30	0	0	0	0											32.53	1.23	9.99	-	1.07	2.87	2.1	1.12	4.69	2.88	5.21	-	0.12	4.01	7.08	11.06	0.85	0.35	-	-	7.62	3.58	-	-	0.05	0.91	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.86		46.05	32.53	1.23	9.99	-	1.07	2.87	2.1	1.12	4.69	2.88	5.21	-	0.12	4.01	7.08	11.06	0.85	0.35	-	-	7.62	3.58	-	-	0.05	0.91	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.86																																																																																				-			32.53	1.23	9.99	-	1.07	2.87	2.1	1.12	4.69	2.88	5.21	-	0.12	4.01	7.08	11.06	0.85	0.35	-	-	7.62	3.58	-	-	0.05	0.91	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.86
H2802_005_0	2007	3	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2076.58	193.36	8814.19	172.15	646.09	21.76	6.82	185.81	123.37	3838.14	170.63	33.74	4.42	286.89	125.77	1287.43	1672.43	19.76		268.82	258.76	1314.54	1200		140.2	166		54.6				109.57	0.28	0.07	300	295.2						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						132	132			66	18	18	44	22			22		22		9				9		9										31		22								22.9	2.13	-	-	3.56	3.84	1.2	0.68	0.23	-	-	0.06	-	0.53	-	0.95	-	-	-	0.2	-	0.97	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	37.53		5.01	22.9	2.13	-	-	3.56	3.84	1.2	0.68	0.23	-	-	0.06	-	0.53	-	0.95	-	-	-	0.2	-	0.97	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	37.53																																																																																				-		0	22.9	2.13	-	-	3.56	3.84	1.2	0.68	0.23	-	-	0.06	-	0.53	-	0.95	-	-	-	0.2	-	0.97	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	37.53
H2803_001_0	2007	9																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1442.13	103.73	613.27	0	69.86	13.51	6.77	340.9	21.93	5714.53	28.08	0	0.35	20.48	3514.71	4261.73	387.48	2	0	0	35.57	1088.93	0	0	31.45	696.46	197.64	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											206.21	206.21	104.85	0	122.33	0.17	0.19	33.65	0.17	1.4	0.14	0	0.21	0.17	20	30	37.5	0.17	0	0	0.21	30	0	0	30	15	30	0	0	0	0											24.78	1.78	5.36	-	0.71	2.36	1.3	0.96	3.83	0.67	3.91	-	0.07	3.58	5.86	10.65	1.21	0.35	-	-	7.46	2.72	-	-	0.08	0.87	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.01		24.43	24.78	1.78	5.36	-	0.71	2.36	1.3	0.96	3.83	0.67	3.91	-	0.07	3.58	5.86	10.65	1.21	0.35	-	-	7.46	2.72	-	-	0.08	0.87	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.01	4600	325 (1a)	325 (1b)	150 (2a)	25 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 25 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	25 (7c 7i)	25 (incl in h2)	25 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 25 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											1.9	0.14	1.51	0.23	0.08	0.28	0.15	0.39	1.49	0.78	1.32	0	0.03	1.39	0.83	1.25	0.16	0.04	0	0	0.88	0.32	0	0	0.01	0	0.06	0	0	0	0											13.22		4.45	26.68	1.92	6.87	0.23	0.8	2.64	1.45	1.34	5.32	1.44	5.23	-	0.1	4.97	6.68	11.9	1.37	0.39	-	-	8.34	3.04	-	-	0.09	0.87	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.23
H2803_002_0	2007	12																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1714.47	95.52	753.75	0	90.19	12.87	5.73	372.18	23.91	5808.82	27.8	0	0.41	21.33	3595.23	3976.04	320.41	2.52	0	0	26.78	1113.62	0	0	31.01	762.85	193.65	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											200.86	200.86	102.13	0	119.16	0.17	0.2	32.52	0.17	1.36	0.13	0	0.2	0.17	20	30	37.5	0.17	0	0	0.2	30	0	0	30	15	30	0	0	0	0											28.7	1.6	6.42	-	0.9	2.19	1.13	1.01	4.07	0.66	3.71	-	0.08	3.63	5.99	9.94	1	0.43	-	-	5.47	2.78	-	-	0.08	0.95	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.22		27.88	28.7	1.6	6.42	-	0.9	2.19	1.13	1.01	4.07	0.66	3.71	-	0.08	3.63	5.99	9.94	1	0.43	-	-	5.47	2.78	-	-	0.08	0.95	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.22	4600	325 (1a)	325 (1b)	150 (2a)	25 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 25 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	25 (7c 7i)	25 (incl in h2)	25 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 25 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.2	0.12	1.81	0.29	0.11	0.26	0.13	0.41	1.58	0.77	1.28	0	0.03	1.41	0.83	1.17	0.13	0.05	0	0	0.64	0.34	0	0	0.01	0	0.06	0	0	0	0											13.63		5.03	30.9	1.72	8.22	0.29	1	2.45	1.27	1.42	5.65	1.43	4.99	-	0.11	5.04	6.83	11.11	1.13	0.48	-	-	6.11	3.12	-	-	0.09	0.95	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.85
H2803_005_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1442.13	103.73	613.27	0	69.86	13.51	6.77	340.9	21.93	5714.53	28.08	0	0.35	20.48	3514.71	4261.73	387.48	2	0	0	35.57	1088.93	0	0	31.45	696.46	197.64	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											195.84	195.84	99.58	0	116.18	0.2	0.22	31.96	0.17	3.98	0.13	0	0.2	0.17	20	30	37.5	0.17	0	0	0.2	30	0	0	30	15	30	0	0	0	0											23.54	1.69	5.09	-	0.68	2.69	1.5	0.91	3.64	1.9	3.71	-	0.07	3.4	5.86	10.65	1.21	0.33	-	-	7.09	2.72	-	-	0.08	0.87	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.12		28.24	23.54	1.69	5.09	-	0.68	2.69	1.5	0.91	3.64	1.9	3.71	-	0.07	3.4	5.86	10.65	1.21	0.33	-	-	7.09	2.72	-	-	0.08	0.87	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.12	4100	325 (1a)	325 (1b)	150 (2a)	25 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 25 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	25 (7c 7i)	25 (incl in h2)	25 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 25 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											1.8	0.13	1.44	0.23	0.08	0.32	0.18	0.37	1.42	0.74	1.26	0	0.03	1.32	0.83	1.25	0.16	0.04	0	0	0.83	0.32	0	0	0.01	0	0.06	0	0	0	0											12.79		5	25.34	1.82	6.52	0.23	0.76	3.01	1.67	1.27	5.06	2.63	4.97	-	0.1	4.72	6.68	11.9	1.37	0.37	-	-	7.92	3.04	-	-	0.09	0.87	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.9
H2803_006_0	2007	9																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1714.47	95.52	753.75	0	90.19	12.87	5.73	372.18	23.91	5808.82	27.8	0	0.41	21.33	3595.23	3976.04	320.41	2.52	0	0	26.78	1113.62	0	0	31.01	762.85	193.65	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											190.57	190.57	96.9	0	113.05	0.19	0.23	30.86	0.16	3.88	0.13	0	0.19	0.16	20	30	37.5	0.16	0	0	0.19	30	0	0	30	15	30	0	0	0	0											27.23	1.52	6.09	-	0.85	2.49	1.32	0.96	3.86	1.88	3.52	-	0.08	3.44	5.99	9.94	1	0.41	-	-	5.19	2.78	-	-	0.08	0.95	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.06		31.91	27.23	1.52	6.09	-	0.85	2.49	1.32	0.96	3.86	1.88	3.52	-	0.08	3.44	5.99	9.94	1	0.41	-	-	5.19	2.78	-	-	0.08	0.95	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.06	4100	325 (1a)	325 (1b)	150 (2a)	25 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 25 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	25 (7c 7i)	25 (incl in h2)	25 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 25 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.09	0.12	1.72	0.29	0.1	0.29	0.16	0.39	1.5	0.73	1.21	0	0.03	1.34	0.83	1.17	0.13	0.05	0	0	0.61	0.34	0	0	0.01	0	0.06	0	0	0	0											13.15		5.62	29.31	1.63	7.8	0.29	0.95	2.79	1.48	1.35	5.36	2.61	4.73	-	0.11	4.78	6.83	11.11	1.13	0.46	-	-	5.8	3.12	-	-	0.09	0.95	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.21
H2803_010_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2259.41	357.51	1150.98		268.26	27.88	24.16	919.28	398.59	2091.24	981.12	67.9	3.45	2064.41		3562.98		540.86		829.32												294.28		158.42	235.67							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							6.64	1.05	1.62	-	0.79	2.62	2.27	1.3	0.39	0.82	0.38	0.07	0.32	2.02	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.52		25.34	6.64	1.05	1.62	-	0.79	2.62	2.27	1.3	0.39	0.82	0.38	0.07	0.32	2.02	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.52		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.3	0.16	0.3	0.38	0.07	0.17	0.15	0.05	0.2	0.14	0.14	0.02	0.02	0.22	0.34	0.22	0.05	0.03	0.15	0.71	0.14	0																				5.99		0	8.95	1.21	1.93	0.38	0.86	2.79	2.42	1.35	0.59	0.96	0.52	0.08	0.34	2.25	0.34	1.62	0.05	0.25	0.15	1.04	0.14	0	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	28.5
H2803_011_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2282.05	212.49	7991.21	149.77	562.1	17.34	5.44	161.66	107.33	3339.17	148.45	29.35	3.84	249.59	111.84	1120.06	1455.02	17.19		233.87	236.97	1143.65	1140		133.19	157.7		51.87				95.32	0.24	0.06	285	280.44						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						132	132			66	18	18	44	22			22		22		9				9		9										31		22								25.1	2.34	-	-	3.09	3.05	0.96	0.59	0.2	-	-	0.05	-	0.46	-	0.82	-	-	-	0.17	-	0.84	-	-	-	-	-	-	-	-	-	0.24	-	0	-	-	-	-	-	-	-	37.91		5.18	25.1	2.34	-	-	3.09	3.05	0.96	0.59	0.2	-	-	0.05	-	0.46	-	0.82	-	-	-	0.17	-	0.84	-	-	-	-	-	-	-	-	-	0.24	-	0	-	-	-	-	-	-	-	37.91		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						2.79	0.08	0.72	0.07	0.32	0.27	0.09	0.04	0.17	0.52	0.58	0.03	0	0.1	0.01	1.5	0.14	0		0.15		0.1	0.06		0.02							0.01	0	0	0.02	0.02						7.8		0	27.88	2.41	0.72	0.07	3.41	3.32	1.04	0.63	0.37	0.52	0.58	0.09	0	0.55	0.01	2.32	0.14	0	-	0.32	-	0.94	0.06	-	0.02	-	-	-	-	-	-	0.26	0	0	0.02	0.02	-	-	-	-	-	45.71
H2803_012_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2346.24	336.81	1585.38		290.96	23.99	20.01	837.89	340.11	2006.31	835.24	59.73	2.65	1853.05		3340.25		478.45		769.81												294.34		136.96	232.58							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							6.99	1	2.27	-	0.87	2.29	1.91	1.2	0.34	0.8	0.33	0.06	0.25	1.84	-	1.33	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	22.21		24.41	6.99	1	2.27	-	0.87	2.29	1.91	1.2	0.34	0.8	0.33	0.06	0.25	1.84	-	1.33	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	22.21		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.03	0.13	0.37	0.37	0.07	0.15	0.12	0.04	0.16	0.12	0.11	0.01	0.01	0.2	0.33	0.18	0.04	0.03	0.12	0.62	0.12	0																				5.33		0	9.02	1.14	2.63	0.37	0.93	2.43	2.03	1.24	0.5	0.91	0.44	0.07	0.27	2.04	0.33	1.51	0.04	0.22	0.12	0.92	0.12	0	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	27.54
H2803_801_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		2027.71	90.57	870.1	0	102.15	13.43	8.47	354.15	26.14	7568.53	35.37	0	0.09	22.45	4212.56	4788.47	324.07	2.98	0	0	49.67	1477.91	0	0	24.58	0	213.86	0	0	0	0											330 (1a)	330 (1b)	165 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											212.54	212.54	106.27	0	112.71	0.16	0.19	30.89	0.16	3.86	0.13	0	0.19	0.16	20	30	37.5	0.16	0	0	0.3	30	0	0	30	0	30	0	0	0	0											35.91	1.6	7.71	-	0.96	2.16	1.62	0.91	4.21	2.44	4.47	-	0.02	3.61	7.02	11.97	1.01	0.48	-	-	14.9	3.69	-	-	0.06	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.3		36.13	35.91	1.6	7.71	-	0.96	2.16	1.62	0.91	4.21	2.44	4.47	-	0.02	3.61	7.02	11.97	1.01	0.48	-	-	14.9	3.69	-	-	0.06	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.3	4575	360 (1a)	360 (1b)	165 (2a)	25 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 25 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	25 (7c 7i)	25 (incl in h2)	25 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 25 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.72	0.12	2.17	0.31	0.11	0.25	0.19	0.37	1.64	0.95	1.53	0	0.01	1.41	1	1.4	0.13	0.06	0	0	1.75	0.45	0	0	0.01	0	0.06	0	0	0	0											16.64		6.33	38.64	1.73	9.88	0.31	1.07	2.42	1.81	1.28	5.85	3.39	6	-	0.03	5.02	8.02	13.38	1.15	0.54	-	-	16.65	4.14	-	-	0.07	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.94
H2905_001_0	2007	6							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			1.01	0	0.17	0.02	0.04	0.08	0.02	0.11	0.08	0.03	0.03	0.03	0.03	0.03	0.12	0.12	0.12	0.12	0.12	0.12	0.03																					2.44	7500	268.1	1.23	185.81		83.59	19.5	4.88	607.46	612.31		6.37				5486.72	2366.02	209.7	3445.97	1160.68	8876.6	5.83																	45.29	3.8			500/Stay	500/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				None	25/visit	25/visit	25/visit	25/visit	None	0.25																	50	200			500	500	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			11.17	0.05	0.77	-	0.7	4.88	1.22	2.53	2.55	-	1.27	-	-	-	-	4.93	0.44	7.18	2.42	-	1.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.82	500	0	12.18	0.05	0.94	0.02	0.74	4.96	1.24	2.64	2.63	0.03	1.3	0.03	0.03	0.03	0.12	5.05	0.56	7.3	2.54	0.12	1.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	44.26	7500	912/Stay	912/Stay	40 Coins	40 Coins	40 - not l.t. 100	50 Coins	50 Coins	50	50	None	40 Coins	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.69	0	0.15	1.72	0.43	0.52	0.52	0	1.12	0	0	0	0	1.6	0.5	1.99	1.74	0	0.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		16.86	500	0	15.78	0.07	3.63	0.02	0.89	6.68	1.67	3.16	3.15	0.03	2.43	0.03	0.03	0.03	0.12	6.65	1.06	9.29	4.28	0.12	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	61.12
H2905_801_0	2007	3							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			1.01	0	0.17	0.02	0.04	0.08	0.02	0.11	0.08	0.03	0.03	0.03	0.03	0.03	0.12	0.12	0.12	0.12	0.12	0.12	0.03																					2.44	7500	268.1	1.23	185.81		83.59	19.5	4.88	607.46	612.31		6.37				5486.72	2366.02	209.7	3445.97	1160.68	8876.6	5.83																	45.29	3.8			500/Stay	500/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				None	25/visit	25/visit	25/visit	25/visit	None	0.25																	50	200			500	500	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			11.17	0.05	0.77	-	0.7	4.88	1.22	2.53	2.55	-	1.27	-	-	-	-	4.93	0.44	7.18	2.42	-	1.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.82	500	0	12.18	0.05	0.94	0.02	0.74	4.96	1.24	2.64	2.63	0.03	1.3	0.03	0.03	0.03	0.12	5.05	0.56	7.3	2.54	0.12	1.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	44.26	7500	912/Stay	912/Stay	40 Coins	40 Coins	40 - not l.t. 100	50 Coins	50 Coins	50	50	None	40 Coins	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.69	0	0.15	1.72	0.43	0.52	0.52	0	1.12	0	0	0	0	1.6	0.5	1.99	1.74	0	0.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		16.86	500	0	15.78	0.07	3.63	0.02	0.89	6.68	1.67	3.16	3.15	0.03	2.43	0.03	0.03	0.03	0.12	6.65	1.06	9.29	4.28	0.12	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	61.12
H2905_802_0	2007	3							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			1.01	0	0.17	0.02	0.04	0.08	0.02	0.11	0.08	0.03	0.03	0.03	0.03	0.03	0.12	0.12	0.12	0.12	0.12	0.12	0.03																					2.44	7500	268.1	1.23	185.81		83.59	19.5	4.88	607.46	612.31		6.37					2366.02	209.7	3445.97	1160.68		5.83																	45.29	3.8			500/Stay	500/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2					25/visit	25/visit	25/visit	25/visit		0.25																	50	200			500	500	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			11.17	0.05	0.77	-	0.7	4.88	1.22	2.53	2.55	-	1.27	-	-	-	-	4.93	0.44	7.18	2.42	-	1.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.82	500	0	12.18	0.05	0.94	0.02	0.74	4.96	1.24	2.64	2.63	0.03	1.3	0.03	0.03	0.03	0.12	5.05	0.56	7.3	2.54	0.12	1.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	44.26	7500	912/Stay	912/Stay	40 Coins	40 Coins	40 - not l.t. 100	50 Coins	50 Coins	50	50	None	40 Coins	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.69	0	0.15	1.72	0.43	0.52	0.52	0	1.12	0	0	0	0	1.61	0.5	2	1.75	0	0.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		16.9	500	0	15.78	0.07	3.63	0.02	0.89	6.68	1.67	3.16	3.15	0.03	2.43	0.03	0.03	0.03	0.12	6.67	1.06	9.31	4.29	0.12	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	61.16
H2905_803_0	2007	3							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			1.01	0	0.17	0.02	0.04	0.08	0.02	0.11	0.08	0.03	0.03	0.03	0.03	0.03	0.12	0.12	0.12	0.12	0.12	0.12	0.03																					2.44	7500	268.1	1.23	185.81		83.59	19.5	4.88	607.46	612.31		6.37				5486.72	2366.02	209.7	3445.97	1160.68	8876.6	5.83																	45.29	3.8			500/Stay	500/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				None	25/visit	25/visit	25/visit	25/visit	None	0.25																	50	200			500	500	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			11.17	0.05	0.77	-	0.7	4.88	1.22	2.53	2.55	-	1.27	-	-	-	-	4.93	0.44	7.18	2.42	-	1.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.82	500	0	12.18	0.05	0.94	0.02	0.74	4.96	1.24	2.64	2.63	0.03	1.3	0.03	0.03	0.03	0.12	5.05	0.56	7.3	2.54	0.12	1.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	44.26	7500	912/Stay	912/Stay	40 Coins	40 Coins	40 - not l.t. 100	50 Coins	50 Coins	50	50	None	40 Coins	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.69	0	0.15	1.72	0.43	0.52	0.52	0	1.12	0	0	0	0	1.6	0.5	1.99	1.74	0	0.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		16.86	500	0	15.78	0.07	3.63	0.02	0.89	6.68	1.67	3.16	3.15	0.03	2.43	0.03	0.03	0.03	0.12	6.65	1.06	9.29	4.28	0.12	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	61.12
H2905_804_0	2007	3							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			1.01	0	0.17	0.02	0.04	0.08	0.02	0.11	0.08	0.03	0.03	0.03	0.03	0.03	0.12	0.12	0.12	0.12	0.12	0.12	0.03																					2.44	7500	268.1	1.23	185.81		83.59	19.5	4.88	607.46	612.31		6.37					2366.02	209.7	3445.97	1160.68		5.83																	45.29	3.8			500/Stay	500/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2					25/visit	25/visit	25/visit	25/visit		0.25																	50	200			500	500	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			11.17	0.05	0.77	-	0.7	4.88	1.22	2.53	2.55	-	1.27	-	-	-	-	4.93	0.44	7.18	2.42	-	1.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.82	500	0	12.18	0.05	0.94	0.02	0.74	4.96	1.24	2.64	2.63	0.03	1.3	0.03	0.03	0.03	0.12	5.05	0.56	7.3	2.54	0.12	1.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	44.26	7500	912/Stay	912/Stay	40 Coins	40 Coins	40 - not l.t. 100	50 Coins	50 Coins	50	50	None	40 Coins	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.69	0	0.15	1.72	0.43	0.52	0.52	0	1.12	0	0	0	0	1.61	0.5	2	1.75	0	0.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		16.9	500	0	15.78	0.07	3.63	0.02	0.89	6.68	1.67	3.16	3.15	0.03	2.43	0.03	0.03	0.03	0.12	6.67	1.06	9.31	4.29	0.12	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	61.16
H2906_003_0	2007	5																					2500											A	A	A	V	T	Coin	Coin	V	P	Coin	Coin	P	Coin	V	V	V	V	Coin	V	V	Coin	V	T	Coin	V	Coin	Coin	Coin	P	V	P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	1107.64	26.34	61.84	73.06	218.64	12.93	8.68	577.32	238.33	3.42	1.76	35.78	0.42	6200.72	3829.48	2311.88	144.05	1.5	812.32	414.07	0	347.68	0.4	32.91	607.68	0	0	0	0	27.36	0											PBP: 1A IP Acute: 100 per stay	1B IP Psych: 100 per stay	2 SNF: 0 per stay plus 30 per day for days 35-100 only	6 Home Health: 0 Custodial Care: 0 per episode	10A Ambulance: 0	11A DME: 10	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0-10	4A ER: 50 4B Urgent Care: 15	9B ASC Services: 50	8A OP C/D/T: 10	8B OP X-Ray: 10	9A OP Hospital: 0	12 Renal Dialysis: 10	3 CORF: 10 5 Partial Hosp: 15 9C OP Substance Abuse: 15 9D Cardiac Rehab: 10	7A PCP: 10 14B Immunizations: 0 separate office visit copay applies 14C Routine Physical Exams: 0 separate office visit copay applies 14D Pap/Pelvic: 0 separate office visit copay applies 14E Prostate Screening: 0 separate office visit copay applies 14F Colorectal Screening: 50 14G Bone Mass Measurement: 0 separate office visit copay applies 14H Mammography: 0 14I Diabetes Monitoring: 0 separate office visit copay may apply	7B Chiropractic: 15 7D Physician Specialist: 15 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 15	7C Occupational Therapy: 10 7I Physical and Speech Therapy: 10	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 20	13A Blood: 10 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 15	10B Transportation: 0	16A Preventive Dental Services: 0 Additional Comprehensive Dental Coverage 20-50	17A Routine Eye Exams: 15	17B Eye Wear: No member cost sharing	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											95.75	95.75	0	0	0	0.1	0.14	47.01	47.88	0.1	0.1	0	0.1	11.67	9.48	14.36	14.36	0.1	0	14.36	0.19	14.78	0	0.29	14.36	0	0	0	0	0	0											8.84	0.21	-	-	-	1.24	1.25	2.26	0.95	0.33	0.17	-	0.04	6.03	3.03	2.77	0.17	0.14	-	0.5	-	0.43	-	9.45	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.52	0	1.71	8.84	0.21	-	-	-	1.24	1.25	2.26	0.95	0.33	0.17	-	0.04	6.03	3.03	2.77	0.17	0.14	-	0.5	-	0.43	-	9.45	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.52	0	20 Coinsurance 500 combined IP Acute and IP Psych Deductible	20 Coinsurance 500 combined IP Acute and IP Psych Deductible	20 Coinsurance	20 Coinsurance	0 Ambulance Copay	20 Coinsurance	20 Coinsurance	50 ER Copay 20 Urgent Care Coinsurane	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance											14.97	0.04	2.24	0.51	0	0.62	0.42	4.19	2.3	0.16	0.33	0.06	0.02	2.43	2.02	3.32	0.11	0.14	0.68	0.84	0	0.17	0	0	0.18	0	0	0	0	0.02	0											35.78	500	1.59	23.81	0.25	2.24	0.51	-	1.86	1.66	6.45	3.25	0.49	0.5	0.06	0.06	8.46	5.05	6.09	0.29	0.29	0.68	1.33	-	0.6	0	9.45	0.91	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	74.3
H2931_002_0	2007	3	h1.	h2.									OP Facility - Other	OP Facility - Other									1500	Complex diag	PET scans											D		Coin	Coin	Coin	V	V	P	P	V	V	V	V	V	V	V	V	V	Coin								Coin			P	V																																																		-	None			644.26		17.32	27.34	6.84	1998	656.57	1078.12	581.46	315.08	3.09	90.53	12416.34	8342.09	110.5	339.43	1182.42	4222.22	22.69											45.29	3.8											25/day >20		0	0	0	50	50	20	50	50	10	10	10	20	10	10	2000	20	0.2											50	200											50		0.2	0.2	0.2	50	50	20	50	50	10	10	10	20	10	10	20	20	0.2											50	200									-	-	2.68	-	3.46	5.47	1.37	8.33	2.74	1.8	2.42	1.31	0	0.08	10.35	13.9	0.09	0.28	1.97	7.04	4.54	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	-	-	-	-	-	-	68.08	0	0	-	-	2.68	-	3.46	5.47	1.37	8.33	2.74	1.8	2.42	1.31	0	0.08	10.35	13.9	0.09	0.28	1.97	7.04	4.54	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	-	-	-	-	-	-	68.08	None																													0.2																																									2.12													2.12	0	0	-	-	2.68	-	3.46	5.47	1.37	8.33	2.74	1.8	2.42	1.31	0	0.08	10.35	13.9	0.09	0.28	1.97	7.04	4.54	-	-	-	-	-	-	-	2.12	-	-	0.19	0.06	-	-	-	-	-	-	-	-	70.2
H2931_004_0	2007	4	g.										OP Facility - Surgery										3000	ASC										A	A	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	V	V	V	V	V	Coin	Coin	Coin	S	Coin	T	V	V	V	V	V				V																																																			-	N/A	242.9	3.54	609.15	2674.33	14.25	19.19	4.8	4721.98	567.51	13.31	13.31	0	1.1	1842.78	8954.23	4261.83	112.85	13.19	26.37	19.78	2904.4	0.55	0	0	0	0	0	0	0	0	0	45.29										700/Stay	700/Stay			20 of EME	20 of EME	20 of EME	50	50	20 of EME	0.2	50	20	50	10	40	20	20	20	20	10	20										25										693.7	693.7			0.2	0.2	0.2	49.55	49.55		0.2	49.55	19.82	49.55	9.91	39.64	19.82	0.2	0.2	0.2	9.91	0.2										24.78										14.04	0.2	-	-	2.82	3.8	0.95	19.5	2.34	-	2.64	-	0	7.61	7.39	14.08	0.19	2.61	5.23	3.92	2.4	0.11	-	-	-	-	-	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	89.94	0	0.99	14.04	0.2	-	-	2.82	3.8	0.95	19.5	2.34	-	2.64	-	0	7.61	7.39	14.08	0.19	2.61	5.23	3.92	2.4	0.11	-	-	-	-	-	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	89.94																																																																																				-			14.04	0.2	-	-	2.82	3.8	0.95	19.5	2.34	-	2.64	-	0	7.61	7.39	14.08	0.19	2.61	5.23	3.92	2.4	0.11	-	-	-	-	-	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	89.94
H2931_006_0	2007	3	g.	h.1.									OP Facility - Surgery	OP Facility - Other									2500	ASC	Complex diag													Coin	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin											V	Coin																																																		-		7553.79	178.77	1476.33	8978.9	9.51	18.06	4.52	2041.57	1732.02	2.61	1.98	0.07	0.49	29.61	6325.81	6968.97	314.58	1068.47	2241.53	38.96	5.31	36.36	0	0	0	0	0	0	0	0	0	333	0.39											25/day		30	20	20	50 per visit	50	20	20	20	20	20	10 visit	40 visit	40 visit	40 visit	40 visit	40 visit	20											25 per visit	50											23.63		0.28	0.19	0.19	47.25	47.25	0.19	0.19	0.19	0.19	0.19	9.45	37.8	37.8	37.8	37.8	37.8	0.19											23.63	0.47									-	-	2.91	-	2.7	3.41	0.85	8.04	6.82	0.49	0.37	0.01	0.09	5.6	4.98	21.95	0.99	3.37	7.06	0.12	1	-	-	-	-	-	-	-	-	-	-	0.66	0.19	-	-	-	-	-	-	-	-	71.62	0	4.14	-	-	2.91	-	2.7	3.41	0.85	8.04	6.82	0.49	0.37	0.01	0.09	5.6	4.98	21.95	0.99	3.37	7.06	0.12	1	-	-	-	-	-	-	-	-	-	-	0.66	0.19	-	-	-	-	-	-	-	-	71.62																																																																																				-			-	-	2.91	-	2.7	3.41	0.85	8.04	6.82	0.49	0.37	0.01	0.09	5.6	4.98	21.95	0.99	3.37	7.06	0.12	1	-	-	-	-	-	-	-	-	-	-	0.66	0.19	-	-	-	-	-	-	-	-	71.62
H2931_014_0	2007	4																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H2931_015_0	2007	4	g.										OP Facility - Surgery										3000	ASC										A	A			Coin	Coin	Coin	V	V	P	Coin	V	V	V	V	V	V	V	Coin	Coin	Coin	Coin	T	V	V	V	V	V				V																																																			-		505.04	0.81			35.93	17.29	5.55	2469.77	579.9	8.45	16.2	0	821.31	6053.4	1934.52	5960	117.15	96.43	0	19.78	8.72	0.55	0	0	0	0	0	0	0	0	0	45.29										700/Stay	700/Stay			20 coins	20 coins	20 coins	50	50		20 coins	50	20	50	10	40	20	0	20 coins	20 coins	20 coins	20 coins										25										693.7	693.7			0.2	0.2	0.2	49.55	49.55		0.2	49.55	19.82	49.55	9.91	39.64	19.82	0.2	0.2	0.2	0.2	0.2										24.78										29.2	0.05	-	-	7.12	3.43	1.1	10.2	2.39	-	3.21	-	1.36	25	1.6	19.69	0.19	0	-	3.92	1.74	0.11	-	-	-	-	-	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	110.39	0	0.99	29.2	0.05	-	-	7.12	3.43	1.1	10.2	2.39	-	3.21	-	1.36	25	1.6	19.69	0.19	0	-	3.92	1.74	0.11	-	-	-	-	-	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	110.39																																																																																				-			29.2	0.05	-	-	7.12	3.43	1.1	10.2	2.39	-	3.21	-	1.36	25	1.6	19.69	0.19	0	-	3.92	1.74	0.11	-	-	-	-	-	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	110.39
H2931_801_0	2007	4	f.	g.									OP Facility - Emergency	OP Facility - Surgery									1500	Urgent care center	ASC													Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	Coin											V	V																																																		-	None					8.09	22.06	2.91	818.59	721.59		0.19	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	12.93											116.12	139.89													20	20	20	50	50		0.2	25/visit	25/visit	25/visit	10/visit	20/visit	10/visit	10/visit	10/visit	10/visit	20											25	25													0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	0.2											25	25									-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	0	0	-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	None																																																																																			-			-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97
H2931_803_0	2007	4	f.	g.									OP Facility - Emergency	OP Facility - Surgery									1500	Urgent care center	ASC													Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	Coin											V	V																																																		-	None					8.09	22.06	2.91	818.59	721.59		0.19	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	12.93											116.12	139.89													20	20	20	50	50		0.2	25/visit	25/visit	25/visit	10/visit	20/visit	10/visit	10/visit	10/visit	10/visit	20											25	25													0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	0.2											25	25									-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	0	0	-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	None																																																																																			-			-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97
H2931_804_0	2007	5	f.	g.									OP Facility - Emergency	OP Facility - Surgery									1500	Urgent care center	ASC													Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	Coin											V	V																																																		-	None					8.09	22.06	2.91	818.59	721.59		0.19	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	12.93											116.12	139.89													20	20	20	50	50		0.2	25/visit	25/visit	25/visit	10/visit	20/visit	10/visit	10/visit	10/visit	10/visit	20											25	25													0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	0.2											25	25									-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	0	0	-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	None																																																																																			-			-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97
H2931_805_0	2007	4	f.	g.									OP Facility - Emergency	OP Facility - Surgery									1500	Urgent care center	ASC													Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	Coin											V	V																																																		-	None					8.09	22.06	2.91	818.59	721.59		0.19	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	12.93											116.12	139.89													20	20	20	50	50		0.2	25/visit	25/visit	25/visit	10/visit	20/visit	10/visit	10/visit	10/visit	10/visit	20											25	25													0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	0.2											25	25									-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	0	0	-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97	None																																																																																			-			-	-	-	-	1.62	4.41	0.58	3.41	3.01	-	0.04	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	2.59	-	-	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	49.97
H2949_002_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1300.46	35.23	785.87	1904.56	170.14	15.61	1.09	382.58	270.96	694.19	31.78	20.95	3.28	434.37	5170.99	4130.81	242.83	442.96	31.03	20635.27	31.79	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											100 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 75; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 75; Outpatient Hospital Copay: 100	5	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											65.26	109.69	74	0	100	0.2	0.2	47.5	94.13	0	0.15	0	0	61.84	9.05	17.23	30	15	0.26	0	0.2	0	0	0	30	30	0	0	0	0	0											7.07	0.32	4.85	-	1.42	3.07	0.22	1.51	2.13	-	4.89	-	-	2.24	3.9	5.93	0.61	0.55	7.93	0.01	6.36	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.91	0	0	7.07	0.32	4.85	-	1.42	3.07	0.22	1.51	2.13	-	4.89	-	-	2.24	3.9	5.93	0.61	0.55	7.93	0.01	6.36	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.91	None																																																																																			-	0	0	7.07	0.32	4.85	-	1.42	3.07	0.22	1.51	2.13	-	4.89	-	-	2.24	3.9	5.93	0.61	0.55	7.93	0.01	6.36	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.91
H2949_007_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1364.57	36.96	785.87	1943.81	173.65	16.31	1.14	401.9	270.96	708.36	33.19	20.95	3.35	434.37	5277.57	4215.95	247.83	452.09	32.41	21099.18	31.79	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											100 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 75; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 75; Outpatient Hospital Copay: 100	5	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											65.26	109.69	74	0	100	0.2	0.2	47.5	94.13	0	0.15	0	0	61.84	9.05	17.23	30	15	0.25	0	0.2	0	0	0	30	30	0	0	0	0	0											7.42	0.34	4.85	-	1.45	3.2	0.23	1.59	2.13	-	5.11	-	-	2.24	3.98	6.05	0.62	0.57	8.16	0.01	6.36	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.21	0	0	7.42	0.34	4.85	-	1.45	3.2	0.23	1.59	2.13	-	5.11	-	-	2.24	3.98	6.05	0.62	0.57	8.16	0.01	6.36	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.21	None																																																																																			-	0	0	7.42	0.34	4.85	-	1.45	3.2	0.23	1.59	2.13	-	5.11	-	-	2.24	3.98	6.05	0.62	0.57	8.16	0.01	6.36	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.21
H2949_009_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1300.46	35.23	785.87	1904.56	170.14	15.51	1.08	382.58	270.96	694.19	31.58	20.95	3.25	434.37	5170.99	4130.81	242.83	442.96	30.84	20635.27	31.79	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											0 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	20 2 exams/yr	0 1/yr	0	0 exam /yr	800 3/yrs	Not Covered	0	Acupuncture: 10 / 12 visits yr; Routine Chiropractic: 10 / 12 visits yr											0	109.69	62	0	100	0.2	0.2	47.5	0	0	0.15	0	0	3.58	4.86	4.46	30	0	0.26	0	0.2	0	0	0	0	0	0	0	0	0	8.93											-	0.32	4.06	-	1.42	3.05	0.22	1.51	-	-	4.86	-	-	0.13	2.09	1.53	0.61	-	7.91	-	6.36	-	-	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	34.55	0	0	-	0.32	4.06	-	1.42	3.05	0.22	1.51	-	-	4.86	-	-	0.13	2.09	1.53	0.61	-	7.91	-	6.36	-	-	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	34.55	None																																																																																			-	0	0	-	0.32	4.06	-	1.42	3.05	0.22	1.51	-	-	4.86	-	-	0.13	2.09	1.53	0.61	-	7.91	-	6.36	-	-	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	34.55
H2949_011_0	2007	2																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1364.57	36.96	785.87	1943.81	173.65	16.28	1.14	401.9	270.96	708.36	33.14	20.95	3.35	434.37	5277.57	4215.95	247.83	452.09	32.35	21099.18	31.79	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											0 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	20 2 exams/yr	0 1/yr	0	0 exam /yr	800 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	109.69	62	0	100	0.2	0.2	47.5	0	0	0.15	0	0	3.58	4.86	4.46	30	0	0.25	0	0.2	0	0	0	0	0	0	0	0	0	0											-	0.34	4.06	-	1.45	3.2	0.23	1.59	-	-	5.1	-	-	0.13	2.14	1.57	0.62	-	8.15	-	6.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.92	0	0	-	0.34	4.06	-	1.45	3.2	0.23	1.59	-	-	5.1	-	-	0.13	2.14	1.57	0.62	-	8.15	-	6.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.92	None																																																																																			-	0	0	-	0.34	4.06	-	1.45	3.2	0.23	1.59	-	-	5.1	-	-	0.13	2.14	1.57	0.62	-	8.15	-	6.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.92
H2949_012_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1300.46	35.23	785.87	1904.56	170.14	16.42	1.15	382.58	270.96	694.19	33.42	20.95	3.44	434.37	5170.99	4130.81	242.83	442.96	32.63	20635.27	31.79	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											50 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											8.71	109.69	74	0	100	0.2	0.2	47.5	50	0	0.15	0	0	36.59	4.86	17.23	30	15	0.25	0	0.2	0	0	0	30	30	0	0	0	0	0											0.94	0.32	4.85	-	1.42	3.22	0.23	1.51	1.13	-	5.15	-	-	1.32	2.09	5.93	0.61	0.55	8.07	0.01	6.36	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.62	0	0	0.94	0.32	4.85	-	1.42	3.22	0.23	1.51	1.13	-	5.15	-	-	1.32	2.09	5.93	0.61	0.55	8.07	0.01	6.36	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.62	None																																																																																			-	0	0	0.94	0.32	4.85	-	1.42	3.22	0.23	1.51	1.13	-	5.15	-	-	1.32	2.09	5.93	0.61	0.55	8.07	0.01	6.36	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.62
H2949_801_0	2007	2																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1387.45	37.58	850.63	1969.14	175.91	10.37	0.72	453.97	354.1	907.24	24.66	27.38	2.54	567.64	5784.76	4621.12	271.65	495.53	20.61	23084.73	39.52	0	0	0	111.58	252.19	199.42	35.78	0	0	640.58											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.9	212.86	97.31	0	106.43	0.3	0.3	10.45	256.03	0	0.23	0	0.3	58.9	40.1	51.69	24.33	51.69	0.3	4.13	0.3	0	0	0	0	0	0	0	0	0	0											24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	0	78.75	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	5000																																																																																			-	0	0	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22
H2949_802_0	2007	2																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1387.45	37.58	850.63	1969.14	175.91	10.37	0.72	453.97	354.1	907.24	24.66	27.38	2.54	567.64	5784.76	4621.12	271.65	495.53	20.61	23084.73	39.52	0	0	0	111.58	252.19	199.42	35.78	0	0	640.58											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.9	212.86	97.31	0	106.43	0.3	0.3	10.45	256.03	0	0.23	0	0.3	58.9	40.1	51.69	24.33	51.69	0.3	4.13	0.3	0	0	0	0	0	0	0	0	0	0											24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	0	78.75	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	5000																																																																																			-	0	0	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22
H2949_803_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1387.45	37.58	850.63	1969.14	175.91	10.37	0.72	453.97	354.1	907.24	24.66	27.38	2.54	567.64	5784.76	4621.12	271.65	495.53	20.61	23084.73	39.52	0	0	0	111.58	252.19	199.42	35.78	0	0	640.58											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.9	212.86	97.31	0	106.43	0.3	0.3	10.45	256.03	0	0.23	0	0.3	58.9	40.1	51.69	24.33	51.69	0.3	4.13	0.3	0	0	0	0	0	0	0	0	0	0											24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	0	78.75	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	5000																																																																																			-	0	0	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22
H2949_804_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1387.45	37.58	850.63	1969.14	175.91	10.37	0.72	453.97	354.1	907.24	24.66	27.38	2.54	567.64	5784.76	4621.12	271.65	495.53	20.61	23084.73	39.52	0	0	0	111.58	252.19	199.42	35.78	0	0	640.58											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											212.9	212.86	97.31	0	106.43	0.3	0.3	10.45	256.03	0	0.23	0	0.3	58.9	40.1	51.69	24.33	51.69	0.3	4.13	0.3	0	0	0	0	0	0	0	0	0	0											24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	0	78.75	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22	5000																																																																																			-	0	0	24.62	0.67	6.9	-	1.56	3.11	0.22	0.4	7.55	-	5.7	-	0.76	2.79	19.33	19.91	0.55	2.13	6.24	7.94	11.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.22
H2960_004_0	2007	8																					4000											A	A	A	V	T	Coin	Coin	V	P	P	P	P	Coin	V	V	V	V	V	V	V	Coin	V	T	Coin	V	Coin	Coin	Coin	P	V	P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1073.36	25.49	59.9	70.8	211.85	12.53	8.41	559.42	230.96	768.1	567.4	34.67	0.41	822.9	3710.93	2240.27	139.6	131.18	787.16	401.24	0	336.9	0.4	0	588.9	0	0	0	0	26.5	0											PBP: 1A IP Acute: 200 per day (days 1-4)	1B IP Psych: 200 per day (days 1-4)	2 SNF: 150 per stay plus 50 per day for days 35-100 only	6 Home Health: 0-150 13C Custodial Care: 150 per episode	10A Ambulance: 150	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0-20	4A ER: 50 4B Urgent Care: 15	9B ASC Services: 200	8A OP C/D/T: 0-50	8B OP X-Ray: 0-40	9A OP Hospital: 0	12 Renal Dialysis: 20	3 CORF: 50 5 Partial Hosp: 35 9C OP Substance Abuse: 35 9D Cardiac Rehab: 15	7A PCP: 10 14B Immunizations: 0 separate office visit copay applies 14C Routine Physical Exams: 0 separate office visit copay applies 14D Pap/Pelvic: 0 separate office visit copay applies 14E Prostate Screening: 0 separate office visit copay applies 14F Colorectal Screening: 50 14G Bone Mass Measurement: 0 separate office visit copay applies 14H Mammography: 0 14I Diabetes Monitoring: 0-30 separate office visit copay may apply	7B Chiropractic: 35 7D Physician Specialist: 35 7F Podiatry: 35	7E Mental Health: 35 7H Psychiatric: 35	7C Occupational Therapy: 25 7I Physical and Speech Therapy: 25	Included in i.2.	7G Other Health Care: 35 18A Medicare Covered Hearing Exams: 35	15 Part B Drugs: 20	13A Blood: 20 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: 0	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: No member cost sharing	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											194	194	321.11	145.5	145.5	0.19	0.19	47.62	194	48.5	38.8	0	0.19	32.45	9.6	33.95	33.95	24.25	0	33.95	0.19	20.6	0	0	19.4	0	0	0	0	0	0											17.35	0.41	1.6	0.86	2.57	2.43	1.63	2.22	3.73	3.1	1.83	-	0.08	2.23	2.97	6.34	0.39	0.27	-	1.14	-	0.58	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.69	0	1.63	17.35	0.41	1.6	0.86	2.57	2.43	1.63	2.22	3.73	3.1	1.83	-	0.08	2.23	2.97	6.34	0.39	0.27	-	1.14	-	0.58	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.69	0																																																																																			-	0	0	17.35	0.41	1.6	0.86	2.57	2.43	1.63	2.22	3.73	3.1	1.83	-	0.08	2.23	2.97	6.34	0.39	0.27	-	1.14	-	0.58	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.69
H2960_009_0	2007	3																					4000											A	A	A	V	T	Coin	Coin	V	P	P	P	P	Coin	V	V	V	V	V	V	V	Coin	V	T	Coin	V	Coin	Coin	Coin	P	V	P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	886.37	21.04	49.5	58.46	174.94	10.34	6.95	461.97	190.72	634.3	468.54	28.63	0.34	822.9	3064.41	1850	115.25	108.32	650.03	331.34	0	278.2	0.3	0	486.3	0	0	0	0	21.9	0											PBP: 1A IP Acute: 150 per day (days 1-4)	1B IP Psych: 150 per day (days 1-4)	2 SNF: 150 per stay plus 50 per day for days 35-100 only	6 Home Health: 0 13C Custodial Care: 150 per episode	10A Ambulance: 100	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0-20	4A ER: 50 4B Urgent Care: 15	9B ASC Services: 150	8A OP C/D/T: 0-50	8B OP X-Ray: 0-40	9A OP Hospital: 0	12 Renal Dialysis: 20	3 CORF: 50 5 Partial Hosp: 30 9C OP Substance Abuse: 30 9D Cardiac Rehab: 15	7A PCP: 10 14B Immunizations: 0 separate office visit copay applies 14C Routine Physical Exams: 0 separate office visit copay applies 14D Pap/Pelvic: 0 separate office visit copay applies 14E Prostate Screening: 0 separate office visit copay applies 14F Colorectal Screening: 50 14G Bone Mass Measurement: 0 separate office visit copay applies 14H Mammography: 0 14I Diabetes Monitoring: 0-30 separate office visit copay may apply	7B Chiropractic: 30 7D Physician Specialist: 30 7F Podiatry: 30	7E Mental Health: 30 7H Psychiatric: 30	7C Occupational Therapy: 25 7I Physical and Speech Therapy: 25	Included in i.2.	7G Other Health Care: 30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 20 16B Comprehensive Dental Services: 30 17A Medicare Covered Eye Exams: 30	10B Transportation: 0	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: No member cost sharing	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											145.5	145.5	321.11	145.5	97	0.19	0.19	47.62	145.5	48.5	38.8	0	0.19	30.6	9.6	29.1	29.1	24.25	0	29.1	0.19	29.9	0	0	0	0	0	0	0	0	0											10.75	0.26	1.32	0.71	1.41	2.01	1.35	1.83	2.31	2.56	1.51	-	0.07	2.1	2.45	4.49	0.28	0.22	-	0.8	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.13	0	1.15	10.75	0.26	1.32	0.71	1.41	2.01	1.35	1.83	2.31	2.56	1.51	-	0.07	2.1	2.45	4.49	0.28	0.22	-	0.8	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.13	0																																																																																			-	0	0	10.75	0.26	1.32	0.71	1.41	2.01	1.35	1.83	2.31	2.56	1.51	-	0.07	2.1	2.45	4.49	0.28	0.22	-	0.8	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.13
H2960_010_0	2007	8																					4000											A	A	A	V	T	Coin	Coin	V	P	P	P	P	Coin	V	V	V	V	V	V	V	Coin	V	T	Coin	V	Coin	Coin	Coin	P	V	P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1114.59	26.51	70.3	83.02	248.46	14.69	9.87	656.03	270.84	900.8	665.37	40.66	0.48	822.9	4351.71	2627.13	163.67	153.84	923.09	470.53	0	395.2	0.5	29.92	690.6	0	0	0	0	31.1	0											PBP: 1A IP Acute: 150 per day (days 1-3)	1B IP Psych: 150 per day (days 1-3)	2 SNF: 150 per stay plus 50 per day for days 35-100 only	6 Home Health: 0 13C Custodial Care: 150 per episode	10A Ambulance: 100	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0-20	4A ER: 50 4B Urgent Care: 15	9B ASC Services: 150	8A OP C/D/T: 0-50	8B OP X-Ray: 0-40	9A OP Hospital: 0	12 Renal Dialysis: 20	3 CORF: 50 5 Partial Hosp: 30 9C OP Substance Abuse: 30 9D Cardiac Rehab: 15	7A PCP: 10 14B Immunizations: 0 separate office visit copay applies 14C Routine Physical Exams: 0 separate office visit copay applies 14D Pap/Pelvic: 0 separate office visit copay applies 14E Prostate Screening: 0 separate office visit copay applies 14F Colorectal Screening: 50 14G Bone Mass Measurement: 0 separate office visit copay applies 14H Mammography: 0 14I Diabetes Monitoring: 0-30 separate office visit copay may apply	7B Chiropractic: 30 7D Physician Specialist: 30 7F Podiatry: 30	7E Mental Health: 30 7H Psychiatric: 30	7C Occupational Therapy: 25 7I Physical and Speech Therapy: 25	Included in i.2.	7G Other Health Care: 30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 20 16B Comprehensive Dental Services: 0-20 17A Medicare Covered Eye Exams: 15	10B Transportation: 0	16A Preventive Dental Services: 0 Additional Comprehensive Dental Coverage 20-50	17A Routine Eye Exams: 15	17B Eye Wear: No member cost sharing	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											145.5	145.5	321.11	145.5	97	0.19	0.19	47.62	145.5	48.5	38.8	0	0.19	30.6	9.6	29.1	29.1	24.25	0	29.1	0.19	15.93	0	0.29	14.55	0	0	0	0	0	0											13.51	0.32	1.88	1.01	2.01	2.85	1.91	2.6	3.28	3.64	2.15	-	0.09	2.1	3.48	6.37	0.4	0.31	-	1.14	-	0.52	-	8.71	0.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.14	0	1.83	13.51	0.32	1.88	1.01	2.01	2.85	1.91	2.6	3.28	3.64	2.15	-	0.09	2.1	3.48	6.37	0.4	0.31	-	1.14	-	0.52	-	8.71	0.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.14	0																																																																																			-	0	0	13.51	0.32	1.88	1.01	2.01	2.85	1.91	2.6	3.28	3.64	2.15	-	0.09	2.1	3.48	6.37	0.4	0.31	-	1.14	-	0.52	-	8.71	0.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.14
H2961_002_0	2007	6	h1.	h2.	f.	g.							OP Facility - Other	OP Facility - Other	OP Facility - UC	OP Facility - Surgery							1500													D	V	Coin	Coin	Coin	V	V	P	P	V	V	V	V	V	V	V	V	V	Coin		T									P	V	V	V																																																-				1154.3	1672	15.71	24.8	6.2	1998	656.57	1078.12	581.46	315.08	3.09	90.53	12416.34	8342.09	110.5	339.43	1182.42	4222.22	17.09	0.02	3401.01									45.29	3.8	116.12	139.89									25/day >20		20	20	20	50	50	20	50	50	10	10	10	20	10	10	20	20	10		5/Trip									25	25	50	200									25	0	0.2	0.2	0.2	50	50	20	50	50	10	10	10	20	10	10	20	20	0.1		0									25	25	50	200							-	-	2.4	-	3.14	4.96	1.24	8.33	2.74	1.8	2.42	1.31	0	0.08	10.35	13.9	0.09	0.28	1.97	7.04	1.71	-	-	-	-	-	-	-	-	-	-	0.09	0.01	0.48	2.33	-	-	-	-	-	-	66.68	0	0	-	-	2.4	-	3.14	4.96	1.24	8.33	2.74	1.8	2.42	1.31	0	0.08	10.35	13.9	0.09	0.28	1.97	7.04	1.71	-	-	-	-	-	-	-	-	-	-	0.09	0.01	0.48	2.33	-	-	-	-	-	-	66.68																														323.9357724																																									3.1													3.1			-	-	2.4	-	3.14	4.96	1.24	8.33	2.74	1.8	2.42	1.31	0	0.08	10.35	13.9	0.09	0.28	1.97	7.04	1.71	-	-	-	-	-	-	-	3.1	-	-	0.09	0.01	0.48	2.33	-	-	-	-	-	-	69.78
H2961_011_0	2007	5																					2500													D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin		T						Coin																																																						-				1238	7527.9	21.61	30.87	7.72	781.08	847.5	11.18	27.08	20.92	0	14785.15	6325.81	6968.97	314.58	1068.47	2241.53	38.96	5.52		376.03						10.6															25/day >20	3PC5CR3HS	20	20	20	50 per visit	25/vist ASC 50 OH	20	20	20 per visit	20 per visit	20 per visit	10 per visit	40 per visit	20 per visit	20	20	20	20		2 per trip						20															22.95	3.78	0.18	0.18	0.18	45.9	27.54	0.18	0.18	18.36	18.36	18.36	9.18	36.72	18.36	18.36	18.36	18.36	0.18		1.99																			-	-	2.37	2.37	3.97	5.67	1.42	2.99	1.95	2.05	4.97	0.03	-	22.62	4.84	21.33	0.48	1.63	3.43	0.06	1.01	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.25	0	7.63	-	-	2.37	2.37	3.97	5.67	1.42	2.99	1.95	2.05	4.97	0.03	-	22.62	4.84	21.33	0.48	1.63	3.43	0.06	1.01	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.25																														20																																									2.12													2.12			-	-	2.37	2.37	3.97	5.67	1.42	2.99	1.95	2.05	4.97	0.03	-	22.62	4.84	21.33	0.48	1.63	3.43	0.06	1.01	-	0.06	-	-	-	-	-	2.12	-	-	-	-	-	-	-	-	-	-	-	-	85.37
H2961_801_0	2007	9	f.	g.									OP Facility - Emergency	OP Facility - Surgery									1500	Urgent care center	ASC												V	Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	S		T									V	V																																																		-	None				1525	7.71	24.25	0.98	702.44	581.7		3.8	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	148.03		1983.44									116.12	139.89												3PC5CGR3HS	0	0	0	50	50		0.2	25	25	25	10	20	10	10	1000	10	7		5/Trip									25	25												3.8	0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	7		5									25	25									-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41	0	0	-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41	None																																																																																			-			-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41
H2961_805_0	2007	7	f.	g.									OP Facility - Emergency	OP Facility - Surgery									1500	Urgent care center	ASC												V	Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	S		T									V	V																																																		-	None				1525	7.71	24.25	0.98	702.44	581.7		3.8	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	148.03		1983.44									116.12	139.89												3PC5CGR3HS	0	0	0	50	50		0.2	25	25	25	10	20	10	10	1000	10	7		5/Trip									25	25												3.8	0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	7		5									25	25									-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41	0	0	-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41	None																																																																																			-			-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41
H2961_806_0	2007	7	f.	g.									OP Facility - Emergency	OP Facility - Surgery									1500	Urgent care center	ASC												V	Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	S		T									V	V																																																		-	None				1525	7.71	24.25	0.98	702.44	581.7		3.8	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	148.03		1983.44									116.12	139.89												3PC5CGR3HS	0	0	0	50	50		0.2	25	25	25	10	20	10	10	1000	10	7		5/Trip									25	25												3.8	0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	7		5									25	25									-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41	0	0	-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41	None																																																																																			-			-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41
H2961_807_0	2007	7	f.	g.									OP Facility - Emergency	OP Facility - Surgery										Urgent care center	ASC												V	Coin	Coin	Coin	V	V		Coin	V	V	V	V	V	V	V	V	V	S		T									V	V																																																		-					1525	7.71	24.25	0.98	702.44	581.7		3.8	0	0	414.53	11099.34	10160.47	72.14	1899.95	925.12	5181.49	148.03		1983.44									116.12	139.89												3PC5CGR3HS	0	0	0	50	50		0.2	25	25	25	10	20	10	10	1000	10	7		5/Trip									25	25												3.8	0.2	0.2	0.2	50	50		0.2	25	25	25	10	20	10	10	10	10	7		5									25	25									-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41	0	0	-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41																																																																																				-			-	-	-	0.48	1.54	4.85	0.2	2.93	2.42	-	0.76	-	-	0.86	9.25	16.93	0.06	1.58	0.77	4.32	0.09	-	0.83	-	-	-	-	-	-	-	-	0.24	0.29	-	-	-	-	-	-	-	-	48.41
H3107_004_0	2007	5																					0											D	D	D		Coin	Coin	Coin	V	P		Coin			V	V	V	Coin	V		V	Coin																																																														-	0	2046.24	77.4	829.87		7.19	9.93	3.2	278.6	311.91		45.13			178.37	4995.14	5409.04	1.45	228.93		108.81	39.09																					130/day up to 1820 max per admit	130/day up to 1820 max per admit	0 for 1st 5 days; 125/day from days 6-100		20 coin	20 coin	20 coin	50 copay	300 per visit		20 coin			25 copay	15 copay	25 copay	50 coin	25 copay		250 IP surgery 200 Am Surg Phys	20 coin																					97.01	92.63	111.08		0.2	0.2	0.2	49.95	299.89		0.09			24.98	14.75	24.94	0.35	23.38		238.72	0.2																					16.54	0.6	7.68	-	1.43	1.99	0.64	1.16	7.79	-	4.03	-	-	0.37	6.14	11.24	0.51	0.45	-	2.16	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.56	0	0	16.54	0.6	7.68	-	1.43	1.99	0.64	1.16	7.79	-	4.03	-	-	0.37	6.14	11.24	0.51	0.45	-	2.16	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.56	0																																																																																			-	0	0	16.54	0.6	7.68	-	1.43	1.99	0.64	1.16	7.79	-	4.03	-	-	0.37	6.14	11.24	0.51	0.45	-	2.16	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.56
H3107_005_0	2007	5																					0											Ded	Ded	Ded	Ded	Ded	Ded	Ded	V	Ded	Ded				V	V	V	Coin	V		Ded	Ded																					35.62	0.41	4.27	0	0.83	0.01	0.01		2.58	0					0	3.41	0.04			3.94	0.41																					51.53	0								279.06						178.67	5453.21	5883.27	1.45	251.82																								Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	50 copay	Apply to Deductible	Apply to Deductible				20 copay	10 copay	20 copay	50 coin	20 copay		Apply to Deductible	Apply to Deductible																												49.95						19.98	9.58	19	0.35	18.71																								-	-	-	-	-	-	-	1.16	-	-	-	-	-	0.3	4.35	9.31	0.51	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.03	2375	0	35.62	0.41	4.27	0	0.83	0.01	0.01	1.16	2.58	0	-	-	-	0.3	4.35	12.73	0.55	0.39	-	3.94	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.56	0																																																																																			-	0	0	35.62	0.41	4.27	0	0.83	0.01	0.01	1.16	2.58	0	-	-	-	0.3	4.35	12.73	0.55	0.39	-	3.94	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.56
H3107_006_0	2007	6																					0											Ded	Ded	Ded	Ded	Ded	Ded	Ded	V	Ded	Ded				V	V	V	Coin	V		Ded	Ded																					33.97	0.39	4.07	0	0.79	0.01	0.01		2.46	0					0	3.26	0.04			3.76	0.39																					49.15	0								271.32						173.71	4993.49	5409.67	1.44	228.93																								Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	50 copay	Apply to Deductible	Apply to Deductible				25 copay	15 copay	25 copay	50 coin	25 copay		Apply to Deductible	Apply to Deductible																												49.95						24.98	14.31	23.62	0.36	23.38																								-	-	-	-	-	-	-	1.13	-	-	-	-	-	0.36	5.95	10.65	0.51	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.05	2400	0	33.97	0.39	4.07	0	0.79	0.01	0.01	1.13	2.46	0	-	-	-	0.36	5.95	13.91	0.55	0.45	-	3.76	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.21	0																																																																																			-	0	0	33.97	0.39	4.07	0	0.79	0.01	0.01	1.13	2.46	0	-	-	-	0.36	5.95	13.91	0.55	0.45	-	3.76	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.21
H3107_008_0	2007	4																					0											D	D	D			Coin	Coin	V	P					V	V	V	Coin	V			Coin																																																														-	0	2032.81	76.89	829.87			9.93	3.2	278.34	311.61					178.2	5453	5883.27	1.45	251.82			39.09																					80/day up to 800 max per admit	80/day up to 800 max per admit	0 for 1st 10 days; 75/day from days 11-100			20 coin	20 coin	50 copay	100 per surgery					20 copay	10 copay	20 copay	50 coin	20 copay			20 coin																					53.84	51.41	50.97			0.2	0.2	49.95	99.96					19.98	9.84	19.9	0.35	18.71			0.2																					9.12	0.33	3.52	-	-	1.99	0.64	1.16	2.6	-	-	-	-	0.3	4.47	9.76	0.51	0.39	-	-	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.6	0	0	9.12	0.33	3.52	-	-	1.99	0.64	1.16	2.6	-	-	-	-	0.3	4.47	9.76	0.51	0.39	-	-	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.6	0																																																																																			-	0	0	9.12	0.33	3.52	-	-	1.99	0.64	1.16	2.6	-	-	-	-	0.3	4.47	9.76	0.51	0.39	-	-	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.6
H3107_009_0	2007	5																					0											D	D	D		Coin	Coin	Coin	V	P		Coin			V	V	V	Coin	V		V	Coin																																																														-	0	2038.35	77.1	829.87		7.19	9.93	3.2	271.29	303.72		43.58			173.69	4993.01	5409.04	1.44	228.93		108.81	39.09																					130/day up to 1820 max per admit	130/day up to 1820 max per admit	0 for 1st 5 days; 125/day from days 6-100		20	20	20	50 copay	300 per visit		20			25 copay	15 copay	25 copay	50	25 copay		250 IP surgery 200 Am Surg Phys	20 coin																					97.01	92.63	111.08		0.2	0.2	0.2	49.95	299.89		0.09			24.98	14.75	24.94	0.36	23.38		238.72	0.2																					16.48	0.6	7.68	-	1.43	1.99	0.64	1.13	7.59	-	3.87	-	-	0.36	6.14	11.24	0.51	0.45	-	2.16	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.09	0	0	16.48	0.6	7.68	-	1.43	1.99	0.64	1.13	7.59	-	3.87	-	-	0.36	6.14	11.24	0.51	0.45	-	2.16	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.09	0																																																																																			-	0	0	16.48	0.6	7.68	-	1.43	1.99	0.64	1.13	7.59	-	3.87	-	-	0.36	6.14	11.24	0.51	0.45	-	2.16	7.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.09
H3107_801_0	2007	6																					0											D	D	D		Coin	Coin	Coin	P	Coin		Coin			V	V	V	Coin	V	Coin	V	Coin																																																														-	0	2046.34	77.4	829.91		7.2	9.93	3.2	278.8	35.07		45.15			178.49	4997.55	5411.63	1.45	229.04	14.05	108.86	39.11																					300/day up to 3000 max per admit	300/day up to 3000 max per admit	160/day		30 coins	30 coins	30 coins	50 copay	30 coins		30 coins			40 copay	20 copay	40 copay	50 coins	40 copay	30 coins	250 IP surgery 200 Am Surg Phys	30 coins																					202.3	193.17	142.18		0.3	0.3	0.3	49.95	0.3		0.09			39.97	19.66	39.91	0.35	37.42	0.3	238.72	0.3																					34.5	1.25	9.83	-	2.15	2.98	0.96	1.16	10.52	-	4.03	-	-	0.59	8.19	18	0.51	0.71	4.21	2.17	11.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5	0	0	34.5	1.25	9.83	-	2.15	2.98	0.96	1.16	10.52	-	4.03	-	-	0.59	8.19	18	0.51	0.71	4.21	2.17	11.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5	0																																																																																			-	0	0	34.5	1.25	9.83	-	2.15	2.98	0.96	1.16	10.52	-	4.03	-	-	0.59	8.19	18	0.51	0.71	4.21	2.17	11.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5
H3107_803_0	2007	5																					0											D	D	D		Coin	Coin	Coin	P	Coin		Coin			V	V	V	Coin	V	Coin	V	Coin																																																														-	0	2046.34	77.4	829.91		7.2	9.93	3.2	278.8	35.07		45.15			178.49	4997.55	5411.63	1.45	229.04	14.05	108.86	39.11																					300/day up to 3000 max per admit	300/day up to 3000 max per admit	160/day		30 coins	30 coins	30 coins	50 copay	30 coins		30 coins			40 copay	20 copay	40 copay	50 coins	40 copay	30 coins	250 IP surgery 200 Am Surg Phys	30 coins																					202.3	193.17	142.18		0.3	0.3	0.3	49.95	0.3		0.09			39.97	19.66	39.91	0.35	37.42	0.3	238.72	0.3																					34.5	1.25	9.83	-	2.15	2.98	0.96	1.16	10.52	-	4.03	-	-	0.59	8.19	18	0.51	0.71	4.21	2.17	11.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5	0	0	34.5	1.25	9.83	-	2.15	2.98	0.96	1.16	10.52	-	4.03	-	-	0.59	8.19	18	0.51	0.71	4.21	2.17	11.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5	0																																																																																			-	0	0	34.5	1.25	9.83	-	2.15	2.98	0.96	1.16	10.52	-	4.03	-	-	0.59	8.19	18	0.51	0.71	4.21	2.17	11.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5
H3112_001_0	2007	5																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin		V	V	V	Coin	Coin	S	Coin			V		V				V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		351	3.77	56.26	0	3.3	14.86	0.68	6.64	34.26	13.39	35.64	0	10.15	36.18	0	6154.68	190.71	559.45	20.54	102.2	1025.28	2.74	0	0	373.64	0	143.67	0	0	0	288.69											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 7f 15											0.07	0.05	0.2	0	0.2	0.2	0.2	0.34	0.2	0.2	0.2	0	0.2	0.14	0	15.82	20	20	0.27	0.21	25	0.17	0	0	20	0	6.75	0	0	0	20											26.3	0.19	10.99	-	0.66	2.97	0.14	2.25	6.85	2.68	7.13	-	2.03	5.07	-	8.12	0.32	0.93	5.47	21.26	2.14	0.46	-	-	0.62	-	0.08	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	107.14	0	0	26.3	0.19	10.99	-	0.66	2.97	0.14	2.25	6.85	2.68	7.13	-	2.03	5.07	-	8.12	0.32	0.93	5.47	21.26	2.14	0.46	-	-	0.62	-	0.08	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	107.14																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	26.3	0.19	10.99	-	0.66	2.97	0.14	2.25	6.85	2.68	7.13	-	2.03	5.07	-	8.12	0.32	0.93	5.47	21.26	2.14	0.46	-	-	0.62	-	0.08	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	107.14
H3113_001_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						2400	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1871.26	174.24	9459.85	184.76	693.42	25.06	7.86	199.42	132.4	4119.29	183.13	36.21	4.74	307.9	134.98	1381.74	1794.94	21.2		288.51	277.71	1410.84	1200		140.2	166		54.6				117.59	0.3	0.07	300	295.2						(1a) 175/day	(1b) 175/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 35/visit	(8a) 0/visit	(8b) 0/visit	(9a) 35/visit	(12) 0/proc	(9a) 35/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 15/visit	(7e/7h) 32.5/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 15/visit	(15) 0/proc	(16b/17a) 15/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 32.5/visit 75/25 Ind/Grp Blended Copay	(9d) 35/visit	(7f1) 0/visit	(18a1) 0/visit						159	159			68	18	18	45	32			32		32		14	30			14		14										32	30	32								24.79	2.31	-	-	3.94	4.55	1.43	0.75	0.35	-	-	0.1	-	0.82	-	1.57	4.42	-	-	0.33	-	1.6	-	-	-	-	-	-	-	-	-	0.31	0	0	-	-	-	-	-	-	-	47.27		4.76	24.79	2.31	-	-	3.94	4.55	1.43	0.75	0.35	-	-	0.1	-	0.82	-	1.57	4.42	-	-	0.33	-	1.6	-	-	-	-	-	-	-	-	-	0.31	0	0	-	-	-	-	-	-	-	47.27																																																																																				-		0	24.79	2.31	-	-	3.94	4.55	1.43	0.75	0.35	-	-	0.1	-	0.82	-	1.57	4.42	-	-	0.33	-	1.6	-	-	-	-	-	-	-	-	-	0.31	0	0	-	-	-	-	-	-	-	47.27
H3152_022_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1793.71		1530.74	1139.82	228.28	20.67		362.25	155.25	609.39	847.02	0	0	293.24	2381.2	4109.08	0	749.46	0	0	242.37																					850/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per visit	35 per visit	35 X-ray; 20 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.12	35	35	35	35	45																					20.73	-	8.65	1.9	1.9	4.13	-	1.45	2.59	1.78	4.64	-	-	0.86	3.97	11.68	-	2.19	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.38			20.73	-	8.65	1.9	1.9	4.13	-	1.45	2.59	1.78	4.64	-	-	0.86	3.97	11.68	-	2.19	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.38																																																																																				-			20.73	-	8.65	1.9	1.9	4.13	-	1.45	2.59	1.78	4.64	-	-	0.86	3.97	11.68	-	2.19	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.38
H3152_041_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1705.69		1455.63	1083.89	217.08	20.17		344.48	147.63	579.49	805.46	0	0	278.85	2264.36	3907.45	0	712.68	0	0	230.48																					900/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per visit	35 per visit	35 X-ray; 20 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					146.87		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.08	35	35	35	35	45																					20.88	-	8.23	1.81	1.81	4.03	-	1.38	2.46	1.69	4.42	-	-	0.81	3.77	11.1	-	2.08	-	-	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.33			20.88	-	8.23	1.81	1.81	4.03	-	1.38	2.46	1.69	4.42	-	-	0.81	3.77	11.1	-	2.08	-	-	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.33																																																																																				-			20.88	-	8.23	1.81	1.81	4.03	-	1.38	2.46	1.69	4.42	-	-	0.81	3.77	11.1	-	2.08	-	-	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.33
H3152_044_0	2007	6																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S			V																																																											-		1894.61		1616.85	1203.94	241.12	23.3		382.63	163.98	643.67	894.67	0	0	309.74	2515.15	4340.23	0	791.62	0	0	256.01			3781.12																		992/admission		0 days 1-20 100 days 21+	0 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	400 per visit	50 per visit	49.1705505756306 X-ray; 20 CAT PET MRI	50 per visit	30 per visit	50 per visit	0 per visit	50 per visit; 30 dialysis visit	50 per visit	50 per visit	50 per visit	50 per visit	45 per script			5 per visit																		161.82		40.15	0	100	0.2		48	400	50	67.1	50	30	50	0	49.17	50	50	50	50	45			5																		25.55	-	5.41	-	2.01	4.66	-	1.53	5.47	2.68	5	-	-	1.29	-	17.78	-	3.3	-	-	0.96	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.22			25.55	-	5.41	-	2.01	4.66	-	1.53	5.47	2.68	5	-	-	1.29	-	17.78	-	3.3	-	-	0.96	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.22																																																																																				-			25.55	-	5.41	-	2.01	4.66	-	1.53	5.47	2.68	5	-	-	1.29	-	17.78	-	3.3	-	-	0.96	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.22
H3152_045_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1583.74		1200.97	675.78	131.78	18.81		376.81	239.43	957.04	1370.41		119.59	452.25	2558.51	5476.01		1146.37			257.89				792.62		51.19															50/day 1-10		0/day 1-5 75/day 6-14 100/day 15-100	20	100	20		50 ER 25 urgent care	100	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45				0		0															40.82		73.07	20	100	0.2		46.75	100	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															5.39	-	7.31	1.13	1.1	3.76	-	1.47	2	1.99	5.78	-	0.25	0.94	2.13	11.41	-	2.39	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.02			5.39	-	7.31	1.13	1.1	3.76	-	1.47	2	1.99	5.78	-	0.25	0.94	2.13	11.41	-	2.39	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.02																																																																																				-			5.39	-	7.31	1.13	1.1	3.76	-	1.47	2	1.99	5.78	-	0.25	0.94	2.13	11.41	-	2.39	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.02
H3152_046_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1580.66		1198.63	674.47	131.53	18.78		376.08	238.96	955.18	1367.74		119.36	451.38	2553.54	5465.37		1144.14			257.39				791.08		51.09															75/day 1-10		0/day 1-5 75/day 6-14 100/day 15-100	20	100	20		50 ER 25 urgent care	100	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45				0		0															61.23		73.07	20	100	0.2		46.75	100	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															8.07	-	7.3	1.12	1.1	3.76	-	1.47	1.99	1.99	5.77	-	0.25	0.94	2.13	11.39	-	2.38	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.61			8.07	-	7.3	1.12	1.1	3.76	-	1.47	1.99	1.99	5.77	-	0.25	0.94	2.13	11.39	-	2.38	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.61																																																																																				-			8.07	-	7.3	1.12	1.1	3.76	-	1.47	1.99	1.99	5.77	-	0.25	0.94	2.13	11.39	-	2.38	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.61
H3152_047_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1585.82		1202.55	676.67	131.96	18.84		377.31	239.74	958.29	1372.21		119.75	452.85	2561.87	5483.2		1147.87			258.23				793.66		51.26															50/day 1-10		0/day 1-5 75/day 6-14 100/day 15-100	20	100	0		50 ER  25 Urgent Care	100	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45				0		0															40.82		73.07	20	100	0		46.75	100	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															5.39	-	7.32	1.13	1.1	-	-	1.47	2	2	5.79	-	0.25	0.94	2.13	11.42	-	2.39	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.31			5.39	-	7.32	1.13	1.1	-	-	1.47	2	2	5.79	-	0.25	0.94	2.13	11.42	-	2.39	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.31																																																																																				-			5.39	-	7.32	1.13	1.1	-	-	1.47	2	2	5.79	-	0.25	0.94	2.13	11.42	-	2.39	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.31
H3152_048_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1624.79		1232.1	693.3	135.2	19.3		386.58	245.64	981.85	1405.93		122.69	463.98	2624.83	5617.97		1176.09			264.58				813.17		52.52															0		0/day 1-5 75/day 6-14 100/day 15-100	20	100	0		50 ER   25 urgent care	100	15	15 routine 100 complex	15	15	15	0	15	15	15	15	15	45				0		0															0		73.07	20	100	0		46.75	100	15	44.07	15	15	15	0	15	15	15	15	15	45				0		0															-	-	7.5	1.16	1.13	-	-	1.51	2.05	1.23	5.16	-	0.15	0.58	-	7.02	-	1.47	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.95			-	-	7.5	1.16	1.13	-	-	1.51	2.05	1.23	5.16	-	0.15	0.58	-	7.02	-	1.47	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.95																																																																																				-			-	-	7.5	1.16	1.13	-	-	1.51	2.05	1.23	5.16	-	0.15	0.58	-	7.02	-	1.47	-	-	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.95
H3152_053_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1765.06		1506.29	1121.61	224.63	21.19		356.47	152.77	599.66	833.49	0	0	288.56	2343.17	4043.44	0	737.49	0	0	238.5																					300/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per visit	25 per visit	25 X-ray; 125 CAT PET MRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script																					48.94		67.84	20	100	0.2		48	200	25	59.2	25	25	25	10	25	25	25	25	25	45																					7.2	-	8.52	1.87	1.87	4.24	-	1.43	2.55	1.25	4.11	-	-	0.6	1.95	8.42	-	1.54	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.43			7.2	-	8.52	1.87	1.87	4.24	-	1.43	2.55	1.25	4.11	-	-	0.6	1.95	8.42	-	1.54	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.43																																																																																				-			7.2	-	8.52	1.87	1.87	4.24	-	1.43	2.55	1.25	4.11	-	-	0.6	1.95	8.42	-	1.54	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.43
H3152_801_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1472.4		1303.1	824.96	187.71	19.04		356.12	245.87	12.35	58.12	0	0	464.42	2307.14	8451.38	0	1182.16	0	0	7.6																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					17.63	-	10.86	2.41	2.35	5.71	-	1.48	3.07	2.47	11.62	-	-	1.35	6.73	24.65	-	3.45	-	-	1.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.31			17.63	-	10.86	2.41	2.35	5.71	-	1.48	3.07	2.47	11.62	-	-	1.35	6.73	24.65	-	3.45	-	-	1.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.31																																																																																				-			17.63	-	10.86	2.41	2.35	5.71	-	1.48	3.07	2.47	11.62	-	-	1.35	6.73	24.65	-	3.45	-	-	1.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.31
H3152_804_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1472.4		1303.1	824.96	187.71	19.04		356.12	245.87	12.35	58.12	0	0	464.42	2307.14	8451.38	0	1182.16	0	0	7.6																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					17.63	-	10.86	2.41	2.35	5.71	-	1.48	3.07	2.47	11.62	-	-	1.35	6.73	24.65	-	3.45	-	-	1.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.31			17.63	-	10.86	2.41	2.35	5.71	-	1.48	3.07	2.47	11.62	-	-	1.35	6.73	24.65	-	3.45	-	-	1.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.31																																																																																				-			17.63	-	10.86	2.41	2.35	5.71	-	1.48	3.07	2.47	11.62	-	-	1.35	6.73	24.65	-	3.45	-	-	1.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.31
H3154_004_0	2007	9	t.										OP Facility - Other										3100	ASC										A		D	V	T	coin		V	coin	O				V	V	V		V	V	V					V	P	V	P				V										49.27		7.33	0.14	2.53	2.43		-	1.2	-				15.51	-	-		-	6.41	15.6					-	-	-	-				-										100.43	3100	384.79		1289	31.38	-	16.65		220.76	8.21	-				106.12	4302.08	4409.67		-	799.76	3233.61					0	0.15	0.01	0.14				15.54										1750 Plan Deductible applies		1750 Plan Deductible applies	1750 Plan Deductible applies	1750 Plan Deductible applies	1750 Plan Deductible applies		50 copay per visit	1750 Plan Deductible applies					1750 Plan Deductible applies	15/visit;.  Util displayed = FFS Util/28 since 72 of PCPs are capped	35/visit includes PT/SP/OT OP consultations Podiatry Chiro. Psychiatry			1750 Plan Deductible applies	range 15/visit - 35/visit					15 - 35 copay per exam	100 max coverage amount	15 - 35 copay per exam	750 max coverage amount (per 3 yrs)				100 copay per visit										-		-	-	-	-		35.16	-	-				-	14.22	33.18		-	-	33.18					-	-	-	-				1101.6										-	-	-	-	-	-	-	0.65	-	-	-	-	-	-	5.1	12.19	-	-	-	8.94	-	-	-	-	-	-	-	-	-	-	-	1.43	-	-	-	-	-	-	-	-	-	28.31	1750	7.12	49.27	-	7.33	0.14	2.53	2.43	-	0.65	1.2	-	-	-	-	15.51	5.1	12.19	-	-	6.41	24.54	-	-	-	-	-	-	-	-	-	-	-	1.43	-	-	-	-	-	-	-	-	-	128.74	3100	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	no	0	49.27	-	7.33	0.14	2.53	2.43	-	0.65	1.2	-	-	-	-	15.51	5.1	12.19	-	-	6.41	24.54	-	-	-	-	-	-	-	-	-	-	-	1.43	-	-	-	-	-	-	-	-	-	128.74
H3154_005_0	2007	10	t.										OP Facility - Other										5000	ASC										A		D	V	T	coin		V	V					V	V	V		V	V	V					V	P	V	P				V										-		-	-	-	-		-	-					-	-	-		-	-	-					-	-	-	-				-										-	6200	372		1245	30	355	16		213	8					103	4155	4259		-	902	3123					0	0.14	0.01	0.14				15										900/admission		25 copay each days 1-20; 100 copay each day days 21-100	35 copay	150 copay per trip	20 coins		50 copay per visit	150 copay for non-surgical visits					300 copay for surgical visits	15/visit;.  Util displayed = FFS Util/28 since 72 of PCPs are capped	35/visit includes PT/SP/OT OP consultations Podiatry Chiro. Psychiatry		35 copay	35 copay	range 15/visit - 35/visit					15 - 35 copay per exam	100 max coverage amount	15 - 35 copay per exam	750 max coverage amount (per 3 yrs)				100 copay per visit										696		42	28	116	0		29	1663					2121	12	27		-	27	27					-	-	-	-				898										21.55	-	4.33	0.07	3.43	2.49	-	0.51	1.1	-	-	-	-	18.12	4.01	9.6	-	-	2.03	7.04	-	-	-	-	-	-	-	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	75.41	0	22.11	21.55	-	4.33	0.07	3.43	2.49	-	0.51	1.1	-	-	-	-	18.12	4.01	9.6	-	-	2.03	7.04	-	-	-	-	-	-	-	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	75.41	n/a	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins											0.44	-	0.05	0	0	0.16	-	-	0.04	-	-	-	-	0.19	0.04	0.07	-	0.01	0.13	0.55	0.02	1.27	-	-	-	0	0	-	0	0	0											2.98	900	0.78	21.99	-	4.38	0.07	3.43	2.64	-	0.51	1.14	-	-	-	-	18.31	4.06	9.67	-	0.01	2.16	7.59	0.02	1.27	-	-	-	0	0	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	78.38
H3154_006_0	2007	10	t.										OP Facility - Other										5000	ASC										A		D	V	T	coin		V	V					V	V	V		V	V	V					V	P	V	P				V										-		-	-	-	-		-	-					-	-	-		-	-	-					-	-	-	-				-										-	6200	372		1245	30	355	16		213	8					103	4155	4259		-	902	3123					0	0.14	0.01	0.14				15										900/admission		25 copay each days 1-20; 100 copay each day days 21-100	35 copay	150 copay	20 coins		50 copay per visit	150 copay for non-surgical visits					300 copay for surgical visits	15/visit;.  Util displayed = FFS Util/28 since 72 of PCPs are capped	35/visit includes PT/SP/OT OP consultations Podiatry Chiro. Psychiatry		35 copay	35 copay	range 15/visit - 35/visit					15 - 35 copay per exam	100 max coverage amount	15 - 35 copay per exam	750 max coverage amount (per 3 yrs)				100 copay per visit										696		42	28	116	0		29	1663					2121	12	27		-	27	27					-	-	-	-				898										21.55	-	4.33	0.07	3.43	2.49	-	0.51	1.1	-	-	-	-	18.12	4.01	9.6	-	-	2.03	7.04	-	-	-	-	-	-	-	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	75.41	0	22.11	21.55	-	4.33	0.07	3.43	2.49	-	0.51	1.1	-	-	-	-	18.12	4.01	9.6	-	-	2.03	7.04	-	-	-	-	-	-	-	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	75.41	n/a	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins	900 deductible 35 coins										0.444121081	0	0.049435422	0.000849498	0.003716097	0.158615959	0	0	0.037089918	0	0	0	0	0.193689691	0.042153574	0.069350337	0	0.005012276	0.131574497	0.551820875	0.022473607	1.26553526	0	0	0	0.000226533	6.08E-05	0	0	0	0											2.98	900	0.78	21.99	-	4.38	0.07	3.43	2.64	-	0.51	1.14	-	-	-	-	18.31	4.06	9.67	-	0.01	2.16	7.59	0.02	1.27	-	-	-	0	0	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	78.38
H3154_801_0	2007	9	t.										OP Facility - Other										No	ASC										A		D	V	T	coin		V	V					V	V	V		V	V	V					V	P	V	P				V										-	-	-	-	-	-	-	-	-		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-										-	3000	325.34	-	978.2	16.74	0.8	14.76	-	190.88	4.33		-	-	-	108.17	4605.88	4988.36	-	-	1010	3782.37	-	-	-	-	0	0.15	0	0.11	-	-	-	18.4										750 Inpatient deductible		0 cost sharing	0 cost sharing	0 cost sharing	0 cost sharing		50 copay waived upon admit w/I 24hrs	0 cost sharing					0 cost sharing	15/visit	35/visit includes PT/SP/OT OP consultations Podiatry Chiro. Psychiatry			Office visit cost share may apply	range 15/visit - 35/visit					15 - 35 copay per exam	100 max coverage amount	15 - 35 copay per exam	750 max coverage amount (per 3 yrs)				0 cost sharing										453.92	-	-	-	-	-	-	36.68	-		-	-	-	-	15	35	-	-	-	35	-	-	-	-	-	-	-	-	-	-	-	-										12.31	-	-	-	-	-	-	0.58	-	-	-	-	-	-	5.76	14.55	-	-	-	11.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.23	0	0	12.31	-	-	-	-	-	-	0.58	-	-	-	-	-	-	5.76	14.55	-	-	-	11.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.23	3000	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins											0.07	0	0.04	0	0.01	0.12	0	0	0	0	0	0	0	0.04	0.03	0.06	0	0.02	0.08	0.3	0.01	0.89	0	0	0	0	0	0	0	0	0											1.66	1000	0	12.37	-	0.04	-	0.01	0.12	-	0.58	-	-	-	-	-	0.04	5.79	14.61	-	0.02	0.08	11.33	0.01	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.88
H3154_802_0	2007	10	t.										OP Facility - Other										No	ASC										A		D	V	T	coin		V	V					V	V	V		V	V	V					V	P	V	P				V										-	-	-	-	-	-	-	-	-		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-										-	3000	325.34	-	978.2	16.74	0.8	14.76	-	190.88	4.33		-	-	-	108.17	4605.88	4988.36	-	-	1010	3782.37	-	-	-	-	0	0.15	0	0.11	-	-	-	18.4										750 Inpatient deductible		0 cost sharing	0 cost sharing	0 cost sharing	0 cost sharing		50 copay waived upon admit w/I 24hrs	0 cost sharing					0 cost sharing	15/visit	35/visit includes PT/SP/OT OP consultations Podiatry Chiro. Psychiatry			Office visit cost share may apply	range 15/visit - 35/visit					15 - 35 copay per exam	100 max coverage amount	15 - 35 copay per exam	750 max coverage amount (per 3 yrs)				0 cost sharing										453.92	-	-	-	-	-	-	36.68	-		-	-	-	-	15	35	-	-	-	35	-	-	-	-	-	-	-	-	-	-	-	-										12.31	-	-	-	-	-	-	0.58	-	-	-	-	-	-	5.76	14.55	-	-	-	11.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.23	0	0	12.31	-	-	-	-	-	-	0.58	-	-	-	-	-	-	5.76	14.55	-	-	-	11.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.23	3000	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins											0.07	0	0.04	0	0.01	0.12	0	0	0	0	0	0	0	0.04	0.03	0.06	0	0.02	0.08	0.3	0.01	0.89	0	0	0	0	0	0	0	0	0											1.66	1000	0	12.37	-	0.04	-	0.01	0.12	-	0.58	-	-	-	-	-	0.04	5.79	14.61	-	0.02	0.08	11.33	0.01	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.88
H3154_805_0	2007	10	t.										OP Facility - Other										No	ASC										A		D	V	T	coin		V	V					V	V	V		V	V	V					V	P	V	P				V										-	-	-	-	-	-	-	-	-		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-										-	3000	325.34	-	978.2	16.74	0.8	14.76	-	190.88	4.33		-	-	-	108.17	4605.88	4988.36	-	-	1010	3782.37	-	-	-	-	0	0.15	0	0.11	-	-	-	18.4										750 Inpatient deductible		0 cost sharing	0 cost sharing	0 cost sharing	0 cost sharing		50 copay waived upon admit w/I 24hrs	0 cost sharing					0 cost sharing	15/visit	35/visit includes PT/SP/OT OP consultations Podiatry Chiro. Psychiatry			Office visit cost share may apply	range 15/visit - 35/visit					15 - 35 copay per exam	100 max coverage amount	15 - 35 copay per exam	750 max coverage amount (per 3 yrs)				0 cost sharing										453.92	-	-	-	-	-	-	36.68	-		-	-	-	-	15	35	-	-	-	35	-	-	-	-	-	-	-	-	-	-	-	-										12.31	-	-	-	-	-	-	0.58	-	-	-	-	-	-	5.76	14.55	-	-	-	11.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.23	0	0	12.31	-	-	-	-	-	-	0.58	-	-	-	-	-	-	5.76	14.55	-	-	-	11.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.23	3000	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins	1000 deductible 20 coins											0.07	0	0.04	0	0.01	0.12	0	0	0	0	0	0	0	0.04	0.03	0.06	0	0.02	0.08	0.3	0.01	0.89	0	0	0	0	0	0	0	0	0											1.66	1000	0	12.37	-	0.04	-	0.01	0.12	-	0.58	-	-	-	-	-	0.04	5.79	14.61	-	0.02	0.08	11.33	0.01	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.88
H3156_021_0	2007	6																					3000											D	D	D		T	Coin	Coin	V	V		V			V	V	V	V	V	V		S	O		V	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	1198.74	25.34	1506.15	0	237.83	21.79	1	268.36	223.46	0	467.91	0	0	70.67	5484.68	6721.22	239.57	702.78	712.24	0	1317.24	0	0	495	388.78	0	157.36	0	0	0	0											100/day 500 max/stay; 200/day 1000 max/stay	100/day 500 max/stay	25 Copay/Day	0 Copay	50 Copay/Trip	20 Coinsurance	20 Coinsurance	50/Visit; 15 PCP Urgent Care; 25 SCP Urgent Care	75/Visit; 150/Visit	0 Copay	25 Copay/Visit		0 Copay	25 Copay/Visit for PT/OT/ST	15 Copay/Visit	25 Copay/Visit	25 Copay/Visit	25 Copay/Visit	25 Copay/Visit		25 Copay/Script	0 Copay		10 Copay/Visit	25 Copay/Visit	0 Copay	25 Copay/Visit	0 Copay		0 Copay												109.86	100	25	0	50	0.2	0.2	44.04	82.41	0	25	0	0	25	15	25	25	25	25	0	25	0	0	10	25	0	25	0	0	0	0											10.97	0.21	3.14	-	0.99	4.25	0.19	0.98	1.53	-	0.97	-	-	0.15	6.86	14	0.5	1.46	1.48	-	2.74	-	-	0.41	0.81	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52	0	0.11	10.97	0.21	3.14	-	0.99	4.25	0.19	0.98	1.53	-	0.97	-	-	0.15	6.86	14	0.5	1.46	1.48	-	2.74	-	-	0.41	0.81	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52	3000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50/Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance		30 Coinsurance			0 Copay												0.97	0.01	0.15	0.11	0.02	0.07	0	0.01	0.06	0.02	0.06		0.02	0.06	0.1	0.15	0.01	0.02	0.14	0.41	0.08	0.01		0.01	0.01		0															2.5	0	0	11.94	0.22	3.29	0.11	1.01	4.32	0.2	1	1.59	0.02	1.04	-	0.02	0.21	6.96	14.15	0.5	1.48	1.62	0.41	2.83	0.01	-	0.43	0.82	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.5
H3156_024_0	2007	3																					3000											D	D	D		T	Coin	Coin	V	V		V			V	V	V	V	V	V		S	O		V	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	1198.74	25.34	1506.15	0	237.83	21.79	1	268.36	223.46	0	467.91	0	0	70.67	5484.68	6721.22	239.57	702.78	712.24	0	1317.24	0	0	495	388.78	0	157.36	0	0	0	0											100/day 500 max/stay; 200/day 1000 max/stay	100/day 500 max/stay	25 Copay/Day	0 Copay	50 Copay/Trip	20 Coinsurance	20 Coinsurance	50/Visit; 15 PCP Urgent Care; 25 SCP Urgent Care	75/Visit; 150/Visit	0 Copay	25 Copay/Visit		0 Copay	25 Copay/Visit for PT/OT/ST	15 Copay/Visit	25 Copay/Visit	25 Copay/Visit	25 Copay/Visit	25 Copay/Visit		25 Copay/Script	0 Copay		10 Copay/Visit	25 Copay/Visit	0 Copay	25 Copay/Visit	0 Copay		0 Copay												109.86	100	25	0	50	0.2	0.2	44.04	82.41	0	25	0	0	25	15	25	25	25	25	0	25	0	0	10	25	0	25	0	0	0	0											10.97	0.21	3.14	-	0.99	4.25	0.19	0.98	1.53	-	0.97	-	-	0.15	6.86	14	0.5	1.46	1.48	-	2.74	-	-	0.41	0.81	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52	0	0.11	10.97	0.21	3.14	-	0.99	4.25	0.19	0.98	1.53	-	0.97	-	-	0.15	6.86	14	0.5	1.46	1.48	-	2.74	-	-	0.41	0.81	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52	3000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50/Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance		30 Coinsurance			0 Copay												0.97	0.01	0.15	0.11	0.02	0.07	0	0.01	0.06	0.02	0.06		0.02	0.06	0.1	0.15	0.01	0.02	0.14	0.41	0.08	0.01		0.01	0.01		0			0												2.5	0	0	11.94	0.22	3.29	0.11	1.01	4.32	0.2	1	1.59	0.02	1.04	-	0.02	0.21	6.96	14.15	0.5	1.48	1.62	0.41	2.83	0.01	-	0.43	0.82	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.5
H3156_801_0	2007	3																					None											Coin		Coin	Coin	Coin	Coin		Coin	Coin	Coin					Coin						Coin	Coin																																																													-	N/A	398.3		28.01	10.05	19.83	22.19		8.14	36.08	45.32					297.09						75.6	0.27																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07		0.16	0	0.24	0.24		0.24	0.24	0.24					0.24						0.24	0.24																				26.57	-	4.58	-	4.68	5.24	-	1.92	8.51	10.7	-	-	-	-	70.11	-	-	-	-	-	17.84	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	150.22		0	26.57	-	4.58	-	4.68	5.24	-	1.92	8.51	10.7	-	-	-	-	70.11	-	-	-	-	-	17.84	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	150.22	None																																																																																			-		0	26.57	-	4.58	-	4.68	5.24	-	1.92	8.51	10.7	-	-	-	-	70.11	-	-	-	-	-	17.84	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	150.22
H3156_802_0	2007	6																					None											Coin		Coin	Coin	Coin	Coin		Coin	Coin	Coin					Coin						Coin	Coin																																																													-	N/A	398.3		28.01	10.05	19.83	22.19		8.14	36.08	45.32					297.09						75.6	0.27																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07		0.16	0	0.24	0.24		0.24	0.24	0.24					0.24						0.24	0.24																				26.57	-	4.58	-	4.68	5.24	-	1.92	8.51	10.7	-	-	-	-	70.11	-	-	-	-	-	17.84	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	150.22			26.57	-	4.58	-	4.68	5.24	-	1.92	8.51	10.7	-	-	-	-	70.11	-	-	-	-	-	17.84	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	150.22	None																																																																																			-			26.57	-	4.58	-	4.68	5.24	-	1.92	8.51	10.7	-	-	-	-	70.11	-	-	-	-	-	17.84	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	150.22
H3164_003_0	2007	5																																Coin	Coin	Coin	P	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	Coin	P	Coin	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		381.79	23.2	39.13		10.26	4.63	5.39	565.43	33.55	21.29	23.97	2.26	2.41	36.27	58.49	117.14	4.42	3.7	29.97	52.75	10.09	1.67					0.69															ffs medicare (1a)	ffs medicare (1b)	0 1-20 days; 125 21-100 days (2)	0 (6)	20 (10a)	20 (11a)	20 (11b 11c)	50 (4a);  20 (4b)	20 (9b)	20 (8a 8b)	20 (8a 8b)	20 (9a)	20 (12)	20 (3 5 9a 9c 9d)	20 (7a 14b 14c 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	50 (7e);  50 (7h)	20 (7c 7i)	20 (incl in h2)	20 (14i)	20 (15)	0 (17b);  20 (13a 16b 17a)	0 (10b)	0 n/c (16a 16b1-16b3 16b5-16b8)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 (18b)	0 n/c	0 (14a)	0 (13b 13c 13d 13e)											0.06	0.06	0.15		0.24	0.24	0.24	49.73	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24					0.2															24.77	1.51	5.97	-	2.42	1.09	1.27	2.34	7.92	5.02	5.66	0.53	0.57	8.56	13.8	27.64	1.04	0.87	7.07	12.45	2.38	0.39	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.44	138	0	24.77	1.51	5.97	-	2.42	1.09	1.27	2.34	7.92	5.02	5.66	0.53	0.57	8.56	13.8	27.64	1.04	0.87	7.07	12.45	2.38	0.39	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.44																																																																																				-		0	24.77	1.51	5.97	-	2.42	1.09	1.27	2.34	7.92	5.02	5.66	0.53	0.57	8.56	13.8	27.64	1.04	0.87	7.07	12.45	2.38	0.39	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.44
H3204_001_0	2007	4																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V						V	V		V																																																								-		198	5	281		205	316	35	370	685					399	3497	3583	106	329						0	486		31															500 deductible	500 deductible	125 per day (days 21-100)		50 per run	25 per item	25 per prosthetic device	50 ER 25/40 Urgent	175 per surgery					15 / 20 per visit (rehab)	20 per visit	35 per visit	35 per visit	20 per visit						35 per visit	35 per visit		35 per visit															500	500	125		50	25	25	42.95	175					17.5	20	35	35	20						35	35		35															8.24	0.2	2.93	-	0.86	0.66	0.07	1.33	9.99	-	-	-	-	0.58	5.83	10.45	0.31	0.55	-	-	-	-	-	0	1.42	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.5			8.24	0.2	2.93	-	0.86	0.66	0.07	1.33	9.99	-	-	-	-	0.58	5.83	10.45	0.31	0.55	-	-	-	-	-	0	1.42	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.5																																																																																				-			8.24	0.2	2.93	-	0.86	0.66	0.07	1.33	9.99	-	-	-	-	0.58	5.83	10.45	0.31	0.55	-	-	-	-	-	0	1.42	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.5
H3204_007_0	2007	4																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V						V	V		V																																																								-		232	6	312		241	371	44	435	804					469	4202	4304	127	395						0	577		37															200 deductible	250 deductible	50 per day (days 21-100)		50 per run	10 per item	10 per prosthetic device	50 ER 25/40 Urgent	100 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit						25 per visit	25 per visit		25 per visit															200	250	50		50	10	10	42.95	100					12.5	15	25	25	15						25	25		25															3.87	0.12	1.3	-	1.01	0.31	0.04	1.56	6.7	-	-	-	-	0.49	5.25	8.97	0.26	0.49	-	-	-	-	-	0	1.2	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.64			3.87	0.12	1.3	-	1.01	0.31	0.04	1.56	6.7	-	-	-	-	0.49	5.25	8.97	0.26	0.49	-	-	-	-	-	0	1.2	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.64																																																																																				-			3.87	0.12	1.3	-	1.01	0.31	0.04	1.56	6.7	-	-	-	-	0.49	5.25	8.97	0.26	0.49	-	-	-	-	-	0	1.2	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.64
H3204_008_0	2007	2																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V						V	V		V																																																								-		196	5	263		204	313	37	367	679					396	3548	3635	107	334						0	488		31															250 deductible	250 deductible	50 per day (days 21-100)		50 per run	10 per item	10 per prosthetic device	50 ER 25/40 Urgent	100 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit						25 per visit	25 per visit		25 per visit															100	250	50		50	10	10	42.95	100					12.5	15	25	25	15						25	25		25															1.64	0.1	1.1	-	0.85	0.26	0.03	1.32	5.66	-	-	-	-	0.41	4.44	7.57	0.22	0.42	-	-	-	-	-	0	1.02	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.09			1.64	0.1	1.1	-	0.85	0.26	0.03	1.32	5.66	-	-	-	-	0.41	4.44	7.57	0.22	0.42	-	-	-	-	-	0	1.02	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.09																																																																																				-			1.64	0.1	1.1	-	0.85	0.26	0.03	1.32	5.66	-	-	-	-	0.41	4.44	7.57	0.22	0.42	-	-	-	-	-	0	1.02	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.09
H3204_801_0	2007	3																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V						V	V		V																																																								-		155	4	218		163	257	29	296	549					319	2792	2898	83	269						0	396		25															500 deductible	500 deductible	100 per day (days 21-100)		50 per run	25 per item	25 per prosthetic device	50 ER 25/40 Urgent	150 per surgery					15 / 20 per visit (rehab)	20 per visit	35 per visit	35 per visit	20 per visit						35 per visit	35 per visit		35 per visit															500	500	100		50	25	25	42.95	150					17.5	20	35	35	20						35	35		35															6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09																																																																																				-			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09
H3204_802_0	2007	2																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V						V	V		V																																																								-		155	4	218		163	257	29	296	549					319	2792	2898	83	269						0	396		25															500 deductible	500 deductible	100 per day (days 21-100)		50 per run	25 per item	25 per prosthetic device	50 ER 25/40 Urgent	150 per surgery					15 / 20 per visit (rehab)	20 per visit	35 per visit	35 per visit	20 per visit						35 per visit	35 per visit		35 per visit															500	500	100		50	25	25	42.95	150					17.5	20	35	35	20						35	35		35															6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09																																																																																				-			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09
H3204_803_0	2007	3																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V						V	V		V																																																								-		155	4	218		163	257	29	296	549					319	2792	2898	83	269						0	396		25															500 deductible	500 deductible	100 per day (days 21-100)		50 per run	25 per item	25 per prosthetic device	50 ER 25/40 Urgent	150 per surgery					15 / 20 per visit (rehab)	20 per visit	35 per visit	35 per visit	20 per visit						35 per visit	35 per visit		35 per visit															500	500	100		50	25	25	42.95	150					17.5	20	35	35	20						35	35		35															6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09																																																																																				-			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09
H3204_804_0	2007	2																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V						V	V		V																																																								-		155	4	218		163	257	29	296	549					319	2792	2898	83	269						0	396		25															500 deductible	500 deductible	100 per day (days 21-100)		50 per run	25 per item	25 per prosthetic device	50 ER 25/40 Urgent	150 per surgery					15 / 20 per visit (rehab)	20 per visit	35 per visit	35 per visit	20 per visit						35 per visit	35 per visit		35 per visit															500	500	100		50	25	25	42.95	150					17.5	20	35	35	20						35	35		35															6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09																																																																																				-			6.44	0.16	1.82	-	0.68	0.54	0.06	1.06	6.86	-	-	-	-	0.46	4.65	8.45	0.24	0.45	-	-	-	-	-	0	1.16	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.09
H3206_001_0	2007	4																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V							V		V																																																								-		196	3	302		208	2480	53	400	327					610	3061	4231	111	1027							264		113															250 deductible	250 deductible	100 per day (days 21-100)		50 per run	10 per item	10 prosthetic	50 ER 25/40 Urgent	125 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit							25 per visit		25 per visit															250	250	100		50	10	10	45.04	125					12.56	15	25	25	15							25		25															4.08	0.06	2.52	-	0.87	2.07	0.04	1.5	3.41	-	-	-	-	0.64	3.83	8.82	0.23	1.28	-	-	-	-	-	-	0.55	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.12			4.08	0.06	2.52	-	0.87	2.07	0.04	1.5	3.41	-	-	-	-	0.64	3.83	8.82	0.23	1.28	-	-	-	-	-	-	0.55	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.12		750 deductible	750 deductible	115 per day (days 21-100)		50 per run	25 per item	25 prosthetics / 10 diabetes mont.	50 ER 25/40 Urgent	20 coinsurance	10 coinsurance	10 coinsurance			25 per visit (rehab)	25 / 30 per visit	35 / 50  per visit	50 coinsurance	25 per visit	10 coinsurance	10 coinsurance (lab)	20 coinsurance				50 per visit		35 per visit															1.39	0.02	0.32		0.1	0.6	0.02	0.18	0.47	0.09	0.25			0.15	0.65	1.73	0.04	0.22	0.19	0.09	0.13				0.12		0.04															6.82			5.46	0.08	2.84	-	0.97	2.67	0.07	1.68	3.89	0.09	0.25	-	-	0.79	4.48	10.54	0.28	1.51	0.19	0.09	0.13	-	-	-	0.67	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.95
H3206_002_0	2007	4																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V							V		V																																																								-		210	3	325		224	2666	57	429	352					655	3290	4547	119	1104							283		121															250 deductible	250 deductible	100 per day (days 21-100)		50 per run	10 per item	10 prosthetic	50 ER 25/40 Urgent	125 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit							25 per visit		25 per visit															250	250	100		50	10	10	45.04	125					12.56	15	25	25	15							25		25															4.38	0.06	2.71	-	0.93	2.22	0.05	1.61	3.67	-	-	-	-	0.69	4.11	9.47	0.25	1.38	-	-	-	-	-	-	0.59	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.37			4.38	0.06	2.71	-	0.93	2.22	0.05	1.61	3.67	-	-	-	-	0.69	4.11	9.47	0.25	1.38	-	-	-	-	-	-	0.59	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.37		750 deductible	750 deductible	115 per day (days 21-100)		50 per run	25 per item	25 prosthetics / 10 diabetes mont.	50 ER 25/40 Urgent	20 coinsurance	10 coinsurance	10 coinsurance			25 per visit (rehab)	25 / 30 per visit	35 / 50  per visit	50 coinsurance	25 per visit	10 coinsurance	10 coinsurance (lab)	20 coinsurance				50 per visit		35 per visit															1.49	0.02	0.34		0.11	0.65	0.02	0.2	0.51	0.1	0.27			0.16	0.7	1.86	0.05	0.24	0.21	0.1	0.14				0.13		0.04															7.33			5.87	0.08	3.05	-	1.04	2.87	0.07	1.81	4.18	0.1	0.27	-	-	0.84	4.82	11.33	0.3	1.62	0.21	0.1	0.14	-	-	-	0.72	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.71
H3206_003_0	2007	2																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V							V		V																																																								-		175	2	270		186	2214	47	357	292					544	2733	3777	99	917							235		101															250 deductible	250 deductible	50 per day (days 21-100)		50 per run	10 per item	10 prosthetic	50 ER 25/40 Urgent	100 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit							25 per visit		25 per visit															250	250	50		50	10	10	45.04	100					12.56	15	25	25	15							25		25															3.64	0.05	1.12	-	0.78	1.85	0.04	1.34	2.44	-	-	-	-	0.57	3.42	7.87	0.21	1.15	-	-	-	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.16			3.64	0.05	1.12	-	0.78	1.85	0.04	1.34	2.44	-	-	-	-	0.57	3.42	7.87	0.21	1.15	-	-	-	-	-	-	0.49	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.16		750 deductible	750 deductible	115 per day (days 21-100)		50 per run	25 per item	25 prosthetics / 10 diabetes mont.	50 ER 25/40 Urgent	20 coinsurance	10 coinsurance	10 coinsurance			25 per visit (rehab)	25 / 30 per visit	35 / 50  per visit	50 coinsurance	25 per visit	10 coinsurance	10 coinsurance (lab)	20 coinsurance				50 per visit		35 per visit															1.24	0.02	0.29		0.09	0.54	0.02	0.16	0.42	0.08	0.22			0.13	0.58	1.54	0.04	0.2	0.17	0.08	0.12				0.11		0.03															6.09			4.88	0.07	1.41	-	0.86	2.38	0.06	1.5	2.86	0.08	0.22	-	-	0.7	4	9.41	0.25	1.35	0.17	0.08	0.12	-	-	-	0.6	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.25
H3206_801_0	2007	3																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V							V		V																																																								-		193	3	299		206	2451	52	395	323					602	3025	4181	109	1015							261		112															250 deductible	250 deductible	50 per day (days 21-100)		50 per run	10 per item	10 prosthetic	50 ER 25/40 Urgent	100 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit							25 per visit		25 per visit															250	250	50		50	10	10	45.04	100					12.56	15	25	25	15							25		25															4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84			4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84		750 deductible	750 deductible	115 per day (days 21-100)		50 per run	25 per item	25 prosthetics / 10 diabetes mont.	50 ER 25/40 Urgent	20 coinsurance	10 coinsurance	10 coinsurance			25 per visit (rehab)	25 / 30 per visit	35 / 50  per visit	50 coinsurance	25 per visit	10 coinsurance	10 coinsurance (lab)	20 coinsurance				50 per visit		35 per visit															1.37	0.02	0.32		0.1	0.6	0.02	0.18	0.47	0.09	0.25			0.15	0.65	1.71	0.04	0.22	0.19	0.09	0.13				0.12		0.04															6.74			5.4	0.08	1.56	-	0.96	2.64	0.06	1.66	3.16	0.09	0.25	-	-	0.78	4.43	10.42	0.27	1.49	0.19	0.09	0.13	-	-	-	0.66	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.58
H3206_802_0	2007	2																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V							V		V																																																								-		193	3	299		206	2451	52	395	323					602	3025	4181	109	1015							261		112															250 deductible	250 deductible	50 per day (days 21-100)		50 per run	10 per item	10 prosthetic	50 ER 25/40 Urgent	100 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit							25 per visit		25 per visit															250	250	50		50	10	10	45.04	100					12.56	15	25	25	15							25		25															4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84			4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84		750 deductible	750 deductible	115 per day (days 21-100)		50 per run	25 per item	25 prosthetics / 10 diabetes mont.	50 ER 25/40 Urgent	20 coinsurance	10 coinsurance	10 coinsurance			25 per visit (rehab)	25 / 30 per visit	35 / 50  per visit	50 coinsurance	25 per visit	10 coinsurance	10 coinsurance (lab)	20 coinsurance				50 per visit		35 per visit															1.37	0.02	0.32		0.1	0.6	0.02	0.18	0.47	0.09	0.25			0.15	0.65	1.71	0.04	0.22	0.19	0.09	0.13				0.12		0.04															6.74			5.4	0.08	1.56	-	0.96	2.64	0.06	1.66	3.16	0.09	0.25	-	-	0.78	4.43	10.42	0.27	1.49	0.19	0.09	0.13	-	-	-	0.66	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.58
H3206_803_0	2007	3																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V							V		V																																																								-		193	3	299		206	2451	52	395	323					602	3025	4181	109	1015							261		112															250 deductible	250 deductible	50 per day (days 21-100)		50 per run	10 per item	10 prosthetic	50 ER 25/40 Urgent	100 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit							25 per visit		25 per visit															250	250	50		50	10	10	45.04	100					12.56	15	25	25	15							25		25															4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84			4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84		750 deductible	750 deductible	115 per day (days 21-100)		50 per run	25 per item	25 prosthetics / 10 diabetes mont.	50 ER 25/40 Urgent	20 coinsurance	10 coinsurance	10 coinsurance			25 per visit (rehab)	25 / 30 per visit	35 / 50  per visit	50 coinsurance	25 per visit	10 coinsurance	10 coinsurance (lab)	20 coinsurance				50 per visit		35 per visit															1.37	0.02	0.32		0.1	0.6	0.02	0.18	0.47	0.09	0.25			0.15	0.65	1.71	0.04	0.22	0.19	0.09	0.13				0.12		0.04															6.74			5.4	0.08	1.56	-	0.96	2.64	0.06	1.66	3.16	0.09	0.25	-	-	0.78	4.43	10.42	0.27	1.49	0.19	0.09	0.13	-	-	-	0.66	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.58
H3206_804_0	2007	2																																Ded	Ded	D		T	O	O	V	V					V	V	V	V	V							V		V																																																								-		193	3	299		206	2451	52	395	323					602	3025	4181	109	1015							261		112															250 deductible	250 deductible	50 per day (days 21-100)		50 per run	10 per item	10 prosthetic	50 ER 25/40 Urgent	100 per surgery					10 / 15 per visit (rehab)	15 per visit	25 per visit	25 per visit	15 per visit							25 per visit		25 per visit															250	250	50		50	10	10	45.04	100					12.56	15	25	25	15							25		25															4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84			4.03	0.06	1.24	-	0.86	2.04	0.04	1.48	2.7	-	-	-	-	0.63	3.78	8.71	0.23	1.27	-	-	-	-	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.84		750 deductible	750 deductible	115 per day (days 21-100)		50 per run	25 per item	25 prosthetics / 10 diabetes mont.	50 ER 25/40 Urgent	20 coinsurance	10 coinsurance	10 coinsurance			25 per visit (rehab)	25 / 30 per visit	35 / 50  per visit	50 coinsurance	25 per visit	10 coinsurance	10 coinsurance (lab)	20 coinsurance				50 per visit		35 per visit															1.37	0.02	0.32		0.1	0.6	0.02	0.18	0.47	0.09	0.25			0.15	0.65	1.71	0.04	0.22	0.19	0.09	0.13				0.12		0.04															6.74			5.4	0.08	1.56	-	0.96	2.64	0.06	1.66	3.16	0.09	0.25	-	-	0.78	4.43	10.42	0.27	1.49	0.19	0.09	0.13	-	-	-	0.66	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.58
H3207_001_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	V	P																																																				-		1053.1	34.28			71.56	7.51	18.2	294.75	319.84		375.98			260.76	2954.34	3833.64	181.72	317.32							108.56		194.36															100 per admit Unlimited days	100 per day for days 1-5 Medicare Limits Apply	0 per day for days 0-100 Medicare Limits Apply	0 per visit copayment	50 per trip	10 per Item	10 per Item	50 per ER visit 20 per Urgent Care visit	75 per visit copayment	0 Copayment	50 per MRI MRA PET CT and NM; 10 Therapeutic Radiology; 0 for OP X-Rays	0 Copayment	75 per monthly bill copayment	5 OP Rehab 5 CORF 10 Partial Hosp.	10 per visit Copayment	20 per visit Copayment	10 per visit Copayment	5 per visit Copayment	No Cost Sharing	No Cost Sharing	No Cost Sharing	Not Covered	Not Covered	Not Covered	30 per visit Copayment	150 Maximum 2-Year Benefit	20 per visit Copayment	Not Covered	Not Covered	No Cost Sharing	Not Covered											20.05	41.74			50	0.1	0.1	49.97	75		48.3			5.45	10	19.14	10	5							30		20															1.76	0.12	-	-	0.3	0.75	1.82	1.23	2	-	1.51	-	-	0.12	2.46	6.12	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.06		0	1.76	0.12	-	-	0.3	0.75	1.82	1.23	2	-	1.51	-	-	0.12	2.46	6.12	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.06		200 per day for days 1-5 Unlimited Days	200 per day for days 1-5 Medicare Limits Apply	20 for days 21-100	No Cost Sharing	50 per trip	20 per item	20 per item	50 per ER visit 40 per Urgent Care visit	150 per visit copayment	10 Coinsurance	20 per MRI MRA PET CT and NM; 20 Therapeutic Radiology; 10 for OP X-Rays	No Cost Sharing	150 per monthly bill copayment	20 for OP Rehab 10 for CORF 20 Partial Hosp.	20 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	40 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	20 per visit Copayment	20 Coinsurance	No Cost Sharing	No Cost Sharing	20 Coinsurance	Not Covered	Not Covered	Not Covered	20 Coinsurance	150 Maximum 2-Year Benefit	20 Coinsurance	Not Covered	Not Covered	No Cost Sharing	Not Covered											1.34	0.06	0.31		0.05	0.34	0.82	0.22	0.72	0.17	0.45			0.29	0.9	2.05	0.05	0.13			0.58				0.03		0.04															8.55		0	3.1	0.18	0.31	-	0.35	1.09	2.64	1.45	2.72	0.17	1.96	-	-	0.41	3.36	8.17	0.21	0.26	-	-	0.58	-	-	-	0.3	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.61
H3207_002_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	V	P																																																				-		1062.2	34.58			72.18	7.64	18.52	297.28	322.6		379.23			263.01	2979.32	3866.77	183.29	320.06							108.56		194.36															100 per admit Unlimited days	100 per day for days 1-5 Medicare Limits Apply	0 per day for days 0-100 Medicare Limits Apply	0 per visit copayment	50 per trip	10 per Item	10 per Item	50 per ER visit 20 per Urgent Care visit	75 per visit copayment	0 Copayment	50 per MRI MRA PET CT and NM; 10 Therapeutic Radiology; 0 for OP X-Rays	0 Copayment	75 per monthly bill copayment	5 OP Rehab 5 CORF 10 Partial Hosp.	10 per visit Copayment	20 per visit Copayment	10 per visit Copayment	5 per visit Copayment	No Cost Sharing	No Cost Sharing	No Cost Sharing	Not Covered	Not Covered	Not Covered	30 per visit Copayment	150 Maximum 2-Year Benefit	20 per visit Copayment	Not Covered	Not Covered	No Cost Sharing	Not Covered											20.05	41.74			50	0.1	0.1	49.97	75		48.3			5.45	10	19.14	10	5							30		20															1.77	0.12	-	-	0.3	0.76	1.85	1.24	2.02	-	1.53	-	-	0.12	2.48	6.17	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.24		0	1.77	0.12	-	-	0.3	0.76	1.85	1.24	2.02	-	1.53	-	-	0.12	2.48	6.17	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.24		200 per day for days 1-5 Unlimited Days	200 per day for days 1-5 Medicare Limits Apply	20 for days 21-100	No Cost Sharing	50 per trip	20 per item	20 per item	50 per ER visit 40 per Urgent Care visit	150 per visit copayment	10 Coinsurance	20 per MRI MRA PET CT and NM; 20 Therapeutic Radiology; 10 for OP X-Rays	No Cost Sharing	150 per monthly bill copayment	20 for OP Rehab 10 for CORF 20 Partial Hosp.	20 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	40 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	20 per visit Copayment	20 Coinsurance	No Cost Sharing	No Cost Sharing	20 Coinsurance	Not Covered	Not Covered	Not Covered	20 Coinsurance	150 Maximum 2-Year Benefit	20 Coinsurance	Not Covered	Not Covered	No Cost Sharing	Not Covered											1.35	0.06	0.31		0.05	0.34	0.83	0.22	0.73	0.17	0.46			0.3	0.91	2.07	0.06	0.13			0.59				0.03		0.04															8.65		0	3.12	0.18	0.31	-	0.35	1.11	2.69	1.46	2.74	0.17	1.99	-	-	0.41	3.39	8.24	0.21	0.26	-	-	0.59	-	-	-	0.3	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.89
H3207_003_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	V	P																																																				-		1062.2	34.58			72.18	7.64	18.52	297.28	322.6		379.23			263.01	2979.32	3866.77	183.29	320.06							108.56		194.36															100 per admit Unlimited days	100 per day for days 1-5 Medicare Limits Apply	0 per day for days 0-100 Medicare Limits Apply	0 per visit copayment	50 per trip	10 per Item	10 per Item	50 per ER visit 20 per Urgent Care visit	75 per visit copayment	0 Copayment	50 per MRI MRA PET CT and NM; 10 Therapeutic Radiology; 0 for OP X-Rays	0 Copayment	75 per monthly bill copayment	5 OP Rehab 5 CORF 10 Partial Hosp.	10 per visit Copayment	20 per visit Copayment	10 per visit Copayment	5 per visit Copayment	No Cost Sharing	No Cost Sharing	No Cost Sharing	Not Covered	Not Covered	Not Covered	30 per visit Copayment	150 Maximum 2-Year Benefit	20 per visit Copayment	Not Covered	Not Covered	No Cost Sharing	Not Covered											20.05	41.74			50	0.1	0.1	49.97	75		48.3			5.45	10	19.14	10	5							30		20															1.77	0.12	-	-	0.3	0.76	1.85	1.24	2.02	-	1.53	-	-	0.12	2.48	6.17	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.24		0	1.77	0.12	-	-	0.3	0.76	1.85	1.24	2.02	-	1.53	-	-	0.12	2.48	6.17	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.24		200 per day for days 1-5 Unlimited Days	200 per day for days 1-5 Medicare Limits Apply	20 for days 21-100	No Cost Sharing	50 per trip	20 per item	20 per item	50 per ER visit 40 per Urgent Care visit	150 per visit copayment	10 Coinsurance	20 per MRI MRA PET CT and NM; 20 Therapeutic Radiology; 10 for OP X-Rays	No Cost Sharing	150 per monthly bill copayment	20 for OP Rehab 10 for CORF 20 Partial Hosp.	20 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	40 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	20 per visit Copayment	20 Coinsurance	No Cost Sharing	No Cost Sharing	20 Coinsurance	Not Covered	Not Covered	Not Covered	20 Coinsurance	150 Maximum 2-Year Benefit	20 Coinsurance	Not Covered	Not Covered	No Cost Sharing	Not Covered											1.35	0.06	0.31		0.05	0.34	0.83	0.22	0.73	0.17	0.46			0.3	0.91	2.07	0.06	0.13			0.59				0.03		0.04															8.65		0	3.12	0.18	0.31	-	0.35	1.11	2.69	1.46	2.74	0.17	1.99	-	-	0.41	3.39	8.24	0.21	0.26	-	-	0.59	-	-	-	0.3	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.89
H3207_004_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	V	P																																																				-		1053.66	34.3			71.6	7.51	18.22	294.9	320.01		376.19			260.9	2955.89	3835.7	181.82	317.49							108.56		194.36															100 per admit Unlimited days	100 per day for days 1-5 Medicare Limits Apply	0 per day for days 0-100 Medicare Limits Apply	0 per visit copayment	50 per trip	10 per Item	10 per Item	50 per ER visit 20 per Urgent Care visit	75 per visit copayment	0 Copayment	50 per MRI MRA PET CT and NM; 10 Therapeutic Radiology; 0 for OP X-Rays	0 Copayment	75 per monthly bill copayment	5 OP Rehab 5 CORF 10 Partial Hosp.	10 per visit Copayment	20 per visit Copayment	10 per visit Copayment	5 per visit Copayment	No Cost Sharing	No Cost Sharing	No Cost Sharing	Not Covered	Not Covered	Not Covered	30 per visit Copayment	150 Maximum 2-Year Benefit	20 per visit Copayment	Not Covered	Not Covered	No Cost Sharing	Not Covered											20.05	41.74			50	0.1	0.1	49.97	75		48.3			5.45	10	19.14	10	5							30		20															1.76	0.12	-	-	0.3	0.75	1.82	1.23	2	-	1.51	-	-	0.12	2.46	6.12	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.07		0	1.76	0.12	-	-	0.3	0.75	1.82	1.23	2	-	1.51	-	-	0.12	2.46	6.12	0.15	0.13	-	-	-	-	-	-	0.27	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.07		200 per day for days 1-5 Unlimited Days	200 per day for days 1-5 Medicare Limits Apply	20 for days 21-100	No Cost Sharing	50 per trip	20 per item	20 per item	50 per ER visit 40 per Urgent Care visit	150 per visit copayment	10 Coinsurance	20 per MRI MRA PET CT and NM; 20 Therapeutic Radiology; 10 for OP X-Rays	No Cost Sharing	150 per monthly bill copayment	20 for OP Rehab 10 for CORF 20 Partial Hosp.	20 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	40 per visit Copayment 20 for Routine Physical Exams Med Cov Hearing	20 per visit Copayment	20 Coinsurance	No Cost Sharing	No Cost Sharing	20 Coinsurance	Not Covered	Not Covered	Not Covered	20 Coinsurance	150 Maximum 2-Year Benefit	20 Coinsurance	Not Covered	Not Covered	No Cost Sharing	Not Covered											1.34	0.06	0.31		0.05	0.34	0.82	0.22	0.72	0.17	0.45			0.29	0.9	2.05	0.05	0.13			0.58				0.03		0.04															8.55		0	3.1	0.18	0.31	-	0.35	1.09	2.64	1.45	2.72	0.17	1.97	-	-	0.41	3.36	8.17	0.21	0.26	-	-	0.58	-	-	-	0.3	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.63
H3208_001_0	2007	5																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin			V		V				V																																																				-	5000	210.42		651.4	1369.8	303	19.6		310.47	363.27	373.91	725.35	44.09		1217.03	4698.57	3585.78	170.42	639.17	18.03	6.08	10.35	10.27			550.8		79.2				577.8											275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.			25 per visit		25 per visit				15/25											262.74		19.11	9.55	95.54	0.1		47.77	47.77	47.77	47.77	23.89		47.77	9.55	28.66	23.89	23.89	0.1	0.1	0.1	0.1			25		25				20											4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	1.15	-	0.17	-	-	-	0.96	-	-	-	-	-	-	-	-	-	-	43.48	0	1.92	4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	1.15	-	0.17	-	-	-	0.96	-	-	-	-	-	-	-	-	-	-	43.48	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			50 copay		50 copay				20 coinsurance											4.3		0.98	0.46		0.43			0.47	0.14	0.31	0.01		0.38	0.49	0.52	0.03	0.03	0.43	0.28	0.25	0.24			0.26		0.04				0.16											10.19	500	1.74	8.91	-	2.01	1.56	2.41	2.3	-	1.24	1.92	1.63	3.19	0.1	-	5.23	4.23	9.08	0.37	1.3	2.15	0.86	1.24	1.23	-	-	1.4	-	0.2	-	-	-	1.13	-	-	-	-	-	-	-	-	-	-	53.67
H3208_801_0	2007	2																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	210.42		651.4	1369.8	303	19.6		310.47	363.27	373.91	725.35	44.09		1217.03	4698.57	3585.78	170.42	639.17	18.03	6.08	10.35	10.27																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				262.74		19.11	9.55	95.54	0.1		47.77	47.77	47.77	47.77	23.89		47.77	9.55	28.66	23.89	23.89	0.1	0.1	0.1	0.1																				4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	0	1.92	4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				4.3		0.98	0.46		0.43			0.47	0.14	0.31	0.01		0.38	0.49	0.52	0.03	0.03	0.43	0.28	0.25	0.24																				9.74	500	1.71	8.91	-	2.01	1.56	2.41	2.3	-	1.24	1.92	1.63	3.19	0.1	-	5.23	4.23	9.08	0.37	1.3	2.15	0.86	1.24	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.94
H3208_802_0	2007	2																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	210.42		651.4	1369.8	303	19.6		310.47	363.27	373.91	725.35	44.09		1217.03	4698.57	3585.78	170.42	639.17	18.03	6.08	10.35	10.27																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				262.74		19.11	9.55	95.54	0.1		47.77	47.77	47.77	47.77	23.89		47.77	9.55	28.66	23.89	23.89	0.1	0.1	0.1	0.1																				4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	0	1.92	4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				4.3		0.98	0.46		0.43			0.47	0.14	0.31	0.01		0.38	0.49	0.52	0.03	0.03	0.43	0.28	0.25	0.24																				9.74	500	1.71	8.91	-	2.01	1.56	2.41	2.3	-	1.24	1.92	1.63	3.19	0.1	-	5.23	4.23	9.08	0.37	1.3	2.15	0.86	1.24	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.94
H3208_803_0	2007	2																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	210.42		651.4	1369.8	303	19.6		310.47	363.27	373.91	725.35	44.09		1217.03	4698.57	3585.78	170.42	639.17	18.03	6.08	10.35	10.27																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				262.74		19.11	9.55	95.54	0.1		47.77	47.77	47.77	47.77	23.89		47.77	9.55	28.66	23.89	23.89	0.1	0.1	0.1	0.1																				4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	0	1.92	4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				4.3		0.98	0.46		0.43			0.47	0.14	0.31	0.01		0.38	0.49	0.52	0.03	0.03	0.43	0.28	0.25	0.24																				9.74	500	1.71	8.91	-	2.01	1.56	2.41	2.3	-	1.24	1.92	1.63	3.19	0.1	-	5.23	4.23	9.08	0.37	1.3	2.15	0.86	1.24	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.94
H3208_804_0	2007	2																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	210.42		651.4	1369.8	303	19.6		310.47	363.27	373.91	725.35	44.09		1217.03	4698.57	3585.78	170.42	639.17	18.03	6.08	10.35	10.27																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				262.74		19.11	9.55	95.54	0.1		47.77	47.77	47.77	47.77	23.89		47.77	9.55	28.66	23.89	23.89	0.1	0.1	0.1	0.1																				4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	0	1.92	4.61	-	1.04	1.09	2.41	1.87	-	1.24	1.45	1.49	2.89	0.09	-	4.84	3.74	8.56	0.34	1.27	1.72	0.58	0.99	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				4.3		0.98	0.46		0.43			0.47	0.14	0.31	0.01		0.38	0.49	0.52	0.03	0.03	0.43	0.28	0.25	0.24																				9.74	500	1.71	8.91	-	2.01	1.56	2.41	2.3	-	1.24	1.92	1.63	3.19	0.1	-	5.23	4.23	9.08	0.37	1.3	2.15	0.86	1.24	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.94
H3209_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1703.58	158.63	7795.64	146.1	548.35	1233.37	5994.26	157.7	104.7	3257.45	144.82	28.64	3.75	243.48	109.1	1092.65	1419.41	16.77		228.15	231.17	1115.66	2137.5		133.19	315.4		51.87				92.99	0.23	0.06	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						64	64			64			43	21			21		21																		9										9.15	0.85	-	-	2.95	-	-	0.56	0.19	-	-	0.05	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	14.25		2.33	9.15	0.85	-	-	2.95	-	-	0.56	0.19	-	-	0.05	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	14.25		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						2.03	0.06	0.68	0.07	0.3	0.26	0.08	0.03	0.16	0.49	0.55	0.03	0	0.09	0.01	1.43	0.13	0		0.14		0.1	0.11		0.02							0	0	0	0.02	0.02						6.84		0	11.18	0.91	0.68	0.07	3.25	0.26	0.08	0.6	0.35	0.49	0.55	0.08	0	0.53	0.01	1.43	0.13	0	-	0.14	-	0.1	0.11	-	0.02	-	-	-	-	-	-	0.07	0	0	0.02	0.02	-	-	-	-	-	21.09
H3209_002_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V		V	V																																																-		2282.28	327.63	1542.16		283.03	22.7	18.94	815.05	330.84	1951.62	812.47	58.1	2.5	1802.54		3249.19		465.41		748.83												286.31		133.23	226.24							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							6.91	0.99	2.24	-	0.86	2.2	1.83	1.18	0.33	0.79	0.33	0.06	0.24	1.82	-	1.31	-	0.19	-	0.3	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	21.84		23.27	6.91	0.99	2.24	-	0.86	2.2	1.83	1.18	0.33	0.79	0.33	0.06	0.24	1.82	-	1.31	-	0.19	-	0.3	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	21.84		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 per Visit	30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							1.92	0.13	0.35	0.35	0.06	0.14	0.12	0.04	0.15	0.11	0.1	0.01	0.01	0.19	0.32	0.17	0.04	0.03	0.11	0.58	0.11	0																				5.06		0	8.83	1.12	2.59	0.35	0.92	2.34	1.95	1.23	0.48	0.9	0.43	0.07	0.26	2	0.32	1.48	0.04	0.21	0.11	0.89	0.11	0	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	26.9
H3251_002_0	2007	3																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	O	V	T	V	P	P	P	P		P																																																					-		1308.94	65.08	1100.6	254.27	290.44	2103.07	347.38	315.45	244.92	2119.1	1047.96	6.77	5.14	386.18	6105.27	8593.64	195.81	557.7	2630.84	970.49	1566.29		0.91	0.43	861.37	161.14	7.49	2.74		267.01												200 Copay / Adm	200 Copay / Adm	Various Copays	Various Copays	75 Copay	Various Copays	Various Copays	50 Copay	50 Copay	Various Copays	CT 50; MRI 100 Copay	Various Copays	Various Copays	Various Copays	5 Copay	15 Copay	20 Copay	20 Copay	Various Copays	Various Copays	Various Copays		Various Copays	Various Copays	20-30 Copay	Various Copays	20 Copay	Various Copays		Various Copays												33.76	9.15	0.29	0.16	99.07	7.36	0	53.83	99.56	0.13	13.8	4.42	0	11.66	0.7	4.85	13.61	15.14	1.91	9.13	0.02		3.78	0	15.35	0.03	41.09	0		9.46												3.68	0.05	0.03	0	2.4	1.29	0	1.41	2.03	0.02	1.21	0	-	0.38	0.36	3.47	0.22	0.7	0.42	0.74	0	-	0	-	1.1	0	0.03	-	-	0.21	-	-	-	-	-	-	-	-	-	-	-	19.76			3.68	0.05	0.03	0	2.4	1.29	0	1.41	2.03	0.02	1.21	0	-	0.38	0.36	3.47	0.22	0.7	0.42	0.74	0	-	0	-	1.1	0	0.03	-	-	0.21	-	-	-	-	-	-	-	-	-	-	-	19.76																																																																																				-			3.68	0.05	0.03	0	2.4	1.29	0	1.41	2.03	0.02	1.21	0	-	0.38	0.36	3.47	0.22	0.7	0.42	0.74	0	-	0	-	1.1	0	0.03	-	-	0.21	-	-	-	-	-	-	-	-	-	-	-	19.76
H3251_018_0	2007	2																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	O	V	T	V	P	P	P	P		P																																																					-		1145.41	64.08	436.54	267.71	158.52	1838.6	180.62	305.23	270.55	1422.49	208.82	1.52	14.1	204.63	5020.88	6839.27	168.79	1093.92	1813.46	496.89	988.22		0	0.76	1008.28	284.65	14.86	0.38		170.33												250 Copay / Adm	250 Copay / Adm	Various Copays	Various Copays	100 Copay	Various Copays	Various Copays	50 Copay	100 Copay	Various Copays	CT 50; MRI 100 Copay	Various Copays	Various Copays	Various Copays	15 Copay	20 Copay	20 Copay	20 Copay	Various Copays	Various Copays	Various Copays		Various Copays	Various Copays	20-30 Copay	Various Copays	20 Copay	Various Copays		Various Copays												36.52	31.37	0.23	0.21	80.27	6.24	0.23	54.5	94.48	0.07	12.42	86.48	0	43.84	8.98	7.1	17.97	10.02	5.5	9.39	0.2		0	8.65	13.23	0.56	15.41	0		17.47												3.49	0.17	0.01	0	1.06	0.96	0	1.39	2.13	0.01	0.22	0.01	-	0.75	3.76	4.05	0.25	0.91	0.83	0.39	0.02	-	-	0	1.11	0.01	0.02	-	-	0.25	-	-	-	-	-	-	-	-	-	-	-	21.79			3.49	0.17	0.01	0	1.06	0.96	0	1.39	2.13	0.01	0.22	0.01	-	0.75	3.76	4.05	0.25	0.91	0.83	0.39	0.02	-	-	0	1.11	0.01	0.02	-	-	0.25	-	-	-	-	-	-	-	-	-	-	-	21.79																																																																																				-			3.49	0.17	0.01	0	1.06	0.96	0	1.39	2.13	0.01	0.22	0.01	-	0.75	3.76	4.05	0.25	0.91	0.83	0.39	0.02	-	-	0	1.11	0.01	0.02	-	-	0.25	-	-	-	-	-	-	-	-	-	-	-	21.79
H3251_021_0	2007	3																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	O	V	T	V	P	P	P	P		P																																																					-		1586.92	78.91	1334.34	308.27	352.12	2549.7	421.16	382.45	296.93	2569.14	1270.51	8.21	6.23	468.19	7401.86	10418.68	237.39	676.14	3189.55	1176.6	1898.92		1.11	0.52	1044.3	195.36	9.08	3.32		323.71												200 Copay / Adm	200 Copay / Adm	Various Copays	Various Copays	750 Copay	Various Copays	Various Copays	50 Copay	50 Copay	Various Copays	CT 50; MRI 100 Copay	Various Copays	Various Copays	Various Copays	5 Copay	15 Copay	20 Copay	20 Copay	Various Copays	Various Copays	Various Copays		Various Copays	Various Copays	20-30 Copay	Various Copays	20 Copay	Various Copays		Various Copays												33.76	9.15	0.29	0.16	99.07	7.36	0	53.83	99.56	0.13	13.8	4.42	0	11.66	0.7	5.11	13.61	15.14	1.91	9.13	0.02		3.78	0	15.35	0.03	41.09	0		9.46												4.46	0.06	0.03	0	2.91	1.56	0	1.72	2.46	0.03	1.46	0	-	0.45	0.43	4.43	0.27	0.85	0.51	0.9	0	-	0	-	1.34	0	0.03	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	24.18			4.46	0.06	0.03	0	2.91	1.56	0	1.72	2.46	0.03	1.46	0	-	0.45	0.43	4.43	0.27	0.85	0.51	0.9	0	-	0	-	1.34	0	0.03	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	24.18																																																																																				-			4.46	0.06	0.03	0	2.91	1.56	0	1.72	2.46	0.03	1.46	0	-	0.45	0.43	4.43	0.27	0.85	0.51	0.9	0	-	0	-	1.34	0	0.03	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	24.18
H3251_022_0	2007	2																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	O	V	T	V	P	P	P	P		P																																																					-		1496.19	83.71	570.24	349.7	207.07	2401.68	235.94	398.7	353.41	1858.13	272.77	1.99	18.42	267.3	6558.52	8933.79	220.48	1428.93	2368.84	649.06	1290.87		0	1	1317.06	371.82	19.41	0.5		222.5												250 Copay / Adm	250 Copay / Adm	Various Copays	Various Copays	100 Copay	Various Copays	Various Copays	50 Copay	100 Copay	Various Copays	CT 50; MRI 100 Copay	Various Copays	Various Copays	Various Copays	15 Copay	20 Copay	20 Copay	20 Copay	Various Copays	Various Copays	Various Copays		Various Copays	Various Copays	20-30 Copay	Various Copays	20 Copay	Various Copays		Various Copays												36.52	31.37	0.23	0.21	80.27	6.24	0.23	54.5	94.48	0.07	12.42	86.48	0	43.84	8.98	7.1	17.97	10.02	5.5	9.39	0.2		0	8.65	13.23	0.56	15.41	0		17.47												4.55	0.22	0.01	0.01	1.39	1.25	0	1.81	2.78	0.01	0.28	0.01	-	0.98	4.91	5.29	0.33	1.19	1.08	0.51	0.02	-	-	0	1.45	0.02	0.02	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	28.46			4.55	0.22	0.01	0.01	1.39	1.25	0	1.81	2.78	0.01	0.28	0.01	-	0.98	4.91	5.29	0.33	1.19	1.08	0.51	0.02	-	-	0	1.45	0.02	0.02	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	28.46																																																																																				-			4.55	0.22	0.01	0.01	1.39	1.25	0	1.81	2.78	0.01	0.28	0.01	-	0.98	4.91	5.29	0.33	1.19	1.08	0.51	0.02	-	-	0	1.45	0.02	0.02	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	28.46
H3251_801_0	2007	4																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	O	V	T	V	P	P	P	P		P																																																					-		1332.1	67.06	1059.25	263.99	284.53	2140.07	339.28	324.4	255.75	2106.71	984.7	6.38	6.34	377.61	6176.12	8667.03	198.98	637.55	2620.93	946.96	1549.83		0.84	0.48	906.01	180.58	8.58	2.55		264.42												200 Copay / Adm	200 Copay / Adm	Various Copays	Various Copays	75 Copay	Various Copays	Various Copays	50 Copay	75 Copay	Various Copays	CT 50; MRI 100 Copay	Various Copays	Various Copays	Various Copays	5 Copay	20 Copay	20 Copay	20 Copay	Various Copays	Various Copays	Various Copays		Various Copays	Various Copays	20-30 Copay	Various Copays	20 Copay	Various Copays		Various Copays												34.04	11.6	0.29	0.16	97.86	7.25	0.01	53.9	98.94	0.13	13.77	6.68	0	13.67	1.48	6.42	14.04	14.13	2.2	9.15	0.04		3.78	1.57	15.08	0.12	35.95	0		10.06												3.78	0.06	0.03	0	2.32	1.29	0	1.46	2.11	0.02	1.13	0	-	0.43	0.76	4.64	0.23	0.75	0.48	0.72	0	-	0	0	1.14	0	0.03	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	21.61			3.78	0.06	0.03	0	2.32	1.29	0	1.46	2.11	0.02	1.13	0	-	0.43	0.76	4.64	0.23	0.75	0.48	0.72	0	-	0	0	1.14	0	0.03	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	21.61																																																																																				-			3.78	0.06	0.03	0	2.32	1.29	0	1.46	2.11	0.02	1.13	0	-	0.43	0.76	4.64	0.23	0.75	0.48	0.72	0	-	0	0	1.14	0	0.03	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	21.61
H3251_804_0	2007	3																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	O	V	T	V	P	P	P	P		P																																																					-		1332.1	67.06	1059.25	263.99	284.53	2140.07	339.28	324.4	255.75	2106.71	984.7	6.38	6.34	377.61	6176.12	8667.03	198.98	637.55	2620.93	946.96	1549.83		0.84	0.48	906.01	180.58	8.58	2.55		264.42												200 Copay / Adm	200 Copay / Adm	Various Copays	Various Copays	75 Copay	Various Copays	Various Copays	50 Copay	75 Copay	Various Copays	CT 50; MRI 100 Copay	Various Copays	Various Copays	Various Copays	5 Copay	20 Copay	20 Copay	20 Copay	Various Copays	Various Copays	Various Copays		Various Copays	Various Copays	20-30 Copay	Various Copays	20 Copay	Various Copays		Various Copays												34.04	11.6	0.29	0.16	97.86	7.25	0.01	53.9	98.94	0.13	13.77	6.68	0	13.67	1.48	6.42	14.04	14.13	2.2	9.15	0.04		3.78	1.57	15.08	0.12	35.95	0		10.06												3.78	0.06	0.03	0	2.32	1.29	0	1.46	2.11	0.02	1.13	0	-	0.43	0.76	4.64	0.23	0.75	0.48	0.72	0	-	0	0	1.14	0	0.03	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	21.61			3.78	0.06	0.03	0	2.32	1.29	0	1.46	2.11	0.02	1.13	0	-	0.43	0.76	4.64	0.23	0.75	0.48	0.72	0	-	0	0	1.14	0	0.03	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	21.61																																																																																				-			3.78	0.06	0.03	0	2.32	1.29	0	1.46	2.11	0.02	1.13	0	-	0.43	0.76	4.64	0.23	0.75	0.48	0.72	0	-	0	0	1.14	0	0.03	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	21.61
H3305_007_0	2007	4	h.6.										OP Facility - Other											MH Substance Abuse										A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	Coin	O	T	P	P	P	P	P	O	V	Coin	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		285.54	3.72	983.98	1470.72	469.84	0.71	1.11	291.23	298.91	5622.01	618.52	51.11	18.03	745.26	7897.58	13874.5	0.96	1095.05	3724.83	0	4.42	0	8.76	919.44	487.64	222.36	69.83	7.78	0	0	0.91	0.55										100 per admit 300 OOP Max Unlimited Days	100 per admit 300 OOP Max	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 20 per Visit for Visits 21+	50 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	75 Ambulatory Surgical Copay	No Cost Sharing	20 per Visit for X-rays only	No Cost Sharing	No Cost Sharing	20 OP Rehab includes Cardiac Rehab	15 per Visit	20 per Specialist Visit 15 per Pelvic Exam	20 for 1st OP MH visit 50 thereafter	20 per Visit	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	No Cost Sharing	300 MAB Preventive Only no cost sharing prior to MAB	15 per Visit	100 MAB no cost sharing prior to MAB	20 per Visit	600 Max Benefit Every 3 Years	Not Applicable	Check with PBP	30 Travel Benefit with 3000 MAB	20 for 1st OP MH visit 50 thereafter 50 for Substance Abuse										85.72	85.72	32.96	4.66	50	0.2	0.2	48.59	75	0	9.27	0	0	8.2	8.4	9.27	0.44	20	0	0	0.2	0	0	0	15	0	20	0	0	0	0.3	0.42										2.04	0.03	2.7	0.57	1.96	0.14	0.22	1.18	1.87	-	0.48	-	-	0.51	5.53	10.72	0.42	1.83	-	-	0.88	-	-	-	0.61	-	0.12	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	32.3			2.04	0.03	2.7	0.57	1.96	0.14	0.22	1.18	1.87	-	0.48	-	-	0.51	5.53	10.72	0.42	1.83	-	-	0.88	-	-	-	0.61	-	0.12	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	32.3		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-			2.04	0.03	2.7	0.57	1.96	0.14	0.22	1.18	1.87	-	0.48	-	-	0.51	5.53	10.72	0.42	1.83	-	-	0.88	-	-	-	0.61	-	0.12	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	32.3
H3305_011_0	2007	5	h.6.										OP Facility - Other											MH Substance Abuse										A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	Coin	O	T	P	P	P	P	P	O	V	Coin	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		285.54	3.72	983.98	1470.72	469.84	0.71	1.11	291.23	298.91	5622.01	618.52	51.11	18.03	745.26	7897.58	13874.5	0.95	1095.05	3724.83	0	4.41	0	8.76	919.44	487.64	222.36	69.83	7.78	0	0	0.91	0.55										100 per admit 300 OOP Max Unlimited Days	100 per admit 300 OOP Max	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 20 per Visit for Visits 21+	50 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	75 Ambulatory Surgical Copay	No Cost Sharing	20 per Visit for X-rays only	No Cost Sharing	No Cost Sharing	20 OP Rehab includes Cardiac Rehab	15 per Visit	20 per Specialist Visit 15 per Pelvic Exam	20 for 1st OP MH visit 50 thereafter	20 per Visit	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	No Cost Sharing	300 MAB Preventive Only no cost sharing prior to MAB	15 per Visit	100 MAB no cost sharing prior to MAB	20 per Visit	600 Max Benefit Every 3 Years	Not Applicable	Check with PBP	30 Travel Benefit with 3000 MAB	20 for 1st OP MH visit 50 thereafter 50 for Substance Abuse										85.72	85.72	32.96	4.66	50	0.2	0.2	48.59	75	0	9.27	0	0	8.2	8.4	9.27	0.44	20	0	0	0.2	0	0	0	15	0	20	0	0	0	0.3	0.42										2.04	0.03	2.7	0.57	1.96	0.14	0.22	1.18	1.87	-	0.48	-	-	0.51	5.53	10.72	0.42	1.83	-	-	0.88	-	-	-	0.61	-	0.12	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	32.3			2.04	0.03	2.7	0.57	1.96	0.14	0.22	1.18	1.87	-	0.48	-	-	0.51	5.53	10.72	0.42	1.83	-	-	0.88	-	-	-	0.61	-	0.12	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	32.3		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-			2.04	0.03	2.7	0.57	1.96	0.14	0.22	1.18	1.87	-	0.48	-	-	0.51	5.53	10.72	0.42	1.83	-	-	0.88	-	-	-	0.61	-	0.12	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	32.3
H3305_801_0	2007	5	h.6.										Professional											MH Substance Abuse										A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	Coin	O	T	P	P	P	P	P	O	V	Coin	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		280.85	3.07	1446.63	1628.93	447.66	0.72	1.39	270.86	300.71	6467.72	472.73	64.08	18.16	805.26	8164.95	15261.1	1.05	1270.43	3776.38	0	11.63	0	13.75	0	508.11	0	81.67	0	0	0	0.91	0.62										100 per admit 300 OOP Max Unlimited Days	100 per admit 300 OOP Max	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 20 per Visit for Visits 21+	50 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	No Cost Sharing Includes ASC	No Cost Sharing	20 per Visit for X-rays only	No Cost Sharing	No Cost Sharing	20 OP Rehab includes Cardiac Rehab	15 per Visit	20 per Specialist Visit 15 per Pelvic Exam	20 for 1st OP MH visit 50 thereafter	20 per Visit	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	No Cost Sharing	Not Covered rider available	15 per Visit	Not Covered rider available	20 per Visit	Not Covered rider available	Not Applicable	Check with PBP	30 Travel Benefit - 3000 MAB	20 for 1st OP MH visit 50 thereafter 50 for Substance Abuse										85.72	85.72	32.96	4.66	50	0.2	0.2	48.36	0	0	8.72	0	0	8.28	8.28	9.59	0.44	20	0	0	0.2	0	0	0	15	0	20	0	0	0	0.3	0.43										2.01	0.02	3.97	0.63	1.87	0.14	0.28	1.09	-	-	0.34	-	-	0.56	5.63	12.2	0.46	2.12	-	-	2.33	-	-	-	0.64	-	0.14	-	-	-	0.27	0.27	-	-	-	-	-	-	-	-	-	34.96	0		2.01	0.02	3.97	0.63	1.87	0.14	0.28	1.09	-	-	0.34	-	-	0.56	5.63	12.2	0.46	2.12	-	-	2.33	-	-	-	0.64	-	0.14	-	-	-	0.27	0.27	-	-	-	-	-	-	-	-	-	34.96		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-			2.01	0.02	3.97	0.63	1.87	0.14	0.28	1.09	-	-	0.34	-	-	0.56	5.63	12.2	0.46	2.12	-	-	2.33	-	-	-	0.64	-	0.14	-	-	-	0.27	0.27	-	-	-	-	-	-	-	-	-	34.96
H3305_803_0	2007	5	h.6.										Professional											MH Substance Abuse										A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	Coin	O	T	P	P	P	P	P	O	V	Coin	Coin										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		280.85	3.07	1446.63	1628.93	447.66	0.71	1.38	270.86	300.71	6467.72	472.73	64.08	18.16	805.26	8164.95	15261.1	1.04	1270.43	3776.38	0	11.55	0	13.75	0	508.11	0	81.67	0	0	0	0.9	0.61										100 per admit 300 OOP Max Unlimited Days	100 per admit 300 OOP Max	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 20 per Visit for Visits 21+	50 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	No Cost Sharing Includes ASC	No Cost Sharing	20 per Visit for X-rays only	No Cost Sharing	No Cost Sharing	20 OP Rehab includes Cardiac Rehab	15 per Visit	20 per Specialist Visit 15 per Pelvic Exam	20 for 1st OP MH visit 50 thereafter	20 per Visit	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	No Cost Sharing	Not Covered rider available	15 per Visit	Not Covered rider available	20 per Visit	Not Covered rider available	Not Applicable	Check with PBP	30 Travel Benefit - 3000 MAB	20 for 1st OP MH visit 50 thereafter 50 for Substance Abuse										85.72	85.72	32.96	4.66	50	0.2	0.2	48.36	0	0	8.72	0	0	8.28	8.28	9.59	0.44	20	0	0	0.2	0	0	0	15	0	20	0	0	0	0.3	0.43										2.01	0.02	3.97	0.63	1.87	0.14	0.28	1.09	-	-	0.34	-	-	0.56	5.63	12.2	0.46	2.12	-	-	2.31	-	-	-	0.64	-	0.14	-	-	-	0.27	0.26	-	-	-	-	-	-	-	-	-	34.93	0		2.01	0.02	3.97	0.63	1.87	0.14	0.28	1.09	-	-	0.34	-	-	0.56	5.63	12.2	0.46	2.12	-	-	2.31	-	-	-	0.64	-	0.14	-	-	-	0.27	0.26	-	-	-	-	-	-	-	-	-	34.93		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-			2.01	0.02	3.97	0.63	1.87	0.14	0.28	1.09	-	-	0.34	-	-	0.56	5.63	12.2	0.46	2.12	-	-	2.31	-	-	-	0.64	-	0.14	-	-	-	0.27	0.26	-	-	-	-	-	-	-	-	-	34.93
H3307_002_0	2007	6																					0											D	D	D		Coin	Coin	Coin	V	P		Coin			V	V	V	Coin	V		V	Coin																																																														-	0	2029.38	61.8	1465.89		7.64	7.64	8.35	217.81	216.92		14.46			281.77	6049.61	5730.65	2.4	399.36		106.48	40.52																					120/day up to 840 max per admit	120/day up to 840 max per admit	0 for 1st 10 days; 120/day from days 11-100		20 coins	20 coins	20 coins	50 copay	300 per surgery		20 coins			25 copay	15 copay	25 copay	50 coins	25 copay		250 IP surgery 200 Am Surg Phys	20 coins																					89.32	72.63	88.76		0.2	0.2	0.2	50	298.8		0.19			24.6	14.27	24.84	0.5	23.51		218.33	0.2																					15.1	0.37	10.84	-	1.53	1.53	1.67	0.91	5.4	-	2.82	-	-	0.58	7.19	11.86	1.19	0.78	-	1.94	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82	0	0	15.1	0.37	10.84	-	1.53	1.53	1.67	0.91	5.4	-	2.82	-	-	0.58	7.19	11.86	1.19	0.78	-	1.94	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82	0																																																																																			-	0	0	15.1	0.37	10.84	-	1.53	1.53	1.67	0.91	5.4	-	2.82	-	-	0.58	7.19	11.86	1.19	0.78	-	1.94	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82
H3307_011_0	2007	5																					0											Ded	Ded	Ded	Ded	Ded	Ded	Ded	V	Ded	Ded				V	V	V	Coin	V		Ded	Ded																					27.83	0.32	3.33	0	0.65	0.01	0.01		2.02	0					0	2.67	0.03			3.08	0.32																					40.26	0								201.31						212.48	5487.38	6074.99	2.22	358.66																								Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	50 copay	Apply to Deductible	Apply to Deductible				20 copay	10 copay	20 copay	50 coinsurance	20 copay		Apply to Deductible	Apply to Deductible																												49.72						20	9.87	19.89	0.44	18.95																								-	-	-	-	-	-	-	0.83	-	-	-	-	-	0.35	4.51	10.07	0.98	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.31	1675	0	27.83	0.32	3.33	0	0.65	0.01	0.01	0.83	2.02	0	-	-	-	0.35	4.51	12.73	1.01	0.57	-	3.08	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.58	0																																																																																			-	0	0	27.83	0.32	3.33	0	0.65	0.01	0.01	0.83	2.02	0	-	-	-	0.35	4.51	12.73	1.01	0.57	-	3.08	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.58
H3307_012_0	2007	5																					0											D	D	D		Coin	Coin	Coin	V	P		Coin			V	V	V	Coin	V		V	Coin																																																														-	0	1723.96	38.5	901.49		6.54	7.1	2.62	312.39	219.05		44.58			282.98	5501.47	5975.17	2.69	211.17		104.54	27.15																					130/day up to 1560 max per admit	130/day up to 1560 max per admit	0 for 1st 5 days; 125/day from days 6-100		20	20	20	50 copay	300 per visit		20			25 copay	15 copay	25 copay	50	25 copay		250 IP surgery 200 Am Surg Phys	20 coin																					111.97	152.93	119.11		0.2	0.2	0.2	49.95	299.89		0.07			24.95	14.89	24.9	0.41	23.43		236.71	0.2																					16.09	0.49	8.95	-	1.3	1.42	0.52	1.3	5.47	-	3.16	-	-	0.59	6.83	12.4	1.1	0.41	-	2.06	5.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.52	0	0	16.09	0.49	8.95	-	1.3	1.42	0.52	1.3	5.47	-	3.16	-	-	0.59	6.83	12.4	1.1	0.41	-	2.06	5.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.52	0																																																																																			-	0	0	16.09	0.49	8.95	-	1.3	1.42	0.52	1.3	5.47	-	3.16	-	-	0.59	6.83	12.4	1.1	0.41	-	2.06	5.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.52
H3307_013_0	2007	5																					0											Ded	Ded	Ded	Ded	Ded	Ded	Ded	V	Ded	Ded				V	V	V	Coin	V		Ded	Ded																					34.2	0.4	4.1	0	0.8	0.01	0.01		2.48	0					0	3.28	0.04			3.78	0.39																					49.49	0								313.14						283.65	6007.28	6486.82	2.72	232.29																								Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	Apply to Deductible	50 copay	Apply to Deductible	Apply to Deductible				20 copay	10 copay	20 copay	50 coin	20 copay		Apply to Deductible	Apply to Deductible																												49.95						20.69	9.53	18.75	0.41	19.7																								-	-	-	-	-	-	-	1.3	-	-	-	-	-	0.49	4.77	10.13	1.11	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.18	2275	0	34.2	0.4	4.1	0	0.8	0.01	0.01	1.3	2.48	0	-	-	-	0.49	4.77	13.42	1.14	0.38	-	3.78	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.68	0																																																																																			-	0	0	34.2	0.4	4.1	0	0.8	0.01	0.01	1.3	2.48	0	-	-	-	0.49	4.77	13.42	1.14	0.38	-	3.78	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.68
H3307_015_0	2007	4																					0																		V						V		V	Coin	V						Coin																																																											-	0								86.1						152.06		5550.52	0.78	1818.17						13.08																									50 copay						5 copay		5 copay	50 coin	5 copay						coins varying by class of service from 0 to 70																									49.52						4.65		4.95	0.5	4.86						0.6																		-	-	-	-	-	-	-	0.36	-	-	-	-	-	0.06	-	2.29	0.39	0.74	-	-	-	-	-	7.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.67	0	0	-	-	-	-	-	-	-	0.36	-	-	-	-	-	0.06	-	2.29	0.39	0.74	-	-	-	-	-	7.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.67	0																																																																																			-	0	0	-	-	-	-	-	-	-	0.36	-	-	-	-	-	0.06	-	2.29	0.39	0.74	-	-	-	-	-	7.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.67
H3307_018_0	2007	5																					0											D	D	D			Coin	Coin	V	P					V	V	V	Coin	V			Coin																																																														-	0	2036.56	64.09	1475.46			7.59	8.57	218.35	217.12					276.97	5905.44	5682.96	2.38	398.2			40.5																					80/day up to 800 max per admit	80/day up to 800 max per admit	0 for 1st 10 days; 75/day from days 11-100			20 coin	20 coin	50 Copay	100 per surgery					20 Copay	10 copay	20 copay	50 Coin	20 copay			20 coin																					72.17	55.09	53.78			0.2	0.2	49.72	99.61					19.77	9.82	19.87	0.5	18.8			0.2																					12.25	0.29	6.61	-	-	1.52	1.71	0.9	1.8	-	-	-	-	0.46	4.83	9.41	1.18	0.62	-	-	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.7	0	0	12.25	0.29	6.61	-	-	1.52	1.71	0.9	1.8	-	-	-	-	0.46	4.83	9.41	1.18	0.62	-	-	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.7	0																																																																																			-	0	0	12.25	0.29	6.61	-	-	1.52	1.71	0.9	1.8	-	-	-	-	0.46	4.83	9.41	1.18	0.62	-	-	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.7
H3307_019_0	2007	4																					0											D	D	D			Coin	Coin	V	P					V	V	V	Coin	V			Coin																																																														-	0	1708.32	38.15	901.49			7.1	2.62	312.36	219.03					282.95	6006.96	6486.82	2.71	232.29			24.74																					80/day up to 800 max per admit	80/day up to 800 max per admit	0 for 1st 10 days; 75/day from days 11-100			20 coin	20 coin	50 copay	100 per surgery					20 copay	10 copay	20 copay	50 coin	20 copay			20 coin																					64.9	88.65	54.65			0.2	0.2	49.95	83.3					19.96	9.93	19.86	0.41	18.74			0.2																					9.24	0.28	4.11	-	-	1.42	0.52	1.3	1.52	-	-	-	-	0.47	4.97	10.73	1.1	0.36	-	-	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.98	0	0	9.24	0.28	4.11	-	-	1.42	0.52	1.3	1.52	-	-	-	-	0.47	4.97	10.73	1.1	0.36	-	-	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.98	0																																																																																			-	0	0	9.24	0.28	4.11	-	-	1.42	0.52	1.3	1.52	-	-	-	-	0.47	4.97	10.73	1.1	0.36	-	-	4.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.98
H3307_020_0	2007	4																					0																		P						V		V	V	V																																																																	-	0								260.35						229.09		5651.85	606.78	625.07																															50 copay						10 copay		10 copay	20 copay	10 copay																															50						10		10	20	10																								-	-	-	-	-	-	-	1.08	-	-	-	-	-	0.19	-	4.71	1.01	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.52	0	0	-	-	-	-	-	-	-	1.08	-	-	-	-	-	0.19	-	4.71	1.01	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.52	0																																																																																			-	0	0	-	-	-	-	-	-	-	1.08	-	-	-	-	-	0.19	-	4.71	1.01	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.52
H3307_802_0	2007	6																					0											D	D	D		Coin	Coin	Coin	P	Coin		Coin			V	V	V	Coin	V	Coin	V	Coin																																																														-	0	1919.78	55.4	1295.41		7	7.28	6.75	231.06	24.89		21.22			264.91	5473.24	5439.17	2.32	326.74	28.85	100.74	33.06																					250/day up to 2500 max per admit	250/day up to 2500 max per admit	160/day		30 coins	30 coins	30 coins	50 copay	30 coins		30 coins			40 copay	20 copay	40 copay	50 coins	40 copay	30 coins	250 IP surgery 200 Am Surg Phys	30 coins																					172.99	166.23	136.67		0.3	0.3	0.3	49.99	0.3		0.23			39.67	19.6	39.77	0.48	37.62	0.3	222.52	0.3																					27.68	0.77	14.75	-	2.1	2.18	2.02	0.96	7.47	-	4.94	-	-	0.88	8.94	18.02	1.11	1.02	8.65	1.87	9.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.29	0	0	27.68	0.77	14.75	-	2.1	2.18	2.02	0.96	7.47	-	4.94	-	-	0.88	8.94	18.02	1.11	1.02	8.65	1.87	9.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.29	0																																																																																			-	0	0	27.68	0.77	14.75	-	2.1	2.18	2.02	0.96	7.47	-	4.94	-	-	0.88	8.94	18.02	1.11	1.02	8.65	1.87	9.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.29
H3307_804_0	2007	4																					0											D	D	D		Coin	Coin	Coin	P	Coin		Coin			V	V	V	Coin	V	Coin	V	Coin																																																														-	0	1919.8	55.41	1295.46		7	7.28	6.75	231.05	24.89		21.22			264.9	5473.23	5439.11	2.32	326.75	28.85	100.74	33.06																					250/day up to 2500 max per admit	250/day up to 2500 max per admit	160/day		30 coins	30 coins	30 coins	50 copay	30 coins		30 coins			40 copay	20 copay	40 copay	50 coins	40 copay	30 coins	250 IP surgery 200 Am Surg Phys	30 coins																					172.99	166.22	136.67		0.3	0.3	0.3	49.99	0.3		0.23			39.67	19.6	39.77	0.48	37.62	0.3	222.52	0.3																					27.68	0.77	14.75	-	2.1	2.18	2.02	0.96	7.47	-	4.94	-	-	0.88	8.94	18.02	1.11	1.02	8.66	1.87	9.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.29	0	0	27.68	0.77	14.75	-	2.1	2.18	2.02	0.96	7.47	-	4.94	-	-	0.88	8.94	18.02	1.11	1.02	8.66	1.87	9.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.29	0																																																																																			-	0	0	27.68	0.77	14.75	-	2.1	2.18	2.02	0.96	7.47	-	4.94	-	-	0.88	8.94	18.02	1.11	1.02	8.66	1.87	9.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.29
H3312_002_0	2007	5																																D		D	V	T	Coin		V	P	V	V		V	V	V	V		V	V	V	S				V		V																																																								-		1986.13		1046.27	496.1	160.41	15.42		274.74	142.66	1212.57	1146.98		151.57	218.95	4298.68	5083.15		854.95			251.23				910.82		84.75															75/day 1-10		0/day 1-8 75/day 9-15 100/day 16 - 100	20	100	20		50 ER 20 urgent care	150	20	100 complex 20 routine		20	20	10	20		20	20	20	45				0		0															61.23		64.79	20	100	0.2		46.1	150	20	47.36		20	20	10	20		20	20	20	45				0		0															10.13	-	5.65	0.83	1.34	3.08	-	1.06	1.78	2.02	4.53	-	0.25	0.36	3.58	8.47	-	1.42	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.46			10.13	-	5.65	0.83	1.34	3.08	-	1.06	1.78	2.02	4.53	-	0.25	0.36	3.58	8.47	-	1.42	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.46																																																																																				-			10.13	-	5.65	0.83	1.34	3.08	-	1.06	1.78	2.02	4.53	-	0.25	0.36	3.58	8.47	-	1.42	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.46
H3312_018_0	2007	5																																D		D	V	T	Coin		V	P	V	V		V	V	V	V		V	V	V	S				V		V																																																								-		1802.1		1104.35	606.29	158.97	15.78		312.72	215.16	1320.49	1525.26		111.14	369.36	3338.71	5485.4		610.7	0	0	247.42				888.72		83.91															175 day 1-10		0/day 1-10; 100/day 11-100	35	100	20		50 ER 25 urgent care	100	35	100 complex 35 routine		35	35	20	35 Specialist; 30 Renal Dialysis		35	35	35	45				0		0															142.87		63.47	35	100	0.2		46.75	100	35	57.23		30	35	20	34.43		35	35	35	45				0		0															21.46	-	5.84	1.77	1.32	3.16	-	1.22	1.79	3.85	7.27	-	0.28	1.08	5.56	15.74	-	1.78	-	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.05			21.46	-	5.84	1.77	1.32	3.16	-	1.22	1.79	3.85	7.27	-	0.28	1.08	5.56	15.74	-	1.78	-	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.05																																																																																				-			21.46	-	5.84	1.77	1.32	3.16	-	1.22	1.79	3.85	7.27	-	0.28	1.08	5.56	15.74	-	1.78	-	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.05
H3312_025_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		2360.73		1304.46	636.25	135.2	19.87		213.91	133.92	1085.1	1270.5	0	2.9	252	3471.59	5485.76		875.06			244.5				910.95		93.73															250/day 1-10		0/day 1-10; 100/day 11-100	25	100	20		50 ER 20 urgent care	200	20	100 complex 20 routine	20	20	20	10	20	20	20	20	20	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness												204.1		63.47	25	100	0.2		46.1	200	20	47.36	20	20	20	10	20	20	20	20	20	45	0	0	0	0	0	0	0	0	0	0											40.15	-	6.9	1.33	1.13	3.97	-	0.82	2.23	1.81	5.01	-	0	0.42	2.89	9.14	-	1.46	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.19			40.15	-	6.9	1.33	1.13	3.97	-	0.82	2.23	1.81	5.01	-	0	0.42	2.89	9.14	-	1.46	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.19																																																																																				-			40.15	-	6.9	1.33	1.13	3.97	-	0.82	2.23	1.81	5.01	-	0	0.42	2.89	9.14	-	1.46	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.19
H3312_028_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		2014.85		1061.4	503.27	162.73	15.64		278.71	144.72	1230.1	1163.56	0	153.76	222.11	4360.84	5156.66		867.31			254.87				923.99		85.98															0		0/day 1-8 75/day 9-15 100/day 16-100	20	100	20		50 ER 20 urgent care	100	20	100 complex 20 routine	20	20	20	0	20	20	20	20	20	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness	0											0		64.79	20	100	0.2		46.1	100	20	47.36	20	20	20	0	20	20	20	20	20	45	0	0	0	0	0	0	0	0	0	0											-	-	5.73	0.84	1.36	3.13	-	1.07	1.21	2.05	4.59	-	0.26	0.37	-	8.59	-	1.45	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.6			-	-	5.73	0.84	1.36	3.13	-	1.07	1.21	2.05	4.59	-	0.26	0.37	-	8.59	-	1.45	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.6																																																																																				-			-	-	5.73	0.84	1.36	3.13	-	1.07	1.21	2.05	4.59	-	0.26	0.37	-	8.59	-	1.45	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.6
H3312_036_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		2048.58		1079.17	511.7	165.46	15.91		283.37	147.15	1250.7	1183.05	0	156.34	225.83	4433.86	5243		881.83			259.13				939.46		87.41															0		0/day 1-8 75/day 9-15 100/day 16-100	10	100	20		50 ER 20 urgent care	0	10	100 complex 10 routine	10	10	10	0	10	10	10	10	10	45	0	Not Covered	Not Covered	0	100 every 24 months	0	750 every 36 months	N/A	Fitness												0		64.79	10	100	0.2		46.1	0	10	40.78	10	10	10	0	10	10	10	10	10	45	0	0	0	0	0	0	0	0	0	0											-	-	5.83	0.43	1.38	3.18	-	1.09	-	1.04	4.02	-	0.13	0.19	-	4.37	-	0.73	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.36			-	-	5.83	0.43	1.38	3.18	-	1.09	-	1.04	4.02	-	0.13	0.19	-	4.37	-	0.73	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.36																																																																																				-			-	-	5.83	0.43	1.38	3.18	-	1.09	-	1.04	4.02	-	0.13	0.19	-	4.37	-	0.73	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.36
H3312_037_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1998.57		1052.83	499.21	161.42	15.52		276.46	143.56	1220.17	1154.17	0	152.52	220.32	4325.62	5115.01		860.31			252.81				916.53		85.28															0		0/day 1-8 75/day 9-15 100/day 16-100	20	100	20		50 ER 20 urgent care	150	20	100 complex 20 routine	20	20	20	10	20	20	20	20	20	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness	0											0		64.79	20	100	0.2		46.1	150	25	50.65	20	20	20	10	20	20	20	20	20	45	0	0	0	0	0	0	0	0	0	0											-	-	5.68	0.83	1.35	3.1	-	1.06	1.79	2.54	4.87	-	0.25	0.37	3.6	8.53	-	1.43	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.37			-	-	5.68	0.83	1.35	3.1	-	1.06	1.79	2.54	4.87	-	0.25	0.37	3.6	8.53	-	1.43	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.37																																																																																				-			-	-	5.68	0.83	1.35	3.1	-	1.06	1.79	2.54	4.87	-	0.25	0.37	3.6	8.53	-	1.43	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.37
H3312_040_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1790.29		1097.12	602.31	157.92	15.68		310.67	213.75	1311.84	1515.27	0	110.41	366.94	3316.83	5449.46		606.7			245.8				882.9		83.36															225/day 1-10		0/day 1-10; 100/day 11-100	35	100	20		50 ER 25 urgent care	200	35	100 complex 35 routine	35	30	35	25	35 Specialist; 30 Renal Dialysis	35	35	35	35	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness												183.69		63.47	35	100	0.2		46.75	200	35	57.23	35	30	35	25	34.42	35	35	35	35	45	0	0	0	0	0	0	0	0	0												27.4	-	5.8	1.76	1.32	3.14	-	1.21	3.56	3.83	7.23	-	0.28	1.07	6.91	15.63	-	1.77	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.82			27.4	-	5.8	1.76	1.32	3.14	-	1.21	3.56	3.83	7.23	-	0.28	1.07	6.91	15.63	-	1.77	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.82																																																																																				-			27.4	-	5.8	1.76	1.32	3.14	-	1.21	3.56	3.83	7.23	-	0.28	1.07	6.91	15.63	-	1.77	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.82
H3312_043_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		2340.04		1293.03	630.67	134.01	19.7		212.04	132.75	1075.59	1259.36	0	2.87	249.79	3441.16	5437.67		867.39			242.35				902.96		92.91															250/day 1-10		0/day 1-10; 100/day 11-100	25	100	20		50 ER 20 urgent care	250	25	100 complex 25 routine	25	25	25	15	25	25	25	25	25	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness												204.1		63.47	25	100	0.2		46.1	250	25	50.65	25	25	25	15	25	25	25	25	25	45	0	0	0	0	0	0	0	0	0	0											39.8	-	6.84	1.31	1.12	3.94	-	0.81	2.77	2.24	5.32	-	0.01	0.52	4.3	11.33	-	1.81	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.02			39.8	-	6.84	1.31	1.12	3.94	-	0.81	2.77	2.24	5.32	-	0.01	0.52	4.3	11.33	-	1.81	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.02																																																																																				-			39.8	-	6.84	1.31	1.12	3.94	-	0.81	2.77	2.24	5.32	-	0.01	0.52	4.3	11.33	-	1.81	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.02
H3312_044_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		2372.49		1310.96	639.42	135.87	19.97		214.98	134.59	1090.51	1276.83	0	2.91	253.25	3488.88	5513.07		879.42			245.71				915.48		94.19															100/day 1-10		0/day 1-10; 100/day 11-100	25	100	20		50 ER 20 urgent care	175	25	100 complex 25 routine	25	25	25	5	25	25	25	25	25	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness												81.64		63.47	25	100	0.2		46.1	175	25	50.65	25	25	25	5	25	25	25	25	25	45	0	0	0	0	0	0	0	0	0	0											16.14	-	6.93	1.33	1.13	3.99	-	0.83	1.96	2.27	5.39	-	0.01	0.53	1.45	11.49	-	1.83	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.21			16.14	-	6.93	1.33	1.13	3.99	-	0.83	1.96	2.27	5.39	-	0.01	0.53	1.45	11.49	-	1.83	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.21																																																																																				-			16.14	-	6.93	1.33	1.13	3.99	-	0.83	1.96	2.27	5.39	-	0.01	0.53	1.45	11.49	-	1.83	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.21
H3312_045_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				175/day 1-10	175/day 1-10	0/day 1-10; 100/day 11-100	0	150	20	20	50 ER 50 Urgent Care	200	25	25 routine 100 complex	25	25	25	20	25	25	25	25	25	45	0																				142.87	142.87	63.47	0	150	0.2	0.2	50	200	25	50.65	25	25	25	20	25	25	25	25	25	45	0																				18.53	0.36	6.72	-	2.88	3.14	0.2	1.74	5.74	4.56	4.75	-	-	-	9.05	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.15			18.53	0.36	6.72	-	2.88	3.14	0.2	1.74	5.74	4.56	4.75	-	-	-	9.05	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.15																																																																																				-			18.53	0.36	6.72	-	2.88	3.14	0.2	1.74	5.74	4.56	4.75	-	-	-	9.05	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.15
H3312_046_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-10; 100/day 11-100	0	150	20	20	50 ER 50 Urgent Care	200	20	20 routine 100 complex	20	20	20	15	20	20	20	20	20	45	0																				122.46	122.46	63.47	0	150	0.2	0.2	50	200	20	47.36	20	20	20	15	20	20	20	20	20	45	0																				15.88	0.31	6.72	-	2.88	3.14	0.2	1.74	5.74	3.65	4.44	-	-	-	6.78	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.87			15.88	0.31	6.72	-	2.88	3.14	0.2	1.74	5.74	3.65	4.44	-	-	-	6.78	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.87																																																																																				-			15.88	0.31	6.72	-	2.88	3.14	0.2	1.74	5.74	3.65	4.44	-	-	-	6.78	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.87
H3312_047_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				100/day 1-10	100/day 1-10	0/day 1-10; 100/day 11-100	0	150	20	20	50 ER 50 urgent care	200	15	15 routine 100 complex	15	15	15	5	15	15	15	15	15	45	0																				81.64	81.64	63.47	0	150	0.2	0.2	50	200	15	44.07	15	15	15	5	15	15	15	15	15	45	0																				10.59	0.21	6.72	-	2.88	3.14	0.2	1.74	5.74	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.64			10.59	0.21	6.72	-	2.88	3.14	0.2	1.74	5.74	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.64																																																																																				-			10.59	0.21	6.72	-	2.88	3.14	0.2	1.74	5.74	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.64
H3312_048_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				250/day 1-12	250/day 1-12	0/day 1-10; 100/day 11-100	0	150	20	20	50 ER 50 urgent care	200	30	30 routine 100 complex	30	30	30	20	30	30	30	30	30	45	0																				214.32	214.32	63.47	0	150	0.2	0.2	50	200	30	53.94	30	30	30	20	30	30	30	30	30	45	0																				27.8	0.54	6.72	-	2.88	3.14	0.2	1.74	5.74	5.47	5.05	-	-	-	9.05	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.92			27.8	0.54	6.72	-	2.88	3.14	0.2	1.74	5.74	5.47	5.05	-	-	-	9.05	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.92																																																																																				-			27.8	0.54	6.72	-	2.88	3.14	0.2	1.74	5.74	5.47	5.05	-	-	-	9.05	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.92
H3312_049_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				225/day 1-12	225/day 1-12	0/day 1-10; 100/day 11-100	0	150	20	20	50 ER 50 urgent care	200	25	25 routine 100 complex	25	25	25	15	25	25	25	25	25	45	0																				192.89	192.89	63.47	0	150	0.2	0.2	50	200	25	50.65	25	25	25	15	25	25	25	25	25	45	0																				25.02	0.49	6.72	-	2.88	3.14	0.2	1.74	5.74	4.56	4.75	-	-	-	6.78	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.5			25.02	0.49	6.72	-	2.88	3.14	0.2	1.74	5.74	4.56	4.75	-	-	-	6.78	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.5																																																																																				-			25.02	0.49	6.72	-	2.88	3.14	0.2	1.74	5.74	4.56	4.75	-	-	-	6.78	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.5
H3312_050_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				100/day 1-12	100/day 1-12	0/day 1-10; 100/day 11-100	0	150	20	20	50 ER 50 urgent care	200	15	15 routine 100 complex	15	15	15	5	15	15	15	15	15	45	0																				85.73	85.73	63.47	0	150	0.2	0.2	50	200	15	44.07	15	15	15	5	15	15	15	15	15	45	0																				11.12	0.22	6.72	-	2.88	3.14	0.2	1.74	5.74	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.18			11.12	0.22	6.72	-	2.88	3.14	0.2	1.74	5.74	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.18																																																																																				-			11.12	0.22	6.72	-	2.88	3.14	0.2	1.74	5.74	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.18
H3312_052_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1832.27		1122.85	616.44	161.63	16.04		317.96	218.76	1342.6	1550.8	0	113	375.54	3394.61	5577.25	0	620.93	0	0	251.56				903.6		85.31	0	0	0												100/day 1-10		0/day 1-10; 100/day 11-100	35	100	20		50 ER 25 urgent care	200	25	100 complex 25 routine	25	25	25	10	25	25	25	25	25	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness												81.64		63.47	35	100	0.2		46.75	200	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0	0	0	0												12.47	-	5.94	1.8	1.35	3.21	-	1.24	3.65	2.8	6.55	-	0.24	0.78	2.83	11.62	-	1.29	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.69			12.47	-	5.94	1.8	1.35	3.21	-	1.24	3.65	2.8	6.55	-	0.24	0.78	2.83	11.62	-	1.29	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.69																																																																																				-			12.47	-	5.94	1.8	1.35	3.21	-	1.24	3.65	2.8	6.55	-	0.24	0.78	2.83	11.62	-	1.29	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.69
H3312_801_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1399.71		622.99	655.41	105.49	19.94		201.43	185.57	18.17	56.44	0	0	350.52	3718.92	8287.27	0	926.4	0	0	7.65																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					16.76	-	5.19	1.91	1.32	5.98	-	0.84	2.32	3.63	11.29	-	-	1.02	10.85	24.17	-	2.7	-	-	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.52			16.76	-	5.19	1.91	1.32	5.98	-	0.84	2.32	3.63	11.29	-	-	1.02	10.85	24.17	-	2.7	-	-	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.52																																																																																				-			16.76	-	5.19	1.91	1.32	5.98	-	0.84	2.32	3.63	11.29	-	-	1.02	10.85	24.17	-	2.7	-	-	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.52
H3312_804_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1399.71		622.99	655.41	105.49	19.94		201.43	185.57	18.17	56.44	0	0	350.52	3718.92	8287.27	0	926.4	0	0	7.65																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					16.76	-	5.19	1.91	1.32	5.98	-	0.84	2.32	3.63	11.29	-	-	1.02	10.85	24.17	-	2.7	-	-	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.52			16.76	-	5.19	1.91	1.32	5.98	-	0.84	2.32	3.63	11.29	-	-	1.02	10.85	24.17	-	2.7	-	-	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.52																																																																																				-			16.76	-	5.19	1.91	1.32	5.98	-	0.84	2.32	3.63	11.29	-	-	1.02	10.85	24.17	-	2.7	-	-	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.52
H3327_001_0	2007	7																																D	D	D	V	T	Coin	Coin	V	V	P	P		V	V	V	V	V	V	P	V	S	V	T	V	V	V	V	V		O	V											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0											-		0	0	1062	0	0	8.35	5.43	203	203.8	0	212		0	30.45	3128	4621	354	309	395	1683	0	546	0	0	0	0	0	0		0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay days 1-10 25 copay days 11-100	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 75 copay  9B ASC Services: 75 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0-15 copay depending on the radiology services		12 Renal Dialysis: 0 copay	3 CORF: 20 copay  5 Partial Hosp: 0 copay 9D Cardiac Rehab: 20 copay	7A PCP: 5 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 20 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay  9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  20 copay 7I Physical and Speech Therapy:  20 copay	7D Physician Specialist: 0-15 copay depending on the radiology services	7B Chiropractic:  25 copay 7F Podiatry:  20 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  20 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 20 copay	10B Transportation: Not Covered	16A Preventive Dental Services: 0 copay  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay		14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											0	0	25	0	0	0.06	0	48.76	75	0	15		0	20	5	20	20	20	15	21.94	0	20	0	0	0	0	0	0		0	0											-	-	2.21	-	-	0.54	-	0.82	1.27	-	0.27	-	-	0.05	1.3	7.7	0.59	0.52	0.49	3.08	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.76	0	0	-	-	2.21	-	-	0.54	-	0.82	1.27	-	0.27	-	-	0.05	1.3	7.7	0.59	0.52	0.49	3.08	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.76																																																																																				-			-	-	2.21	-	-	0.54	-	0.82	1.27	-	0.27	-	-	0.05	1.3	7.7	0.59	0.52	0.49	3.08	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.76
H3327_002_0	2007	7																																D	D	D	V	T	Coin	Coin	V	V	P	P		V	V	V	V	V	V	P	V	S	V	T	V	V	V	V	V		O	V											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0											-		0	0	0	0	0	8.35	5.43	203	0	0	0		0	30.45	0	5347.97	393	343	0	1762	0	564	0	0	0	0	0	0		0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 0 copay  9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay		12 Renal Dialysis: 0 copay	3 CORF: 5 copay  5 Partial Hosp: 0 copay 9D Cardiac Rehab: 5 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 5 copay	7E Mental Health:   5 copay 7H Psychiatric:   5 copay  9C OP Substance Abuse: 5 copay	7C Occupational Therapy:  5 copay 7I Physical and Speech Therapy:  5 copay   9C OP Substance Abuse: 5 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  15 copay 7F Podiatry:  15 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  0 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 15 copay	10B Transportation: Not Covered	16A Preventive Dental Services: 0 copay  16B Comprehensive Dental Service: 0 copay	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay		14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											0	0	0	0	0	0.06	0	48.76	0	0	0		0	5	0	5	5	5	0	15	0	15	0	0	0	0	0	0		0	0											-	-	-	-	-	0.54	-	0.82	-	-	-	-	-	0.01	-	2.23	0.16	0.14	-	2.2	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.82	0	0	-	-	-	-	-	0.54	-	0.82	-	-	-	-	-	0.01	-	2.23	0.16	0.14	-	2.2	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.82																																																																																				-			-	-	-	-	-	0.54	-	0.82	-	-	-	-	-	0.01	-	2.23	0.16	0.14	-	2.2	-	0.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.82
H3327_003_0	2007	7																																D	D	D	V	T	Coin	Coin	V	V	P	P		V	V	V	V	V	V	P	V	S	V	T	V	V	V	V	V		O	V											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0											-	12000	0	0	943.5	0	0	7.42	4.81	180.2	180.88	0	188.7		0	27.06	3268	4102.95	369	273.7	351.05	1493.45	0	484.5	0	0	0	0	0	0		0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay days 1-10 25 copay days 11-100	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 75 copay  9B ASC Services: 75 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0-15 copay depending on the radiology services		12 Renal Dialysis: 0 copay	3 CORF: 20 copay 5 Partial Hosp: 0 copay 9D Cardiac Rehab: 20 copay	7A PCP: 5 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 20 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay  9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  20 copay 7I Physical and Speech Therapy:  20 copay	7D Physician Specialist: 0-15 copay depending on the radiology services	7B Chiropractic:  25 copay 7F Podiatry:  20 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  20 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 20 copay	10B Transportation: Not Covered	16A Preventive Dental Services: Not covered  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay		14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											0	0	25	0	0	0.07	0	48.76	75	0	15		0	20	5	20	20	20	15	21.94	0	20	0	0	0	0	0	0		0	0											-	-	1.97	-	-	0.48	-	0.73	1.13	-	0.24	-	-	0.05	1.36	6.84	0.62	0.46	0.44	2.73	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.84	0	0	-	-	1.97	-	-	0.48	-	0.73	1.13	-	0.24	-	-	0.05	1.36	6.84	0.62	0.46	0.44	2.73	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.84		PBP: 1A IP Acute:  15 coins	1B IP Psych: not covered	2 SNF: 15 coins	6 Home Health: 15 coins	10A Ambulance: Not covered	11A DME: 15 coins	11B Prosthetic Medical Supplies: 15 coins 11C Diabetes Monitoring Supplies: 15 coins	4A ER: Not covered  4B Urgent Care: Not covered	9A Outpatient Hospital: 15 coins  9B ASC Services: 15 coins	8A OP C/D/T: 15 coins	8B OP X-Ray: 15 coins		12 Renal Dialysis: Not covered	3 CORF: 15 coins 5 Partial Hosp: 15 coins 9D Cardiac Rehab: 15 coins	7A PCP: not covered	7D Physician Specialist: 15 coins 14B Immunizations: 15 coins 14C Routine Physical:  15 coins  14D Pap Smears:  15 coins 14D Pelvic Exams:  15 coins 14E Prostate Screening:  15 coins 14F Colorectal Screening:  15 coins 14G Bone Mass Measurement:  15 coins 14H Mammography:  15 coins 14I Diabetes Monitoring:  15 coins	7E Mental Health:   Not covered 7H Psychiatric: Not covered    9C OP Substance Abuse: Not covered	7C Occupational Therapy:  15 coins 7I Physical and Speech Therapy:  15 coins	7D Physician Specialist Radiology: 15 coins	7B Chiropractic:  15 coins 7F Podiatry:  15 coins for medically necessary services 15 coins for 4 routine exams 7G Other Health Care:  15 coins 18A Medicare Covered Hearing Exams:  15 coins	15 Part B Drugs: Not covered	13A Blood: 15 coins 17A Medicare Covered Eye Exams: 15 coins	10B Transportation: Not Covered	16A Preventive Dental Services: Not covered  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 15 coins	17B Eye Wear:  15 coins	18A Routine Hearing Exams: 15 coins	18B Hearing Aids: 15 coins		14A Health Education/Wellness Programs: Not covered	13B Acupuncture: Not Covered											8.87	0	1.42	0.68	0	0.26	0.17	0.15	0.51	0.2	0.54		0	0.52	0	3.46	0	0.07	0.77	1.3	0.15	0.13	0	0	0.11	0.03	0.05	0.02		0	0											19.4	0	2.5	8.87	-	3.39	0.68	-	0.75	0.17	0.88	1.64	0.2	0.77	-	0	0.56	1.36	10.3	0.62	0.52	1.21	4.03	0.15	0.94	-	-	0.11	0.03	0.05	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	37.24
H3327_014_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	P	P		V	V	V	V	V	V	P	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	8.58	5.57	208	0	0	218		0	31.3	0	5001	375	338	423	1869	0	598	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 0 copay  9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0-15 copay depending on the radiology services		12 Renal Dialysis: 0 copay	3 CORF: 10 copay  5 Partial Hosp: 0 copay 9D Cardiac Rehab: 10 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 10 copay	7E Mental Health:   15 copay 7H Psychiatric:   15 copay  9C OP Substance Abuse: 15 copay	7C Occupational Therapy:  10 copay 7I Physical and Speech Therapy:  10 copay	7D Physician Specialist: 0-15 copay depending on the radiology services	7B Chiropractic:  10 copay 7F Podiatry:  10 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  10 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 10 copay	10B Transportation: Not Covered	16A Preventive Dental Services: 0 copay  16B Comprehensive Dental Service: 0 copay	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay	19 POS: N/A	14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											0	0	0	0	0	0.07	0	48.76	0	0	15		0	10	0	10	15	10	15	10	0	10	0	0	0	0	0	0	0	0	0											-	-	-	-	-	0.56	-	0.85	-	-	0.27	-	-	0.03	-	4.17	0.47	0.28	0.53	1.56	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.2	0	0	-	-	-	-	-	0.56	-	0.85	-	-	0.27	-	-	0.03	-	4.17	0.47	0.28	0.53	1.56	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.2																																																																																				-			-	-	-	-	-	0.56	-	0.85	-	-	0.27	-	-	0.03	-	4.17	0.47	0.28	0.53	1.56	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.2
H3327_015_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0																				-		318.03	5.28	62.93	24.72	7.31	8.96	6.19	4.9	23.4	9.15	24.86		0.36	23.89	30.87	148.65	4.63	3.16	34.45	53.95	6.72	5.76																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	4A ER: Medicare Cost-Sharing subject to 50 maximum	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing		Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing otherwise	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.06	0.06	0.18	0	0.24	0.24	0.24	0.22	0.24	0.24	0.24		0.24	0.24	0.23	0.23	0.24	0.24	0.24	0.24	0.24	0.24																				17.62	0.29	11.08	-	1.72	2.11	1.46	1.09	5.52	2.16	5.87	-	0.08	5.64	6.99	34.17	1.09	0.75	8.13	12.73	1.59	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.45	0	0	17.62	0.29	11.08	-	1.72	2.11	1.46	1.09	5.52	2.16	5.87	-	0.08	5.64	6.99	34.17	1.09	0.75	8.13	12.73	1.59	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.45																																																																																				-			17.62	0.29	11.08	-	1.72	2.11	1.46	1.09	5.52	2.16	5.87	-	0.08	5.64	6.99	34.17	1.09	0.75	8.13	12.73	1.59	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.45
H3327_021_0	2007	6																																D	D	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V		O	O											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0											-		856	15.14	376	0	236.67	6.5	7.52	346	349.6	0	366.99		0	52.01	2361	5062	241.07	277	427	1456	0	604	0	0	0	0	0	0		0	0											PBP: 1A IP Acute: 75 copay days 1-5	1B IP Psych: 75 copay days 1-5	2 SNF: 25 copay days 1-10 0 copay days 11-100	6 Home Health: 0 copay	10A Ambulance: 50 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 75 copay   9B ASC Services: 75 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0-15 copay depending on the radiology services		12 Renal Dialysis: 0 copay	3 CORF: 25 copay  5 Partial Hosp: 0 copay 9D Cardiac Rehab: 25 copay	7A PCP: 10 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 25 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay   9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  25 copay 7I Physical and Speech Therapy:  25 copay	7D Physician Specialist: 0-15 copay depending on the radiology services	7B Chiropractic:  25 copay 7F Podiatry:  25 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  25 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 25 copay	10B Transportation: Not Covered	16A Preventive Dental Services: n/a  16B Comprehensive Dental Service: n/a	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay		14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											75	75	25	0	50	0.05	0	48.75	75	0	15		0	25	10	25	20	25	15	25	0	25	0	0	0	0	0	0		0	0											5.35	0.09	0.78	-	0.99	0.35	-	1.41	2.19	-	0.46	-	-	0.11	1.97	10.55	0.4	0.58	0.53	3.03	-	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03	0	0	5.35	0.09	0.78	-	0.99	0.35	-	1.41	2.19	-	0.46	-	-	0.11	1.97	10.55	0.4	0.58	0.53	3.03	-	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03																																																																																				-			5.35	0.09	0.78	-	0.99	0.35	-	1.41	2.19	-	0.46	-	-	0.11	1.97	10.55	0.4	0.58	0.53	3.03	-	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.03
H3327_022_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	O											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		858	15.17	0	0	0	6.5	7.52	346	0	0	366.99		0	52.01	2492	5343	249.11	293	436	1548	0	639	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 50 copay days 1-5	1B IP Psych: 50 copay days 1-5	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 0 copay   9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0-15 copay depending on the radiology services		12 Renal Dialysis: 0 copay	3 CORF: 15 copay  5 Partial Hosp: 0 copay 9D Cardiac Rehab: 15 copay	7A PCP: 5 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 15 copay	7E Mental Health:  15 copay 7H Psychiatric:  15 copay  9C OP Substance Abuse: 15 copay	7C Occupational Therapy:  15 copay 7I Physical and Speech Therapy:  15 copay	7D Physician Specialist: 0-15 copay depending on the radiology services	7B Chiropractic:  15 copay 7F Podiatry:  15 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  15 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 15 copay	10B Transportation: Not Covered	16A Preventive Dental Services: n/a  16B Comprehensive Dental Service: n/a	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay	19 POS: N/A	14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											50	50	0	0	0	0.05	0	48.75	0	0	15		0	15	5	15	15	15	15	15	0	15	0	0	0	0	0	0	0	0	0											3.58	0.06	-	-	-	0.35	-	1.41	-	-	0.46	-	-	0.07	1.04	6.68	0.31	0.37	0.55	1.94	-	0.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.59	0	0	3.58	0.06	-	-	-	0.35	-	1.41	-	-	0.46	-	-	0.07	1.04	6.68	0.31	0.37	0.55	1.94	-	0.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.59																																																																																				-			3.58	0.06	-	-	-	0.35	-	1.41	-	-	0.46	-	-	0.07	1.04	6.68	0.31	0.37	0.55	1.94	-	0.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.59
H3327_023_0	2007	6																																D	D	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V		O	O											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0											-	3500	751.4	15.63	329.8	0	244.44	5.7	6.53	304.3	306.51	0	322.11		0	45.65	2492	4542.4	248.97	249.05	379.1	1309	0	542.3	0	0	0	0	0	0		0	0											PBP: 1A IP Acute: 75 copay days 1-5	1B IP Psych: 75 copay days 1-5	2 SNF: 25 copay days 1-10 0 copay days 11-100	6 Home Health: 0 copay	10A Ambulance: 50 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 75 copay   9B ASC Services: 75 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0-15 copay depending on the radiology services		12 Renal Dialysis: 0 copay	3 CORF: 20 copay  5 Partial Hosp: 0 copay 9D Cardiac Rehab: 20 copay	7A PCP: 10 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 20 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay   9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  20 copay 7I Physical and Speech Therapy:  20 copay	7D Physician Specialist: 0-15 copay depending on the radiology services	7B Chiropractic:  20 copay 7F Podiatry:  20 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  20 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 20 copay	10B Transportation: Not Covered	16A Preventive Dental Services: n/a  16B Comprehensive Dental Service: n/a	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay		14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											75	75	25	0	50	0.05	0	48.75	75	0	15		0	20	10	20	20	20	15	20	0	20	0	0	0	0	0	0		0	0											4.7	0.1	0.69	-	1.02	0.3	-	1.24	1.92	-	0.4	-	-	0.08	2.08	7.57	0.41	0.42	0.47	2.18	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.47	0	0	4.7	0.1	0.69	-	1.02	0.3	-	1.24	1.92	-	0.4	-	-	0.08	2.08	7.57	0.41	0.42	0.47	2.18	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.47		PBP: 1A IP Acute:  20 coins	1B IP Psych: not covered	2 SNF: 20 coins	6 Home Health: 20 coins	10A Ambulance: Not covered	11A DME: 20 coins	11B Prosthetic Medical Supplies: 20 coins 11C Diabetes Monitoring Supplies: 20 coins	4A ER: Not covered  4B Urgent Care: Not covered	9A Outpatient Hospital: 20 coins   9B ASC Services: 20 coins	8A OP C/D/T: 20 coins	8B OP X-Ray: 20 coins		12 Renal Dialysis: Not covered	3 CORF: 20 coins  5 Partial Hosp: 20 coins 9D Cardiac Rehab: 20 coins	7A PCP: not covered	7D Physician Specialist: 20 coins 14B Immunizations: 20 coins 14C Routine Physical:  20 coins  14D Pap Smears:  20 coins 14D Pelvic Exams:  20 coins 14E Prostate Screening:  20 coins 14F Colorectal Screening:  20 coins 14G Bone Mass Measurement:  20 coins 14H Mammography:  20 coins 14I Diabetes Monitoring:  20 coins	7E Mental Health:   Not covered 7H Psychiatric:   Not covered   9C OP Substance Abuse: Not covered	7C Occupational Therapy:  20 coins 7I Physical and Speech Therapy:  20 coins	7D Physician Specialist Radiology: 20 coins	7B Chiropractic:  20 coins 7F Podiatry:  20 coins for medically necessary services 20 coins for 4 routine exams 7G Other Health Care:  20 coins 18A Medicare Covered Hearing Exams:  20 coins	15 Part B Drugs: Not covered	13A Blood: 20 coins 17A Medicare Covered Eye Exams: 20 coins	10B Transportation: Not Covered	16A Preventive Dental Services: Not covered  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 20 coins	17B Eye Wear:  20 coins	18A Routine Hearing Exams: 20 coins	18B Hearing Aids: 20 coins		14A Health Education/Wellness Programs: Not covered	13B Acupuncture: Not Covered											4.48	0	0.94	0.35	0	0.22	0.2	0.22	0.41	0.16	0.44		0	0.42	0	2.14	0	0.03	0.5	0.66	0.12	0.08	0	0	0.14	0	0.03	0.02		0	0											11.57	0	6.15	9.17	0.1	1.63	0.35	1.02	0.52	0.2	1.45	2.33	0.16	0.84	-	0	0.5	2.08	9.71	0.41	0.45	0.98	2.84	0.12	0.99	-	-	0.14	-	0.03	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	36.03
H3327_024_0	2007	6																																A	A	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V		O	O											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0											-		267	3.86	0	0	0	6.5	7.52	346	349.6	0	0		0	52.01	2544	5286.86	257.15	302	0	1598	0	659	0	0	0	0	0	0		0	0											PBP: 1A IP Acute: 300 copay per stay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins for first 200 covered expenses 20 coins after first 200 covered expenses	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 25 copay	9A Outpatient Hospital: 35 copay   9B ASC Services: 35 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay		12 Renal Dialysis: 0 copay	3 CORF: 10 copay  5 Partial Hosp: 0 copay 9D Cardiac Rehab: 10 copay	7A PCP: 5 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 15 copay	7E Mental Health:   10 copay 7H Psychiatric:   10 copay   9C OP Substance Abuse: 10 copay	7C Occupational Therapy:  10 copay 7I Physical and Speech Therapy:  10 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  10 copay 7F Podiatry:  10 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  10 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 10 copay	10B Transportation: Not Covered	16A Preventive Dental Services: n/a  16B Comprehensive Dental Service: n/a	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay		14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											300	300	0	0	0	0.05	0	48.75	35	0	0		0	10	5	15	10	10	0	10	0	10	0	0	0	0	0	0		0	0											6.68	0.1	-	-	-	0.35	-	1.41	1.02	-	-	-	-	0.04	1.06	6.61	0.21	0.25	-	1.33	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.6	0	0	6.68	0.1	-	-	-	0.35	-	1.41	1.02	-	-	-	-	0.04	1.06	6.61	0.21	0.25	-	1.33	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.6																																																																																				-			6.68	0.1	-	-	-	0.35	-	1.41	1.02	-	-	-	-	0.04	1.06	6.61	0.21	0.25	-	1.33	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.6
H3327_026_0	2007	8																																A	A	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V																				0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0																				-		0	0	0	0	0	0	0	519.66	0	0	0		0	59.91	0	6879.55	2355.7	1090.85	0	2102.74	0	0																				PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 10 copay	9A Outpatient Hospital: 0 copay   9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay		12 Renal Dialysis: 0 copay	3 CORF: 10 copay  5  Partial Hosp:  0 copay 9D Cardiac Rehab: 10 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 10 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay   9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  10 copay 7I Physical and Speech Therapy:  10 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  10 copay 7F Podiatry:  10 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  10 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay																				0	0	0	0	0	0	0	47.66	0	0	0		0	10	0	10	20	10	0	10	0	0																				-	-	-	-	-	-	-	2.06	-	-	-	-	-	0.05	-	5.73	3.93	0.91	-	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.43	0	0	-	-	-	-	-	-	-	2.06	-	-	-	-	-	0.05	-	5.73	3.93	0.91	-	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.43																																																																																				-			-	-	-	-	-	-	-	2.06	-	-	-	-	-	0.05	-	5.73	3.93	0.91	-	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.43
H3327_027_0	2007	7																																A	A	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V																				0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0																				-		375.73	45.61	0	3168.48	512.04	0	0	855.44	316.58	0	0		0	101.79	6896.47	5987.03	1589.06	735.84	0	1418.43	0	0																				PBP: 1A IP Acute: 300 copay per stay	1B IP Psych: 300 copay per stay	2 SNF: 0 copay	6 Home Health: 10 copay	10A Ambulance: 50 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 20 copay	9A Outpatient Hospital: 35 copay   9B ASC Services: 35 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay		12 Renal Dialysis: 0 copay	3 CORF: 20 copay  5  Partial Hosp:  0 copay 9D Cardiac Rehab: 20 copay	7A PCP: 10 copay 14B Immunizations: 0 copay 14C Routine Physical:  10 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 20 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay    9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  20 copay 7I Physical and Speech Therapy:  20 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  20 copay 7F Podiatry:  20 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  20 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay																				300	300	0	10	50	0	0	49.16	35	0	0		0	20	10	20	20	20	0	20	0	0																				9.39	1.14	-	2.64	2.13	-	-	3.5	0.92	-	-	-	-	0.17	5.75	9.98	2.65	1.23	-	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	0	0	9.39	1.14	-	2.64	2.13	-	-	3.5	0.92	-	-	-	-	0.17	5.75	9.98	2.65	1.23	-	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87																																																																																				-			9.39	1.14	-	2.64	2.13	-	-	3.5	0.92	-	-	-	-	0.17	5.75	9.98	2.65	1.23	-	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87
H3327_028_0	2007	7																																D	D	D	V	T	Coin	Coin	V	P	P	P		P	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V		V	V											0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0											-		0	0	0	0	0	0	0	157	0	0	0		0	0	0	0	356	0	0	1806	0	538	0	0	314	0	0	0		0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 5 copay	9A Outpatient Hospital: 0 copay   9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay		12 Renal Dialysis: 0 copay	3 CORF: 0 copay  5  Partial Hosp:  0 copay 9D Cardiac Rehab: 0 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 0 copay	7E Mental Health:   50 copay 7H Psychiatric:   50 copay   9C OP Substance Abuse: 50 copay	7C Occupational Therapy:  0 copay 7I Physical and Speech Therapy:  0 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  10 copay 7F Podiatry:  5 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  0 copay 18A Medicare Covered Hearing Exams:  5 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 10 copay	10B Transportation: Not Covered	16A Preventive Dental Services: 0 copay  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 10 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay		14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											0	0	0	0	0	0	0	47.76	0	0	0		0	0	0	0	50	0	0	6.85	0	10	0	0	10	0	0	0		0	0											-	-	-	-	-	-	-	0.62	-	-	-	-	-	-	-	-	1.48	-	-	1.03	-	0.45	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.85	0	0	-	-	-	-	-	-	-	0.62	-	-	-	-	-	-	-	-	1.48	-	-	1.03	-	0.45	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.85																																																																																				-			-	-	-	-	-	-	-	0.62	-	-	-	-	-	-	-	-	1.48	-	-	1.03	-	0.45	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.85
H3327_029_0	2007	7																																A	A	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V																				0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0																				-		0	0	0	0	0	0	0	417.23	0	0	0		0	48.1	0	5523.58	1891.39	875.84	0	1688.28	0	0																				PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 10 copay	9A Outpatient Hospital: 0 copay   9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay		12 Renal Dialysis: 0 copay	3 CORF: 10 copay  5  Partial Hosp:  0 copay 9D Cardiac Rehab: 10 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 10 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay   9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  10 copay 7I Physical and Speech Therapy:  10 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  10 copay 7F Podiatry:  10 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  10 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay																				0	0	0	0	0	0	0	47.66	0	0	0		0	10	0	10	20	10	0	10	0	0																				-	-	-	-	-	-	-	1.66	-	-	-	-	-	0.04	-	4.6	3.15	0.73	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.59	0	0	-	-	-	-	-	-	-	1.66	-	-	-	-	-	0.04	-	4.6	3.15	0.73	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.59																																																																																				-			-	-	-	-	-	-	-	1.66	-	-	-	-	-	0.04	-	4.6	3.15	0.73	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.59
H3327_030_0	2007	7																																A	A	D	V	T	Coin	Coin	V	V	V	V		V	V	V	V	V	V	V	V	S	V																				0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0	0	0																				-		0	0	0	0	0	0	0	503.74	0	0	0		0	58.52	0	5824.68	1873.61	867.61	0	1672.41	0	0																				PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 10 copay	9A Outpatient Hospital: 0 copay 9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay		12 Renal Dialysis: 0 copay	3 CORF: 10 copay  5  Partial Hosp:  0 copay  9D Cardiac Rehab: 10 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 10 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay  9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  10 copay 7I Physical and Speech Therapy:  10 copay	8B OP X-Ray: 0 copay	7B Chiropractic:  10 copay 7F Podiatry:  10 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  10 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay																				0	0	0	0	0	0	0	47.96	0	0	0		0	10	0	10	20	10	0	10	0	0																				-	-	-	-	-	-	-	2.01	-	-	-	-	-	0.05	-	4.85	3.12	0.72	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.16	0	0	-	-	-	-	-	-	-	2.01	-	-	-	-	-	0.05	-	4.85	3.12	0.72	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.16																																																																																				-			-	-	-	-	-	-	-	2.01	-	-	-	-	-	0.05	-	4.85	3.12	0.72	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.16
H3327_801_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		332.05	5.64	47.44	30.82	4.55	9.77	5.97	3.46	15.87	6.21	16.87	0.43	0.06	15.87	82.61	113.02	2.02	5.38	33.31	58.58	4.72	5.36																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.74	0.28	8.04	-	1.07	2.31	1.41	0.82	3.75	1.47	3.98	0.1	0.01	3.74	18.95	26.67	0.48	1.27	7.86	13.82	1.11	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.15	0	0	16.74	0.28	8.04	-	1.07	2.31	1.41	0.82	3.75	1.47	3.98	0.1	0.01	3.74	18.95	26.67	0.48	1.27	7.86	13.82	1.11	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.15																																																																																				-			16.74	0.28	8.04	-	1.07	2.31	1.41	0.82	3.75	1.47	3.98	0.1	0.01	3.74	18.95	26.67	0.48	1.27	7.86	13.82	1.11	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.15
H3327_802_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		332.05	5.64	47.44	30.82	4.55	9.77	5.97	3.46	15.87	6.21	16.87	0.43	0.06	15.87	82.61	113.02	2.02	5.38	33.31	58.58	4.72	5.36																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.74	0.28	8.04	-	1.07	2.31	1.41	0.82	3.75	1.47	3.98	0.1	0.01	3.74	18.95	26.67	0.48	1.27	7.86	13.82	1.11	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.15	0	0	16.74	0.28	8.04	-	1.07	2.31	1.41	0.82	3.75	1.47	3.98	0.1	0.01	3.74	18.95	26.67	0.48	1.27	7.86	13.82	1.11	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.15																																																																																				-			16.74	0.28	8.04	-	1.07	2.31	1.41	0.82	3.75	1.47	3.98	0.1	0.01	3.74	18.95	26.67	0.48	1.27	7.86	13.82	1.11	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.15
H3327_803_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		290.71	5.81	41.54	26.98	4.69	8.55	5.23	3.56	13.9	5.44	14.77	0.38	0.06	13.88	85.11	98.96	2.08	4.71	29.16	51.98	4.86	4.69																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.65	0.29	7.04	-	1.11	2.02	1.23	0.84	3.28	1.28	3.49	0.09	0.01	3.28	19.53	23.35	0.49	1.11	6.88	12.27	1.15	1.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.5	0	0	14.65	0.29	7.04	-	1.11	2.02	1.23	0.84	3.28	1.28	3.49	0.09	0.01	3.28	19.53	23.35	0.49	1.11	6.88	12.27	1.15	1.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.5		Medicare Cost-Sharing	1B IP Psych: not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	10A Ambulance: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	4A ER: Not covered  4B Urgent Care: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	12 Renal Dialysis: Not covered	Medicare Cost-Sharing	7A PCP: not covered	Medicare Cost-Sharing	7E Mental Health:   Not covered 7H Psychiatric: Not covered    9C OP Substance Abuse: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	15 Part B Drugs: Not covered	Medicare Cost-Sharing																				3.72	0	2.02	0	0	0.54	0.33	0	1	0.39	1.07	0.03	0	1	0	5.83	0	0.29	1.88	3.14	0	0.3																				21.56	0	0	18.37	0.29	9.06	-	1.11	2.56	1.57	0.84	4.28	1.68	4.55	0.12	0.01	4.28	19.53	29.19	0.49	1.4	8.76	15.41	1.15	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.06
H3327_804_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		290.71	5.81	41.54	26.98	4.69	8.55	5.23	3.56	13.9	5.44	14.77	0.38	0.06	13.88	85.11	98.96	2.08	4.71	29.16	51.98	4.86	4.69																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.65	0.29	7.04	-	1.11	2.02	1.23	0.84	3.28	1.28	3.49	0.09	0.01	3.28	19.53	23.35	0.49	1.11	6.88	12.27	1.15	1.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.5	0	0	14.65	0.29	7.04	-	1.11	2.02	1.23	0.84	3.28	1.28	3.49	0.09	0.01	3.28	19.53	23.35	0.49	1.11	6.88	12.27	1.15	1.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.5		Medicare Cost-Sharing	1B IP Psych: not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	10A Ambulance: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	4A ER: Not covered  4B Urgent Care: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	12 Renal Dialysis: Not covered	Medicare Cost-Sharing	7A PCP: not covered	Medicare Cost-Sharing	7E Mental Health:   Not covered 7H Psychiatric: Not covered    9C OP Substance Abuse: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	15 Part B Drugs: Not covered	Medicare Cost-Sharing																				3.72	0	2.02	0	0	0.54	0.33	0	1	0.39	1.07	0.03	0	1	0	5.83	0	0.29	1.88	3.14	0	0.3																				21.56	0	0	18.37	0.29	9.06	-	1.11	2.56	1.57	0.84	4.28	1.68	4.55	0.12	0.01	4.28	19.53	29.19	0.49	1.4	8.76	15.41	1.15	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.06
H3327_805_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		212.29	2.28	48.94	24.76	6.61	14.71	8.96	4.52	21.24	8.31	22.58	0.58	0.08	21.22	36.49	93.74	1.54	4	34.22	45.56	6.32	5.12																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.67	0.18	9.49	-	1.56	3.47	2.12	1.07	5.01	1.96	5.33	0.14	0.02	5.01	8.4	22.12	0.36	0.94	8.08	10.75	1.49	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38	0	0	16.67	0.18	9.49	-	1.56	3.47	2.12	1.07	5.01	1.96	5.33	0.14	0.02	5.01	8.4	22.12	0.36	0.94	8.08	10.75	1.49	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38																																																																																				-			16.67	0.18	9.49	-	1.56	3.47	2.12	1.07	5.01	1.96	5.33	0.14	0.02	5.01	8.4	22.12	0.36	0.94	8.08	10.75	1.49	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38
H3327_806_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		212.29	2.28	48.94	24.76	6.61	14.71	8.96	4.52	21.24	8.31	22.58	0.58	0.08	21.22	36.49	93.74	1.54	4	34.22	45.56	6.32	5.12																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.67	0.18	9.49	-	1.56	3.47	2.12	1.07	5.01	1.96	5.33	0.14	0.02	5.01	8.4	22.12	0.36	0.94	8.08	10.75	1.49	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38	0	0	16.67	0.18	9.49	-	1.56	3.47	2.12	1.07	5.01	1.96	5.33	0.14	0.02	5.01	8.4	22.12	0.36	0.94	8.08	10.75	1.49	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38																																																																																				-			16.67	0.18	9.49	-	1.56	3.47	2.12	1.07	5.01	1.96	5.33	0.14	0.02	5.01	8.4	22.12	0.36	0.94	8.08	10.75	1.49	1.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.38
H3327_807_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		183.3	2.32	42.25	21.38	6.71	12.7	7.74	4.59	18.34	7.17	19.49	0.5	0.08	18.32	37.06	80.94	1.57	3.45	29.54	39.64	6.42	4.42																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.4	0.18	8.19	-	1.58	3	1.83	1.08	4.33	1.69	4.6	0.12	0.02	4.32	8.53	19.1	0.37	0.81	6.97	9.35	1.52	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.05	0	0	14.4	0.18	8.19	-	1.58	3	1.83	1.08	4.33	1.69	4.6	0.12	0.02	4.32	8.53	19.1	0.37	0.81	6.97	9.35	1.52	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.05		Medicare Cost-Sharing	1B IP Psych: not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	10A Ambulance: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	4A ER: Not covered  4B Urgent Care: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	12 Renal Dialysis: Not covered	Medicare Cost-Sharing	7A PCP: not covered	Medicare Cost-Sharing	7E Mental Health:   Not covered 7H Psychiatric: Not covered    9C OP Substance Abuse: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	15 Part B Drugs: Not covered	Medicare Cost-Sharing																				2.82	0	1.45	0	0	0.53	0.32	0	0.76	0.3	0.81	0.02	0	0.76	0	3.55	0	0.15	1.29	1.72	0	0.19																				14.69	0	0	17.22	0.18	9.64	-	1.58	3.53	2.15	1.08	5.09	1.99	5.41	0.14	0.02	5.09	8.53	22.65	0.37	0.97	8.27	11.08	1.52	1.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.73
H3327_808_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		183.3	2.32	42.25	21.38	6.71	12.7	7.74	4.59	18.34	7.17	19.49	0.5	0.08	18.32	37.06	80.94	1.57	3.45	29.54	39.64	6.42	4.42																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	14B Immunizations: 0 copay Medicare Cost-Sharing all other PCP services	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing																				0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.4	0.18	8.19	-	1.58	3	1.83	1.08	4.33	1.69	4.6	0.12	0.02	4.32	8.53	19.1	0.37	0.81	6.97	9.35	1.52	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.05	0	0	14.4	0.18	8.19	-	1.58	3	1.83	1.08	4.33	1.69	4.6	0.12	0.02	4.32	8.53	19.1	0.37	0.81	6.97	9.35	1.52	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.05		Medicare Cost-Sharing	1B IP Psych: not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	10A Ambulance: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	4A ER: Not covered  4B Urgent Care: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	12 Renal Dialysis: Not covered	Medicare Cost-Sharing	7A PCP: not covered	Medicare Cost-Sharing	7E Mental Health:   Not covered 7H Psychiatric: Not covered    9C OP Substance Abuse: Not covered	Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing	15 Part B Drugs: Not covered	Medicare Cost-Sharing																				2.82	0	1.45	0	0	0.53	0.32	0	0.76	0.3	0.81	0.02	0	0.76	0	3.55	0	0.15	1.29	1.72	0	0.19																				14.69	0	0	17.22	0.18	9.64	-	1.58	3.53	2.15	1.08	5.09	1.99	5.41	0.14	0.02	5.09	8.53	22.65	0.37	0.97	8.27	11.08	1.52	1.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.73
H3328_001_0	2007	2																					3000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	V	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-	6000	1670.05	118.86	988.41		123.87	6.34	10.96	263.07	29.76		12.03	2.08	0.37	13.22	3973.48	6318	519.05	870.75		815.51	23.02																					125 per day for days 1-10	125 per day for days 1-10	110 per day for days 1-27		50 per trip	0	0	50 per visit	0		0 to 20	0.1	0.2	0	5 per visit	25 per visit	25 per visit	25 per visit		25 Urgent Care	0.2																					72.84	72.84	86.61		39.37	0.08	0.08	39.37	0.08		0.16	0.08	0.16	0.07	3.94	19.69	19.43	19.58		18.35	0.16																					10.14	0.72	7.13	-	0.41	0.5	0.86	0.86	2.34	-	1.89	0.16	0.06	0.95	1.3	10.36	0.84	1.42	-	1.25	3.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.84		12.11	10.14	0.72	7.13	-	0.41	0.5	0.86	0.86	2.34	-	1.89	0.16	0.06	0.95	1.3	10.36	0.84	1.42	-	1.25	3.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.84		200 per day for days 1-10	200 per day for days 1-10	165 per day for days 1-36		50 per trip	0	0	50 per visit	0	0	20 to 30	0.2	0.3	0	20 per visit	40 per visit	40 per visit	40 per visit	20	40 Urgent Care	0.3																					2.02	0.14	0.63	0.2	0.05	0.16	0.23	0.11	0.59	0.45	0.39	0.04	0.01	0.23	0.61	2.08	0.17	0.29	0.57	0.25	0.71																					9.9		1.56	12.15	0.87	7.76	0.2	0.46	0.66	1.09	0.97	2.93	0.45	2.28	0.21	0.07	1.18	1.91	12.45	1.01	1.71	0.57	1.5	4.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.74
H3328_002_0	2007	3																																A	A	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	Coin	V	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		2319.87	1352.14		2917.55	322.58			896.38	258.46						4607.37	5756.05	4799.02	633.48		362.53																						300	30000		10	50			50	35						10	20	20	20		20																						48.35	24.24		10	50			49.99	35						10	20	19.83	19.9		17.74																						9.35	2.73	-	2.43	1.34	-	-	3.73	0.75	-	-	-	-	-	3.84	9.59	7.93	1.05	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.29		0	9.35	2.73	-	2.43	1.34	-	-	3.73	0.75	-	-	-	-	-	3.84	9.59	7.93	1.05	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.29																																																																																				-		0	9.35	2.73	-	2.43	1.34	-	-	3.73	0.75	-	-	-	-	-	3.84	9.59	7.93	1.05	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.29
H3328_003_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	V	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-	6000	1670.05	118.86	988.41		123.87	6.34	10.96	263.07	29.76		12.03	2.08	0.37	13.22	3973.48	6318	519.05	870.75		815.51	23.02																					125 per day for days 1-10	125 per day for days 1-10	110 per day for days 1-27		50 per trip	0	0	50 per visit	0		0 to 20	0.1	0.2	0	5 per visit	25 per visit	25 per visit	25 per visit		25 Urgent Care	0.2																					72.84	72.84	86.61		39.37	0.08	0.08	39.37	0.08		0.16	0.08	0.16	0.07	3.94	19.69	19.43	19.58		18.35	0.16																					10.14	0.72	7.13	-	0.41	0.5	0.86	0.86	2.34	-	1.89	0.16	0.06	0.95	1.3	10.36	0.84	1.42	-	1.25	3.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.84		12.11	10.14	0.72	7.13	-	0.41	0.5	0.86	0.86	2.34	-	1.89	0.16	0.06	0.95	1.3	10.36	0.84	1.42	-	1.25	3.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.84		200 per day for days 1-10	200 per day for days 1-10	165 per day for days 1-36		50 per trip	0	0	50 per visit	0	0	20 to 30	0.2	0.3	0	20 per visit	40 per visit	40 per visit	40 per visit	20	40 Urgent Care	0.3																					2.02	0.14	0.63	0.2	0.05	0.16	0.23	0.11	0.59	0.45	0.39	0.04	0.01	0.23	0.61	2.08	0.17	0.29	0.57	0.25	0.71																					9.9		1.56	12.15	0.87	7.76	0.2	0.46	0.66	1.09	0.97	2.93	0.45	2.28	0.21	0.07	1.18	1.91	12.45	1.01	1.71	0.57	1.5	4.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.74
H3328_006_0	2007	2																					3000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	V	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-	6000	2135.26	162.37	1001		126.74	5.48	6.37	228.13	28.32		21.99	3.14	1.69	22.33	3739.87	7463.67	1206.62	2006		1225.06	19.41																					100 per day for days 1-10	100 per day for days 1-10	75 per day for days 1-40		50 per trip	0	0	50 per visit	0		0 to 20	0.1	0.2	0	5 per visit	15 per visit	15 per visit	15 per visit		15 per visit	0.2																					58.27	58.27	59.06		39.37	0.08	0.08	39.39	0.08		0.16	0.08	0.08	0.06	3.94	11.81	11.64	11.26		10.66	0.16																					10.37	0.79	4.93	-	0.42	0.43	0.5	0.75	2.23	-	3.46	0.25	0.13	1.37	1.23	7.35	1.17	1.88	-	1.09	3.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.4		11.18	10.37	0.79	4.93	-	0.42	0.43	0.5	0.75	2.23	-	3.46	0.25	0.13	1.37	1.23	7.35	1.17	1.88	-	1.09	3.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.4		150 per day for days 1-10	150 per day for days 1-10	125 per day for days 1-36		50 per trip	0	0	50 per visit	0	0	20 to 30	0.2	0.3	0	10 per visit	30 per visit	30 per visit	30 per visit	20	30 per visit	0.3																					1.93	0.15	0.48	0.81	0.05	0.14	0.13	0.09	0.51	0.59	0.51	0.06	0.03	0.32	0.3	1.85	0.29	0.47	0.8	0.27	0.59																					10.38		1.63	12.3	0.94	5.41	0.81	0.47	0.57	0.63	0.84	2.74	0.59	3.97	0.3	0.16	1.69	1.53	9.19	1.46	2.35	0.8	1.36	3.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.78
H3328_007_0	2007	3																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	V	V	V	V	V	Coin	P	P	P	P	P	P	P	P	P	P																																																				-									594.13						1005.71		6207.98	2389.03	2184.09		367.14																													50 per visit						20		10 per visit	20	10		10																													49.97						17.86		10	20	10		10																						-	-	-	-	-	-	-	2.47	-	-	-	-	-	1.5	-	5.17	3.98	1.82	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.25		0	-	-	-	-	-	-	-	2.47	-	-	-	-	-	1.5	-	5.17	3.98	1.82	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.25																																																																																				-		0	-	-	-	-	-	-	-	2.47	-	-	-	-	-	1.5	-	5.17	3.98	1.82	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.25
H3328_008_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	V	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-	6000	2135.26	162.37	1001		126.74	5.48	6.37	228.13	28.32		21.99	3.14	1.69	22.33	3739.87	7463.67	1206.62	2006		1225.06	19.41																					100 per day for days 1-10	100 per day for days 1-10	75 per day for days 1-40		50 per trip	0	0	50 per visit	0		0 to 20	0.1	0.2	0	5 per visit	15 per visit	15 per visit	15 per visit		15 per visit	0.2																					58.27	58.27	59.06		39.37	0.08	0.08	39.39	0.08		0.16	0.08	0.08	0.06	3.94	11.81	11.64	11.26		10.66	0.16																					10.37	0.79	4.93	-	0.42	0.43	0.5	0.75	2.23	-	3.46	0.25	0.13	1.37	1.23	7.35	1.17	1.88	-	1.09	3.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.4		11.18	10.37	0.79	4.93	-	0.42	0.43	0.5	0.75	2.23	-	3.46	0.25	0.13	1.37	1.23	7.35	1.17	1.88	-	1.09	3.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.4		150 per day for days 1-10	150 per day for days 1-10	125 per day for days 1-36		50 per trip	0	0	50 per visit	0	0	20 to 30	0.2	0.3	0	10 per visit	30 per visit	30 per visit	30 per visit	20	30 per visit	0.3																					1.93	0.15	0.48	0.81	0.05	0.14	0.13	0.09	0.51	0.59	0.51	0.06	0.03	0.32	0.3	1.85	0.29	0.47	0.8	0.27	0.59																					10.38		1.63	12.3	0.94	5.41	0.81	0.47	0.57	0.63	0.84	2.74	0.59	3.97	0.3	0.16	1.69	1.53	9.19	1.46	2.35	0.8	1.36	3.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.78
H3328_009_0	2007	3																					3000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	V	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-	6000	1760.48	104.78	843.92		75.66	4.7	7.53	195.77	31.93		19.39	2.82	0.41	15.33	3995.11	7835.76	745.55	1968.93		1339.96	28.05																					125 per day for days 1-10	125 per day for days 1-10	110 per day for days 1-27		50 per trip	0	0	50 per visit	0		0 to 20	0.1	0.2	0	5 per visit	25 per visit	25 per visit	25 per visit		25 Urgent Care	0.2																					72.84	72.84	86.62		39.37	0.08	0.08	39.39	0.08		0.16	0.08	0.08	0.06	3.94	19.69	19.34	19.04		17.56	0.16																					10.69	0.64	6.09	-	0.25	0.37	0.59	0.64	2.51	-	3.05	0.22	0.03	0.95	1.31	12.85	1.2	3.12	-	1.96	4.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.91		13.74	10.69	0.64	6.09	-	0.25	0.37	0.59	0.64	2.51	-	3.05	0.22	0.03	0.95	1.31	12.85	1.2	3.12	-	1.96	4.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.91		200 per day for days 1-10	200 per day for days 1-10	165 per day for days 1-36		50 per trip	0	0	50 per visit	0	0	20 to 30	0.2	0.3	0	20 per visit	40 per visit	40 per visit	40 per visit	20	40 Urgent Care	0.3																					3.38	0.2	0.54	0.78	0.05	0.18	0.25	0.13	1	0.9	0.84	0.09	0.01	0.36	0.97	4.11	0.38	1.01	1.44	0.64	1.36																					18.63		2.93	14.06	0.84	6.63	0.78	0.3	0.55	0.84	0.77	3.52	0.9	3.9	0.31	0.04	1.31	2.28	16.96	1.58	4.13	1.44	2.6	5.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.54
H3328_010_0	2007	3																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	V	V	V	V	V	Coin	P	P	P	P	P	P	P	P	P	P																																																				-									754.67						916.08		7282.76	5359.17	1372.26		454.65																													50 per visit						10		10 per visit	20	10		10																													49.98						15.69		10	20	10		10																						-	-	-	-	-	-	-	3.14	-	-	-	-	-	1.2	-	6.07	8.93	1.14	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.86		0	-	-	-	-	-	-	-	3.14	-	-	-	-	-	1.2	-	6.07	8.93	1.14	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.86		150																	15 / 25	20-Oct		20																																																														-		0	-	-	-	-	-	-	-	3.14	-	-	-	-	-	1.2	-	6.07	8.93	1.14	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.86
H3328_011_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	V	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-	6000	1760.48	104.78	843.92		75.66	4.7	7.53	195.77	31.93		19.39	2.82	0.41	15.33	3995.11	7835.76	745.55	1968.93		1339.96	28.05																					125 per day for days 1-10	125 per day for days 1-10	110 per day for days 1-27		50 per trip	0	0	50 per visit	0		0 to 20	0.1	0.2	0	5 per visit	25 per visit	25 per visit	25 per visit		25 Urgent Care	0.2																					72.84	72.84	86.62		39.37	0.08	0.08	39.39	0.08		0.16	0.08	0.08	0.06	3.94	19.69	19.34	19.04		17.56	0.16																					10.69	0.64	6.09	-	0.25	0.37	0.59	0.64	2.51	-	3.05	0.22	0.03	0.95	1.31	12.85	1.2	3.12	-	1.96	4.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.91		13.74	10.69	0.64	6.09	-	0.25	0.37	0.59	0.64	2.51	-	3.05	0.22	0.03	0.95	1.31	12.85	1.2	3.12	-	1.96	4.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.91		200 per day for days 1-10	200 per day for days 1-10	165 per day for days 1-36		50 per trip	0	0	50 per visit	0	0	20 to 30	0.2	0.3	0	20 per visit	40 per visit	40 per visit	40 per visit	20	40 Urgent Care	0.3																					3.38	0.2	0.54	0.78	0.05	0.18	0.25	0.13	1	0.9	0.84	0.09	0.01	0.36	0.97	4.11	0.38	1.01	1.44	0.64	1.36																					18.63		2.93	14.06	0.84	6.63	0.78	0.3	0.55	0.84	0.77	3.52	0.9	3.9	0.31	0.04	1.31	2.28	16.96	1.58	4.13	1.44	2.6	5.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.54
H3330_021_1	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2030.12	97.89	1588.96	188.07	405.09	6.33	6.33	220.56	71.13	0	0	0	0	866.36	7029.39	6175.36	144.64	99.22	366.3	4252.44	222.38	0	0	40.67	1318.2	0	60.52	0	0	0	0											100 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	15 Copay	25 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											14.72	0	4.78	0	100	0	0	50	75	0	0	0	0	75	5	15	25	15	15	15	0	15	20	10	15	0	15	0	20	20	20											2.49	-	0.63	-	3.38	-	-	0.92	0.44	-	-	-	-	5.41	2.93	7.72	0.3	0.12	0.46	5.32	-	-	-	0.03	1.65	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.88	0	0	2.49	-	0.63	-	3.38	-	-	0.92	0.44	-	-	-	-	5.41	2.93	7.72	0.3	0.12	0.46	5.32	-	-	-	0.03	1.65	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.88	none																																																																																			-	0	0	2.49	-	0.63	-	3.38	-	-	0.92	0.44	-	-	-	-	5.41	2.93	7.72	0.3	0.12	0.46	5.32	-	-	-	0.03	1.65	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.88
H3330_021_2	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2217.22	97.89	1371.38	226.47	222.16	7.42	7.42	202.29	133.92	0	0	0	0	494.92	6866	6003.53	141.28	96.92	357.79	4153.6	272.71	0	0	37.82	1256.79	0	72.97	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	0	0	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	15	0	15	0	20	20	20											14.68	-	0.55	-	1.85	-	-	0.84	0.84	-	-	-	-	3.09	5.72	10.01	0.35	0.16	0.6	6.92	-	-	-	0.03	1.57	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.3	0	0	14.68	-	0.55	-	1.85	-	-	0.84	0.84	-	-	-	-	3.09	5.72	10.01	0.35	0.16	0.6	6.92	-	-	-	0.03	1.57	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.3	none																																																																																			-	0	0	14.68	-	0.55	-	1.85	-	-	0.84	0.84	-	-	-	-	3.09	5.72	10.01	0.35	0.16	0.6	6.92	-	-	-	0.03	1.57	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.3
H3330_021_3	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2386.26	97.89	1295.25	240.75	124.17	5.31	5.31	286.24	134.08	0	0	0	0	1404.5	7763.7	6854.24	159.75	109.59	404.57	4696.66	295.68	0	0	40.77	1168.89	0	46.67	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	20 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	0	0	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	15	0	15	0	20	20	20											15.8	-	0.52	-	1.03	-	-	1.19	0.84	-	-	-	-	8.78	6.47	11.42	0.4	0.18	0.67	7.83	-	-	-	0.03	1.46	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.69	0	0	15.8	-	0.52	-	1.03	-	-	1.19	0.84	-	-	-	-	8.78	6.47	11.42	0.4	0.18	0.67	7.83	-	-	-	0.03	1.46	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.69	none																																																																																			-	0	0	15.8	-	0.52	-	1.03	-	-	1.19	0.84	-	-	-	-	8.78	6.47	11.42	0.4	0.18	0.67	7.83	-	-	-	0.03	1.46	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.69
H3330_023_1	2007	11																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2044.11	97.89	1583.58	187.43	403.72	6.34	6.34	219.82	70.88	0	0	0	0	863.42	7029.39	6969.44	144.64	99.22	366.3	4252.44	221.62	0	0	40.53	1313.73	0	60.31	0	0	0	0											250 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	25 Copay	25 Copay	25 Copay	25 Copay	25 Copay	0 Copay	15 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											36.79	0	4.78	0	100	0	0	50	75	0	0	0	0	75	5	25	25	25	25	25	0	15	20	10	15	0	15	0	20	20	20											6.27	-	0.63	-	3.36	-	-	0.92	0.44	-	-	-	-	5.4	2.93	14.52	0.3	0.21	0.76	8.86	-	-	-	0.03	1.64	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.35	0	0	6.27	-	0.63	-	3.36	-	-	0.92	0.44	-	-	-	-	5.4	2.93	14.52	0.3	0.21	0.76	8.86	-	-	-	0.03	1.64	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.35	none																																																																																			-	0	0	6.27	-	0.63	-	3.36	-	-	0.92	0.44	-	-	-	-	5.4	2.93	14.52	0.3	0.21	0.76	8.86	-	-	-	0.03	1.64	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.35
H3330_023_2	2007	11																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2230.38	97.89	1365.52	225.51	221.21	7.4	7.4	201.43	133.35	0	0	0	0	492.8	6866	6677.12	141.28	96.92	357.79	4153.6	271.54	0	0	37.66	1251.41	0	72.66	0	0	0	0											300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											86.79	0	4.78	0	100	0	0	50	75	0	0	0	0	75	10	30	30	30	30	30	0	10	20	10	15	0	15	0	20	20	20											16.13	-	0.54	-	1.84	-	-	0.84	0.83	-	-	-	-	3.08	5.72	16.69	0.35	0.24	0.89	10.38	-	-	-	0.03	1.56	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.25	0	0	16.13	-	0.54	-	1.84	-	-	0.84	0.83	-	-	-	-	3.08	5.72	16.69	0.35	0.24	0.89	10.38	-	-	-	0.03	1.56	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.25	none																																																																																			-	0	0	16.13	-	0.54	-	1.84	-	-	0.84	0.83	-	-	-	-	3.08	5.72	16.69	0.35	0.24	0.89	10.38	-	-	-	0.03	1.56	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.25
H3330_023_3	2007	11																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2396.68	97.89	1287.81	239.36	123.46	5.3	5.3	284.59	133.31	0	0	0	0	1396.42	7763.7	7594.7	159.75	109.59	404.57	4696.66	293.99	0	0	40.53	1162.17	0	46.4	0	0	0	0											300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											86.79	0	4.78	0	100	0	0	50	75	0	0	0	0	75	10	30	30	30	30	30	0	10	20	10	15	0	15	0	20	20	20											17.33	-	0.51	-	1.03	-	-	1.19	0.83	-	-	-	-	8.73	6.47	18.99	0.4	0.27	1.01	11.74	-	-	-	0.03	1.45	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.05	0	0	17.33	-	0.51	-	1.03	-	-	1.19	0.83	-	-	-	-	8.73	6.47	18.99	0.4	0.27	1.01	11.74	-	-	-	0.03	1.45	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.05	none																																																																																			-	0	0	17.33	-	0.51	-	1.03	-	-	1.19	0.83	-	-	-	-	8.73	6.47	18.99	0.4	0.27	1.01	11.74	-	-	-	0.03	1.45	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.05
H3330_025_1	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2010.92	97.89	1574.63	186.37	401.44	6.31	6.31	218.57	70.48	0	0	0	0	858.54	6738.87	7015.07	96.43	66.15	244.2	2834.96	220.37	0	0	40.3	1306.31	0	59.97	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	none																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03
H3330_025_2	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2162.99	97.89	1339.25	221.17	216.96	7.19	7.19	197.55	130.79	0	0	0	0	483.32	6134.09	5544.77	94.19	64.61	238.53	4153.6	266.32	0	0	36.94	1227.34	0	71.26	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	none																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03
H3330_025_3	2007	5																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2359.81	97.89	1281.46	238.18	122.85	5.3	5.3	283.19	132.65	0	0	0	0	1389.55	6511.24	6904.57	159.75	109.59	404.57	4696.66	292.54	0	0	40.33	1156.45	0	46.17	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	20	20	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	25	0	15	0	20	20	20											15.62	-	0.51	-	1.02	1.06	1.06	1.18	0.83	-	-	-	-	8.68	5.43	11.51	0.4	0.18	0.67	7.83	-	-	-	0.03	2.41	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.49	0	0	15.62	-	0.51	-	1.02	1.06	1.06	1.18	0.83	-	-	-	-	8.68	5.43	11.51	0.4	0.18	0.67	7.83	-	-	-	0.03	2.41	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.49	none																																																																																			-	0	0	15.62	-	0.51	-	1.02	1.06	1.06	1.18	0.83	-	-	-	-	8.68	5.43	11.51	0.4	0.18	0.67	7.83	-	-	-	0.03	2.41	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.49
H3330_026_0	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2140.07	97.89	1568.45	203.09	362.78	6.52	6.52	227.68	88.24	0	0	0	0	864.12	5183.68	7547.31	145.19	99.6	367.69	4268.54	241.8	0	0	41.17	1328.52	0	63.07	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	50 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	50	0	0	50	75	0	0	0	0	0	10	20	30	20	20	20	0	10	20	10	15	0	15	0	20	20	20											14.17	-	0.62	-	1.51	-	-	0.95	0.55	-	-	-	-	-	4.32	12.58	0.36	0.17	0.61	7.11	-	-	-	0.03	1.66	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.73	0	0	14.17	-	0.62	-	1.51	-	-	0.95	0.55	-	-	-	-	-	4.32	12.58	0.36	0.17	0.61	7.11	-	-	-	0.03	1.66	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.73	none																																																																																			-	0	0	14.17	-	0.62	-	1.51	-	-	0.95	0.55	-	-	-	-	-	4.32	12.58	0.36	0.17	0.61	7.11	-	-	-	0.03	1.66	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.73
H3330_029_0	2007	12																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	1960.81	97.89	1478.6	191.46	341.99	5.99	5.99	214.64	83.19	0	0	0	0	814.62	6174.82	5547.31	145.19	99.6	367.69	4268.54	0	0	0	0	1038.43	0	59.46	0	0	0	0											0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Coinsurance	0 Coinsurance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	none																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H3330_030_1	2007	10	s.										Professional										none	Podiatry										D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O	V																																																			-	n/a	2427.82	97.89	1885.92	223.21	480.8	7.51	7.51	261.79	84.42	0	0	0	0	1028.27	8133.06	7316.05	144.64	99.22	366.3	4252.44	263.94	0	0	48.27	1564.56	0	71.83	0	0	0	0	2699.01										250 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	0 Copay	25 Copay	25 Copay	25 Copay	25 Copay	25 Copay	0 Copay	15 Copay	20 Copay	10 Copay	15 Copay	0 Copay	20 Copay	0 Copay	20 Copay	20 Copay	20 Copay	0 Copay										36.79	0	4.78	0	100	0	0	50	75	0	0	0	0	75	0	25	25	25	25	25	0	15	20	10	15	0	20	0	20	20	20	0										7.44	-	0.75	-	4.01	-	-	1.09	0.53	-	-	-	-	6.43	-	15.24	0.3	0.21	0.76	8.86	-	-	-	0.04	1.96	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.73	0	0	7.44	-	0.75	-	4.01	-	-	1.09	0.53	-	-	-	-	6.43	-	15.24	0.3	0.21	0.76	8.86	-	-	-	0.04	1.96	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.73	none																																																																																			-	0	0	7.44	-	0.75	-	4.01	-	-	1.09	0.53	-	-	-	-	6.43	-	15.24	0.3	0.21	0.76	8.86	-	-	-	0.04	1.96	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.73
H3330_030_2	2007	10	s.										Professional										none	Podiatry										D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O	V																																																			-	n/a	2796.83	97.89	1714.71	283.17	277.78	9.39	9.39	252.94	167.45	0	0	0	0	618.82	7944.73	7118.14	141.28	96.92	357.79	4153.6	340.98	0	0	47.29	1571.43	0	91.24	0	0	0	0	2699.01										300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	20 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay	0 Copay										86.79	0	4.78	0	100	0	0	50	75	0	0	0	0	75	5	30	30	30	30	30	0	10	20	10	20	0	15	0	20	20	20	0										20.23	-	0.68	-	2.31	-	-	1.05	1.05	-	-	-	-	3.87	3.31	17.8	0.35	0.24	0.89	10.38	-	-	-	0.04	2.62	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.95	0	0	20.23	-	0.68	-	2.31	-	-	1.05	1.05	-	-	-	-	3.87	3.31	17.8	0.35	0.24	0.89	10.38	-	-	-	0.04	2.62	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.95	none																																																																																			-	0	0	20.23	-	0.68	-	2.31	-	-	1.05	1.05	-	-	-	-	3.87	3.31	17.8	0.35	0.24	0.89	10.38	-	-	-	0.04	2.62	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.95
H3330_030_3	2007	12	s.										Professional										none	Podiatry										D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O	V																																																			-	n/a	2802.74	97.89	1512.41	281.11	144.99	6.45	6.45	334.22	156.56	0	0	0	0	1639.97	8788.93	8205.56	159.75	109.59	404.57	4696.66	345.26	0	0	47.6	1364.86	0	54.49	0	0	0	0	2699.01										300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0Coinsurance	0Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay	0 Copay										86.79	0	4.78	0	100	0	0	50	75	0	0	0	0	75	5	30	30	30	30	30	0	10	20	10	15	0	15	0	20	20	20	0										20.27	-	0.6	-	1.21	-	-	1.39	0.98	-	-	-	-	10.25	3.66	20.51	0.4	0.27	1.01	11.74	-	-	-	0.04	1.71	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.12	0	0	20.27	-	0.6	-	1.21	-	-	1.39	0.98	-	-	-	-	10.25	3.66	20.51	0.4	0.27	1.01	11.74	-	-	-	0.04	1.71	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.12	none																																																																																			-	0	0	20.27	-	0.6	-	1.21	-	-	1.39	0.98	-	-	-	-	10.25	3.66	20.51	0.4	0.27	1.01	11.74	-	-	-	0.04	1.71	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.12
H3330_802_1	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2125.57	97.89	1660.23	196.5	423.26	6.71	6.71	230.46	74.32	0	0	0	0	905.22	7029.39	7027.68	144.64	99.22	366.3	4252.44	232.35	0	0	42.49	1377.33	0	63.23	0	0	0	0											100 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	15 Copay	25 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											14.72	0	4.78	0	100	20	20	50	75	0	0	0	0	75	5	15	25	15	15	15	0	15	20	10	25	0	15	0	20	20	20											2.61	-	0.66	-	3.53	1.34	1.34	0.96	0.46	-	-	-	-	5.66	2.93	8.78	0.3	0.12	0.46	5.32	-	-	-	0.04	2.87	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.46	0	0	2.61	-	0.66	-	3.53	1.34	1.34	0.96	0.46	-	-	-	-	5.66	2.93	8.78	0.3	0.12	0.46	5.32	-	-	-	0.04	2.87	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.46	none																																																																																			-	0	0	2.61	-	0.66	-	3.53	1.34	1.34	0.96	0.46	-	-	-	-	5.66	2.93	8.78	0.3	0.12	0.46	5.32	-	-	-	0.04	2.87	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.46
H3330_802_2	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2323.36	97.89	1434.25	236.86	232.35	7.87	7.87	211.57	140.06	0	0	0	0	517.61	6866	6765.46	141.28	96.92	357.79	4153.6	285.21	0	0	39.56	1314.4	0	76.31	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	20	20	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	25	0	15	0	20	20	20											15.38	-	0.57	-	1.94	1.57	1.57	0.88	0.88	-	-	-	-	3.24	5.72	11.28	0.35	0.16	0.6	6.92	-	-	-	0.03	2.74	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.92	0	0	15.38	-	0.57	-	1.94	1.57	1.57	0.88	0.88	-	-	-	-	3.24	5.72	11.28	0.35	0.16	0.6	6.92	-	-	-	0.03	2.74	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.92	none																																																																																			-	0	0	15.38	-	0.57	-	1.94	1.57	1.57	0.88	0.88	-	-	-	-	3.24	5.72	11.28	0.35	0.16	0.6	6.92	-	-	-	0.03	2.74	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.92
H3330_802_3	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2491.32	97.89	1350.03	250.93	129.43	5.6	5.6	298.34	139.75	0	0	0	0	1463.9	7763.7	7657.35	159.75	109.59	404.57	4696.66	308.19	0	0	42.49	1218.33	0	92.41	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	20 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	20	20	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	25	0	20	0	20	20	20											16.49	-	0.54	-	1.08	1.12	1.12	1.24	0.87	-	-	-	-	9.15	6.47	12.76	0.4	0.18	0.67	7.83	-	-	-	0.04	2.54	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.66	0	0	16.49	-	0.54	-	1.08	1.12	1.12	1.24	0.87	-	-	-	-	9.15	6.47	12.76	0.4	0.18	0.67	7.83	-	-	-	0.04	2.54	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.66	none																																																																																			-	0	0	16.49	-	0.54	-	1.08	1.12	1.12	1.24	0.87	-	-	-	-	9.15	6.47	12.76	0.4	0.18	0.67	7.83	-	-	-	0.04	2.54	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.66
H3330_804_1	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2150.77	97.89	1662.42	196.76	423.82	6.7	6.7	230.76	74.41	0	0	0	0	906.41	7029.39	6858.78	144.64	99.22	366.3	4252.44	232.66	0	0	42.55	1379.15	0	63.31	0	0	0	0											250 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	25 Copay	25 Copay	25 Copay	25 Copay	25 Copay	0 Copay	15 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											36.79	0	4.78	0	100	20	20	50	75	0	0	0	0	75	5	25	25	25	25	25	0	15	20	10	25	0	15	0	20	20	20											6.59	-	0.66	-	3.53	1.34	1.34	0.96	0.47	-	-	-	-	5.67	2.93	14.29	0.3	0.21	0.76	8.86	-	-	-	0.04	2.87	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.89	0	0	6.59	-	0.66	-	3.53	1.34	1.34	0.96	0.47	-	-	-	-	5.67	2.93	14.29	0.3	0.21	0.76	8.86	-	-	-	0.04	2.87	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.89	none																																																																																			-	0	0	6.59	-	0.66	-	3.53	1.34	1.34	0.96	0.47	-	-	-	-	5.67	2.93	14.29	0.3	0.21	0.76	8.86	-	-	-	0.04	2.87	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.89
H3330_804_2	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2349.09	97.89	1435.14	237	232.49	7.82	7.82	211.7	140.15	0	0	0	0	517.93	6866	6558.85	141.28	96.92	357.79	4153.6	285.39	0	0	39.58	1315.22	0	76.36	0	0	0	0											300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											86.79	0	4.78	0	100	20	20	50	75	0	0	0	0	75	10	30	30	30	30	30	0	10	20	10	25	0	15	0	20	20	20											16.99	-	0.57	-	1.94	1.56	1.56	0.88	0.88	-	-	-	-	3.24	5.72	16.4	0.35	0.24	0.89	10.38	-	-	-	0.03	2.74	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.48	0	0	16.99	-	0.57	-	1.94	1.56	1.56	0.88	0.88	-	-	-	-	3.24	5.72	16.4	0.35	0.24	0.89	10.38	-	-	-	0.03	2.74	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.48	none																																																																																			-	0	0	16.99	-	0.57	-	1.94	1.56	1.56	0.88	0.88	-	-	-	-	3.24	5.72	16.4	0.35	0.24	0.89	10.38	-	-	-	0.03	2.74	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.48
H3330_804_3	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2507.29	97.89	1344.91	249.98	128.94	5.57	5.57	297.21	139.22	0	0	0	0	1458.34	7763.7	7469.47	159.75	109.59	404.57	4696.66	307.02	0	0	42.33	1213.7	0	48.45	0	0	0	0											300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											86.79	0	4.78	0	100	20	20	50	75	0	0	0	0	75	10	30	30	30	30	30	0	10	20	10	25	0	15	0	20	20	20											18.13	-	0.54	-	1.07	1.11	1.11	1.24	0.87	-	-	-	-	9.11	6.47	18.67	0.4	0.27	1.01	11.74	-	-	-	0.04	2.53	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.39	0	0	18.13	-	0.54	-	1.07	1.11	1.11	1.24	0.87	-	-	-	-	9.11	6.47	18.67	0.4	0.27	1.01	11.74	-	-	-	0.04	2.53	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.39	none																																																																																			-	0	0	18.13	-	0.54	-	1.07	1.11	1.11	1.24	0.87	-	-	-	-	9.11	6.47	18.67	0.4	0.27	1.01	11.74	-	-	-	0.04	2.53	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.39
H3330_806_1	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2010.92	97.89	1574.63	186.37	401.44	6.31	6.31	218.57	70.48	0	0	0	0	858.54	6988.87	6765.07	96.43	66.15	244.2	2834.96	220.37	0	0	40.3	1306.31	0	59.97	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	none																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03
H3330_806_2	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2162.99	97.89	1339.25	221.17	216.96	7.19	7.19	197.55	130.79	0	0	0	0	483.32	6134.09	5544.77	94.19	64.61	238.53	4153.6	266.32	0	0	36.94	1227.34	0	71.26	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	none																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.03
H3330_806_3	2007	5																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2357.94	97.89	1280.49	238	122.76	5.29	5.29	282.97	132.55	0	0	0	0	1388.49	6996.93	6404.57	159.75	109.59	404.57	4696.66	292.31	0	0	40.3	1155.57	0	46.13	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	20	20	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	25	0	15	0	20	20	20											15.61	-	0.51	-	1.02	1.06	1.06	1.18	0.83	-	-	-	-	8.68	5.83	10.67	0.4	0.18	0.67	7.83	-	-	-	0.03	2.41	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.03	0	0	15.61	-	0.51	-	1.02	1.06	1.06	1.18	0.83	-	-	-	-	8.68	5.83	10.67	0.4	0.18	0.67	7.83	-	-	-	0.03	2.41	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.03	none																																																																																			-	0	0	15.61	-	0.51	-	1.02	1.06	1.06	1.18	0.83	-	-	-	-	8.68	5.83	10.67	0.4	0.18	0.67	7.83	-	-	-	0.03	2.41	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.03
H3330_808_0	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2205.35	97.89	1614.19	209.02	373.36	6.83	6.83	234.32	90.82	0	0	0	0	889.32	9173.49	9547.31	96.79	66.4	245.13	2845.7	248.86	0	0	42.37	1367.26	0	64.91	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	50 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	20 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	50	20	20	50	75	0	0	0	0	0	10	20	30	20	20	20	0	10	20	10	15	0	20	0	20	20	20											14.6	-	0.64	-	1.56	1.37	1.37	0.98	0.57	-	-	-	-	-	7.64	15.91	0.24	0.11	0.41	4.74	-	-	-	0.04	1.71	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.99	0	0	14.6	-	0.64	-	1.56	1.37	1.37	0.98	0.57	-	-	-	-	-	7.64	15.91	0.24	0.11	0.41	4.74	-	-	-	0.04	1.71	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.99	none																																																																																			-	0	0	14.6	-	0.64	-	1.56	1.37	1.37	0.98	0.57	-	-	-	-	-	7.64	15.91	0.24	0.11	0.41	4.74	-	-	-	0.04	1.71	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.99
H3330_809_1	2007	10																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a								223.37								10635.32	180.66	123.93																								0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0Coinsurance	0Coinsurance	50 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	10 Copay	20 Copay	10 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	10 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay											0	0	0	0	0	0	0	50	0	0	0	0	0	0	0	10	20	10	0	0	0	0	0	10	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.93	-	-	-	-	-	-	-	8.86	0.3	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2	0	0	-	-	-	-	-	-	-	0.93	-	-	-	-	-	-	-	8.86	0.3	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2	none																																																																																			-	0	0	-	-	-	-	-	-	-	0.93	-	-	-	-	-	-	-	8.86	0.3	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2
H3330_809_2	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a								199.79								10746.01	182.25	125.02																								0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0Coinsurance	0Coinsurance	50 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	10 Copay	20 Copay	10 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	10 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay											0	0	0	0	0	0	0	50	0	0	0	0	0	0	0	10	20	10	0	0	0	0	0	10	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.83	-	-	-	-	-	-	-	8.96	0.3	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2	0	0	-	-	-	-	-	-	-	0.83	-	-	-	-	-	-	-	8.96	0.3	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2	none																																																																																			-	0	0	-	-	-	-	-	-	-	0.83	-	-	-	-	-	-	-	8.96	0.3	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2
H3330_809_3	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a								280.5								10392.05	167.74	115.07																								0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0Coinsurance	0Coinsurance	50 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	10 Copay	20 Copay	10 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay											0	0	0	0	0	0	0	50	0	0	0	0	0	0	0	10	20	10	0	0	0	0	0	10	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.17	-	-	-	-	-	-	-	8.66	0.28	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2	0	0	-	-	-	-	-	-	-	1.17	-	-	-	-	-	-	-	8.66	0.28	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2	none																																																																																			-	0	0	-	-	-	-	-	-	-	1.17	-	-	-	-	-	-	-	8.66	0.28	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.2
H3330_810_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	1966.57	97.89	1482.74	191.99	342.95	6.26	6.26	215.24	83.42	0	0	0	0	816.9	6221.31	5547.31	145.19	99.6	367.69	4268.54	228.59	0	0	0	1041.34	0	59.63	0	0	0	0											0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Coinsurance	0 Coinsurance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	none																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H3330_811_1	2007	9	s.										Professional										none	Podiatry										D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O	V																																																			-	n/a	2593.51	97.89	2009.64	237.86	512.34	8.09	8.09	278.96	89.96	0	0	0	0	1095.72	8120.86	7816.05	144.64	99.22	366.3	4252.44	281.25	0	0	51.43	1667.19	0	76.54	0	0	0	0	2699.01										250 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0.2 Copay	0.2 Copay	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	0 Copay	25 Copay	25 Copay	25 Copay	25 Copay	25 Copay	0 Copay	15 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay	Copay										36.79	0	4.78	0	100	20	20	50	75	0	0	0	0	75	0	25	25	25	25	25	0	15	20	10	25	0	20	0	20	20	20	0										7.95	-	0.8	-	4.27	1.62	1.62	1.16	0.56	-	-	-	-	6.85	-	16.28	0.3	0.21	0.76	8.86	-	-	-	0.04	3.47	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89	0	0	7.95	-	0.8	-	4.27	1.62	1.62	1.16	0.56	-	-	-	-	6.85	-	16.28	0.3	0.21	0.76	8.86	-	-	-	0.04	3.47	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89	none																																																																																			-	0	0	7.95	-	0.8	-	4.27	1.62	1.62	1.16	0.56	-	-	-	-	6.85	-	16.28	0.3	0.21	0.76	8.86	-	-	-	0.04	3.47	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89
H3330_811_2	2007	9	s.										Professional										none	Podiatry										D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O	V																																																			-	n/a	2969.5	97.89	1817	300.07	294.35	9.92	9.92	268.02	177.44	0	0	0	0	655.74	8287.57	8118.14	141.28	96.92	357.79	4153.6	361.32	0	0	50.11	1665.17	0	96.68	0	0	0	0	2699.01										300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay	0 Copay										86.79	0	4.78	0	100	20	20	50	75	0	0	0	0	75	5	30	30	30	30	30	0	10	20	10	25	0	15	0	20	20	20	0										21.48	-	0.72	-	2.45	1.98	1.98	1.12	1.11	-	-	-	-	4.1	3.45	20.3	0.35	0.24	0.89	10.38	-	-	-	0.04	3.47	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.2	0	0	21.48	-	0.72	-	2.45	1.98	1.98	1.12	1.11	-	-	-	-	4.1	3.45	20.3	0.35	0.24	0.89	10.38	-	-	-	0.04	3.47	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.2	none																																																																																			-	0	0	21.48	-	0.72	-	2.45	1.98	1.98	1.12	1.11	-	-	-	-	4.1	3.45	20.3	0.35	0.24	0.89	10.38	-	-	-	0.04	3.47	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.2
H3330_811_3	2007	9	s.										Professional										none	Podiatry										D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O	V																																																			-	n/a	2873.78	97.89	1549.45	287.99	148.54	6.76	6.76	342.41	160.39	0	0	0	0	1680.14	9402.8	8205.56	159.75	109.59	404.57	4696.66	353.71	0	0	48.77	1398.29	0	55.82	0	0	0	0	2699.01										300 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	30 Copay	30 Copay	30 Copay	30 Copay	30 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay	0 Copay										86.79	0	4.78	0	100	20	20	50	75	0	0	0	0	75	5	30	30	30	30	30	0	10	20	10	25	0	15	0	20	20	20	0										20.79	-	0.62	-	1.24	1.35	1.35	1.43	1	-	-	-	-	10.5	3.92	20.51	0.4	0.27	1.01	11.74	-	-	-	0.04	2.91	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.16	0	0	20.79	-	0.62	-	1.24	1.35	1.35	1.43	1	-	-	-	-	10.5	3.92	20.51	0.4	0.27	1.01	11.74	-	-	-	0.04	2.91	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.16	none																																																																																			-	0	0	20.79	-	0.62	-	1.24	1.35	1.35	1.43	1	-	-	-	-	10.5	3.92	20.51	0.4	0.27	1.01	11.74	-	-	-	0.04	2.91	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.16
H3333_023_0	2007	5																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1606.34	99.44	773.02	23.7	130.91	7.65	10.66	329.57	344.03		25.89		1.56	218.34	3788.64	4863.08	3.39	605.28	24.51	411.84	21.06	23.71			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															48.34	48.24	30.42	0.11	75.47	0.15	0.15	37.74	125.5		0.15		37.74	36.15	11.32	23.09	0.38	22.64	0.15	22.64	0.15	22.64			22.64		22.64															6.47	0.4	1.96	2.68	0.82	1.16	1.61	1.04	3.6	-	3.91	-	0	0.66	3.57	9.36	1.28	1.14	3.7	0.78	3.18	0.04	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.05		15.61	6.47	0.4	1.96	2.68	0.82	1.16	1.61	1.04	3.6	-	3.91	-	0	0.66	3.57	9.36	1.28	1.14	3.7	0.78	3.18	0.04	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.05																																																																																				-		0	6.47	0.4	1.96	2.68	0.82	1.16	1.61	1.04	3.6	-	3.91	-	0	0.66	3.57	9.36	1.28	1.14	3.7	0.78	3.18	0.04	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.05
H3333_024_0	2007	4																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1633.43	101.12	786.05	24.1	133.12	7.78	10.84	335.12	349.84		26.33		1.59	222.02	3852.53	4945.09	3.45	615.48	24.92	418.79	21.42	24.11			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															21.58	25.58	33.05	0.12	41	0.16	0.16	28.7	34.09		0.08		41	28.95	4.1	12.79	0.41	12.3	0.08	12.3	0.16	12.3			12.3		12.3															2.94	0.22	2.16	2.96	0.45	1.28	1.78	0.8	0.99	-	2.16	-	0.01	0.54	1.32	5.27	1.41	0.63	2.04	0.43	3.51	0.02	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3		6.87	2.94	0.22	2.16	2.96	0.45	1.28	1.78	0.8	0.99	-	2.16	-	0.01	0.54	1.32	5.27	1.41	0.63	2.04	0.43	3.51	0.02	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3																																																																																				-		0	2.94	0.22	2.16	2.96	0.45	1.28	1.78	0.8	0.99	-	2.16	-	0.01	0.54	1.32	5.27	1.41	0.63	2.04	0.43	3.51	0.02	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3
H3333_025_0	2007	7																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1874.41	116.58	903.36	31.28	106.5	7.3	9.35	281.42	338.21		27.19		1.77	226.88	3794.16	6196.9	4.59	1057.87	36.74	620.2	25.18	20.29			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															45.91	45.81	28.88	0.11	71.67	0.14	0.14	35.84	112.49		0.14		35.84	43.51	10.75	21.94	0.36	21.5	0.14	21.5	0.14	21.5			21.5		21.5															7.17	0.45	2.17	3.36	0.64	1.05	1.34	0.84	3.17	-	3.9	-	0.01	0.82	3.4	11.33	1.65	1.9	5.27	1.11	3.61	0.04	-	-	0.23	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86		21.29	7.17	0.45	2.17	3.36	0.64	1.05	1.34	0.84	3.17	-	3.9	-	0.01	0.82	3.4	11.33	1.65	1.9	5.27	1.11	3.61	0.04	-	-	0.23	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86																																																																																				-		0	7.17	0.45	2.17	3.36	0.64	1.05	1.34	0.84	3.17	-	3.9	-	0.01	0.82	3.4	11.33	1.65	1.9	5.27	1.11	3.61	0.04	-	-	0.23	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86
H3333_026_0	2007	7																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1606.34	99.44	773.02	23.7	130.91	7.65	10.66	329.57	344.03		25.89		1.56	218.34	3788.64	4863.08	3.39	605.28	24.51	411.84	21.06	23.71			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															48.34	48.24	30.42	0.11	75.47	0.15	0.15	37.74	125.5		0.15		37.74	36.15	11.32	23.09	0.38	22.64	0.15	22.64	0.15	22.64			22.64		22.64															6.47	0.4	1.96	2.68	0.82	1.16	1.61	1.04	3.6	-	3.91	-	0	0.66	3.57	9.36	1.28	1.14	3.7	0.78	3.18	0.04	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.05		15.61	6.47	0.4	1.96	2.68	0.82	1.16	1.61	1.04	3.6	-	3.91	-	0	0.66	3.57	9.36	1.28	1.14	3.7	0.78	3.18	0.04	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.05																																																																																				-		0	6.47	0.4	1.96	2.68	0.82	1.16	1.61	1.04	3.6	-	3.91	-	0	0.66	3.57	9.36	1.28	1.14	3.7	0.78	3.18	0.04	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.05
H3333_027_0	2007	6																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1906.02	118.55	918.6	31.81	108.3	7.43	9.51	286.15	343.92		27.65		1.8	230.7	3858.15	6301.41	4.67	1075.71	37.36	630.66	25.61	20.63			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															19.49	24.64	31.77	0.12	39.42	0.16	0.16	27.6	30.94		0.08		39.42	38.5	3.94	12.31	0.39	11.83	0.08	11.83	0.16	11.83			11.83		11.83															3.1	0.24	2.43	3.76	0.36	1.17	1.5	0.66	0.89	-	2.18	-	0.01	0.74	1.27	6.47	1.84	1.06	2.95	0.62	4.04	0.02	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.65		9.56	3.1	0.24	2.43	3.76	0.36	1.17	1.5	0.66	0.89	-	2.18	-	0.01	0.74	1.27	6.47	1.84	1.06	2.95	0.62	4.04	0.02	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.65																																																																																				-		0	3.1	0.24	2.43	3.76	0.36	1.17	1.5	0.66	0.89	-	2.18	-	0.01	0.74	1.27	6.47	1.84	1.06	2.95	0.62	4.04	0.02	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.65
H3333_028_0	2007	7																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1633.43	101.12	786.05	24.1	133.12	7.78	10.84	335.12	349.84		26.33		1.59	222.02	3852.53	4945.09	3.45	615.48	24.92	418.79	21.42	24.11			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															21.58	25.58	33.05	0.12	41	0.16	0.16	28.7	34.09		0.08		41	28.95	4.1	12.79	0.41	12.3	0.08	12.3	0.16	12.3			12.3		12.3															2.94	0.22	2.16	2.96	0.45	1.28	1.78	0.8	0.99	-	2.16	-	0.01	0.54	1.32	5.27	1.41	0.63	2.04	0.43	3.51	0.02	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3		6.87	2.94	0.22	2.16	2.96	0.45	1.28	1.78	0.8	0.99	-	2.16	-	0.01	0.54	1.32	5.27	1.41	0.63	2.04	0.43	3.51	0.02	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3																																																																																				-		0	2.94	0.22	2.16	2.96	0.45	1.28	1.78	0.8	0.99	-	2.16	-	0.01	0.54	1.32	5.27	1.41	0.63	2.04	0.43	3.51	0.02	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.3
H3333_029_0	2007	4																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1874.41	116.58	903.36	31.28	106.5	7.3	9.35	281.42	338.21		27.19		1.77	226.88	3794.16	6196.9	4.59	1057.87	36.74	620.2	25.18	20.29			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															45.91	45.81	28.88	0.11	71.67	0.14	0.14	35.84	112.49		0.14		35.84	43.51	10.75	21.94	0.36	21.5	0.14	21.5	0.14	21.5			21.5		21.5															7.17	0.45	2.17	3.36	0.64	1.05	1.34	0.84	3.17	-	3.9	-	0.01	0.82	3.4	11.33	1.65	1.9	5.27	1.11	3.61	0.04	-	-	0.23	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86		21.29	7.17	0.45	2.17	3.36	0.64	1.05	1.34	0.84	3.17	-	3.9	-	0.01	0.82	3.4	11.33	1.65	1.9	5.27	1.11	3.61	0.04	-	-	0.23	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86																																																																																				-		0	7.17	0.45	2.17	3.36	0.64	1.05	1.34	0.84	3.17	-	3.9	-	0.01	0.82	3.4	11.33	1.65	1.9	5.27	1.11	3.61	0.04	-	-	0.23	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86
H3333_030_0	2007	4																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1906.02	118.55	918.6	31.81	108.3	7.43	9.51	286.15	343.92		27.65		1.8	230.7	3858.15	6301.41	4.67	1075.71	37.36	630.66	25.61	20.63			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															19.49	24.64	31.77	0.12	39.42	0.16	0.16	27.6	30.94		0.08		39.42	38.5	3.94	12.31	0.39	11.83	0.08	11.83	0.16	11.83			11.83		11.83															3.1	0.24	2.43	3.76	0.36	1.17	1.5	0.66	0.89	-	2.18	-	0.01	0.74	1.27	6.47	1.84	1.06	2.95	0.62	4.04	0.02	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.65		9.56	3.1	0.24	2.43	3.76	0.36	1.17	1.5	0.66	0.89	-	2.18	-	0.01	0.74	1.27	6.47	1.84	1.06	2.95	0.62	4.04	0.02	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.65																																																																																				-		0	3.1	0.24	2.43	3.76	0.36	1.17	1.5	0.66	0.89	-	2.18	-	0.01	0.74	1.27	6.47	1.84	1.06	2.95	0.62	4.04	0.02	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.65
H3333_801_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		279.24	6.88	30.25		5.52	7.35	9.79	10.5	35.42	24.75	26.23	2.24	0.4	21.38	22.64	45.57	4	7.13	30.86	107.53	23.01	0.13																				Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08		0	18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08																																																																																				-		0	18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08
H3333_805_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		279.24	6.88	30.25		5.52	7.35	9.79	10.5	35.42	24.75	26.23	2.24	0.4	21.38	22.64	45.57	4	7.13	30.86	107.53	23.01	0.13																				Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08		0	18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08																																																																																				-		0	18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08
H3333_806_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		279.24	6.88	30.25		5.52	7.35	9.79	10.5	35.42	24.75	26.23	2.24	0.4	21.38	22.64	45.57	4	7.13	30.86	107.53	23.01	0.13																				Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08		0	18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08																																																																																				-		0	18.48	0.46	5.42	-	1.3	1.73	2.31	2.48	8.36	5.84	6.19	0.53	0.09	5.05	5.34	10.76	0.94	1.68	7.28	25.38	5.43	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.08
H3335_002_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	225.77	3.27	1529.79	0	226.64	56402.2	58.24	415.68	378.15	0	801.24	0	217.3	235.99	4426.52	5421.86	185.54	544.29	995.85	2114.15	1008.22	14.58	0	0	349.91	0	149.96	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											200	200	25	0	50	0.97	43.01	47.43	100	0	20	0	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	0											3.76	0.05	3.19	-	0.94	4.57	0.21	1.64	3.15	-	1.34	-	0.36	0.39	5.53	9.04	0.31	0.91	1.66	3.52	1.68	0.02	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.12	0	0	3.76	0.05	3.19	-	0.94	4.57	0.21	1.64	3.15	-	1.34	-	0.36	0.39	5.53	9.04	0.31	0.91	1.66	3.52	1.68	0.02	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.12		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.17	0.02	0.47	0.21	0.05	0.17	0.01	0.08	0.15	0.06	0.15	0	0.05	0.16	0.17	0.32	0.01	0.03	0.23	0.68	0.14	0.02	0	0	0.03	0	0	0	0	0	0											5.38	0	0.95	5.93	0.08	3.66	0.21	0.99	4.73	0.22	1.73	3.3	0.06	1.49	-	0.41	0.56	5.71	9.36	0.32	0.93	1.89	4.2	1.82	0.04	-	-	0.61	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.5
H3335_003_0	2007	4																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	226.22	3.28	1529.79	0	226.64	56402.2	58.24	416.87	383.17	0	811.9	0	217.85	236.58	4759.69	5596.34	191.73	562.43	1009.1	2136.64	1018.95	14.58	0	0	361.57	0	154.96	0	0	0	1140											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											100	100	25	0	50	0.97	43.01	46.91	35	0	15	0	15	15	5	15	15	15	15	15	15	15	0	0	15	0	15	0	0	0	50.39											1.89	0.03	3.19	-	0.94	4.57	0.21	1.63	1.12	-	1.01	-	0.27	0.3	1.98	7	0.24	0.7	1.26	2.67	1.27	0.02	-	-	0.45	-	0.19	-	-	-	4.79	-	-	-	-	-	-	-	-	-	-	35.73	0	0	1.89	0.03	3.19	-	0.94	4.57	0.21	1.63	1.12	-	1.01	-	0.27	0.3	1.98	7	0.24	0.7	1.26	2.67	1.27	0.02	-	-	0.45	-	0.19	-	-	-	4.79	-	-	-	-	-	-	-	-	-	-	35.73		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.17	0.02	0.47	0.22	0.05	0.18	0.01	0.09	0.17	0.07	0.17	0	0.05	0.17	0.65	0.61	0.01	0.06	0.25	0.8	0.15	0.02	0	0	0.04	0	0.02	0	0	0	0.25											6.7	0	0.62	4.06	0.05	3.66	0.22	0.99	4.74	0.22	1.72	1.28	0.07	1.18	-	0.32	0.47	2.64	7.61	0.25	0.76	1.51	3.47	1.42	0.04	-	-	0.49	-	0.21	-	-	-	5.04	-	-	-	-	-	-	-	-	-	-	42.43
H3335_004_0	2007	2																					1500																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	288.57	4.18	1713.47	0	237.2	59633.43	61.58	376.9	341.51	2233.27	1131.58	0	582.78	1825.17	4755.21	6625.47	216.02	1901.04	5283.24	29329.68	1123.87	639.08	0	0	364.88	0	166.46	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											528.43	391.45	18.97	0	100	0.27	12.1	46.56	45.44	2.72	14.57	0	7.89	8.95	3.46	4.91	4.86	1.53	4.28	2.36	12.71	3.06	0	0	15	0	1.89	0	0	0	0											12.71	0.14	2.71	-	1.98	1.36	0.06	1.46	1.29	0.51	1.37	-	0.38	1.36	1.37	2.71	0.09	0.24	1.89	5.77	1.19	0.16	-	-	0.46	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.23	0	21.52	12.71	0.14	2.71	-	1.98	1.36	0.06	1.46	1.29	0.51	1.37	-	0.38	1.36	1.37	2.71	0.09	0.24	1.89	5.77	1.19	0.16	-	-	0.46	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.23	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.17	0.02	0.46	0.15	0.1	0.18	0.01	0.08	0.17	0.07	0.18	0	0.05	0.18	0.65	0.66	0.01	0.07	0.25	0.84	0.16	0.02	0	0	0.04	0	0.02	0	0	0	0											6.55	0	0.6	14.88	0.16	3.17	0.15	2.08	1.54	0.07	1.54	1.47	0.57	1.56	-	0.43	1.54	2.02	3.37	0.1	0.31	2.14	6.61	1.35	0.18	-	-	0.5	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.78
H3335_005_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	246.63	3.57	1731.14	0	239.62	59633.43	61.58	375.71	338.06	0	716.29	0	194.26	210.97	4467.02	5532.57	196.38	576.07	945.84	2237.62	1067.11	14.71	0	0	353.11	0	151.33	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											250	250	25	0	50	0.89	39.32	47.13	100	0	20	0	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	0											5.14	0.07	3.61	-	1	4.41	0.2	1.48	2.82	-	1.19	-	0.32	0.35	5.58	9.22	0.33	0.96	1.58	3.73	1.78	0.02	-	-	0.59	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.64	0	0	5.14	0.07	3.61	-	1	4.41	0.2	1.48	2.82	-	1.19	-	0.32	0.35	5.58	9.22	0.33	0.96	1.58	3.73	1.78	0.02	-	-	0.59	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.64		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.21	0.02	0.47	0.14	0.05	0.17	0.01	0.08	0.16	0.06	0.16	0	0.05	0.17	0.17	0.32	0.01	0.03	0.22	0.71	0.14	0.02	0	0	0.03	0	0	0	0	0	0											5.39	0	0.91	7.34	0.1	4.07	0.14	1.05	4.58	0.21	1.55	2.98	0.06	1.36	-	0.37	0.52	5.75	9.54	0.34	0.99	1.8	4.44	1.92	0.04	-	-	0.62	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.03
H3335_006_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	246.88	3.58	1731.14	0	239.62	59633.43	61.58	376.9	342.54	0	725.81	0	194.75	211.5	4803.25	5711.11	202.92	595.28	958.42	2261.42	1078.46	14.71	0	0	364.88	0	156.38	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											200	200	25	0	50	0.89	39.32	46.56	35	0	15	0	15	15	5	15	15	15	15	15	15	15	0	0	15	0	15	0	0	0	0											4.11	0.06	3.61	-	1	4.41	0.2	1.46	1	-	0.91	-	0.24	0.26	2	7.14	0.25	0.74	1.2	2.83	1.35	0.02	-	-	0.46	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.45	0	0	4.11	0.06	3.61	-	1	4.41	0.2	1.46	1	-	0.91	-	0.24	0.26	2	7.14	0.25	0.74	1.2	2.83	1.35	0.02	-	-	0.46	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.45		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.21	0.02	0.47	0.15	0.05	0.18	0.01	0.08	0.17	0.07	0.18	0	0.05	0.14	0.66	0.63	0.01	0.07	0.24	0.84	0.15	0.02	0	0	0.04	0	0.02	0	0	0	0											6.46	0	0.57	6.32	0.08	4.07	0.15	1.05	4.6	0.21	1.54	1.17	0.07	1.08	-	0.3	0.41	2.66	7.77	0.26	0.81	1.44	3.67	1.5	0.04	-	-	0.5	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.91
H3335_007_0	2007	2																					1500																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	258.32	3.74	1133.48	0	199.98	50276.09	51.92	578.9	546.02	3570.67	1809.23	0	931.79	2918.17	4562.34	6142.06	181.39	1596.3	5070.37	22108.96	943.71	538.4	0	0	350.08	0	159.71	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											562.81	416.92	19.9	0	100	0.3	13.28	47.85	36.19	2.16	11.6	0	6.28	7.13	3.55	5.09	4.99	1.57	3.65	2.76	13.06	3.2	0	0	15	0	1.95	0	0	0	0											12.12	0.13	1.88	-	1.67	1.26	0.06	2.31	1.65	0.64	1.75	-	0.49	1.73	1.35	2.6	0.08	0.21	1.54	5.09	1.03	0.14	-	-	0.44	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.18	0	18.53	12.12	0.13	1.88	-	1.67	1.26	0.06	2.31	1.65	0.64	1.75	-	0.49	1.73	1.35	2.6	0.08	0.21	1.54	5.09	1.03	0.14	-	-	0.44	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.18	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											1.99	0.02	0.31	0.12	0.09	0.16	0.01	0.12	0.21	0.08	0.23	0	0.06	0.22	0.63	0.61	0.01	0.06	0.2	0.72	0.13	0.01	0	0	0.04	0	0.02	0	0	0	0											6.07	0	0.55	14.11	0.15	2.19	0.12	1.75	1.42	0.06	2.43	1.86	0.73	1.98	-	0.55	1.96	1.98	3.22	0.09	0.27	1.74	5.81	1.16	0.16	-	-	0.48	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.25
H3335_008_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	220.78	3.2	1145.16	0	202.02	50276.09	51.92	577.75	540.5	0	1145.23	0	310.6	337.3	4285.84	5150.96	164.9	483.73	907.73	1878.92	896.05	14.12	0	0	338.79	0	145.19	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											250	250	25	0	50	0.94	41.51	48.21	100	0	20	0	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	0											4.6	0.07	2.39	-	0.84	3.93	0.18	2.32	4.5	-	1.91	-	0.52	0.56	5.36	8.58	0.27	0.81	1.51	3.13	1.49	0.02	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.81	0	0	4.6	0.07	2.39	-	0.84	3.93	0.18	2.32	4.5	-	1.91	-	0.52	0.56	5.36	8.58	0.27	0.81	1.51	3.13	1.49	0.02	-	-	0.56	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.81		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.02	0.02	0.31	0.11	0.04	0.15	0.01	0.12	0.2	0.08	0.2	0	0.06	0.21	0.16	0.3	0.01	0.02	0.18	0.61	0.12	0.01	0	0	0.03	0	0	0	0	0	0											5	0	0.83	6.62	0.09	2.7	0.11	0.89	4.08	0.19	2.44	4.7	0.08	2.11	-	0.58	0.77	5.52	8.88	0.28	0.83	1.69	3.74	1.61	0.04	-	-	0.59	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.8
H3335_009_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	221.01	3.2	1145.16	0	202.02	50276.09	51.92	578.9	547.67	0	1160.46	0	311.38	338.15	4608.43	5315.92	170.4	499.85	919.8	1898.91	905.58	14.12	0	0	350.08	0	150.03	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											200	200	25	0	50	0.94	41.51	47.85	35	0	15	0	15	15	5	15	15	15	15	15	15	15	0	0	15	0	15	0	0	0	0											3.68	0.05	2.39	-	0.84	3.93	0.18	2.31	1.6	-	1.45	-	0.39	0.42	1.92	6.64	0.21	0.62	1.15	2.37	1.13	0.02	-	-	0.44	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.94	0	0	3.68	0.05	2.39	-	0.84	3.93	0.18	2.31	1.6	-	1.45	-	0.39	0.42	1.92	6.64	0.21	0.62	1.15	2.37	1.13	0.02	-	-	0.44	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.94		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.03	0.02	0.31	0.12	0.04	0.16	0.01	0.12	0.22	0.09	0.22	0	0.06	0.18	0.63	0.58	0.01	0.05	0.2	0.72	0.13	0.02	0	0	0.04	0	0.02	0	0	0	0											5.99	0	0.51	5.71	0.08	2.7	0.12	0.89	4.09	0.19	2.43	1.81	0.09	1.67	-	0.45	0.61	2.55	7.23	0.22	0.68	1.35	3.09	1.26	0.03	-	-	0.48	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.93
H3335_013_0	2007	2																					1500																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	264.29	3.83	1398.4	0	236.89	59553.63	61.5	337.14	299.66	1959.59	992.91	0	511.37	1601.5	4995.99	6947.87	225.38	1983.43	5525	29875.7	1172.58	666.89	0	0	383.35	0	174.89	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											561.75	416.14	20.94	0	100	0.3	13.06	45.96	44.81	2.68	14.37	0	7.78	8.82	3.5	4.95	4.92	1.55	4.18	2.34	12.87	3.09	0	0	15	0	1.92	0	0	0	0											12.37	0.13	2.44	-	1.97	1.46	0.07	1.29	1.12	0.44	1.19	-	0.33	1.18	1.46	2.87	0.09	0.26	1.92	5.82	1.26	0.17	-	-	0.48	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.35	0	19.97	12.37	0.13	2.44	-	1.97	1.46	0.07	1.29	1.12	0.44	1.19	-	0.33	1.18	1.46	2.87	0.09	0.26	1.92	5.82	1.26	0.17	-	-	0.48	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.35	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.07	0.02	0.41	0.18	0.1	0.19	0.01	0.07	0.15	0.06	0.16	0	0.04	0.16	0.69	0.69	0.01	0.07	0.25	0.84	0.17	0.02	0	0	0.04	0	0.02	0	0	0	0											6.42	0	0.56	14.45	0.16	2.85	0.18	2.08	1.66	0.08	1.36	1.27	0.5	1.35	-	0.38	1.33	2.14	3.56	0.1	0.33	2.18	6.66	1.42	0.19	-	-	0.52	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.77
H3335_014_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	225.88	3.27	1412.82	0	239.3	59553.63	61.5	335.88	296.63	0	628.51	0	170.46	185.11	4693.2	5803.13	204.89	601.04	989.12	2334.59	1113.35	15.46	0	0	370.99	0	158.99	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											250	250	25	0	50	0.94	41.62	46.63	100	0	20	0	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	0											4.71	0.07	2.94	-	1	4.67	0.21	1.31	2.47	-	1.05	-	0.28	0.31	5.87	9.67	0.34	1	1.65	3.89	1.86	0.03	-	-	0.62	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2	0	0	4.71	0.07	2.94	-	1	4.67	0.21	1.31	2.47	-	1.05	-	0.28	0.31	5.87	9.67	0.34	1	1.65	3.89	1.86	0.03	-	-	0.62	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.2		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.11	0.02	0.41	0.17	0.05	0.18	0.01	0.07	0.14	0.05	0.14	0	0.04	0.14	0.17	0.34	0.01	0.03	0.22	0.71	0.15	0.02	0	0	0.03	0	0	0	0	0	0											5.21	0	0.88	6.81	0.09	3.36	0.17	1.05	4.84	0.22	1.38	2.61	0.05	1.19	-	0.32	0.45	6.04	10.01	0.35	1.03	1.87	4.6	2	0.04	-	-	0.65	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.41
H3335_015_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	226.11	3.28	1412.82	0	239.3	59553.63	61.5	337.14	300.56	0	636.87	0	170.89	185.58	5046.46	5990.33	211.72	621.07	1002.28	2359.43	1125.2	15.46	0	0	383.35	0	164.29	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											200	200	25	0	50	0.94	41.62	45.96	35	0	15	0	15	15	5	15	15	15	15	15	15	15	0	0	15	0	15	0	0	0	0											3.77	0.05	2.94	-	1	4.67	0.21	1.29	0.88	-	0.8	-	0.21	0.23	2.1	7.49	0.26	0.78	1.25	2.95	1.41	0.02	-	-	0.48	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33	0	0	3.77	0.05	2.94	-	1	4.67	0.21	1.29	0.88	-	0.8	-	0.21	0.23	2.1	7.49	0.26	0.78	1.25	2.95	1.41	0.02	-	-	0.48	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.11	0.02	0.41	0.18	0.05	0.19	0.01	0.07	0.15	0.06	0.15	0	0.04	0.12	0.69	0.66	0.01	0.07	0.25	0.84	0.16	0.02	0	0	0.04	0	0.02	0	0	0	0											6.33	0	0.54	5.88	0.08	3.36	0.18	1.05	4.86	0.22	1.36	1.03	0.06	0.95	-	0.26	0.36	2.8	8.14	0.28	0.84	1.5	3.79	1.57	0.04	-	-	0.52	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.33
H3335_016_0	2007	2																					1500																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	305.54	4.43	1047.03	0	216.37	54396.48	56.17	662.63	632.51	4136.28	2095.82	0	1079.39	3380.42	4262.84	5688.7	163.44	1438.32	4516.62	20346.66	850.31	485.59	0	0	327.1	0	149.23	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											522.96	387.4	19.42	0	100	0.29	12.87	48.24	34.89	2.09	11.19	0	6.06	6.87	3.62	5.18	5.09	1.6	3.49	2.72	13.32	3.27	0	0	15	0	1.99	0	0	0	0											13.32	0.14	1.69	-	1.8	1.32	0.06	2.66	1.84	0.72	1.95	-	0.54	1.94	1.29	2.46	0.07	0.19	1.32	4.61	0.94	0.13	-	-	0.41	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.43	0	20.14	13.32	0.14	1.69	-	1.8	1.32	0.06	2.66	1.84	0.72	1.95	-	0.54	1.94	1.29	2.46	0.07	0.19	1.32	4.61	0.94	0.13	-	-	0.41	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.43	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.24	0.02	0.28	0.18	0.09	0.17	0.01	0.14	0.24	0.09	0.26	0	0.07	0.25	0.59	0.57	0.01	0.05	0.17	0.65	0.12	0.01	0	0	0.04	0	0.02	0	0	0	0											6.28	0	0.61	15.55	0.17	1.98	0.18	1.9	1.49	0.07	2.81	2.08	0.81	2.21	-	0.62	2.19	1.87	3.02	0.08	0.24	1.49	5.26	1.07	0.14	-	-	0.44	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.71
H3335_017_0	2007	4																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	261.14	3.78	1057.83	0	218.58	54396.48	56.17	661.55	626.12	0	1326.65	0	359.8	390.73	4004.49	4776.09	148.58	435.85	808.6	1692.97	807.37	13.19	0	0	316.55	0	135.66	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											250	250	25	0	50	0.93	41.1	48.54	100	0	20	0	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	0											5.44	0.08	2.2	-	0.91	4.21	0.19	2.68	5.22	-	2.21	-	0.6	0.65	5.01	7.96	0.25	0.73	1.35	2.82	1.35	0.02	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.62	0	0	5.44	0.08	2.2	-	0.91	4.21	0.19	2.68	5.22	-	2.21	-	0.6	0.65	5.01	7.96	0.25	0.73	1.35	2.82	1.35	0.02	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.62		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.27	0.02	0.29	0.16	0.05	0.16	0.01	0.14	0.22	0.09	0.23	0	0.07	0.24	0.15	0.28	0.01	0.02	0.15	0.56	0.11	0.01	0	0	0.03	0	0	0	0	0	0											5.29	0	0.88	7.71	0.1	2.49	0.16	0.96	4.37	0.2	2.82	5.44	0.09	2.44	-	0.67	0.89	5.16	8.24	0.26	0.75	1.5	3.38	1.46	0.04	-	-	0.56	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.91
H3335_018_0	2007	4																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	261.4	3.79	1057.83	0	218.58	54396.48	56.17	662.63	634.43	0	1344.29	0	360.7	391.72	4305.9	4928.73	153.53	450.38	819.35	1710.98	815.96	13.19	0	0	327.1	0	140.18	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											200	200	25	0	50	0.93	41.1	48.24	35	0	15	0	15	15	5	15	15	15	15	15	15	15	0	0	15	0	15	0	0	0	0											4.36	0.06	2.2	-	0.91	4.21	0.19	2.66	1.85	-	1.68	-	0.45	0.49	1.79	6.16	0.19	0.56	1.02	2.14	1.02	0.02	-	-	0.41	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.56	0	0	4.36	0.06	2.2	-	0.91	4.21	0.19	2.66	1.85	-	1.68	-	0.45	0.49	1.79	6.16	0.19	0.56	1.02	2.14	1.02	0.02	-	-	0.41	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.56		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.27	0.02	0.29	0.18	0.05	0.17	0.01	0.14	0.24	0.1	0.25	0	0.07	0.21	0.59	0.54	0.01	0.05	0.17	0.66	0.12	0.02	0	0	0.04	0	0.02	0	0	0	0											6.2	0	0.56	6.63	0.09	2.49	0.18	0.96	4.38	0.2	2.81	2.09	0.1	1.93	-	0.52	0.7	2.39	6.7	0.2	0.61	1.19	2.79	1.14	0.03	-	-	0.44	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.76
H3335_019_0	2007	3																					1500																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	285.36	4.13	1099.62	0	234.69	59001.66	60.93	688.27	655.45	4286.31	2171.84	0	1118.54	3503.03	4623.73	6170.3	177.27	1560.09	4899	22069.2	922.3	526.7	0	0	354.79	0	161.86	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											529.45	392.22	19.23	0	100	0.29	12.75	48.17	34.55	2.07	11.08	0	6	6.8	3.59	5.15	5.04	1.59	3.46	2.69	13.19	3.25	0	0	15	0	1.97	0	0	0	0											12.59	0.14	1.76	-	1.96	1.42	0.06	2.76	1.89	0.74	2	-	0.56	1.99	1.38	2.65	0.07	0.21	1.41	4.95	1.01	0.14	-	-	0.44	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.16	0	20.9	12.59	0.14	1.76	-	1.96	1.42	0.06	2.76	1.89	0.74	2	-	0.56	1.99	1.38	2.65	0.07	0.21	1.41	4.95	1.01	0.14	-	-	0.44	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.16	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.14	0.02	0.3	0.14	0.1	0.18	0.01	0.15	0.25	0.1	0.26	0	0.07	0.26	0.64	0.62	0.01	0.06	0.18	0.7	0.13	0.01	0	0	0.04	0	0.02	0	0	0	0											6.38	0	0.67	14.73	0.16	2.06	0.14	2.06	1.6	0.07	2.91	2.13	0.83	2.27	-	0.63	2.24	2.02	3.26	0.08	0.26	1.6	5.65	1.15	0.16	-	-	0.48	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.54
H3335_020_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	243.89	3.53	1110.96	0	237.09	59001.66	60.93	687.11	648.83	0	1374.77	0	372.85	404.9	4343.51	5180.43	161.16	472.75	877.05	1836.3	875.72	14.31	0	0	343.34	0	147.15	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											250	250	25	0	50	0.93	41.1	48.48	100	0	20	0	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	0											5.08	0.07	2.31	-	0.99	4.56	0.21	2.78	5.41	-	2.29	-	0.62	0.67	5.43	8.63	0.27	0.79	1.46	3.06	1.46	0.02	-	-	0.57	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.94	0	0	5.08	0.07	2.31	-	0.99	4.56	0.21	2.78	5.41	-	2.29	-	0.62	0.67	5.43	8.63	0.27	0.79	1.46	3.06	1.46	0.02	-	-	0.57	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.94		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.17	0.02	0.3	0.13	0.05	0.17	0.01	0.15	0.23	0.09	0.23	0	0.07	0.24	0.16	0.3	0.01	0.02	0.16	0.6	0.12	0.01	0	0	0.03	0	0	0	0	0	0											5.29	0	0.98	7.25	0.1	2.62	0.13	1.04	4.74	0.22	2.92	5.63	0.09	2.52	-	0.69	0.92	5.59	8.94	0.28	0.81	1.63	3.66	1.58	0.04	-	-	0.6	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.23
H3335_021_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	244.14	3.54	1110.96	0	237.09	59001.66	60.93	688.27	657.44	0	1393.05	0	373.79	405.93	4670.44	5346	166.53	488.51	888.71	1855.84	885.04	14.31	0	0	354.79	0	152.05	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											200	200	25	0	50	0.93	41.1	48.17	35	0	15	0	15	15	5	15	15	15	15	15	15	15	0	0	15	0	15	0	0	0	0											4.07	0.06	2.31	-	0.99	4.56	0.21	2.76	1.92	-	1.74	-	0.47	0.51	1.95	6.68	0.21	0.61	1.11	2.32	1.11	0.02	-	-	0.44	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.23	0	0	4.07	0.06	2.31	-	0.99	4.56	0.21	2.76	1.92	-	1.74	-	0.47	0.51	1.95	6.68	0.21	0.61	1.11	2.32	1.11	0.02	-	-	0.44	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.23		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.17	0.02	0.3	0.15	0.05	0.19	0.01	0.15	0.25	0.1	0.25	0	0.07	0.21	0.64	0.59	0.01	0.05	0.18	0.7	0.13	0.02	0	0	0.04	0	0.02	0	0	0	0											6.3	0	0.62	6.24	0.08	2.62	0.15	1.04	4.75	0.22	2.91	2.17	0.1	2	-	0.54	0.72	2.59	7.27	0.22	0.66	1.29	3.02	1.23	0.03	-	-	0.48	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.53
H3335_031_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2500	0	0	1671.53	0	227.37	56584.41	58.43	636.71	603.99	0	1279.8	0	343.4	372.93	4666.08	5537.09	169.38	496.86	942.56	1887.54	900.16	14.89	0	0	369.23	0	158.24	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											0	0	25	0	50	1.01	44.59	47.94	35	0	15	0	15	15	10	15	15	15	15	15	15	15	0	0	15	0	15	0	0	0	0											-	-	3.48	-	0.95	4.75	0.22	2.54	1.76	-	1.6	-	0.43	0.47	3.89	6.92	0.21	0.62	1.18	2.36	1.13	0.02	-	-	0.46	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.18	0	0	-	-	3.48	-	0.95	4.75	0.22	2.54	1.76	-	1.6	-	0.43	0.47	3.89	6.92	0.21	0.62	1.18	2.36	1.13	0.02	-	-	0.46	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.18		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.51	0.03	0.51	0.31	0.05	0.19	0.01	0.14	0.21	0.08	0.22	0	0.06	0.18	0.64	0.61	0.01	0.05	0.23	0.76	0.13	0.02	0	0	0.04	0	0.02	0	0	0	0											7	0	0.77	2.51	0.03	3.99	0.31	1	4.94	0.23	2.68	1.97	0.08	1.81	-	0.49	0.65	4.53	7.53	0.22	0.68	1.41	3.12	1.26	0.04	-	-	0.5	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.18
H3335_032_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	248.8	3.61	1671.53	0	227.37	56584.41	58.43	635.5	596.08	0	1263	0	342.53	371.99	4520.27	5365.81	163.91	480.83	930.19	1867.68	890.68	14.89	0	0	357.32	0	153.14	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											100	100	25	0	50	1.01	44.59	48.29	100	0	20	0	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	0											2.07	0.03	3.48	-	0.95	4.75	0.22	2.56	4.97	-	2.11	-	0.57	0.62	5.65	8.94	0.27	0.8	1.55	3.11	1.48	0.02	-	-	0.6	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.01	0	0	2.07	0.03	3.48	-	0.95	4.75	0.22	2.56	4.97	-	2.11	-	0.57	0.62	5.65	8.94	0.27	0.8	1.55	3.11	1.48	0.02	-	-	0.6	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 14											2.5	0.03	0.51	0.3	0.05	0.18	0.01	0.13	0.21	0.08	0.21	0	0.06	0.22	0.19	0.33	0.01	0.03	0.23	0.7	0.13	0.02	0	0	0.03	0	0	0	0	0	0											6.15	0	0.98	4.58	0.06	3.99	0.3	1	4.93	0.23	2.69	5.17	0.08	2.32	-	0.63	0.84	5.84	9.27	0.28	0.83	1.78	3.81	1.61	0.04	-	-	0.63	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.16
H3335_801_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1649.81	34.82	1562.26	0	229.11	56447.35	58.29	469.5	386.18	2525.4	1279.6	0	659.02	2063.91	5925.23	6597.25	206.32	1815.74	5635.07	25894.14	1073.44	610.95	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				116.1	59.04	57.9	0	79.32	0.61	48.79	76.88	150.29	7.92	42.5	0	26.1	29.59	11.87	16.32	20.43	6.44	13.91	10.36	53.46	12.29	0	0	0	0	0	0	0	0	0											15.96	0.17	7.54	-	1.51	2.85	0.24	3.01	4.84	1.67	4.53	-	1.43	5.09	5.86	8.97	0.35	0.97	6.53	22.36	4.78	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.3	138	0	15.96	0.17	7.54	-	1.51	2.85	0.24	3.01	4.84	1.67	4.53	-	1.43	5.09	5.86	8.97	0.35	0.97	6.53	22.36	4.78	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.3		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.88	0.01	0.44	0	0.08	0.27	0.01	0.06	0.25	0.1	0.27	0	0.08	0.27	0.3	0.45	0.02	0.05	0.39	1.2	0.24	0.03	0	0	0	0	0	0	0	0	0											5.4	0	0	16.84	0.18	7.98	-	1.59	3.12	0.25	3.06	5.09	1.77	4.8	-	1.51	5.36	6.16	9.43	0.37	1.02	6.93	23.55	5.02	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.69
H3335_802_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1898.64	40.08	1773.75	0	243.04	59879.21	61.83	425.66	346.38	2265.13	1147.72	0	591.1	1851.2	5999.29	6764.33	219.1	1928.16	5369.83	30276.25	1139.9	648.05	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				115.52	58.74	71.59	0	75.43	1.05	46.4	30.84	174.22	10.42	55.87	0	30.25	34.3	10.82	14.8	18.62	5.87	16.4	9.29	48.71	11.13	0	0	0	0	0	0	0	0	0											18.28	0.2	10.58	-	1.53	5.23	0.24	1.09	5.03	1.97	5.34	-	1.49	5.29	5.41	8.35	0.34	0.94	7.34	23.43	4.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.3	138	0	18.28	0.2	10.58	-	1.53	5.23	0.24	1.09	5.03	1.97	5.34	-	1.49	5.29	5.41	8.35	0.34	0.94	7.34	23.43	4.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.3		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.96	0.01	0.56	0	0.08	0.28	0.01	0.06	0.26	0.1	0.28	0	0.08	0.28	0.28	0.44	0.02	0.05	0.39	1.23	0.24	0.03	0	0	0	0	0	0	0	0	0											5.65	0	0	19.24	0.21	11.14	-	1.61	5.51	0.25	1.15	5.29	2.07	5.62	-	1.57	5.57	5.69	8.78	0.36	0.99	7.73	24.67	4.87	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	112.95
H3335_803_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1582.37	33.4	1161.32	0	202.81	49965.71	51.59	648.38	548.13	3584.47	1816.22	0	935.39	2929.44	5696.95	6207.91	182.09	1602.47	5100.64	22743.4	947.36	540.34	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				115.34	58.65	63.77	0	79.62	1.11	48.98	24.33	133.48	7.98	42.8	0	23.18	26.28	10.7	14.83	18.4	5.8	13.44	10.48	48.16	11.19	0	0	0	0	0	0	0	0	0											15.21	0.16	6.17	-	1.35	4.61	0.21	1.31	6.1	2.38	6.48	-	1.81	6.42	5.08	7.67	0.28	0.77	5.71	19.86	3.8	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.88	138	0	15.21	0.16	6.17	-	1.35	4.61	0.21	1.31	6.1	2.38	6.48	-	1.81	6.42	5.08	7.67	0.28	0.77	5.71	19.86	3.8	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.88		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.8	0.01	0.32	0	0.07	0.24	0.01	0.07	0.32	0.13	0.34	0	0.1	0.34	0.27	0.4	0.01	0.04	0.3	1.05	0.2	0.03	0	0	0	0	0	0	0	0	0											5.05	0	0	16.01	0.17	6.5	-	1.42	4.85	0.22	1.38	6.42	2.51	6.82	-	1.9	6.75	5.34	8.07	0.29	0.82	6.02	20.9	4	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.93
H3335_805_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1557.21	32.87	1442.88	0	241.93	59604.71	61.55	379.16	302.94	1981.08	1003.8	0	516.97	1619.06	6282.57	7070.51	227.85	2005.18	5597.3	30730.2	1185.44	674.05	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				126.1	64.13	65.96	0	79.84	1.11	49.11	29.55	168.46	10.07	54.02	0	29.25	33.17	10.74	14.71	18.49	5.83	15.68	9.02	48.37	11.06	0	0	0	0	0	0	0	0	0											16.36	0.18	7.93	-	1.61	5.51	0.25	0.93	4.25	1.66	4.52	-	1.26	4.48	5.62	8.67	0.35	0.97	7.32	23.09	4.78	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.37	138	0	16.36	0.18	7.93	-	1.61	5.51	0.25	0.93	4.25	1.66	4.52	-	1.26	4.48	5.62	8.67	0.35	0.97	7.32	23.09	4.78	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.37		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.86	0.01	0.42	0	0.08	0.29	0.01	0.05	0.22	0.09	0.24	0	0.07	0.24	0.3	0.46	0.02	0.05	0.39	1.22	0.25	0.03	0	0	0	0	0	0	0	0	0											5.28	0	0	17.23	0.18	8.35	-	1.69	5.8	0.27	0.98	4.48	1.75	4.76	-	1.33	4.71	5.92	9.12	0.37	1.03	7.7	24.31	5.03	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.65
H3335_806_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1788.82	37.76	1083.09	0	221.54	54581.48	56.36	749.76	641.07	4192.27	2124.19	0	1094	3426.18	5374.24	5805.43	165.65	1457.79	4587.36	21148.83	861.82	492.03	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				118.12	60.07	64.97	0	78.83	1.1	48.49	24.12	131.44	7.86	42.15	0	22.82	25.88	11.14	15.5	19.18	6.05	13.15	10.57	50.18	11.72	0	0	0	0	0	0	0	0	0											17.61	0.19	5.86	-	1.46	4.98	0.23	1.51	7.02	2.75	7.46	-	2.08	7.39	4.99	7.5	0.26	0.73	5.03	18.62	3.6	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.75	138	0	17.61	0.19	5.86	-	1.46	4.98	0.23	1.51	7.02	2.75	7.46	-	2.08	7.39	4.99	7.5	0.26	0.73	5.03	18.62	3.6	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.75		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.93	0.01	0.31	0	0.08	0.26	0.01	0.08	0.37	0.14	0.39	0	0.11	0.39	0.26	0.39	0.01	0.04	0.26	0.98	0.19	0.03	0	0	0	0	0	0	0	0	0											5.25	0	0	18.53	0.2	6.17	-	1.53	5.24	0.24	1.59	7.39	2.89	7.85	-	2.19	7.78	5.25	7.89	0.28	0.77	5.29	19.6	3.79	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105
H3335_807_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1643.96	34.7	1117.95	0	236.17	58185.31	60.08	765.3	652.91	4269.7	2163.42	0	1114.2	3489.46	5729.09	6188.74	176.59	1554.04	4890.24	22545.22	918.73	524.51	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				118.09	60.05	63.55	0	78.83	1.1	48.49	24.1	131.44	7.86	42.15	0	22.82	25.88	11.14	15.5	19.18	6.05	13.15	10.57	50.18	11.72	0	0	0	0	0	0	0	0	0											16.18	0.17	5.92	-	1.55	5.31	0.24	1.54	7.15	2.8	7.6	-	2.12	7.53	5.32	7.99	0.28	0.78	5.36	19.85	3.84	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.05	138	0	16.18	0.17	5.92	-	1.55	5.31	0.24	1.54	7.15	2.8	7.6	-	2.12	7.53	5.32	7.99	0.28	0.78	5.36	19.85	3.84	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.05		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.85	0.01	0.31	0	0.08	0.28	0.01	0.08	0.38	0.15	0.4	0	0.11	0.4	0.28	0.42	0.01	0.04	0.28	1.04	0.2	0.03	0	0	0	0	0	0	0	0	0											5.37	0	0	17.03	0.18	6.23	-	1.63	5.59	0.26	1.62	7.53	2.94	8	-	2.23	7.92	5.6	8.41	0.3	0.82	5.64	20.89	4.04	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.42
H3335_811_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1773.73	37.44	1669.99	0	224.87	55401.56	57.21	702.66	595.53	3894.47	1973.29	0	1016.28	3182.8	5919.5	6360.08	178.32	1569.27	5149.36	23114	927.73	529.98	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				126.38	64.27	66.03	0	85.54	1.19	52.62	23.06	125.77	7.52	40.33	0	21.84	24.76	11.71	16.32	20.15	6.35	16.76	11.49	52.72	12.35	0	0	0	0	0	0	0	0	0											18.68	0.2	9.19	-	1.6	5.49	0.25	1.35	6.24	2.44	6.63	-	1.85	6.57	5.78	8.65	0.3	0.83	7.19	22.13	4.08	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.99	138	0	18.68	0.2	9.19	-	1.6	5.49	0.25	1.35	6.24	2.44	6.63	-	1.85	6.57	5.78	8.65	0.3	0.83	7.19	22.13	4.08	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.99		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.98	0.01	0.48	0	0.08	0.29	0.01	0.07	0.33	0.13	0.35	0	0.1	0.35	0.3	0.46	0.02	0.04	0.38	1.16	0.21	0.03	0	0	0	0	0	0	0	0	0											5.79	0	0	19.66	0.21	9.67	-	1.69	5.78	0.26	1.42	6.57	2.57	6.98	-	1.95	6.91	6.08	9.1	0.32	0.87	7.57	23.29	4.29	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.78
H3335_813_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1649.81	34.82	1562.26	0	229.11	56447.35	58.29	469.5	386.18	2525.4	1279.6	0	659.02	2063.91	5925.23	6597.25	206.32	1815.74	5635.07	25894.14	1073.44	610.95	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				116.1	59.04	57.9	0	79.32	0.61	48.79	76.88	150.29	7.92	42.5	0	26.1	29.59	11.87	16.32	20.43	6.44	13.91	10.36	53.46	12.29	0	0	0	0	0	0	0	0	0											15.96	0.17	7.54	-	1.51	2.85	0.24	3.01	4.84	1.67	4.53	-	1.43	5.09	5.86	8.97	0.35	0.97	6.53	22.36	4.78	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.3	138	0	15.96	0.17	7.54	-	1.51	2.85	0.24	3.01	4.84	1.67	4.53	-	1.43	5.09	5.86	8.97	0.35	0.97	6.53	22.36	4.78	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.3		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.88	0.01	0.44	0	0.08	0.27	0.01	0.06	0.25	0.1	0.27	0	0.08	0.27	0.3	0.45	0.02	0.05	0.39	1.2	0.24	0.03	0	0	0	0	0	0	0	0	0											5.4	0	0	16.84	0.18	7.98	-	1.59	3.12	0.25	3.06	5.09	1.77	4.8	-	1.51	5.36	6.16	9.43	0.37	1.02	6.93	23.55	5.02	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.69
H3335_814_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1898.64	40.08	1773.75	0	243.04	59879.21	61.83	425.66	346.38	2265.13	1147.72	0	591.1	1851.2	5999.29	6764.33	219.1	1928.16	5369.83	30276.25	1139.9	648.05	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				115.52	58.74	71.59	0	75.43	1.05	46.4	30.84	174.22	10.42	55.87	0	30.25	34.3	10.82	14.8	18.62	5.87	16.4	9.29	48.71	11.13	0	0	0	0	0	0	0	0	0											18.28	0.2	10.58	-	1.53	5.23	0.24	1.09	5.03	1.97	5.34	-	1.49	5.29	5.41	8.35	0.34	0.94	7.34	23.43	4.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.3	138	0	18.28	0.2	10.58	-	1.53	5.23	0.24	1.09	5.03	1.97	5.34	-	1.49	5.29	5.41	8.35	0.34	0.94	7.34	23.43	4.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.3		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.96	0.01	0.56	0	0.08	0.28	0.01	0.06	0.26	0.1	0.28	0	0.08	0.28	0.28	0.44	0.02	0.05	0.39	1.23	0.24	0.03	0	0	0	0	0	0	0	0	0											5.65	0	0	19.24	0.21	11.14	-	1.61	5.51	0.25	1.15	5.29	2.07	5.62	-	1.57	5.57	5.69	8.78	0.36	0.99	7.73	24.67	4.87	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	112.95
H3335_815_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1582.37	33.4	1161.32	0	202.81	49965.71	51.59	648.38	548.13	3584.47	1816.22	0	935.39	2929.44	5696.95	6207.91	182.09	1602.47	5100.64	22743.4	947.36	540.34	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				115.34	58.65	63.77	0	79.62	1.11	48.98	24.33	133.48	7.98	42.8	0	23.18	26.28	10.7	14.83	18.4	5.8	13.44	10.48	48.16	11.19	0	0	0	0	0	0	0	0	0											15.21	0.16	6.17	-	1.35	4.61	0.21	1.31	6.1	2.38	6.48	-	1.81	6.42	5.08	7.67	0.28	0.77	5.71	19.86	3.8	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.88	138	0	15.21	0.16	6.17	-	1.35	4.61	0.21	1.31	6.1	2.38	6.48	-	1.81	6.42	5.08	7.67	0.28	0.77	5.71	19.86	3.8	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.88		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.8	0.01	0.32	0	0.07	0.24	0.01	0.07	0.32	0.13	0.34	0	0.1	0.34	0.27	0.4	0.01	0.04	0.3	1.05	0.2	0.03	0	0	0	0	0	0	0	0	0											5.05	0	0	16.01	0.17	6.5	-	1.42	4.85	0.22	1.38	6.42	2.51	6.82	-	1.9	6.75	5.34	8.07	0.29	0.82	6.02	20.9	4	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.93
H3335_816_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1557.21	32.87	1442.88	0	241.93	59604.71	61.55	379.16	302.94	1981.08	1003.8	0	516.97	1619.06	6282.57	7070.51	227.85	2005.18	5597.3	30730.2	1185.44	674.05	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				126.1	64.13	65.96	0	79.84	1.11	49.11	29.55	168.46	10.07	54.02	0	29.25	33.17	10.74	14.71	18.49	5.83	15.68	9.02	48.37	11.06	0	0	0	0	0	0	0	0	0											16.36	0.18	7.93	-	1.61	5.51	0.25	0.93	4.25	1.66	4.52	-	1.26	4.48	5.62	8.67	0.35	0.97	7.32	23.09	4.78	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.37	138	0	16.36	0.18	7.93	-	1.61	5.51	0.25	0.93	4.25	1.66	4.52	-	1.26	4.48	5.62	8.67	0.35	0.97	7.32	23.09	4.78	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.37		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.86	0.01	0.42	0	0.08	0.29	0.01	0.05	0.22	0.09	0.24	0	0.07	0.24	0.3	0.46	0.02	0.05	0.39	1.22	0.25	0.03	0	0	0	0	0	0	0	0	0											5.28	0	0	17.23	0.18	8.35	-	1.69	5.8	0.27	0.98	4.48	1.75	4.76	-	1.33	4.71	5.92	9.12	0.37	1.03	7.7	24.31	5.03	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.65
H3335_817_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1788.82	37.76	1083.09	0	221.54	54581.48	56.36	749.76	641.07	4192.27	2124.19	0	1094	3426.18	5374.24	5805.43	165.65	1457.79	4587.36	21148.83	861.82	492.03	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				118.12	60.07	64.97	0	78.83	1.1	48.49	24.12	131.44	7.86	42.15	0	22.82	25.88	11.14	15.5	19.18	6.05	13.15	10.57	50.18	11.72	0	0	0	0	0	0	0	0	0											17.61	0.19	5.86	-	1.46	4.98	0.23	1.51	7.02	2.75	7.46	-	2.08	7.39	4.99	7.5	0.26	0.73	5.03	18.62	3.6	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.75	138	0	17.61	0.19	5.86	-	1.46	4.98	0.23	1.51	7.02	2.75	7.46	-	2.08	7.39	4.99	7.5	0.26	0.73	5.03	18.62	3.6	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.75		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.93	0.01	0.31	0	0.08	0.26	0.01	0.08	0.37	0.14	0.39	0	0.11	0.39	0.26	0.39	0.01	0.04	0.26	0.98	0.19	0.03	0	0	0	0	0	0	0	0	0											5.25	0	0	18.53	0.2	6.17	-	1.53	5.24	0.24	1.59	7.39	2.89	7.85	-	2.19	7.78	5.25	7.89	0.28	0.77	5.29	19.6	3.79	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105
H3335_818_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1643.96	34.7	1117.95	0	236.17	58185.31	60.08	765.3	652.91	4269.7	2163.42	0	1114.2	3489.46	5729.09	6188.74	176.59	1554.04	4890.24	22545.22	918.73	524.51	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				118.09	60.05	63.55	0	78.83	1.1	48.49	24.1	131.44	7.86	42.15	0	22.82	25.88	11.14	15.5	19.18	6.05	13.15	10.57	50.18	11.72	0	0	0	0	0	0	0	0	0											16.18	0.17	5.92	-	1.55	5.31	0.24	1.54	7.15	2.8	7.6	-	2.12	7.53	5.32	7.99	0.28	0.78	5.36	19.85	3.84	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.05	138	0	16.18	0.17	5.92	-	1.55	5.31	0.24	1.54	7.15	2.8	7.6	-	2.12	7.53	5.32	7.99	0.28	0.78	5.36	19.85	3.84	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.05		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.85	0.01	0.31	0	0.08	0.28	0.01	0.08	0.38	0.15	0.4	0	0.11	0.4	0.28	0.42	0.01	0.04	0.28	1.04	0.2	0.03	0	0	0	0	0	0	0	0	0											5.37	0	0	17.03	0.18	6.23	-	1.63	5.59	0.26	1.62	7.53	2.94	8	-	2.23	7.92	5.6	8.41	0.3	0.82	5.64	20.89	4.04	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.42
H3335_819_0	2007	2																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1773.73	37.44	1669.99	0	224.87	55401.56	57.21	702.66	595.53	3894.47	1973.29	0	1016.28	3182.8	5919.5	6360.08	178.32	1569.27	5149.36	23114	927.73	529.98	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				126.38	64.27	66.03	0	85.54	1.19	52.62	23.06	125.77	7.52	40.33	0	21.84	24.76	11.71	16.32	20.15	6.35	16.76	11.49	52.72	12.35	0	0	0	0	0	0	0	0	0											18.68	0.2	9.19	-	1.6	5.49	0.25	1.35	6.24	2.44	6.63	-	1.85	6.57	5.78	8.65	0.3	0.83	7.19	22.13	4.08	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.99	138	0	18.68	0.2	9.19	-	1.6	5.49	0.25	1.35	6.24	2.44	6.63	-	1.85	6.57	5.78	8.65	0.3	0.83	7.19	22.13	4.08	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.99		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.98	0.01	0.48	0	0.08	0.29	0.01	0.07	0.33	0.13	0.35	0	0.1	0.35	0.3	0.46	0.02	0.04	0.38	1.16	0.21	0.03	0	0	0	0	0	0	0	0	0											5.79	0	0	19.66	0.21	9.67	-	1.69	5.78	0.26	1.42	6.57	2.57	6.98	-	1.95	6.91	6.08	9.1	0.32	0.87	7.57	23.29	4.29	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.78
H3336_001_0	2007	13																					UNLIMITED											D	D	D		T	COIN		V		P	P			V		V	COIN	V		V							P																																																								-	0	2020.45	150.25	1055.7		792.68	4.28		645.77		4242	2121			60.6		3485	6.69	701.95		646.4							48.96															40 days 1-15	40 days 1-15	60 days 1-30		40 per trip	10 coinsurance		50 per ER Visit / 25 per UR Visit		5 per procedure	5 per procedure			25 per Substance Abuse visit		10 per visit	50 coinsurance	10 per visit		15 Chiro copay/ 10 Podiatry							15 per procedure															37.2	37.2	57.62		40	0.1		48.87		5	5			25		10	0.5	10		11.32							15															6.26	0.47	5.07	-	2.64	0.43	-	2.63	-	1.77	0.88	-	-	0.13	-	2.9	3.35	0.58	-	0.61	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.78	0	0	6.26	0.47	5.07	-	2.64	0.43	-	2.63	-	1.77	0.88	-	-	0.13	-	2.9	3.35	0.58	-	0.61	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.78																																																																																				-		0	6.26	0.47	5.07	-	2.64	0.43	-	2.63	-	1.77	0.88	-	-	0.13	-	2.9	3.35	0.58	-	0.61	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.78
H3336_003_0	2007	10																					UNLIMITED																		V						V		V	V	V		V																																																															-	0								1070.47						339.36		5996.37	2267.45	2793.66		1403.9																													50 copay ER/ 10 UR						20 copay Substance Abuse		10 copay	20 copay	10 copay		10 chiro copay/ 10 podiatry																													47.19						20		10	20	10		10																						-	-	-	-	-	-	-	4.21	-	-	-	-	-	0.57	-	5	3.78	2.33	-	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.05		0	-	-	-	-	-	-	-	4.21	-	-	-	-	-	0.57	-	5	3.78	2.33	-	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.05																																																																																				-		0	-	-	-	-	-	-	-	4.21	-	-	-	-	-	0.57	-	5	3.78	2.33	-	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.05
H3336_004_0	2007	4																					UNLIMITED											D	D	D		T	COIN		V		P	P			V		V	V	V		V							P																																																								-		2302.91	169.78	1333.2		872.3	6.46		710.34		4666.2	2333.1			66.66		3999.6	749.93	772.15		711.04							54.35															40 days 1-15	40 days 1-15	50 days 1-30		40 per trip	10 coinsurance		50 per ER Visit / 25 per UR Visit		5 per procedure	5 per procedure			25 per visit		10 per visit	50 coinsurance	10 per visit		15 Chiro copay/ 10 Podiatry							15 per procedure															37.2	37.2	48.02		40	0.1		48.99		5	5			25		10	58.89	10		11.31							15															7.14	0.53	5.33	-	2.91	0.65	-	2.9	-	1.94	0.97	-	-	0.14	-	3.33	3.68	0.64	-	0.67	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.9		0	7.14	0.53	5.33	-	2.91	0.65	-	2.9	-	1.94	0.97	-	-	0.14	-	3.33	3.68	0.64	-	0.67	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.9																																																																																				-		0	7.14	0.53	5.33	-	2.91	0.65	-	2.9	-	1.94	0.97	-	-	0.14	-	3.33	3.68	0.64	-	0.67	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.9
H3336_006_0	2007	7																					UNLIMITED											D	D	D		COIN			V	COIN			COIN	COIN																																																																						-	0	2921.13	161.47	1031.19		11.56			1070.47	17.31			6.74	2.78																													Medicare covered benefit only	Medicare covered benefit only	Medicare covered benefit only		20 coinsurance			50 ER/ 20 coinsurance UR	20 coinsurance			20 coinsurance	20 coinsurance																													155.7	155.7	74.55		0.2			47.98	0.2			0.2	0.2																													37.9	2.1	6.41	-	2.31	-	-	4.28	3.46	-	-	1.35	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.36	0	0	37.9	2.1	6.41	-	2.31	-	-	4.28	3.46	-	-	1.35	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.36																																																																																				-	0	0	37.9	2.1	6.41	-	2.31	-	-	4.28	3.46	-	-	1.35	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.36
H3336_007_0	2007	4																					UNLIMITED											D	D	D		COIN			V	COIN			COIN	COIN																																																																						-	0	2921.13	161.47	1031.19		11.56			1070.47	17.31			6.74	2.78																													Medicare covered benefit only	Medicare covered benefit only	Medicare covered benefit only		20 coinsurance			50 ER/ 20 coinsurance UR	20 coinsurance			20 coinsurance	20 coinsurance																													155.7	155.7	74.55		0.2			47.98	0.2			0.2	0.2																													37.9	2.1	6.41	-	2.31	-	-	4.28	3.46	-	-	1.35	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.36			37.9	2.1	6.41	-	2.31	-	-	4.28	3.46	-	-	1.35	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.36																																																																																				-			37.9	2.1	6.41	-	2.31	-	-	4.28	3.46	-	-	1.35	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.36
H3337_001_0	2007	3																					none													D		T	Coin	Coin	V					Coin	V			V	V		V							V																																																								-	none			90		160	10.02	0.87	190					0.65	210			630	210		35							100																	0 0-20 days. 25 after		50 co-pay/trip	20 co-insurance	20 co-insurance	50 co-pay/visit					20 co-insurance	20 co-pay/visit			20 co-pay/visit	20 co-pay/visit		50 co-pay/visit							20 co-pay/visit																	25		50	0.2	0.2	50					0.2	20			20	20		50							20															-	-	0.19	-	0.67	2	0.17	0.79	-	-	-	-	0.13	0.35	-	-	1.05	0.35	-	0.15	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.02	6.02	0	-	-	0.19	-	0.67	2	0.17	0.79	-	-	-	-	0.13	0.35	-	-	1.05	0.35	-	0.15	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.02	none																																																																																			-	0	0	-	-	0.19	-	0.67	2	0.17	0.79	-	-	-	-	0.13	0.35	-	-	1.05	0.35	-	0.15	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.02
H3337_002_0	2007	5																					none																		V						V		V	V	V		V							V																																																								-	none								280						210		4000	630	335		2040																													50 co-pay /visit						20 co-pay /visit		10 co-pay /visit	20 co-pay /visit	10 co-pay /visit		10 co-pay /visit																													50						20		10	20	10		10																						-	-	-	-	-	-	-	1.17	-	-	-	-	-	0.35	-	3.33	1.05	0.28	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.88			-	-	-	-	-	-	-	1.17	-	-	-	-	-	0.35	-	3.33	1.05	0.28	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.88	none																																																																																			-			-	-	-	-	-	-	-	1.17	-	-	-	-	-	0.35	-	3.33	1.05	0.28	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.88
H3337_003_0	2007	5																					none																		V						V		V	V	V		V																																																															-	none								240						210		4000	630	130		2040																													50 co-pay/visit						20 co-pay/visit		10 co-pay/visit	20 co-pay/visit	10 co-pay/visit		10 co-pay/visit																													50						20		10	20	10		10																						-	-	-	-	-	-	-	1	-	-	-	-	-	0.35	-	3.33	1.05	0.11	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.54			-	-	-	-	-	-	-	1	-	-	-	-	-	0.35	-	3.33	1.05	0.11	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.54	none																																																																																			-			-	-	-	-	-	-	-	1	-	-	-	-	-	0.35	-	3.33	1.05	0.11	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.54
H3337_004_0	2007	4											Respite Care										none											D	D	D		T	Coin	Coin	V					Coin	V			V	V		V							V					O																																																			-	none	1200	16.2	90		160	0	0.87	190					0.65	210			630	210		35							100					100										150 0-9 days	150 0-9 days	0 0-100 days. Max 100 days limit		50 co-pay/trip	0-500 0; >500 10 co-insurance	20 co-insurance	50 co-pay/visit					20 co-insurance	20 co-pay/visit			20 co-pay/visit	20 co-pay/visit		50 co-pay/visit							20 co-pay/visit					0 0-2hrs/wk										150	150			50	0.1	0.2	50					0.2	20			20	20		50							20															15	0.2	-	-	0.67	-	0.17	0.79	-	-	-	-	0.13	0.35	-	-	1.05	0.35	-	0.15	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.03	19.03	0	15	0.2	-	-	0.67	-	0.17	0.79	-	-	-	-	0.13	0.35	-	-	1.05	0.35	-	0.15	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.03	none																																																																																			-	0	0	15	0.2	-	-	0.67	-	0.17	0.79	-	-	-	-	0.13	0.35	-	-	1.05	0.35	-	0.15	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.03
H3340_001_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	433.54	0	0	0	0	0	236.83	0	11589.43	1673.21	755.84	0	1313.65	0	0	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 0 per day (unlimited days)	1B IP Psych - 0 per day (190 day lifetime limit)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 0	11B Pros./Med Supp. - 0; 11C Diabetes Mon Supplies - 0	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	3 CORF - 10; 5 Partial Hosp - 20; 7C Occupational Therapy - 10; 7I PT and ST Services - 10; 9D Cardiac Rehab Svcs - 10	7A Primary Care - 0; 14B Immunizations - 0; 14C Routine Physical Exams - 0; 14D Pap/Pelvic - 0; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 0	7D Physician Specialist - 10	7E Mental Health - 20; 7H Psychiatric Services - 20; 9C Outpatient Sub Abuse - 20	7C Occupational Therapy - 10; 7I PT and ST Services - 10	8B Outpatient X-Rays - 0	7B Chiropractic Services - 10; 7F Podiatry Services - 10; 7G Other Health Care - 0; 16B Comp Dental - 0; 18A Hearing Exams (Medicare Covered) - 0	15 Medicare Part B Rx Drugs - 0	13A Blood - 0; 17A Eye Exams (Medicare Covered) - 0	10B Transportation - 0	16A Preventative Dental - 0	17A Eye Exams (Routine) - 0	17B Eye Wear - 0	18A Hearing Exams (Routine) - 0	18B Hearing Aids - 0	19 POS - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered; Respite Care - not covered											0	0	0	0	0	0	0	47.98	0	0	0	0	0	10	0	10	20	10	0	10	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.73	-	-	-	-	-	0.2	-	9.66	2.79	0.63	-	1.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.1	0	0	-	-	-	-	-	-	-	1.73	-	-	-	-	-	0.2	-	9.66	2.79	0.63	-	1.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.1	0	PBP: 1A IP Acute - 0 per day (unlimited days)	1B IP Psych - 0 per day (190 day lifetime limit)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 0	11B Pros./Med Supp. - 0; 11C Diabetes Mon Supplies - 0	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	3 CORF - 10; 5 Partial Hosp - 20; 7C Occupational Therapy - 10; 7I PT and ST Services - 10; 9D Cardiac Rehab Svcs - 10	7A Primary Care - 0; 14B Immunizations - 0; 14C Routine Physical Exams - 0; 14D Pap/Pelvic - 0; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 0	7D Physician Specialist - 10	7E Mental Health - 20; 7H Psychiatric Services - 20; 9C Outpatient Sub Abuse - 20	7C Occupational Therapy - 10; 7I PT and ST Services - 10	8B Outpatient X-Rays - 0	7B Chiropractic Services - 10; 7F Podiatry Services - 10; 7G Other Health Care - 0; 16B Comp Dental - 0; 18A Hearing Exams (Medicare Covered) - 0	15 Medicare Part B Rx Drugs - 0	13A Blood - 0; 17A Eye Exams (Medicare Covered) - 0	10B Transportation - 0	16A Preventative Dental - 0	17A Eye Exams (Routine) - 0	17B Eye Wear - 0	18A Hearing Exams (Routine) - 0	18B Hearing Aids - 0	19 POS - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered; Respite Care - not covered											0	0	0	0	0	0	0	0.48	0	0	0	0	0	0.05	0	1.39	0.47	0.11	0	0.21	0	0	0	0	0	0	0	0	0	0	0											2.7	0	0	-	-	-	-	-	-	-	2.21	-	-	-	-	-	0.25	-	11.05	3.25	0.74	-	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.8
H3340_002_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	398.29	0	0	0	0	0	207.97	0	10050.67	1540.45	703.35	0	1280.42	0	0	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 0 per day (unlimited days)	1B IP Psych - 0 per day (190 day lifetime limit)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 0	11B Pros./Med Supp. - 0; 11C Diabetes Mon Supplies - 0	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	3 CORF - 20; 5 Partial Hosp - 20; 7C Occupational Therapy - 20; 7I PT and ST Services - 20; 9D Cardiac Rehab Svcs - 20	7A Primary Care - 0; 14B Immunizations - 0; 14C Routine Physical Exams - 0; 14D Pap/Pelvic - 0; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 0	7D Physician Specialist - 10	7E Mental Health - 20; 7H Psychiatric Services - 20; 9C Outpatient Sub Abuse - 20	7C Occupational Therapy - 20; 7I PT and ST Services - 20	8B Outpatient X-Rays - 0	7B Chiropractic Services - 20; 7F Podiatry Services - 20; 7G Other Health Care - 0; 16B Comp Dental - not covered; 18A Hearing Exams (Medicare Covered) - 0	15 Medicare Part B Rx Drugs - 0	13A Blood - 0; 17A Eye Exams (Medicare Covered) - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - 0	17B Eye Wear - 0	18A Hearing Exams (Routine) - 0	18B Hearing Aids - 0	19 POS - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											0	0	0	0	0	0	0	47.92	0	0	0	0	0	20	0	10	20	20	0	20	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.59	-	-	-	-	-	0.35	-	8.38	2.57	1.17	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.19	0	0	-	-	-	-	-	-	-	1.59	-	-	-	-	-	0.35	-	8.38	2.57	1.17	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.19	0	PBP: 1A IP Acute - 0 per day (unlimited days)	1B IP Psych - 0 per day (190 day lifetime limit)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 0	11B Pros./Med Supp. - 0; 11C Diabetes Mon Supplies - 0	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	3 CORF - 20; 5 Partial Hosp - 20; 7C Occupational Therapy - 20; 7I PT and ST Services - 20; 9D Cardiac Rehab Svcs - 20	7A Primary Care - 0; 14B Immunizations - 0; 14C Routine Physical Exams - 0; 14D Pap/Pelvic - 0; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 0	7D Physician Specialist - 10	7E Mental Health - 20; 7H Psychiatric Services - 20; 9C Outpatient Sub Abuse - 20	7C Occupational Therapy - 20; 7I PT and ST Services - 20	8B Outpatient X-Rays - 0	7B Chiropractic Services - 20; 7F Podiatry Services - 20; 7G Other Health Care - 0; 16B Comp Dental - not covered; 18A Hearing Exams (Medicare Covered) - 0	15 Medicare Part B Rx Drugs - 0	13A Blood - 0; 17A Eye Exams (Medicare Covered) - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - 0	17B Eye Wear - 0	18A Hearing Exams (Routine) - 0	18B Hearing Aids - 0	19 POS - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											0	0	0	0	0	0	0	0.41	0	0	0	0	0	0.08	0	2.37	0.79	0.37	0	0.71	0	0	0	0	0	0	0	0	0	0	0											4.72	0	0	-	-	-	-	-	-	-	2	-	-	-	-	-	0.43	-	10.75	3.36	1.54	-	2.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.91
H3342_001_0	2007	5																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	5000	1752.96		864.36					174.61	258.99						4744.34	7445.31	322.33	1268.83							168.65	184.88					162											#1A 50/day days 1-8 0/day days 9-90	#1B 0	#2 25/day 1-100 days.	#6 0	#10A 0	#11A 0	#11B 0 #11C 0	#4A 50	#9A 0/100 #9B 100	#8A 0	#8A 0/100 #8B 0		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											39.37		25					50	100						10	22.62	25	24.96							10	29					25											5.75	-	1.8	-	-	-	-	0.73	2.16	-	-	-	-	-	3.95	14.03	0.67	2.64	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	32.66			5.75	-	1.8	-	-	-	-	0.73	2.16	-	-	-	-	-	3.95	14.03	0.67	2.64	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	32.66		#1A 20	#1B 50	#2 50	#6 20	#10A 20	#11A 50	#11B 50 #11C 50	#4A 50	#9A 20 #9B 20	#8A 0	#8A 20 #8B 20		#12 20	#3 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 50 #7D 20 #7F 20 #7G 20 #4B 20	#7E 50 #7H 50 #5 20 #9C 50	#7C 50 #7I 50		#14I 20	#15 20	#13A 20	#10B 20	#16A  #16B 20	#17A 0	#17B 0	#18A 0	#18B 0	#19 n/c	#14A 50	#13B n/c #7F 20											5.17	0.31	1.9	0.39	0.4	0.54	1.31	0.1	1.04	0.19	0.53	0.03	0.03	0.22	0.99	7.61	0.22	0.55	1.65	0.6	1.21				0	0	0	0			0.02											25.03	150	3.07	10.92	0.31	3.7	0.39	0.4	0.54	1.31	0.83	3.19	0.19	0.53	0.03	0.03	0.22	4.95	21.64	0.89	3.19	1.65	0.6	1.21	-	-	-	0.14	0.45	0	0	-	-	0.36	-	-	-	-	-	-	-	-	-	-	57.69
H3342_002_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	5000	1765.18		849.83		0.17	4.9	1.4	198.99	245.94		495.86				4419.62	7270.87	225.34	1105.2							153.12	167.85					162											#1A 125/day days 1-10 0/day days 11-90.	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/35/300 #8B 0/35		#12 0	#3 0 #9D 0	#7A 15 #14B 0 #14C 15 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											105.89		50		50	0.2	0.2	50	300		35				15	22.91	25	24.97							10	29					25											15.58	-	3.54	-	0	0.98	0.28	0.83	6.15	-	1.45	-	-	-	5.52	13.88	0.47	2.3	-	-	-	-	-	-	0.13	0.41	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	51.85			15.58	-	3.54	-	0	0.98	0.28	0.83	6.15	-	1.45	-	-	-	5.52	13.88	0.47	2.3	-	-	-	-	-	-	0.13	0.41	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	51.85		#1A 20	#1B 50	#2 50	#6 20	#10A 20	#11A 50	#11B 50 #11C 50	#4A 50	#9A 20 #9B 20	#8A 0	#8A 20 #8B 20		#12 20	#3 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 50 #7D 20 #7F 20 #7G 20 #4B	#7E 50 #7H 50 #5 20 #9C 50	#7C 50 #7I 50		#14I 20	#15 20	#13A 20	#10B 20	#16A n/c #16B 20	#17A 0	#17B 0	#18A 0	#18B 0	#19 n/c	#14A 50	#13B n/c #7F 20											4.84	0.26	1.93	0.43	0.46	0.6	1.09	0.13	1.41	0.17	0.92	0.06	0.03	0.25	1.19	7.23	0.21	0.84	1.71	0.86	1.78				0	0	0	0			0.02											26.41	150	2.53	20.41	0.26	5.47	0.43	0.46	1.58	1.37	0.95	7.56	0.17	2.37	0.06	0.03	0.25	6.71	21.12	0.68	3.14	1.71	0.86	1.78	-	-	-	0.13	0.41	0	0	-	-	0.36	-	-	-	-	-	-	-	-	-	-	78.26
H3342_003_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	5000	2009.54		943.04		12.23	5.77	2.13	152.55	224.72		169.19				4438.69	7635.2	296.42	1365.11							158.98	174.28					162											#1A 100/day days 1-8 0/day days 9-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/35/200 #8B 0/25		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											76.52		50		50	0.2	0.2	50	200		25				10	22.8	25	25							10	29					25											12.81	-	3.93	-	0.05	1.15	0.43	0.64	3.75	-	0.35	-	-	-	3.7	14.5	0.62	2.84	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	45.66			12.81	-	3.93	-	0.05	1.15	0.43	0.64	3.75	-	0.35	-	-	-	3.7	14.5	0.62	2.84	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	45.66		#1A 20	#1B 50	#2 50	#6 20	#10A 20	#11A 50	#11B 50 #11C 50	#4A 50	#9A 20 #9B 20	#8A 0	#8A 20 #8B 20		#12 20	#3 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 50 #7D 20 #7F 20 #7G 20 #4B	#7E 50 #7H 50 #5 20 #9C 50	#7C 50 #7I 50		#14I 20	#15 20	#13A 20	#10B 20	#16A n/c #16B 20	#17A 0	#17B 0	#18A 0	#18B 0	#19 n/c	#14A 50	#13B n/c #7F 20											4.85	0.22	2.31	0.44	0.28	0.7	1.35	0.1	0.74	0.09	0.77	0.04	0.01	0.09	0.93	8.43	0.29	0.69	1.87	0.91	1.61				0	0	0	0			0.02											26.73	150	2.54	17.66	0.22	6.24	0.44	0.33	1.86	1.78	0.73	4.49	0.09	1.12	0.04	0.01	0.09	4.63	22.94	0.91	3.53	1.87	0.91	1.61	-	-	-	0.13	0.42	0	0	-	-	0.36	-	-	-	-	-	-	-	-	-	-	72.39
H3342_004_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	5000	2062.31		883.48		14.6	7.18	2.44	202	259.35		383.2				5493.44	7894.72	198.16	1281.16							158.33	173.57					162											#1A 100/day days 1-8 0/day days 9-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/25/200 #8B 0/25		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											78.67		50		50	0.2	0.2	50	200		25				10	22.64	25	25							10	29					25											13.52	-	3.68	-	0.06	1.44	0.49	0.84	4.32	-	0.8	-	-	-	4.58	14.89	0.41	2.67	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	48.59			13.52	-	3.68	-	0.06	1.44	0.49	0.84	4.32	-	0.8	-	-	-	4.58	14.89	0.41	2.67	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	48.59		#1A 20	#1B 50	#2 50	#6 20	#10A 20	#11A 50	#11B 50 #11C 50	#4A 50	#9A 20 #9B 20	#8A 0	#8A 20 #8B 20		#12 20	#3 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 50 #7D 20 #7F 20 #7G 20 #4B	#7E 50 #7H 50 #5 20 #9C 50	#7C 50 #7I 50		#14I 20	#15 20	#13A 20	#10B 20	#16A n/c #16B 20	#17A 0	#17B 0	#18A 0	#18B 0	#19 n/c	#14A 50	#13B n/c #7F 20											5.11	0.24	1.99	0.37	0.23	0.87	1.61	0.12	0.98	0.16	1.2	0.02	0.02	0.17	1.03	8.02	0.19	0.87	1.88	1.07	2.46				0	0	0	0			0.02											28.63	150	3.04	18.63	0.24	5.67	0.37	0.29	2.31	2.1	0.97	5.3	0.16	2	0.02	0.02	0.17	5.6	22.91	0.6	3.54	1.88	1.07	2.46	-	-	-	0.13	0.42	0	0	-	-	0.36	-	-	-	-	-	-	-	-	-	-	77.22
H3342_006_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	5000	1765.18		849.83		0.17	4.9	1.4	198.99	245.94		495.86				4419.62	7270.87	225.34	1105.2							153.12	167.85					162											#1A 125/day days 1-10 0/day days 11-90.	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/35/300 #8B 0/35		#12 0	#3 0 #9D 0	#7A 15 #14B 0 #14C 15 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											105.89		50		50	0.2	0.2	50	300		35				15	22.91	25	24.97							10	29					25											15.58	-	3.54	-	0	0.98	0.28	0.83	6.15	-	1.45	-	-	-	5.52	13.88	0.47	2.3	-	-	-	-	-	-	0.13	0.41	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	51.85			15.58	-	3.54	-	0	0.98	0.28	0.83	6.15	-	1.45	-	-	-	5.52	13.88	0.47	2.3	-	-	-	-	-	-	0.13	0.41	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	51.85		#1A 20	#1B 50	#2 50	#6 20	#10A 20	#11A 50	#11B 50 #11C 50	#4A 50	#9A 20 #9B 20	#8A 0	#8A 20 #8B 20		#12 20	#3 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 50 #7D 20 #7F 20 #7G 20 #4B	#7E 50 #7H 50 #5 20 #9C 50	#7C 50 #7I 50		#14I 20	#15 20	#13A 20	#10B 20	#16A n/c #16B 20	#17A 0	#17B 0	#18A 0	#18B 0	#19 n/c	#14A 50	#13B n/c #7F 20											4.84	0.26	1.93	0.43	0.46	0.6	1.09	0.13	1.41	0.17	0.92	0.06	0.03	0.25	1.19	7.23	0.21	0.84	1.71	0.86	1.78				0	0	0	0			0.02											26.41	150	2.53	20.41	0.26	5.47	0.43	0.46	1.58	1.37	0.95	7.56	0.17	2.37	0.06	0.03	0.25	6.71	21.12	0.68	3.14	1.71	0.86	1.78	-	-	-	0.13	0.41	0	0	-	-	0.36	-	-	-	-	-	-	-	-	-	-	78.26
H3342_007_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	5000	2009.54		943.04		12.23	5.77	2.13	152.55	224.72		169.19				4438.69	7635.2	296.42	1365.11							158.98	174.28					162											#1A 100/day days 1-8 0/day days 9-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/25/200 #8B 0/25		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											76.52		50		50	0.2	0.2	50	200		25				10	22.8	25	25							10	29					25											12.81	-	3.93	-	0.05	1.15	0.43	0.64	3.75	-	0.35	-	-	-	3.7	14.5	0.62	2.84	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	45.66			12.81	-	3.93	-	0.05	1.15	0.43	0.64	3.75	-	0.35	-	-	-	3.7	14.5	0.62	2.84	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	45.66		#1A 20	#1B 50	#2 50	#6 20	#10A 20	#11A 50	#11B 50 #11C 50	#4A 50	#9A 20 #9B 20	#8A 0	#8A 20 #8B 20		#12 20	#3 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 50 #7D 20 #7F 20 #7G 20 #4B	#7E 50 #7H 50 #5 20 #9C 50	#7C 50 #7I 50		#14I 20	#15 20	#13A 20	#10B 20	#16A n/c #16B 20	#17A 0	#17B 0	#18A 0	#18B 0	#19 n/c	#14A 50	#13B n/c #7F 20											4.85	0.22	2.31	0.44	0.28	0.7	1.35	0.1	0.74	0.09	0.77	0.04	0.01	0.09	0.93	8.43	0.29	0.69	1.87	0.91	1.61				0	0	0	0			0.02											26.73	150	2.54	17.66	0.22	6.24	0.44	0.33	1.86	1.78	0.73	4.49	0.09	1.12	0.04	0.01	0.09	4.63	22.94	0.91	3.53	1.87	0.91	1.61	-	-	-	0.13	0.42	0	0	-	-	0.36	-	-	-	-	-	-	-	-	-	-	72.39
H3342_008_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	5000	2062.31		883.48		14.6	7.18	2.44	202	259.35		383.2				5493.44	7894.72	198.16	1281.16							158.33	173.57					162											#1A 100/day days 1-8 0/day days 9-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/25/200 #8B 0/25		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											78.67		50		50	0.2	0.2	50	200		25				10	22.64	25	25							10	29					25											13.52	-	3.68	-	0.06	1.44	0.49	0.84	4.32	-	0.8	-	-	-	4.58	14.89	0.41	2.67	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	48.59			13.52	-	3.68	-	0.06	1.44	0.49	0.84	4.32	-	0.8	-	-	-	4.58	14.89	0.41	2.67	-	-	-	-	-	-	0.13	0.42	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	48.59		#1A 20	#1B 50	#2 50	#6 20	#10A 20	#11A 50	#11B 50 #11C 50	#4A 50	#9A 20 #9B 20	#8A 0	#8A 20 #8B 20		#12 20	#3 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 50 #7D 20 #7F 20 #7G 20 #4B	#7E 50 #7H 50 #5 20 #9C 50	#7C 50 #7I 50		#14I 20	#15 20	#13A 20	#10B 20	#16A n/c #16B 20	#17A 0	#17B 0	#18A 0	#18B 0	#19 n/c	#14A 50	#13B n/c #7F 20											5.11	0.24	1.99	0.37	0.23	0.87	1.61	0.12	0.98	0.16	1.2	0.02	0.02	0.17	1.03	8.02	0.19	0.87	1.88	1.07	2.46				0	0	0	0			0.02											28.63	150	3.04	18.63	0.24	5.67	0.37	0.29	2.31	2.1	0.97	5.3	0.16	2	0.02	0.02	0.17	5.6	22.91	0.6	3.54	1.88	1.07	2.46	-	-	-	0.13	0.42	0	0	-	-	0.36	-	-	-	-	-	-	-	-	-	-	77.22
H3342_801_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		278.54	3.82	27.81	13.01	7.61	5.82	11.41	184.37	40.48	6.21	32.16	1.22	0.88	7.39	43.98	158.56	2.43	8	35.97	17.61	36.07																					Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.05	0.05	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.25	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.04	138	0	15.25	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.04		Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											2.04	0.03	0.66		0.39	0.32	0.63	0.1	1.21	0.19	0.96	0.04	0.03	0.22	1.14	8.64	0.1	0.34	1.98	0.95	2																					21.96	138	0	17.29	0.24	5.35	-	2.19	1.69	3.33	0.87	10.76	1.65	8.55	0.32	0.23	1.96	11.52	46.06	0.67	2.23	10.47	5.1	10.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141
H3342_802_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		278.54	3.82	27.81	13.01	7.61	5.82	11.41	184.37	40.48	6.21	32.16	1.22	0.88	7.39	43.98	158.56	2.43	8	35.97	17.61	36.07																					Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.05	0.05	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.25	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.04	138	0	15.25	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.04		Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											2.04	0.03	0.66		0.39	0.32	0.63	0.1	1.21	0.19	0.96	0.04	0.03	0.22	1.14	8.64	0.1	0.34	1.98	0.95	2																					21.96	138	0	17.29	0.24	5.35	-	2.19	1.69	3.33	0.87	10.76	1.65	8.55	0.32	0.23	1.96	11.52	46.06	0.67	2.23	10.47	5.1	10.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141
H3342_803_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		278.54	3.82	27.81	13.01	7.61	5.82	11.41	184.37	40.48	6.21	32.16	1.22	0.88	7.39	43.98	158.56	2.43	8	35.97	17.61	36.07																					Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.57	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.36	138	0	15.57	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.36		Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											2.08	0.03	0.66		0.39	0.32	0.63	0.1	1.21	0.19	0.96	0.04	0.03	0.22	1.14	8.64	0.1	0.34	1.98	0.95	2																					22.01	138	0	17.65	0.24	5.35	-	2.19	1.69	3.33	0.87	10.76	1.65	8.55	0.32	0.23	1.96	11.52	46.06	0.67	2.23	10.47	5.1	10.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.37
H3342_804_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		278.54	3.82	27.81	13.01	7.61	5.82	11.41	184.37	40.48	6.21	32.16	1.22	0.88	7.39	43.98	158.56	2.43	8	35.97	17.61	36.07																					Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.57	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.36	138	0	15.57	0.21	4.69	-	1.79	1.37	2.69	0.77	9.55	1.47	7.59	0.29	0.21	1.74	10.38	37.42	0.57	1.89	8.49	4.16	8.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.36		Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											2.08	0.03	0.66		0.39	0.32	0.63	0.1	1.21	0.19	0.96	0.04	0.03	0.22	1.14	8.64	0.1	0.34	1.98	0.95	2																					22.01	138	0	17.65	0.24	5.35	-	2.19	1.69	3.33	0.87	10.76	1.65	8.55	0.32	0.23	1.96	11.52	46.06	0.67	2.23	10.47	5.1	10.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.37
H3344_001_0	2007	8																					0											A	A	Coin	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	V	V	P	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	188.61	4	29.7	1257.52	81.24	6.35	4.99	245.82	462.51	0	533.46	40.09	0	424.09	5008.26	3050.68	189.06	517.5	839.51	1011.08	10.59	608.54	0	0	554.25	554.25	13.18	0	0	0	0											PBP: 1A IP Acute: 100 per admit	1B IP Psych: 100 per admit	2 SNF: 20	6 Home Health: 10	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 50	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 15	12 Renal Dialysis: 0	3 CORF: 15 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 5 14B Immunizations: 5 14C Routine Physical Exams: 5 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 20 7H Psychiatric: 20	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 20	7B Chiropractic: 25 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											100	100	0.2	10	50	0.2	0.2	48.45	50	0	20	15	0	15.88	5	20	20	15	20	19.61	0.2	20	0	0	5	36.33	20	0	0	0	0											1.57	0.03	5.94	1.05	0.34	1.27	1	0.99	1.93	-	0.89	0.05	-	0.56	2.09	5.08	0.32	0.65	1.4	1.65	2.12	1.01	-	-	0.23	1.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.87	0	0	1.57	0.03	5.94	1.05	0.34	1.27	1	0.99	1.93	-	0.89	0.05	-	0.56	2.09	5.08	0.32	0.65	1.4	1.65	2.12	1.01	-	-	0.23	1.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.87	3500	PBP: 1A IP Acute: 250 Deductible 20 Coinsurance	1B IP Psych: 250 Deductible 40 Coinsurance	2 SNF: 250 Deductible 20 Coinsurance	6 Home Health: 250 Deductible 20 Coinsurance	10A Ambulance: 50	11A DME: 250 Deductible 40 Coinsurance 11C Diabetes Monitoring Supplies: 250 Deductible 20 Coinsurance	11B Prosthetic Medical Supplies: 250 Deductible 20 Coinsurance	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 250 Deductible 20 Coinsurance	8A OP C/D/T: 250 Deductible 20 Coinsurance	8B OP X-Ray: 250 Deductible 20 Coinsurance	9A OP Hospital: 250 Deductible 20 Coinsurance	12 Renal Dialysis: 250 Deductible 20 Coinsurance	3 CORF: 250 Deductible 20 Coinsurance 5 Partial Hosp: 250 Deductible 40 Coinsurance 9C OP Substance Abuse: 250 Deductible 50 Coinsurance 9D Cardiac Rehab: 25	7A PCP: 30 14B Immunizations: 250 Deductible 20 Coinsurance 14C Routine Physical Exams: 30 14D Pap Smears: 250 Deductible 20 Coinsurance 14D Pelvic Exams: 250 Deductible 20 Coinsurance 14E Prostate Screening: 250 Deductible 20 Coinsurance 14F Colorectal Screening: 250 Deductible 20 Coinsurance 14G Bone Mass Measurement: 250 Deductible 20 Coinsurance 14H Mammography: 250 Deductible 20 Coinsurance 14I Diabetes Monitoring: 250 Deductible 20 Coinsurance	7D Physician Specialist: 30	7E Mental Health: 250 Deductible 50 Coinsurance 7H Psychiatric: 250 Deductible 50 Coinsurance	7C Occupational Therapy: 25 7I Physical and Speech Therapy: 25	8B OP X-Ray: 250 Deductible 20 Coinsurance	7B Chiropractic: 250 Deductible 20 Coinsurance 7F Podiatry: 250 Deductible 20 Coinsurance 18A Medicare Covered Hearing Exams: 250 Deductible 20 Coinsurance	15 Part B Drugs: 250 Deductible 20 Coinsurance	13A Blood: 250 Deductible 20 Coinsurance 16B Comprehensive Dental Services: 250 Deductible 20 Coinsurance 17A Medicare Covered Eye Exams: 30	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 30	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 250 Deductible 20 Coinsurance	13B Acupuncture: Not Covered											3.43	0.09	0.77	0.43	0.01	0.48	0.27	0.19	0.34	0.13	0.36	0.01	0	0.31	1.55	1.61	0.06	0.34	0.46	0.54	0.11	0.16	0	0	0.1	0.09	0.01	0	0	0	0											11.88	250	5.84	5.01	0.12	6.71	1.48	0.35	1.75	1.27	1.18	2.27	0.13	1.25	0.06	0	0.87	3.64	6.69	0.38	0.99	1.86	2.2	2.23	1.18	-	-	0.33	1.77	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.75
H3344_003_0	2007	8																					0											A	A	A	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	V	V	P	V	Coin	V	T	V	V	V	V	Coin	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	1257.52	81.24	6.35	4.99	246.63	462.51	0	533.46	40.09	0	424.09	0	3187.99	201.66	517.5	901.66	1042.29	10.59	649.12	0	0	554.25	554.25	14.06	6.51	0	0	0											PBP: 1A IP Acute: 0	1B IP Psych: 0	2 SNF: 0	6 Home Health: 10	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 25	9B ASC Services: 25	8A OP C/D/T: 0	8B OP X-Ray: 10	9A OP Hospital: 10	12 Renal Dialysis: 0	3 CORF: 15 5 Partial Hosp: 10 9C OP Substance Abuse: 10 9D Cardiac Rehab: 15	7A PCP: 0 14B Immunizations: 0 14C Routine Physical Exams: 0 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-10	7D Physician Specialist: 10	7E Mental Health: 10 7H Psychiatric: 10	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 10	7B Chiropractic: 10 7F Podiatry: 10 7G Other Health Care: 10 18A Medicare Covered Hearing Exams: 10	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 10	10B Transportation: Not Covered	16A Preventive Dental Services: 0	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 10	18B Hearing Aids: 50	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0	0	0	10	50	0.2	0.2	47.8	25	0	10	10	0	14.12	0	10	10	15	10	10	0.2	10	0	0	5	36.33	10	0.5	0	0	0											-	-	-	1.05	0.34	1.27	1	0.98	0.96	-	0.44	0.03	-	0.5	-	2.66	0.17	0.65	0.75	0.87	2.12	0.54	-	-	0.23	1.68	0.01	3.25	-	-	-	-	-	-	-	-	-	-	-	-	-	19.5	0	0	-	-	-	1.05	0.34	1.27	1	0.98	0.96	-	0.44	0.03	-	0.5	-	2.66	0.17	0.65	0.75	0.87	2.12	0.54	-	-	0.23	1.68	0.01	3.25	-	-	-	-	-	-	-	-	-	-	-	-	-	19.5	3500	PBP: 1A IP Acute: 20 Coinsurance	1B IP Psych: 40 Coinsurance	2 SNF: 20 Coinsurance	6 Home Health: 20 Coinsurance	10A Ambulance: 50	11A DME: 40 Coinsurance 11C Diabetes Monitoring Supplies: 20 Coinsurance	11B Prosthetic Medical Supplies: 20 Coinsurance	4A ER: 50 4B Urgent Care: 25	9B ASC Services: 20 Coinsurance	8A OP C/D/T: 20 Coinsurance	8B OP X-Ray: 20 Coinsurance	9A OP Hospital: 20 Coinsurance	12 Renal Dialysis: 20 Coinsurance	3 CORF: 20 Coinsurance 5 Partial Hosp: 40 Coinsurance 9C OP Substance Abuse: 50 Coinsurance 9D Cardiac Rehab: 25	7A PCP: 25 14B Immunizations: 20 Coinsurance 14C Routine Physical Exams: 25 14D Pap Smears: 20 Coinsurance 14D Pelvic Exams: 20 Coinsurance 14E Prostate Screening: 20 Coinsurance 14F Colorectal Screening: 20 Coinsurance 14G Bone Mass Measurement: 20 Coinsurance 14H Mammography: 20 Coinsurance 14I Diabetes Monitoring: 20 Coinsurance	7D Physician Specialist: 25	7E Mental Health: 50 Coinsurance 7H Psychiatric: 50 Coinsurance	7C Occupational Therapy: 25 7I Physical and Speech Therapy: 25	8B OP X-Ray: 20 Coinsurance	7B Chiropractic: 20 Coinsurance 7F Podiatry: 20 Coinsurance 18A Medicare Covered Hearing Exams: 20 Coinsurance	15 Part B Drugs: 20 Coinsurance	13A Blood: 20 Coinsurance 16B Comprehensive Dental Services: 20 Coinsurance 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: 50	17A Routine Eye Exams: 25	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 20 Coinsurance	13B Acupuncture: Not Covered											2.83	0.08	0.64	0.35	0.01	0.45	0.26	0.18	0.28	0.11	0.3	0.01	0	0.27	1.29	1.33	0.06	0.34	0.38	0.45	0.09	0.06	0	0.46	0.12	0.09	0.01	0	0	0	0											10.47	0	6.09	2.83	0.08	0.64	1.4	0.35	1.73	1.25	1.17	1.25	0.11	0.74	0.04	0	0.77	1.29	3.99	0.23	0.99	1.13	1.32	2.21	0.6	-	0.46	0.35	1.77	0.02	3.25	-	-	-	-	-	-	-	-	-	-	-	-	-	29.98
H3344_801_0	2007	6																					0											A	A	Coin	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	187.86	3.99	29.7	1238.07	81.24	6.35	4.99	244.88	462.51	0	533.46	40.09	0.62	424.09	4653.05	2897.82	1.49	517.5	812.61	992.52	10.59	595.02	0	0	554.25	554.25	12.89	0	0	0	0											PBP: 1A IP Acute: 500 per admit	1B IP Psych: 500 per admit	2 SNF: 20	6 Home Health: 15	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 30	9A OP Hospital: 30	12 Renal Dialysis: 30	3 CORF: 15 5 Partial Hosp: 30 9C OP Substance Abuse: 50 9D Cardiac Rehab: 15	7A PCP: 20 14B Immunizations: 20 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 30 14I Diabetes Monitoring: 0-30	7D Physician Specialist: 30	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 30	7B Chiropractic: 25 7F Podiatry: 30 7G Other Health Care: 10-30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 30 17A Medicare Covered Eye Exams: 30	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 30	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											500	500	0.2	15	50	0.2	0.2	49.04	75	0	30	25	30	15	20	30	0.5	15	30	28.49	0.2	30	0	0	5	36.33	30	0	0	0	0											7.83	0.17	5.94	1.55	0.34	1.27	1	1	2.89	-	1.33	0.08	0	0.53	7.76	7.24	0.75	0.65	2.03	2.36	2.12	1.49	-	-	0.23	1.68	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.26	0	0	7.83	0.17	5.94	1.55	0.34	1.27	1	1	2.89	-	1.33	0.08	0	0.53	7.76	7.24	0.75	0.65	2.03	2.36	2.12	1.49	-	-	0.23	1.68	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.26	0	PBP: 1A IP Acute: 1000 Deductible 30 Coinsurance	1B IP Psych: 1000 Deductible 50 Coinsurance	2 SNF: 1000 Deductible 30 Coinsurance	6 Home Health: 1000 Deductible 30 Coinsurance	10A Ambulance: 50	11A DME: 1000 Deductible 50 Coinsurance 11C Diabetes Monitoring Supplies: 1000 Deductible 30 Coinsurance	11B Prosthetic Medical Supplies: 1000 Deductible 30 Coinsurance	4A ER: 50 4B Urgent Care: 1000 Deductible 30 Coinsurance	9B ASC Services: 1000 Deductible 30 Coinsurance	8A OP C/D/T: 1000 Deductible 30 Coinsurance	8B OP X-Ray: 1000 Deductible 30 Coinsurance	9A OP Hospital: 1000 Deductible 30 Coinsurance	12 Renal Dialysis: 1000 Deductible 30 Coinsurance	3 CORF: 1000 Deductible 30 Coinsurance 5 Partial Hosp: 1000 Deductible 50 Coinsurance 9C OP Substance Abuse: 1000 Deductible 50 Coinsurance 9D Cardiac Rehab: 1000 Deductible 30 Coinsurance	7A PCP: 1000 Deductible 30 Coinsurance 14B Immunizations: 1000 Deductible 30 Coinsurance 14C Routine Physical Exams: 1000 Deductible 30 Coinsurance 14D Pap Smears: 1000 Deductible 30 Coinsurance 14D Pelvic Exams: 1000 Deductible 30 Coinsurance 14E Prostate Screening: 1000 Deductible 30 Coinsurance 14F Colorectal Screening: 1000 Deductible 30 Coinsurance 14G Bone Mass Measurement: 1000 Deductible 30 Coinsurance 14H Mammography: 1000 Deductible 30 Coinsurance 14I Diabetes Monitoring: 1000 Deductible 30 Coinsurance	7D Physician Specialist: 1000 Deductible 30 Coinsurance	7E Mental Health: 1000 Deductible 50 Coinsurance 7H Psychiatric: 1000 Deductible 50 Coinsurance	7C Occupational Therapy: 1000 Deductible 30 Coinsurance 7I Physical and Speech Therapy: 1000 Deductible 30 Coinsurance	8B OP X-Ray: 1000 Deductible 30 Coinsurance	7B Chiropractic: 1000 Deductible 30 Coinsurance 7F Podiatry: 1000 Deductible 30 Coinsurance 18A Medicare Covered Hearing Exams: 1000 Deductible 30 Coinsurance	15 Part B Drugs: 1000 Deductible 30 Coinsurance	13A Blood: 1000 Deductible 30 Coinsurance 16B Comprehensive Dental Services: 1000 Deductible 30 Coinsurance 17A Medicare Covered Eye Exams: 1000 Deductible 30 Coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 1000 Deductible 30 Coinsurance	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 1000 Deductible 30 Coinsurance	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 1000 Deductible 30 Coinsurance	13B Acupuncture: Not Covered											9.12	0.13	2.05	1.14	0.01	0.73	0.43	0.18	0.91	0.36	0.97	0.02	0	0.91	1.66	3.41	0.07	0.15	1.23	1.45	0.29	0.19	0	0	0.12	0.09	0.03	0	0	0	0											25.68	1000	0	16.95	0.3	7.99	2.69	0.35	2	1.43	1.18	3.8	0.36	2.3	0.11	0	1.44	9.41	10.65	0.82	0.8	3.27	3.8	2.41	1.67	-	-	0.35	1.77	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.93
H3344_802_0	2007	3																					0											A	A	Coin	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	188.24	3.99	29.7	1238.07	81.24	6.35	4.99	245.56	462.51	0	533.46	40.09	0.62	424.09	4907.12	3008.55	1.49	517.5	832.09	1005.25	10.59	608.54	0	0	554.25	554.25	13.18	0	0	0	0											PBP: 1A IP Acute: 250 per admit	1B IP Psych: 250 per admit	2 SNF: 20	6 Home Health: 15	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 20	3 CORF: 15 5 Partial Hosp: 20 9C OP Substance Abuse: 50 9D Cardiac Rehab: 15	7A PCP: 10 14B Immunizations: 10 14C Routine Physical Exams: 10 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 20 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 20	7B Chiropractic: 25 7F Podiatry: 20 7G Other Health Care: 10-20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	0.2	15	50	0.2	0.2	48.48	75	0	20	20	20	15.88	10	20	0.5	15	20	20.97	0.2	20	0	0	5	36.33	20	0	0	0	0											3.92	0.08	5.94	1.55	0.34	1.27	1	0.99	2.89	-	0.89	0.07	0	0.56	4.09	5.01	0.75	0.65	1.39	1.76	2.12	1.01	-	-	0.23	1.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.21	0	0	3.92	0.08	5.94	1.55	0.34	1.27	1	0.99	2.89	-	0.89	0.07	0	0.56	4.09	5.01	0.75	0.65	1.39	1.76	2.12	1.01	-	-	0.23	1.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.21	0	PBP: 1A IP Acute: 1000 Deductible 30 Coinsurance	1B IP Psych: 1000 Deductible 50 Coinsurance	2 SNF: 1000 Deductible 30 Coinsurance	6 Home Health: 1000 Deductible 30 Coinsurance	10A Ambulance: 50	11A DME: 1000 Deductible 50 Coinsurance 11C Diabetes Monitoring Supplies: 1000 Deductible 30 Coinsurance	11B Prosthetic Medical Supplies: 1000 Deductible 30 Coinsurance	4A ER: 50 4B Urgent Care: 1000 Deductible 30 Coinsurance	9B ASC Services: 1000 Deductible 30 Coinsurance	8A OP C/D/T: 1000 Deductible 30 Coinsurance	8B OP X-Ray: 1000 Deductible 30 Coinsurance	9A OP Hospital: 1000 Deductible 30 Coinsurance	12 Renal Dialysis: 1000 Deductible 30 Coinsurance	3 CORF: 1000 Deductible 30 Coinsurance 5 Partial Hosp: 1000 Deductible 50 Coinsurance 9C OP Substance Abuse: 1000 Deductible 50 Coinsurance 9D Cardiac Rehab: 1000 Deductible 30 Coinsurance	7A PCP: 1000 Deductible 30 Coinsurance 14B Immunizations: 1000 Deductible 30 Coinsurance 14C Routine Physical Exams: 1000 Deductible 30 Coinsurance 14D Pap Smears: 1000 Deductible 30 Coinsurance 14D Pelvic Exams: 1000 Deductible 30 Coinsurance 14E Prostate Screening: 1000 Deductible 30 Coinsurance 14F Colorectal Screening: 1000 Deductible 30 Coinsurance 14G Bone Mass Measurement: 1000 Deductible 30 Coinsurance 14H Mammography: 1000 Deductible 30 Coinsurance 14I Diabetes Monitoring: 1000 Deductible 30 Coinsurance	7D Physician Specialist: 1000 Deductible 30 Coinsurance	7E Mental Health: 1000 Deductible 50 Coinsurance 7H Psychiatric: 1000 Deductible 50 Coinsurance	7C Occupational Therapy: 1000 Deductible 30 Coinsurance 7I Physical and Speech Therapy: 1000 Deductible 30 Coinsurance	8B OP X-Ray: 1000 Deductible 30 Coinsurance	7B Chiropractic: 1000 Deductible 30 Coinsurance 7F Podiatry: 1000 Deductible 30 Coinsurance 18A Medicare Covered Hearing Exams: 1000 Deductible 30 Coinsurance	15 Part B Drugs: 1000 Deductible 30 Coinsurance	13A Blood: 1000 Deductible 30 Coinsurance 16B Comprehensive Dental Services: 1000 Deductible 30 Coinsurance 17A Medicare Covered Eye Exams: 1000 Deductible 30 Coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 1000 Deductible 30 Coinsurance	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 1000 Deductible 30 Coinsurance	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 1000 Deductible 30 Coinsurance	13B Acupuncture: Not Covered											9.12	0.13	2.05	1.14	0.01	0.73	0.43	0.18	0.91	0.36	0.97	0.02	0	0.91	1.66	3.41	0.07	0.15	1.23	1.45	0.29	0.19	0	0	0.12	0.09	0.03	0	0	0	0											25.68	1000	0	13.05	0.22	7.99	2.69	0.35	2	1.43	1.18	3.8	0.36	1.86	0.09	0	1.47	5.75	8.42	0.82	0.8	2.62	3.2	2.41	1.2	-	-	0.35	1.77	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.88
H3345_001_1	2007	11																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2171.03	0	1621.09	191.87	413.28	7.02	7.02	236.1	72.56	0	0	0	0	883.87	6609.44	6021.45	144.75	99.3	366.58	4255.63	226.7	0	0	41.46	1344.85	0	0	0	0	0	0											100 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0 coinsurance	0 coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	15 Copay	25 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	20 Copay	0 Copay	15 copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											14.72	0	4.78	0	100	0	0	50	75	0	0	0	0	75	5	15	25	15	15	15	0	15	20	0	15	0	15	0	20	20	20											2.66	-	0.65	-	3.44	-	-	0.98	0.45	-	-	-	-	5.52	2.75	7.53	0.3	0.12	0.46	5.32	-	-	-	-	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.88	0	0	2.66	-	0.65	-	3.44	-	-	0.98	0.45	-	-	-	-	5.52	2.75	7.53	0.3	0.12	0.46	5.32	-	-	-	-	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.88	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	20 Coinsurance	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	n/a											3.26	0.07	0.42	0.05	0.11	0.07	0.07	0	0.09	0	0	0.29	0.16	0.01	1.14	1.4	0.03	0.02	0.07	0.66	0.13	0	0	0	0.08	0	0.01	0	0	0	0											8.13	0	0	5.92	0.07	1.07	0.05	3.56	0.07	0.07	0.98	0.54	-	-	0.29	0.16	5.53	3.89	8.93	0.33	0.14	0.53	5.98	0.13	-	-	-	1.76	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.01
H3345_001_2	2007	11																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2402.17	0	1422.94	234.99	230.51	8.19	8.19	220.23	138.96	0	0	0	0	513.53	6667.48	5823.39	141.38	96.99	358.06	4156.72	282.75	0	0	0	1304.04	0	75.71	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0 coinsurance	0 coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	0 Copay	15 copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	0	0	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	0	15	0	15	0	20	20	20											15.9	-	0.57	-	1.92	-	-	0.92	0.87	-	-	-	-	3.21	5.56	9.71	0.35	0.16	0.6	6.93	-	-	-	-	1.63	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.41	0	0	15.9	-	0.57	-	1.92	-	-	0.92	0.87	-	-	-	-	3.21	5.56	9.71	0.35	0.16	0.6	6.93	-	-	-	-	1.63	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.41	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	20 Coinsurance	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	n/a											2.06	0.04	0.24	0.03	0.05	0.05	0.05	0	0.04	0	0	0.15	0.08	0	0.67	0.82	0.02	0.01	0.04	0.39	0.11	0	0	0	0.05	0	0.01	0	0	0	0											4.91	0	0	17.96	0.04	0.8	0.03	1.97	0.05	0.05	0.92	0.91	-	-	0.15	0.08	3.21	6.22	10.53	0.37	0.17	0.64	7.32	0.11	-	-	-	1.68	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.33
H3345_001_3	2007	11																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2446.9	0	1275.83	237.14	122.31	5.74	5.74	295.82	132.07	0	0	0	0	1383.44	6917.59	6411.63	159.87	109.67	404.87	4700.19	291.03	0	0	0	1151.36	0	45.97	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	0 coinsurance	0 coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	0	0	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	15	0	15	0	20	20	20											16.2	-	0.51	-	1.02	-	-	1.23	0.83	-	-	-	-	8.65	5.76	10.69	0.4	0.18	0.67	7.83	-	-	-	-	1.44	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.47	0	0	16.2	-	0.51	-	1.02	-	-	1.23	0.83	-	-	-	-	8.65	5.76	10.69	0.4	0.18	0.67	7.83	-	-	-	-	1.44	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.47	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	20 Coinsurance	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	n/a											3.22	0.06	0.34	0.07	0.04	0.05	0.05	0	0.11	0	0	0.52	0.29	0.02	1.14	1.4	0.03	0.02	0.07	0.67	0.18	0	0	0	0.07	0	0.01	0	0	0	0											8.33	0	0	19.42	0.06	0.84	0.07	1.05	0.05	0.05	1.23	0.93	-	-	0.52	0.29	8.66	6.9	12.09	0.43	0.2	0.74	8.5	0.18	-	-	-	1.51	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.8
H3345_801_5	2007	7																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2172.64	0	1622.29	192.01	413.59	7.02	7.02	236.27	72.62	0	0	0	0	884.53	6122.41	6521.45	144.75	99.3	366.58	4255.63	226.87	0	0	41.49	1345.85	0	0	0	0	0	0											100 Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	5 Copay	15 Copay	25 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	20 Copay	0 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											14.72	0	4.78	0	100	0.2	0.2	50	75	0	0	0	0	75	5	15	25	15	15	15	0	15	20	0	25	0	15	0	20	20	20											2.66	-	0.65	-	3.45	1.4	1.4	0.98	0.45	-	-	-	-	5.53	2.55	8.15	0.3	0.12	0.46	5.32	-	-	-	-	2.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.24	0	0	2.66	-	0.65	-	3.45	1.4	1.4	0.98	0.45	-	-	-	-	5.53	2.55	8.15	0.3	0.12	0.46	5.32	-	-	-	-	2.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.24	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	20 Coinsurance	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	n/a											3.26	0.07	0.42	0.05	0.11	0.07	0.07	0	0.09	0	0	0.29	0.16	0.01	1.14	1.4	0.03	0.02	0.07	0.66	0.13	0	0	0	0.08	0	0.01	0	0	0	0											8.13	0	0	5.92	0.07	1.07	0.05	3.56	1.47	1.47	0.98	0.54	-	-	0.29	0.16	5.54	3.69	9.55	0.33	0.14	0.53	5.98	0.13	-	-	-	2.89	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.38
H3345_801_6	2007	7																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2403.71	0	1423.86	235.14	230.66	8.2	8.2	220.37	139.05	0	0	0	0	513.86	6178.56	6323.39	141.38	96.99	358.06	4156.72	282.93	0	0	0	1304.88	0	75.76	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	0 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	0.2	0.2	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	0	25	0	15	0	20	20	20											15.91	-	0.57	-	1.92	1.64	1.64	0.92	0.87	-	-	-	-	3.21	5.15	10.54	0.35	0.16	0.6	6.93	-	-	-	-	2.72	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.22	0	0	15.91	-	0.57	-	1.92	1.64	1.64	0.92	0.87	-	-	-	-	3.21	5.15	10.54	0.35	0.16	0.6	6.93	-	-	-	-	2.72	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.22	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	20 Coinsurance	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	n/a											2.06	0.04	0.24	0.03	0.05	0.05	0.05	0	0.04	0	0	0.15	0.08	0	0.67	0.82	0.02	0.01	0.04	0.39	0.11	0	0	0	0.05	0	0.01	0	0	0	0											4.91	0	0	17.97	0.04	0.81	0.03	1.97	1.69	1.69	0.92	0.91	-	-	0.15	0.08	3.22	5.82	11.36	0.37	0.17	0.64	7.32	0.11	-	-	-	2.77	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.13
H3345_801_7	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	O	O																																																				-	n/a	2520.67	0	1314.29	244.29	126	5.91	5.91	304.74	136.05	0	0	0	0	1425.14	6981.44	6911.63	159.87	109.67	404.87	4700.19	299.81	0	0	0	1186.07	0	47.35	0	0	0	0											250 (day 1) /50 day (days 2-10) Copay	0 Copay	25 (days 21-100) Copay	0 Copay	100 Copay	20Coinsurance	20Coinsurance	50 Copay	75 Copay	0 Copay	0 Copay	0 Copay	0 Copay	75 Copay	10 Copay	20 Copay	30 Copay	20 Copay	20 Copay	20 Copay	0 Copay	10 Copay	20 Copay	10 Copay	25 Copay	0 Copay	15 Copay	0 Copay	20 Copay	20 Copay	20 Copay											79.43	0	4.78	0	100	0.2	0.2	50	75	0	0	0	0	75	10	20	30	20	20	20	0	10	20	10	25	0	15	0	20	20	20											16.69	-	0.52	-	1.05	1.18	1.18	1.27	0.85	-	-	-	-	8.91	5.82	11.52	0.4	0.18	0.67	7.83	-	-	-	-	2.47	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.61	0	0	16.69	-	0.52	-	1.05	1.18	1.18	1.27	0.85	-	-	-	-	8.91	5.82	11.52	0.4	0.18	0.67	7.83	-	-	-	-	2.47	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.61	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	20 Coinsurance	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	20 Coinsurance	20 Coinsurance	20 Coinsurance	n/a	n/a	n/a	n/a											3.22	0.06	0.34	0.07	0.04	0.05	0.05	0	0.11	0	0	0.52	0.29	0.02	1.14	1.4	0.03	0.02	0.07	0.67	0.18	0	0	0	0.07	0	0.01	0	0	0	0											8.33	0	0	19.91	0.06	0.86	0.07	1.09	1.23	1.23	1.27	0.96	-	-	0.52	0.29	8.92	6.96	12.92	0.43	0.2	0.74	8.5	0.18	-	-	-	2.54	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.94
H3346_001_0	2007	6	h.6.	h.7.	h.8.								OP Facility - Other	OP Facility - Other	OP Facility - Other									MH Substance Abuse	Diagnostic Radiology	Other								A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	S	Coin	T	P	P	P	P	P	O	V	P	Coin	V	V								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0								-	2500	308.9	4.03	1021.11	1559.43	494.64	0.74	1.16	308.79	316.94	5961.11	365.27	54.19	19.12	605.34	8433.39	14815.82	1.01	1169.34	3977.54	0	256.76	3.69	9.23	967.98	520.72	237.44	74.57	8.3	0	0	586.1	0.58	290.55	184.87								No Cost Sharing	No Cost Sharing	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 15 per Visit for Visits 21+	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	15 OP Rehab includes Cardiac Rehab	10 per Visit	15 per Specialist Visit	15 for 1st OP MH visit 50 thereafter	15 per Visit	No Cost Sharing	No Cost Sharing	15 Copayment other Part B Rx	20 Coinsurance for Diabetes Supplies	No Cost Sharing	300 MAB no cost sharing prior to MAB	10 per Visit	100 MAB no cost sharing prior to MAB	15 per Visit	600 Max Benefit Every 3 Years	Not Applicable	Check with PBP	No Cost Sharing	15 for 1st OP MH visit 50 thereafter 15 per Visit for Sub Abuse	15 per Visit	No Cost Sharing								0	0	30.32	3.22	32.2	0.18	0.18	44.71	0	0	0	0	0	7.39	5.15	6.49	0.39	13.8	0	0	13.8	0.18	0	0	9.2	0	13.8	0	0	0	0	0.34	13.8	0								-	-	2.58	0.42	1.33	0.14	0.21	1.15	-	-	-	-	-	0.37	3.62	8.02	0.4	1.34	-	-	0.3	0.68	-	-	0.4	-	0.09	-	-	-	-	0.19	0.33	-	-	-	-	-	-	-	-	21.56	0	0	-	-	2.58	0.42	1.33	0.14	0.21	1.15	-	-	-	-	-	0.37	3.62	8.02	0.4	1.34	-	-	0.3	0.68	-	-	0.4	-	0.09	-	-	-	-	0.19	0.33	-	-	-	-	-	-	-	-	21.56		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	No Cost Sharing	20 Coinsurance	20 Coinsurance OP Rehab includes Cardiac Rehab	25 per Visit	25 per Specialist Visit	50 Coinsurance	20 Coinsurance	No Cost Sharing	No Cost Sharing	25 per Script	20 Coinsurance for Diabetes Supplies	No Cost Sharing	300 MAB Preventive Only no cost sharing prior to MAB	25 per Visit	100 MAB no cost sharing prior to MAB	25 per Visit	600 Max Benefit Every 3 Years	Not Applicable	Check with PBP	No Cost Sharing	50 Coinsurance	25 per Visit	No Cost Sharing								5.27	0.05	0.94	0.31	0.12	0.02	0.03	0.1	0.9	0.41	0.85	0	0.06	0.52	0.79	1.16	0.05	0.06	0	0	0.04	0.08	0	0	0.09	0	0.01	0	0	0	0	0.03	0.05	0								11.93	500	1.54	5.27	0.05	3.52	0.73	1.44	0.15	0.24	1.25	0.9	0.41	0.85	-	0.06	0.89	4.41	9.18	0.45	1.4	-	-	0.34	0.76	-	-	0.49	-	0.1	-	-	-	-	0.22	0.38	-	-	-	-	-	-	-	-	33.49
H3346_002_0	2007	5	h.6.	h.7.	h.8.								OP Facility - Other	OP Facility - Other	OP Facility - Other									MH Substance Abuse	Diagnostic Radiology	Other								A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	S	Coin	T	P	P	P	P	P	O	V	P	Coin	V	V								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0								-	2500	324.86	4.24	1073.87	1640	520.2	0.78	1.22	324.75	333.32	6269.12	384.15	56.99	20.11	636.62	8869.14	15581.35	1.06	1229.76	4183.06	0	270.03	3.88	9.7	1018	547.63	249.71	78.42	8.73	0	0	616.39	0.61	305.56	194.42								No Cost Sharing	No Cost Sharing	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 15 per Visit for Visits 21+	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	15 OP Rehab includes Cardiac Rehab	10 per Visit	15 per Specialist Visit	15 for 1st OP MH visit 50 thereafter	15 per Visit	No Cost Sharing	No Cost Sharing	15 Copayment other Part B Rx	20 Coinsurance for Diabetes Supplies	No Cost Sharing	300 MAB no cost sharing prior to MAB	10 per Visit	100 MAB no cost sharing prior to MAB	15 per Visit	600 Max Benefit Every 3 Years	Not Applicable	Check with PBP	No Cost Sharing	15 for 1st OP MH visit 50 thereafter 15 per Visit for Sub Abuse	15 per Visit	No Cost Sharing								0	0	30.32	3.22	32.2	0.18	0.18	44.71	0	0	0	0	0	7.39	5.15	6.49	0.39	13.8	0	0	13.8	0.18	0	0	9.2	0	13.8	0	0	0	0	0.34	13.8	0								-	-	2.71	0.44	1.4	0.14	0.22	1.21	-	-	-	-	-	0.39	3.81	8.43	0.42	1.41	-	-	0.31	0.71	-	-	0.42	-	0.09	-	-	-	-	0.2	0.35	-	-	-	-	-	-	-	-	22.67	0	0	-	-	2.71	0.44	1.4	0.14	0.22	1.21	-	-	-	-	-	0.39	3.81	8.43	0.42	1.41	-	-	0.31	0.71	-	-	0.42	-	0.09	-	-	-	-	0.2	0.35	-	-	-	-	-	-	-	-	22.67		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	No Cost Sharing	20 Coinsurance	20 Coinsurance OP Rehab includes Cardiac Rehab	25 per Visit	25 per Specialist Visit	50 Coinsurance	20 Coinsurance	No Cost Sharing	No Cost Sharing	25 per Script	20 Coinsurance for Diabetes Supplies	No Cost Sharing	300 MAB Preventive Only no cost sharing prior to MAB	25 per Visit	100 MAB no cost sharing prior to MAB	25 per Visit	600 Max Benefit Every 3 Years	Not Applicable	Check with PBP	No Cost Sharing	50 Coinsurance	25 per Visit	No Cost Sharing								5.55	0.06	0.98	0.33	0.12	0.02	0.03	0.11	0.95	0.43	0.9	0	0.06	0.54	0.83	1.22	0.06	0.06	0	0	0.05	0.08	0	0	0.09	0	0.01	0	0	0	0	0.03	0.05	0								12.55	500	1.62	5.55	0.06	3.7	0.77	1.52	0.16	0.26	1.32	0.95	0.43	0.9	-	0.06	0.94	4.63	9.65	0.47	1.47	-	-	0.36	0.8	-	-	0.51	-	0.1	-	-	-	-	0.23	0.4	-	-	-	-	-	-	-	-	35.23
H3346_801_0	2007	6	h.6.	h.7.	h.8.								OP Facility - Other	OP Facility - Other	OP Facility - Other									MH Substance Abuse	Diagnostic Radiology	Other								A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	S	Coin	T	P	P	P	P	P	O	V	P	Coin	V	V								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0								-	2500	283.44	3.1	1414.18	1590.07	443.96	0.71	1.37	264.39	293.54	6313.41	257.65	62.55	17.72	591.93	8213.39	15351.64	1.05	1277.97	3798.78	0	2000.58	3.5	13.64	0	511.13	0	82.15	0	0	0	552.19	0.6	203.81	194.12								No Cost Sharing	No Cost Sharing	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 15 per Visit for Visits 21+	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	15 OP Rehab includes Cardiac Rehab	10 per Visit	15 per Specialist Visit	15 for 1st OP MH visit 50 thereafter	15 per Visit	No Cost Sharing	No Cost Sharing	15 Copayment other Part B Rx	20 Coinsurance for Diabetes Supplies	No Cost Sharing	Rider Avaliable	10 per Visit	Rider Avaliable	15 per Visit	Rider Avaliable	Not Applicable	Check with PBP	No Cost Sharing	15 for 1st OP MH visit 50 thereafter 15 per Visit for Sub Abuse	15 per Visit	No Cost Sharing								0	0	30.32	3.22	32.2	0.18	0.18	44.49	0	0	0	0	0	7.59	5.08	6.62	0.39	13.8	0	0	13.8	0.18	0	0	9.2	0	13.8	0	0	0	0	0.3	13.8	0								-	-	3.57	0.43	1.19	0.13	0.25	0.98	-	-	-	-	-	0.37	3.47	8.47	0.41	1.47	-	-	2.3	0.64	-	-	0.39	-	0.09	-	-	-	-	0.18	0.23	-	-	-	-	-	-	-	-	24.59	0	0	-	-	3.57	0.43	1.19	0.13	0.25	0.98	-	-	-	-	-	0.37	3.47	8.47	0.41	1.47	-	-	2.3	0.64	-	-	0.39	-	0.09	-	-	-	-	0.18	0.23	-	-	-	-	-	-	-	-	24.59		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	No Cost Sharing	20 Coinsurance	20 Coinsurance OP Rehab includes Cardiac Rehab	25 per Visit	25 per Specialist Visit	50 Coinsurance	20 Coinsurance	No Cost Sharing	No Cost Sharing	25 per Script	20 Coinsurance for Diabetes Supplies	No Cost Sharing	Rider Avaliable	25 per Visit	Rider Avaliable	25 per Visit	Rider Avaliable	Not Applicable	Check with PBP	No Cost Sharing	50 Coinsurance	25 per Visit	No Cost Sharing								4.97	0.04	0.84	0.33	0.1	0.02	0.03	0.09	0.79	0.41	0.81	0	0.05	0.48	0.76	1.23	0.06	0.06	0	0	0.33	0.07	0	0	0.09	0	0.01	0	0	0	0	0.03	0.03	0								11.63	500	1.43	4.97	0.04	4.41	0.75	1.29	0.15	0.29	1.07	0.79	0.41	0.81	-	0.05	0.85	4.23	9.69	0.47	1.53	-	-	2.63	0.72	-	-	0.48	-	0.11	-	-	-	-	0.2	0.27	-	-	-	-	-	-	-	-	36.22
H3346_802_0	2007	11	h.6.	h.7.	h.8.								OP Facility - Other	OP Facility - Other	OP Facility - Other									MH Substance Abuse	Diagnostic Radiology	Other								A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	Coin	P	P	P	S	Coin	T	P	P	P	P	P	O	V	P	Coin	V	V								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0								-	2500	273.15	2.99	1362.85	1532.35	427.85	0.68	1.32	254.8	282.88	6084.24	248.29	60.28	17.08	570.44	7915.25	14794.39	1.01	1231.58	3660.89	0	1927.96	3.37	13.15	0	492.58	0	79.17	0	0	0	532.15	0.58	196.41	187.07								No Cost Sharing	No Cost Sharing	0 for days 0-15 65 for days 16-100	No Copay for visits 1-20 15 per Visit for Visits 21+	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	15 OP Rehab includes Cardiac Rehab	10 per Visit	15 per Specialist Visit	15 for 1st OP MH visit 50 thereafter	15 per Visit	No Cost Sharing	No Cost Sharing	15 Copayment other Part B Rx	20 Coinsurance for Diabetes Supplies	No Cost Sharing	Rider Available	10 per Visit	Rider Available	15 per Visit	Rider Available	Not Applicable	Check with PBP	No Cost Sharing	15 for 1st OP MH visit 50 thereafter 15 per Visit for Sub Abuse	15 per Visit	No Cost Sharing								0	0	30.32	3.22	32.2	0.18	0.18	44.49	0	0	0	0	0	7.59	5.08	6.62	0.39	13.8	0	0	13.8	0.18	0	0	9.2	0	13.8	0	0	0	0	0.3	13.8	0								-	-	3.44	0.41	1.15	0.13	0.24	0.94	-	-	-	-	-	0.36	3.35	8.16	0.4	1.42	-	-	2.22	0.62	-	-	0.38	-	0.09	-	-	-	-	0.17	0.23	-	-	-	-	-	-	-	-	23.7	0	0	-	-	3.44	0.41	1.15	0.13	0.24	0.94	-	-	-	-	-	0.36	3.35	8.16	0.4	1.42	-	-	2.22	0.62	-	-	0.38	-	0.09	-	-	-	-	0.17	0.23	-	-	-	-	-	-	-	-	23.7		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	35 per trip	20 Coinsurance	20 Coinsurance	50 per ER Visit 20 per Urgent Care Visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	No Cost Sharing	20 Coinsurance	20 Coinsurance OP Rehab includes Cardiac Rehab	25 per Visit	25 per Specialist Visit	50 Coinsurance	20 Coinsurance	No Cost Sharing	No Cost Sharing	25 per Script	20 Coinsurance for Diabetes Supplies	No Cost Sharing	Rider Available	25 per Visit	Rider Available	25 per Visit	Rider Available	Not Applicable	Check with PBP	No Cost Sharing	50 Coinsurance	25 per Visit	No Cost Sharing								4.79	0.04	0.81	0.32	0.1	0.02	0.03	0.08	0.76	0.4	0.78	0	0.05	0.46	0.73	1.18	0.05	0.06	0	0	0.32	0.07	0	0	0.08	0	0.01	0	0	0	0	0.02	0.03	0								11.21	500	1.38	4.79	0.04	4.25	0.73	1.25	0.14	0.28	1.03	0.76	0.4	0.78	-	0.05	0.82	4.08	9.34	0.45	1.48	-	-	2.54	0.69	-	-	0.46	-	0.1	-	-	-	-	0.2	0.26	-	-	-	-	-	-	-	-	34.91
H3347_001_0	2007	5																					3100											D	D	D	V	T	Coin	P	V	V	V	V	V	V	V	V	V	V	V	Coin	V	Coin	O	V	V	V	V	V	V	V	V	V																																																				-		3246.46		1767.54		712.47	7.8		223.67	166.64							34142.1	194.9	2843.98	47.94		10.65																					#1A 500 per Admit #1B 500 per Admit		#2 0/day days 1-10 50/day days 11-20 100/day days 21-100	#6 0 #13C 0	#10A 50 #10B 50	#11A 20 #11B 20 #11C 0		#4A 50 #4B 50	#9A 200 #9B 200				#12 0	#3 0 #5 0 #9D 0		#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0 #7B 20 #7D 20 #7F 20 #7G 0 #9C 20 #14I 25	#7E 20 #7H 20	#7C 10 #7I 10	#8A 20 #8B 20		#15 20																					51.63		53.34		50	0.18		36.12	131.3							3.08	4.53	2.91	0.12		0.2																					13.97	-	7.86	-	2.97	1.43	-	0.67	1.82	-	-	-	-	-	-	8.75	0.07	0.69	5.94	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.31		0	13.97	-	7.86	-	2.97	1.43	-	0.67	1.82	-	-	-	-	-	-	8.75	0.07	0.69	5.94	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.31																																																																																				-		0	13.97	-	7.86	-	2.97	1.43	-	0.67	1.82	-	-	-	-	-	-	8.75	0.07	0.69	5.94	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.31
H3351_001_0	2007	3																																A	A	D		T	coin	coin	V	V		V		V	V	V	V	V	V	V	V	S			coin	V		V				P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		259.24	5.79	2369.77	0	249.79	5.57	14.12	258.35	351.09	0	982.35	0	18.89	493.58	4650.74	6198.13	243.1	823.48	574.89	55.84	125.47	0	0	15.65	1219.62	0	49.78	0	0	0	158.05											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											350	350	25	0	50	0.2	0.05	50	50	0	10	0	10	10	5	10	10	10	10	10	10	0	0	0.32	10	0	10	0	0	0	33.7											7.56	0.17	4.94	-	1.04	1.1	0.7	1.08	1.46	-	0.82	-	0.02	0.41	1.94	5.17	0.2	0.69	0.48	0.05	0.1	-	-	5.04	1.02	-	0.04	-	-	-	0.44	-	-	-	-	-	-	-	-	-	-	34.45			7.56	0.17	4.94	-	1.04	1.1	0.7	1.08	1.46	-	0.82	-	0.02	0.41	1.94	5.17	0.2	0.69	0.48	0.05	0.1	-	-	5.04	1.02	-	0.04	-	-	-	0.44	-	-	-	-	-	-	-	-	-	-	34.45																																																																																				-			7.56	0.17	4.94	-	1.04	1.1	0.7	1.08	1.46	-	0.82	-	0.02	0.41	1.94	5.17	0.2	0.69	0.48	0.05	0.1	-	-	5.04	1.02	-	0.04	-	-	-	0.44	-	-	-	-	-	-	-	-	-	-	34.45
H3351_002_0	2007	4																																A	A	D		T	coin	coin	V	V		V		V	V	V	V	V	V	V	V	S				V		V				P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		250.82	5.03	2369.77	0	250.03	5.57	14.12	259.05	354.65	0	921.35	0	5.25	491.07	4256.95	6109.41	213.09	809.12	545.29	62.15	133.5	0	0	0	1180.95	0	50.54	0	0	0	158.05											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											300	300	25	0	50	0.2	0.06	50	35	0	15	0	15	15	10	15	15	15	15	15	15	0	0	0	15	0	15	0	0	0	33.57											6.27	0.13	4.94	-	1.04	1.1	0.79	1.08	1.03	-	1.15	-	0.01	0.61	3.55	7.64	0.27	1.01	0.68	0.08	0.17	-	-	-	1.48	-	0.06	-	-	-	0.44	-	-	-	-	-	-	-	-	-	-	33.52			6.27	0.13	4.94	-	1.04	1.1	0.79	1.08	1.03	-	1.15	-	0.01	0.61	3.55	7.64	0.27	1.01	0.68	0.08	0.17	-	-	-	1.48	-	0.06	-	-	-	0.44	-	-	-	-	-	-	-	-	-	-	33.52																																																																																				-			6.27	0.13	4.94	-	1.04	1.1	0.79	1.08	1.03	-	1.15	-	0.01	0.61	3.55	7.64	0.27	1.01	0.68	0.08	0.17	-	-	-	1.48	-	0.06	-	-	-	0.44	-	-	-	-	-	-	-	-	-	-	33.52
H3351_006_0	2007	5																																		D		T	coin	coin	V		V		V	V	V	V	V	V	V	V	V	O	O		V	V		V				O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	942.46	0	195.02	10.39	2.67	246.2	348.69	0	503.1	0	26.46	1041.38	5036.47	5239.56	592.01	573.33	771.56	597.65	310.9	6.9	0	1498.84	668.58	0	40.71	0	0	0	243.85											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0	0	25	0	35	0.18	0.13	47.11	50	0	20	0	20	20	5	20	20	20	20	20	20	20	0	37.49	20	0	20	0	0	0	43.02											-	-	1.96	-	0.57	1.92	0.33	0.97	1.45	-	0.84	-	0.04	1.74	2.1	8.73	0.99	0.96	1.29	1	0.52	0.01	-	4.68	1.11	-	0.07	-	-	-	0.87	-	-	-	-	-	-	-	-	-	-	32.14			-	-	1.96	-	0.57	1.92	0.33	0.97	1.45	-	0.84	-	0.04	1.74	2.1	8.73	0.99	0.96	1.29	1	0.52	0.01	-	4.68	1.11	-	0.07	-	-	-	0.87	-	-	-	-	-	-	-	-	-	-	32.14																																																																																				-			-	-	1.96	-	0.57	1.92	0.33	0.97	1.45	-	0.84	-	0.04	1.74	2.1	8.73	0.99	0.96	1.29	1	0.52	0.01	-	4.68	1.11	-	0.07	-	-	-	0.87	-	-	-	-	-	-	-	-	-	-	32.14
H3351_007_0	2007	2																																A	A	D		T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	O	O			V		V				O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		174	2.43	942.46	0	216.04	10.39	2.67	233.65	348.69	0	565.76	0.18	6.24	1321.98	4656.11	5600.74	621.64	605.73	709.38	435.66	363.07	1.47	0	0	710.37	0	47.13	0	0	0	243.85											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											100	100	25	0	50	0.15	0.08	45.68	50	0	10	50	10	10	5	10	10	10	10	10	10	10	0	0	10	0	10	0	0	0	37.34											1.45	0.02	1.96	-	0.9	1.57	0.21	0.89	1.45	-	0.47	0	0.01	1.1	1.94	4.67	0.52	0.5	0.59	0.36	0.3	0	-	-	0.59	-	0.04	-	-	-	0.76	-	-	-	-	-	-	-	-	-	-	20.31			1.45	0.02	1.96	-	0.9	1.57	0.21	0.89	1.45	-	0.47	0	0.01	1.1	1.94	4.67	0.52	0.5	0.59	0.36	0.3	0	-	-	0.59	-	0.04	-	-	-	0.76	-	-	-	-	-	-	-	-	-	-	20.31																																																																																				-			1.45	0.02	1.96	-	0.9	1.57	0.21	0.89	1.45	-	0.47	0	0.01	1.1	1.94	4.67	0.52	0.5	0.59	0.36	0.3	0	-	-	0.59	-	0.04	-	-	-	0.76	-	-	-	-	-	-	-	-	-	-	20.31
H3351_008_0	2007	2																																A	A	D		T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	O	O			V		V				O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		174	2.43	942.46	0	216.04	10.39	2.67	232.07	347.63	0	551.1	0.18	6.21	1315.34	4330.18	5244.82	582.79	567.87	691	422.19	351.85	1.42	0	0	665.98	0	44.18	0	0	0	241.42											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											100	100	25	0	50	0.15	0.08	46.94	65	0	20	50	20	20	15	20	20	20	20	20	20	20	0	0	20	0	20	0	0	0	37.18											1.45	0.02	1.96	-	0.9	1.57	0.21	0.91	1.88	-	0.92	0	0.01	2.19	5.41	8.74	0.97	0.95	1.15	0.7	0.59	0	-	-	1.11	-	0.07	-	-	-	0.75	-	-	-	-	-	-	-	-	-	-	32.48			1.45	0.02	1.96	-	0.9	1.57	0.21	0.91	1.88	-	0.92	0	0.01	2.19	5.41	8.74	0.97	0.95	1.15	0.7	0.59	0	-	-	1.11	-	0.07	-	-	-	0.75	-	-	-	-	-	-	-	-	-	-	32.48																																																																																				-			1.45	0.02	1.96	-	0.9	1.57	0.21	0.91	1.88	-	0.92	0	0.01	2.19	5.41	8.74	0.97	0.95	1.15	0.7	0.59	0	-	-	1.11	-	0.07	-	-	-	0.75	-	-	-	-	-	-	-	-	-	-	32.48
H3351_009_0	2007	2																																A	A	D		T	coin	coin	V	V		V		V	V	V	V	V	V	V	V	S				V		V				P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		250.57	5.03	2369.77	0	250.03	5.57	14.12	259.05	352.51	0	902.01	0	5.23	488.6	4256.95	5775.05	201.64	765.62	533.85	60.84	130.69	0	0	0	1117.45	0	47.82	0	0	0	156.47											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											350	350	25	0	50	0.2	0.06	50	65	0	25	0	25	25	10	25	25	25	25	25	25	0	0	0	25	0	25	0	0	0	34.72											7.31	0.15	4.94	-	1.04	1.1	0.79	1.08	1.91	-	1.88	-	0.01	1.02	3.55	12.03	0.42	1.6	1.11	0.13	0.27	-	-	-	2.33	-	0.1	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	43.2		0	7.31	0.15	4.94	-	1.04	1.1	0.79	1.08	1.91	-	1.88	-	0.01	1.02	3.55	12.03	0.42	1.6	1.11	0.13	0.27	-	-	-	2.33	-	0.1	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	43.2																																																																																				-			7.31	0.15	4.94	-	1.04	1.1	0.79	1.08	1.91	-	1.88	-	0.01	1.02	3.55	12.03	0.42	1.6	1.11	0.13	0.27	-	-	-	2.33	-	0.1	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	43.2
H3351_801_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1771.1	23.13	2046.62	2240.77	217.06	615.59	506.45	489.96	653.91	15497.73	2353.66	0	17.82	1388.44	7250.48	13034	313.31	1280.88	3232.22	2595.38	2183.97	46.66	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				125.53	51.44	45.77	0	135.88	24.48	79.59	87.56	209.94	2.73	31.08	0	145.06	18.33	14.57	26.9	17.97	10.52	29.84	14.19	78.05	63.2	0	0	0	0	0	0	0	0	0											18.53	0.1	7.81	-	2.46	1.26	3.36	3.57	11.44	3.52	6.1	-	0.22	2.12	8.8	29.22	0.47	1.12	8.04	3.07	14.2	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.64			18.53	0.1	7.81	-	2.46	1.26	3.36	3.57	11.44	3.52	6.1	-	0.22	2.12	8.8	29.22	0.47	1.12	8.04	3.07	14.2	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.64																																																																																				-			18.53	0.1	7.81	-	2.46	1.26	3.36	3.57	11.44	3.52	6.1	-	0.22	2.12	8.8	29.22	0.47	1.12	8.04	3.07	14.2	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.64
H3351_802_0	2007	4																																coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		205.15	3.08	23.74	22.66	8.63	10.39	2.67	15.8	36.5	5.51	15.51	4.22	0.43	22.53	25.78	83.52	4.35	3.76	28.33	90.4	3.36	0.05	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.53	0.25	4.5	-	2.04	2.45	0.63	3.73	8.61	1.3	3.66	1	0.1	5.32	6.08	19.71	1.03	0.89	6.69	21.33	0.79	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.65			16.53	0.25	4.5	-	2.04	2.45	0.63	3.73	8.61	1.3	3.66	1	0.1	5.32	6.08	19.71	1.03	0.89	6.69	21.33	0.79	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.65																																																																																				-			16.53	0.25	4.5	-	2.04	2.45	0.63	3.73	8.61	1.3	3.66	1	0.1	5.32	6.08	19.71	1.03	0.89	6.69	21.33	0.79	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.65
H3351_803_0	2007	3																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1771.1	23.13	2046.62	2240.77	217.06	615.59	506.45	489.96	653.91	15497.73	2353.66	0	17.82	1388.44	7250.48	13034	313.31	1280.88	3232.22	2595.38	2183.97	46.66	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				125.53	51.44	45.77	0	135.88	24.48	79.59	87.56	209.94	2.73	31.08	0	145.06	18.33	14.57	26.9	17.97	10.52	29.84	14.19	78.05	63.2	0	0	0	0	0	0	0	0	0											18.53	0.1	7.81	-	2.46	1.26	3.36	3.57	11.44	3.52	6.1	-	0.22	2.12	8.8	29.22	0.47	1.12	8.04	3.07	14.2	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.64			18.53	0.1	7.81	-	2.46	1.26	3.36	3.57	11.44	3.52	6.1	-	0.22	2.12	8.8	29.22	0.47	1.12	8.04	3.07	14.2	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.64																																																																																				-			18.53	0.1	7.81	-	2.46	1.26	3.36	3.57	11.44	3.52	6.1	-	0.22	2.12	8.8	29.22	0.47	1.12	8.04	3.07	14.2	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.64
H3351_804_0	2007	3																																coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		205.15	3.08	23.74	22.66	8.63	10.39	2.67	15.8	36.5	5.51	15.51	4.22	0.43	22.53	25.78	83.52	4.35	3.76	28.33	90.4	3.36	0.05	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.08	0.08	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.53	0.25	4.5	-	2.04	2.45	0.63	3.73	8.61	1.3	3.66	1	0.1	5.32	6.08	19.71	1.03	0.89	6.69	21.33	0.79	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.65			16.53	0.25	4.5	-	2.04	2.45	0.63	3.73	8.61	1.3	3.66	1	0.1	5.32	6.08	19.71	1.03	0.89	6.69	21.33	0.79	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.65																																																																																				-			16.53	0.25	4.5	-	2.04	2.45	0.63	3.73	8.61	1.3	3.66	1	0.1	5.32	6.08	19.71	1.03	0.89	6.69	21.33	0.79	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.65
H3359_001_0	2007	8																																D	D	D			Coin		P						P		V	Coin	V			S			P			V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1265.5	95.1	586.95	0	0	3.86	0	178.57	0	0	0	0	0	48.05	0	5506.89	4.07	464.99	0	0	41.99	0	0	617.09	0	0	0.23	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 7g 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												50	50	50	0	0	0.09	0	50	0	0	0	0	0	10	0	10	0.23	10	0	0	25	0	0	31.04	0	0	10	0	0	0	0											5.27	0.4	2.45	-	-	0.35	-	0.74	-	-	-	-	-	0.04	-	4.59	0.94	0.39	-	-	0.09	-	-	1.6	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.85	0	0	5.27	0.4	2.45	-	-	0.35	-	0.74	-	-	-	-	-	0.04	-	4.59	0.94	0.39	-	-	0.09	-	-	1.6	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.85																																																																																				-			5.27	0.4	2.45	-	-	0.35	-	0.74	-	-	-	-	-	0.04	-	4.59	0.94	0.39	-	-	0.09	-	-	1.6	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.85
H3359_019_0	2007	9																																D	D	D			Coin		P						P		V	Coin	V			S						V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1262.82	69.41	541.22	0	0	2.47	0	166.73	0	0	0	0	0	96.65	0	4478.79	1.9	303.62	0	0	26.88	0	0	0	0	0	0.3	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 7g 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												50	50	50	0	0	0.09	0	50	0	0	0	0	0	10	0	10	0.22	10	0	0	25	0	0	0	0	0	10	0	0	0	0											5.26	0.29	2.26	-	-	0.22	-	0.69	-	-	-	-	-	0.08	-	3.73	0.42	0.25	-	-	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26	0	0	5.26	0.29	2.26	-	-	0.22	-	0.69	-	-	-	-	-	0.08	-	3.73	0.42	0.25	-	-	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26																																																																																				-			5.26	0.29	2.26	-	-	0.22	-	0.69	-	-	-	-	-	0.08	-	3.73	0.42	0.25	-	-	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26
H3359_021_0	2007	8																																Coin	Coin	Coin		Coin			Coin	Coin	Coin	Coin		Coin	Coin																												0	0	0	0	0	0.28	0.04	0.69	0	1.24	0.02	0	0.01	0.09	1.89	3.83	0.16	0.15	0.01	0.22	0.01	0.01	0	0	0	0	0	0	0	0	0											8.66		591.31	37.53	37.39	0	18.9	0	0	9.02	4.88	11.99	22.57	0	1.42	6.55	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 7g 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.05	0.06	0.08	0	0.2	0	0	0.1	0.13	0	0.12	0	0	0.03	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											29.98	2.09	3.15	-	3.78	-	-	0.9	0.64	0.01	2.65	-	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.37	138	0	29.98	2.09	3.15	-	3.78	0.28	0.04	1.59	0.64	1.25	2.66	-	0.01	0.26	1.89	3.83	0.16	0.15	0.01	0.22	0.01	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.03																																																																																				-			29.98	2.09	3.15	-	3.78	0.28	0.04	1.59	0.64	1.25	2.66	-	0.01	0.26	1.89	3.83	0.16	0.15	0.01	0.22	0.01	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.03
H3359_026_0	2007	9																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	575.21	0	0	0	0	0	189.58	0	8557.74	2157.71	5027.61	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 7g 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	50	0	0	0	0	0	10	0	10	20	10	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	2.4	-	-	-	-	-	0.16	-	7.13	3.6	4.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.47	0	0	-	-	-	-	-	-	-	2.4	-	-	-	-	-	0.16	-	7.13	3.6	4.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.47																																																																																				-			-	-	-	-	-	-	-	2.4	-	-	-	-	-	0.16	-	7.13	3.6	4.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.47
H3359_027_0	2007	8																																D	D	D			Coin		P						P		V	Coin	V			S						V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1296.78	71.27	547.48	0	0	2.48	0	171.21	0	0	0	0	0	99.25	0	4496.98	1.91	304.85	0	0	26.99	0	0	0	0	0	0.3	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 7g 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												50	50	50	0	0	0.09	0	50	0	0	0	0	0	10	0	10	0.22	10	0	0	25	0	0	0	0	0	10	0	0	0	0											5.4	0.3	2.28	-	-	0.22	-	0.71	-	-	-	-	-	0.08	-	3.75	0.42	0.25	-	-	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.48	0	0	5.4	0.3	2.28	-	-	0.22	-	0.71	-	-	-	-	-	0.08	-	3.75	0.42	0.25	-	-	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.48																																																																																				-			5.4	0.3	2.28	-	-	0.22	-	0.71	-	-	-	-	-	0.08	-	3.75	0.42	0.25	-	-	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.48
H3359_804_0	2007	7																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		268.87	2.89	50.13	0	4.79	16.41	0.75	3.89	17.52	6.85	18.62	0	5.19	18.44	28.74	47.04	2.46	6.82	41.2	133.53	33.48	4.18	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99	138	0	14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99																																																																																				-			14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99
H3359_805_0	2007	6																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		268.87	2.89	50.13	0	4.79	16.41	0.75	3.89	17.52	6.85	18.62	0	5.19	18.44	28.74	47.04	2.46	6.82	41.2	133.53	33.48	4.18	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99	138	0	14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99																																																																																				-			14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99
H3359_806_0	2007	7																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		268.87	2.89	50.13	0	4.79	16.41	0.75	3.89	17.52	6.85	18.62	0	5.19	18.44	28.74	47.04	2.46	6.82	41.2	133.53	33.48	4.18	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99	138	0	14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99																																																																																				-			14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99
H3359_807_0	2007	7																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		268.87	2.89	50.13	0	4.79	16.41	0.75	3.89	17.52	6.85	18.62	0	5.19	18.44	28.74	47.04	2.46	6.82	41.2	133.53	33.48	4.18	0	0	0	0	0	0	0	0	0											FFS Medicare	FFS Medicare	FFS Medicare		FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				0.05	0.05	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99	138	0	14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99																																																																																				-			14.35	0.15	8.47	-	1.13	3.87	0.18	0.92	4.14	1.62	4.39	-	1.23	4.35	6.78	11.1	0.58	1.61	9.72	31.51	7.9	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.99
H3361_019_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1670.79	32.78	868.55	879.87	330.7	13.79	2.35	361.89	345.08	2757.26	1338.19	0	729.66	786.29	3489.4	6895.83	156.53	684.5	3361.24	19490.26	10.25	13.07	0	381	483.21	172.15	128.96	4.99	0	172.84	843.2											200  days 1 - 5	200  days 1 - 5	119  days 21 - 100	10	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	0 - 100		0 - 30	30 to 100	5	0 to 30	20 to 30	30	0 -100	0 to 35	0 -20	0.2	0	0	0	0	35	0		0	0 to 0											127.58	127.58	27.01	10	100	0.2	0.2	50	135	0	25	0	20	64.02	4.08	29.09	22.5	30	9.99	1.14	0.13	0.2	0	0	0	0	35	0	0	0	0											17.76	0.35	1.95	0.73	2.76	2.76	0.47	1.51	3.88	-	2.79	-	1.22	4.19	1.19	16.72	0.29	1.71	2.8	1.86	1.37	2.61	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.3		0	17.76	0.35	1.95	0.73	2.76	2.76	0.47	1.51	3.88	-	2.79	-	1.22	4.19	1.19	16.72	0.29	1.71	2.8	1.86	1.37	2.61	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.3	0																																																																																			-		0	17.76	0.35	1.95	0.73	2.76	2.76	0.47	1.51	3.88	-	2.79	-	1.22	4.19	1.19	16.72	0.29	1.71	2.8	1.86	1.37	2.61	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.3
H3361_020_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1947.47	35.95	1118.76	1277.69	334.58	11.16	2.36	273.96	186.34	1365.14	725.14	0	411.21	437.54	3499.47	6983.24	177.87	767.38	3112.69	20843.34	7.29	20.57	1200	381	444.83	164.63	139.5	5.61	0	212.12	843.2											0  unlimited	0  unlimited	0  days 1 - 100	0	0	20	20	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 -4 0		0 - 15	15 to 0	0	0 to 15	5 to 15	15	0 - 40	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											0	0	0	0	0	0.2	0.2	0	0	0	10	0	10	7.81	0	15	7.5	15	4.05	1.14	0.13	0.2	0	0	0	0	20	0	0	0	0											-	-	-	-	-	2.23	0.47	-	-	-	0.6	-	0.34	0.28	-	8.73	0.11	0.96	1.05	1.99	0.98	4.11	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.09		0	-	-	-	-	-	2.23	0.47	-	-	-	0.6	-	0.34	0.28	-	8.73	0.11	0.96	1.05	1.99	0.98	4.11	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.09	0																																																																																			-		0	-	-	-	-	-	2.23	0.47	-	-	-	0.6	-	0.34	0.28	-	8.73	0.11	0.96	1.05	1.99	0.98	4.11	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.09
H3361_021_0	2007	6																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1827.65	36.51	1105.54	779.56	289.48	10.48	2.04	276.09	239.23	2073.61	993.91	0	555.84	598.18	3288.5	6850.43	161.62	718.86	3320.24	19935.41	7.69	13.33	0	381	441.58	174.46	127.03	5.45	0	158.49	843.2											250  days 1 - 5	250  days 1 - 5	119  days 21 - 100	10	100	20	20	50	175-ASC/ 175-OP/ 175-Non Surg	0	0 - 100		0 - 35	35 to 100	10	0 to 35	25 to 35	35	0 - 100	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											159.48	159.48	27.01	10	100	0.2	0.2	50	175	0	25	0	23.33	66.55	8.17	33.67	27.5	35	9.98	1.07	0.13	0.2	0	0	0	0	25	0	0	0	0											24.29	0.49	2.49	0.65	2.41	2.1	0.41	1.15	3.49	-	2.07	-	1.08	3.32	2.24	19.22	0.37	2.1	2.76	1.78	1.03	2.67	-	-	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.37		0	24.29	0.49	2.49	0.65	2.41	2.1	0.41	1.15	3.49	-	2.07	-	1.08	3.32	2.24	19.22	0.37	2.1	2.76	1.78	1.03	2.67	-	-	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.37	0																																																																																			-		0	24.29	0.49	2.49	0.65	2.41	2.1	0.41	1.15	3.49	-	2.07	-	1.08	3.32	2.24	19.22	0.37	2.1	2.76	1.78	1.03	2.67	-	-	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.37
H3361_022_0	2007	9																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1474.84	28.22	712.41	825.63	257.21	10.56	2	296.08	243.38	2256.74	1102.08	0	633.42	678.53	3303.66	6292.31	141.2	622.31	3039.55	17753.33	6.97	9.7	0	381	439.93	174.17	148.84	6.4	0	160.22	843.2											150  days 1 - 5	150  days 1 - 5	119  days 21 - 100	0	100	20	20	50	125-ASC/ 125-OP/ 125-Non Surg	0	0 - 100		0 - 30	30 to 75	10	0 to 30	20 to 30	30	0 - 100	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											95.69	95.69	27.01	0	100	0.2	0.2	50	125	0	25	0	20	51.71	8.09	29.18	22.5	30	10.04	1.03	0.13	0.2	0	0	0	0	25	0	0	0	0											11.76	0.22	1.6	-	2.14	2.11	0.4	1.23	2.54	-	2.3	-	1.06	2.92	2.23	15.3	0.26	1.56	2.54	1.52	0.93	1.94	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89		0	11.76	0.22	1.6	-	2.14	2.11	0.4	1.23	2.54	-	2.3	-	1.06	2.92	2.23	15.3	0.26	1.56	2.54	1.52	0.93	1.94	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89	0																																																																																			-		0	11.76	0.22	1.6	-	2.14	2.11	0.4	1.23	2.54	-	2.3	-	1.06	2.92	2.23	15.3	0.26	1.56	2.54	1.52	0.93	1.94	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.89
H3361_024_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1360.39	24.35	853.6	1406.35	286.18	12.16	2.59	259.03	197.93	1501.95	803.1	0	464.32	492.88	3957.35	7666.85	192.06	833.99	3420.06	22643.59	6.16	20.93	1200	381	430.09	165.08	186.45	7.78	0	245.52	843.2											0  unlimited	0  unlimited	0  days 1 - 100	0	0	20	20	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 40		0 - 15	15 to 0	0	0 to 15	5 to 15	15	0 - 40	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											0	0	0	0	0	0.2	0.2	0	0	0	10	0	10	7.83	0	15	7.5	15	4.05	1.11	0.13	0.2	0	0	0	0	20	0	0	0	0											-	-	-	-	-	2.43	0.52	-	-	-	0.67	-	0.39	0.32	-	9.58	0.12	1.04	1.15	2.09	0.83	4.19	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.64		0	-	-	-	-	-	2.43	0.52	-	-	-	0.67	-	0.39	0.32	-	9.58	0.12	1.04	1.15	2.09	0.83	4.19	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.64	0																																																																																			-		0	-	-	-	-	-	2.43	0.52	-	-	-	0.67	-	0.39	0.32	-	9.58	0.12	1.04	1.15	2.09	0.83	4.19	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.64
H3361_027_0	2007	6																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1684.98	32.6	1276.47	1700.5	352.86	14.8	2.94	242.95	238.67	1526.39	760.05	0	433.27	463.62	4642.85	9547.9	233.53	1024.09	4255.95	28830.54	6.92	26.46	0	381	450.63	174.15	193.13	8.11	0	289.21	296											75  days 1 - 5	75  days 1 - 5	25  days 8 - 100	0	50	20	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	0 - 75		0 - 30	30 to 75	5	0 to 30	20 to 30	30	0 - 75	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											47.84	47.84	15.2	0	50	0.2	0.2	50	45	0	18.75	0	20	51.71	4.05	29.05	22.5	30	7.52	1.17	0.13	0.2	0	0	0	0	25	0	0	0	0											6.72	0.13	1.62	-	1.47	2.96	0.59	1.01	0.9	-	1.19	-	0.72	2	1.57	23.12	0.44	2.56	2.67	2.82	0.93	5.29	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.09		0	6.72	0.13	1.62	-	1.47	2.96	0.59	1.01	0.9	-	1.19	-	0.72	2	1.57	23.12	0.44	2.56	2.67	2.82	0.93	5.29	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.09	0																																																																																			-		0	6.72	0.13	1.62	-	1.47	2.96	0.59	1.01	0.9	-	1.19	-	0.72	2	1.57	23.12	0.44	2.56	2.67	2.82	0.93	5.29	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.09
H3361_028_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2117.15	44.75	1463.59	1614.11	483.76	22.4	4.2	597.36	609.61	4228.33	1959.71	0	1039.77	1129.32	4908.3	9819.69	201.78	887.8	5336.6	24390.99	9.87	15.6	0	381	485.25	182.65	207.96	8.5	0	257.8	296											200  days 1 - 5	200  days 1 - 5	119  days 21 - 100	10	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 35	35 to 100	15	0 to 35	25 to 35	35	0 - 75	0 to 35	0 -20	0.2	0	0	0	0	35	0		0	0 to 0											127.58	127.58	27.01	10	100	0.2	0.2	50	135	0	30	0	23.33	66.85	12.49	33.67	27.5	35	11.86	0.97	0.13	0.2	0	0	0	0	35	0	0	0	0											22.51	0.48	3.29	1.35	4.03	4.48	0.84	2.49	6.86	-	4.9	-	2.02	6.29	5.11	27.55	0.46	2.59	5.28	1.97	1.32	3.12	-	-	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54		0	22.51	0.48	3.29	1.35	4.03	4.48	0.84	2.49	6.86	-	4.9	-	2.02	6.29	5.11	27.55	0.46	2.59	5.28	1.97	1.32	3.12	-	-	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54	0																																																																																			-		0	22.51	0.48	3.29	1.35	4.03	4.48	0.84	2.49	6.86	-	4.9	-	2.02	6.29	5.11	27.55	0.46	2.59	5.28	1.97	1.32	3.12	-	-	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54
H3361_029_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2175.07	45.58	1464.27	2001.13	367.7	15.99	2.8	214.54	217.86	1495.96	698.19	0	374.66	406.11	4741.05	11167.56	295.16	1244.03	4609.32	35628.66	6.28	32.11	0	381	466.45	178.17	199.91	8.3	0	254.19	296											100  days 1 - 5	100  days 1 - 5	50  days 8 - 100	0	50	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	15 - 75		0 - 25	25 to 100	15	0 to 25	15 to 25	25	0 - 75	0 to 35	0 -20	0.2	0	0	0	0	35	0		0	0 to 0											63.79	63.79	30.4	0	50	0.2	0.2	50	135	0	30	0	16.67	61.68	12.45	24.2	17.5	25	11.88	1.08	0.13	0.2	0	0	0	0	35	0	0	0	0											11.56	0.24	3.71	-	1.53	3.2	0.56	0.89	2.45	-	1.75	-	0.52	2.09	4.92	22.52	0.43	2.59	4.56	3.21	0.84	6.42	-	-	-	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.59		0	11.56	0.24	3.71	-	1.53	3.2	0.56	0.89	2.45	-	1.75	-	0.52	2.09	4.92	22.52	0.43	2.59	4.56	3.21	0.84	6.42	-	-	-	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.59	0																																																																																			-		0	11.56	0.24	3.71	-	1.53	3.2	0.56	0.89	2.45	-	1.75	-	0.52	2.09	4.92	22.52	0.43	2.59	4.56	3.21	0.84	6.42	-	-	-	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.59
H3361_031_0	2007	3																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1982.58	37.58	1365.49	2250.68	7.58	19.77	4.06	5.57	28.61	1745.39	28.74	0	8.82	18.97	5745	73.7	3.41	4.23	4991.65	140.63	9.5	37.43	1200	381	0	0	0	0	0	365.88	1163.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											179	133.79	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.14	0.2	2.95	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											29.57	0.42	3.07	-	1.52	-	-	1.11	5.72	-	1.44	-	1.32	3.79	-	14.74	0.49	0.85	1.23	10.85	1.27	7.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.89		0	29.57	0.42	3.07	-	1.52	-	-	1.11	5.72	-	1.44	-	1.32	3.79	-	14.74	0.49	0.85	1.23	10.85	1.27	7.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.89	0																																																																																			-		0	29.57	0.42	3.07	-	1.52	-	-	1.11	5.72	-	1.44	-	1.32	3.79	-	14.74	0.49	0.85	1.23	10.85	1.27	7.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.89
H3361_039_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1185.53	21.35	876.59	1494.61	283.02	12.73	2.72	199.6	192.2	1172.99	595.05	0	360.3	382.68	3903.63	7670.28	191.64	849.19	3206.38	22502.69	6.49	23.47	1200	0	0	0	0	0	0	260.69	843.2											200  days 1 - 5	200  days 1 - 5	119  days 21 - 100	0	100	20	20	50	100-ASC/ 150-OP/ 100-Non Surg	0	0 - 100		0 - 10	10 to 100	10	0 to 15	5 to 10	10	0 - 100	0 to 20	0 -20	0.2	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											127.58	127.58	27.01	0	100	0.2	0.2	50	140	0	25	0	6.67	53.07	8.01	10.26	6.25	10	10.13	1.33	0.13	0.2	0	0	0	0	0	0	0	0	0											12.6	0.23	1.97	-	2.36	2.55	0.54	0.83	2.24	-	1.24	-	0.2	1.69	2.6	6.56	0.1	0.71	2.71	2.5	0.87	4.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.2		0	12.6	0.23	1.97	-	2.36	2.55	0.54	0.83	2.24	-	1.24	-	0.2	1.69	2.6	6.56	0.1	0.71	2.71	2.5	0.87	4.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.2	0																																																																																			-		0	12.6	0.23	1.97	-	2.36	2.55	0.54	0.83	2.24	-	1.24	-	0.2	1.69	2.6	6.56	0.1	0.71	2.71	2.5	0.87	4.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.2
H3361_043_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1938.7	34.9	1464.54	2407.38	456.01	20.61	4.41	322.2	310.1	1890.34	970.92	0	581.78	617.81	6689.79	13198.1	334.75	1481.59	5228.51	36194.42	10.54	37.98	1200	381	604.13	227.48	258.91	10.59	0	421.16	843.2											0  unlimited	0  unlimited	0  days 1 - 100	0	0	20	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 15	0 to 0	0	0 - 50	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											0	0	0	0	0	0.2	0.2	50	0	0	12.5	0	0	0	0	0.74	0	0	5.06	1.15	0.13	0.2	0	0	0	0	20	0	0	0	0											-	-	-	-	-	4.12	0.88	1.34	-	-	1.01	-	-	-	-	0.81	-	-	2.21	3.46	1.41	7.6	-	-	-	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28		0	-	-	-	-	-	4.12	0.88	1.34	-	-	1.01	-	-	-	-	0.81	-	-	2.21	3.46	1.41	7.6	-	-	-	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	0																																																																																			-		0	-	-	-	-	-	4.12	0.88	1.34	-	-	1.01	-	-	-	-	0.81	-	-	2.21	3.46	1.41	7.6	-	-	-	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28
H3361_047_0	2007	4																					0											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1860.12	35.73	1532.14	1859.06	488.27	24.73	4.26	451.29	449.37	2961.11	1531.1	0	798.05	858.37	6033.42	12133.98	269.03	1180.82	5981.57	32964.81	8.96	7723.92	0	0	585.13	420.84	250.77	0	0	370.78	547.2											300  per admit	300  per admit	0  per day	10	50	0	0	50	35-ASC/ 35-OP/ 35-Non Surg	0	0 - 0		0 - 0	20 to 0	10	0 to 20	20 to 20	20	0 - 0	0 to 3	0 -20	0	0	Not Covered	0	0	0	0		Oct-00	0 to 0											54.24	54.24	0	10	50	0	0	50	35	0	0	0	0	10.3	8.24	13.61	20	20	0	0.99	0.13	0	0	0	0	0	0	0	0	0	0											8.41	0.16	-	1.55	2.03	-	-	1.88	1.31	-	-	-	-	0.74	4.14	13.76	0.45	1.97	-	2.72	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.32		0	8.41	0.16	-	1.55	2.03	-	-	1.88	1.31	-	-	-	-	0.74	4.14	13.76	0.45	1.97	-	2.72	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.32	0																																																																																			-		0	8.41	0.16	-	1.55	2.03	-	-	1.88	1.31	-	-	-	-	0.74	4.14	13.76	0.45	1.97	-	2.72	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.32
H3361_050_0	2007	5																					0											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1974.63	37.21	1457.02	2265.66	426.25	19.7	4.07	289.57	281.61	1759.73	930.07	0	519.59	553.89	5799.17	12220.73	289.96	1341.06	5268.15	35485.05	9.54	8332.24	0	0	559.41	413.21	239.75	0	0	371.78	547.2											0  unlimited	0  unlimited	0  per day	0	0	0	0	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 0		0 - 0	10 to 0	0	0 to 10	20 to 20	10	0 - 0	0 to 4	0 -20	0	0	Not Covered	0	0	0	0		0	0 to 0											0	0	0	0	0	0	0	50	0	0	0	0	0	5.2	0	6.59	20	10	0	1.11	0.13	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.21	-	-	-	-	-	0.24	-	6.71	0.48	1.12	-	3.3	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.33		0	-	-	-	-	-	-	-	1.21	-	-	-	-	-	0.24	-	6.71	0.48	1.12	-	3.3	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.33	0																																																																																			-		0	-	-	-	-	-	-	-	1.21	-	-	-	-	-	0.24	-	6.71	0.48	1.12	-	3.3	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.33
H3361_051_0	2007	7																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1319.32	23.82	973.66	1641.03	310.69	14.02	2.99	218.92	210.85	1287.57	660.57	0	395.11	419.7	4283.89	8426.96	210.67	933.36	3568.88	24731.74	7.14	25.88	1200	381	411.34	154.86	176.29	7.21	0	285.8	627.2											100  days 1 - 3	100  days 1 - 3	50  days 8 - 100	0	50	20	20	50	75-ASC/ 75-OP/ 75-Non Surg	0	0 - 750		0 - 10	10 to 50	0	0 to 15	5 to 10	10	0 - 75	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											46.87	46.87	30.4	0	50	0.2	0.2	50	75	0	18.75	0	6.67	29.14	0	10.26	6.25	10	7.59	1.34	0.13	0.2	0	0	0	0	20	0	0	0	0											5.15	0.09	2.47	-	1.29	2.8	0.6	0.91	1.32	-	1.03	-	0.22	1.02	-	7.21	0.11	0.78	2.26	2.75	0.96	5.18	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.45		0	5.15	0.09	2.47	-	1.29	2.8	0.6	0.91	1.32	-	1.03	-	0.22	1.02	-	7.21	0.11	0.78	2.26	2.75	0.96	5.18	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.45	0																																																																																			-		0	5.15	0.09	2.47	-	1.29	2.8	0.6	0.91	1.32	-	1.03	-	0.22	1.02	-	7.21	0.11	0.78	2.26	2.75	0.96	5.18	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.45
H3361_056_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1542.91	28.96	1236.69	1430.45	352.38	14.23	2.93	263.81	257.97	1632.48	818.4	0	471.81	503.98	4565.45	9070.19	223.72	986.65	4221.43	25671.86	6.93	22.38	0	381	440.14	171.77	188.63	8	0	294.18	1784											50  days 1 - 5	50  days 1 - 5	75  days 8 - 100	0	50	20	20	50	50-ASC/ 75-OP/ 50-Non Surg	0	0 - 75		0 - 0	10 to 50	0	0 to 15	5 to 10	10	0 - 75	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											31.9	31.9	45.6	0	50	0.2	0.2	50	70	0	18.75	0	0	29.26	0	10.28	6.25	10	7.55	1.18	0.13	0.2	0	0	0	0	25	0	0	0	0											4.1	0.08	4.7	-	1.47	2.85	0.59	1.1	1.5	-	1.28	-	-	1.23	-	7.77	0.12	0.82	2.66	2.52	0.93	4.48	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.57		0	4.1	0.08	4.7	-	1.47	2.85	0.59	1.1	1.5	-	1.28	-	-	1.23	-	7.77	0.12	0.82	2.66	2.52	0.93	4.48	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.57	0																																																																																			-		0	4.1	0.08	4.7	-	1.47	2.85	0.59	1.1	1.5	-	1.28	-	-	1.23	-	7.77	0.12	0.82	2.66	2.52	0.93	4.48	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.57
H3361_057_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1921.9	35.14	1365.26	1913.31	431.43	19.57	3.81	347.57	337.77	2106.94	1066.11	0	623.95	664.95	6102.65	11434.68	266.47	1182.82	5393.91	31707.89	8.55	22.98	0	381	586.78	232.29	251.48	10.82	0	402.42	2331.2											50  days 1 - 10	50  days 1 - 10	75  days 8 - 100	0	50	20	20	50	50-ASC/ 75-OP/ 50-Non Surg	0	0 - 75		0 - 10	10 to 50	0	0 to 15	5 to 10	10	0 - 75	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											41.49	41.49	45.6	0	50	0.2	0.2	50	70	0	18.75	0	6.67	29.2	0	10.24	6.25	10	7.57	1.08	0.13	0.2	0	0	0	0	25	0	0	0	0											6.64	0.12	5.19	-	1.8	3.91	0.76	1.45	1.97	-	1.67	-	0.35	1.62	-	9.76	0.14	0.99	3.4	2.85	1.15	4.6	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.88		0	6.64	0.12	5.19	-	1.8	3.91	0.76	1.45	1.97	-	1.67	-	0.35	1.62	-	9.76	0.14	0.99	3.4	2.85	1.15	4.6	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.88	0																																																																																			-		0	6.64	0.12	5.19	-	1.8	3.91	0.76	1.45	1.97	-	1.67	-	0.35	1.62	-	9.76	0.14	0.99	3.4	2.85	1.15	4.6	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.88
H3361_059_0	2007	6																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1506.98	28.73	1158.56	1501.12	389.77	19.7	3.41	358.9	356.61	2339.11	1146.07	0	635.51	682.99	4849.75	9520.09	225.19	989.38	4499.77	26233.97	7.16	21.82	0	381	469.49	169.5	201.21	7.89	0	301.11	843.2											100  days 1 - 10	100  days 1 - 10	119  days 21 - 100	10	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	0 - 75		0 - 10	10 to 100	0	0 to 15	5 to 10	10	0 - 75	0 to 35	0 -20	0.2	0	0	0	0	35	0		0	0 to 0											82.98	82.98	27.01	10	100	0.2	0.2	50	135	0	18.75	0	6.67	53.62	0	10.28	6.25	10	7.52	1.18	0.13	0.2	0	0	0	0	35	0	0	0	0											10.42	0.2	2.61	1.25	3.25	3.94	0.68	1.5	4.01	-	1.79	-	0.35	3.05	-	8.15	0.12	0.82	2.82	2.58	0.96	4.36	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.46		0	10.42	0.2	2.61	1.25	3.25	3.94	0.68	1.5	4.01	-	1.79	-	0.35	3.05	-	8.15	0.12	0.82	2.82	2.58	0.96	4.36	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.46	0																																																																																			-		0	10.42	0.2	2.61	1.25	3.25	3.94	0.68	1.5	4.01	-	1.79	-	0.35	3.05	-	8.15	0.12	0.82	2.82	2.58	0.96	4.36	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.46
H3361_062_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1393.12	25.97	1245.84	2076.89	370.42	16.68	3.36	442.84	441.15	2909.76	1420.64	0	782.88	842.2	4533.09	8158.25	171.48	760.24	4198.51	20724.12	7.81	12.67	0	381	438.49	174.45	187.93	8.12	0	290.43	547.2											100  days 1 - 4	100  days 1 - 4	50  days 8 - 100	0	50	20	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	0 - 50		0 - 30	30 to 50	5	0 to 30	20 to 30	30	0 - 50	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											56.44	56.44	30.4	0	50	0.2	0.2	50	67.5	0	12.5	0	20	39.7	4.03	29.28	22.5	30	5.03	0.99	0.13	0.2	0	0	0	0	20	0	0	0	0											6.55	0.12	3.16	-	1.54	3.34	0.67	1.85	2.48	-	1.48	-	1.3	2.79	1.52	19.91	0.32	1.9	1.76	1.7	1.05	2.53	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.29		0	6.55	0.12	3.16	-	1.54	3.34	0.67	1.85	2.48	-	1.48	-	1.3	2.79	1.52	19.91	0.32	1.9	1.76	1.7	1.05	2.53	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.29	0																																																																																			-		0	6.55	0.12	3.16	-	1.54	3.34	0.67	1.85	2.48	-	1.48	-	1.3	2.79	1.52	19.91	0.32	1.9	1.76	1.7	1.05	2.53	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.29
H3361_064_0	2007	3																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2025.09	39.06	1402.5	2223.32	6.75	17.67	3.51	4.65	24.25	1715.59	23.73	0	7.69	16.56	5620.06	66.4	3.19	3.82	32.57	126.35	8.28	33.56	1200	381	0	0	0	0	0	350.51	1728											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											143.22	121.56	27.01	0	0.2	0	0	0.2	0.2	0	0.2	0	0.15	0.2	0	0.2	0.14	0.2	0.04	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											24.17	0.4	3.16	-	1.35	-	-	0.93	4.85	-	4.75	-	1.15	3.31	-	13.28	0.45	0.76	1.34	9.6	1.11	6.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.31		0	24.17	0.4	3.16	-	1.35	-	-	0.93	4.85	-	4.75	-	1.15	3.31	-	13.28	0.45	0.76	1.34	9.6	1.11	6.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.31	0																																																																																			-		0	24.17	0.4	3.16	-	1.35	-	-	0.93	4.85	-	4.75	-	1.15	3.31	-	13.28	0.45	0.76	1.34	9.6	1.11	6.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.31
H3361_065_0	2007	3																					0											D	D	D	V	Coin	O	O	V	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1843.78	34.5	1385.22	1945.61	9.32	24.39	4.26	442.49	27.17	2844.21	26.2	0	8.27	17.87	6103.08	65.83	2.98	3.06	29.04	131.2	8.91	27.16	0	381	0	0	0	0	0	386.93	2275.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	50	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											118.8	113.61	27.01	0	0.2	0	0	50	0.2	0	0.2	0	0.15	0.2	0	0.2	0.14	0.2	0.04	0.07	0.13	0.2	0	0	0	0	0	0	0	0	0											18.25	0.33	3.12	-	1.86	-	-	1.84	5.43	-	5.24	-	1.24	3.57	-	13.17	0.41	0.61	1.19	9.37	1.19	5.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.27		0	18.25	0.33	3.12	-	1.86	-	-	1.84	5.43	-	5.24	-	1.24	3.57	-	13.17	0.41	0.61	1.19	9.37	1.19	5.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.27	0																																																																																			-		0	18.25	0.33	3.12	-	1.86	-	-	1.84	5.43	-	5.24	-	1.24	3.57	-	13.17	0.41	0.61	1.19	9.37	1.19	5.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.27
H3361_067_0	2007	3																					0											D	D	D	V	Coin	O	O	V	Coin	V	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1821.82	33.96	1400.2	1651.71	6.33	16.49	3.41	319.74	24.09	1971.44	23.4	0	7.51	610.97	5437.31	54.94	2.77	2.83	28.41	115.17	8.08	25.2	0	381	0	0	0	0	0	353.09	2275.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	50	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0.2 to 20 OP Hosp	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.27	121.63	27.01	0	0.2	0	0	50	0.2	0	0.15	0	0.15	35.12	0	0.2	0.13	0.2	0.03	0.07	0.13	0.2	0	0	0	0	0	0	0	0	0											21.6	0.34	3.15	-	1.27	-	-	1.33	4.82	-	3.51	-	1.13	1.79	-	10.99	0.36	0.57	0.87	7.65	1.08	5.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.49		0	21.6	0.34	3.15	-	1.27	-	-	1.33	4.82	-	3.51	-	1.13	1.79	-	10.99	0.36	0.57	0.87	7.65	1.08	5.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.49	0																																																																																			-		0	21.6	0.34	3.15	-	1.27	-	-	1.33	4.82	-	3.51	-	1.13	1.79	-	10.99	0.36	0.57	0.87	7.65	1.08	5.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.49
H3361_068_0	2007	3																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	V	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1678.31	30.02	1202.86	1770.08	6.89	17.76	3.49	4.42	22.65	1948.53	1033.82	0	7.28	15.62	5551.07	49.83	2.63	2.26	5021.83	110.09	7.84	20.38	0	381	0	0	0	0	0	372.84	2275.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											140.02	121.51	27.01	0	0.2	0	0	0.2	0.2	0	0	0	0.15	0.2	0	0.2	0.13	0.2	0	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											19.58	0.3	2.71	-	1.38	-	-	0.88	4.53	-	-	-	1.09	3.12	-	9.97	0.34	0.45	-	8.64	1.05	4.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.12		0	19.58	0.3	2.71	-	1.38	-	-	0.88	4.53	-	-	-	1.09	3.12	-	9.97	0.34	0.45	-	8.64	1.05	4.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.12	0																																																																																			-		0	19.58	0.3	2.71	-	1.38	-	-	0.88	4.53	-	-	-	1.09	3.12	-	9.97	0.34	0.45	-	8.64	1.05	4.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.12
H3361_069_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1941.79	36.76	1451.88	1817.6	6.72	17.54	3.58	4.88	25.18	1967.25	24.67	0	7.86	16.95	5600.93	60.35	2.96	3.22	30.84	123.56	8.47	7678.3	0	381	0	0	0	0	0	357.63	1728											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	20	20	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.19	121.38	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.15	0	0.13	0.2	0	0.2	0.14	0.2	0.03	0.07	0.13	0	0	0	0	0	0	0	0	0	0											23.01	0.37	3.27	-	1.34	3.51	0.72	0.98	5.04	-	3.7	-	1.05	3.39	-	12.07	0.4	0.64	0.95	9.11	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.68		0	23.01	0.37	3.27	-	1.34	3.51	0.72	0.98	5.04	-	3.7	-	1.05	3.39	-	12.07	0.4	0.64	0.95	9.11	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.68	0																																																																																			-		0	23.01	0.37	3.27	-	1.34	3.51	0.72	0.98	5.04	-	3.7	-	1.05	3.39	-	12.07	0.4	0.64	0.95	9.11	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.68
H3361_072_0	2007	4																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1669.72	30.95	1431.6	2482.61	7.64	19.96	4.02	5.6	28.74	3446.32	27.47	0	8.65	18.69	5470.21	45.32	2.54	1.7	28.57	114.06	9.31	15.24	0	381	0	0	0	0	0	351.75	2275.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											147.32	123.84	27.01	0	0.2	0	0	0.2	0.2	0	0.2	0	0.15	0.2	0	0.2	0.13	0.2	0.04	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											20.5	0.32	3.22	-	1.53	-	-	1.12	5.75	-	5.49	-	1.3	3.74	-	9.06	0.32	0.34	1.17	9.43	1.25	3.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.58		0	20.5	0.32	3.22	-	1.53	-	-	1.12	5.75	-	5.49	-	1.3	3.74	-	9.06	0.32	0.34	1.17	9.43	1.25	3.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.58	0																																																																																			-		0	20.5	0.32	3.22	-	1.53	-	-	1.12	5.75	-	5.49	-	1.3	3.74	-	9.06	0.32	0.34	1.17	9.43	1.25	3.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.58
H3361_076_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1562.7	29.71	1300.27	1345.14	352.88	13.9	2.83	266.1	261.3	1669.57	819.66	0	474.66	507.83	4500.62	8957.34	222.8	957.07	4211.33	25402.49	6.68	21.26	0	381	434.72	171.82	186.31	8	0	285.95	2035.2											125  days 1 - 5	125  days 1 - 5	50  days 8 - 100	0	100	20	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	0 - 100		0 - 15	15 to 50	5	0 to 15	5 to 15	15	0 - 100	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											79.74	79.74	30.4	0	100	0.2	0.2	50	67.5	0	25	0	10	31.88	4.04	15	7.5	15	10.05	1.14	0.13	0.2	0	0	0	0	25	0	0	0	0											10.38	0.2	3.29	-	2.94	2.78	0.57	1.11	1.47	-	1.71	-	0.4	1.35	1.52	11.2	0.14	1.2	3.53	2.41	0.9	4.25	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.71		0	10.38	0.2	3.29	-	2.94	2.78	0.57	1.11	1.47	-	1.71	-	0.4	1.35	1.52	11.2	0.14	1.2	3.53	2.41	0.9	4.25	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.71	0																																																																																			-		0	10.38	0.2	3.29	-	2.94	2.78	0.57	1.11	1.47	-	1.71	-	0.4	1.35	1.52	11.2	0.14	1.2	3.53	2.41	0.9	4.25	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.71
H3361_077_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1358.37	25.05	978.28	1339.48	306.49	13.83	2.68	256.58	250.55	1580.62	783.05	0	459.25	490.31	4247.53	7933.26	185.5	804.55	3741.55	21969.66	6.02	15.7	0	381	408.92	161.89	175.25	7.54	0	277.7	2035.2											75  days 1 - 5	75  days 1 - 5	50  days 8 - 100	0	100	20	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	0 - 100		0 - 15	15 to 50	5	0 to 15	5 to 15	15	0 - 100	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											47.84	47.84	30.4	0	100	0.2	0.2	50	67.5	0	25	0	10	31.83	4.02	15	7.5	15	10.09	1.07	0.13	0.2	0	0	0	0	25	0	0	0	0											5.42	0.1	2.48	-	2.55	2.77	0.54	1.07	1.41	-	1.63	-	0.38	1.3	1.42	9.92	0.12	1.01	3.15	1.95	0.81	3.14	-	-	-	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.51		0	5.42	0.1	2.48	-	2.55	2.77	0.54	1.07	1.41	-	1.63	-	0.38	1.3	1.42	9.92	0.12	1.01	3.15	1.95	0.81	3.14	-	-	-	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.51	0																																																																																			-		0	5.42	0.1	2.48	-	2.55	2.77	0.54	1.07	1.41	-	1.63	-	0.38	1.3	1.42	9.92	0.12	1.01	3.15	1.95	0.81	3.14	-	-	-	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.51
H3361_079_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2120.8	39.94	1756.38	1872.75	484.28	19.03	3.91	366.59	359.06	2280.83	1140.65	0	654.94	700.03	6216.66	12337.8	303.19	1336.63	5831.26	34672.65	9.24	29.1	0	381	599.57	237	256.96	11.03	0	399.2	2035.2											100  days 1 - 10	100  days 1 - 10	50  days 8 - 100	0	50	20	20	50	50-ASC/ 75-OP/ 50-Non Surg	0	0 - 75		0 - 10	10 to 50	0	0 to 15	5 to 10	10	0 - 75	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											82.98	82.98	30.4	0	50	0.2	0.2	50	70	0	18.75	0	6.67	29.27	0	10.28	6.25	10	7.54	1.15	0.13	0.2	0	0	0	0	25	0	0	0	0											14.67	0.28	4.45	-	2.02	3.81	0.78	1.53	2.09	-	1.78	-	0.36	1.71	-	10.57	0.16	1.11	3.67	3.33	1.24	5.82	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.89		0	14.67	0.28	4.45	-	2.02	3.81	0.78	1.53	2.09	-	1.78	-	0.36	1.71	-	10.57	0.16	1.11	3.67	3.33	1.24	5.82	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.89	0																																																																																			-		0	14.67	0.28	4.45	-	2.02	3.81	0.78	1.53	2.09	-	1.78	-	0.36	1.71	-	10.57	0.16	1.11	3.67	3.33	1.24	5.82	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.89
H3361_080_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2393.35	47.12	1679.03	2540.85	474.14	20.22	3.92	306.5	302.16	1947.66	950.24	0	545.41	584.39	6333.56	13565.55	352.17	1495.63	5647.84	41678.76	9.15	38.89	0	381	615.12	474.67	263.62	11.05	0	384.11	1784											75  days 1 - 10	75  days 1 - 10	50  days 8 - 100	0	50	20	20	50	100-ASC/ 100-OP/ 100-Non Surg	0	15 - 75		0 - 20	20 to 100	5	0 to 20	10 to 20	20	0 - 75	0 to 35	0 -20	0.2	0	0	0	0	35	0		0	0 to 0											62.23	62.23	30.4	0	50	0.2	0.2	50	100	0	30	0	13.33	58.65	4.07	19.67	12.5	20	12.02	1.19	0.13	0.2	0	0	0	0	35	0	0	0	0											12.41	0.24	4.25	-	1.98	4.04	0.78	1.28	2.52	-	2.38	-	0.61	2.86	2.15	22.23	0.37	2.49	5.65	4.14	1.23	7.78	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.15		0	12.41	0.24	4.25	-	1.98	4.04	0.78	1.28	2.52	-	2.38	-	0.61	2.86	2.15	22.23	0.37	2.49	5.65	4.14	1.23	7.78	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.15	0																																																																																			-		0	12.41	0.24	4.25	-	1.98	4.04	0.78	1.28	2.52	-	2.38	-	0.61	2.86	2.15	22.23	0.37	2.49	5.65	4.14	1.23	7.78	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.15
H3361_081_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2176.41	41.38	1731.21	2037.38	481.82	19.67	4	352.62	345.63	2199.08	1098.62	0	629.72	673.25	6253.77	12665.9	316.47	1391.99	5800.47	36286.76	9.44	32.08	0	381	603.9	235	258.81	10.94	0	397.17	1488											75  days 1 - 10	75  days 1 - 10	50  days 8 - 100	0	50	20	20	50	50-ASC/ 75-OP/ 50-Non Surg	0	0 - 75		0 - 10	10 to 50	0	0 to 15	5 to 10	10	0 - 75	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											62.23	62.23	30.4	0	50	0.2	0.2	50	70	0	18.75	0	6.67	29.28	0	10.29	6.25	10	7.54	1.17	0.13	0.2	0	0	0	0	25	0	0	0	0											11.29	0.21	4.39	-	2.01	3.93	0.8	1.47	2.02	-	1.72	-	0.35	1.64	-	10.86	0.16	1.16	3.64	3.55	1.27	6.42	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.42		0	11.29	0.21	4.39	-	2.01	3.93	0.8	1.47	2.02	-	1.72	-	0.35	1.64	-	10.86	0.16	1.16	3.64	3.55	1.27	6.42	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.42	0																																																																																			-		0	11.29	0.21	4.39	-	2.01	3.93	0.8	1.47	2.02	-	1.72	-	0.35	1.64	-	10.86	0.16	1.16	3.64	3.55	1.27	6.42	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.42
H3361_084_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1692.55	29.7	1544.17	2630.33	477.9	21.3	4.27	533.31	525.45	3382.79	1677.29	0	949.33	1016.96	6479.84	11519.09	254.46	1136.28	5302.46	27447.55	9.69	16.89	0	381	585.56	232.68	250.95	10.83	0	411.37	2035.2											0  unlimited	0  unlimited	0  days 1 - 100	0	50	20	20	50	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 50		0 - 0	0	0	0 to 15	0 to 0	0	0 - 50	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											0	0	0	0	50	0.2	0.2	50	0	0	12.5	0	0	0	0	0.58	0	0	5.06	0.77	0.13	0.2	0	0	0	0	20	0	0	0	0											-	-	-	-	1.99	4.26	0.85	2.22	-	-	1.75	-	-	-	-	0.55	-	-	2.24	1.76	1.3	3.38	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.72		0	-	-	-	-	1.99	4.26	0.85	2.22	-	-	1.75	-	-	-	-	0.55	-	-	2.24	1.76	1.3	3.38	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.72	0																																																																																			-		0	-	-	-	-	1.99	4.26	0.85	2.22	-	-	1.75	-	-	-	-	0.55	-	-	2.24	1.76	1.3	3.38	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.72
H3361_086_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1105.48	19.21	849.46	1449.92	275.85	12.19	2.66	229.57	191.01	1146.52	616.4	0	361.97	383.51	3843.02	7367.96	184.06	819.71	3240.54	21252.58	6.45	22.08	1200	381	367.65	140.32	157.57	6.53	0	263.84	547.2											0  unlimited&	0  unlimited	0  days 1 - 100	0	0	20	20	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 40		0 - 5	5 to 0	0	0 to 15	5 to 5	5	0 - 40	0 to 4	0 -20	0.2	0	0	0	0	0	0		0	0 to 0											0	0	0	0	0	0.2	0.2	0	0	0	10	0	3.33	2.61	0	5.48	5	5	4.06	1.08	0.13	0.2	0	0	0	0	0	0	0	0	0											-	-	-	-	-	2.44	0.53	-	-	-	0.51	-	0.1	0.08	-	3.36	0.08	0.34	1.1	1.92	0.86	4.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.75		0	-	-	-	-	-	2.44	0.53	-	-	-	0.51	-	0.1	0.08	-	3.36	0.08	0.34	1.1	1.92	0.86	4.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.75	0																																																																																			-		0	-	-	-	-	-	2.44	0.53	-	-	-	0.51	-	0.1	0.08	-	3.36	0.08	0.34	1.1	1.92	0.86	4.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.75
H3361_098_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	2041.66	38.59	1566.41	2119.53	533.69	26.93	4.68	489.72	485.65	3171.82	1558.31	0	868.23	932.38	6678.74	13013.95	307.07	1351.23	6138.13	35840.3	9.81	29.9	0	381	645.86	234.01	276.8	10.9	0	418.73	2035.2											100  days 1 - 5	100  days 1 - 5	75  days 8 - 100	0	50	20	20	50	50-ASC/ 75-OP/ 50-Non Surg	0	0 - 75		0 - 10	10 to 75	0	0 to 15	5 to 10	10	0 - 75	0 to 35	0 -20	0.2	0	0	0	0	35	0		0	0 to 0											63.79	63.79	45.6	0	50	0.2	0.2	50	70	0	18.75	0	6.67	41.48	0	10.27	6.25	10	7.53	1.19	0.13	0.2	0	0	0	0	35	0	0	0	0											10.85	0.21	5.95	-	2.22	5.39	0.94	2.04	2.83	-	2.43	-	0.48	3.22	-	11.14	0.16	1.13	3.85	3.56	1.31	5.98	-	-	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.51		0	10.85	0.21	5.95	-	2.22	5.39	0.94	2.04	2.83	-	2.43	-	0.48	3.22	-	11.14	0.16	1.13	3.85	3.56	1.31	5.98	-	-	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.51	0																																																																																			-		0	10.85	0.21	5.95	-	2.22	5.39	0.94	2.04	2.83	-	2.43	-	0.48	3.22	-	11.14	0.16	1.13	3.85	3.56	1.31	5.98	-	-	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.51
H3361_099_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1701.7	33.11	1298.52	1610.44	429.1	21.78	3.74	398.44	397.78	2635.93	1283.16	0	703.44	757.38	5258.84	10330.24	233.07	1021.09	4999.12	29038.18	7.87	23.96	0	381	510.94	182.83	218.97	8.51	0	318.84	547.2											100  days 1 - 5	100  days 1 - 5	119  days 21 - 100	20	100	20	20	50	50-ASC/ 100-OP/ 100-Non Surg	0	0 - 75		0 - 30	30 to 50	0	0 to 30	20 to 30	30	0 - 75	0 to 35	0 -20	0.2	0	0	0	0	35	0		0	0 to 0											63.79	63.79	27.01	20	100	0.2	0.2	50	95	0	18.75	0	20	39.71	0	29.11	22.5	30	7.5	1.15	0.13	0.2	0	0	0	0	35	0	0	0	0											9.05	0.18	2.92	2.68	3.58	4.36	0.75	1.66	3.15	-	2	-	1.17	2.51	-	25.06	0.44	2.55	3.13	2.79	1.05	4.79	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.46		0	9.05	0.18	2.92	2.68	3.58	4.36	0.75	1.66	3.15	-	2	-	1.17	2.51	-	25.06	0.44	2.55	3.13	2.79	1.05	4.79	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.46	0																																																																																			-		0	9.05	0.18	2.92	2.68	3.58	4.36	0.75	1.66	3.15	-	2	-	1.17	2.51	-	25.06	0.44	2.55	3.13	2.79	1.05	4.79	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.46
H3361_100_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1836.44	36.46	1538.4	1365.23	386.58	15.38	3.02	285.83	284.42	1871.4	899.88	0	505.66	543.74	4771.25	9883.04	236.24	1031.45	4759.84	28596.37	7.07	23.61	0	381	464.18	183.4	198.93	8.54	0	285.78	547.2											250  days 1 - 5	250  days 1 - 5	50  days 8 - 100	0	100	20	20	50	50-ASC/ 150-OP/ 100-Non Surg	0	0 - 100		0 - 30	30 to 100	0	0 to 30	20 to 30	30	0 - 100	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											159.48	159.48	30.4	0	100	0.2	0.2	50	135	0	25	0	20	63.95	0	29.03	22.5	30	9.99	1.08	0.13	0.2	0	0	0	0	25	0	0	0	0											24.41	0.48	3.9	-	3.22	3.08	0.6	1.19	3.2	-	1.87	-	0.84	2.9	-	23.91	0.44	2.58	3.96	2.58	0.95	4.72	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.25		0	24.41	0.48	3.9	-	3.22	3.08	0.6	1.19	3.2	-	1.87	-	0.84	2.9	-	23.91	0.44	2.58	3.96	2.58	0.95	4.72	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.25	0																																																																																			-		0	24.41	0.48	3.9	-	3.22	3.08	0.6	1.19	3.2	-	1.87	-	0.84	2.9	-	23.91	0.44	2.58	3.96	2.58	0.95	4.72	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.25
H3361_101_0	2007	3																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1266.09	23.18	1131.44	1916	343.72	15.43	3.1	402.26	399.41	2615.52	1282.83	0	712.64	765.65	4271.9	7730.4	169.5	752.99	3869.89	19387.2	7.16	11.88	0	381	411.4	163.61	176.32	7.62	0	277.84	2035.2											100  per admit	100  per admit	50  days 8 - 100	0	100	20	20	50	25-ASC/ 75-OP/ 50-Non Surg	0	0 - 50		0 - 10	10 to 75	0	0 to 15	5 to 10	10	0 - 50	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											19.08	19.08	30.4	0	100	0.2	0.2	50	67.5	0	12.5	0	6.67	41.49	0	10.22	6.25	10	5.04	1	0.13	0.2	0	0	0	0	20	0	0	0	0											2.01	0.04	2.87	-	2.86	3.09	0.62	1.68	2.25	-	1.34	-	0.4	2.65	-	6.59	0.09	0.63	1.63	1.61	0.96	2.38	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.96		0	2.01	0.04	2.87	-	2.86	3.09	0.62	1.68	2.25	-	1.34	-	0.4	2.65	-	6.59	0.09	0.63	1.63	1.61	0.96	2.38	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.96	0																																																																																			-		0	2.01	0.04	2.87	-	2.86	3.09	0.62	1.68	2.25	-	1.34	-	0.4	2.65	-	6.59	0.09	0.63	1.63	1.61	0.96	2.38	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.96
H3361_102_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1446.66	26.82	1304.42	2151.19	384.49	17.3	3.48	456.11	453.83	2985.69	1460.1	0	806.96	867.7	4735.59	8510.28	178.29	791.36	4347.33	21575.34	8.07	13.21	0	381	456.99	181.79	195.85	8.46	0	304.87	547.2											0  days 1 - 4	0  per admit	25  days 8 - 100	0	50	20	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	0 - 50		0 - 30	30 to 50	0	0 to 30	20 to 30	30	0 - 50	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											0	0	15.2	0	50	0.2	0.2	50	45	0	12.5	0	20	39.7	0	29.3	22.5	30	5.03	0.99	0.13	0.2	0	0	0	0	20	0	0	0	0											-	-	1.65	-	1.6	3.46	0.7	1.9	1.7	-	1.52	-	1.34	2.87	-	20.78	0.33	1.98	1.82	1.78	1.08	2.64	-	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.49		0	-	-	1.65	-	1.6	3.46	0.7	1.9	1.7	-	1.52	-	1.34	2.87	-	20.78	0.33	1.98	1.82	1.78	1.08	2.64	-	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.49	0																																																																																			-		0	-	-	1.65	-	1.6	3.46	0.7	1.9	1.7	-	1.52	-	1.34	2.87	-	20.78	0.33	1.98	1.82	1.78	1.08	2.64	-	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.49
H3361_104_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1585.14	29.77	1146.58	1484.1	344.43	15.6	2.99	287.45	281.84	1794.49	883.18	0	513.24	548.79	4757.89	8939.27	199.13	880.88	4274.73	25051.6	6.72	17.81	0	381	459.26	181.82	196.82	8.47	0	305.69	547.2											75  days 1 - 5	75  days 1 - 5	25  days 8 - 100	0	100	20	20	50	25-ASC/ 50-OP/ 25-Non Surg	0	0 - 100		0 - 30	30 to 25	0	0 to 30	20 to 30	30	0 - 100	0 to 25	0 -20	0.2	0	0	0	0	25	0		0	0 to 0											47.84	47.84	15.2	0	100	0.2	0.2	50	45	0	25	0	20	27.59	0	29.22	22.5	30	10.07	1.05	0.13	0.2	0	0	0	0	25	0	0	0	0											6.32	0.12	1.45	-	2.87	3.12	0.6	1.2	1.06	-	1.84	-	0.86	1.26	-	21.77	0.37	2.2	3.59	2.19	0.9	3.56	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.68		0	6.32	0.12	1.45	-	2.87	3.12	0.6	1.2	1.06	-	1.84	-	0.86	1.26	-	21.77	0.37	2.2	3.59	2.19	0.9	3.56	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.68	0																																																																																			-		0	6.32	0.12	1.45	-	2.87	3.12	0.6	1.2	1.06	-	1.84	-	0.86	1.26	-	21.77	0.37	2.2	3.59	2.19	0.9	3.56	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.68
H3361_105_0	2007	4																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	P	P	P	P	P	P	P	P																																																				-		0	0	0	0	0	0	0	482.07	0	0	0	0	0	598.37	0	5879.05	2789.33	1594.27	0	6471.29	0	0	0	0	0	0	0	0	0	0	0											100 Covered	100 Covered	100 Covered	100 Covered	100 Covered	100 Covered	100 Covered	50 ER Copay 10 UC Copay	100 Covered	100 Covered	100 Covered	100 Covered	100 Covered	10 OP Rehab 20 MH/SA Copay	100 Covered	10 Specialist Copay	20 MH Copay	10 Therapy (PT/OT/ST) Copay	100 Covered	10 Specialist Copay	100 Covered	100 Covered	Not Covered	Not Covered	100 Covered	100 Covered	100 Covered	100 Covered	Not Covered	100 Covered	100 Covered											0	0	0	0	0	0	0	46	0	0	0	0	0	13.82	0	10	20	10	0	10	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.85	-	-	-	-	-	0.69	-	4.9	4.65	1.33	-	5.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.81	0	0	-	-	-	-	-	-	-	1.85	-	-	-	-	-	0.69	-	4.9	4.65	1.33	-	5.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.81		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-	0	0	-	-	-	-	-	-	-	1.85	-	-	-	-	-	0.69	-	4.9	4.65	1.33	-	5.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.81
H3361_106_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1479.86	27.09	1026.75	1578.54	326.98	13.54	2.83	276.59	219.13	1407.96	749.31	0	427.32	454.36	4191.24	8293.26	210.25	908.73	3697.43	24679.97	6.81	25.06	1200	381	452.63	170.13	173.42	7.08	0	268.68	843.2											0  unlimited	0  unlimited	0  days 1 - 100	0	0	20	20	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 40		0 - 15	15 to 0	0	0 to 15	5 to 15	15	0 - 40	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											0	0	0	0	0	0.2	0.2	0	0	0	10	0	10	7.81	0	15	7.5	15	4.05	1.12	0.13	0.2	0	0	0	0	20	0	0	0	0											-	-	-	-	-	2.71	0.57	-	-	-	0.62	-	0.36	0.3	-	10.37	0.13	1.14	1.25	2.31	0.91	5.01	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.96		0	-	-	-	-	-	2.71	0.57	-	-	-	0.62	-	0.36	0.3	-	10.37	0.13	1.14	1.25	2.31	0.91	5.01	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.96	0																																																																																			-		0	-	-	-	-	-	2.71	0.57	-	-	-	0.62	-	0.36	0.3	-	10.37	0.13	1.14	1.25	2.31	0.91	5.01	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.96
H3361_107_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1647.71	30.24	844.59	956.5	306.12	8.4	1.78	326.5	147.04	1197.34	636.87	0	362.6	385.63	2787.28	5528.85	140.36	606.33	2464.8	16467.69	5.26	15.2	1200	381	429.29	159.91	108.48	4.39	0	160.5	843.2											0  unlimited	0  unlimited	0  days 1 - 100	0	0	20	20	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 - 40		0 - 15	15 to 0	0	0 to 15	5 to 15	15	0 - 40	0 to 20	0 -20	0.2	0	0	0	0	20	0		0	0 to 0											0	0	0	0	0	0.2	0.2	0	0	0	10	0	10	7.81	0	15	7.5	15	4.05	1.14	0.13	0.2	0	0	0	0	20	0	0	0	0											-	-	-	-	-	1.68	0.36	-	-	-	0.53	-	0.3	0.25	-	6.91	0.09	0.76	0.83	1.56	0.71	3.04	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.2		0	-	-	-	-	-	1.68	0.36	-	-	-	0.53	-	0.3	0.25	-	6.91	0.09	0.76	0.83	1.56	0.71	3.04	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.2	0																																																																																			-		0	-	-	-	-	-	1.68	0.36	-	-	-	0.53	-	0.3	0.25	-	6.91	0.09	0.76	0.83	1.56	0.71	3.04	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.2
H3361_109_0	2007	2																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1861.78	35.78	1075.66	1654.24	10.08	13.91	2.81	8.38	20.72	1539.4	27.88	0	8.5	18.3	4240.47	54.71	3.06	3.76	3737	124.51	6.71	26.15	1200	381	0	0	0	0	0	250.08	1163.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											174.45	132.19	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.14	0.2	2.91	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											27.07	0.39	2.42	-	2.02	-	-	1.68	4.14	-	1.39	-	1.27	3.66	-	10.94	0.44	0.75	0.9	9.5	0.9	5.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.71		0	27.07	0.39	2.42	-	2.02	-	-	1.68	4.14	-	1.39	-	1.27	3.66	-	10.94	0.44	0.75	0.9	9.5	0.9	5.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.71	0																																																																																			-		0	27.07	0.39	2.42	-	2.02	-	-	1.68	4.14	-	1.39	-	1.27	3.66	-	10.94	0.44	0.75	0.9	9.5	0.9	5.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.71
H3361_110_0	2007	3																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1908.47	35.78	1324.24	2210.87	7.25	18.87	3.86	5.14	26.63	1719.54	27.67	0	8.55	18.37	5675.65	69.93	3.27	4	4879.6	133.25	9.21	35.46	1200	381	0	0	0	0	0	365.8	1163.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											175.85	132.87	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.14	0.2	2.87	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											27.97	0.4	2.98	-	1.45	-	-	1.03	5.33	-	1.38	-	1.28	3.67	-	13.99	0.46	0.8	1.17	10.37	1.23	7.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.6		0	27.97	0.4	2.98	-	1.45	-	-	1.03	5.33	-	1.38	-	1.28	3.67	-	13.99	0.46	0.8	1.17	10.37	1.23	7.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.6	0																																																																																			-		0	27.97	0.4	2.98	-	1.45	-	-	1.03	5.33	-	1.38	-	1.28	3.67	-	13.99	0.46	0.8	1.17	10.37	1.23	7.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.6
H3361_111_0	2007	3																					0											D	D	D	V	Coin	O	O	Coin	Coin	V	Coin	V	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1903.64	35.13	1334.53	2267.07	7.18	18.62	3.87	5.16	26.63	1770.13	27.6	0	8.6	18.46	5864.06	68.44	3.21	3.89	4971.19	130.12	9.26	34.6	1200	381	0	0	0	0	0	383.84	1163.2											952  0 (1-60) 238(61-90) 476 (91+)	952 - 238  0 (1-60) 238(61-90) 476 (91+)	119  days 21 - 100	0	0	0	0	0	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0 - 0.2		0 - 0.2	0	0	0 to 0.2	0.2 to 0.2	0	0 - 0.2	0 to 0.2	0 -20	0.2	0	0	Not Covered	Not Covered	Not Covered	0		0	0 to 0											163.5	128.89	27.01	0	0.2	0	0	0.2	0.2	0	0.05	0	0.15	0.2	0	0.2	0.14	0.2	2.77	0.08	0.13	0.2	0	0	0	0	0	0	0	0	0											25.94	0.38	3	-	1.44	-	-	1.03	5.33	-	1.38	-	1.29	3.69	-	13.69	0.45	0.78	1.15	10.25	1.24	6.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.95		0	25.94	0.38	3	-	1.44	-	-	1.03	5.33	-	1.38	-	1.29	3.69	-	13.69	0.45	0.78	1.15	10.25	1.24	6.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.95	0																																																																																			-		0	25.94	0.38	3	-	1.44	-	-	1.03	5.33	-	1.38	-	1.29	3.69	-	13.69	0.45	0.78	1.15	10.25	1.24	6.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.95
H3362_003_0	2007	9																					0											A	A	A	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	202.09	4.57	0	1327.19	84.82	5.9	0	242.95	467.77	0	567.94	37.05	0.57	742.13	5733.72	3322.23	0.91	531.37	894.75	969.55	11.03	674.15	0	0	577.7	577.7	15.57	0	0	0	0											PBP: 1A IP Acute: 250 per admit	1B IP Psych: 250 per admit	2 SNF: 0	6 Home Health: 5	10A Ambulance: 25	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 0	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 35	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 0	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 5 14B Immunizations: 5 14C Routine Physical Exams: 5 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 20	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	0	5	25	0.2	0	48.5	35	0	20	20	0	20	5	20	0.5	20	20	20	0.2	20	0	0	5	36.33	20	0	0	0	0											4.21	0.1	-	0.55	0.18	1.18	-	0.98	1.36	-	0.95	0.06	-	1.24	2.39	5.54	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.53	0	0	4.21	0.1	-	0.55	0.18	1.18	-	0.98	1.36	-	0.95	0.06	-	1.24	2.39	5.54	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.53	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.21	0.1	-	0.55	0.18	1.18	-	0.98	1.36	-	0.95	0.06	-	1.24	2.39	5.54	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.53
H3362_004_0	2007	9																					0											A	A	A	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	202.09	4.57	0	1307.28	84.82	5.9	0	242.95	467.77	0	561.69	37.05	0.57	742.13	5613.31	3252.46	0.91	531.37	894.75	969.55	11.03	674.15	0	0	577.7	577.7	15.57	0	0	0	0											PBP: 1A IP Acute: 375 per admit	1B IP Psych: 375 per admit	2 SNF: 0	6 Home Health: 10	10A Ambulance: 25	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 0	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 35	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 0	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 10 14B Immunizations: 10 14C Routine Physical Exams: 10 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 20	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											375	375	0	10	25	0.2	0	48.5	35	0	20	20	0	20	10	20	0.5	20	20	20	0.2	20	0	0	5	36.33	20	0	0	0	0											6.32	0.14	-	1.09	0.18	1.18	-	0.98	1.36	-	0.94	0.06	-	1.24	4.68	5.42	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.38	0	0	6.32	0.14	-	1.09	0.18	1.18	-	0.98	1.36	-	0.94	0.06	-	1.24	4.68	5.42	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.38	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.32	0.14	-	1.09	0.18	1.18	-	0.98	1.36	-	0.94	0.06	-	1.24	4.68	5.42	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.38
H3362_016_0	2007	5																					0											A	A	A	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	202.09	4.57	0	1327.19	84.82	5.9	0	242.95	467.77	0	567.94	37.05	0.57	742.13	5733.72	3322.23	0.91	531.37	894.75	969.55	11.03	674.15	0	0	577.7	577.7	15.57	0	0	0	0											PBP: 1A IP Acute: 250 per admit	1B IP Psych: 250 per admit	2 SNF: 0	6 Home Health: 5	10A Ambulance: 25	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 0	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 35	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 0	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 5 14B Immunizations: 5 14C Routine Physical Exams: 5 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 20	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	0	5	25	0.2	0	48.5	35	0	20	20	0	20	5	20	0.5	20	20	20	0.2	20	0	0	5	36.33	20	0	0	0	0											4.21	0.1	-	0.55	0.18	1.18	-	0.98	1.36	-	0.95	0.06	-	1.24	2.39	5.54	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.53	0	0	4.21	0.1	-	0.55	0.18	1.18	-	0.98	1.36	-	0.95	0.06	-	1.24	2.39	5.54	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.53	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.21	0.1	-	0.55	0.18	1.18	-	0.98	1.36	-	0.95	0.06	-	1.24	2.39	5.54	0.46	0.89	1.49	1.62	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.53
H3362_017_0	2007	9																					0											A	A	Coin	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.08	4.54	29.72	1287.38	84.82	5.9	1.64	242.95	467.77	0	542.95	37.05	0.57	742.13	5223.42	3026.55	0.91	548.9	875.96	949.19	11.03	674.15	0	0	577.7	577.7	15.05	0	0	0	0											PBP: 1A IP Acute: 500 per admit	1B IP Psych: 500 per admit	2 SNF: 20	6 Home Health: 15	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0-20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 30	9A OP Hospital: 30	12 Renal Dialysis: 30	3 CORF: 15 5 Partial Hosp: 30 9C OP Substance Abuse: 50 9D Cardiac Rehab: 15	7A PCP: 25 14B Immunizations: 25 14C Routine Physical Exams: 25 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 30 14I Diabetes Monitoring: 0-30	7D Physician Specialist: 30	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 30	7B Chiropractic: 25 7f Podiatry 30 7G Other Health Care: 30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 30 17A Medicare Covered Eye Exams: 30	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 30	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											500	500	0.2	15	50	0.2	0.2	49	75	0	30	30	30	30	25	30	0.5	15	30	28.63	0.2	30	0	0	5	36.33	30	0	0	0	0											8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.36	0.09	0	1.86	10.88	7.57	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.17	0	0	8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.36	0.09	0	1.86	10.88	7.57	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.17	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.36	0.09	0	1.86	10.88	7.57	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.17
H3362_018_0	2007	5																					0											A	A	Coin	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.08	4.54	29.72	1287.38	84.82	5.9	1.64	242.95	467.77	0	546.35	37.05	0.57	742.13	5286.49	3063.09	0.91	548.9	875.96	949.19	11.03	674.15	0	0	577.7	577.7	15.05	0	0	0	0											PBP: 1A IP Acute: 500 per admit	1B IP Psych: 500 per admit	2 SNF: 20	6 Home Health: 15	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0-20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 30	9A OP Hospital: 30	12 Renal Dialysis: 30	3 CORF: 15 5 Partial Hosp: 30 9C OP Substance Abuse: 50 9D Cardiac Rehab: 15	7A PCP: 25 14B Immunizations: 25 14C Routine Physical Exams: 25 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 30 14I Diabetes Monitoring: 0-30	7D Physician Specialist: 30	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 30	7B Chiropractic: 25 7f Podiatry 30 7G Other Health Care: 30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 30 17A Medicare Covered Eye Exams: 30	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 30	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											500	500	0.2	15	50	0.2	0.2	49	75	0	30	30	30	30	20	30	0.5	15	30	28.63	0.2	30	0	0	5	36.33	30	0	0	0	0											8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.37	0.09	0	1.86	8.81	7.66	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.2	0	0	8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.37	0.09	0	1.86	8.81	7.66	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.2	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.37	0.09	0	1.86	8.81	7.66	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.2
H3362_020_0	2007	10																					0											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	665.79	29.8	0	0	1714.29	10.25	26.2	594.44	190.54	0	931.94	39.24	0	2259.26	0	7118.75	5.14	34.99	5285.19	17229.39	2.13	535.34	0	0	577.8	577.7	0	0	0	0	0											PBP: 1A IP Acute: 250 per Admit	1B IP Psych: 250 per Admit	2 SNF: 0	6 Home Health: 0	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 5	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 5	9C OP Hospital: 5	12 Renal Dialysis: 0	3 CORF: 5 5 Partial Hosp: 5 9C OP Substance Abuse: 50 9D Cardiac Rehab: 5	7A PCP: 0 14B Immunizations: 0 14C Routine Physical Exams: 0 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-5	7D Physician Specialist: 5	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 5 7I Physical and Speech Therapy: 5	8B OP X-Ray: 5	7B Chiropractic: 5 7F Podiatry: 5 7G Other Health Care: 5 18A Medicare Covered Hearing Exams: 5	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 5 17A Medicare Covered Eye Exams: 5	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 10	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	0	0	50	0.2	0.2	49.72	75	0	5	5	0	5	0	5	0.5	5	5	5	0.2	5	0	0	5	36.33	0	0	0	0	0											13.87	0.62	-	-	7.14	2.05	5.23	2.46	1.19	-	0.39	0.02	-	0.94	-	2.97	2.57	0.01	2.2	7.18	0.43	0.22	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.49	0	0	13.87	0.62	-	-	7.14	2.05	5.23	2.46	1.19	-	0.39	0.02	-	0.94	-	2.97	2.57	0.01	2.2	7.18	0.43	0.22	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.49	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	13.87	0.62	-	-	7.14	2.05	5.23	2.46	1.19	-	0.39	0.02	-	0.94	-	2.97	2.57	0.01	2.2	7.18	0.43	0.22	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.49
H3362_801_0	2007	7																					0											A	A	Coin	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.08	4.54	29.72	1287.38	84.82	5.9	1.64	242.95	467.77	0	546.35	37.05	0.57	742.13	5286.49	3063.09	0.91	548.9	875.96	949.19	11.03	674.15	0	0	577.7	577.7	15.05	0	0	0	0											PBP: 1A IP Acute: 500 per admit	1B IP Psych: 500 per admit	2 SNF: 20	6 Home Health: 15	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0-20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 30	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 30	9A OP Hospital: 30	12 Renal Dialysis: 30	3 CORF: 15 5 Partial Hosp: 30 9C OP Substance Abuse: 50 9D Cardiac Rehab: 15	7A PCP: 25 14B Immunizations: 25 14C Routine Physical Exams: 25 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 30 14I Diabetes Monitoring: 0-30	7D Physician Specialist: 30	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 30	7B Chiropractic: 25 7f Podiatry 30 7G Other Health Care: 30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 30 17A Medicare Covered Eye Exams: 30	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 30	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											500	500	0.2	15	50	0.2	0.2	49	75	0	30	30	30	30	20	30	0.5	15	30	28.63	0.2	30	0	0	5	36.33	30	0	0	0	0											8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.37	0.09	0	1.86	8.81	7.66	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.2	0	0	8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.37	0.09	0	1.86	8.81	7.66	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.2	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.38	0.19	5.94	1.61	0.35	1.18	0.33	0.99	2.92	-	1.37	0.09	0	1.86	8.81	7.66	0.46	0.69	2.19	2.27	2.21	1.69	-	-	0.24	1.75	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.2
H3362_807_0	2007	7																					0											A	A	A	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	Coin	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.08	4.54	117.5	1266.14	84.82	5.9	1.64	242.95	467.77	0	555.44	37.05	0.57	742.13	5378.23	3116.25	1	531.37	894.75	969.55	11.03	674.15	0	0	577.7	577.7	15.57	0	7.02	0	0											PBP: 1A IP Acute: 500 per admit	1B IP Psych: 500 per admit	2 SNF: 500 per admit	6 Home Health: 20	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0-20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 20	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 20 14B Immunizations: 20 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 20 7H Psychiatric: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 20	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS:  500 Deductible 20 Coin	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											500	500	500	20	50	0.2	0.2	48.5	75	0	20	20	20	20	20	20	0.2	20	20	20	0.2	20	0	0	20	36.33	20	0	0.17	0	0											8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	1.2	-	-	-	-	-	-	-	-	-	-	-	-	49.18	0	0	8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	1.2	-	-	-	-	-	-	-	-	-	-	-	-	49.18	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	1.2	-	-	-	-	-	-	-	-	-	-	-	-	49.18
H3362_811_0	2007	4																					0											A	A	Coin	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	202.09	4.57	0	1287.38	84.82	5.9	1.64	242.95	467.77	0	561.69	37.05	0.57	742.13	5613.31	3252.46	0.91	548.9	894.75	969.55	11.03	674.15	0	0	577.7	577.7	15.57	0	0	0	0											PBP: 1A IP Acute: 250 per admit	1B IP Psych: 250 per admit	2 SNF: 0	6 Home Health: 15	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0-20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 20	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 50 9D Cardiac Rehab: 15	7A PCP: 10 14B Immunizations: 10 14C Routine Physical Exams: 10 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 20 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 20	7B Chiropractic: 25 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	0	15	50	0.2	0.2	48.5	75	0	20	20	20	20	10	20	0.5	15	20	21.37	0.2	20	0	0	5	36.33	20	0	0	0	0											4.21	0.1	-	1.61	0.35	1.18	0.33	0.98	2.92	-	0.94	0.06	0	1.24	4.68	5.42	0.46	0.69	1.49	1.73	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.72	0	0	4.21	0.1	-	1.61	0.35	1.18	0.33	0.98	2.92	-	0.94	0.06	0	1.24	4.68	5.42	0.46	0.69	1.49	1.73	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.72	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.21	0.1	-	1.61	0.35	1.18	0.33	0.98	2.92	-	0.94	0.06	0	1.24	4.68	5.42	0.46	0.69	1.49	1.73	2.21	1.12	-	-	0.24	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.72
H3362_812_0	2007	7																					0											A	A	A	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.08	4.54	117.5	1266.14	84.82	5.9	1.64	242.95	467.77	0	555.44	37.05	0.57	742.13	5378.23	3116.25	1	531.37	894.75	969.55	11.03	674.15	0	0	577.7	577.7	15.57	0	0	0	0											PBP: 1A IP Acute: 0	1B IP Psych: 0	2 SNF: 500 per admit	6 Home Health: 20	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0-20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 20	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 20 14B Immunizations: 20 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 20 7H Psychiatric: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 20	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											500	500	500	20	50	0.2	0.2	48.5	75	0	20	20	20	20	20	20	0.2	20	20	20	0.2	20	0	0	20	36.33	20	0	0	0	0											8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.98	0	0	8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.98	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.98
H3362_814_0	2007	6																					0											A	A	A	V	T	Coin	Coin	V	V	P	P	V	V	V	V	V	Coin	V	P	V	Coin	O	T	V	V	V	V	V	Coin	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	201.08	4.54	117.5	1266.14	84.82	5.9	1.64	242.95	467.77	0	555.44	37.05	0.57	742.13	5378.23	3116.25	1	531.37	894.75	969.55	11.03	674.15	0	0	577.7	577.7	15.57	0	7.02	0	0											PBP: 1A IP Acute: 500 per admit	1B IP Psych: 500 per admit	2 SNF: 500 per admit	6 Home Health: 20	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 0-20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 75	8A OP C/D/T: 0	8B OP X-Ray: 20	9A OP Hospital: 20	12 Renal Dialysis: 20	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 20 14B Immunizations: 20 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-20	7D Physician Specialist: 20	7E Mental Health: 20 7H Psychiatric: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 20	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 20 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: 20	18B Hearing Aids: Not Covered	19 POS:  500 Deductible 20 Coin	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											500	500	500	20	50	0.2	0.2	48.5	75	0	20	20	20	20	20	20	0.2	20	20	20	0.2	20	0	0	20	36.33	20	0	0.17	0	0											8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	1.2	-	-	-	-	-	-	-	-	-	-	-	-	49.18	0	0	8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	1.2	-	-	-	-	-	-	-	-	-	-	-	-	49.18	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.38	0.19	4.9	2.11	0.35	1.18	0.33	0.98	2.92	-	0.93	0.06	0	1.24	8.96	5.19	0.2	0.89	1.49	1.62	2.21	1.12	-	-	0.96	1.75	0.03	-	1.2	-	-	-	-	-	-	-	-	-	-	-	-	49.18
H3366_008_0	2007	3																					none											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	0	0	0	0	0	18.21	1.14	245.62	27.25	0	0	0	0.47	523.47	5314.43	7885.3	272.67	899.89	0	220.3	7.85	902.39	0	2000	0	0	0	0	0	0	0																0 of first 200/year then 20 for DME / 0 for Supplies	0 of first 200/year then 20	50 ER / 25 UC					20	20 OP SA/20 OP Therapy	0 PCP	20 SCP / 20 Chiro / 20 Medicare Podiatrist /0 Routine Podiatrist	25 MH	20 Therapy / 20 Cardiac		0 Hearing / 0 Preventive	20	15 Vision/0 Blood		5 for Preventive / 5 - 660 for Emergency / 5 - 45 for Diagnostic / 5 - 485 for Restorative / 5 - 425 for Endo/Perio/Extractions / 5 - 600 for Oral/Maxillo																		0	0	0	0	0	0.1	0.12	41.57	0	0	0	0	0.2	20	0	19.1	25	20	0	0	0.2	14.1	0	5	0	0	0	0	0	0	0											-	-	-	-	-	1.78	0.14	0.85	-	-	-	-	0.09	0.87	-	12.55	0.57	1.5	-	-	1.57	1.06	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82	0	0	-	-	-	-	-	1.78	0.14	0.85	-	-	-	-	0.09	0.87	-	12.55	0.57	1.5	-	-	1.57	1.06	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82	none																																																																																			-	0	0	-	-	-	-	-	1.78	0.14	0.85	-	-	-	-	0.09	0.87	-	12.55	0.57	1.5	-	-	1.57	1.06	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.82
H3366_021_0	2007	3																					none											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	0	0	0	0	0	18.26	1.14	274.85	27.32	0	0	0	0.47	523.47	0	0	272.67	899.89	0	27.13	7.87	53.98	0	2000	0	0	0	0	0	0	0																0 of first 200/year then 20 for DME / 0 for Supplies	0 of first 200/year then 20	25 ER / 10 UC					20	20 OP SA/20 OP Therapy	0 PCP	0 SCP / 0 Chiro / 0 Medicare Podiatrist /0 Routine Podiatrist	25 MH	20 Therapy / 20 Cardiac		0 Hearing / 0 Preventive	20	0 Vision/0 Blood		5 for Preventive / 5 - 660 for Emergency / 5 - 45 for Diagnostic / 5 - 485 for Restorative / 5 - 425 for Endo/Perio/Extractions / 5 - 600 for Oral/Maxillo																		0	0	0	0	0	0.1	0.12	19.94	0	0	0	0	0.2	20	0	0	25	20	0	0	0.2	0	0	5	0	0	0	0	0	0	0											-	-	-	-	-	1.79	0.14	0.46	-	-	-	-	0.09	0.87	-	-	0.57	1.5	-	-	1.57	-	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.82	0	0	-	-	-	-	-	1.79	0.14	0.46	-	-	-	-	0.09	0.87	-	-	0.57	1.5	-	-	1.57	-	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.82	none																																																																																			-	0	0	-	-	-	-	-	1.79	0.14	0.46	-	-	-	-	0.09	0.87	-	-	0.57	1.5	-	-	1.57	-	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.82
H3366_022_0	2007	4																					none											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	0	0	0	0	0	23.5	1.47	358.99	35.17	0	0	0	0.6	684.56	7220.6	10753.94	364.23	1175.37	0	298.14	10.13	1214.38	0	2000	0	0	0	0	0	0	0																0 of first 200/year then 20 for DME / 0 for Supplies	12	25 ER / 10 UC					20	20 OP SA/20 OP Therapy	0 PCP	10 SCP / 10 Chiro / 10 Medicare Podiatrist /10 Routine Podiatrist	20 MH	20 Therapy / 20 Cardiac		0 Hearing / 0 Preventive	20	10 Vision/0 Blood		5 for Preventive / 5 - 660 for Emergency / 5 - 45 for Diagnostic / 5 - 485 for Restorative / 5 - 425 for Endo/Perio/Extractions / 5 - 600 for Oral/Maxillo																		0	0	0	0	0	0.1	0.12	19.94	0	0	0	0	0.2	20	0	9.99	20	20	0	0	0.2	9.42	0	5	0	0	0	0	0	0	0											-	-	-	-	-	2.3	0.18	0.6	-	-	-	-	0.12	1.14	-	8.95	0.61	1.96	-	-	2.03	0.95	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.67	0	0	-	-	-	-	-	2.3	0.18	0.6	-	-	-	-	0.12	1.14	-	8.95	0.61	1.96	-	-	2.03	0.95	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.67	none																																																																																			-	0	0	-	-	-	-	-	2.3	0.18	0.6	-	-	-	-	0.12	1.14	-	8.95	0.61	1.96	-	-	2.03	0.95	-	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.67
H3366_803_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	880.76	9.87	1240.45	0	209.9	18.63	1.17	245.21	259.77	0	814.59	0	0.48	299.37	4932.37	7186.51	278.23	897.85	0	315.5	8.03	874.26	0	0	0	0	0	0	0	0	0											300 per day; days 1-6	300 per day; days 1-6	75 per day; days 1-15		150	20	20	50 ER / 40 UC	200		20 for x-rays/radiation therapy / 150 for CT / 200 for MRI/MRA/SPECT		20	40 OP SA/40 OP Therapy	40 PCP	40 SCP / 40 Chiro / 40 Medicare Podiatrist /0 Routine Podiatrist	40 MH	40 Therapy / 0 Cardiac		40 Hearing / 0 Preventive	20	40 Vision/0 Blood																				300	300	25.96	0	150	0.2	0.2	46.63	200	0	47.82	0	0.2	40	39.98	38.07	40	31.47	0	13.82	0.2	37.48	0	0	0	0	0	0	0	0	0											22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	none																																																																																			-	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37
H3366_805_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	880.76	9.87	1240.45	0	209.9	18.63	1.17	245.21	259.77	0	814.59	0	0.48	299.37	4932.37	7186.51	278.23	897.85	0	315.5	8.03	874.26	0	0	0	0	0	0	0	0	0											300 per day; days 1-6	300 per day; days 1-6	75 per day; days 1-15		150	20	20	50 ER / 40 UC	200		20 for x-rays/radiation therapy / 150 for CT / 200 for MRI/MRA/SPECT		20	40 OP SA/40 OP Therapy	40 PCP	40 SCP / 40 Chiro / 40 Medicare Podiatrist /0 Routine Podiatrist	40 MH	40 Therapy / 0 Cardiac		40 Hearing / 0 Preventive	20	40 Vision/0 Blood																				300	300	25.96	0	150	0.2	0.2	46.63	200	0	47.82	0	0.2	40	39.98	38.07	40	31.47	0	13.82	0.2	37.48	0	0	0	0	0	0	0	0	0											22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	none																																																																																			-	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37
H3366_806_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	880.76	9.87	1240.45	0	209.9	18.63	1.17	245.21	259.77	0	814.59	0	0.48	299.37	4932.37	7186.51	278.23	897.85	0	315.5	8.03	874.26	0	0	0	0	0	0	0	0	0											300 per day; days 1-6	300 per day; days 1-6	75 per day; days 1-15		150	20	20	50 ER / 40 UC	200		20 for x-rays/radiation therapy / 150 for CT / 200 for MRI/MRA/SPECT		20	40 OP SA/40 OP Therapy	40 PCP	40 SCP / 40 Chiro / 40 Medicare Podiatrist /0 Routine Podiatrist	40 MH	40 Therapy / 0 Cardiac		40 Hearing / 0 Preventive	20	40 Vision/0 Blood																				300	300	25.96	0	150	0.2	0.2	46.63	200	0	47.82	0	0.2	40	39.98	38.07	40	31.47	0	13.82	0.2	37.48	0	0	0	0	0	0	0	0	0											22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	none																																																																																			-	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37
H3366_808_0	2007	1																					none											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	880.76	9.87	1240.45	0	209.9	18.63	1.17	245.21	259.77	0	814.59	0	0.48	299.37	4932.37	7186.51	278.23	897.85	0	315.5	8.03	874.26	0	0	0	0	0	0	0	0	0											300 per day; days 1-6	300 per day; days 1-6	75 per day; days 1-15		150	20	20	50 ER / 40 UC	200		20 for x-rays/radiation therapy / 150 for CT / 200 for MRI/MRA/SPECT		20	40 OP SA/40 OP Therapy	40 PCP	40 SCP / 40 Chiro / 40 Medicare Podiatrist /0 Routine Podiatrist	40 MH	40 Therapy / 0 Cardiac		40 Hearing / 0 Preventive	20	40 Vision/0 Blood																				300	300	25.96	0	150	0.2	0.2	46.63	200	0	47.82	0	0.2	40	39.98	38.07	40	31.47	0	13.82	0.2	37.48	0	0	0	0	0	0	0	0	0											22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37	none																																																																																			-	0	0	22.02	0.25	2.68	-	2.62	3.73	0.23	0.95	4.33	-	3.25	-	0.1	1	16.43	22.8	0.93	2.35	-	0.36	1.61	2.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.37
H3370_001_0	2007	4																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-				960.4					176.83								7626.55	352.29	1297.43							187.39	205.42					180											#1A 0	#1B 0	#2 20/day days 1-100	#6 0	#10A 0	#11A 0	#11B 0 #11C 0	#4A 50	#9A 0 #9B 0	#8A 0	#8A 0 #8B 0		#12 0	#3 0 #9D 0	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 15 #7D 15 #7F 15 #7G 15 #4B 15	#7E 25 #7H 25 #5 25 #9C 25	#7C 15 #7I 15		#14I 0	#15 0	#13A 0	#10B n/c	#16A 0 #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 15													20					50								13.63	25	14.99							10	29					15											-	-	1.6	-	-	-	-	0.74	-	-	-	-	-	-	-	8.66	0.73	1.62	-	-	-	-	-	-	0.16	0.5	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	14.24			-	-	1.6	-	-	-	-	0.74	-	-	-	-	-	-	-	8.66	0.73	1.62	-	-	-	-	-	-	0.16	0.5	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	14.24																																																																																				-			-	-	1.6	-	-	-	-	0.74	-	-	-	-	-	-	-	8.66	0.73	1.62	-	-	-	-	-	-	0.16	0.5	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	14.24
H3370_002_0	2007	6																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		1961.31		944.25		0.18	5.19	1.48	210.83	260.26		524.74				4676.84	7813.5	250.37	1181.26							170.13	186.5					180											#1A 125/day days 1-10 0/day days 11-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/35/300 #8B 0/35		#12 0	#3 0 #9D 0	#7A 15 #14B 0 #14C 15 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											105.89		50		50	0.2	0.2	50	300		35				15	22.92	25	24.97							10	29					25											17.31	-	3.93	-	0	1.04	0.3	0.88	6.51	-	1.53	-	-	-	5.85	14.93	0.52	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	56.21			17.31	-	3.93	-	0	1.04	0.3	0.88	6.51	-	1.53	-	-	-	5.85	14.93	0.52	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	56.21																																																																																				-			17.31	-	3.93	-	0	1.04	0.3	0.88	6.51	-	1.53	-	-	-	5.85	14.93	0.52	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	56.21
H3370_003_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		2232.83		1047.82		12.96	6.11	2.25	161.54	237.8		179.04				4697.02	8205.07	327.93	1459.79							176.65	193.64					180											#1A 100/day days 1-8 0/day days 9-90	#1B 0	#2 55/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/25/200 #8B 0/25		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											76.52		55		50	0.2	0.2	50	200		25				10	22.81	25	25							10	29					25											14.24	-	4.8	-	0.05	1.22	0.45	0.67	3.96	-	0.37	-	-	-	3.91	15.59	0.68	3.04	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	50			14.24	-	4.8	-	0.05	1.22	0.45	0.67	3.96	-	0.37	-	-	-	3.91	15.59	0.68	3.04	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	50																																																																																				-			14.24	-	4.8	-	0.05	1.22	0.45	0.67	3.96	-	0.37	-	-	-	3.91	15.59	0.68	3.04	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	50
H3370_004_0	2007	6																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		2291.45		981.64		15.46	7.6	2.59	213.91	274.44		405.52				5813.16	8482.28	219.95	1369.54							175.92	192.85					180											#1A 100/day days 1-8 0/day days 9-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/25/200 #8B 0/25		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											78.67		50		50	0.2	0.2	50	200		25				10	22.65	25	25							10	29					25											15.02	-	4.09	-	0.06	1.52	0.52	0.89	4.57	-	0.84	-	-	-	4.84	16.01	0.46	2.85	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	52.68			15.02	-	4.09	-	0.06	1.52	0.52	0.89	4.57	-	0.84	-	-	-	4.84	16.01	0.46	2.85	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	52.68																																																																																				-			15.02	-	4.09	-	0.06	1.52	0.52	0.89	4.57	-	0.84	-	-	-	4.84	16.01	0.46	2.85	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	52.68
H3370_009_0	2007	2																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		2291.45		981.64		15.46	7.6	2.59	213.91	274.44		405.52				5813.16	8482.28	219.95	1369.54							175.92	192.85					180											#1A 100/day days 1-8 0/day days 9-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/25/200 #8B 0/25		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											78.67		50		50	0.2	0.2	50	200		25				10	22.65	25	25							10	29					25											15.02	-	4.09	-	0.06	1.52	0.52	0.89	4.57	-	0.84	-	-	-	4.84	16.01	0.46	2.85	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	52.68			15.02	-	4.09	-	0.06	1.52	0.52	0.89	4.57	-	0.84	-	-	-	4.84	16.01	0.46	2.85	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	52.68																																																																																				-			15.02	-	4.09	-	0.06	1.52	0.52	0.89	4.57	-	0.84	-	-	-	4.84	16.01	0.46	2.85	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	52.68
H3370_010_0	2007	2																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		1961.31		944.25		0.18	5.19	1.48	210.83	260.26		524.74				4676.84	7813.5	250.37	1181.26							170.13	186.5					180											#1A 125/day days 1-10 0/day days 11-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/35/300 #8B 0/35		#12 0	#3 0 #9D 0	#7A 15 #14B 0 #14C 15 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											105.89		50		50	0.2	0.2	50	300		35				15	22.92	25	24.97							10	29					25											17.31	-	3.93	-	0	1.04	0.3	0.88	6.51	-	1.53	-	-	-	5.85	14.93	0.52	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	56.21			17.31	-	3.93	-	0	1.04	0.3	0.88	6.51	-	1.53	-	-	-	5.85	14.93	0.52	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	56.21																																																																																				-			17.31	-	3.93	-	0	1.04	0.3	0.88	6.51	-	1.53	-	-	-	5.85	14.93	0.52	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	56.21
H3370_011_0	2007	2																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		2232.83		1047.82		12.96	6.11	2.25	161.54	237.8		179.04				4697.02	8205.07	327.93	1459.79							176.65	193.64					180											#1A 50/day days 1-8 0/day days 9-90	#1B 0	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/100 #9B 100	#8A 0	#8A 0/25/100 #8B 0/25		#12 0	#3 0 #9D 0	#7A 5 #14B 0 #14C 5 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 20 #7D 20 #7F 20 #7G 20 #4B 20	#7E 25 #7H 25 #5 25 #9C 25	#7C 20 #7I 20		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 20											38.26		50		50	0.2	0.2	50	100		25				5	18.22	25	20							10	29					20											7.12	-	4.37	-	0.05	1.22	0.45	0.67	1.98	-	0.37	-	-	-	1.96	12.46	0.68	2.43	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	34.69			7.12	-	4.37	-	0.05	1.22	0.45	0.67	1.98	-	0.37	-	-	-	1.96	12.46	0.68	2.43	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	34.69																																																																																				-			7.12	-	4.37	-	0.05	1.22	0.45	0.67	1.98	-	0.37	-	-	-	1.96	12.46	0.68	2.43	-	-	-	-	-	-	0.15	0.47	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	34.69
H3370_012_0	2007	6																																D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		1942.08	3.89	944.25		0.16	4.55	1.3	210.83	260.26		524.74				4676.84	7813.5	268.44	1181.26							170.13	186.5					180											#1A 125/day days 1-10 0/day days 11-90	#1B 150 copay/admit	#2 55/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/35/300 #8B 0/35		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											105.89	150	55		50	0.2	0.2	50	300		35				10	22.88	25	24.97							10	29					25											17.14	0.05	4.33	-	0	0.91	0.26	0.88	6.51	-	1.53	-	-	-	3.9	14.9	0.56	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	54.38			17.14	0.05	4.33	-	0	0.91	0.26	0.88	6.51	-	1.53	-	-	-	3.9	14.9	0.56	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	54.38																																																																																				-			17.14	0.05	4.33	-	0	0.91	0.26	0.88	6.51	-	1.53	-	-	-	3.9	14.9	0.56	2.46	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	54.38
H3370_013_0	2007	3																																D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		1942.08	3.89	944.25		0.16	4.55	1.3	210.83	260.26		524.74				4676.84	7813.5	268.44	1181.26							170.13	186.5					180											#1A 75/day days 1-8 0/day days 9-90	#1B 150 copay/admit	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/200 #9B 200	#8A 0	#8A 0/35/200 #8B 0/35		#12 0	#3 0 #9D 0	#7A 5 #14B 0 #14C 5 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 20 #7D 20 #7F 20 #7G 20 #4B 20	#7E 25 #7H 25 #5 25 #9C 25	#7C 20 #7I 20		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 20											63.53	150	50		50	0.2	0.2	50	200		35				5	18.28	25	19.98							10	29					20											10.28	0.05	3.93	-	0	0.91	0.26	0.88	4.34	-	1.53	-	-	-	1.95	11.9	0.56	1.97	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	39.45			10.28	0.05	3.93	-	0	0.91	0.26	0.88	4.34	-	1.53	-	-	-	1.95	11.9	0.56	1.97	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	39.45																																																																																				-			10.28	0.05	3.93	-	0	0.91	0.26	0.88	4.34	-	1.53	-	-	-	1.95	11.9	0.56	1.97	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	39.45
H3370_014_0	2007	4																																D	A	D	V	P	P	P	V	V	V	V	V	V	V	V	V	V	V	V	P	Coin	P	P	P	V	P	P	P	P	P	P	V	V	V	V	V	V	V	V	V	V																																										-		1708.3	94.93	809.23		126.15			348.03	332.36		30.43			178.62		6812.87	365.71	666.89							132.39	149.39																#1A 50/day days 1-8 0/day days 9-90	#1B 150 copay/admit	#2 15/day days 1-100	#6 0	#10A 50	#11A 0	#11B 0 #11C 0	#4A 50	#9A 0/100 #9B 100	#8A 0	#8A 0/100 #8B 0		#12 0	#3 0 #9D 0	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 15 #7D 15 #7F 15 #7G 15 #4B 15	#7E 25 #7H 25 #5 25 #9C 25	#7C 15 #7I 15		#14I 0	#15 0	#13A 0	#10B n/c	#16A 0 #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c	none	none	none	none	none	none	none	none	none	none	38.9	14.18	15		50			49.84	100		15			17.45		14.99	25	15							10	29																5.54	0.11	1.01	-	0.53	-	-	1.45	2.77	-	0.04	-	-	0.26	-	8.51	0.76	0.83	-	-	-	-	-	-	0.11	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.27		0	5.54	0.11	1.01	-	0.53	-	-	1.45	2.77	-	0.04	-	-	0.26	-	8.51	0.76	0.83	-	-	-	-	-	-	0.11	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.27		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																										-		0	5.54	0.11	1.01	-	0.53	-	-	1.45	2.77	-	0.04	-	-	0.26	-	8.51	0.76	0.83	-	-	-	-	-	-	0.11	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.27
H3370_015_0	2007	2																																D	A	D	V	P	P	P	V	V	V	V	V	V	V	V	V	V	V	V	P	Coin	P	P	P	V	P	P	P	P	P	P	V	V	V	V	V	V	V	V	V	V																																										-		1708.3	94.93	809.23		126.15			348.03	332.36		30.43			178.62		6812.87	365.71	666.89							132.39	149.39																#1A 50/day days 1-8 0/day days 9-90	#1B 150 copay/admit	#2 15/day days 1-100	#6 0	#10A 50	#11A 0	#11B 0 #11C 0	#4A 50	#9A 0/100 #9B 100	#8A 0	#8A 0/100 #8B 0		#12 0	#3 0 #9D 0	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 15 #7D 15 #7F 15 #7G 15 #4B 15	#7E 25 #7H 25 #5 25 #9C 25	#7C 15 #7I 15		#14I 0	#15 0	#13A 0	#10B n/c	#16A 0 #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c	none	none	none	none	none	none	none	none	none	none	38.9	14.18	15		50			49.84	100		15			17.45		14.99	25	15							10	29																5.54	0.11	1.01	-	0.53	-	-	1.45	2.77	-	0.04	-	-	0.26	-	8.51	0.76	0.83	-	-	-	-	-	-	0.11	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.27		0	5.54	0.11	1.01	-	0.53	-	-	1.45	2.77	-	0.04	-	-	0.26	-	8.51	0.76	0.83	-	-	-	-	-	-	0.11	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.27		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																										-		0	5.54	0.11	1.01	-	0.53	-	-	1.45	2.77	-	0.04	-	-	0.26	-	8.51	0.76	0.83	-	-	-	-	-	-	0.11	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.27
H3370_016_0	2007	6																																D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		1883.82	3.77	915.92		0.16	4.41	1.26	204.51	252.45		509				4536.54	7579.09	260.39	1145.83							165.03	180.91					180											#1A 150/day days 1-10 0/day days 11-90	#1B 150 copay/admit	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/35/100 #8B 0/35		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A 0 #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											127.07	150	50		50	0.2	0.2	50	300		35				10	22.88	25	24.97							10	29					25											19.95	0.05	3.82	-	0	0.88	0.25	0.85	6.31	-	1.48	-	-	-	3.78	14.45	0.54	2.38	-	-	-	-	-	-	0.14	0.44	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	55.7			19.95	0.05	3.82	-	0	0.88	0.25	0.85	6.31	-	1.48	-	-	-	3.78	14.45	0.54	2.38	-	-	-	-	-	-	0.14	0.44	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	55.7																																																																																				-			19.95	0.05	3.82	-	0	0.88	0.25	0.85	6.31	-	1.48	-	-	-	3.78	14.45	0.54	2.38	-	-	-	-	-	-	0.14	0.44	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	55.7
H3370_017_0	2007	2																																D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		1883.82	3.77	915.92		0.16	4.41	1.26	204.51	252.45		509				4536.54	7579.09	260.39	1145.83							165.03	180.91					180											#1A 150/day days 1-10 0/day days 11-90	#1B 150 copay/admit	#2 50/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/35/100 #8B 0/35		#12 0	#3 0 #9D 0	#7A 10 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25 #4B 25	#7E 25 #7H 25 #5 25 #9C 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B n/c	#16A 0 #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 25											127.07	150	50		50	0.2	0.2	50	300		35				10	22.88	25	24.97							10	29					25											19.95	0.05	3.82	-	0	0.88	0.25	0.85	6.31	-	1.48	-	-	-	3.78	14.45	0.54	2.38	-	-	-	-	-	-	0.14	0.44	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	55.7			19.95	0.05	3.82	-	0	0.88	0.25	0.85	6.31	-	1.48	-	-	-	3.78	14.45	0.54	2.38	-	-	-	-	-	-	0.14	0.44	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	55.7																																																																																				-			19.95	0.05	3.82	-	0	0.88	0.25	0.85	6.31	-	1.48	-	-	-	3.78	14.45	0.54	2.38	-	-	-	-	-	-	0.14	0.44	-	-	-	-	0.38	-	-	-	-	-	-	-	-	-	-	55.7
H3370_018_0	2007	4																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-																																											#1A 0	#1B 0	#2 0	#6 0	#10A 0	#11A 0	#11B 0 #11C 0	#4A 0	#9A 0 #9B 0	#8A 0	#8A 0 #8B 0		#12 0	#3 0 #9D 0	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 0 #7D 0 #7F 0 #7G 0 #4B 0	#7E 0 #7H 0 #5 0 #9C 0	#7C 0 #7I 0		#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 0	#17B 0/0/0	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 0																																																				-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H3370_019_0	2007	2																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-				960.4					176.83								7626.55	352.29	1297.43							187.39	205.42					180											#1A 0	#1B 0	#2 15/day days 1-100	#6 0	#10A 0	#11A 0	#11B 0 #11C 0	#4A 50	#9A 0 #9B 0	#8A 0	#8A 0 #8B 0		#12 0	#3 0 #9D 0	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 15 #7D 15 #7F 15 #7G 15 #4B 15	#7E 25 #7H 25 #5 25 #9C 25	#7C 15 #7I 15		#14I 0	#15 0	#13A 0	#10B n/c	#16A 0 #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 15													15					50								13.63	25	14.99							10	29					15											-	-	1.2	-	-	-	-	0.74	-	-	-	-	-	-	-	8.66	0.73	1.62	-	-	-	-	-	-	0.16	0.5	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	13.83			-	-	1.2	-	-	-	-	0.74	-	-	-	-	-	-	-	8.66	0.73	1.62	-	-	-	-	-	-	0.16	0.5	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	13.83																																																																																				-			-	-	1.2	-	-	-	-	0.74	-	-	-	-	-	-	-	8.66	0.73	1.62	-	-	-	-	-	-	0.16	0.5	-	-	-	-	0.23	-	-	-	-	-	-	-	-	-	-	13.83
H3370_020_0	2007	6																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-		1961.31		944.25		0.18	5.19	1.48	210.83	260.26		498.53				4676.84	7618.66	250.37	1145.94							170.13	186.5					180											#1A 400/day day 1 125/day days 2-10 0/day days 11-90	#1B 0	#2 55/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50	#9A 0/300 #9B 300	#8A 0	#8A 0/300/20 #8B 0/20		#12 0	#3 0 #9D 0	#7A 15 #14B 0 #14C 10 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 30 #7D 30 #7F 30 #7G 30 #4B 30	#7E 25 #7H 25 #5 25 #9C 25	#7C 30 #7I 30		#14I 0	#15 0	#13A 0	#10B n/c	#16A n/c #16B 0	#17A 10	#17B 0/25/45	#18A 0	#18B 0	#19 n/c	#14A 0	#13B n/c #7F 30											158.08		55		50	0.2	0.2	50	300		120.01				15	26.83	25	29.95							10	29					30											25.84	-	4.33	-	0	1.04	0.3	0.88	6.51	-	4.99	-	-	-	5.85	17.03	0.52	2.86	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	71.17			25.84	-	4.33	-	0	1.04	0.3	0.88	6.51	-	4.99	-	-	-	5.85	17.03	0.52	2.86	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	71.17																																																																																				-			25.84	-	4.33	-	0	1.04	0.3	0.88	6.51	-	4.99	-	-	-	5.85	17.03	0.52	2.86	-	-	-	-	-	-	0.14	0.45	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	71.17
H3370_801_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		293.96	3.72	30.69	13.91	8.05	6.07	11.99	196.07	40.23	6.96	30.77	1.22	0.87	7.8	45.49	165.88	2.95	7.79	37.18	20.4	35.81	0																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.05	0.05	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16	0.2	5.21	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.59	138	0	16	0.2	5.21	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.59																																																																																				-			16	0.2	5.21	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.59
H3370_802_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		293.96	3.72	30.69	13.91	8.05	6.07	11.99	196.07	40.23	6.96	30.77	1.22	0.87	7.8	45.49	165.88	2.95	7.79	37.18	20.4	35.81	0																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.05	0.05	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16	0.2	5.21	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.59	138	0	16	0.2	5.21	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.59																																																																																				-			16	0.2	5.21	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.59
H3370_803_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		293.96	3.72	30.69	13.91	8.05	6.07	11.99	196.07	40.23	6.96	30.77	1.22	0.87	7.8	45.49	165.88	2.95	7.79	37.18	20.4	35.81	0																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.91	0.23	5.22	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.53	138	0	17.91	0.23	5.22	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.53																																																																																				-			17.91	0.23	5.22	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.53
H3370_804_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		293.96	3.72	30.69	13.91	8.05	6.07	11.99	196.07	40.23	6.96	30.77	1.22	0.87	7.8	45.49	165.88	2.95	7.79	37.18	20.4	35.81	0																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.91	0.23	5.22	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.53	138	0	17.91	0.23	5.22	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.53																																																																																				-			17.91	0.23	5.22	-	1.9	1.43	2.83	0.82	9.49	1.64	7.26	0.29	0.2	1.84	10.74	39.15	0.7	1.84	8.78	4.81	8.45	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.53
H3379_001_0	2007	5																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2921.38	49.74	1633.07	0	218.83	10.09	7.33	243.87	24.54	15170.43	51.12	0	5.04	18.53	5014.86	6755.48	184.23	6.88	0	0	13.58	1891.13	0	0	18.51	0	222.07	0	0	0	0											250 (1a)	250 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	14 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	15 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 15 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	15 (17a)	0 n/c (17b1-17b5)	15 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											121.69	121.69	60.85	0	85.19	0.15	0.18	24.34	0.1	2.73	0.07	0	0.15	0.1	5	15	37.5	0.1	0	0	0.15	15	0	0	15	0	15	0	0	0	0											29.63	0.5	8.28	-	1.55	1.47	1.3	0.49	2.39	3.45	3.76	-	0.74	1.8	2.09	8.44	0.58	0.67	-	-	1.98	2.36	-	-	0.02	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.79		60.7	29.63	0.5	8.28	-	1.55	1.47	1.3	0.49	2.39	3.45	3.76	-	0.74	1.8	2.09	8.44	0.58	0.67	-	-	1.98	2.36	-	-	0.02	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.79																																																																																				-			29.63	0.5	8.28	-	1.55	1.47	1.3	0.49	2.39	3.45	3.76	-	0.74	1.8	2.09	8.44	0.58	0.67	-	-	1.98	2.36	-	-	0.02	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.79
H3379_002_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						2000	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		2695.56	118.11	13632.95	41.58	753.47	51.77	4.28	118.13	78.88	2724.76	170.2	7.38	7.77	120.85	55301.32	2595.72	3234.77	98.75		175.13	59.18	1750.96	26.42		134.15										153.52	295.2						(1a) 250/day	(1b) 250/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 35/visit	(8a) 0/visit	(8b) 0/visit	(9a) 35/visit	(12) 0/proc	(9a) 35/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 15/visit	(7e/7h) 32.5/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 15/visit	(15) 0/proc	(16b/17a) 15/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit										(7f1) 0/visit	(18a1) 0/visit						191	191			57	15	15	38	27			27		27		11	25			11		11																				42.9	1.88	-	-	3.6	7.91	0.65	0.38	0.18	-	-	0.02	-	0.27	-	2.48	6.69	-	-	0.17	-	1.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.79		21.26	42.9	1.88	-	-	3.6	7.91	0.65	0.38	0.18	-	-	0.02	-	0.27	-	2.48	6.69	-	-	0.17	-	1.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.79																																																																																				-		0	42.9	1.88	-	-	3.6	7.91	0.65	0.38	0.18	-	-	0.02	-	0.27	-	2.48	6.69	-	-	0.17	-	1.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.79
H3379_005_0	2007	5																					950											D	D	D	V	T	Coin	Coin	V	V	P	P	O	Coin	O	V	V	Coin	P	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		0	0	0	0	0	7.03	6.44	103.99	0	19542.72	0	0	2.08	0.29	0	5469.71	1.4	0	0	0	16.19	2072.51	0	0	48.45	0	217.91	0	0	0	0											0 (1a)	0 (1b)	0 (2a)	0 (6a)	0 (10a)	20 (11a)	20 (11b 11c)	50 (4a 4b)	0 (9b)	8 (8a 8b)	5/0 (8a 8b)	0 (incl in h5)	20 (12)	0 (3 9d 9a); 50 (5); 50/50 (9c)	0 (7a 14c 14b 14d 14e 14f 14g 14h)	10 (7b 7d 7f 7g)	50/50 (7e 7h)	0 (7c 7i)	0 (incl in h2)	0 (14i)	20 (15)	0 (13a 17b); 10 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	10 (17a)	0 (17b1-17b5)	10 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											0	0	0	0	0	0.16	0.17	40.58	0	2.6	0	0	0.16	0	0	10	0.5	0	0	0	0.16	10	0	0	10	0	10	0	0	0	0											-	-	-	-	-	1.14	1.08	0.35	-	4.23	-	-	0.34	0	-	4.56	0.7	-	-	-	2.63	1.73	-	-	0.04	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.98		2.22	-	-	-	-	-	1.14	1.08	0.35	-	4.23	-	-	0.34	0	-	4.56	0.7	-	-	-	2.63	1.73	-	-	0.04	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.98																																																																																				-			-	-	-	-	-	1.14	1.08	0.35	-	4.23	-	-	0.34	0	-	4.56	0.7	-	-	-	2.63	1.73	-	-	0.04	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.98
H3379_007_0	2007	7																					3400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1848.06	147.69	886.16	0	234.49	11.65	6.26	444.58	32.36	8551.57	42.27	0	0.17	21.42	3749.52	3855.62	634.39	3.45	0	0	22.05	734.01	0	0	117.74	0	218.99	0	0	0	0											325 (1a)	325 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											188.22	188.22	104.25	0	101.35	0.17	0.2	28.96	0.17	3.47	0.13	0	0.17	0.17	10	30	37.5	0.17	0	0	0.17	30	0	0	30	0	30	0	0	0	0											28.99	2.32	7.7	-	1.98	2.02	1.25	1.07	5.62	2.48	5.34	-	0.03	3.72	3.12	9.64	1.98	0.6	-	-	3.83	1.84	-	-	0.29	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.37		48.37	28.99	2.32	7.7	-	1.98	2.02	1.25	1.07	5.62	2.48	5.34	-	0.03	3.72	3.12	9.64	1.98	0.6	-	-	3.83	1.84	-	-	0.29	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.37																																																																																				-			28.99	2.32	7.7	-	1.98	2.02	1.25	1.07	5.62	2.48	5.34	-	0.03	3.72	3.12	9.64	1.98	0.6	-	-	3.83	1.84	-	-	0.29	-	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.37
H3379_012_0	2007	5																					3400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1848.87	161.06	879.98	0	279.21	14.1	6.08	516.47	31.25	7445.29	43.48	0	0.21	23.78	3414.4	4000.97	686.75	1.82	0	0	21.81	695.75	0	0	156.69	0	217.11	0	0	0	0											325 (1a)	325 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											187.23	187.23	103.7	0	100.82	0.17	0.2	28.8	0.17	3.46	0.13	0	0.17	0.17	10	30	37.5	0.17	0	0	0.17	30	0	0	30	0	30	0	0	0	0											28.85	2.51	7.6	-	2.35	2.44	1.2	1.24	5.4	2.14	5.46	-	0.04	4.11	2.85	10	2.15	0.31	-	-	3.77	1.74	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.09		49.36	28.85	2.51	7.6	-	2.35	2.44	1.2	1.24	5.4	2.14	5.46	-	0.04	4.11	2.85	10	2.15	0.31	-	-	3.77	1.74	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.09																																																																																				-			28.85	2.51	7.6	-	2.35	2.44	1.2	1.24	5.4	2.14	5.46	-	0.04	4.11	2.85	10	2.15	0.31	-	-	3.77	1.74	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.09
H3379_022_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1845.31	171.82	8136.73	158.92	596.44	18.54	5.82	171.53	113.89	3543.14	157.52	31.15	4.08	264.84	116.1	1188.48	1543.89	18.24		248.15	238.87	1213.51	2250		140.2	166		54.6				101.15	0.25	0.06	300	295.2						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						135	135			68	18	18	45	23			23		23		9				9		9										32		23								20.78	1.93	-	-	3.36	3.34	1.05	0.64	0.21	-	-	0.06	-	0.5	-	0.89	-	-	-	0.19	-	0.91	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	34.13		3.76	20.78	1.93	-	-	3.36	3.34	1.05	0.64	0.21	-	-	0.06	-	0.5	-	0.89	-	-	-	0.19	-	0.91	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	34.13																																																																																				-		0	20.78	1.93	-	-	3.36	3.34	1.05	0.64	0.21	-	-	0.06	-	0.5	-	0.89	-	-	-	0.19	-	0.91	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	34.13
H3379_024_0	2007	6																					3200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1658.83	144.51	759.75	0	260.54	13.49	5.82	467.09	28.98	6733.46	40.33	0	0.2	22.05	3185.98	3733.31	640.81	1.74	0	0	22.94	649.21	0	0	146.21	0	202.59	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											179.74	179.74	91.39	0	106.63	0.18	0.2	30.46	0.15	3.66	0.11	0	0.18	0.15	10	30	37.5	0.15	0	0	0.18	30	0	0	30	0	30	0	0	0	0											24.85	2.16	5.79	-	2.31	2.47	1.19	1.19	4.41	2.05	4.47	-	0.04	3.36	2.65	9.33	2	0.27	-	-	4.19	1.62	-	-	0.37	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.23		37.46	24.85	2.16	5.79	-	2.31	2.47	1.19	1.19	4.41	2.05	4.47	-	0.04	3.36	2.65	9.33	2	0.27	-	-	4.19	1.62	-	-	0.37	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.23		350 (1a)	350 (1b)	180 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	18 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	38 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 38 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	38 (17a)	0 n/c (17b1-17b5)	38 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											6.91	0.6	2.14	0.25	0.38	0.4	0.17	0.26	1.16	0.6	1.29	0	0.01	0.89	0.61	1.17	0.22	0.05	0	0	0	0.2	0	0	0.05	0	0.06	0	0	0	0											17.43		0	31.76	2.77	7.92	0.25	2.69	2.87	1.36	1.45	5.58	2.65	5.75	-	0.04	4.25	3.27	10.5	2.23	0.32	-	-	4.19	1.83	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.66
H3379_030_0	2007	3																					2800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1907.27	166.15	907.77	0	288.03	15	6.48	532.78	33.26	7680.47	46.27	0	0.23	25.31	3522.25	4127.35	708.45	1.94	0	0	23.21	717.73	0	0	161.64	0	223.97	0	0	0	0											325 (1a)	325 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											168.34	168.34	93.24	0	90.65	0.16	0.18	25.9	0.16	3.11	0.11	0	0.16	0.16	10	30	37.5	0.16	0	0	0.16	30	0	0	30	0	30	0	0	0	0											26.76	2.33	7.05	-	2.18	2.33	1.18	1.15	5.17	1.99	5.23	-	0.04	3.94	2.94	10.32	2.21	0.3	-	-	3.61	1.79	-	-	0.4	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.47		58.51	26.76	2.33	7.05	-	2.18	2.33	1.18	1.15	5.17	1.99	5.23	-	0.04	3.94	2.94	10.32	2.21	0.3	-	-	3.61	1.79	-	-	0.4	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.47																																																																																				-			26.76	2.33	7.05	-	2.18	2.33	1.18	1.15	5.17	1.99	5.23	-	0.04	3.94	2.94	10.32	2.21	0.3	-	-	3.61	1.79	-	-	0.4	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.47
H3379_031_0	2007	3																					2800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1848.87	161.06	879.98	0	279.21	14.1	6.08	516.47	31.25	7445.29	43.48	0	0.21	23.78	3414.4	4000.97	686.75	1.82	0	0	21.81	695.75	0	0	156.69	0	217.11	0	0	0	0											325 (1a)	325 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											171.71	171.71	95.1	0	92.46	0.16	0.18	26.42	0.16	3.17	0.12	0	0.16	0.16	10	30	37.5	0.16	0	0	0.16	30	0	0	30	0	30	0	0	0	0											26.46	2.3	6.97	-	2.15	2.23	1.12	1.14	4.95	1.97	5.01	-	0.03	3.77	2.85	10	2.15	0.29	-	-	3.46	1.74	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.53		54.92	26.46	2.3	6.97	-	2.15	2.23	1.12	1.14	4.95	1.97	5.01	-	0.03	3.77	2.85	10	2.15	0.29	-	-	3.46	1.74	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.53																																																																																				-			26.46	2.3	6.97	-	2.15	2.23	1.12	1.14	4.95	1.97	5.01	-	0.03	3.77	2.85	10	2.15	0.29	-	-	3.46	1.74	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.53
H3379_034_0	2007	6																					2600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1658.83	144.51	759.75	0	260.54	13.49	5.82	467.09	28.98	6733.46	40.33	0	0.2	22.05	3185.98	3733.31	640.81	1.74	0	0	22.94	649.21	0	0	146.21	0	202.59	0	0	0	0											295 (1a)	295 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											160.22	160.22	97.76	0	95.05	0.16	0.19	27.16	0.16	3.26	0.12	0	0.16	0.16	10	30	37.5	0.16	0	0	0.16	30	0	0	30	0	30	0	0	0	0											22.15	1.93	6.19	-	2.06	2.2	1.1	1.06	4.72	1.83	4.78	-	0.03	3.6	2.65	9.33	2	0.28	-	-	3.74	1.62	-	-	0.37	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.15		46.54	22.15	1.93	6.19	-	2.06	2.2	1.1	1.06	4.72	1.83	4.78	-	0.03	3.6	2.65	9.33	2	0.28	-	-	3.74	1.62	-	-	0.37	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.15		350 (1a)	350 (1b)	180 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	18 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	38 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 38 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	38 (17a)	0 n/c (17b1-17b5)	38 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											6.91	0.6	2.14	0.25	0.38	0.4	0.17	0.26	1.16	0.6	1.29	0	0.01	0.89	0.61	1.17	0.22	0.05	0	0	0	0.2	0	0	0.05	0	0.06	0	0	0	0											17.43		0	29.06	2.53	8.33	0.25	2.44	2.6	1.27	1.32	5.89	2.43	6.06	-	0.04	4.48	3.27	10.5	2.23	0.34	-	-	3.74	1.83	-	-	0.41	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.57
H3384_013_0	2007	7																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-		259.7	2.5	50.62		243.7	11.91	0.49	262.56	360.85		825.88	0.18	4.26	9.11	4797.3	4366.19	0.36	581.28	895.19	1117.64	22.94	0.08			687.37		0.49															250 Copay	250 Copay	250 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	100 copay		75 Copay	50 Coinsurance	25 Copay	20 Coinsurance	10 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Copay		25 Copay															250	250	250		50	0.25	0.25	50	100		75	0.5	25	0.2	10	25	0.5	25	25	25	0.2	25			25		25															5.41	0.05	1.05	-	1.02	2.98	0.12	1.09	3.01	-	5.16	0.09	0.01	1.82	4	9.1	0.18	1.21	1.86	2.33	4.59	0	-	-	1.43	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51			5.41	0.05	1.05	-	1.02	2.98	0.12	1.09	3.01	-	5.16	0.09	0.01	1.82	4	9.1	0.18	1.21	1.86	2.33	4.59	0	-	-	1.43	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51																																																																																				-			5.41	0.05	1.05	-	1.02	2.98	0.12	1.09	3.01	-	5.16	0.09	0.01	1.82	4	9.1	0.18	1.21	1.86	2.33	4.59	0	-	-	1.43	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51
H3384_015_0	2007	3																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-		259.7	2.5	50.62		243.7	11.91	0.51	262.56	360.85		825.88	0.18	4.23	9.11	4797.3	4366.19	0.36	581.28	895.19	1117.64	22.94	0.08			687.37		0.49															250 Copay	250 Copay	250 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	100 Copay		75 Copay	50 Coinsurance	25 Copay	20 Coinsurance	10 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Copay		25 Copay															250	250	250		50	0.25	0.25	50	100		75	0.5	25	0.2	10	25	0.5	25	25	25	0.2	25			25		25															5.41	0.05	1.05	-	1.02	2.98	0.13	1.09	3.01	-	5.16	0.09	0.01	1.82	4	9.1	0.18	1.21	1.86	2.33	4.59	0	-	-	1.43	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.52			5.41	0.05	1.05	-	1.02	2.98	0.13	1.09	3.01	-	5.16	0.09	0.01	1.82	4	9.1	0.18	1.21	1.86	2.33	4.59	0	-	-	1.43	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.52																																																																																				-			5.41	0.05	1.05	-	1.02	2.98	0.13	1.09	3.01	-	5.16	0.09	0.01	1.82	4	9.1	0.18	1.21	1.86	2.33	4.59	0	-	-	1.43	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.52
H3384_019_0	2007	6																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-		250.35	1.02	46.36		211.02	12.67	0.69	231.78	377.63		609.19	0.04	0.03	3.59	4306.15	3719.65	0.5	478.77	1121.23	960.51	28.73	7.17			655.45		1.9															500 Copay	500 Copay	500 Copay		75 Copay	30 Coinsurance	30 Coinsurance	50 Copay	75 Copay		30 Copay	50 Coinsurance	30 Copay	50 Coinsurance	20 Copay	30 Copay	50 Coinsurance	30 Copay	30 Copay	30 Copay	20 Coinsurance	30 Copay			30 Copay		30 Copay															500	500	500		75	0.3	0.3	50	75		30	0.5	30	0.5	20	30	0.5	30	30	30	0.2	30			30		30															10.43	0.04	1.93	-	1.32	3.8	0.21	0.97	2.36	-	1.52	0.02	0	1.79	7.18	9.3	0.25	1.2	2.8	2.4	5.75	0.02	-	-	1.64	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.93			10.43	0.04	1.93	-	1.32	3.8	0.21	0.97	2.36	-	1.52	0.02	0	1.79	7.18	9.3	0.25	1.2	2.8	2.4	5.75	0.02	-	-	1.64	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.93																																																																																				-			10.43	0.04	1.93	-	1.32	3.8	0.21	0.97	2.36	-	1.52	0.02	0	1.79	7.18	9.3	0.25	1.2	2.8	2.4	5.75	0.02	-	-	1.64	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.93
H3384_022_0	2007	4																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin				V																																																										-		250.35	1.02	46.36		217.23	12.67	0.71	231.78	377.63		624.37	0.04	0.04	3.59	4667.04	3773.26	0.5	493.57	1128.51	965.51	28.73				669.6																	250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	75 Copay		25 Copay	50 Coinsurance	25 Copay	50 Coinsurance	5 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance				25 Copay																	250	250	250		50	0.3	0.3	50	75		25	0.5	25	0.5	5	25	0.5	25	25	25	0.2				25																	5.22	0.02	0.97	-	0.91	3.8	0.21	0.97	2.36	-	1.3	0.02	0	1.79	1.94	7.86	0.25	1.03	2.35	2.01	5.75	-	-	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.15			5.22	0.02	0.97	-	0.91	3.8	0.21	0.97	2.36	-	1.3	0.02	0	1.79	1.94	7.86	0.25	1.03	2.35	2.01	5.75	-	-	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.15																																																																																				-			5.22	0.02	0.97	-	0.91	3.8	0.21	0.97	2.36	-	1.3	0.02	0	1.79	1.94	7.86	0.25	1.03	2.35	2.01	5.75	-	-	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.15
H3384_040_0	2007	5																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin				V																																																										-		259.7	2.5	50.62		243.7	11.29	0.51	262.56	360.85		780.27	0.18	4.3	8.62	4955.08	4408.29	0.36	594.45	898.05	1120.25	22.94				697.68																	250 Copay	250 Copay	250 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	100 Copay		75 Copay	50 Coinsurance	20 Copay	20 Coinsurance	5 Copay	20 Copay	50 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance				20 Copay																	250	250	250		50	0.25	0.25	50	100		75	0.5	20	0.2	5	20	0.5	20	20	20	0.2				20																	5.41	0.05	1.05	-	1.02	2.82	0.13	1.09	3.01	-	4.88	0.09	0.01	1.72	2.06	7.35	0.18	0.99	1.5	1.87	4.59	-	-	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.98			5.41	0.05	1.05	-	1.02	2.82	0.13	1.09	3.01	-	4.88	0.09	0.01	1.72	2.06	7.35	0.18	0.99	1.5	1.87	4.59	-	-	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.98																																																																																				-			5.41	0.05	1.05	-	1.02	2.82	0.13	1.09	3.01	-	4.88	0.09	0.01	1.72	2.06	7.35	0.18	0.99	1.5	1.87	4.59	-	-	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.98
H3384_041_0	2007	5																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-		191.8	0.48	37.44		217.23	12.67	0.69	231.78	407.45		624.37	0.04	0.04	3.59	4667.04	3773.26	0.5	493.57	1128.51	965.51	28.73	8.71			669.6		1.92															250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	50 Copay		25 Copay	50 Coinsurance	25 Copay	50 Coinsurance	5 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Copay		25 Copay															250	250	250		50	0.3	0.3	50	50		25	0.5	25	0.5	5	25	0.5	25	25	25	0.2	25			25		25															4	0.01	0.78	-	0.91	3.8	0.21	0.97	1.7	-	1.3	0.02	0	1.79	1.94	7.86	0.25	1.03	2.35	2.01	5.75	0.02	-	-	1.39	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.09			4	0.01	0.78	-	0.91	3.8	0.21	0.97	1.7	-	1.3	0.02	0	1.79	1.94	7.86	0.25	1.03	2.35	2.01	5.75	0.02	-	-	1.39	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.09																																																																																				-			4	0.01	0.78	-	0.91	3.8	0.21	0.97	1.7	-	1.3	0.02	0	1.79	1.94	7.86	0.25	1.03	2.35	2.01	5.75	0.02	-	-	1.39	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.09
H3384_044_0	2007	6																																A			V	T			V	V			V	V	V	V	V	V	V	V	V		V																																																													-		804.3			337.54	782.78			745.32	659.25			0	0	2358.37	11210.94	8676.94	2146.41	903.7	2392.03	2323.85		7.68																				10 Copay			10 Copay	50 Copay			50 Copay	35 Copay			20 Copay	20 Copay	20 Copay	10 Copay	20 Copay	20 Copay	20 Copay	20 Copay	20 Copay		20 Copay																				10			10	50			50	35			20	20	20	10	20	20	20	20	20		20																				0.67	-	-	0.28	3.26	-	-	3.11	1.92	-	-	0	-	3.93	9.34	14.46	3.58	1.51	3.99	3.87	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.93			0.67	-	-	0.28	3.26	-	-	3.11	1.92	-	-	0	-	3.93	9.34	14.46	3.58	1.51	3.99	3.87	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.93																																																																																				-			0.67	-	-	0.28	3.26	-	-	3.11	1.92	-	-	0	-	3.93	9.34	14.46	3.58	1.51	3.99	3.87	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.93
H3384_045_0	2007	7																																																	V																																																																	-																			391.72																																									20 Copay																																									20																								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.65			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.65																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.65
H3384_051_0	2007	3																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-		250.35	1.02	46.36		217.23	12.67	0.71	231.78	377.63		631.56	0.04	0.06	3.59	4955.75	3862.61	0.5	518.23	1140.64	973.83	28.73	11.11			693.17		1.96															100 Copay	100 Copay	100 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	75 Copay		15 Copay	50 Coinsurance	15 Copay	50 Coinsurance	5 Copay	15 Copay	50 Coinsurance	15 Copay	15 Copay	15 Copay	20 Coinsurance	15 Copay			15 Copay		15 Copay															100	100	100		50	0.3	0.3	50	75		15	0.5	15	0.5	5	15	0.5	15	15	15	0.2	15			15		15															2.09	0.01	0.39	-	0.91	3.8	0.21	0.97	2.36	-	0.79	0.02	0	1.79	2.06	4.83	0.25	0.65	1.43	1.22	5.75	0.01	-	-	0.87	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.39			2.09	0.01	0.39	-	0.91	3.8	0.21	0.97	2.36	-	0.79	0.02	0	1.79	2.06	4.83	0.25	0.65	1.43	1.22	5.75	0.01	-	-	0.87	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.39																																																																																				-			2.09	0.01	0.39	-	0.91	3.8	0.21	0.97	2.36	-	0.79	0.02	0	1.79	2.06	4.83	0.25	0.65	1.43	1.22	5.75	0.01	-	-	0.87	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.39
H3384_052_0	2007	4																																A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-		250.35	1.02	46.36		217.23	12.67	0.69	231.78	377.63		627.97	0.04	0.05	5.05	4522.68	3809	0.5	503.43	1133.36	968.84	28.73	10.37			679.02		1.94															350 Copay	350 Copay	350 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	75 Copay		20 Copay	50 Coinsurance	20 Copay	50 Coinsurance	10 Copay	20 Copay	50 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															350	350	350		50	0.3	0.3	50	75		20	0.5	20	0.5	10	20	0.5	20	20	20	0.2	20			20		20															7.3	0.03	1.35	-	0.91	3.8	0.21	0.97	2.36	-	1.05	0.02	0	2.53	3.77	6.35	0.25	0.84	1.89	1.61	5.75	0.02	-	-	1.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.12			7.3	0.03	1.35	-	0.91	3.8	0.21	0.97	2.36	-	1.05	0.02	0	2.53	3.77	6.35	0.25	0.84	1.89	1.61	5.75	0.02	-	-	1.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.12																																																																																				-			7.3	0.03	1.35	-	0.91	3.8	0.21	0.97	2.36	-	1.05	0.02	0	2.53	3.77	6.35	0.25	0.84	1.89	1.61	5.75	0.02	-	-	1.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.12
H3384_053_0	2007	7																																D	D	D		T	Coin	Coin	V	Coin		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin				V																																																										-		692.94	5.18	108.85		243.7	11.54	0.5	262.56	24.46		799.76	0.18	4.15	9.11	4797.3	4324.1	0.36	568.11	892.34	1115.02	22.94				677.06																	260/day 1300 max	260/day 1300 max	260/day 1300 max		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	20 Coinsurance		75 Copay	50 Coinsurance	30 Copay	20 Coinsurance	10 Copay	30 Copay	50 Coinsurance	30 Copay	30 Copay	30 Copay	20 Coinsurance				30 Copay																	260	260	260		50	0.25	0.25	50	0.2		75	0.5	30	0.2	10	30	0.5	30	30	30	0.2				30																	15.01	0.11	2.36	-	1.02	2.89	0.13	1.09	4.89	-	5	0.09	0.01	1.82	4	10.81	0.18	1.42	2.23	2.79	4.59	-	-	-	1.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.12			15.01	0.11	2.36	-	1.02	2.89	0.13	1.09	4.89	-	5	0.09	0.01	1.82	4	10.81	0.18	1.42	2.23	2.79	4.59	-	-	-	1.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.12																																																																																				-			15.01	0.11	2.36	-	1.02	2.89	0.13	1.09	4.89	-	5	0.09	0.01	1.82	4	10.81	0.18	1.42	2.23	2.79	4.59	-	-	-	1.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.12
H3384_801_0	2007	4																																D	D	D		T	Coin	Coin	V	Coin		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin				V																																																										-		180.37	1.14	34.1		227.58	12.13	0.55	243.82	22.22		692.18	0.1	1.69	9.04	4629.81	4005.25	0.44	527.93	1037.01	1025.14	26.39				676.5																	350 Copay	350 Copay	350 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	20 Coinsurance		75 Copay	50 Coinsurance	25 Copay	20 Coinsurance	10 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance				30 Copay																	350	350	350		50	0.25	0.25	50	0.2		75	0.5	25	0.2	10	25	0.5	25	25	25	0.2				25																	5.26	0.03	0.99	-	0.95	3.03	0.14	1.02	4.44	-	4.33	0.05	0	1.81	3.86	8.34	0.22	1.1	2.16	2.14	5.28	-	-	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56			5.26	0.03	0.99	-	0.95	3.03	0.14	1.02	4.44	-	4.33	0.05	0	1.81	3.86	8.34	0.22	1.1	2.16	2.14	5.28	-	-	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56																																																																																				-			5.26	0.03	0.99	-	0.95	3.03	0.14	1.02	4.44	-	4.33	0.05	0	1.81	3.86	8.34	0.22	1.1	2.16	2.14	5.28	-	-	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56
H3384_802_0	2007	5																																D	D	D		T	Coin	Coin	V	Coin		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin				V																																																										-		183.95	1.16	34.78		232.47	12.76	0.58	248.4	24.18		705.2	0.11	1.72	9.83	4729.22	4091.25	0.47	539.27	1059.27	1047.15	28.33				691.02																	350 Copay	350 Copay	350 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	20 Coinsurance		75 Copay	50 Coinsurance	25 Copay	20 Coinsurance	10 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance				25 Copay																	350	350	350		50	0.25	0.25	50	0.2		75	0.5	25	0.2	10	25	0.5	25	25	25	0.2				25																	5.37	0.03	1.01	-	0.97	3.19	0.15	1.04	4.84	-	4.41	0.05	0	1.97	3.94	8.52	0.23	1.12	2.21	2.18	5.67	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.34			5.37	0.03	1.01	-	0.97	3.19	0.15	1.04	4.84	-	4.41	0.05	0	1.97	3.94	8.52	0.23	1.12	2.21	2.18	5.67	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.34																																																																																				-			5.37	0.03	1.01	-	0.97	3.19	0.15	1.04	4.84	-	4.41	0.05	0	1.97	3.94	8.52	0.23	1.12	2.21	2.18	5.67	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.34
H3384_803_0	2007	4																																D	D	D		T	Coin	Coin	V	Coin		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin				V																																																										-		180.37	1.14	34.1		227.58	12.13	0.55	243.82	22.22		692.18	0.1	1.69	9.04	4629.81	4005.25	0.44	527.93	1037.01	1025.14	26.39				676.5																	350 Copay	350 Copay	350 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	20 Coinsurance		75 Copay	50 Coinsurance	25 Copay	20 Coinsurance	10 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance				25 Copay																	350	350	350		50	0.25	0.25	50	0.2		75	0.5	25	0.2	10	25	0.5	25	25	25	0.2				25																	5.26	0.03	0.99	-	0.95	3.03	0.14	1.02	4.44	-	4.33	0.05	0	1.81	3.86	8.34	0.22	1.1	2.16	2.14	5.28	-	-	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56			5.26	0.03	0.99	-	0.95	3.03	0.14	1.02	4.44	-	4.33	0.05	0	1.81	3.86	8.34	0.22	1.1	2.16	2.14	5.28	-	-	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56																																																																																				-			5.26	0.03	0.99	-	0.95	3.03	0.14	1.02	4.44	-	4.33	0.05	0	1.81	3.86	8.34	0.22	1.1	2.16	2.14	5.28	-	-	-	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56
H3384_804_0	2007	6																																D	D	D		T	Coin	Coin	V	Coin		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin				V																																																										-		183.95	1.16	34.78		232.47	12.76	0.58	248.4	24.18		705.2	0.11	1.72	9.83	4729.22	4091.25	0.47	539.27	1059.27	1047.15	28.33				691.02																	350 Copay	350 Copay	350 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	20 Coinsurance		75 Copay	50 Coinsurance	25 Copay	20 Coinsurance	10 Copay	25 Copay	50 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance				25 Copay																	350	350	350		50	0.25	0.25	50	0.2		75	0.5	25	0.2	10	25	0.5	25	25	25	0.2				25																	5.37	0.03	1.01	-	0.97	3.19	0.15	1.04	4.84	-	4.41	0.05	0	1.97	3.94	8.52	0.23	1.12	2.21	2.18	5.67	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.34			5.37	0.03	1.01	-	0.97	3.19	0.15	1.04	4.84	-	4.41	0.05	0	1.97	3.94	8.52	0.23	1.12	2.21	2.18	5.67	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.34																																																																																				-			5.37	0.03	1.01	-	0.97	3.19	0.15	1.04	4.84	-	4.41	0.05	0	1.97	3.94	8.52	0.23	1.12	2.21	2.18	5.67	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.34
H3387_005_0	2007	4																																D	D	D	P	P	P	P	V	V	P	P	P	P	P	P	P	P	P	P	P	Coin	P	T	P	P	P	P	P	P	P	P																																																				-									343.36						813.69	1966.44	1787.24	694.95	1017.49																								#1A 0	#1B 0	#2 0	#6 0	#10A 0	#11A 0	#11B 0 #11C 0	#4A 50 #4B 10	#9A 0 #9B 0	#8A 0	#8B 0	#9A 0	#12 0	#3 10 #5 0 #9C 20 #9D 10	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 0 #7D 10 #7F 10 #7G 0	#7E 20 #7H 20	#7C 10 #7I 10	0 (incl in h2)	#14I 0	#15 0	#13A 0 #16B 0	#10B 0 n/c	#16A 0 n/c	#17A 0	#17B 0	#18A 0	#18B 0	0 n/c	#14A 0	#13B 0 n/c #13C 0 #13D 0 #13E 0																		48.55						19.42	10	10	20	10																								-	-	-	-	-	-	-	1.39	-	-	-	-	-	1.32	1.64	1.49	1.16	0.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.84		0	-	-	-	-	-	-	-	1.39	-	-	-	-	-	1.32	1.64	1.49	1.16	0.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.84																																																																																				-		0	-	-	-	-	-	-	-	1.39	-	-	-	-	-	1.32	1.64	1.49	1.16	0.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.84
H3388_001_0	2007	1	f.	i.6.	i.6.	i.6.		i.6.					OP Facility - Emergency	Professional	Professional	Professional		Professional						Urgent Care	Podiatrist	Chiropractor	Physical Exam		Bone Mass					D				t	coin		v		v	v		v	o	v	v		v							v	coin	v					v	v	v	v	v	v																																														-		1908.52				606.32	15.94		291.6	1765.7	7650.9	4903.43		64.75	111.83	3758	15376.57		1080.2		2108.4					1580.25	0.3	110.13					455.21	339.14	597.45	373.82		233.6					250 inpatient copay per stay - capped at 3 copays				50 for Medicare-covered ambulance services.	20 coin per tiem		50 ( waived if admitted)	100 min/max for medicare covered service	12 copay for each Medicare covered service	12 copay for each Medicare covered service		12 per session in area/ 12 persession out of area	12 per session in area/ 12 persession out of area	12 copay for each Medicare covered service	12 copay for each Medicare covered service		12 copay for each Medicare covered service		12 copay for each Medicare covered service					12 copay for each Routine Eye exam	20 after cataract surg	12 copay for each Medicare covered service					12 - 35 copay for each Medicare benefit  35  World wide coverage	12 copay for each Medicare covered service	12 copay for each Medicare covered service	12 copay for each Medicare covered service		12 copay for each Medicare covered service					41.94				23.16	0.2		46.91	29.36	1.88	0.91		25.95	11.8	11.34	3.95		11.6		11.8					7.06	0.2	3.27					8.96	11.32	11.85	3.85		2.05					6.67	-	-	-	1.17	3.19	-	1.14	4.32	1.2	0.37	-	0.14	0.11	3.55	5.06	-	1.04	-	2.07	-	-	-	-	0.93	0.06	0.03	-	-	-	-	0.34	0.32	0.59	0.12	-	0.04	-	-	-	-	32.47			6.67	-	-	-	1.17	3.19	-	1.14	4.32	1.2	0.37	-	0.14	0.11	3.55	5.06	-	1.04	-	2.07	-	-	-	-	0.93	0.06	0.03	-	-	-	-	0.34	0.32	0.59	0.12	-	0.04	-	-	-	-	32.47																																																																																				-			6.67	-	-	-	1.17	3.19	-	1.14	4.32	1.2	0.37	-	0.14	0.11	3.55	5.06	-	1.04	-	2.07	-	-	-	-	0.93	0.06	0.03	-	-	-	-	0.34	0.32	0.59	0.12	-	0.04	-	-	-	-	32.47
H3388_002_0	2007	2	f.	i.6.	i.6.	i.6.		i.6.					OP Facility - Emergency	Professional	Professional	Professional		Professional						Urgent Care	Podiatrist	Chiropractor	Physical Exam		Bone Mass					D				t	coin		v		v	v		v	o	v	v		v							v	coin	v					v	v	v	v	v	v																																														-		1908.52				606.32	15.94		291.6	1765.7	7650.9	4903.43		64.75	111.83	3758	15376.57		1080.2		2108.4					1580.25	0.3	110.13					455.21	339.14	597.45	373.82		233.6					250 inpatient copay per stay - capped at 3 copays				50 for Medicare-covered ambulance services.	20 coin per tiem		50 ( waived if admitted)	100 min/max for medicare covered service	12 copay for each Medicare covered service	12 copay for each Medicare covered service		12 per session in area/ 12 persession out of area	12 per session in area/ 12 persession out of area	12 copay for each Medicare covered service	12 copay for each Medicare covered service		12 copay for each Medicare covered service		12 copay for each Medicare covered service					12 copay for each Routine Eye exam	20 after cataract surg	12 copay for each Medicare covered service					12 - 35 copay for each Medicare benefit  35  World wide coverage	12 copay for each Medicare covered service	12 copay for each Medicare covered service	12 copay for each Medicare covered service		12 copay for each Medicare covered service					41.94				23.16	0.2		46.91	29.36	1.88	0.91		25.95	11.8	11.34	3.95		11.6		11.8					7.06	0.2	3.27					8.96	11.32	11.85	3.85		2.05					6.67	-	-	-	1.17	3.19	-	1.14	4.32	1.2	0.37	-	0.14	0.11	3.55	5.06	-	1.04	-	2.07	-	-	-	-	0.93	0.06	0.03	-	-	-	-	0.34	0.32	0.59	0.12	-	0.04	-	-	-	-	32.47			6.67	-	-	-	1.17	3.19	-	1.14	4.32	1.2	0.37	-	0.14	0.11	3.55	5.06	-	1.04	-	2.07	-	-	-	-	0.93	0.06	0.03	-	-	-	-	0.34	0.32	0.59	0.12	-	0.04	-	-	-	-	32.47																																																																																				-			6.67	-	-	-	1.17	3.19	-	1.14	4.32	1.2	0.37	-	0.14	0.11	3.55	5.06	-	1.04	-	2.07	-	-	-	-	0.93	0.06	0.03	-	-	-	-	0.34	0.32	0.59	0.12	-	0.04	-	-	-	-	32.47
H3388_003_0	2007	1	f.	i.6.	i.6.	i.6.		i.6.					OP Facility - Emergency	Professional	Professional	Professional		Professional						Urgent Care	Podiatrist	Chiropractor	Physical Exam		Bone Mass					D				t	coin		v		v	v		v	v	v	v		v		v					v	coin	v					v	v	v	v		v																																														-		1902.78				606.02	15.92		291.6	1765.7	7650.66	4903.55		64.75	109.44	3953.95	15134.42		1045.54		2108.36					1586.65	0.3	104.59					455.21	329.47	562.17	373.82		233.6					500 inpatient copay per stay - capped at 3 copays				50 for Medicare-covered ambulance services.	30 coin per tiem		50 ( waived if admitted)	125 min/max for medicare covered service	0-20 copay for each Medicare covered service	20 copay for each Medicare covered service		20 per session in area/ 20 per session out of area	20 copay for each Medicare covered service	5 copay for each Medicare covered service	20 copay for each Medicare covered service		20 copay for each Medicare covered service		20 copay for each Medicare covered service					20 copay for each Routine Eye exam	20 after cataract surg	20 copay for each Medicare covered service					5/20 - 35 copay for each Medicare benefit  35  World wide coverage	20 copay for each Medicare covered service	20 copay for each Medicare covered service	20 copay for each Medicare covered service		20 copay for each Medicare covered service					85.28				46.32	0.3		46.91	36.7	0.78	0.91		10.81	19.67	4.73	6.58		19.33		5.01					11.77	0.2	5.45					8.96	18.87	19.75	3.85		0.85					13.52	-	-	-	2.34	4.78	-	1.14	5.4	0.5	0.37	-	0.06	0.18	1.56	8.3	-	1.68	-	0.88	-	-	-	-	1.56	0.06	0.05	-	-	-	-	0.34	0.52	0.93	0.12	-	0.02	-	-	-	-	44.29			13.52	-	-	-	2.34	4.78	-	1.14	5.4	0.5	0.37	-	0.06	0.18	1.56	8.3	-	1.68	-	0.88	-	-	-	-	1.56	0.06	0.05	-	-	-	-	0.34	0.52	0.93	0.12	-	0.02	-	-	-	-	44.29																																																																																				-			13.52	-	-	-	2.34	4.78	-	1.14	5.4	0.5	0.37	-	0.06	0.18	1.56	8.3	-	1.68	-	0.88	-	-	-	-	1.56	0.06	0.05	-	-	-	-	0.34	0.52	0.93	0.12	-	0.02	-	-	-	-	44.29
H3388_004_0	2007	2	f.	i.6.	i.6.	i.6.		i.6.					OP Facility - Emergency	Professional	Professional	Professional		Professional						Urgent Care	Podiatrist	Chiropractor	Physical Exam		Bone Mass					D				t	coin		v		v	v		v	v	v	v		v		v					v	coin	v					v	v	v	v		v																																														-		1902.78				606.02	15.92		291.6	1765.7	7650.66	4903.55		64.75	109.44	3953.95	15134.42		1045.54		2108.36					1586.65	0.3	104.59					455.21	329.47	562.17	373.82		233.6					500 inpatient copay per stay - capped at 3 copays				50 for Medicare-covered ambulance services.	30 coin per tiem		50 ( waived if admitted)	125 min/max for medicare covered service	0-20 copay for each Medicare covered service	20 copay for each Medicare covered service		20 per session in area/ 20 per session out of area	20 copay for each Medicare covered service	5 copay for each Medicare covered service	20 copay for each Medicare covered service		20 copay for each Medicare covered service		20 copay for each Medicare covered service					20 copay for each Routine Eye exam	20 after cataract surg	20 copay for each Medicare covered service					5/20 - 35 copay for each Medicare benefit  35  World wide coverage	20 copay for each Medicare covered service	20 copay for each Medicare covered service	20 copay for each Medicare covered service		20 copay for each Medicare covered service					85.28				46.32	0.3		46.91	36.7	0.78	0.91		10.81	19.67	4.73	6.58		19.33		5.01					11.77	0.2	5.45					8.96	18.87	19.75	3.85		0.85					13.52	-	-	-	2.34	4.78	-	1.14	5.4	0.5	0.37	-	0.06	0.18	1.56	8.3	-	1.68	-	0.88	-	-	-	-	1.56	0.06	0.05	-	-	-	-	0.34	0.52	0.93	0.12	-	0.02	-	-	-	-	44.29			13.52	-	-	-	2.34	4.78	-	1.14	5.4	0.5	0.37	-	0.06	0.18	1.56	8.3	-	1.68	-	0.88	-	-	-	-	1.56	0.06	0.05	-	-	-	-	0.34	0.52	0.93	0.12	-	0.02	-	-	-	-	44.29																																																																																				-			13.52	-	-	-	2.34	4.78	-	1.14	5.4	0.5	0.37	-	0.06	0.18	1.56	8.3	-	1.68	-	0.88	-	-	-	-	1.56	0.06	0.05	-	-	-	-	0.34	0.52	0.93	0.12	-	0.02	-	-	-	-	44.29
H3388_801_0	2007	2	f.	i.6.	i.6.	i.6.		i.6.					OP Facility - Emergency	Professional	Professional	Professional		Professional						Urgent Care	Podiatrist	Chiropractor	Physical Exam		Bone Mass					D				t	coin		v		v	v		v	v	v	v		v							v	coin	v					v	v	v	v		v																																														-		1906				606.02	15.94		291.6	1765.7	7650.66	4903.55		64.75	108.36	3499.07	15134.42		1030.37		2108.36					1508	0.31	102.54					455.21	323.42	551.15	373.82		233.6					500 inpatient copay per stay				100 for Medicare-covered ambulance services.	30 coin per tiem		50 ( waived if admitted)	100 min/max for medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service		25 copay for each Medicare covered service					25 copay for each Medicare covered service	20 after cataract surg	25 copay for each Medicare covered service					25 - 35 copay for each Medicare benefit  35  World wide coverage	25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service					85.38				46.32	0.3		46.91	36.7	3.92	0.91		54.06	24.58	23.63	8.23		24.17		5.01					14.71	0.2	6.81					8.96	23.58	24.69	3.85		4.27					13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11			13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11																																																																																				-			13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11
H3388_803_0	2007	2	f.	i.6.	i.6.	i.6.		i.6.					OP Facility - Emergency	Professional	Professional	Professional		Professional						Urgent Care	Podiatrist	Chiropractor	Physical Exam		Bone Mass					D				t	coin		v		v	v		v	v	v	v		v							v	coin	v					v	v	v	v		v																																														-		1906				606.02	15.94		291.6	1765.7	7650.66	4903.55		64.75	108.36	3499.07	15134.42		1030.37		2108.36					1508	0.31	102.54					455.21	323.42	551.15	373.82		233.6					500 inpatient copay per stay				100 for Medicare-covered ambulance services.	30 coin per tiem		50 ( waived if admitted)	100 min/max for medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service		25 copay for each Medicare covered service					25 copay for each Medicare covered service	20 after cataract surg	25 copay for each Medicare covered service					25 - 35 copay for each Medicare benefit  35  World wide coverage	25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service					85.38				46.32	0.3		46.91	36.7	3.92	0.91		54.06	24.58	23.63	8.23		24.17		5.01					14.71	0.2	6.81					8.96	23.58	24.69	3.85		4.27					13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11			13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11																																																																																				-			13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11
H3388_804_0	2007	2	f.	i.6.	i.6.	i.6.		i.6.					OP Facility - Emergency	Professional	Professional	Professional		Professional						Urgent Care	Podiatrist	Chiropractor	Physical Exam		Bone Mass					D				t	coin		v		v	v		v	v	v	v		v							v	coin	v					v	v	v	v		v																																														-		1906				606.02	15.94		291.6	1765.7	7650.66	4903.55		64.75	108.36	3499.07	15134.42		1030.37		2108.36					1508	0.31	102.54					455.21	323.42	551.15	373.82		233.6					500 inpatient copay per stay				100 for Medicare-covered ambulance services.	30 coin per tiem		50 ( waived if admitted)	100 min/max for medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service		25 copay for each Medicare covered service					25 copay for each Medicare covered service	20 after cataract surg	25 copay for each Medicare covered service					25 - 35 copay for each Medicare benefit  35  World wide coverage	25 copay for each Medicare covered service	25 copay for each Medicare covered service	25 copay for each Medicare covered service		25 copay for each Medicare covered service					85.38				46.32	0.3		46.91	36.7	3.92	0.91		54.06	24.58	23.63	8.23		24.17		5.01					14.71	0.2	6.81					8.96	23.58	24.69	3.85		4.27					13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11			13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11																																																																																				-			13.56	-	-	-	2.34	4.78	-	1.14	5.4	2.5	0.37	-	0.29	0.22	6.89	10.38	-	2.08	-	0.88	-	-	-	-	1.85	0.06	0.06	-	-	-	-	0.34	0.64	1.13	0.12	-	0.08	-	-	-	-	55.11
H3404_001_0	2007	1																					3100											A		D	V	T	Coin		V	Coin					V						V	S	V			V																	0		0	0	0	0		0	0					0						0	0	0			0																	-		229.16		664.77	30.21	184.56	13.96		634.12	2.08					3085.9						18785.56	611.09	42.89			52.42																	350 Copay		75 copay on days 11-100	None	50 Coapy	20 coin		50 Copay	None					25 Copay/ None						15/30 Copay	25 Copay	25 Copay			15 Copay																	303.98		58.12	0	44.51	0.18		44.51	0					4.01						17.36	17.8	22.25			13.35																	5.8	-	3.22	-	0.68	2.48	-	2.35	-	-	-	-	-	1.03	-	-	-	-	-	27.17	0.91	0.08	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79		4.53	5.8	-	3.22	-	0.68	2.48	-	2.35	-	-	-	-	-	1.03	-	-	-	-	-	27.17	0.91	0.08	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79		20		20	20	20	20		20	20					20						20	20	20			20																	2.18		0.21	0	0.07	0.15		0.29	0.02					1.44						1.92	0.05	0			0.01																	6.35			7.99	-	3.43	0	0.75	2.63	-	2.64	0.02	-	-	-	-	2.47	-	-	-	-	-	29.09	0.96	0.08	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.14
H3404_002_0	2007	3																					3100											A		D	V	T	Coin		V	Coin					V						V	S	V			V																	0		0	0	0	0		0	0					0						0	0	0			0																	-		229.16		664.77	30.21	184.56	13.96		634.12	2.08					3085.9						18785.56	611.09	42.89			52.42																	750 Copay		100 copay on days 11-100	None	100 Coapy	20 coin		50 Copay	None					30 Copay/None						30/45 Copay	20 Copay	25 Copay			30 Copay																	541.29		65.55	0	78.03	0.16		39.01	0					0.94						26.92	15.61	8.78			10.73																	10.34	-	3.63	-	1.2	2.18	-	2.06	-	-	-	-	-	0.24	-	-	-	-	-	42.14	0.79	0.03	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.66		16.67	10.34	-	3.63	-	1.2	2.18	-	2.06	-	-	-	-	-	0.24	-	-	-	-	-	42.14	0.79	0.03	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.66		20		20	20	20	20		20	20					20						20	20	20			20																	2.18		0.21	0	0.07	0.15		0.29	0.02					1.44						1.92	0.05	0			0																	6.34			12.52	-	3.84	0	1.27	2.32	-	2.35	0.02	-	-	-	-	1.68	-	-	-	-	-	44.06	0.85	0.04	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.01
H3404_801_0	2007	2																					3100											Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0		0		0	0		0	0					0	0						0	0																				-		207.47		20.04		6.22	13.96		27.72	2.08					136.78	182.31						10.04	0.46																				Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.08		0.21		0.24	0.24		0.24	0.24					0.24	0.24						0.24	0.24																				16.48	-	4.14	-	1.47	3.29	-	6.54	0.49	-	-	-	-	32.28	43.03	-	-	-	-	-	2.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.2			16.48	-	4.14	-	1.47	3.29	-	6.54	0.49	-	-	-	-	32.28	43.03	-	-	-	-	-	2.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.2		Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.79		0.12		0.08	0.17		0.34	0.03					1.7	2.26						0.12	0.01																				5.63			17.28	-	4.26	-	1.54	3.47	-	6.88	0.52	-	-	-	-	33.98	45.29	-	-	-	-	-	2.49	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.83
H3404_803_0	2007	2																					3100											Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0		0		0	0		0	0					0	0						0	0																				-		207.47		20.04		6.22	13.96		27.72	2.08					136.78	182.31						10.04	0.46																				Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.08		0.21		0.24	0.24		0.24	0.24					0.24	0.24						0.24	0.24																				16.48	-	4.14	-	1.47	3.29	-	6.54	0.49	-	-	-	-	32.28	43.03	-	-	-	-	-	2.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.2			16.48	-	4.14	-	1.47	3.29	-	6.54	0.49	-	-	-	-	32.28	43.03	-	-	-	-	-	2.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.2		Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.79		0.12		0.08	0.17		0.34	0.03					1.7	2.26						0.12	0.01																				5.63			17.28	-	4.26	-	1.54	3.47	-	6.88	0.52	-	-	-	-	33.98	45.29	-	-	-	-	-	2.49	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.83
H3404_805_0	2007	2																					3100											Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0		0		0	0		0	0					0	0						0	0																				-		207.47		20.04		6.22	13.96		27.72	2.08					136.78	182.31						10.04	0.46																				Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.08		0.21		0.24	0.24		0.24	0.24					0.24	0.24						0.24	0.24																				16.48	-	4.14	-	1.47	3.29	-	6.54	0.49	-	-	-	-	32.28	43.03	-	-	-	-	-	2.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.2			16.48	-	4.14	-	1.47	3.29	-	6.54	0.49	-	-	-	-	32.28	43.03	-	-	-	-	-	2.37	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.2		Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.79		0.12		0.08	0.17		0.34	0.03					1.7	2.26						0.12	0.01																				5.63			17.28	-	4.26	-	1.54	3.47	-	6.88	0.52	-	-	-	-	33.98	45.29	-	-	-	-	-	2.49	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.83
H3405_001_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								3000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1233.98	9.01	442.69	2112.15	123.16	0.69	0.05	199.85	435.63	803.38	547.76	36.52	374.47	310.4	7060.37	8374.88			308.83		9.52			7.24								64.95	0.47	15.49								175/day (1-5)	175/day (1-5)	0/day (1-13) 75/day (14-100)	15/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-75/ Visit	50-75/ Visit	50/ Visit	0/ Procedure	35-75/ Visit	15/ Visit	35/ Visit			50/ Visit		20 Coins			25-75								175/day (1-5)	175/day (1-5)	20 Coins								75.84	75.84	7.51	9.56	63.71	0.13	0.13	31.62	74.23	36.93	34.51	31.86	0	26.8	9.56	22.3			31.86		0.13			0.25								75.84	75.84	0.13								7.8	0.06	0.28	1.68	0.65	0.09	0.01	0.53	2.69	2.47	1.58	0.1	-	0.69	5.62	15.56	-	-	0.82	-	1.21	-	-	1.83	-	-	-	-	-	-	-	0.41	0	1.97	-	-	-	-	-	-	-	46.06	0	25.19	7.8	0.06	0.28	1.68	0.65	0.09	0.01	0.53	2.69	2.47	1.58	0.1	-	0.69	5.62	15.56	-	-	0.82	-	1.21	-	-	1.83	-	-	-	-	-	-	-	0.41	0	1.97	-	-	-	-	-	-	-	46.06	3000	30 Coins	30 Coins	30 Coins	30 Coins	100/Trip	40 Coins		50/Visit	30 Coins	30 Coins			0/Procedure		30 Coins	30 Coins					20 Coins			50-80										30 Coins								8.5	0.03	0.28	0.39	0.26	0.04		0.25	3.51	4.15			0		2.63	3.16					0.57			1.9										0.9								26.58	0	0	16.3	0.09	0.56	2.07	0.91	0.12	0.01	0.78	6.21	6.62	1.58	0.1	-	0.69	8.25	18.73	-	-	0.82	-	1.78	-	-	3.73	-	-	-	-	-	-	-	0.41	0	2.88	-	-	-	-	-	-	-	72.64
H3405_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		253.45	1.91	450.45	2149.17	125.32	0.71	0.05	247.99	443.27	817.46	557.36	37.16	381.04	315.84	7184.14	8521.69			314.24		9.86											13.34	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.67	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.38	2.13	0.31	-	0.99	14.97	24.85	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.64	0	0	12.67	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.38	2.13	0.31	-	0.99	14.97	24.85	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.64		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.25	0.02	0.39	0.53	0.26	0.05		0.26	4.85	5.73			0		1.82	4.37					0.59																					21.11	0	0	14.93	0.11	0.72	2.32	1.31	0.22	0.01	1.19	12.24	8.11	2.13	0.31	-	0.99	16.78	29.22	-	-	0.92	-	2.56	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.75
H3405_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		249.59	1.88	443.6	2116.51	123.42	0.69	0.05	244.22	436.53	805.04	548.89	36.59	375.25	311.04	7074.95	8392.17			309.47		9.56											13.14	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.48	0.09	0.33	1.76	1.03	0.17	0.01	0.92	7.28	2.35	2.1	0.3	-	0.98	14.74	24.48	-	-	0.9	-	1.91	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.49	0	0	12.48	0.09	0.33	1.76	1.03	0.17	0.01	0.92	7.28	2.35	2.1	0.3	-	0.98	14.74	24.48	-	-	0.9	-	1.91	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.49		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.22	0.02	0.38	0.52	0.26	0.05		0.25	4.71	5.55			0		1.76	4.24					0.57																					20.51	0	0	14.7	0.11	0.7	2.28	1.29	0.22	0.01	1.17	11.98	7.9	2.1	0.3	-	0.98	16.5	28.71	-	-	0.9	-	2.48	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	93
H3405_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		253.45	1.91	450.45	2149.17	125.32	0.71	0.05	247.99	443.27	817.46	557.36	37.16	381.04	315.84	7184.14	8521.69			314.24		9.86											13.34	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.67	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.38	2.13	0.31	-	0.99	14.97	24.85	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.64	0	0	12.67	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.38	2.13	0.31	-	0.99	14.97	24.85	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.64		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.25	0.02	0.39	0.53	0.26	0.05		0.26	4.85	5.73			0		1.82	4.37					0.59																					21.11	0	0	14.93	0.11	0.72	2.32	1.31	0.22	0.01	1.19	12.24	8.11	2.13	0.31	-	0.99	16.78	29.22	-	-	0.92	-	2.56	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.75
H3405_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		249.59	1.88	443.6	2116.51	123.42	0.69	0.05	244.22	436.53	805.04	548.89	36.59	375.25	311.04	7074.95	8392.17			309.47		9.56											13.14	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.48	0.09	0.33	1.76	1.03	0.17	0.01	0.92	7.28	2.35	2.1	0.3	-	0.98	14.74	24.48	-	-	0.9	-	1.91	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.49	0	0	12.48	0.09	0.33	1.76	1.03	0.17	0.01	0.92	7.28	2.35	2.1	0.3	-	0.98	14.74	24.48	-	-	0.9	-	1.91	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.49		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.22	0.02	0.38	0.52	0.26	0.05		0.25	4.71	5.55			0		1.76	4.24					0.57																					20.51	0	0	14.7	0.11	0.7	2.28	1.29	0.22	0.01	1.17	11.98	7.9	2.1	0.3	-	0.98	16.5	28.71	-	-	0.9	-	2.48	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	93
H3435_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							12.82	13.81	394.76	435.65		294.27	57.35		1012.99		6162.34	140.44			991.41					137.43		289.34						12.95	385.5		102.64	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.28	2.45	1.2	1.61	-	0.44	0.21	-	3.75	-	9.12	0.21	-	-	1.47	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.57	-	0.15	0.23	-	-	-	-	24.4		2.97	-	-	-	-	-	2.28	2.45	1.2	1.61	-	0.44	0.21	-	3.75	-	9.12	0.21	-	-	1.47	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.57	-	0.15	0.23	-	-	-	-	24.4		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.09	0.03	0.28	0.28	0.04	0.08	0.08	0.03	0.26	0.15	0.16	0.02	0	0.15		0.29	0.01	0.03	0.18	0.66	0.16	0			0.01		0.01															5		0	2.09	0.03	0.28	0.28	0.04	2.35	2.54	1.22	1.88	0.15	0.59	0.23	0	3.89	-	9.4	0.22	0.03	0.18	2.13	0.16	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.57	-	0.15	0.23	-	-	-	-	29.4
H3435_002_0	2007	2	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							12.82	13.81	394.76	435.65		294.27	57.35		1012.99		6162.32	140.44			991.41					137.43		289.34						12.95	385.5		102.64	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.28	2.45	1.2	1.61	-	0.44	0.21	-	3.75	-	9.12	0.21	-	-	1.47	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.57	-	0.15	0.23	-	-	-	-	24.4		2.97	-	-	-	-	-	2.28	2.45	1.2	1.61	-	0.44	0.21	-	3.75	-	9.12	0.21	-	-	1.47	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.57	-	0.15	0.23	-	-	-	-	24.4		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.09	0.03	0.28	0.28	0.04	0.08	0.08	0.03	0.26	0.15	0.16	0.02	0	0.15		0.29	0.01	0.03	0.18	0.66	0.16	0			0.01		0.01															5		0	2.09	0.03	0.28	0.28	0.04	2.35	2.54	1.22	1.88	0.15	0.59	0.23	0	3.89	-	9.4	0.22	0.03	0.18	2.13	0.16	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.57	-	0.15	0.23	-	-	-	-	29.4
H3435_003_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								30.11	721.67	561		425.98	89.86		1693.72		6783.15	435.08			1447.13							289.34						66.63	350.02		282.19	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit											17	34	42		17	42		42		17	17			17							20						17	17		17	20					-	-	-	-	-	-	5.06	2.07	1.97	-	0.6	0.31	-	5.93	-	9.51	0.61	-	-	2.08	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	29.83		5.45	-	-	-	-	-	-	5.06	2.07	1.97	-	0.6	0.31	-	5.93	-	9.51	0.61	-	-	2.08	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	29.83		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.93	0.11	0.29	0.36	0.06	0.16	0.18	0.04	0.32	0.19	0.2	0.03	0.01	0.22		0.33	0.03	0.03	0.21	0.8	0.19	0			0.01		0.01															6.73		0	2.93	0.11	0.29	0.36	0.06	0.16	5.25	2.12	2.29	0.19	0.8	0.34	0.01	6.15	-	9.84	0.64	0.03	0.21	2.88	0.19	0	-	-	0.01	-	0.49	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	36.56
H3449_005_0	2007	2																					3100											A		D	V	T	Coin		V	V					V						V	O	V			V																	0		0	0	0	0		0	0					0						0	0	0			0																	-		234.74		680.95	30.94	189.05	13.91		649.55	270.05					3161.01						19242.81	625.96	97.64			93.25																	350 Copay		75 copay on days 11-100	None	50 Coapy	20 coin		50 Copay	None					25 Copay/ None						15 Copay	25 Copay	25 Copay			15 Copay																	311.23		61.24	0	45.62	0.18		45.62	0					4.11						13.69	18.25	22.81			13.69																	6.09	-	3.47	-	0.72	2.54	-	2.47	-	-	-	-	-	1.08	-	-	-	-	-	21.95	0.95	0.19	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.56		2.93	6.09	-	3.47	-	0.72	2.54	-	2.47	-	-	-	-	-	1.08	-	-	-	-	-	21.95	0.95	0.19	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.56																																																																																				-			6.09	-	3.47	-	0.72	2.54	-	2.47	-	-	-	-	-	1.08	-	-	-	-	-	21.95	0.95	0.19	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.56
H3449_012_0	2007	1																					3100											A		D	V	T	Coin		V	V					V						V	S	V			V																	0		0	0	0	0		0	0					0						0	0	0			0																	-		234.74		680.95	30.94	189.05	13.91		649.55	270.05					3161.01						19242.81	625.96	97.64			97.64																	350 Copay		75 copay on days 11-100	None	50 Coapy	20 coin		50 Copay	None					25 Copay/ None						15 Copay	25 Copay	25 Copay			15 Copay																	311.23		61.24	0	45.62	0.18		45.62	0					4.11						13.69	18.25	22.81			13.69																	6.09	-	3.47	-	0.72	2.54	-	2.47	-	-	-	-	-	1.08	-	-	-	-	-	21.95	0.95	0.19	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.57		2.93	6.09	-	3.47	-	0.72	2.54	-	2.47	-	-	-	-	-	1.08	-	-	-	-	-	21.95	0.95	0.19	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.57																																																																																				-			6.09	-	3.47	-	0.72	2.54	-	2.47	-	-	-	-	-	1.08	-	-	-	-	-	21.95	0.95	0.19	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.57
H3449_013_0	2007	3																					3100											A		D	V	T	Coin		V	Coin					V						V	S	V			V																	0		0	0	0	0		0	0					0						0	0	0			0																	-		234.74		680.95	30.94	189.05	13.91		649.55	2.08					3161.01						19242.81	625.96	97.64			97.64																	750 Copay		100 copay on days 11-100	None	100 Coapy	20 coin		50 Copay	None					30 Copay/None						30 Copay	25 Copay	25 Copay			30 Copay																	547.04		68.62	0	79.06	0.16		39.53	0					7.12						23.72	15.81	19.77			18.27																	10.7	-	3.89	-	1.25	2.2	-	2.14	-	-	-	-	-	1.87	-	-	-	-	-	38.03	0.82	0.16	-	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.22		15.19	10.7	-	3.89	-	1.25	2.2	-	2.14	-	-	-	-	-	1.87	-	-	-	-	-	38.03	0.82	0.16	-	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.22																																																																																				-			10.7	-	3.89	-	1.25	2.2	-	2.14	-	-	-	-	-	1.87	-	-	-	-	-	38.03	0.82	0.16	-	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.22
H3449_801_0	2007	2																					3100											Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0		0	0	0	0		0	0					0	0						0	0																				-		186.83		12.46	0.41	3.41	10.26		19.27	4.31					94.34	195.93						19.05	0.55																				Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.08		0.21	0	0.24	0.24		0.24	0.24					0.24	0.24						0.24	0.24																				14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33			14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33																																																																																				-			14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33
H3449_805_0	2007	2																					3100											Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0		0	0	0	0		0	0					0	0						0	0																				-		186.83		12.46	0.41	3.41	10.26		19.27	4.31					94.34	195.93						19.05	0.55																				Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.08		0.21	0	0.24	0.24		0.24	0.24					0.24	0.24						0.24	0.24																				14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33			14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33																																																																																				-			14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33
H3449_808_0	2007	2																					3100											Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0		0	0	0	0		0	0					0	0						0	0																				-		186.83		12.46	0.41	3.41	10.26		19.27	4.31					94.34	195.93						19.05	0.55																				Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.08		0.21	0	0.24	0.24		0.24	0.24					0.24	0.24						0.24	0.24																				14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33			14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33																																																																																				-			14.84	-	2.57	-	0.8	2.42	-	4.55	1.02	-	-	-	-	22.26	46.24	-	-	-	-	-	4.5	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.33
H3449_810_0	2007	5																					3100											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-		314.43		14.28		6.74	16.32		33.68	3.56					105.01	310.72						13.5	0.58																				Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing	Medicare Cost Sharing																				0.08		0.21		0.24	0.24		0.24	0.24					0.24	0.24						0.24	0.24																				25.27	-	2.99	-	1.59	3.85	-	7.95	0.84	-	-	-	-	24.78	73.33	-	-	-	-	-	3.18	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.92			25.27	-	2.99	-	1.59	3.85	-	7.95	0.84	-	-	-	-	24.78	73.33	-	-	-	-	-	3.18	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.92																																																																																				-			25.27	-	2.99	-	1.59	3.85	-	7.95	0.84	-	-	-	-	24.78	73.33	-	-	-	-	-	3.18	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.92
H3456_001_0	2007	6																					3100											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1801.07	156.9	673.54	0	272	14.7	6.34	553.43	35.84	7978.1	49.87	0	0.24	27.27	3326.13	3897.54	669	1.9	0	0	25.02	677.73	0	0	152.64	0	211.5	0	0	0	0											295 (1a)	295 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											168.11	168.11	91.18	0	99.73	0.17	0.19	27.78	0.17	1.14	0.13	0	0.17	0.17	15	30	37.5	0.17	0	0	0.17	30	0	0	30	0	30	0	0	0	0											25.23	2.2	5.12	-	2.26	2.51	1.24	1.28	6.13	0.76	6.5	-	0.04	4.67	4.16	9.74	2.09	0.32	-	-	4.28	1.69	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.13		46.92	25.23	2.2	5.12	-	2.26	2.51	1.24	1.28	6.13	0.76	6.5	-	0.04	4.67	4.16	9.74	2.09	0.32	-	-	4.28	1.69	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.13																																																																																				-			25.23	2.2	5.12	-	2.26	2.51	1.24	1.28	6.13	0.76	6.5	-	0.04	4.67	4.16	9.74	2.09	0.32	-	-	4.28	1.69	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.13
H3456_010_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1563.63	145.6	8385.49	163.78	614.67	1382.55	6719.3	176.77	117.37	3651.46	162.33	32.1	4.2	272.93	119.65	1224.82	1591.09	18.8		255.74	246.17	1250.61	1200		140.2	166		54.6				104.24	0.26	0.07	300	295.2						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						65	65			65			43	22			22		22																		9										8.44	0.79	-	-	3.32	-	-	0.64	0.21	-	-	0.06	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	14.02		2.21	8.44	0.79	-	-	3.32	-	-	0.64	0.21	-	-	0.06	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	14.02																																																																																				-		0	8.44	0.79	-	-	3.32	-	-	0.64	0.21	-	-	0.06	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	14.02
H3456_016_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2209.49	349.61	1125.55		262.33	26.13	22.64	898.97	389.79	2045.04	959.44	66.4	3.19	2018.8		3484.26		528.91		811												287.78		154.92	230.47							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							6.66	1.05	1.63	-	0.79	2.52	2.19	1.3	0.39	0.82	0.39	0.07	0.31	2.03	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.36		23.98	6.66	1.05	1.63	-	0.79	2.52	2.19	1.3	0.39	0.82	0.39	0.07	0.31	2.03	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.36																																																																																				-		0	6.66	1.05	1.63	-	0.79	2.52	2.19	1.3	0.39	0.82	0.39	0.07	0.31	2.03	-	1.4	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.36
H3456_020_0	2007	3																					2500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1801.07	156.9	673.54	0	272	14.7	6.34	553.43	35.84	7978.1	49.87	0	0.24	27.27	3326.13	3897.54	669	1.9	0	0	25.02	677.73	0	0	152.64	0	211.5	0	0	0	0											295 (1a)	295 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											150.59	150.59	81.68	0	89.34	0.15	0.18	24.89	0.15	3.06	0.12	0	0.15	0.15	15	30	37.5	0.15	0	0	0.15	30	0	0	30	0	30	0	0	0	0											22.6	1.97	4.58	-	2.02	2.25	1.14	1.15	5.49	2.04	5.82	-	0.04	4.18	4.16	9.74	2.09	0.29	-	-	3.83	1.69	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.01		54.7	22.6	1.97	4.58	-	2.02	2.25	1.14	1.15	5.49	2.04	5.82	-	0.04	4.18	4.16	9.74	2.09	0.29	-	-	3.83	1.69	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.01																																																																																				-			22.6	1.97	4.58	-	2.02	2.25	1.14	1.15	5.49	2.04	5.82	-	0.04	4.18	4.16	9.74	2.09	0.29	-	-	3.83	1.69	-	-	0.38	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.01
H3456_801_0	2007	4																					4300											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1561.85	158.96	513.69	0	184.22	13.48	7.51	525.96	43.98	10806.36	59.23	0	0.51	34.64	4247.66	4721.45	664.32	3.32	0	0	23.04	1090.37	0	0	176.84	0	235.16	0	0	0	0											350 (1a)	350 (1b)	165 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											220.71	220.71	104.05	0	110.36	0.19	0.21	31.53	0.19	3.78	0.14	0	0.19	0.19	35	35	37.5	0.19	0	0	0.19	35	0	0	35	0	35	0	0	0	0											28.73	2.92	4.45	-	1.69	2.55	1.57	1.38	8.32	3.41	8.54	-	0.1	6.55	12.39	13.77	2.08	0.63	-	-	4.36	3.18	-	-	0.52	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.82		43.82	28.73	2.92	4.45	-	1.69	2.55	1.57	1.38	8.32	3.41	8.54	-	0.1	6.55	12.39	13.77	2.08	0.63	-	-	4.36	3.18	-	-	0.52	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.82																																																																																				-			28.73	2.92	4.45	-	1.69	2.55	1.57	1.38	8.32	3.41	8.54	-	0.1	6.55	12.39	13.77	2.08	0.63	-	-	4.36	3.18	-	-	0.52	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.82
H3619_001_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1212.01	8.84	434.81	2074.54	120.97	0.68	0.05	196.29	427.88	789.08	538.01	35.87	367.81	304.87	6934.67	8225.77			303.33		9.38											63.79	0.47	15.26								175/day (1-5)	175/day (1-5)	0/day (1-13) 75/day (14-100)	15/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125-200/ Visit	0-90/ Visit	50-90/ Visit	50/ Visit	0/ Procedure	35-90/ Visit	15/ Visit	35/ Visit			50/ Visit		20 Coins											175/day (1-5)	175/day (1-5)	20 Coins								119.04	119.04	11.79	15	100	0.2	0.2	49.63	149.75	69.55	56.67	50	0	44.71	15	35			50		0.2											119.04	119.04	0.2								12.02	0.09	0.43	2.59	1.01	0.14	0.01	0.81	5.34	4.57	2.54	0.15	-	1.14	8.67	23.99	-	-	1.26	-	1.88	-	-	-	-	-	-	-	-	-	-	0.63	0	3.05	-	-	-	-	-	-	-	70.32	0	0	12.02	0.09	0.43	2.59	1.01	0.14	0.01	0.81	5.34	4.57	2.54	0.15	-	1.14	8.67	23.99	-	-	1.26	-	1.88	-	-	-	-	-	-	-	-	-	-	0.63	0	3.05	-	-	-	-	-	-	-	70.32		30 Coins	30 Coins	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			0/Procedure		30 Coins	30 Coins					20 Coins													30 Coins								9.37	0.04	0.31	0.43	0.28	0.03		0.28	3.87	4.57			0		2.9	3.49					0.62													1								27.19	500	1.14	21.4	0.12	0.74	3.02	1.29	0.16	0.01	1.09	9.21	9.15	2.54	0.15	-	1.14	11.57	27.48	-	-	1.26	-	2.5	-	-	-	-	-	-	-	-	-	-	0.63	0	4.05	-	-	-	-	-	-	-	97.52
H3619_004_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1281.32	9.35	459.67	2193.19	127.89	0.74	0.06	207.52	452.35	834.21	568.78	37.92	388.84	322.31	7331.28	8696.23			320.68		10.26											67.44	0.49	16.7								190/day (1-5)	190/day (1-5)	0/day (1-10) 100/day (11-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125-200/ Visit	0-90/ Visit	50-90/ Visit	50/ Visit	0/ Procedure	35-90/ Visit	10/ Visit	40/ Visit			100/ Visit		20 Coins											190/day (1-5)	190/day (1-5)	20 Coins								129.24	129.24	20.38	10	100	0.2	0.2	49.63	149.75	69.55	56.67	50	0	44.71	10	40			100		0.2											129.24	129.24	0.2								13.8	0.1	0.78	1.83	1.07	0.15	0.01	0.86	5.64	4.83	2.69	0.16	-	1.2	6.11	28.99	-	-	2.67	-	2.05	-	-	-	-	-	-	-	-	-	-	0.73	0.01	3.34	-	-	-	-	-	-	-	77.01	0	0	13.8	0.1	0.78	1.83	1.07	0.15	0.01	0.86	5.64	4.83	2.69	0.16	-	1.2	6.11	28.99	-	-	2.67	-	2.05	-	-	-	-	-	-	-	-	-	-	0.73	0.01	3.34	-	-	-	-	-	-	-	77.01		750/admit	750/admit	20 Coins	20 Coins	100/Trip	20 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		20 Coins	20 Coins					20 Coins													20 Coins								1.89	0.01	0.19	0.26	0.27	0.02		0.26	2.41	2.84			0		1.8	2.17					0.58													0.62								13.32	0	0	15.69	0.11	0.97	2.09	1.33	0.17	0.01	1.12	8.05	7.67	2.69	0.16	-	1.2	7.91	31.15	-	-	2.67	-	2.63	-	-	-	-	-	-	-	-	-	-	0.73	0.01	3.96	-	-	-	-	-	-	-	90.33
H3619_005_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1242.94	9.07	445.9	2127.48	124.06	0.7	0.05	201.3	438.8	809.21	551.74	36.78	377.19	312.65	7111.63	8435.68			311.07		9.66											65.42	0.48	15.71								190/day (1-5)	190/day (1-5)	0/day (1-10) 100/day (11-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125-200/ Visit	0-90/ Visit	50-90/ Visit	50/ Visit	0/ Procedure	35-90/ Visit	10/ Visit	35/ Visit			50/ Visit		20 Coins											190/day (1-5)	190/day (1-5)	20 Coins								129.24	129.24	20.38	10	100	0.2	0.2	49.63	149.75	69.55	56.67	50	0	44.71	10	35			50		0.2											129.24	129.24	0.2								13.39	0.1	0.76	1.77	1.03	0.14	0.01	0.83	5.48	4.69	2.61	0.15	-	1.16	5.93	24.6	-	-	1.3	-	1.93	-	-	-	-	-	-	-	-	-	-	0.7	0.01	3.14	-	-	-	-	-	-	-	69.73	0	0	13.39	0.1	0.76	1.77	1.03	0.14	0.01	0.83	5.48	4.69	2.61	0.15	-	1.16	5.93	24.6	-	-	1.3	-	1.93	-	-	-	-	-	-	-	-	-	-	0.7	0.01	3.14	-	-	-	-	-	-	-	69.73		750/admit	750/admit	20 Coins	20 Coins	100/Trip	20 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		20 Coins	20 Coins					20 Coins													20 Coins								1.83	0.01	0.18	0.25	0.26	0.02		0.26	2.26	2.67			0		1.7	2.04					0.55													0.58								12.61	0	0	15.22	0.11	0.94	2.02	1.29	0.16	0.01	1.09	7.74	7.36	2.61	0.15	-	1.16	7.62	26.64	-	-	1.3	-	2.48	-	-	-	-	-	-	-	-	-	-	0.7	0.01	3.72	-	-	-	-	-	-	-	82.34
H3619_006_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1236.75	9.03	443.68	2116.9	123.44	0.69	0.05	200.3	436.62	805.19	548.99	36.6	375.32	311.1	7076.26	8393.73			309.52		9.56											65.09	0.48	15.56								175/day (1-5)	175/day (1-5)	0/day (1-13) 75/day (14-100)	15/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125-200/ Visit	0-90/ Visit	50-90/ Visit	50/ Visit	0/ Procedure	35-90/ Visit	15/ Visit	35/ Visit			50/ Visit		20 Coins											175/day (1-5)	175/day (1-5)	20 Coins								119.04	119.04	11.79	15	100	0.2	0.2	49.63	149.75	69.55	56.67	50	0	44.71	15	35			50		0.2											119.04	119.04	0.2								12.27	0.09	0.44	2.65	1.03	0.14	0.01	0.83	5.45	4.67	2.59	0.15	-	1.16	8.85	24.48	-	-	1.29	-	1.91	-	-	-	-	-	-	-	-	-	-	0.65	0	3.11	-	-	-	-	-	-	-	71.75	0	0	12.27	0.09	0.44	2.65	1.03	0.14	0.01	0.83	5.45	4.67	2.59	0.15	-	1.16	8.85	24.48	-	-	1.29	-	1.91	-	-	-	-	-	-	-	-	-	-	0.65	0	3.11	-	-	-	-	-	-	-	71.75		30 Coins	30 Coins	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			0/Procedure		30 Coins	30 Coins					20 Coins													30 Coins								9.52	0.04	0.32	0.43	0.3	0.03		0.3	3.93	4.64			0		2.95	3.54					0.63													1.01								27.64	500	0	21.78	0.13	0.75	3.08	1.33	0.17	0.01	1.13	9.38	9.31	2.59	0.15	-	1.16	11.79	28.02	-	-	1.29	-	2.55	-	-	-	-	-	-	-	-	-	-	0.65	0	4.12	-	-	-	-	-	-	-	99.39
H3619_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1245.75	9.09	446.91	2132.3	124.34	0.7	0.05	246.04	439.79	811.05	552.99	36.87	378.05	313.36	7127.73	8454.78			311.78		9.7											13.23	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									121.11	125.13	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.57	0.09	0.33	1.78	1.04	0.17	0.01	0.93	7.33	2.37	2.11	0.31	-	0.98	14.85	24.66	-	-	0.91	-	1.94	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.05	0	0	12.57	0.09	0.33	1.78	1.04	0.17	0.01	0.93	7.33	2.37	2.11	0.31	-	0.98	14.85	24.66	-	-	0.91	-	1.94	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.05		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.38	0.52	0.26	0.05		0.26	4.78	5.64			0		1.79	4.3					0.58																					20.8	0	0	14.81	0.11	0.71	2.3	1.3	0.22	0.01	1.18	12.11	8	2.11	0.31	-	0.98	16.64	28.96	-	-	0.91	-	2.52	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	93.84
H3619_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		247.64	1.87	440.12	2099.91	122.45	0.68	0.05	242.31	433.11	798.73	544.59	36.31	372.3	308.6	7019.48	8326.37			307.04		9.41											13.03	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.38	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.22	2.33	2.08	0.3	-	0.97	14.62	24.29	-	-	0.9	-	1.88	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.91	0	0	12.38	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.22	2.33	2.08	0.3	-	0.97	14.62	24.29	-	-	0.9	-	1.88	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.91		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.2	0.02	0.37	0.51	0.26	0.04		0.25	4.63	5.47			0		1.73	4.17					0.56																					20.21	0	0	14.58	0.11	0.69	2.26	1.28	0.21	0.01	1.17	11.85	7.8	2.08	0.3	-	0.97	16.36	28.45	-	-	0.9	-	2.44	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	92.12
H3619_806_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		251.46	1.9	446.91	2132.3	124.34	0.7	0.05	246.04	439.79	811.05	552.99	36.87	378.05	313.36	7127.73	8454.78			311.78		9.7											13.23	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.57	0.09	0.33	1.78	1.04	0.17	0.01	0.93	7.33	2.37	2.11	0.31	-	0.98	14.85	24.66	-	-	0.91	-	1.94	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.05	0	0	12.57	0.09	0.33	1.78	1.04	0.17	0.01	0.93	7.33	2.37	2.11	0.31	-	0.98	14.85	24.66	-	-	0.91	-	1.94	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	73.05		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.38	0.52	0.26	0.05		0.26	4.78	5.64			0		1.79	4.3					0.58																					20.8	0	0	14.81	0.11	0.71	2.3	1.3	0.22	0.01	1.18	12.11	8	2.11	0.31	-	0.98	16.64	28.96	-	-	0.91	-	2.52	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	93.84
H3619_807_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		247.64	1.87	440.12	2099.91	122.45	0.68	0.05	242.31	433.11	798.73	544.59	36.31	372.3	308.6	7019.48	8326.37			307.04		9.41											13.03	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.38	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.22	2.33	2.08	0.3	-	0.97	14.62	24.29	-	-	0.9	-	1.88	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.91	0	0	12.38	0.09	0.32	1.75	1.02	0.17	0.01	0.91	7.22	2.33	2.08	0.3	-	0.97	14.62	24.29	-	-	0.9	-	1.88	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.91		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.2	0.02	0.37	0.51	0.26	0.04		0.25	4.63	5.47			0		1.73	4.17					0.56																					20.21	0	0	14.58	0.11	0.69	2.26	1.28	0.21	0.01	1.17	11.85	7.8	2.08	0.3	-	0.97	16.36	28.45	-	-	0.9	-	2.44	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	92.12
H3620_001_0	2007	4																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		1099.82	24.04	393.21	0	210.9	6.79	5.29	299.44	151.05	0	0	0	0	504.26	3106.12	5642.15	123.41	235.7	0	1065.9	0	0	0	0	38.38	0	1.9	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 CORF/PT/ST/OT	15 PCP Copay	30 Specialist Copay	30 Copay	30 Copay		30 Copay Specialists; 35 Hearing/Speech		30 Copay			30 Copay		30 Copay															120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	30	0	30	0	0	0	0											11	0.24	0.82	-	1.32	1.36	1.05	1.25	2.2	-	-	-	-	1.26	3.88	14.11	0.31	0.59	-	2.66	-	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.15			11	0.24	0.82	-	1.32	1.36	1.05	1.25	2.2	-	-	-	-	1.26	3.88	14.11	0.31	0.59	-	2.66	-	-	-	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.15		850/admit	850/admit	100/day for days21-100	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	225 Copay	20 Coinsurance	20 Coinsurance	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	30 Copay	No Copay	No Copay	No Copay	30 Copay	No Copay	30 Coapy	No Copay	No Copay													0.69	0.01	0.17	0	0.08	0.08	0.06	0.07	0.15	0.15	0.28	0	0.01	0.49	0.43	1.16	0.01	0.05	0.34	0.1	0.37	0	0	0	0.01	0	0	0	0													4.71			11.69	0.25	0.99	-	1.4	1.44	1.11	1.32	2.35	0.15	0.28	-	0.01	1.75	4.31	15.27	0.32	0.64	0.34	2.76	0.37	-	-	-	0.11	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.86
H3620_801_0	2007	3																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		426.17	5.89	267.43	0	151.05	7.27	5.94	240.16	157.89	0	0	0	0	616.27	3516.71	7911.51	112.1	224.01	0	903.36	0	0	0	0	0	0	0	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 CORF/PT/ST/OT	15 PCP Copay	30 Specialist Copay	30 Copay	30 Copay		30 Copay Specialists; 35 Hearing/Speech		30 Copay																				120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	0	0	0	0	0	0	0											4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57			4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57		850/admit	850/admit	100/day for days21-100	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	225 Copay	20 Coinsurance	20 Coinsurance	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	30 Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay											0.27	0	0.12	0	0.07	0.08	0.07	0.05	0.16	0.2	0.34	0	0.03	0.56	0.49	1.51	0.01	0.06	0.34	0.1	0.46	0	0	0	0	0	0	0	0													4.92			4.53	0.06	0.68	-	1.01	1.53	1.25	1.05	2.46	0.2	0.34	-	0.03	2.1	4.89	21.29	0.29	0.62	0.34	2.36	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.49
H3620_802_0	2007	4																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		426.17	5.89	267.43	0	151.05	7.27	5.94	240.16	157.89	0	0	0	0	616.27	3516.71	7911.51	112.1	224.01	0	903.36	0	0	0	0	0	0	0	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 CORF/PT/ST/OT	15 PCP Copay	30 Specialist Copay	30 Copay	30 Copay		30 Copay Specialists; 35 Hearing/Speech		30 Copay																				120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	0	0	0	0	0	0	0											4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57			4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57		850/admit	850/admit	100/day for days21-100	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	225 Copay	20 Coinsurance	20 Coinsurance	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	30 Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay											0.27	0	0.12	0	0.07	0.08	0.07	0.05	0.16	0.2	0.34	0	0.03	0.56	0.49	1.51	0.01	0.06	0.34	0.1	0.46	0	0	0	0	0	0	0	0													4.92			4.53	0.06	0.68	-	1.01	1.53	1.25	1.05	2.46	0.2	0.34	-	0.03	2.1	4.89	21.29	0.29	0.62	0.34	2.36	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.49
H3620_803_0	2007	3																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		426.17	5.89	267.43	0	151.05	7.27	5.94	240.16	157.89	0	0	0	0	616.27	3516.71	7911.51	112.1	224.01	0	903.36	0	0	0	0	0	0	0	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 CORF/PT/ST/OT	15 PCP Copay	30 Specialist Copay	30 Copay	30 Copay		30 Copay Specialists; 35 Hearing/Speech		30 Copay																				120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	0	0	0	0	0	0	0											4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57			4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57		850/admit	850/admit	100/day for days21-100	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	225 Copay	20 Coinsurance	20 Coinsurance	No Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	30 Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay	No Copay													0.27	0	0.12	0	0.07	0.08	0.07	0.05	0.16	0.2	0.34	0	0.03	0.56	0.49	1.51	0.01	0.06	0.34	0.1	0.46	0	0	0	0	0	0	0	0													4.92			4.53	0.06	0.68	-	1.01	1.53	1.25	1.05	2.46	0.2	0.34	-	0.03	2.1	4.89	21.29	0.29	0.62	0.34	2.36	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.49
H3620_804_0	2007	4																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		426.17	5.89	267.43	0	151.05	7.27	5.94	240.16	157.89	0	0	0	0	616.27	3516.71	7911.51	112.1	224.01	0	903.36	0	0	0	0	0	0	0	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 CORF/PT/ST/OT	15 PCP Copay	30 Specialist Copay	30 Copay	30 Copay		30 Copay Specialists; 35 Hearing/Speech		30 Copay																				120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	0	0	0	0	0	0	0											4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57			4.26	0.06	0.56	-	0.94	1.45	1.18	1	2.3	-	-	-	-	1.54	4.4	19.78	0.28	0.56	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.57		850/admit	850/admit	100/day for days21-100		20 Coinsurance	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	225 Copay	20 Coinsurance	20 Coinsurance		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	30 Copay																					0.27	0	0.12	0	0.07	0.08	0.07	0.05	0.16	0.2	0.34	0	0.03	0.56	0.49	1.51	0.01	0.06	0.34	0.1	0.46	0	0	0	0	0	0	0	0													4.92			4.53	0.06	0.68	-	1.01	1.53	1.25	1.05	2.46	0.2	0.34	-	0.03	2.1	4.89	21.29	0.29	0.62	0.34	2.36	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.49
H3623_001_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0																			200/day 1-10	200/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	35	35 routine 100 complex	35	30	35	15	35 Specialist 30 Renal Dialysis	35	35	35	35	45	0	Not Covered																			163.28	163.28	65.39	20	100	0.2	0.2	46.75	150	35	53.94	35	30	35	15	34.46	35	35	35	35	45	0	0																			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.05	-	-	-	6.78	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.79			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.05	-	-	-	6.78	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.79																																																																																				-			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.05	-	-	-	6.78	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.79
H3623_002_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45	0																				122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	25	50.65	25	25	25	10	25	25	25	25	25	45	0																				15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	4.56	4.75	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.1			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	4.56	4.75	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.1																																																																																				-			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	4.56	4.75	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.1
H3623_003_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				0	0	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	20	20 routine 100 complex	20	20	20	0	20	20	20	20	20	45	0																				0	0	65.39	20	100	0.2	0.2	46.75	150	20	47.36	20	20	20	0	20	20	20	20	20	45	0																				-	-	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.07			-	-	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.07																																																																																				-			-	-	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.07
H3623_004_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				200/day 1-10	200/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 urgent care	150	35	35 routine 100 complex	35	30	35	20	35 Specialist 30 Renal Dialysis	35	35	35	35	45	0																				163.28	163.28	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	20	34.46	35	35	35	35	45	0																				21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.36			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.36																																																																																				-			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.36
H3623_005_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 urgent care	150	30	30 routine 100 complex	30	30	30	10	30	30	30	30	30	45	0																				122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	30	53.94	30	30	30	10	30	30	30	30	30	45	0																				15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.42			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.42																																																																																				-			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	4.52	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.42
H3623_006_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				50/day 1-10	50/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 urgent care	150	20	20 routine 100 complex	20	20	20	0	20	20	20	20	20	45	0																				40.82	40.82	65.39	20	100	0.2	0.2	46.75	150	20	47.36	20	20	20	0	20	20	20	20	20	45	0																				5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47																																																																																				-			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47
H3623_007_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				200/day 1-10	200/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 urgent care	150	35	35 routine 100 complex	35	30	35	20	35 Specialist 30 Renal Dialysis	35	35	35	35	45	0																				163.28	163.28	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	20	34.46	35	35	35	35	45	0																				21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.36			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.36																																																																																				-			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.36
H3623_008_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 routine	150	30	30 routine 100 complex	30	30	30	15	30	30	30	30	30	45	0																				122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	30	53.94	30	30	30	15	30	30	30	30	30	45	0																				15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68																																																																																				-			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68
H3623_009_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				0	0	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	20	20 routine 100 complex	20	20	20	0	20	20	20	20	20	45	0																				0	0	65.39	20	100	0.2	0.2	46.75	150	20	47.36	20	20	20	0	20	20	20	20	20	45	0																				-	-	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.07			-	-	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.07																																																																																				-			-	-	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.07
H3623_010_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				200/day 1-10	200/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	0	0	50 ER 25 Urgent Care	150	30	30 routine 100 complex	30	30	30	15	30	30	30	30	30	45	0																				163.28	163.28	65.39	20	100	0.2	0.2	46.75	150	30	53.94	30	30	30	15	30	30	30	30	30	45	0																				21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.08			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.08																																																																																				-			21.18	0.41	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.08
H3623_011_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	30	30 routine 100 complex	30	30	30	15	30	30	30	30	30	45	0																				122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	30	53.94	30	30	30	15	30	30	30	30	30	45	0																				15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68																																																																																				-			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68
H3623_012_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				50/day 1-10	50/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	20	20 routine 100 complex	20	20	20	0	20	20	20	20	20	45	0																				40.82	40.82	65.39	20	100	0.2	0.2	46.75	150	20	47.36	20	20	20	0	20	20	20	20	20	45	0																				5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47																																																																																				-			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47
H3623_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H3623_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H3624_001_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5	0	0	0											150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 35 urgent care	150	35	35 routine 100 complex	35	30	35	15	35 Specialist 30 Renal Dialysis	35	35	35	35	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	500 Every 3 Years	N/A	Fitness	0											122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	15	34.4	35	35	35	35	45	0	0	0	0	0	0	0	0	0	0											13.98	0.27	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	5.97	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.51			13.98	0.27	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	5.97	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.51		30	30	30	30	100	30	30	50 ER 30 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45	0	Not Covered	Not Covered	30	0	30	0	N/A	Not Covered	0											4.96	0	0.8	0.72	0.16	0.41	0	0.14	0.51	0.18	0.5	0	0.16	0.55	0.64	0.81	0.03	0.09	0.6	2.17	0.08	0	0	0	0.08	0	0.02	0	0	0	0											13.61	500	12.53	18.94	0.27	6.9	3.78	1.85	3.18	0.18	1.57	4.29	5.79	5.21	-	0.16	0.55	6.62	17.73	0.54	1.55	3.01	5.81	0.08	-	-	-	0.08	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.12
H3624_002_0	2007	4																																D		D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5	0	0	0											150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 35 urgent care	150	35	35 routine 100 complex	35	30	35	15	35 Specialist 30 Renal Dialysis	35	35	35	35	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	500 Every 3 Years	N/A	Fitness	0											122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	15	34.4	35	35	35	35	45	0	0	0	0	0	0	0	0	0	0											13.98	0.27	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	5.97	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.51			13.98	0.27	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	5.97	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.51		30	30	30	30	100	30	30	50 ER 30 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45	0	Not Covered	Not Covered	30	0	30	0	N/A	Not Covered	0											4.96	0	0.8	0.72	0.16	0.41	0	0.14	0.51	0.18	0.5	0	0.16	0.55	0.64	0.81	0.03	0.09	0.6	2.17	0.08	0	0	0	0.08	0	0.02	0	0	0	0											13.61	500	12.53	18.94	0.27	6.9	3.78	1.85	3.18	0.18	1.57	4.29	5.79	5.21	-	0.16	0.55	6.62	17.73	0.54	1.55	3.01	5.81	0.08	-	-	-	0.08	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.12
H3624_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1210	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4680.93	5938.14	170.51	986.68	1348.5	2445.82	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															14.49	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.87			14.49	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.87		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		22.41	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.68	18.61	0.55	3.01	4.89	10.6	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	117.14
H3624_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1210	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4680.93	5938.14	170.51	986.68	1348.5	2445.82	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															14.49	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.87			14.49	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.65	17.32	0.5	2.88	3.93	7.13	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.87		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		22.41	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.68	18.61	0.55	3.01	4.89	10.6	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	117.14
H3653_004_0	2007	6																					Unlimited											A	A	D		T	Coin	Coin	V	V						V	V	V			V					V		V																																																								-		351.92	5.16	1004.81		256.84	10.86	5.51	609.38	553.31						7482.65	9736.69	772.17			25534.85					241.05		20.74															325 per admit OOP 975	325 per admit OOP 975	75 per day after 15 days		50 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	100 per visit						10 per visit	20 per visit	20 per visit			20 per visit					20 per visit		20 per visit															281.93	294.1	60.22		50	0.19	0.16	7.18	100						9.39	9.16	12.48			0.22					0.12		16.91															8.27	0.13	5.04	-	1.07	2.09	0.88	0.36	4.61	-	-	-	-	-	5.86	7.44	0.8	-	-	0.47	-	-	-	-	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.05		0	8.27	0.13	5.04	-	1.07	2.09	0.88	0.36	4.61	-	-	-	-	-	5.86	7.44	0.8	-	-	0.47	-	-	-	-	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.05																																																																																				-			8.27	0.13	5.04	-	1.07	2.09	0.88	0.36	4.61	-	-	-	-	-	5.86	7.44	0.8	-	-	0.47	-	-	-	-	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.05
H3653_015_0	2007	4																					Unlimited											A	A	D		T	Coin	Coin	V	V	V	V				V	V	V	V		V							V																																																								-		242.7	3.56	692.95		177.13	7.49	3.8	420.25	381.58	9516.95	1269.55				5160.28	6714.74	532.51	1981.87		17609.67							14.3															195 per day for days 1-15	195 per day for days 1-15	95 per day		150 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	175 per visit	2 per visit	5 or 50 per visit routine or advanced respectively.				15 per visit	35 per visit	35 per visit	35 per visit		35 per visit							30 per visit															871.12	908.74	140.7		150	0.19	0.16	7.18	175	2	17.71				14.09	16.04	21.84	23.79		0.38							29.59															17.62	0.27	8.12	-	2.21	1.44	0.61	0.25	5.56	1.59	1.87	-	-	-	6.06	8.97	0.97	3.93	-	0.56	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.08		0	17.62	0.27	8.12	-	2.21	1.44	0.61	0.25	5.56	1.59	1.87	-	-	-	6.06	8.97	0.97	3.93	-	0.56	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.08																																																																																				-			17.62	0.27	8.12	-	2.21	1.44	0.61	0.25	5.56	1.59	1.87	-	-	-	6.06	8.97	0.97	3.93	-	0.56	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.08
H3653_018_0	2007	5																					Unlimited											A	A	D		T	Coin	Coin	V	V						V	V	V			V					V		V																																																								-		263.39	3.86	752.04		192.23	8.13	4.13	456.08	414.12						5600.27	7287.28	577.92			19111.16					180.41		15.52															325 per admit OOP 975	325 per admit OOP 975	75 per day after 15 days		50 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	100 per visit						10 per visit	20 per visit	20 per visit			20 per visit					20 per visit		20 per visit															281.93	294.1	60.22		50	0.19	0.16	7.18	100						9.39	9.16	12.48			0.22					0.12		16.91															6.19	0.09	3.77	-	0.8	1.57	0.66	0.27	3.45	-	-	-	-	-	4.38	5.57	0.6	-	-	0.35	-	-	-	-	0	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.73		0	6.19	0.09	3.77	-	0.8	1.57	0.66	0.27	3.45	-	-	-	-	-	4.38	5.57	0.6	-	-	0.35	-	-	-	-	0	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.73																																																																																				-			6.19	0.09	3.77	-	0.8	1.57	0.66	0.27	3.45	-	-	-	-	-	4.38	5.57	0.6	-	-	0.35	-	-	-	-	0	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.73
H3653_020_0	2007	2																					Unlimited											A	A	D		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin				Coin																																																								-		565.32	8.75	1633.29		8.5	17.13	8.69	9.75	48.33	37.16	43.46	0	0.32	63.83	88.8	220.12	11.96	9.86	0	19.52	53	13.74	0.02				0.31															995 per admit	995 per admit	95 per day		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance				20 Coinsurance															921.23	963.63	79.39		0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2				0.2															43.4	0.7	10.81	-	1.7	3.43	1.74	1.95	9.67	7.43	8.69	-	0.06	12.77	17.76	44.02	2.39	1.97	-	3.9	10.6	2.75	0	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	185.81		0	43.4	0.7	10.81	-	1.7	3.43	1.74	1.95	9.67	7.43	8.69	-	0.06	12.77	17.76	44.02	2.39	1.97	-	3.9	10.6	2.75	0	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	185.81																																																																																				-			43.4	0.7	10.81	-	1.7	3.43	1.74	1.95	9.67	7.43	8.69	-	0.06	12.77	17.76	44.02	2.39	1.97	-	3.9	10.6	2.75	0	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	185.81
H3653_803_0	2007	2																					Unlimited											A	A	D		T	Coin	Coin	V	V	V	V				V	V	V	V		V							V																																																								-		319.42	4.68	912.01		233.12	9.86	5.01	553.09	502.21	12525.44	1670.88				6791.54	8837.4	700.85	2608.38		23176.43							18.82															195 per day for days 1-15	195 per day for days 1-15	95 per day		150 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	175 per visit	2 per visit	5 or 50 per visit routine or advanced respectively.				15 per visit	35 per visit	35 per visit	35 per visit		35 per visit							35 per visit															871.12	908.74	140.7		150	0.2	0.2	7.18	175	2	17.71				12.14	16.04	21.84	23.79		0.38							29.59															23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24		0	23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24																																																																																				-			23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24
H3653_806_0	2007	3																					Unlimited											A	A	D		T	Coin	Coin	V	V	V	V				V	V	V	V		V							V																																																								-		249.85	3.87	721.84		181.34	7.57	3.84	434.23	394.88	9194.18	1228.92				5308.28	6879.98	546.83	2037.7		18336.92							15.04															195 per day for days 1-15	195 per day for days 1-15	95 per day		150 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	175 per visit	2 per visit	5 or 50 per visit routine or advanced respectively.				15 per visit	35 per visit	35 per visit	35 per visit		35 per visit							35 per visit															868.76	908.74	141.43		150	0.2	0.2	7.27	175	2	17.71				12.16	16.01	21.75	23.81		0.37							29.5															18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01			18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01																																																																																				-			18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01
H3653_807_0	2007	3																					Unlimited											A	A	D		T	Coin	Coin	V	V	V	V				V	V	V	V		V							V																																																								-		319.42	4.68	912.01		233.12	9.86	5.01	553.09	502.21	12525.44	1670.88				6791.54	8837.4	700.85	2608.38		23176.43							18.82															195 per day for days 1-15	195 per day for days 1-15	95 per day		150 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	175 per visit	2 per visit	5 or 50 per visit routine or advanced respectively.				15 per visit	35 per visit	35 per visit	35 per visit		35 per visit							35 per visit															871.12	908.74	140.7		150	0.2	0.2	7.18	175	2	17.71				12.14	16.04	21.84	23.79		0.38							29.59															23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24		0	23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24																																																																																				-			23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24
H3653_808_0	2007	3																					Unlimited											A	A	D		T	Coin	Coin	V	V	V	V				V	V	V	V		V							V																																																								-		249.85	3.87	721.84		181.34	7.57	3.84	434.23	394.88	9194.18	1228.92				5308.28	6879.98	546.83	2037.7		18336.92							15.04															195 per day for days 1-15	195 per day for days 1-15	95 per day		150 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	175 per visit	2 per visit	5 or 50 per visit routine or advanced respectively.				15 per visit	35 per visit	35 per visit	35 per visit		35 per visit							35 per visit															868.76	908.74	141.43		150	0.2	0.2	7.27	175	2	17.71				12.16	16.01	21.75	23.81		0.37							29.5															18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01			18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01																																																																																				-			18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01
H3653_809_0	2007	3																					Unlimited											A	A	D		T	Coin	Coin	V	V	V	V				V	V	V	V		V							V																																																								-		319.42	4.68	912.01		233.12	9.86	5.01	553.09	502.21	12525.44	1670.88				6791.54	8837.4	700.85	2608.38		23176.43							18.82															195 per day for days 1-15	195 per day for days 1-15	95 per day		150 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	175 per visit	2 per visit	5 or 50 per visit routine or advanced respectively.				15 per visit	35 per visit	35 per visit	35 per visit		35 per visit							35 per visit															871.12	908.74	140.7		150	0.2	0.2	7.18	175	2	17.71				12.14	16.04	21.84	23.79		0.38							29.59															23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24		0	23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24																																																																																				-			23.19	0.35	10.69	-	2.91	1.97	1	0.33	7.32	2.09	2.47	-	-	-	6.87	11.81	1.28	5.17	-	0.74	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.24
H3653_810_0	2007	3																					Unlimited											A	A	D		T	Coin	Coin	V	V	V	V				V	V	V	V		V							V																																																								-		249.85	3.87	721.84		181.34	7.57	3.84	434.23	394.88	9194.18	1228.92				5308.28	6879.98	546.83	2037.7		18336.92							15.04															195 per day for days 1-15	195 per day for days 1-15	95 per day		150 per trip	20 Coinsurance	20 Coinsurance	50 per visit if ER	175 per visit	2 per visit	5 or 50 per visit routine or advanced respectively.				15 per visit	35 per visit	35 per visit	35 per visit		35 per visit							35 per visit															868.76	908.74	141.43		150	0.2	0.2	7.27	175	2	17.71				12.16	16.01	21.75	23.81		0.37							29.5															18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01			18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01																																																																																				-			18.09	0.29	8.51	-	2.27	1.51	0.77	0.26	5.76	1.53	1.81	-	-	-	5.38	9.18	0.99	4.04	-	0.57	-	-	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01
H3655_013_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	390.5	7.28	584.88		316.21	12.31	4.15	354.83	452.76	927.75	1112.63	49.84	30.7	0.88	5807.39	1924.61	4.8	461.25			221.29				21.7		162					1061.82	21.45	82.78	393.18	116.37	0.04	873.97	2.48			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			404.71	456.86	68.24		68.24	0.18	0.18	45.5	159.23	46.46	54.22	159.23	31.5	22.75	9.1	22.75	22.75	22.75			27.5				22.75		22.75					22.75	45.5	22.75	22.75	9.1	0.18	22.75	22.75			13.17	0.28	3.33	-	1.8	2.24	0.75	1.35	6.01	3.59	5.03	0.66	0.08	0	4.4	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.83		5.23	13.17	0.28	3.33	-	1.8	2.24	0.75	1.35	6.01	3.59	5.03	0.66	0.08	0	4.4	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.83	2750																																																																																			-			13.17	0.28	3.33	-	1.8	2.24	0.75	1.35	6.01	3.59	5.03	0.66	0.08	0	4.4	3.65	0.01	0.87	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.01	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	52.83
H3655_023_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	2250.79	56.41	584.88		316.21	12.31	4.15	354.83	452.76	927.75	1112.63	49.84	30.7	0.88	5807.39	1924.61	4.8	461.25			221.29				21.7		162					1061.82	21.45	82.78	393.18	116.37	0.04	873.97	2.48			150/day with 1500 yearly max	150/day with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			88.26	89.93	68.55		68.55	0.18	0.18	45.7	137.1	46.67	54.47	137.1	31.64	22.85	9.14	22.85	22.85	22.85			27.63				22.85		22.85					22.85	45.7	22.85	22.85	9.14	0.18	22.85	22.85			16.55	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.66	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.58		5.23	16.55	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.66	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.58	2750																																																																																			-			16.55	0.42	3.34	-	1.81	2.25	0.76	1.35	5.17	3.61	5.05	0.57	0.08	0	4.42	3.66	0.01	0.88	-	-	0.51	-	-	-	0.04	-	0.31	-	-	-	-	2.02	0.08	0.16	0.75	0.09	0.01	1.66	0	-	-	55.58
H3655_801_0	2007	5	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	374.43	4.96	316.38		0.25	13.56	6.15	301.46	541.16	954.22	1240.43	42.78	10.66	0	6594.69	2237.52	2.76	736.73			252.53				31.11		162					1128.45	24.68	146.69	479.65	159.46	0.05	1014.18	3.16			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			406.58	423.83	68.36		68.36	0.18	0.18	45.57	159.51	46.75	55.15	159.51	31.9	22.79	9.11	22.79	22.79	22.79			34.36				22.79		22.79					22.79	45.57	22.79	22.79	9.11	0.18	22.79	22.79			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85		5.23	12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85	2750																																																																																			-			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85
H3655_803_0	2007	2	H.6	H.7	I.7	I.8	I.9	I.10	I.11	I.12			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	374.43	4.96	316.38		0.25	13.56	6.15	301.46	541.16	954.22	1240.43	42.78	10.66	0	6594.69	2237.52	2.76	736.73			252.53				31.11		162					1128.45	24.68	146.69	479.65	159.46	0.05	1014.18	3.16			600/admit with 1200 yearly max	600/admit with 1200 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			406.58	423.83	68.36		68.36	0.18	0.18	45.57	159.51	46.75	55.15	159.51	31.9	22.79	9.11	22.79	22.79	22.79			34.36				22.79		22.79					22.79	45.57	22.79	22.79	9.11	0.18	22.79	22.79			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85		5.23	12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85	2750																																																																																			-			12.69	0.18	1.8	-	0	2.47	1.12	1.14	7.19	3.72	5.7	0.57	0.03	0	5.01	4.25	0.01	1.4	-	-	0.72	-	-	-	0.06	-	0.31	-	-	-	-	2.14	0.09	0.28	0.91	0.12	0.01	1.93	0.01	-	-	53.85
H3659_001_0	2007	8																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1924.11	129.1	1251.83	0	190.85	12.85	5.26	391.3	38.7	8147.96	39.04	0	0.86	16.85	3614.24	3348.14	455.33	1.83	0	0	31.53	708.22	0	0	122.61	0	177.06	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											179.23	179.23	97.76	0	114.06	0.16	0.19	31.83	0.13	1.3	0.1	0	0.2	0.13	20	35	37.5	0.13	0	0	0.2	35	0	0	35	0	35	0	0	0	0											28.74	1.93	10.2	-	1.81	2.09	0.98	1.04	5.04	0.89	4.06	-	0.17	2.2	6.02	9.77	1.42	0.24	-	-	6.16	2.07	-	-	0.36	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.7		34.83	28.74	1.93	10.2	-	1.81	2.09	0.98	1.04	5.04	0.89	4.06	-	0.17	2.2	6.02	9.77	1.42	0.24	-	-	6.16	2.07	-	-	0.36	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.7	4650	300/375 (1a)	300/375 (1b)	170/225 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	38 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 38 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	38 (17a)	0 n/c (17b1-17b5)	38 (18a)	0 (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.73	0.18	1.01	0.84	0.4	0.55	0.26	0.23	1.66	0.78	1.32	0	0.04	0.72	1.89	2.33	0.35	0.08	0	0	1.35	0.49	0	0	0.09	0	0.12	0	0	0	0											17.42		5.99	31.46	2.11	11.2	0.84	2.21	2.64	1.24	1.27	6.7	1.66	5.38	-	0.2	2.92	7.92	12.09	1.78	0.32	-	-	7.52	2.56	-	-	0.44	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.12
H3659_003_0	2007	7																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2070.44	120.59	1792.68	0	235.11	14.06	4.56	497.13	25.96	9339.9	39.19	0	2.08	28.69	4413.3	4197.09	487.52	3.78	0	0	24.37	1030.72	0	0	46.74	0	208.91	0	0	0	0											280 (1a)	280 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											188.94	188.94	101.22	0	118.09	0.17	0.19	32.84	0.13	1.35	0.11	0	0.2	0.13	15	35	37.5	0.13	0	0	0.2	35	0	0	35	0	35	0	0	0	0											32.6	1.9	15.12	-	2.31	2.37	0.87	1.36	3.5	1.05	4.22	-	0.42	3.87	5.52	12.24	1.52	0.51	-	-	4.93	3.01	-	-	0.14	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.07		36.02	32.6	1.9	15.12	-	2.31	2.37	0.87	1.36	3.5	1.05	4.22	-	0.42	3.87	5.52	12.24	1.52	0.51	-	-	4.93	3.01	-	-	0.14	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.07																																																																																				-			32.6	1.9	15.12	-	2.31	2.37	0.87	1.36	3.5	1.05	4.22	-	0.42	3.87	5.52	12.24	1.52	0.51	-	-	4.93	3.01	-	-	0.14	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.07
H3659_031_0	2007	7																					2950											D	D	D	V	T	Coin	Coin	V	V	P	P	O	Coin	O	V	V	V	P	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1868.46	130.48	1245.43	0	173.56	14.48	5.31	590.81	357.17	9032.77	5151.48	0	1.7	671.46	4636.27	3836.31	533.34	731.85	0	0	29.34	852.06	0	0	98.46	0	217.62	0	0	0	0											200 (1a)	200 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	190 (9b)	25 (8a 8b)	25/100 (8a 8b)	150/100 (incl in h5)	30 (12)	50 (3 9d); 60 (5); 35/35 (9c); 150/100 (9a)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	35/35 (7e 7h)	50 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											105.23	105.23	52.62	0	92.08	0.16	0.2	25.39	99.97	5.26	43.93	0	0.16	77.91	15	35	35	26.31	0	0	0.16	35	0	0	35	0	35	0	0	0	0											16.39	1.14	5.46	-	1.33	2.29	1.06	1.25	2.98	3.96	18.86	-	0.27	4.36	5.8	11.19	1.56	1.6	-	-	4.63	2.49	-	-	0.29	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.53		58.63	16.39	1.14	5.46	-	1.33	2.29	1.06	1.25	2.98	3.96	18.86	-	0.27	4.36	5.8	11.19	1.56	1.6	-	-	4.63	2.49	-	-	0.29	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.53																																																																																				-			16.39	1.14	5.46	-	1.33	2.29	1.06	1.25	2.98	3.96	18.86	-	0.27	4.36	5.8	11.19	1.56	1.6	-	-	4.63	2.49	-	-	0.29	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.53
H3659_033_0	2007	8																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1939.08	130.1	1261.58	0	192.33	13.05	5.34	394.34	39.3	8211.37	39.65	0	0.87	17.12	3642.37	3374.2	458.88	1.85	0	0	32.02	713.73	0	0	123.56	0	178.44	0	0	0	0											280 (1a)	280 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											169.28	169.28	84.64	0	105.8	0.18	0.21	29.52	0.12	1.21	0.1	0	0.18	0.12	10	30	37.5	0.12	0	0	0.18	30	0	0	30	0	30	0	0	0	0											27.35	1.84	8.9	-	1.7	2.37	1.14	0.97	4.75	0.83	3.82	-	0.16	2.07	3.04	8.44	1.43	0.22	-	-	5.81	1.78	-	-	0.31	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.37		40.21	27.35	1.84	8.9	-	1.7	2.37	1.14	0.97	4.75	0.83	3.82	-	0.16	2.07	3.04	8.44	1.43	0.22	-	-	5.81	1.78	-	-	0.31	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.37	3900	295 (1a)	295 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	15 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.51	0.17	0.83	0.85	0.37	0.52	0.25	0.22	1.56	0.73	1.26	0	0.03	0.68	1.24	2.16	0.36	0.07	0	0	1.27	0.46	0	0	0.08	0	0.11	0	0	0	0											15.74		6.79	29.86	2	9.73	0.85	2.07	2.89	1.39	1.19	6.32	1.55	5.08	-	0.19	2.75	4.28	10.6	1.79	0.3	-	-	7.08	2.24	-	-	0.39	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.1
H3659_050_0	2007	7																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1924.11	129.1	1251.83	0	190.85	12.85	5.26	391.3	38.7	8147.96	39.04	0	0.86	16.85	3614.24	3348.14	455.33	1.83	0	0	31.53	708.22	0	0	122.61	0	177.06	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											170.77	170.77	93.15	0	108.67	0.16	0.18	30.32	0.12	3.73	0.1	0	0.19	0.12	20	35	37.5	0.12	0	0	0.19	35	0	0	35	0	35	0	0	0	0											27.38	1.84	9.72	-	1.73	1.99	0.95	0.99	4.81	2.53	3.87	-	0.16	2.09	6.02	9.77	1.42	0.23	-	-	5.87	2.07	-	-	0.36	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.3		38.94	27.38	1.84	9.72	-	1.73	1.99	0.95	0.99	4.81	2.53	3.87	-	0.16	2.09	6.02	9.77	1.42	0.23	-	-	5.87	2.07	-	-	0.36	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.3	4200	300/375 (1a)	300/375 (1b)	170/225 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	38 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 38 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	38 (17a)	0 n/c (17b1-17b5)	38 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.6	0.17	0.96	0.52	0.38	0.53	0.22	0.22	1.58	0.74	1.26	0	0.04	0.69	1.18	1.45	0.22	0.07	0	0	1.29	0.31	0	0	0.05	0	0.08	0	0	0	0											14.54		8.87	29.98	2.01	10.67	0.52	2.11	2.52	1.17	1.21	6.39	3.27	5.13	-	0.19	2.78	7.2	11.21	1.64	0.3	-	-	7.16	2.37	-	-	0.41	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.84
H3659_051_0	2007	5																					4200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2070.44	120.59	1792.68	0	235.11	14.06	4.56	497.13	25.96	9339.9	39.19	0	2.08	28.69	4413.3	4197.09	487.52	3.78	0	0	24.37	1030.72	0	0	46.74	0	208.91	0	0	0	0											280 (1a)	280 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											177.7	177.7	95.2	0	111.06	0.16	0.18	30.88	0.13	3.81	0.1	0	0.19	0.13	15	35	37.5	0.13	0	0	0.19	35	0	0	35	0	35	0	0	0	0											30.66	1.79	14.22	-	2.18	2.23	0.83	1.28	3.29	2.96	3.97	-	0.4	3.64	5.52	12.24	1.52	0.48	-	-	4.64	3.01	-	-	0.14	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.6		41.6	30.66	1.79	14.22	-	2.18	2.23	0.83	1.28	3.29	2.96	3.97	-	0.4	3.64	5.52	12.24	1.52	0.48	-	-	4.64	3.01	-	-	0.14	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.6																																																																																				-			30.66	1.79	14.22	-	2.18	2.23	0.83	1.28	3.29	2.96	3.97	-	0.4	3.64	5.52	12.24	1.52	0.48	-	-	4.64	3.01	-	-	0.14	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.6
H3659_054_0	2007	6																					2350											D	D	D	V	T	Coin	Coin	V	V	P	P	O	Coin	O	V	V	V	P	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1868.46	130.48	1245.43	0	173.56	14.48	5.31	590.81	357.17	9032.77	5151.48	0	1.7	671.46	4636.27	3836.31	533.34	731.85	0	0	29.34	852.06	0	0	98.46	0	217.62	0	0	0	0											200 (1a)	200 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	150 (9b)	25 (8a 8b)	25/100 (8a 8b)	150/100 (incl in h5)	30 (12)	50 (3 9d); 60 (5); 35/35 (9c); 150/100 (9a)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	35/35 (7e 7h)	50 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											94.65	94.65	47.32	0	82.82	0.14	0.19	22.83	70.99	4.73	39.51	0	0.14	70.07	15	35	35	23.66	0	0	0.14	35	0	0	35	0	35	0	0	0	0											14.74	1.03	4.91	-	1.2	2.06	1	1.12	2.11	3.56	16.96	-	0.24	3.92	5.8	11.19	1.56	1.44	-	-	4.16	2.49	-	-	0.29	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.41		64.55	14.74	1.03	4.91	-	1.2	2.06	1	1.12	2.11	3.56	16.96	-	0.24	3.92	5.8	11.19	1.56	1.44	-	-	4.16	2.49	-	-	0.29	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.41																																																																																				-			14.74	1.03	4.91	-	1.2	2.06	1	1.12	2.11	3.56	16.96	-	0.24	3.92	5.8	11.19	1.56	1.44	-	-	4.16	2.49	-	-	0.29	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.41
H3659_055_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1939.08	130.1	1261.58	0	192.33	13.05	5.34	394.34	39.3	8211.37	39.65	0	0.87	17.12	3642.37	3374.2	458.88	1.85	0	0	32.02	713.73	0	0	123.56	0	178.44	0	0	0	0											280 (1a)	280 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											158.7	158.7	79.35	0	99.19	0.17	0.21	27.68	0.11	3.4	0.09	0	0.17	0.11	10	30	37.5	0.11	0	0	0.17	30	0	0	30	0	30	0	0	0	0											25.64	1.72	8.34	-	1.59	2.22	1.1	0.91	4.45	2.33	3.58	-	0.15	1.94	3.04	8.44	1.43	0.21	-	-	5.44	1.78	-	-	0.31	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.07		45.24	25.64	1.72	8.34	-	1.59	2.22	1.1	0.91	4.45	2.33	3.58	-	0.15	1.94	3.04	8.44	1.43	0.21	-	-	5.44	1.78	-	-	0.31	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.07	3400	295 (1a)	295 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	15 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.35	0.16	0.78	0.48	0.35	0.49	0.2	0.2	1.47	0.68	1.18	0	0.03	0.64	0.71	1.22	0.2	0.07	0	0	1.2	0.26	0	0	0.04	0	0.06	0	0	0	0											12.77		9.76	27.99	1.88	9.12	0.48	1.94	2.71	1.3	1.11	5.92	3.01	4.76	-	0.18	2.58	3.74	9.66	1.64	0.28	-	-	6.64	2.04	-	-	0.35	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.84
H3659_056_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2290.07	362.36	1166.6		271.9	28.07	24.32	931.75	404	2119.62	994.43	68.83	3.43	2092.44		3611.34		548.2		840.58												298.27		160.57	238.87							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							6.76	1.07	1.65	-	0.8	2.65	2.3	1.32	0.4	0.83	0.39	0.07	0.32	2.06	-	1.42	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.87		25.55	6.76	1.07	1.65	-	0.8	2.65	2.3	1.32	0.4	0.83	0.39	0.07	0.32	2.06	-	1.42	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.87																																																																																				-		0	6.76	1.07	1.65	-	0.8	2.65	2.3	1.32	0.4	0.83	0.39	0.07	0.32	2.06	-	1.42	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.87
H3659_057_0	2007	3	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2599.23	242.03	8964.01	175.08	657.08	22.51	7.06	188.97	125.46	3903.38	173.53	34.31	4.49	291.76	127.91	1309.32	1700.86	20.09		273.39	263.15	1336.89	1200		140.2	166		54.6				111.43	0.28	0.07	300	295.2						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						128	128			64	17	17	43	21			21		21		9				9		9										30		21								27.7	2.58	-	-	3.5	3.84	1.2	0.67	0.22	-	-	0.06	-	0.52	-	0.93	-	-	-	0.19	-	0.95	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	42.65		7.37	27.7	2.58	-	-	3.5	3.84	1.2	0.67	0.22	-	-	0.06	-	0.52	-	0.93	-	-	-	0.19	-	0.95	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	42.65																																																																																				-		0	27.7	2.58	-	-	3.5	3.84	1.2	0.67	0.22	-	-	0.06	-	0.52	-	0.93	-	-	-	0.19	-	0.95	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	42.65
H3659_058_0	2007	3	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2461.34	229.19	8488.47	165.79	622.22	20.18	6.33	178.94	118.81	3696.3	164.33	32.49	4.25	276.28	121.12	1239.86	1610.63	19.03		258.88	249.19	1265.97	1200		140.2	166		54.6				105.52	0.27	0.07	300	295.2						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						130	130			65	17	17	43	22			22		22		9				9		9										30		22								26.59	2.48	-	-	3.36	3.49	1.09	0.64	0.21	-	-	0.06	-	0.5	-	0.89	-	-	-	0.19	-	0.91	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	40.69		6.38	26.59	2.48	-	-	3.36	3.49	1.09	0.64	0.21	-	-	0.06	-	0.5	-	0.89	-	-	-	0.19	-	0.91	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	40.69																																																																																				-		0	26.59	2.48	-	-	3.36	3.49	1.09	0.64	0.21	-	-	0.06	-	0.5	-	0.89	-	-	-	0.19	-	0.91	-	-	-	-	-	-	-	-	-	0.27	-	0	-	-	-	-	-	-	-	40.69
H3659_801_0	2007	4																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1679.96	127.78	1041.79	0	168.38	11.84	7.57	365.39	53.96	10756.24	55.34	0	0.46	21.73	4321.51	4510.07	525.97	3.89	0	0	49.49	1209.28	0	0	192.96	0	219.79	0	0	0	0											350 (1a)	350 (1b)	175 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 40 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											223.97	223.97	111.98	0	111.98	0.16	0.18	31.03	0.16	3.84	0.13	0	0.19	0.16	35	40	37.5	0.16	0	0	0.19	40	0	0	40	0	40	0	0	0	0											31.35	2.38	9.72	-	1.57	1.89	1.4	0.94	8.63	3.44	6.95	-	0.09	3.47	12.6	15.03	1.64	0.62	-	-	9.5	4.03	-	-	0.64	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.67		45.84	31.35	2.38	9.72	-	1.57	1.89	1.4	0.94	8.63	3.44	6.95	-	0.09	3.47	12.6	15.03	1.64	0.62	-	-	9.5	4.03	-	-	0.64	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.67																																																																																				-			31.35	2.38	9.72	-	1.57	1.89	1.4	0.94	8.63	3.44	6.95	-	0.09	3.47	12.6	15.03	1.64	0.62	-	-	9.5	4.03	-	-	0.64	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.67
H3659_802_0	2007	2																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1679.96	127.78	1041.79	0	168.38	11.84	7.57	365.39	53.96	10756.24	55.34	0	0.46	21.73	4321.51	4510.07	525.97	3.89	0	0	49.49	1209.28	0	0	192.96	0	219.79	0	0	0	0											350 (1a)	350 (1b)	175 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 40 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											223.97	223.97	111.98	0	111.98	0.16	0.18	31.03	0.16	3.84	0.13	0	0.19	0.16	35	40	37.5	0.16	0	0	0.19	40	0	0	40	0	40	0	0	0	0											31.35	2.38	9.72	-	1.57	1.89	1.4	0.94	8.63	3.44	6.95	-	0.09	3.47	12.6	15.03	1.64	0.62	-	-	9.5	4.03	-	-	0.64	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.67		45.84	31.35	2.38	9.72	-	1.57	1.89	1.4	0.94	8.63	3.44	6.95	-	0.09	3.47	12.6	15.03	1.64	0.62	-	-	9.5	4.03	-	-	0.64	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.67																																																																																				-			31.35	2.38	9.72	-	1.57	1.89	1.4	0.94	8.63	3.44	6.95	-	0.09	3.47	12.6	15.03	1.64	0.62	-	-	9.5	4.03	-	-	0.64	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.67
H3660_028_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P	T	P	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1584.56	58.31	150.68	0	163.45	16.91	1.17	293.43	464.09	0	1469.71	0	0	945.55	0	3579.96	177.96	546.19	0	309.57	0	0	0	0	644.56	0	45.73	0	0	0	0											1A IP Acute: 100 per day (days 1-10) 1B IP Psych: 100 per day (days 1-10)	0	2 SNF: 75 per day for days 11-100 only	0	10A Ambulance: 75	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 20	4A ER: 50 4B Urgent Care: 35	9A OP Hospital: 0-150 9B ASC Services: 0-150	0	8A OP C/D/T: 0-50 8B OP X-Ray: 0-100	0	0	3 CORF: 25 5 Partial Hosp: 25 Part B Rx: 50	7A PCP: 0 14B through 14I Diabetes Monitoring: 0	7B Chiropractic: 25 7D Physician Specialist: 25 7F Podiatry: 25	7E Mental Health: 25 7H Psychiatric: 25 9C OP Substance Abuse: 25	7C Occupational Therapy: 25 7I Physical and Speech Therapy: 25	0	7G Other Health Care: 25 17A Medicare Covered Vision Exams: 25 18A Medicare Covered Hearing Exams: 25	included in h.5.	0	0	0	17A Routine Eye Exams: 25	0	18A Routine Hearing Exams: 25	0	0	14A Health Education/Wellness Programs: 0	0											84.1	0	75	0	75	0.2	0.2	50	150	0	57.39	0	0	36.45	0	25.04	25	25	0	25	0	0	0	0	25	0	25	0	0	0	0											11.11	-	0.94	-	1.02	3.32	0.23	1.22	5.8	-	7.03	-	-	2.87	-	7.47	0.37	1.14	-	0.64	-	-	-	-	1.34	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.61	0	2.1	11.11	-	0.94	-	1.02	3.32	0.23	1.22	5.8	-	7.03	-	-	2.87	-	7.47	0.37	1.14	-	0.64	-	-	-	-	1.34	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.61	0	20 coinsurance	20 coinsurance	75 copay	20 coinsurance	75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	0	20 coinsurance	0	0	Combination of 20 coinsurance and 40 copay	15 copay	40 copay	40 copay	40 copay	0	40 copay	0	0	0	0	40 copay	0	40 copay	0	0	0	0											6.31	0.06	0.49	0.24	0.11	0.55	0.04	0.14	0.77	0	0.78	0	0	0.36	0.65	1.33	0.07	0.21	0	0.11	0	0	0	0	0.24	0	0.02	0	0	0	0											12.47	0	0	17.42	0.06	1.43	0.24	1.14	3.88	0.27	1.36	6.57	-	7.81	-	-	3.23	0.65	8.79	0.44	1.34	-	0.76	-	-	-	-	1.58	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.08
H3660_029_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P	T	P	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1207.02	0	114.78	0	82.82	12.88	0.89	218.16	205.9	0	1026.31	0	0	759.06	0	2811.83	144.87	444.08	0	234	0	0	0	0	490.99	0	34.83	0	0	0	0											1A IP Acute: 175 per day (days 1-10) 1B IP Psych: 175 per day (days 1-10)	0	2 SNF: 100 per day for days 11-100 only	0	10A Ambulance: 75	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 20	4A ER: 50 4B Urgent Care: 35	9A OP Hospital: 0-250 9B ASC Services: 0-150	0	8A OP C/D/T: 0-50 8B OP X-Ray: 0-100	0	0	3 CORF: 30 5 Partial Hosp: 30 Part B Rx: 50	7A PCP: 0 14B through 14I Diabetes Monitoring: 0	7B Chiropractic: 30 7D Physician Specialist: 30 7F Podiatry: 30	7E Mental Health: 30 7H Psychiatric: 30 9C OP Substance Abuse: 30	7C Occupational Therapy: 30 7I Physical and Speech Therapy: 30	0	7G Other Health Care: 30 17A Medicare Covered Vision Exams: 30 18A Medicare Covered Hearing Exams: 30	included in h.5.	0	0	0	17A Routine Eye Exams: 30	0	18A Routine Hearing Exams: 30	0	0	14A Health Education/Wellness Programs: 0	0											167.61	0	100	0	75	0.2	0.2	50	250	0	57.63	0	0	39.88	0	30.02	30	30	0	30	0	0	0	0	30	0	30	0	0	0	0											16.86	-	0.96	-	0.52	2.55	0.18	0.91	4.29	-	4.93	-	-	2.52	-	7.03	0.36	1.11	-	0.59	-	-	-	-	1.23	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.12	0	0.74	16.86	-	0.96	-	0.52	2.55	0.18	0.91	4.29	-	4.93	-	-	2.52	-	7.03	0.36	1.11	-	0.59	-	-	-	-	1.23	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.12	0	30 coinurance	30 coinurance	100 copay	20 coinurance	75 copay	30 coinurance	30 coinurance	50 copay	30 coinurance	30 coinurance	30 coinurance	0	0	Combination of 30 coinsurance and 45 copay	15 copay	45 copay	45 copay	45 copay	0	45 copay	0	0	0	0	45 copay	0	45 copay	0	0	0	0											7.21	0.06	0.5	0.18	0.06	0.43	0.03	0.1	0.88	0.4	0.89	0	0	0.35	0.5	1.17	0.06	0.19	0	0.1	0	0	0	0	0.2	0	0.01	0	0	0	0											13.32	0	0	24.07	0.06	1.45	0.18	0.58	2.98	0.21	1.01	5.17	0.4	5.82	-	-	2.88	0.5	8.2	0.42	1.3	-	0.68	-	-	-	-	1.43	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.44
H3660_801_0	2007	3																					0											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	Coin	P	P	P	P	P	P	S	P	T	P	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1603.63	0	152.49	0	110.04	17.11	1.18	289.84	273.55	0	1363.54	0	0	21.29	4568.7	3735.76	192.47	590.01	0	310.89	0	0	0	0	652.32	0	46.28	0	0	0	0											1A IP Acute: 175 per day (days 1-10) 1B IP Psych: 175 per day (days 1-10)	0	2 SNF: 100 per day for days 11-100 only	0	10A Ambulance: 75	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 20	4A ER: 50 4B Urgent Care: 35	9A OP Hospital: 0-250 9B ASC Services: 0-250	0	8A OP C/D/T: 0-50 8B OP X-Ray: 0-100	0	0	3 CORF: 30 5 Partial Hosp: 30 Part B Rx: 50	7A PCP: 20 14B through 14I Diabetes Monitoring: 0	7B Chiropractic: 40 7D Physician Specialist: 40 7F Podiatry: 40	7E Mental Health: 40 7H Psychiatric: 40 9C OP Substance Abuse: 40	7C Occupational Therapy: 40 7I Physical and Speech Therapy: 40	0	7G Other Health Care: 40 17A Medicare Covered Vision Exams: 40 18A Medicare Covered Hearing Exams: 40	included in h.5.	0	0	0	17A Routine Eye Exams: 40	0	18A Routine Hearing Exams: 40	0	0	14A Health Education/Wellness Programs: 0	0											175	0	100	0	75	0.2	0.2	50	250	0	57.63	0	0	0.16	20	39.98	40	40	0	40	0	0	0	0	40	0	40	0	0	0	0											23.39	-	1.27	-	0.69	3.39	0.24	1.21	5.7	-	6.55	-	-	3.35	7.62	12.45	0.64	1.97	-	1.04	-	-	-	-	2.17	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82	0	0	23.39	-	1.27	-	0.69	3.39	0.24	1.21	5.7	-	6.55	-	-	3.35	7.62	12.45	0.64	1.97	-	1.04	-	-	-	-	2.17	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	23.39	-	1.27	-	0.69	3.39	0.24	1.21	5.7	-	6.55	-	-	3.35	7.62	12.45	0.64	1.97	-	1.04	-	-	-	-	2.17	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82
H3660_802_0	2007	2																					0											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	Coin	P	P	P	P	P	P	S	P	T	P	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1603.63	0	152.49	0	110.04	17.11	1.18	289.84	273.55	0	1363.54	0	0	21.29	4568.7	3735.76	192.47	590.01	0	310.89	0	0	0	0	652.32	0	46.28	0	0	0	0											1A IP Acute: 175 per day (days 1-10) 1B IP Psych: 175 per day (days 1-10)	0	2 SNF: 100 per day for days 11-100 only	0	10A Ambulance: 75	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 20	4A ER: 50 4B Urgent Care: 35	9A OP Hospital: 0-250 9B ASC Services: 0-250	0	8A OP C/D/T: 0-50 8B OP X-Ray: 0-100	0	0	3 CORF: 30 5 Partial Hosp: 30 Part B Rx: 50	7A PCP: 20 14B through 14I Diabetes Monitoring: 0	7B Chiropractic: 40 7D Physician Specialist: 40 7F Podiatry: 40	7E Mental Health: 40 7H Psychiatric: 40 9C OP Substance Abuse: 40	7C Occupational Therapy: 40 7I Physical and Speech Therapy: 40	0	7G Other Health Care: 40 17A Medicare Covered Vision Exams: 40 18A Medicare Covered Hearing Exams: 40	included in h.5.	0	0	0	17A Routine Eye Exams: 40	0	18A Routine Hearing Exams: 40	0	0	14A Health Education/Wellness Programs: 0	0											175	0	100	0	75	0.2	0.2	50	250	0	57.63	0	0	0.16	20	39.98	40	40	0	40	0	0	0	0	40	0	40	0	0	0	0											23.39	-	1.27	-	0.69	3.39	0.24	1.21	5.7	-	6.55	-	-	3.35	7.62	12.45	0.64	1.97	-	1.04	-	-	-	-	2.17	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82	0	0	23.39	-	1.27	-	0.69	3.39	0.24	1.21	5.7	-	6.55	-	-	3.35	7.62	12.45	0.64	1.97	-	1.04	-	-	-	-	2.17	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	23.39	-	1.27	-	0.69	3.39	0.24	1.21	5.7	-	6.55	-	-	3.35	7.62	12.45	0.64	1.97	-	1.04	-	-	-	-	2.17	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.82
H3660_805_0	2007	2																					0											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P	T	P	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1443.27	0	137.24	0	99.03	15.4	1.06	260.86	246.2	0	1227.19	0	0	907.64	4111.83	3362.18	173.22	531	0	279.8	0	0	0	0	587.09	0	41.65	0	0	0	0											1A IP Acute: 175 per day (days 1-10) 1B IP Psych: 175 per day (days 1-10)	0	2 SNF: 100 per day for days 11-100 only	0	10A Ambulance: 75	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 20	4A ER: 50 4B Urgent Care: 35	9A OP Hospital: 0-250 9B ASC Services: 0-250	0	8A OP C/D/T: 0-50 8B OP X-Ray: 0-100	0	0	3 CORF: 40 5 Partial Hosp: 40 Part B Rx: 50	7A PCP: 20 14B through 14I Diabetes Monitoring: 20	7B Chiropractic: 40 7D Physician Specialist: 40 7F Podiatry: 40	7E Mental Health: 40 7H Psychiatric: 40 9C OP Substance Abuse: 40	7C Occupational Therapy: 40 7I Physical and Speech Therapy: 40	0	7G Other Health Care: 40 17A Medicare Covered Vision Exams: 40 18A Medicare Covered Hearing Exams: 40	included in h.5.	0	0	0	17A Routine Eye Exams: 40	0	18A Routine Hearing Exams: 40	0	0	14A Health Education/Wellness Programs: 0	0											175	0	100	0	75	0.2	0.2	50	250	0	57.63	0	0	39.88	20	39.98	40	40	0	40	0	0	0	0	40	0	40	0	0	0	0											21.05	-	1.14	-	0.62	3.05	0.21	1.09	5.13	-	5.89	-	-	3.02	6.85	11.2	0.58	1.77	-	0.93	-	-	-	-	1.96	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.63	0	0	21.05	-	1.14	-	0.62	3.05	0.21	1.09	5.13	-	5.89	-	-	3.02	6.85	11.2	0.58	1.77	-	0.93	-	-	-	-	1.96	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.63	0	20 coinurance	20 coinurance	100 copay	20 coinurance	75 copay	30 coinurance	30 coinurance	50 copay	20 coinurance	20 coinurance	20 coinurance	0	0	Combination of 20 coinsurance and 45 copay	35 copay	55 copay	55 copay	55 copay	0	55 copay	0	0	0	0	55 copay	0	55 copay	0	0	0	0											5.75	0.05	0.59	0.22	0.07	0.51	0.04	0.12	0.7	0.32	0.71	0	0	0.35	1.39	1.71	0.09	0.28	0	0.14	0	0	0	0	0.3	0	0.02	0	0	0	0											13.35	0	0	26.79	0.05	1.74	0.22	0.69	3.56	0.25	1.21	5.83	0.32	6.6	-	-	3.36	8.24	12.91	0.67	2.05	-	1.08	-	-	-	-	2.26	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.98
H3660_806_0	2007	3																					0											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P	T	P	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1443.27	0	137.24	0	99.03	15.4	1.06	260.86	246.2	0	1227.19	0	0	907.64	4111.83	3362.18	173.22	531	0	279.8	0	0	0	0	587.09	0	41.65	0	0	0	0											1A IP Acute: 175 per day (days 1-10) 1B IP Psych: 175 per day (days 1-10)	0	2 SNF: 100 per day for days 11-100 only	0	10A Ambulance: 75	11A DME: 20	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 20	4A ER: 50 4B Urgent Care: 35	9A OP Hospital: 0-250 9B ASC Services: 0-250	0	8A OP C/D/T: 0-50 8B OP X-Ray: 0-100	0	0	3 CORF: 40 5 Partial Hosp: 40 Part B Rx: 50	7A PCP: 20 14B through 14I Diabetes Monitoring: 20	7B Chiropractic: 40 7D Physician Specialist: 40 7F Podiatry: 40	7E Mental Health: 40 7H Psychiatric: 40 9C OP Substance Abuse: 40	7C Occupational Therapy: 40 7I Physical and Speech Therapy: 40	0	7G Other Health Care: 40 17A Medicare Covered Vision Exams: 40 18A Medicare Covered Hearing Exams: 40	included in h.5.	0	0	0	17A Routine Eye Exams: 40	0	18A Routine Hearing Exams: 40	0	0	14A Health Education/Wellness Programs: 0	0											175	0	100	0	75	0.2	0.2	50	250	0	57.63	0	0	39.88	20	39.98	40	40	0	40	0	0	0	0	40	0	40	0	0	0	0											21.05	-	1.14	-	0.62	3.05	0.21	1.09	5.13	-	5.89	-	-	3.02	6.85	11.2	0.58	1.77	-	0.93	-	-	-	-	1.96	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.63	0	0	21.05	-	1.14	-	0.62	3.05	0.21	1.09	5.13	-	5.89	-	-	3.02	6.85	11.2	0.58	1.77	-	0.93	-	-	-	-	1.96	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.63	0	20 coinurance	20 coinurance	100 copay	20 coinurance	75 copay	30 coinurance	30 coinurance	50 copay	20 coinurance	20 coinurance	20 coinurance	0	0	Combination of 20 coinsurance and 45 copay	35 copay	55 copay	55 copay	55 copay	0	55 copay	0	0	0	0	55 copay	0	55 copay	0	0	0	0											5.75	0.05	0.59	0.22	0.07	0.51	0.04	0.12	0.7	0.32	0.71	0	0	0.35	1.39	1.71	0.09	0.28	0	0.14	0	0	0	0	0.3	0	0.02	0	0	0	0											13.35	0	0	26.79	0.05	1.74	0.22	0.69	3.56	0.25	1.21	5.83	0.32	6.6	-	-	3.36	8.24	12.91	0.67	2.05	-	1.08	-	-	-	-	2.26	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.98
H3664_001_0	2007	5																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		1230.8	25.9	464.5	0	244.6	8.03	5.79	319.7	155.9	0	0	0	0	505.2	3259	5845	124.1	269.3	0	1079.8	0	0	0	0	49.7	0	2.7	0	0	0	0											100/day for days 1-5	100/day for days 1-5	20/day for days 16-30		75 Copay	15 Coinsurance	15 Coinsurance	50 ER/Urgent Care Copay	175 Copay					25 CORF/PT/ST/OT	15 PCP Copay	25 Specialist Copay	25 Copay	25 Copay		25 Copay		25 Copay			25 Copay		25 Copay															100	100	20	0	75	0.15	0.15	50	175	0	0	0	0	25	15	25	25	25	0	25	0	25	0	0	25	0	25	0	0	0	0											10.26	0.22	0.77	-	1.53	1.21	0.87	1.33	2.27	-	-	-	-	1.05	4.07	12.18	0.26	0.56	-	2.25	-	-	-	-	0.1	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.94			10.26	0.22	0.77	-	1.53	1.21	0.87	1.33	2.27	-	-	-	-	1.05	4.07	12.18	0.26	0.56	-	2.25	-	-	-	-	0.1	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.94																																																																																				-			10.26	0.22	0.77	-	1.53	1.21	0.87	1.33	2.27	-	-	-	-	1.05	4.07	12.18	0.26	0.56	-	2.25	-	-	-	-	0.1	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.94
H3664_008_0	2007	5																																D	D	D		T	coin	coin	V	V					V	V	V	V	V		V		O			V		V																																																								-		1373.2	28.9	518.2		273	8.96	6.46	356.7	174					563.6	3636.1	6521.4	138.5	300.4		1204.7		0			55.4		3															100/day for days 1-5	100/day for days 1-5	20/day for days 16-30		75 Copay	15 Coinsurance	15 Coinsurance	50 ER/Urgent Care Copay	175 Copay					25 CORF/PT/ST/OT	15 PCP Copay	25 Specialist Copay	25 Copay	25 Copay		25 Copay		25 Copay			25 Copay		25 Copay															100	100	20		75	0.15	0.15	50	175					25	15	25	25	25		25		25			25		25															11.44	0.24	0.86	-	1.71	1.34	0.97	1.49	2.54	-	-	-	-	1.17	4.55	13.59	0.29	0.63	-	2.51	-	-	-	-	0.12	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.44			11.44	0.24	0.86	-	1.71	1.34	0.97	1.49	2.54	-	-	-	-	1.17	4.55	13.59	0.29	0.63	-	2.51	-	-	-	-	0.12	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.44																																																																																				-			11.44	0.24	0.86	-	1.71	1.34	0.97	1.49	2.54	-	-	-	-	1.17	4.55	13.59	0.29	0.63	-	2.51	-	-	-	-	0.12	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.44
H3664_009_0	2007	6																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		761.3	17.7	222.8	0	116	3.9	4.68	232.2	138.1	0	0	0	0	508.7	2678.5	5311.3	125.4	151	0	1072.7	0	0	0	0	48.9	0	1.7	0	0	0	0											150/day for days 1-5	150/day for days 1-5	30/day for days 16-30		125 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	250 Copay					35 CORF/PT/ST/OT	20 PCP Copay	35 Specialist Copay	35 Copay	35 Copay		35 Copay		35 Copay			35 Copay		35 Copay															150	150	30	0	125	0.2	0.2	50	250	0	0	0	0	35	20	35	35	35	0	35	0	35	0	0	35	0	35	0	0	0	0											9.52	0.22	0.56	-	1.21	0.78	0.93	0.97	2.88	-	-	-	-	1.48	4.46	15.49	0.37	0.44	-	3.13	-	-	-	-	0.14	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.58			9.52	0.22	0.56	-	1.21	0.78	0.93	0.97	2.88	-	-	-	-	1.48	4.46	15.49	0.37	0.44	-	3.13	-	-	-	-	0.14	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.58																																																																																				-			9.52	0.22	0.56	-	1.21	0.78	0.93	0.97	2.88	-	-	-	-	1.48	4.46	15.49	0.37	0.44	-	3.13	-	-	-	-	0.14	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.58
H3664_011_0	2007	7																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		827.7	19.2	242.2	0	126.2	4.24	5.09	252.5	150.2	0	0	0	0	553	2936.7	5823.4	137.4	165.6	0	1176.1	0	0	0	0	53.1	0	1.9	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 CORF/PT/ST/OT	15 PCP Copay	30 Specialist Copay	30 Copay	30 Copay		30 Copay		30 Copay			30 Copay		30 Copay															120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	30	0	30	0	0	0	0											8.28	0.19	0.5	-	0.79	0.85	1.01	1.05	2.19	-	-	-	-	1.38	3.67	14.56	0.34	0.41	-	2.94	-	-	-	-	0.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.31			8.28	0.19	0.5	-	0.79	0.85	1.01	1.05	2.19	-	-	-	-	1.38	3.67	14.56	0.34	0.41	-	2.94	-	-	-	-	0.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.31																																																																																				-			8.28	0.19	0.5	-	0.79	0.85	1.01	1.05	2.19	-	-	-	-	1.38	3.67	14.56	0.34	0.41	-	2.94	-	-	-	-	0.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.31
H3664_012_0	2007	6																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		1135.3	24.4	1331.2	0	217.5	7.1	5.66	308.8	155.8	3382.8	1717.2	0	0	520	3173.9	5762.6	125.6	240.7	1736.1	2064.34	0	0	0	0	39.3	0	1.9	0	0	0	0											100/day for days 1-5	100/day for days 1-5	20/day for days 16-30; 75/day days 31-100		75 Copay	15 Coinsurance	15 Coinsurance	50 ER/Urgent Care Copay	175 Copay	20 Copay	20 Copay			30 CORF/PT/ST/OT	20 PCP Copay	30 Specialist Copay	30 Copay	30 Copay	20 Copay	30 Copay Specialists; 35 Hearing/Speech; 20 Lab		35 Copay			35 Copay		35 Copay															100	100	37.66	0	75	0.15	0.15	50	175	20	20	0	0	30	20	30	30	30	20	25.42	0	35	0	0	35	0	35	0	0	0	0											9.46	0.2	4.18	-	1.36	1.06	0.85	1.29	2.27	5.64	2.86	-	-	1.3	5.29	14.41	0.31	0.6	2.89	4.37	-	-	-	-	0.11	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.47			9.46	0.2	4.18	-	1.36	1.06	0.85	1.29	2.27	5.64	2.86	-	-	1.3	5.29	14.41	0.31	0.6	2.89	4.37	-	-	-	-	0.11	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.47																																																																																				-			9.46	0.2	4.18	-	1.36	1.06	0.85	1.29	2.27	5.64	2.86	-	-	1.3	5.29	14.41	0.31	0.6	2.89	4.37	-	-	-	-	0.11	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.47
H3664_013_0	2007	6																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		1525.4	32.7	1788.7	0	292.3	9.54	7.6	415	209.3	4545.4	2307.3	0	0	698.7	4264.6	7743	168.8	323.4	2332.7	2773.7	0	0	0	0	52.7	0	2.6	0	0	0	0											100/day for days 1-5	100/day for days 1-5	20/day for days 16-30; 75/day for days 31-100		75 Copay	15 Coinsurance	15 Coinsurance	50 ER/Urgent Care Copay	175 Copay	20 Copay	20 Copay			30 CORF/PT/ST/OT	20 PCP Copay	30 Specialist Copay	30 Copay	30 Copay	20 Copay	30 Copay Specialists; 35 Hearing/Speech; 20 Lab		35 Copay			35 Copay		35 Copay															100	100	37.66	0	75	0.15	0.15	50	175	20	20	0	0	30	20	30	30	30	20	25.42	0	35	0	0	35	0	35	0	0	0	0											12.71	0.27	5.61	-	1.83	1.43	1.14	1.73	3.05	7.58	3.85	-	-	1.75	7.11	19.36	0.42	0.81	3.89	5.88	-	-	-	-	0.15	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.56			12.71	0.27	5.61	-	1.83	1.43	1.14	1.73	3.05	7.58	3.85	-	-	1.75	7.11	19.36	0.42	0.81	3.89	5.88	-	-	-	-	0.15	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.56																																																																																				-			12.71	0.27	5.61	-	1.83	1.43	1.14	1.73	3.05	7.58	3.85	-	-	1.75	7.11	19.36	0.42	0.81	3.89	5.88	-	-	-	-	0.15	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.56
H3664_014_0	2007	6																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		788.2	18.3	230.6	0	120.1	4.04	4.85	240.5	143	0	0	0	0	526.7	2796.9	5546.1	130.9	157.7	0	1120.1	0	0	0	0	50.6	0	1.8	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 CORF/PT/ST/OT	15 PCP Copay	30 Specialist Copay	30 Copay	30 Copay		30 Copay		30 Copay			30 Copay		30 Copay															120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	30	0	30	0	0	0	0											7.88	0.18	0.48	-	0.75	0.81	0.97	1	2.09	-	-	-	-	1.32	3.5	13.87	0.33	0.39	-	2.8	-	-	-	-	0.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.49			7.88	0.18	0.48	-	0.75	0.81	0.97	1	2.09	-	-	-	-	1.32	3.5	13.87	0.33	0.39	-	2.8	-	-	-	-	0.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.49																																																																																				-			7.88	0.18	0.48	-	0.75	0.81	0.97	1	2.09	-	-	-	-	1.32	3.5	13.87	0.33	0.39	-	2.8	-	-	-	-	0.13	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.49
H3664_801_0	2007	4																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		346.8	4.8	217.6	0	122.9	6.17	5.04	195.4	128.4	0	0	0	0	501.4	2831.2	6369.3	90.3	180.4	0	727.2	0	0	0	0	0	0	0	0	0	0	0											150/day for days 1-5	150/day for days 1-5	30/day for days 16-30		125 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	250 Copay					35 CORF/PT/ST/OT	20 PCP Copay	35 Copay	35 Copay	35 Copay		35 Copay		35 Copay			35 Copay		35 Copay															150	150	30	0	125	0.2	0.2	50	250	0	0	0	0	35	20	35	35	35	0	35	0	35	0	0	35	0	35	0	0	0	0											4.34	0.06	0.54	-	1.28	1.23	1	0.81	2.68	-	-	-	-	1.46	4.72	18.58	0.26	0.53	-	2.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.61			4.34	0.06	0.54	-	1.28	1.23	1	0.81	2.68	-	-	-	-	1.46	4.72	18.58	0.26	0.53	-	2.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.61																																																																																				-			4.34	0.06	0.54	-	1.28	1.23	1	0.81	2.68	-	-	-	-	1.46	4.72	18.58	0.26	0.53	-	2.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.61
H3664_802_0	2007	4																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		407.1	5.6	255.4	0	144.3	7.25	5.92	229.4	150.8	0	0	0	0	588.6	3323.9	7477.7	106	211.8	0	853.8	0	0	0	0	0	0	0	0	0	0	0											150/day for days 1-5	150/day for days 1-5	30/day for days 16-30		125 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	250 Copay					35 CORF/PT/ST/OT	20 PCP Copay	35 Specialist Copay	35 Copay	35 Copay		35 Copay		35 Copay			35 Copay		35 Copay															150	150	30	0	125	0.2	0.2	50	250	0	0	0	0	35	20	35	35	35	0	35	0	35	0	0	35	0	35	0	0	0	0											5.09	0.07	0.64	-	1.5	1.45	1.18	0.96	3.14	-	-	-	-	1.72	5.54	21.81	0.31	0.62	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51			5.09	0.07	0.64	-	1.5	1.45	1.18	0.96	3.14	-	-	-	-	1.72	5.54	21.81	0.31	0.62	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51																																																																																				-			5.09	0.07	0.64	-	1.5	1.45	1.18	0.96	3.14	-	-	-	-	1.72	5.54	21.81	0.31	0.62	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51
H3664_803_0	2007	4																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		346.8	4.8	217.6	0	122.9	6.17	5.04	195.4	128.4	0	0	0	0	501.4	2831.2	6369.3	90.3	180.4	0	727.2	0	0	0	0	0	0	0	0	0	0	0											150/day for days 1-5	150/day for days 1-5	30/day for days 16-30		125 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	250 Copay					35 CORF/PT/ST/OT	20 PCP Copay	35 Copay	35 Copay	35 Copay		35 Copay		35 Copay			35 Copay		35 Copay															150	150	30	0	125	0.2	0.2	50	250	0	0	0	0	35	20	35	35	35	0	35	0	35	0	0	35	0	35	0	0	0	0											4.34	0.06	0.54	-	1.28	1.23	1	0.81	2.68	-	-	-	-	1.46	4.72	18.58	0.26	0.53	-	2.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.61			4.34	0.06	0.54	-	1.28	1.23	1	0.81	2.68	-	-	-	-	1.46	4.72	18.58	0.26	0.53	-	2.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.61																																																																																				-			4.34	0.06	0.54	-	1.28	1.23	1	0.81	2.68	-	-	-	-	1.46	4.72	18.58	0.26	0.53	-	2.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.61
H3664_804_0	2007	4																																D	D	D	V	T	coin	coin	V	V	V	V	V	V	V	V	V	V	V	P	V	S	O	T	P	V	V	V	V	O	O	O																																																				-		407.1	5.6	255.4	0	144.3	7.25	5.92	229.4	150.8	0	0	0	0	588.6	3323.9	7477.7	106	211.8	0	853.8	0	0	0	0	0	0	0	0	0	0	0											150/day for days 1-5	150/day for days 1-5	30/day for days 16-30		125 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	250 Copay					35 CORF/PT/ST/OT	20 PCP Copay	35 Specialist Copay	35 Copay	35 Copay		35 Copay		35 Copay			35 Copay		35 Copay															150	150	30	0	125	0.2	0.2	50	250	0	0	0	0	35	20	35	35	35	0	35	0	35	0	0	35	0	35	0	0	0	0											5.09	0.07	0.64	-	1.5	1.45	1.18	0.96	3.14	-	-	-	-	1.72	5.54	21.81	0.31	0.62	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51			5.09	0.07	0.64	-	1.5	1.45	1.18	0.96	3.14	-	-	-	-	1.72	5.54	21.81	0.31	0.62	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51																																																																																				-			5.09	0.07	0.64	-	1.5	1.45	1.18	0.96	3.14	-	-	-	-	1.72	5.54	21.81	0.31	0.62	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.51
H3668_005_0	2007	4																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	52.39	0	181.35	4.39	2.7	387.21	527.08	2350.65	1509.3	0	0.28	292.52	4013.6	3385.03	182.47	428.43	1551.95	3216.88	30.69	623.52	0	0	328.35	0	153.13	0	0	0	0											PBP: 1A IP Acute: 0 per admit	1B IP Psych: 0 per admit	2 SNF: 200 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 25	9B ASC Services: 15	8A OP C/D/T: 15	8B OP X-Ray: 15	9C OP Hospital: 0	12 Renal Dialysis: 15	3 CORF: 15 5 Partial Hosp: 15 9C OP Substance Abuse: 15 9D Cardiac Rehab: 15	7A PCP: 15 14B Immunizations: 0-15 14C Routine Physical Exams: 15 14D Pap Smears: 15 14D Pelvic Exams: 15 14E Prostate Screening: 15 14F Colorectal Screening: 15-25 14G Bone Mass Measurement: 15-25 14H Mammography: 15-25 14I Diabetes Monitoring: 15-25	7D Physician Specialist: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 15	7B Chiropractic: 25 7F Podiatry: 25 7G Other Health Care: 15-25 18A Medicare Covered Hearing Exams: 25	15 Part B Drugs: 10	13A Blood: 0 16B Comprehensive Dental Services: 25 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 25	17B Eye Wear: Not Covered	18A Routine Hearing Exams: 25	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0	0	200	0	50	0.2	0.2	43.77	15	15	15	0	15	15	15	25	25	15	15	18.66	0.1	25	0	0	25	0	25	0	0	0	0											-	-	0.87	-	0.76	0.88	0.55	1.41	0.66	2.94	1.89	-	0	0.37	5.02	7.05	0.38	0.54	1.94	5	3.07	1.3	-	-	0.68	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.61			-	-	0.87	-	0.76	0.88	0.55	1.41	0.66	2.94	1.89	-	0	0.37	5.02	7.05	0.38	0.54	1.94	5	3.07	1.3	-	-	0.68	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.61																																																																																				-			-	-	0.87	-	0.76	0.88	0.55	1.41	0.66	2.94	1.89	-	0	0.37	5.02	7.05	0.38	0.54	1.94	5	3.07	1.3	-	-	0.68	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.61
H3668_010_0	2007	4																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	60.31	0	229.62	4.04	2.46	356.18	459	2099.77	1331.13	0	0.24	251.22	4293.93	3625.32	192.8	463.05	1665.13	3660.53	27.22	665.17	0	0	339.49	0	161.29	0	0	0	0											PBP: 1A IP Acute: 0 per admit	1B IP Psych: 0 per admit	2 SNF: 200 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 25	9B ASC Services: 15	8A OP C/D/T: 15	8B OP X-Ray: 15	9C OP Hospital: 0	12 Renal Dialysis: 15	3 CORF: 15 5 Partial Hosp: 15 9C OP Substance Abuse: 15 9D Cardiac Rehab: 15	7A PCP: 15 14B Immunizations: 0-15 14C Routine Physical Exams: 15 14D Pap Smears: 15 14D Pelvic Exams: 15 14E Prostate Screening: 15 14F Colorectal Screening: 15-25 14G Bone Mass Measurement: 15-25 14H Mammography: 15-25 14I Diabetes Monitoring: 15-25	7D Physician Specialist: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	8B OP X-Ray: 15	7B Chiropractic: 25 7F Podiatry: 25 7G Other Health Care: 15-25 18A Medicare Covered Hearing Exams: 25	15 Part B Drugs: 10	13A Blood: 0 16B Comprehensive Dental Services: 25 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 25	17B Eye Wear: Not Covered	18A Routine Hearing Exams: 25	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0	0	200	0	50	0.2	0.2	42.75	15	15	15	0	15	15	15	25	25	15	15	18.67	0.1	25	0	0	25	0	25	0	0	0	0											-	-	1.01	-	0.96	0.81	0.48	1.27	0.57	2.62	1.66	-	0	0.31	5.37	7.55	0.4	0.58	2.08	5.7	2.72	1.39	-	-	0.71	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.53			-	-	1.01	-	0.96	0.81	0.48	1.27	0.57	2.62	1.66	-	0	0.31	5.37	7.55	0.4	0.58	2.08	5.7	2.72	1.39	-	-	0.71	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.53																																																																																				-			-	-	1.01	-	0.96	0.81	0.48	1.27	0.57	2.62	1.66	-	0	0.31	5.37	7.55	0.4	0.58	2.08	5.7	2.72	1.39	-	-	0.71	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.53
H3668_011_0	2007	5																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		281.77	3.89	52.39	0	181.35	4.39	2.7	386.34	527.08	2350.65	1509.3	134.9	0.28	292.52	3976.54	3358.45	182.47	408.8	1525.39	3181.41	30.69	623.52	0	0	328.35	0	153.13	0	0	0	0											PBP: 1A IP Acute: 750 per admit	1B IP Psych: 750 per admit	2 SNF: 500 per admit	6 Home Health: 0	10A Ambulance: 100	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 25	9B ASC Services: 200	8A OP C/D/T: 15-30	8B OP X-Ray: 15-30	9C OP Hospital: 30	12 Renal Dialysis: 30	3 CORF: 30 5 Partial Hosp: 30 9C OP Substance Abuse: 30 9D Cardiac Rehab: 30	7A PCP: 15 14B Immunizations: 15 14C Routine Physical Exams: 15 14D Pap Smears: 15 14D Pelvic Exams: 15 14E Prostate Screening: 15 14F Colorectal Screening: 15-30 14G Bone Mass Measurement: 15-30 14H Mammography: 15-30 14I Diabetes Monitoring: 15-30	7D Physician Specialist: 30	7E Mental Health: 30 7H Psychiatric: 30	7C Occupational Therapy: 30 7I Physical and Speech Therapy: 30	8B OP X-Ray: 15-30	7B Chiropractic: 30 7F Podiatry: 30 7G Other Health Care: 15-30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 30 17A Medicare Covered Eye Exams: 30	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 30	17B Eye Wear: Not Covered	18A Routine Hearing Exams: 30	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											750	750	500	0	100	0.2	0.2	45.05	200	25	25	30	30	30	15.11	30	30	30	25	26.85	0.2	30	0	0	30	0	30	0	0	0	0											17.61	0.24	2.18	-	1.51	0.88	0.55	1.45	8.78	4.9	3.14	0.34	0	0.73	5.01	8.4	0.46	1.02	3.18	7.12	6.14	1.56	-	-	0.82	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.4			17.61	0.24	2.18	-	1.51	0.88	0.55	1.45	8.78	4.9	3.14	0.34	0	0.73	5.01	8.4	0.46	1.02	3.18	7.12	6.14	1.56	-	-	0.82	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.4																																																																																				-			17.61	0.24	2.18	-	1.51	0.88	0.55	1.45	8.78	4.9	3.14	0.34	0	0.73	5.01	8.4	0.46	1.02	3.18	7.12	6.14	1.56	-	-	0.82	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.4
H3668_012_0	2007	5																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		300.34	4.33	60.31	0	229.62	4.04	2.46	355.06	459	2099.77	1331.13	134.9	0.24	251.22	4246.4	3591.22	192.8	438.55	1632.38	3614.85	27.22	665.17	0	0	339.49	0	161.29	0	0	0	0											PBP: 1A IP Acute: 750 per admit	1B IP Psych: 750 per admit	2 SNF: 500 per admit	6 Home Health: 0	10A Ambulance: 100	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 25	9B ASC Services: 200	8A OP C/D/T: 15-30	8B OP X-Ray: 15-30	9C OP Hospital: 30	12 Renal Dialysis: 30	3 CORF: 30 5 Partial Hosp: 30 9C OP Substance Abuse: 30 9D Cardiac Rehab: 30	7A PCP: 15 14B Immunizations: 15 14C Routine Physical Exams: 15 14D Pap Smears: 15 14D Pelvic Exams: 15 14E Prostate Screening: 15 14F Colorectal Screening: 15-30 14G Bone Mass Measurement: 15-30 14H Mammography: 15-30 14I Diabetes Monitoring: 15-30	7D Physician Specialist: 30	7E Mental Health: 30 7H Psychiatric: 30	7C Occupational Therapy: 30 7I Physical and Speech Therapy: 30	8B OP X-Ray: 15-30	7B Chiropractic: 30 7F Podiatry: 30 7G Other Health Care: 15-30 18A Medicare Covered Hearing Exams: 30	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 30 17A Medicare Covered Eye Exams: 30	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 30	17B Eye Wear: Not Covered	18A Routine Hearing Exams: 30	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											750	750	500	0	100	0.2	0.2	44.24	200	25	25	30	30	30	15.11	30	30	30	25	26.86	0.2	30	0	0	30	0	30	0	0	0	0											18.77	0.27	2.51	-	1.91	0.81	0.48	1.31	7.65	4.37	2.77	0.34	0	0.63	5.35	8.98	0.48	1.1	3.4	8.09	5.44	1.66	-	-	0.85	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.59			18.77	0.27	2.51	-	1.91	0.81	0.48	1.31	7.65	4.37	2.77	0.34	0	0.63	5.35	8.98	0.48	1.1	3.4	8.09	5.44	1.66	-	-	0.85	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.59																																																																																				-			18.77	0.27	2.51	-	1.91	0.81	0.48	1.31	7.65	4.37	2.77	0.34	0	0.63	5.35	8.98	0.48	1.1	3.4	8.09	5.44	1.66	-	-	0.85	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.59
H3668_801_0	2007	2																																Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		255	2.09	16.66	0	5.39	4.41	2.72	14.74	43.39	7.91	39.36	26.25	0.04	11.59	43.55	111.38	1.6	3.5	20.57	34.73	30.93	7.63	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	9C OP Hospital:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 5 Partial Hosp:  138 Ded and 20 Coinsurance 9C OP Substance Abuse:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 5 14B Immunizations: 0 14D Pap Smears:  138 Ded and 20 Coinsurance 14D Pelvic Exams:  138 Ded and 20 Coinsurance 14E Prostate Screening:  138 Ded and 20 Coinsurance 14F Colorectal Screening:  138 Ded and 20 Coinsurance 14G Bone Mass Measurement:  138 Ded and 20 Coinsurance 14H Mammography:  138 Ded and 20 Coinsurance 14I Diabetes Monitoring:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 0 16B Comprehensive Dental Services:  138 Ded and 20 Coinsurance 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0.07	0.07	0.18	0	0.24	0.24	0.24	0.11	0.24	0.24	0.24	0.24	0.24	0.24	0.22	0.22	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.53	0.15	2.99	-	1.27	1.04	0.64	1.57	10.24	1.87	9.29	6.19	0.01	2.73	9.37	24.3	0.38	0.83	4.85	8.2	7.3	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.56			18.53	0.15	2.99	-	1.27	1.04	0.64	1.57	10.24	1.87	9.29	6.19	0.01	2.73	9.37	24.3	0.38	0.83	4.85	8.2	7.3	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.56																																																																																				-			18.53	0.15	2.99	-	1.27	1.04	0.64	1.57	10.24	1.87	9.29	6.19	0.01	2.73	9.37	24.3	0.38	0.83	4.85	8.2	7.3	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.56
H3668_802_0	2007	3																																Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		255	2.09	16.66	0	5.39	4.41	2.72	14.74	43.39	7.91	39.36	26.25	0.04	11.59	43.55	111.38	1.6	3.5	20.57	34.73	30.93	7.63	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	9C OP Hospital:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 5 Partial Hosp:  138 Ded and 20 Coinsurance 9C OP Substance Abuse:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 5 14B Immunizations: 0 14D Pap Smears:  138 Ded and 20 Coinsurance 14D Pelvic Exams:  138 Ded and 20 Coinsurance 14E Prostate Screening:  138 Ded and 20 Coinsurance 14F Colorectal Screening:  138 Ded and 20 Coinsurance 14G Bone Mass Measurement:  138 Ded and 20 Coinsurance 14H Mammography:  138 Ded and 20 Coinsurance 14I Diabetes Monitoring:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 0 16B Comprehensive Dental Services:  138 Ded and 20 Coinsurance 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0.07	0.07	0.18	0	0.24	0.24	0.24	0.11	0.24	0.24	0.24	0.24	0.24	0.24	0.22	0.22	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.53	0.15	2.99	-	1.27	1.04	0.64	1.57	10.24	1.87	9.29	6.19	0.01	2.73	9.37	24.3	0.38	0.83	4.85	8.2	7.3	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.56			18.53	0.15	2.99	-	1.27	1.04	0.64	1.57	10.24	1.87	9.29	6.19	0.01	2.73	9.37	24.3	0.38	0.83	4.85	8.2	7.3	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.56																																																																																				-			18.53	0.15	2.99	-	1.27	1.04	0.64	1.57	10.24	1.87	9.29	6.19	0.01	2.73	9.37	24.3	0.38	0.83	4.85	8.2	7.3	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.56
H3672_013_0	2007	5																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1769.1	57.9	1847.6	453.4	314.4	10.79	0	425.3	447.7	8446.8	1108.8	670.6	374.5	3006.2	4714.2	3436.8	153.3	170.5	139	0	14.62	0	0	0	222.6	184.1	0.3	0	0	0	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	100	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.43	45.43	0	0	0	20	20	50	100	0	6.05	0	0	7.8	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											6.7	0.22	-	-	-	2.16	-	1.77	3.73	-	0.56	-	-	1.96	5.89	7.16	0.32	0.36	-	-	2.92	-	-	-	0.28	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.25			6.7	0.22	-	-	-	2.16	-	1.77	3.73	-	0.56	-	-	1.96	5.89	7.16	0.32	0.36	-	-	2.92	-	-	-	0.28	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.25	N/A																																																																																			-			6.7	0.22	-	-	-	2.16	-	1.77	3.73	-	0.56	-	-	1.96	5.89	7.16	0.32	0.36	-	-	2.92	-	-	-	0.28	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.25
H3672_014_0	2007	2																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1519.7	58.8	1090.2	423.3	239.1	12.08	0	379.1	453.9	7200.1	1065.6	735.5	309.8	2279.3	4215.9	3173.7	121.5	129.4	130.4	0	4.72	0	0	0	233	192.7	0.5	0	0	0	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	0	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.43	45.43	0	0	0	20	20	50	100	0	3.18	0	0	8.83	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											5.75	0.22	-	-	-	2.42	-	1.58	3.78	-	0.28	-	-	1.68	5.27	6.61	0.25	0.27	-	-	0.94	-	-	-	0.29	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.6			5.75	0.22	-	-	-	2.42	-	1.58	3.78	-	0.28	-	-	1.68	5.27	6.61	0.25	0.27	-	-	0.94	-	-	-	0.29	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.6	N/A																																																																																			-			5.75	0.22	-	-	-	2.42	-	1.58	3.78	-	0.28	-	-	1.68	5.27	6.61	0.25	0.27	-	-	0.94	-	-	-	0.29	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.6
H3672_804_0	2007	2																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1244.6	9.2	599.3	322.4	112.3	9.08	0	266.2	434.4	6672	1029.7	710.3	837.3	1800.5	3815.9	3406.6	58	112.3	143.7	0	19.05	0	0	0	206.9	171.1	0	0	0	0	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	0	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.43	45.43	0	0	0	20	20	50	100	0	8.83	0	0	9.41	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											4.71	0.03	-	-	-	1.82	-	1.11	3.62	-	0.76	-	-	1.41	4.77	7.1	0.12	0.23	-	-	3.81	-	-	-	0.26	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.97			4.71	0.03	-	-	-	1.82	-	1.11	3.62	-	0.76	-	-	1.41	4.77	7.1	0.12	0.23	-	-	3.81	-	-	-	0.26	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.97	N/A																																																																																			-			4.71	0.03	-	-	-	1.82	-	1.11	3.62	-	0.76	-	-	1.41	4.77	7.1	0.12	0.23	-	-	3.81	-	-	-	0.26	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.97
H3672_805_0	2007	2																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1244.6	9.2	599.3	322.4	112.3	9.08	0	266.2	434.4	6672	1029.7	710.3	837.3	1800.5	3815.9	3406.6	58	112.3	143.7	0	19.05	0	0	0	206.9	171.1	0	0	0	0	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	0	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.43	45.43	0	0	0	20	20	50	100	0	8.83	0	0	9.41	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											4.71	0.03	-	-	-	1.82	-	1.11	3.62	-	0.76	-	-	1.41	4.77	7.1	0.12	0.23	-	-	3.81	-	-	-	0.26	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.97			4.71	0.03	-	-	-	1.82	-	1.11	3.62	-	0.76	-	-	1.41	4.77	7.1	0.12	0.23	-	-	3.81	-	-	-	0.26	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.97	N/A																																																																																			-			4.71	0.03	-	-	-	1.82	-	1.11	3.62	-	0.76	-	-	1.41	4.77	7.1	0.12	0.23	-	-	3.81	-	-	-	0.26	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.97
H3706_001_0	2007	4																																A	A	D	V	T	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	V	V	Coin	V	Coin	V																																																													-		673.9	10.3	465.6	0	202	13.01	8.09	358.2	258.7	0	20.9	0	0.3	494.7	0	3427.9	145.6	1160.6	23.35	1080.5	5.81	588																				150/day for days 1-3	150/day for days 1-3	copay for days 21-100		50/ER visit	20 coinsurance	20 prosthetics 0 supplies	50 ER 0/50 urgent care	250/surgery		20 rad therapy/specialized		20 coinsurance	25/visit cardio PT/OT/ST		25/visit	25/visit	25/visit	20 rad therapy/specialized	25/visit chiro pod hearing	20 coinsurance	25/visit vision exams																				150	150	105	0	50	0.2	0.03	35.66	250	0	0.09	0	0.2	25	0	25	25	25	0.09	25	0.2	25																				8.42	0.13	4.07	-	0.84	2.6	0.22	1.06	5.39	-	1.84	-	0.06	1.03	-	7.14	0.3	2.42	2.05	2.25	1.16	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.22			8.42	0.13	4.07	-	0.84	2.6	0.22	1.06	5.39	-	1.84	-	0.06	1.03	-	7.14	0.3	2.42	2.05	2.25	1.16	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.22																																																																																				-			8.42	0.13	4.07	-	0.84	2.6	0.22	1.06	5.39	-	1.84	-	0.06	1.03	-	7.14	0.3	2.42	2.05	2.25	1.16	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.22
H3706_006_0	2007	4																																A	A	D	V	T	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	V	V	Coin	V	Coin	V																																																													-		840.2	14.2	452.5	0	214.7	14.33	8.92	303.5	210.4	0	23.04	0	0.32	406.1	3938.8	3522.9	146.4	1250.3	19.97	1079.8	6.54	604.8																				125/day for days 1-5	125/day for days 1-5	copay for days 21-100		50/ER visit	20 coinsurance	20 prosthetics 0 supplies	50 ER 15/50 urgent care	200/surgery		20 rad therapy/specialized		20 coinsurance	25/visit cardio & PT/OT/ST	15/visit	25/visit	25/visit	15 PCP 25 specialist	20 rad therapy/specialized	25/visit chiro pod hearing	20 coinsurance	25/visit vision exams																				125	125	105	0	50	0.2	0.03	39.01	200	0	0.09	0	0.2	25	15	25	25	24.32	0.09	25	0.2	25																				8.75	0.15	3.96	-	0.89	2.87	0.24	0.99	3.51	-	2.03	-	0.06	0.85	4.92	7.34	0.31	2.53	1.76	2.25	1.31	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.98			8.75	0.15	3.96	-	0.89	2.87	0.24	0.99	3.51	-	2.03	-	0.06	0.85	4.92	7.34	0.31	2.53	1.76	2.25	1.31	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.98																																																																																				-			8.75	0.15	3.96	-	0.89	2.87	0.24	0.99	3.51	-	2.03	-	0.06	0.85	4.92	7.34	0.31	2.53	1.76	2.25	1.31	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.98
H3706_007_0	2007	4																																A	A	D	V	T	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	V	V	Coin	V	Coin	V	V	V	V	V	V	V	Coin	V	V																																																				-		702.8	11	475	0	206.6	13.35	8.28	362.2	262.2	0	21.18	0	0.3	499.6	0	3634	156.6	1254.1	24.47	1195.9	5.85	625.1	0	0	0	0	0	0	19.68	0	0											150/day for days 1-3	150/day for days 1-3	copay for days 21-100		50/ER visit	20 coinsurance	20 prosthetics 0 supplies	50 ER 0/50 urgent care	250/surgery		20 rad therapy/specialized		20 coinsurance	10/visit cardio PT/OT/ST		10/visit	10/visit	10/visit	20 rad therapy/specialized	10/visit chiro pod hearing	20 coinsurance	10/visit vision exams							100 Ded. 20 conisurance													150	150	105	0	50	0.2	0.03	35.72	250	0	0.09	0	0.2	10	0	10	10	10	0.09	10	0.2	10	0	0	0	0	0	0	0.21	0	0											8.79	0.14	4.16	-	0.86	2.67	0.22	1.08	5.46	-	1.86	-	0.06	0.42	-	3.03	0.13	1.05	2.15	1	1.17	0.52	-	-	-	-	-	-	4.05	-	-	-	-	-	-	-	-	-	-	-	-	38.79			8.79	0.14	4.16	-	0.86	2.67	0.22	1.08	5.46	-	1.86	-	0.06	0.42	-	3.03	0.13	1.05	2.15	1	1.17	0.52	-	-	-	-	-	-	4.05	-	-	-	-	-	-	-	-	-	-	-	-	38.79																																																																																				-			8.79	0.14	4.16	-	0.86	2.67	0.22	1.08	5.46	-	1.86	-	0.06	0.42	-	3.03	0.13	1.05	2.15	1	1.17	0.52	-	-	-	-	-	-	4.05	-	-	-	-	-	-	-	-	-	-	-	-	38.79
H3706_008_0	2007	4																																A	A	D	V	T	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	V	V	Coin	V	Coin	V	V	V	V	V	V	V	Coin	V	V																																																				-		840.2	14.2	452.5	0	214.7	14.33	8.92	303.5	210.4	0	23.04	0	0.32	406.1	3938.8	3522.9	146.4	1250.3	19.97	1079.8	6.54	604.8	0	0	0	0	0	0	59.04	0	0											125/day for days 1-5	125/day for days 1-5	copay for days 21-100		50/ER visit	20 coinsurance	20 prosthetics 0 supplies	50 ER 15/50 urgent care	200/surgery		20 rad therapy/specialized		20 coinsurance	25/visit cardio and PT/OT/ST	15/visit	25/visit	25/visit	15 PCP 25 specialist	20 rad therapy/specialized	25/visit chiro pod hearing	20 coinsurance	25/visit vision exams							100 Ded. 20 conisurance													125	125	105	0	50	0.2	0.03	39.01	200	0	0.09	0	0.2	25	15	25	25	24.32	0.09	25	0.2	25	0	0	0	0	0	0	0.21	0	0											8.75	0.15	3.96	-	0.89	2.87	0.24	0.99	3.51	-	2.03	-	0.06	0.85	4.92	7.34	0.31	2.53	1.76	2.25	1.31	1.26	-	-	-	-	-	-	12.53	-	-	-	-	-	-	-	-	-	-	-	-	58.51			8.75	0.15	3.96	-	0.89	2.87	0.24	0.99	3.51	-	2.03	-	0.06	0.85	4.92	7.34	0.31	2.53	1.76	2.25	1.31	1.26	-	-	-	-	-	-	12.53	-	-	-	-	-	-	-	-	-	-	-	-	58.51																																																																																				-			8.75	0.15	3.96	-	0.89	2.87	0.24	0.99	3.51	-	2.03	-	0.06	0.85	4.92	7.34	0.31	2.53	1.76	2.25	1.31	1.26	-	-	-	-	-	-	12.53	-	-	-	-	-	-	-	-	-	-	-	-	58.51
H3706_803_0	2007	2																																A	A	D	V	T	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	V	V	Coin	V	Coin	V																																																													-		1093.2	20.8	459.3	0	202	13.05	7.93	307.1	238.4	0	18.14	0	0.24	441.8	2985.6	2865.5	127.5	1122.3	21.56	1105.4	4.9	478																				100/day for days 1-5	100/day for days 1-5	copay for days 21-100		50/ER visit	20 coinsurance	20 prosthetics 0 supplies	50 ER 25/50 urgent care	150/surgery		20 rad therapy/specialized		20 coinsurance	25/visit cardio & PT/OT/ST	25/visit	25/visit	25/visit	25/visit	20 rad therapy/specialized	25/visit chiro pod hearing	20 coinsurance	25/visit vision exams																				100	100	105	0	50	0.2	0.02	44.08	150	0	0.09	0	0.2	25	25	25	25	25	0.09	25	0.2	25																				9.11	0.17	4.02	-	0.84	2.61	0.18	1.13	2.98	-	1.6	-	0.05	0.92	6.22	5.97	0.27	2.34	1.89	2.3	0.98	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57			9.11	0.17	4.02	-	0.84	2.61	0.18	1.13	2.98	-	1.6	-	0.05	0.92	6.22	5.97	0.27	2.34	1.89	2.3	0.98	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57																																																																																				-			9.11	0.17	4.02	-	0.84	2.61	0.18	1.13	2.98	-	1.6	-	0.05	0.92	6.22	5.97	0.27	2.34	1.89	2.3	0.98	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57
H3706_804_0	2007	2																																A	A	D	V	T	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	V	V	Coin	V	Coin	V																																																													-		1093.2	20.8	459.3	0	202	13.05	7.93	307.1	238.4	0	18.14	0	0.24	441.8	2985.6	2865.5	127.5	1122.3	21.56	1105.4	4.9	478																				100/day for days 1-5	100/day for days 1-5	copay for days 21-100		50/ER visit	20 coinsurance	20 prosthetics 0 supplies	50 ER 25/50 urgent care	150/surgery		20 rad therapy/specialized		20 coinsurance	25/visit cardio & PT/OT/ST	25/visit	25/visit	25/visit	25/visit	20 rad therapy/specialized	25/visit chiro pod hearing	20 coinsurance	25/visit vision exams																				100	100	105	0	50	0.2	0.02	44.08	150	0	0.09	0	0.2	25	25	25	25	25	0.09	25	0.2	25																				9.11	0.17	4.02	-	0.84	2.61	0.18	1.13	2.98	-	1.6	-	0.05	0.92	6.22	5.97	0.27	2.34	1.89	2.3	0.98	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57			9.11	0.17	4.02	-	0.84	2.61	0.18	1.13	2.98	-	1.6	-	0.05	0.92	6.22	5.97	0.27	2.34	1.89	2.3	0.98	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57																																																																																				-			9.11	0.17	4.02	-	0.84	2.61	0.18	1.13	2.98	-	1.6	-	0.05	0.92	6.22	5.97	0.27	2.34	1.89	2.3	0.98	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57
H3708_001_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	Coin																																																				-		442.64	31.03	367.12		28.28	7.69	10.87	23	14.39	42.38	6.26	1.92	6.54	120.15	7.01	23.9	59.57	0.46	26.11	199.78	43.73	0.08																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				34.58	2.42	68.94	-	6.67	1.82	2.57	5.43	3.4	10	1.48	0.45	1.54	28.36	1.65	5.64	14.06	0.11	6.16	47.15	10.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	252.76		0	34.58	2.42	68.94	-	6.67	1.82	2.57	5.43	3.4	10	1.48	0.45	1.54	28.36	1.65	5.64	14.06	0.11	6.16	47.15	10.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	252.76																																																																																				-		0	34.58	2.42	68.94	-	6.67	1.82	2.57	5.43	3.4	10	1.48	0.45	1.54	28.36	1.65	5.64	14.06	0.11	6.16	47.15	10.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	252.76
H3709_001_0	2007	2																					2500											D	D	D		T	Coin	Coin	P	P		V		P	Coin			V	Coin		Coin	Coin	V																																																													-	2500	1111.8	19.6	3457.6		269.3	19.57	0.48	248.1	462.5		128.9		9	16.04			179.2	1.44		157.23	7.02	14.6																				100 / day up to 5 days.	200 / day up to 5 days.	100/day for days 21 to 100.		100 copay	20 coinsurance	20 coinsurance	50 copay for ER and 20 copay for Urgent Care	150 copay for Amb. Surg. Svcs and 20 coinsurance for Cardiac Rehabilitation Services and 40 copay for Outpatient Substance Abuse Svcs		100 copay for CT MRI PET and nuclear medicine studies. 0 copay for all other lab plus 0 for Hospital Based physician costs		35 copay	20 coinsurance and 0 for medical/surgical supplies			40 copay	20 coinsurance		20 copay for Office Visits and 20 coinsurance for other services	20 coinsurance	20 copay for Vision Exams and 0 Coinsurance for OP Blood																				67.89	181.59	21.46		95.47	0.19	0.16	37.01	140.23		79.17		35	0.11			40	0.2		0.09	0.19	20																				6.29	0.3	6.18	-	2.14	3.65	0.08	0.77	5.4	-	0.85	-	0.03	1.78	-	-	0.6	0.29	-	14.18	1.31	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.86	0	6.03	6.29	0.3	6.18	-	2.14	3.65	0.08	0.77	5.4	-	0.85	-	0.03	1.78	-	-	0.6	0.29	-	14.18	1.31	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.86		30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	50 copay for ER and 20 copay for Urgent Care	30 coinsurance	30 coinsurance plus 30 for Hospital Based physician costs			30 coinsurance	30 coinsurance			30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance																				1.88	0.02	0.34	0.21	0.06	0.18	0.01	0.03	0.2	0.05			0	0.14			0.01	0.01	0.14	1.29	0.05	0.09																				4.71	500	4.34	8.17	0.32	6.52	0.21	2.2	3.83	0.09	0.8	5.6	0.05	0.85	-	0.03	1.92	-	-	0.61	0.3	0.14	15.47	1.36	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57
H3709_003_0	2007	2																					2500											D	D	D		T	Coin	Coin	P	P		V		P	Coin			V	Coin		Coin	Coin	V																																																													-	2500	1111.8	19.6	3457.6		269.3	19.57	0.48	248.1	462.5		128.9		9	16.04			179.2	1.44		157.23	7.02	14.6																				100 / day up to 5 days.	200 / day up to 5 days.	100/day for days 21 to 100.		100 copay	20 coinsurance	20 coinsurance	50 copay for ER and 20 copay for Urgent Care	150 copay for Amb. Surg. Svcs and 20 coinsurance for Cardiac Rehabilitation Services and 40 copay for Outpatient Substance Abuse Svcs		100 copay for CT MRI PET and nuclear medicine studies. 0 copay for all other lab plus 0 for Hospital Based physician costs		35 copay	20 coinsurance and 0 for medical/surgical supplies			40 copay	20 coinsurance		20 copay for Office Visits and 20 coinsurance for other services	20 coinsurance	20 copay for Vision Exams and 0 Coinsurance for OP Blood																				67.89	181.59	21.46		95.47	0.19	0.16	37.01	140.23		79.17		35	0.11			40	0.2		0.09	0.19	20																				6.29	0.3	6.18	-	2.14	3.65	0.08	0.77	5.4	-	0.85	-	0.03	1.78	-	-	0.6	0.29	-	14.18	1.31	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.86	0	6.03	6.29	0.3	6.18	-	2.14	3.65	0.08	0.77	5.4	-	0.85	-	0.03	1.78	-	-	0.6	0.29	-	14.18	1.31	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.86		30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	50 copay for ER and 20 copay for Urgent Care	30 coinsurance	30 coinsurance plus 30 for Hospital Based physician costs			30 coinsurance	30 coinsurance			30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance																				1.88	0.02	0.34	0.21	0.06	0.18	0.01	0.03	0.2	0.05			0	0.14			0.01	0.01	0.14	1.29	0.05	0.09																				4.71	500	4.34	8.17	0.32	6.52	0.21	2.2	3.83	0.09	0.8	5.6	0.05	0.85	-	0.03	1.92	-	-	0.61	0.3	0.14	15.47	1.36	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57
H3709_801_0	2007	2																					2500											D	D	D		T	Coin	Coin	P	P		V		P	Coin			V	Coin		Coin	Coin	V																																																													-		1111.8	19.6	3457.6		269.3	19.57	0.48	248.1	462.5		128.9		9	16.04			179.2	1.44		157.23	7.02	14.6																				100 / day up to 5 days.	200 / day up to 5 days.	200/day for days 21 to 100.		200 copay	20 coinsurance	20 coinsurance	50 copay for ER and 20 copay for Urgent Care	250 copay for Amb. Surg. Svcs and 20 coinsurance for Cardiac Rehabilitation Services and 40 copay for Outpatient Substance Abuse Svcs		150 copay for CT MRI PET and nuclear medicine studies. 0 copay for all other lab plus 0 for Hospital Based physician costs		35 copay	20 coinsurance and 0 for medical/surgical supplies			40 copay	20 coinsurance		40 copay for Office Visits and 20 coinsurance for other services	20 coinsurance	40 copay for Vision Exams and 0 Coinsurance for OP Blood																				67.89	181.59	21.46		190.94	0.19	0.16	37.01	224.37		98.96		35	0.11			40	0.2		0.14	0.19	40																				6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58	0	6.03	6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58		30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	50 copay for ER and 20 copay for Urgent Care	30 coinsurance	30 coinsurance plus 30 for Hospital Based physician costs			30 coinsurance	30 coinsurance			30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance																				1.88	0.02	0.34	0.21	0.06	0.18	0.01	0.03	0.2	0.05			0	0.14			0.01	0.01	0.14	1.29	0.05	0.09																				4.71	500	4.34	8.17	0.32	6.52	0.21	4.35	3.83	0.09	0.8	8.85	0.05	1.06	-	0.03	1.92	-	-	0.61	0.3	0.14	22.56	1.36	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.29
H3709_802_0	2007	2																					2500											D	D	D		T	Coin	Coin	P	P		V		P	Coin			V	Coin		Coin	Coin	V																																																													-		1111.8	19.6	3457.6		269.3	19.57	0.48	248.1	462.5		128.9		9	16.04			179.2	1.44		157.23	7.02	14.6																				100 / day up to 5 days.	200 / day up to 5 days.	200/day for days 21 to 100.		200 copay	20 coinsurance	20 coinsurance	50 copay for ER and 20 copay for Urgent Care	250 copay for Amb. Surg. Svcs and 20 coinsurance for Cardiac Rehabilitation Services and 40 copay for Outpatient Substance Abuse Svcs		150 copay for CT MRI PET and nuclear medicine studies. 0 copay for all other lab plus 0 for Hospital Based physician costs		35 copay	20 coinsurance and 0 for medical/surgical supplies			40 copay	20 coinsurance		40 copay for Office Visits and 20 coinsurance for other services	20 coinsurance	40 copay for Vision Exams and 0 Coinsurance for OP Blood																				67.89	181.59	21.46		190.94	0.19	0.16	37.01	224.37		98.96		35	0.11			40	0.2		0.14	0.19	40																				6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58	0	6.03	6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58		30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	50 copay for ER and 20 copay for Urgent Care	30 coinsurance	30 coinsurance plus 30 for Hospital Based physician costs			30 coinsurance	30 coinsurance			30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance																				1.88	0.02	0.34	0.21	0.06	0.18	0.01	0.03	0.2	0.05			0	0.14			0.01	0.01	0.14	1.29	0.05	0.09																				4.71	500	4.34	8.17	0.32	6.52	0.21	4.35	3.83	0.09	0.8	8.85	0.05	1.06	-	0.03	1.92	-	-	0.61	0.3	0.14	22.56	1.36	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.29
H3709_803_0	2007	2																					2500											D	D	D		T	Coin	Coin	P	P		V		P	Coin			V	Coin		Coin	Coin	V																																																													-		1111.8	19.6	3457.6		269.3	19.57	0.48	248.1	462.5		128.9		9	16.04			179.2	1.44		157.23	7.02	14.6																				100 / day up to 5 days.	200 / day up to 5 days.	200/day for days 21 to 100.		200 copay	20 coinsurance	20 coinsurance	50 copay for ER and 20 copay for Urgent Care	250 copay for Amb. Surg. Svcs and 20 coinsurance for Cardiac Rehabilitation Services and 40 copay for Outpatient Substance Abuse Svcs		150 copay for CT MRI PET and nuclear medicine studies. 0 copay for all other lab plus 0 for Hospital Based physician costs		35 copay	20 coinsurance and 0 for medical/surgical supplies			40 copay	20 coinsurance		40 copay for Office Visits and 20 coinsurance for other services	20 coinsurance	40 copay for Vision Exams and 0 Coinsurance for OP Blood																				67.89	181.59	21.46		190.94	0.19	0.16	37.01	224.37		98.96		35	0.11			40	0.2		0.14	0.19	40																				6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58	0	6.03	6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58		30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	50 copay for ER and 20 copay for Urgent Care	30 coinsurance	30 coinsurance plus 30 for Hospital Based physician costs			30 coinsurance	30 coinsurance			30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance																				1.88	0.02	0.34	0.21	0.06	0.18	0.01	0.03	0.2	0.05			0	0.14			0.01	0.01	0.14	1.29	0.05	0.09																				4.71	500	4.34	8.17	0.32	6.52	0.21	4.35	3.83	0.09	0.8	8.85	0.05	1.06	-	0.03	1.92	-	-	0.61	0.3	0.14	22.56	1.36	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.29
H3709_804_0	2007	2																					2500											D	D	D		T	Coin	Coin	P	P		V		P	Coin			V	Coin		Coin	Coin	V																																																													-		1111.8	19.6	3457.6		269.3	19.57	0.48	248.1	462.5		128.9		9	16.04			179.2	1.44		157.23	7.02	14.6																				100 / day up to 5 days.	200 / day up to 5 days.	200/day for days 21 to 100.		200 copay	20 coinsurance	20 coinsurance	50 copay for ER and 20 copay for Urgent Care	250 copay for Amb. Surg. Svcs and 20 coinsurance for Cardiac Rehabilitation Services and 40 copay for Outpatient Substance Abuse Svcs		150 copay for CT MRI PET and nuclear medicine studies. 0 copay for all other lab plus 0 for Hospital Based physician costs		35 copay	20 coinsurance and 0 for medical/surgical supplies			40 copay	20 coinsurance		40 copay for Office Visits and 20 coinsurance for other services	20 coinsurance	40 copay for Vision Exams and 0 Coinsurance for OP Blood																				67.89	181.59	21.46		190.94	0.19	0.16	37.01	224.37		98.96		35	0.11			40	0.2		0.14	0.19	40																				6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58	0	6.03	6.29	0.3	6.18	-	4.29	3.65	0.08	0.77	8.65	-	1.06	-	0.03	1.78	-	-	0.6	0.29	-	21.27	1.31	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.58		30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	50 copay for ER and 20 copay for Urgent Care	30 coinsurance	30 coinsurance plus 30 for Hospital Based physician costs			30 coinsurance	30 coinsurance			30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance	30 coinsurance																				1.88	0.02	0.34	0.21	0.06	0.18	0.01	0.03	0.2	0.05			0	0.14			0.01	0.01	0.14	1.29	0.05	0.09																				4.71	500	4.34	8.17	0.32	6.52	0.21	4.35	3.83	0.09	0.8	8.85	0.05	1.06	-	0.03	1.92	-	-	0.61	0.3	0.14	22.56	1.36	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.29
H3749_001_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1848.91	50.08	792.66	2038.52	182.11	14.02	0.98	414.49	577.51	708.15	26.85	44.65	5.82	925.78	5567.63	4447.67	184.52	476.93	27.48	25069.09	23.9	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											400 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	5	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											69.69	109.69	74	0	100	0.2	0.2	49.77	200	0	0.15	0	0	135.61	5	30	30	30	0.29	0.01	0.2	0	0	0	30	30	0	0	0	0	0											10.74	0.46	4.89	-	1.52	2.75	0.2	1.72	9.63	-	4.14	-	-	10.46	2.32	11.12	0.46	1.19	7.95	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.25	0	0	10.74	0.46	4.89	-	1.52	2.75	0.2	1.72	9.63	-	4.14	-	-	10.46	2.32	11.12	0.46	1.19	7.95	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.25	None																																																																																			-	0	0	10.74	0.46	4.89	-	1.52	2.75	0.2	1.72	9.63	-	4.14	-	-	10.46	2.32	11.12	0.46	1.19	7.95	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.25
H3749_004_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1844.82	49.97	904.7	2038.52	182.11	14.69	1.02	407.51	360.5	709.94	28.28	27.87	3.81	577.9	5567.63	4447.67	184.52	476.93	28.95	23608.15	23.9	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.77	200	0	0.15	0	0	135.61	15	30	30	30	0.28	0.01	0.2	0	0	0	30	30	0	0	0	0	0											20.07	0.46	4.67	-	1.52	2.89	0.2	1.69	6.01	-	4.35	-	-	6.53	6.96	11.12	0.46	1.19	8.1	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.94	0	0	20.07	0.46	4.67	-	1.52	2.89	0.2	1.69	6.01	-	4.35	-	-	6.53	6.96	11.12	0.46	1.19	8.1	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.94	None																																																																																			-	0	0	20.07	0.46	4.67	-	1.52	2.89	0.2	1.69	6.01	-	4.35	-	-	6.53	6.96	11.12	0.46	1.19	8.1	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.94
H3749_007_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1848.91	50.08	792.66	2038.52	182.11	13.93	0.97	414.49	577.51	708.15	26.67	44.65	5.78	925.78	5567.63	4447.67	184.52	476.93	27.3	25069.09	23.9	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											400 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	5	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											69.69	109.69	62	0	100	0.2	0.2	49.77	200	0	0.15	0	0	135.61	5	30	30	30	0.29	0.01	0.2	0	0	0	30	30	0	0	0	0	0											10.74	0.46	4.1	-	1.52	2.73	0.19	1.72	9.63	-	4.11	-	-	10.46	2.32	11.12	0.46	1.19	7.93	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.4	0	0	10.74	0.46	4.1	-	1.52	2.73	0.19	1.72	9.63	-	4.11	-	-	10.46	2.32	11.12	0.46	1.19	7.93	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.4	None																																																																																			-	0	0	10.74	0.46	4.1	-	1.52	2.73	0.19	1.72	9.63	-	4.11	-	-	10.46	2.32	11.12	0.46	1.19	7.93	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.4
H3749_010_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1844.82	49.97	904.7	2038.52	182.11	14.61	1.02	407.51	360.5	709.94	28.12	27.87	3.79	577.9	5567.63	4447.67	184.52	476.93	28.78	23608.15	23.9	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.77	200	0	0.15	0	0	135.61	15	30	30	30	0.28	0.01	0.2	0	0	0	30	30	0	0	0	0	0											20.07	0.46	4.67	-	1.52	2.87	0.2	1.69	6.01	-	4.33	-	-	6.53	6.96	11.12	0.46	1.19	8.09	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.89	0	0	20.07	0.46	4.67	-	1.52	2.87	0.2	1.69	6.01	-	4.33	-	-	6.53	6.96	11.12	0.46	1.19	8.09	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.89	None																																																																																			-	0	0	20.07	0.46	4.67	-	1.52	2.87	0.2	1.69	6.01	-	4.33	-	-	6.53	6.96	11.12	0.46	1.19	8.09	0.01	4.78	-	-	-	0.28	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.89
H3749_011_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	2499.52	67.71	1071.59	2755.86	246.19	16.74	1.17	560.34	780.73	957.34	32.07	60.37	6.95	1251.55	7526.83	6012.76	184.52	644.76	32.82	33890.65	23.9	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											0 per admit	812 Copay Per Stay	0 Copay [Day(s) 1-20]; 120 [Day(s) 21-100]	Covered in Full	50 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0.2	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Office Visit2 teeth cleanings/year and preventative care	Exam 5/12 months	materials copay 5/12 months	5 Exam/12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	97.67	47	0	50	0.2	0.2	12.35	0	0	0.15	0	0.2	0	0	0	10	0	0.09	0	0.2	0	0	0	5	5	5	0	0	0	0											-	0.55	4.2	-	1.03	3.29	0.23	0.58	-	-	4.94	-	1.39	-	-	-	0.15	-	2.83	-	4.78	-	-	-	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.21	0	0	-	0.55	4.2	-	1.03	3.29	0.23	0.58	-	-	4.94	-	1.39	-	-	-	0.15	-	2.83	-	4.78	-	-	-	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.21	None																																																																																			-	0	0	-	0.55	4.2	-	1.03	3.29	0.23	0.58	-	-	4.94	-	1.39	-	-	-	0.15	-	2.83	-	4.78	-	-	-	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.21
H3749_801_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1811.78	49.08	764.2	1986.55	177.46	8.6	0.6	398.56	545.64	669.07	16.25	42.19	3.52	874.69	5331.03	4258.66	176.68	456.66	16.85	24003.77	31.15	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											219.02	218.98	100.11	0	109.49	0.3	0.3	8.1	230.39	0	0.23	0	0.3	53	31.86	43.8	25.03	43.8	0.33	3.73	0.3	0	0	0	0	0	0	0	0	0	0											33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	0	70.72	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	5000																																																																																			-	0	0	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2
H3749_802_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1811.78	49.08	764.2	1986.55	177.46	8.6	0.6	398.56	545.64	669.07	16.25	42.19	3.52	874.69	5331.03	4258.66	176.68	456.66	16.85	24003.77	31.15	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											219.02	218.98	100.11	0	109.49	0.3	0.3	8.1	230.39	0	0.23	0	0.3	53	31.86	43.8	25.03	43.8	0.33	3.73	0.3	0	0	0	0	0	0	0	0	0	0											33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	0	70.72	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	5000																																																																																			-	0	0	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2
H3749_803_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1811.78	49.08	764.2	1986.55	177.46	8.6	0.6	398.56	545.64	669.07	16.25	42.19	3.52	874.69	5331.03	4258.66	176.68	456.66	16.85	24003.77	31.15	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											219.02	218.98	100.11	0	109.49	0.3	0.3	8.1	230.39	0	0.23	0	0.3	53	31.86	43.8	25.03	43.8	0.33	3.73	0.3	0	0	0	0	0	0	0	0	0	0											33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	0	70.72	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	5000																																																																																			-	0	0	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2
H3749_804_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1811.78	49.08	764.2	1986.55	177.46	8.6	0.6	398.56	545.64	669.07	16.25	42.19	3.52	874.69	5331.03	4258.66	176.68	456.66	16.85	24003.77	31.15	0	0	0	113.87	257.37	203.52	36.51	0	0	652.33											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											219.02	218.98	100.11	0	109.49	0.3	0.3	8.1	230.39	0	0.23	0	0.3	53	31.86	43.8	25.03	43.8	0.33	3.73	0.3	0	0	0	0	0	0	0	0	0	0											33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	0	70.72	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2	5000																																																																																			-	0	0	33.07	0.9	6.38	-	1.62	2.58	0.18	0.27	10.48	-	3.75	-	1.06	3.86	14.15	15.54	0.37	1.67	5.52	7.47	9.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.2
H3755_001_0	2007	5																																D	D	D		T	P		V	V	V	P			V	V	V	V	V	P	V		V			V	P	V																																																								-		787.7	28	21.6	0	69.3	24.4	0	286	308.5	2	259.3	0	0	332.4	4078.2	3334.3	98.4	179.6	178.2	239.9	0	218.8	0	0	206.3	49.9	58.41	0	0	0	0											1a. 135 copay day (1st 5 days)	1b. 135 copay day (1st 5 days)	2. 50 copay/day days 21-100	6. no copay	10a. 50 copay	11a. Wheelchairs - 50 copay Power wheelchairs & Scooters - 250 copay	11b. No copay	4a. 50 copay 4b. 50 copay if at ER	9a/9b. 100 copay	8a. 100 copay	8b/14g 100 copay for MRI/CT/Endo/PET/Nuclear	no copay	no copay	3/5. 50 copay	7a/7g/14b/14c/14d/14f/14i 20 copay 14a/14h no copay	7d/7g/16b 30 copay 13d 20	7e/7h/9c. 15 group copay/25 individual copay	7c/7i. 20 copay	8b. 100 copay for MRI/CT/Endo/PET/Nuclear	7b/7f/18a. 30 copay	15. no copay	13a. no copay 17a 30 copay	no copay	no copay	17a1. 20 copay	17b1. 25 copay	18a1. 20 copay	no copay	no copay	no copay	no copay											135	135	50	0	50	56	0	50	100	100	100	0	0	50	20	30	24	20	100	30	0	30	0	0	20	25	20	0	0	0	0											8.86	0.32	0.09	-	0.29	0.11	-	1.19	2.57	0.02	2.16	-	-	1.39	6.8	8.34	0.2	0.3	1.49	0.6	-	0.55	-	-	0.34	0.1	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.8			8.86	0.32	0.09	-	0.29	0.11	-	1.19	2.57	0.02	2.16	-	-	1.39	6.8	8.34	0.2	0.3	1.49	0.6	-	0.55	-	-	0.34	0.1	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.8																																																																																				-			8.86	0.32	0.09	-	0.29	0.11	-	1.19	2.57	0.02	2.16	-	-	1.39	6.8	8.34	0.2	0.3	1.49	0.6	-	0.55	-	-	0.34	0.1	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.8
H3755_002_0	2007	3																																D	D	D		T	P		V	V	V	P			V	V	V	V	V	P	V		V			V	P	V																																																								-		689.7	24.6	19.6	0	60.2	21.2	0	248.5	268.1	1.8	225.3	0	0	288.9	3938	3057.7	93.3	173.4	154.8	220	0	200.7	0	0	191.2	43.4	56.38	0	0	0	0											1a. 25 copay day (1st 5 days)	1b. 25 copay day (1st 5 days)	2. no copay	6. no copay	10a. 50 copay	11a. Wheelchairs - 50 copay Power wheelchairs & Scooters - 250 copay	11b. No copay	4a. 50 copay 4b. 50 copay if at ER	9a/9b. No copay	8a. No copay	8b/14g 100 copay for MRI/CT/Endo/PET/Nuclear	no copay	no copay	3/5. no copay	7a/7g/14b/14c/14d/14f/14i 5 copay 14a/14h no copay	7d/7g/16b 10 copay 13d no copay	7e/7h/9c. 10 group copay/10 individual copay	7c/7i. 10 copay	8b. 100 copay for MRI/CT/Endo/PET/Nuclear	7b/7f/18a. 10 copay	15. no copay	13a. no copay 17a 10 copay	no copay	no copay	17a1. 10 copay	17b1. 10 copay	18a1. 5 copay	no copay	no copay	no copay	no copay											25	25	0	0	50	56	0	50	0	0	100	0	0	0	5	10	10	10	100	10	0	10	0	0	10	10	5	0	0	0	0											1.44	0.05	-	-	0.25	0.1	-	1.04	-	-	1.88	-	-	-	1.64	2.55	0.08	0.14	1.29	0.18	-	0.17	-	-	0.16	0.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.02			1.44	0.05	-	-	0.25	0.1	-	1.04	-	-	1.88	-	-	-	1.64	2.55	0.08	0.14	1.29	0.18	-	0.17	-	-	0.16	0.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.02																																																																																				-			1.44	0.05	-	-	0.25	0.1	-	1.04	-	-	1.88	-	-	-	1.64	2.55	0.08	0.14	1.29	0.18	-	0.17	-	-	0.16	0.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.02
H3755_004_0	2007	3																																D	D	D		T	P		V	V	V	P			V	V	V	V	V	P	V		V			V	P	V																																																								-		689.7	24.6	19.6	0	60.2	21.2	0	248.5	268.1	1.8	225.3	0	0	288.9	3938	3057.7	93.3	173.4	154.8	220	0	200.7	0	0	191.2	43.4	56.38	0	0	0	0											1a. 25 copay day (1st 5 days)	1b. 25 copay day (1st 5 days)	2. no copay	6. no copay	10a. 50 copay	11a. Wheelchairs - 50 copay Power wheelchairs & Scooters - 250 copay	11b. No copay	4a. 50 copay 4b. 50 copay if at ER	9a/9b. No copay	8a. No copay	8b/14g 100 copay for MRI/CT/Endo/PET/Nuclear	no copay	no copay	3/5. no copay	7a/7g/14b/14c/14d/14f/14i 5 copay 14a/14h no copay	7d/7g/16b 10 copay 13d no copay	7e/7h/9c. 10 group copay/10 individual copay	7c/7i. 10 copay	8b. 100 copay for MRI/CT/Endo/PET/Nuclear	7b/7f/18a. 10 copay	15. no copay	13a. no copay 17a 10 copay	no copay	no copay	17a1. 10 copay	17b1. 10 copay	18a1. 5 copay	no copay	no copay	no copay	no copay											25	25	0	0	50	56	0	50	0	0	100	0	0	0	5	10	10	10	100	10	0	10	0	0	10	10	5	0	0	0	0											1.44	0.05	-	-	0.25	0.1	-	1.04	-	-	1.88	-	-	-	1.64	2.55	0.08	0.14	1.29	0.18	-	0.17	-	-	0.16	0.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.02			1.44	0.05	-	-	0.25	0.1	-	1.04	-	-	1.88	-	-	-	1.64	2.55	0.08	0.14	1.29	0.18	-	0.17	-	-	0.16	0.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.02																																																																																				-			1.44	0.05	-	-	0.25	0.1	-	1.04	-	-	1.88	-	-	-	1.64	2.55	0.08	0.14	1.29	0.18	-	0.17	-	-	0.16	0.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.02
H3755_801_0	2007	4																																D	D	D		T	P		V	V	V	P			V	V	V	V	V	P	V		V			V	P	V																																																								-		703.3	25	19.3	0	61.8	21.8	0	255.3	275.4	1.8	231.5	0	0	296.8	3641.3	2977	87.9	160.3	159.1	214.2	0	195.4	0	0	184.2	44.6	52.15	0	0	0	0											1a. 100 copay day (1st 5 days)	1b. 100 copay day (1st 5 days)	2. 50 copay/day days 21-100	6. no copay	10a. 50 copay	11a. Wheelchairs - 50 copay Power wheelchairs & Scooters - 250 copay	11b. No copay	4a. 50 copay 4b. 50 copay if at ER	9a/9b. 100 copay	8a. 100 copay	8b/14g 100 copay for MRI/CT/Endo/PET/Nuclear	no copay	no copay	3/5. 50 copay	7a/7g/14b/14c/14d/14f/14i 20 copay 14a/14h no copay	7d/7g/16b 30 copay 13d 20	7e/7h/9c. 15 group copay/25 individual copay	7c/7i. 20 copay	8b. 100 copay for MRI/CT/Endo/PET/Nuclear	7b/7f/18a. 30 copay	15. no copay	13a. no copay 17a 30 copay	no copay	no copay	17a1. 20 copay	17b1. 25 copay	18a1. 20 copay	no copay	no copay	no copay	no copay											100	100	50	0	50	56	0	50	100	100	100	0	0	50	20	30	24	20	100	30	0	30	0	0	20	25	20	0	0	0	0											5.86	0.21	0.08	-	0.26	0.1	-	1.06	2.3	0.02	1.93	-	-	1.24	6.07	7.44	0.18	0.27	1.33	0.54	-	0.49	-	-	0.31	0.09	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.84			5.86	0.21	0.08	-	0.26	0.1	-	1.06	2.3	0.02	1.93	-	-	1.24	6.07	7.44	0.18	0.27	1.33	0.54	-	0.49	-	-	0.31	0.09	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.84																																																																																				-			5.86	0.21	0.08	-	0.26	0.1	-	1.06	2.3	0.02	1.93	-	-	1.24	6.07	7.44	0.18	0.27	1.33	0.54	-	0.49	-	-	0.31	0.09	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.84
H3805_001_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1275.57	34.55	1137.58	1674.78	218.3	17.45	1.22	398.51	380.47	613.92	29.46	29.42	5.06	609.92	5810.79	3842.86	155.69	727.11	28.91	20010.96	40.4	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	47.49	200	0	0.15	0	0	135.61	15	30	30	30	0.24	0.01	0.2	0	0	0	30	30	0	0	0	0	0											13.87	0.32	5.88	-	1.82	3.43	0.24	1.58	6.34	-	4.54	-	-	6.89	7.26	9.61	0.39	1.82	6.94	0.01	8.08	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.92	0	0	13.87	0.32	5.88	-	1.82	3.43	0.24	1.58	6.34	-	4.54	-	-	6.89	7.26	9.61	0.39	1.82	6.94	0.01	8.08	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.92	None																																																																																			-	0	0	13.87	0.32	5.88	-	1.82	3.43	0.24	1.58	6.34	-	4.54	-	-	6.89	7.26	9.61	0.39	1.82	6.94	0.01	8.08	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.92
H3805_007_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1391.52	37.69	1110.35	1741.53	181.34	14.69	1.02	414.52	332.32	692.8	25.87	25.69	3.8	532.73	5801.2	3652.88	155.69	541.82	25.38	20607.96	40.4	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	47.49	200	0	0.15	0	0	135.61	15	30	30	30	0.27	0.01	0.2	0	0	0	30	30	0	0	0	0	0											15.14	0.34	5.74	-	1.51	2.88	0.2	1.64	5.54	-	3.98	-	-	6.02	7.25	9.13	0.39	1.35	6.74	0.01	8.08	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.89	0	0	15.14	0.34	5.74	-	1.51	2.88	0.2	1.64	5.54	-	3.98	-	-	6.02	7.25	9.13	0.39	1.35	6.74	0.01	8.08	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.89	None																																																																																			-	0	0	15.14	0.34	5.74	-	1.51	2.88	0.2	1.64	5.54	-	3.98	-	-	6.02	7.25	9.13	0.39	1.35	6.74	0.01	8.08	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.89
H3805_010_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1242.71	33.66	1130.07	1741.53	209.35	15.37	1.07	398.51	367.18	633.01	26.6	28.39	4.33	588.61	5808.47	3796.88	155.69	682.27	26.1	20017.08	40.4	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	47.49	200	0	0.15	0	0	135.61	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											13.52	0.31	5.84	-	1.74	3.02	0.21	1.58	6.12	-	4.1	-	-	6.65	7.26	9.49	0.39	1.71	6.79	0.01	8.08	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.75	0	0	13.52	0.31	5.84	-	1.74	3.02	0.21	1.58	6.12	-	4.1	-	-	6.65	7.26	9.49	0.39	1.71	6.79	0.01	8.08	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.75	None																																																																																			-	0	0	13.52	0.31	5.84	-	1.74	3.02	0.21	1.58	6.12	-	4.1	-	-	6.65	7.26	9.49	0.39	1.71	6.79	0.01	8.08	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.75
H3805_011_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1242.71	33.66	1130.07	1674.78	209.35	17.61	1.23	398.51	367.18	633.01	29.88	28.39	4.95	588.61	5808.47	3796.88	155.69	682.27	29.31	20017.08	40.4	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	47.49	200	0	0.15	0	0	135.61	15	30	30	30	0.24	0.01	0.2	0	0	0	30	30	0	0	0	0	0											13.52	0.31	5.84	-	1.74	3.46	0.25	1.58	6.12	-	4.6	-	-	6.65	7.26	9.49	0.39	1.71	6.98	0.01	8.08	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.88	0	0	13.52	0.31	5.84	-	1.74	3.46	0.25	1.58	6.12	-	4.6	-	-	6.65	7.26	9.49	0.39	1.71	6.98	0.01	8.08	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.88	None																																																																																			-	0	0	13.52	0.31	5.84	-	1.74	3.46	0.25	1.58	6.12	-	4.6	-	-	6.65	7.26	9.49	0.39	1.71	6.98	0.01	8.08	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.88
H3805_801_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1289.79	34.94	1116.74	1676.18	205.63	9.74	0.68	385.07	348.8	605.15	16.25	26.97	2.67	559.15	5661.6	3693.3	151.76	657.43	16.34	19671.79	50.51	0	0	0	112.67	254.65	201.37	36.13	0	0	646.16											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.51	209.47	95.76	0	104.74	0.3	0.3	10.3	273.43	0	0.23	0	0.3	62.9	50.43	59.85	23.94	59.85	0.29	3.83	0.3	0	0	0	0	0	0	0	0	0	0											22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	0	83.63	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	5000																																																																																			-	0	0	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66
H3805_802_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1289.79	34.94	1116.74	1676.18	205.63	9.74	0.68	385.07	348.8	605.15	16.25	26.97	2.67	559.15	5661.6	3693.3	151.76	657.43	16.34	19671.79	50.51	0	0	0	112.67	254.65	201.37	36.13	0	0	646.16											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.51	209.47	95.76	0	104.74	0.3	0.3	10.3	273.43	0	0.23	0	0.3	62.9	50.43	59.85	23.94	59.85	0.29	3.83	0.3	0	0	0	0	0	0	0	0	0	0											22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	0	83.63	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	5000																																																																																			-	0	0	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66
H3805_803_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1289.79	34.94	1116.74	1676.18	205.63	9.74	0.68	385.07	348.8	605.15	16.25	26.97	2.67	559.15	5661.6	3693.3	151.76	657.43	16.34	19671.79	50.51	0	0	0	112.67	254.65	201.37	36.13	0	0	646.16											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.51	209.47	95.76	0	104.74	0.3	0.3	10.3	273.43	0	0.23	0	0.3	62.9	50.43	59.85	23.94	59.85	0.29	3.83	0.3	0	0	0	0	0	0	0	0	0	0											22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	0	83.63	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	5000																																																																																			-	0	0	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66
H3805_804_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1289.79	34.94	1116.74	1676.18	205.63	9.74	0.68	385.07	348.8	605.15	16.25	26.97	2.67	559.15	5661.6	3693.3	151.76	657.43	16.34	19671.79	50.51	0	0	0	112.67	254.65	201.37	36.13	0	0	646.16											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											209.51	209.47	95.76	0	104.74	0.3	0.3	10.3	273.43	0	0.23	0	0.3	62.9	50.43	59.85	23.94	59.85	0.29	3.83	0.3	0	0	0	0	0	0	0	0	0	0											22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	0	83.63	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66	5000																																																																																			-	0	0	22.52	0.61	8.91	-	1.79	2.92	0.2	0.33	7.95	-	3.75	-	0.8	2.93	23.79	18.42	0.3	3.28	4.72	6.27	15.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.66
H3810_001_0	2007	3																					None											A	A			T		Coin	V	V				V	V	V	V	V	V		V		O			V						O																																																				-	N/A	244.51	3.16			168.31		6.99	330.82	251.1				21.4	479.84	3784.84	4421.29	143.22	1222.87		1068.79		550.25			411.32						558.74											100/Admit	100/Admit			50/ Trip		20 on Diabetes and Medical Supplies	50 Emerg. Room/ 25 Urgent Care	50 / Visit				15/Visit	15 / Visit PT/OT/ST	15/Visit	15/Visit	15/Visit	15/Visit		15/Visit Chiro/Pod/Hearing		15/Visit Vision Exams			15/Visit Refraction						15/ Visit Care Coordination Alternative Therapy											95.49	95.49			47.74		0.16	41.84	47.74				14.32	14.32	14.32	14.32	14.32	14.32		14.32		14.32			14.32						14.32											1.95	0.03	-	-	0.67	-	1.15	1.15	1	-	-	-	0.03	0.57	4.52	5.28	0.17	1.46	-	1.28	-	0.66	-	-	0.49	-	-	-	-	-	0.67	-	-	-	-	-	-	-	-	-	-	21.06		1	1.95	0.03	-	-	0.67	-	1.15	1.15	1	-	-	-	0.03	0.57	4.52	5.28	0.17	1.46	-	1.28	-	0.66	-	-	0.49	-	-	-	-	-	0.67	-	-	-	-	-	-	-	-	-	-	21.06	N/A																																																																																			-			1.95	0.03	-	-	0.67	-	1.15	1.15	1	-	-	-	0.03	0.57	4.52	5.28	0.17	1.46	-	1.28	-	0.66	-	-	0.49	-	-	-	-	-	0.67	-	-	-	-	-	-	-	-	-	-	21.06
H3810_002_0	2007	3																					None											Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin									V											0	0	0		0.56	1.3	0.86	0.35	0.64	0.43	0.86		0.1	1.31	2.01	4.31	0.33	0.19	0.89	1.46	0.28	0.15									0											16.01	N/A	319.65	21.8	53.42		15.62	35.98	23.89	9.6	17.82	11.84	23.82		2.65	36.3	58.4	119.81	9.15	5.22	24.74	40.42	7.81	4.19									471											Medicare Inpatient Deductibles	Medicare Inpatient Deductibles	Medicare Skilled Nursing Deductibles		20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max		20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max									15 Office Copay											0.07	0.07	0.14		0.2	0.2	0.2	0.2	0.2	0.2	0.2		0.2	0.2	0.19	0.2	0.2	0.2	0.2	0.2	0.2	0.2									15											23.81	1.62	7.25	-	3.12	7.2	4.78	1.93	3.56	2.37	4.76	-	0.53	7.26	11.19	23.96	1.83	1.04	4.95	8.08	1.56	0.84	-	-	-	-	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	122.25	138	0	23.81	1.62	7.25	-	3.69	8.49	5.64	2.28	4.2	2.8	5.62	-	0.63	8.57	13.2	28.27	2.16	1.23	5.84	9.54	1.84	0.99	-	-	-	-	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	138.26	N/A																																																																																			-	0	0	23.81	1.62	7.25	-	3.69	8.49	5.64	2.28	4.2	2.8	5.62	-	0.63	8.57	13.2	28.27	2.16	1.23	5.84	9.54	1.84	0.99	-	-	-	-	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	138.26
H3810_003_0	2007	4																					None											A	A			T		Coin	V	V				V	V	V	V	V	V		V		O			V						O											0	0			0		0	0	0				0	0	0	0	0	0		0		0			0						0											-	N/A	970.23	15.67			208.57		8.65	412.89	311.22				26.95	598.67	4823.66	5580.37	178.8	1516.75		1288.99		704.3			407.75						560.84											100/Day	100/Day			50/ Trip		20 on Diabetes and Medical Supplies	50 Emerg. Room/ 25 Urgent Care	50 / Visit				15/Visit	15/Visit PT/OT/ST	15/Visit	15/Visit	15/Visit	15/Visit		15/Visit Chiro/Pod/Hearing		15/Visit Vision Exams			15/Visit Refraction						15/ Visit Care Coordination Alternative Therapy											46.82	46.82			46.08		0.16	40.22	46.08				13.82	13.82	13.82	13.82	13.82	13.82		13.82		13.82			13.82						13.82											3.79	0.06	-	-	0.8	-	1.37	1.38	1.2	-	-	-	0.03	0.69	5.56	6.43	0.21	1.75	-	1.49	-	0.81	-	-	0.47	-	-	-	-	-	0.65	-	-	-	-	-	-	-	-	-	-	26.67	0	2.27	3.79	0.06	-	-	0.8	-	1.37	1.38	1.2	-	-	-	0.03	0.69	5.56	6.43	0.21	1.75	-	1.49	-	0.81	-	-	0.47	-	-	-	-	-	0.65	-	-	-	-	-	-	-	-	-	-	26.67	N/A																																																																																			-			3.79	0.06	-	-	0.8	-	1.37	1.38	1.2	-	-	-	0.03	0.69	5.56	6.43	0.21	1.75	-	1.49	-	0.81	-	-	0.47	-	-	-	-	-	0.65	-	-	-	-	-	-	-	-	-	-	26.67
H3810_004_0	2007	5																					None											A	A			T		Coin	V	V				V	V	V	V	V	V		V		O			V				Coin		O																																																				-	N/A	236.48	2.97			207.97		8.62	411.95	310.33				27.45	597.22	5022.96	5781.44	186.98	1587.16		1361.47		734.75			425.1				18.29		580.68											100/Admit	100/Admit			50/ Trip		20 on Diabetes and Medical Supplies	50 Emerg. Room/ 25 Urgent Care	50 / Visit				5/Visit	5/Visit PT/OT/ST	5/Visit	5/Visit	5/Visit	5/Visit		5/Visit Chiro/Pod/Hearing		5/Visit Vision Exams			5/Visit Refraction				100 Deductible 20 Coinsurance		5/ Visit Care Coordination Alternative Therapy											79.27	79.27			39.63		0.14	34.58	39.63				3.96	3.96	3.96	3.96	3.96	3.96		3.96		3.96			3.96				0.24		3.96											1.56	0.02	-	-	0.69	-	1.17	1.19	1.02	-	-	-	0.01	0.2	1.66	1.91	0.06	0.52	-	0.45	-	0.24	-	-	0.14	-	-	-	4.32	-	0.19	-	-	-	-	-	-	-	-	-	-	15.36	0	2.89	1.56	0.02	-	-	0.69	-	1.17	1.19	1.02	-	-	-	0.01	0.2	1.66	1.91	0.06	0.52	-	0.45	-	0.24	-	-	0.14	-	-	-	4.32	-	0.19	-	-	-	-	-	-	-	-	-	-	15.36	N/A																																																																																			-			1.56	0.02	-	-	0.69	-	1.17	1.19	1.02	-	-	-	0.01	0.2	1.66	1.91	0.06	0.52	-	0.45	-	0.24	-	-	0.14	-	-	-	4.32	-	0.19	-	-	-	-	-	-	-	-	-	-	15.36
H3810_005_0	2007	5																					None											A	A			T		Coin	V	V				V	V	V	V	V	V		V		O			V				Coin		O																																																				-	N/A	235.09	2.94			207.27		8.59	411.29	309.3				27.43	596	5029.16	5778.62	186.46	1580.78		1348.35		736.21			424.06				18.29		580.45											100/Admit	100/Admit			50/ Trip		20 on Diabetes and Medical Supplies	50 Emerg. Room/ 25 Urgent Care	50 / Visit				5/Visit	5/Visit PT/OT/ST	5/Visit	5/Visit	5/Visit	5/Visit		5/Visit Chiro/Pod/Hearing		5/Visit Vision Exams			5/Visit Refraction				100 Deductible 20 Coinsurance		5/ Visit Care Coordination Alternative Therapy											79.34	79.34			39.67		0.14	34.59	39.67				3.97	3.97	3.97	3.97	3.97	3.97		3.97		3.97			3.97				0.24		3.97											1.55	0.02	-	-	0.69	-	1.17	1.19	1.02	-	-	-	0.01	0.2	1.66	1.91	0.06	0.52	-	0.45	-	0.24	-	-	0.14	-	-	-	4.32	-	0.19	-	-	-	-	-	-	-	-	-	-	15.34	0	2.87	1.55	0.02	-	-	0.69	-	1.17	1.19	1.02	-	-	-	0.01	0.2	1.66	1.91	0.06	0.52	-	0.45	-	0.24	-	-	0.14	-	-	-	4.32	-	0.19	-	-	-	-	-	-	-	-	-	-	15.34	N/A																																																																																			-			1.55	0.02	-	-	0.69	-	1.17	1.19	1.02	-	-	-	0.01	0.2	1.66	1.91	0.06	0.52	-	0.45	-	0.24	-	-	0.14	-	-	-	4.32	-	0.19	-	-	-	-	-	-	-	-	-	-	15.34
H3811_001_0	2007	1																																D	D	D		T	Coin	Coin	V	V					V			P			P		V			V																																																										-		1006.58	20.67	627.67		184.16	19.06	1.33	264.62	297.92					1616.05			174.28			34928.24		1213.25			339.23																	50 days 1-4 0 days 5-90	50 days 1-4 0 days 5-90	0 days 1-10 50 days 11-20 80 days 21-100		50 copay	20 coinsurance	20 coinsurance	50 copay	30 copay					15 copay for therapy and rehab 0 other			15 20 30 40 Copays			10 PCP 15 SCP		Copays (25 22.50 0)			15 copay																	31.49	21.65	37.61		50	0.2	0.2	50	30					5			22.59			4.27		11.73			15																	2.64	0.04	1.97	-	0.77	3.81	0.27	1.1	0.74	-	-	-	-	0.67	-	-	0.33	-	-	12.42	-	1.19	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.37			2.64	0.04	1.97	-	0.77	3.81	0.27	1.1	0.74	-	-	-	-	0.67	-	-	0.33	-	-	12.42	-	1.19	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.37																																																																																				-			2.64	0.04	1.97	-	0.77	3.81	0.27	1.1	0.74	-	-	-	-	0.67	-	-	0.33	-	-	12.42	-	1.19	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.37
H3811_002_0	2007	3																																D	D	D		T	Coin	Coin	V	V					V			P			P		V			V																																																										-		1032.46	20.09	663.38		174.69	18.16	1.27	277.34	275.01					1668.55			168.01			34040.92		1151.55			321.78																	50 days 1-4 0 days 5-90	50 days 1-4 0 days 5-90	0 days 1-10 50 days 11-20 80 days 21-100		50 copay	20 coinsurance	20 coinsurance	50 copay	30 copay					15 copay for therapy and rehab 0 other			15 20 30 40 Copays			10 PCP 15 SCP		Copays (25 22.50 0)			15 copay																	31.49	21.67	37.61		50	0.2	0.2	50	30					5			22.59			4.22		11.72			15																	2.71	0.04	2.08	-	0.73	3.63	0.25	1.16	0.69	-	-	-	-	0.69	-	-	0.32	-	-	11.97	-	1.12	-	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.79			2.71	0.04	2.08	-	0.73	3.63	0.25	1.16	0.69	-	-	-	-	0.69	-	-	0.32	-	-	11.97	-	1.12	-	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.79																																																																																				-			2.71	0.04	2.08	-	0.73	3.63	0.25	1.16	0.69	-	-	-	-	0.69	-	-	0.32	-	-	11.97	-	1.12	-	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.79
H3811_003_0	2007	4																																D	D	D		T	Coin	Coin	V	V					V			P			P		V			V																																																										-		1744.5	36.55	983.9		210.25	22.86	1.6	490.77	351.43					2531.55			220.78			45856.97		1364.19			386.7																	50 days 1-4 0 days 5-90	50 days 1-4 0 days 5-90	0 days 1-10 50 days 11-20 80 days 21-100		50 copay	20 coinsurance	20 coinsurance	50 copay	30 copay					15 copay for therapy and rehab 0 other			15 20 30 40 Copays			10 PCP 15 SCP		Copays (25 22.50 0)			15 copay																	31.49	21.64	60.01		50	0.2	0.2	50	30					4.99			22.59			4.12		11.3			15																	4.58	0.07	4.92	-	0.88	4.57	0.32	2.04	0.88	-	-	-	-	1.05	-	-	0.42	-	-	15.73	-	1.28	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.22			4.58	0.07	4.92	-	0.88	4.57	0.32	2.04	0.88	-	-	-	-	1.05	-	-	0.42	-	-	15.73	-	1.28	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.22																																																																																				-			4.58	0.07	4.92	-	0.88	4.57	0.32	2.04	0.88	-	-	-	-	1.05	-	-	0.42	-	-	15.73	-	1.28	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.22
H3812_001_0	2007	5																					2900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3600	1567.93	129.2	707.8	0	212.82	10.38	4.54	510.38	24.28	6228.41	34.07	0	0.13	18.06	3271.25	3137.76	491.88	1.39	0	0	17.54	613.92	0	0	125.87	0	172.01	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											160.65	160.65	87.63	0	102.23	0.18	0.2	29.21	0.18	1.17	0.13	0	0.18	0.18	10	25	37.5	0.18	0	0	0.18	25	0	0	25	0	25	0	0	0	0											20.99	1.73	5.17	-	1.81	1.82	0.9	1.24	4.25	0.61	4.58	-	0.02	3.17	2.73	6.54	1.54	0.24	-	-	3.07	1.28	-	-	0.26	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.32		35.13	20.99	1.73	5.17	-	1.81	1.82	0.9	1.24	4.25	0.61	4.58	-	0.02	3.17	2.73	6.54	1.54	0.24	-	-	3.07	1.28	-	-	0.26	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.32		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.38	0.2	0.5	0.5	0.38	0.38	0.19	0.26	1.19	0.51	1.29	0	0	0.89	1.59	2.01	0.38	0.07	0	0	0.65	0.4	0	0	0.08	0	0.11	0	0	0	0											13.97		6.95	23.37	1.93	5.67	0.5	2.19	2.2	1.09	1.5	5.45	1.12	5.87	-	0.03	4.05	4.32	8.55	1.92	0.31	-	-	3.72	1.68	-	-	0.34	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.29
H3812_003_0	2007	3																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3000	1567.93	129.2	707.8	0	212.82	10.38	4.54	510.38	24.28	6228.41	34.07	0	0.13	18.06	3271.25	3137.76	491.88	1.39	0	0	17.54	613.92	0	0	125.87	0	172.01	0	0	0	0											225 (1a)	225 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	8 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	15 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 15 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	15 (17a)	0 n/c (17b1-17b5)	15 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											131.6	131.6	58.49	0	102.35	0.18	0.2	29.24	0.12	3.51	0.09	0	0.18	0.12	8	15	37.5	0.12	0	0	0.18	15	0	0	15	0	15	0	0	0	0											17.19	1.42	3.45	-	1.82	1.82	0.9	1.24	2.84	1.82	3.15	-	0.02	2.12	2.18	3.92	1.54	0.16	-	-	3.08	0.77	-	-	0.16	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.82		28.94	17.19	1.42	3.45	-	1.82	1.82	0.9	1.24	2.84	1.82	3.15	-	0.02	2.12	2.18	3.92	1.54	0.16	-	-	3.08	0.77	-	-	0.16	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.82		325 (1a)	325 (1b)	125 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 25 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.13	0.18	0.37	0.22	0.39	0.39	0.17	0.27	0.92	0.53	1.02	0	0.01	0.69	0.86	0.83	0.22	0.05	0	0	0.67	0.17	0	0	0.03	0	0.05	0	0	0	0											10.15		7.46	19.32	1.59	3.82	0.22	2.21	2.22	1.07	1.51	3.76	2.35	4.18	-	0.03	2.8	3.04	4.75	1.76	0.22	-	-	3.74	0.93	-	-	0.19	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.96
H3812_004_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1000	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T		V	P	V	P		O	O																																																				-		2152.11	340.53	1100.21		246.81	23.6	20.45	831.31					2.83								15.79																					(1a) 25 per Day	(1b) 25 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 50 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 0 per Visit	(8a) 0 per Visit	(8b) 0 per Visit	(9a) 0 per Visit	(12) 20 Coinsurance	(9a) 0 per Visit	(7a) 0 per Visit	(7d) 0 per Visit	(7h) 0 per Visit	(7c) 0 per Visit	0 per Visit	(7g) 0 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0											18	18	26		36	14	14	28					14								14																					3.2	0.51	2.36	-	0.73	3.37	2.92	1.96	-	-	-	-	0.4	-	-	-	-	-	-	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.71		7.08	3.2	0.51	2.36	-	0.73	3.37	2.92	1.96	-	-	-	-	0.4	-	-	-	-	-	-	-	2.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.71		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure														1.93	0.13	0.26	0.33	0.06	0.14	0.13	0.04	0.17	0.12	0.12	0.01	0.02	0.19	0.33	0.19	0.04	0.03	0.13	0.6	0.12	0																				5.07		0	5.13	0.64	2.61	0.33	0.79	3.52	3.05	2	0.17	0.12	0.12	0.01	0.42	0.19	0.33	0.19	0.04	0.03	0.13	0.6	2.38	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.78
H3812_005_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1849.04	172.17	7969.15	149.36	560.55	1260.82	6127.67	161.21	107.03	3329.95	148.04	29.27	3.83	248.9	111.53	1116.97	1451	17.14		233.22	236.31	1140.49	2137.5		133.19	157.7		51.87				95.06	0.24	0.06	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						64	64			64			42	21			21		21																		8										9.79	0.91	-	-	2.97	-	-	0.57	0.19	-	-	0.05	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	14.98		2.71	9.79	0.91	-	-	2.97	-	-	0.57	0.19	-	-	0.05	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	14.98		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						2.25	0.06	0.71	0.07	0.32	0.27	0.09	0.04	0.17	0.52	0.58	0.03	0	0.1	0.01	1.5	0.14	0		0.15		0.1	0.11		0.02							0	0	0	0.02	0.02						7.27		0	12.04	0.97	0.71	0.07	3.28	0.27	0.09	0.6	0.36	0.52	0.58	0.08	0	0.54	0.01	1.5	0.14	0	-	0.15	-	0.1	0.11	-	0.02	-	-	-	-	-	-	0.07	0	0	0.02	0.02	-	-	-	-	-	22.25
H3812_801_0	2007	4																					3500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	4100	1646.32	135.66	743.19	0	223.46	10.9	4.76	535.9	25.49	6539.83	35.78	0	0.14	18.97	3434.81	3294.65	516.47	1.46	0	0	18.42	644.62	0	0	132.16	0	180.61	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											168.69	168.69	92.01	0	107.35	0.18	0.21	30.67	0.18	3.68	0.14	0	0.18	0.18	35	35	37.5	0.18	0	0	0.18	35	0	0	35	0	35	0	0	0	0											23.14	1.91	5.7	-	2	2.01	0.98	1.37	4.69	2.01	5.05	-	0.03	3.49	10.02	9.61	1.61	0.27	-	-	3.39	1.88	-	-	0.39	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.06		35.14	23.14	1.91	5.7	-	2	2.01	0.98	1.37	4.69	2.01	5.05	-	0.03	3.49	10.02	9.61	1.61	0.27	-	-	3.39	1.88	-	-	0.39	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.06		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.6	0.21	0.55	0.31	0.42	0.42	0.18	0.28	1.3	0.56	1.4	0	0.01	0.97	1.7	1.4	0.23	0.07	0	0	0.7	0.28	0	0	0.06	0	0.08	0	0	0	0											13.72		9.9	25.74	2.12	6.25	0.31	2.41	2.42	1.16	1.65	5.99	2.56	6.45	-	0.03	4.46	11.72	11.01	1.85	0.34	-	-	4.09	2.16	-	-	0.44	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.78
H3813_001_0	2007	8																					1500											A	A	D		T	O	O	V	P	P	P	V	P	P	V	V	V	V	P	P	S	V					V																																																								-	1500	222.85	2.23	596.74	0	183.45	25765.21	8767.11	296.98	271.97	43.96	835.24	13	713.07	194.27	3405.51	5412.81	125.6	453.5	1015.28	1853.97	142.61	433.68	0	0	0	0	62.34	0	0	0	0											400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											219.28	219.28	13.7	0	27.41	0.26	0.36	25.08	197.35	5.48	5.48	27.41	2.05	4.48	11.98	12.84	19.19	10.96	10.96	2.05	2.05	10.96	0	0	0	0	10.96	0	0	0	0											4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	0	19.19	4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	1500	400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											0.94	0.01	0.18	0	0.1	0.13	0.06	0.16	1.1	0	0.09	0.01	0.03	0.02	0.79	1.39	0.05	0.1	0.23	0.08	0.01	0.09	0	0	0	0	0.02	0	0	0	0											5.59	0	4.88	5.01	0.05	0.86	-	0.52	0.69	0.33	0.78	5.57	0.02	0.47	0.04	0.15	0.09	4.19	7.18	0.25	0.51	1.16	0.39	0.03	0.48	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.88
H3813_002_0	2007	7																					1500											A	A	D		T	O	O	V	P	P	P	V	P	P	V	V	V	V	P	P	S	V					V																																																								-	1500	222.85	2.23	596.74	0	183.45	25765.21	8767.11	296.98	271.97	43.96	835.24	13	713.07	194.27	3405.51	5412.81	125.6	453.5	1015.28	1853.97	142.61	433.68	0	0	0	0	62.34	0	0	0	0											400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											219.28	219.28	13.7	0	27.41	0.26	0.36	25.08	197.35	5.48	5.48	27.41	2.05	4.48	11.98	12.84	19.19	10.96	10.96	2.05	2.05	10.96	0	0	0	0	10.96	0	0	0	0											4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	0	19.19	4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	1500	400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											0.94	0.01	0.18	0	0.1	0.13	0.06	0.16	1.1	0	0.09	0.01	0.03	0.02	0.79	1.39	0.05	0.1	0.23	0.08	0.01	0.09	0	0	0	0	0.02	0	0	0	0											5.59	0	4.88	5.01	0.05	0.86	-	0.52	0.69	0.33	0.78	5.57	0.02	0.47	0.04	0.15	0.09	4.19	7.18	0.25	0.51	1.16	0.39	0.03	0.48	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.88
H3813_003_0	2007	8																					1500											A	A	D		T	O	O	V	P	P	P	V	P	P	V	V	V	V	P	P	S	V					V																																																								-	1500	222.85	2.23	596.74	0	183.45	25765.21	8767.11	296.98	271.97	43.96	835.24	13	713.07	194.27	3405.51	5412.81	125.6	453.5	1015.28	1853.97	142.61	433.68	0	0	0	0	62.34	0	0	0	0											400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											219.28	219.28	13.7	0	27.41	0.26	0.36	25.08	197.35	5.48	5.48	27.41	2.05	4.48	11.98	12.84	19.19	10.96	10.96	2.05	2.05	10.96	0	0	0	0	10.96	0	0	0	0											4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	0	19.19	4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	1500	400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											0.94	0.01	0.18	0	0.1	0.13	0.06	0.16	1.1	0	0.09	0.01	0.03	0.02	0.79	1.39	0.05	0.1	0.23	0.08	0.01	0.09	0	0	0	0	0.02	0	0	0	0											5.59	0	4.88	5.01	0.05	0.86	-	0.52	0.69	0.33	0.78	5.57	0.02	0.47	0.04	0.15	0.09	4.19	7.18	0.25	0.51	1.16	0.39	0.03	0.48	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.88
H3813_801_0	2007	4																					1500											A	A	D		T	O	O	V	P	P	P	V	P	P	V	V	V	V	P	P	S	V					V																																																								-	1500	222.85	2.23	596.74	0	183.45	25765.21	8767.11	296.98	271.97	43.96	835.24	13	713.07	194.27	3405.51	5412.81	125.6	453.5	1015.28	1853.97	142.61	433.68	0	0	0	0	62.34	0	0	0	0											400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											219.28	219.28	13.7	0	27.41	0.26	0.36	25.08	197.35	5.48	5.48	27.41	2.05	4.48	11.98	12.84	19.19	10.96	10.96	2.05	2.05	10.96	0	0	0	0	10.96	0	0	0	0											4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	0	19.19	4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	1500	400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											0.94	0.01	0.18	0	0.1	0.13	0.06	0.16	1.1	0	0.09	0.01	0.03	0.02	0.79	1.39	0.05	0.1	0.23	0.08	0.01	0.09	0	0	0	0	0.02	0	0	0	0											5.59	0	4.88	5.01	0.05	0.86	-	0.52	0.69	0.33	0.78	5.57	0.02	0.47	0.04	0.15	0.09	4.19	7.18	0.25	0.51	1.16	0.39	0.03	0.48	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.88
H3813_802_0	2007	4																					1500											A	A	D		T	O	O	V	P	P	P	V	P	P	V	V	V	V	P	P	S	V					V																																																								-	1500	222.85	2.23	596.74	0	183.45	25765.21	8767.11	296.98	271.97	43.96	835.24	13	713.07	194.27	3405.51	5412.81	125.6	453.5	1015.28	1853.97	142.61	433.68	0	0	0	0	62.34	0	0	0	0											400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											219.28	219.28	13.7	0	27.41	0.26	0.36	25.08	197.35	5.48	5.48	27.41	2.05	4.48	11.98	12.84	19.19	10.96	10.96	2.05	2.05	10.96	0	0	0	0	10.96	0	0	0	0											4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	0	19.19	4.07	0.04	0.68	-	0.42	0.56	0.26	0.62	4.47	0.02	0.38	0.03	0.12	0.07	3.4	5.79	0.2	0.41	0.93	0.32	0.02	0.4	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.28	1500	400 copay per admit	400 copay per admit	0 for 1st 20 days 50 21-100th	0 copay	50 copay	10 coinsurance	Supplies 10 coins Equipment 10 copay	50 ER copay 20 Primary Care and 35 Specialist copay	400 or 10 copay	0 copay	O/P Diag 10 to 100 O/P Radiation Therapy 35 O/P X-Ray 10	50 ER copay 20 Primary Care and 35 Specialist copay	10 coinsurance	10 coinsurance 20 Physical Therapy and O/P Psych copays	20 Office and Hospital Outpatient 20 Inpatient Hospital 10 diabetes monitoring 20 Urgent Care and 0 and 10 Immunizations	35 O/P Surgery PCP specialist Chiro and Podiatrist visits 35 inpatient visits	25 copay per visit	20 copay per visit	20 copay per visit	20 copay per visit	10 coinsurance	20 copay per visit	N/A	N/A	N/A	N/A	20 copay per visit	N/A	N/A	N/A	N/A											0.94	0.01	0.18	0	0.1	0.13	0.06	0.16	1.1	0	0.09	0.01	0.03	0.02	0.79	1.39	0.05	0.1	0.23	0.08	0.01	0.09	0	0	0	0	0.02	0	0	0	0											5.59	0	4.88	5.01	0.05	0.86	-	0.52	0.69	0.33	0.78	5.57	0.02	0.47	0.04	0.15	0.09	4.19	7.18	0.25	0.51	1.16	0.39	0.03	0.48	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.88
H3814_001_0	2007	2																					1500											A		D		T			V	V						V																																																																				-	None	1958.1		1424.44		338.08			570.28	438.33						13122.54																											100 per day up to 5 days		0 Copay Days 0-20 125 days 21+		50 Copay Waived if Admitted			50 Copay Waived if Admitted	200 Per Procedure						15 PCP 20 Specialist Copay																											65.24		20.57		29.21			43.56	168.3						17.33																											10.65	-	2.44	-	0.82	-	-	2.07	6.15	-	-	-	-	-	18.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.07	0	0.41	10.65	-	2.44	-	0.82	-	-	2.07	6.15	-	-	-	-	-	18.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.07	None																																																																																			-	0	0	10.65	-	2.44	-	0.82	-	-	2.07	6.15	-	-	-	-	-	18.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.07
H3814_004_0	2007	6																					1500											A		D		T	Coin		V	V	Coin	Coin				V				Coin	Coin																																																															-	None	1958.1		1424.44		338.08	36.74		570.28	438.33						13122.54																											100 per day up to 5 days		0 Copay Days 0-20 125 days 21+		50 Copay Waived if Admitted	10 Coinsurance (DME/Prosthetics)		50 Copay Waived if Admitted	200 Per Procedure						15 PCP 20 Specialist Copay																											65.24		20.57		29.21	0.08		43.56	168.3						17.33																											10.65	-	2.44	-	0.82	3.09	-	2.07	6.15	-	-	-	-	-	18.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.17	0	0.45	10.65	-	2.44	-	0.82	3.09	-	2.07	6.15	-	-	-	-	-	18.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.17	None																																																																																			-	0	0	10.65	-	2.44	-	0.82	3.09	-	2.07	6.15	-	-	-	-	-	18.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.17
H3814_005_0	2007	1																					1200											A		D		T			V	V						V																																																																				-	None	1670.74		1215.4		288.46			486.59	374.01						11196.76													40			400											100 per day up to 5 days		25 copay per day		50 Copay Waived if Admitted			50 Copay Waived if Admitted	100 Per Procedure						15 Copay per visit													15 Copay per visit			15 Copay per visit											64.58		24.5		28.91			43.12	83.3						14.7													14.7			14.7											8.99	-	2.48	-	0.69	-	-	1.75	2.6	-	-	-	-	-	13.72	-	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	0.49	-	-	-	-	-	-	-	-	-	-	30.77	0	0.63	8.99	-	2.48	-	0.69	-	-	1.75	2.6	-	-	-	-	-	13.72	-	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	0.49	-	-	-	-	-	-	-	-	-	-	30.77	None																																																																																			-	0	0	8.99	-	2.48	-	0.69	-	-	1.75	2.6	-	-	-	-	-	13.72	-	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	0.49	-	-	-	-	-	-	-	-	-	-	30.77
H3814_006_0	2007	5																					1200											A		D		T			V	V						V																																																																				-	None	1670.74		1215.4		288.46			486.59	374.01						11196.76													40			400											100 per day up to 5 days		25 copay per day		50 Copay Waived if Admitted			50 Copay Waived if Admitted	100 Per Procedure						15 Copay per visit													15 Copay per visit			15 Copay per visit											64.58		24.5		28.91			43.12	83.3						14.7													14.7			14.7											8.99	-	2.48	-	0.69	-	-	1.75	2.6	-	-	-	-	-	13.72	-	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	0.49	-	-	-	-	-	-	-	-	-	-	30.77	0	0.63	8.99	-	2.48	-	0.69	-	-	1.75	2.6	-	-	-	-	-	13.72	-	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	0.49	-	-	-	-	-	-	-	-	-	-	30.77	None																																																																																			-	0	0	8.99	-	2.48	-	0.69	-	-	1.75	2.6	-	-	-	-	-	13.72	-	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	0.49	-	-	-	-	-	-	-	-	-	-	30.77
H3814_007_0	2007	4																					None											A		D		T			V	V						V																																																																				-	None	2326.34		1692.32		401.66			677.53	520.77						15590.36																											100 per day up to 5 days		0 per Day days 1-20 125 per day days 21+		50 Copay waived if admitted			50 Copay waived if admitted	200 Copay						15 Copay																											65.9		47.35		29.5			44	170						15																											12.78	-	6.68	-	0.99	-	-	2.48	7.38	-	-	-	-	-	19.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.79	0	0	12.78	-	6.68	-	0.99	-	-	2.48	7.38	-	-	-	-	-	19.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.79	None																																																																																			-	0	0	12.78	-	6.68	-	0.99	-	-	2.48	7.38	-	-	-	-	-	19.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.79
H3815_001_0	2007	7																					Unlimited											D	D	D	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	O	P	P	P	P	P	P	P	P	P	P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	2.15	0	0	159.39	1047.99	78.46	286.43	0	0	0	0	27.25	1.19	2.82	0	193.9	0	0	0	624.77	0	0	0	0	0	0	0	0	0	0											1A - no cost sharing	1B - 150 per admit	2 - no cost sharing	6 - no cost sharing	10A  - 50 copay	11A  - 20 coins.	11B  - 20 coins.	4A - 50 copay	9 - no cost sharing	8B - no cost sharing	no cost sharing	no cost sharing	11C  - 25 copay	30 copay - partial hospitalization	4B  - 25 copay urgent care	7D - no cost sharing	7E & 7H  - 30 copay	7C&7I  - no cost sharing	no cost sharing	no cost sharing	20 coins 1000 OOP max	no cost sharing	10B - no cost sharing		17A - no cost sharing	17B  - no cost sharing	18A - no cost sharing	18B - no cost sharing	no cost sharing	no cost sharing	no cost sharing											0	150	0	0	50	24.7	39.65	50	0	0	0	0	25	30	25	0	30	0	0	0	27.76	0	0	0	0	0	0	0	0	0	0											-	0.03	-	-	0.66	2.16	0.26	1.19	-	-	-	-	0.06	0	0.01	-	0.48	-	-	-	1.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.3			-	0.03	-	-	0.66	2.16	0.26	1.19	-	-	-	-	0.06	0	0.01	-	0.48	-	-	-	1.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.3	0	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			-	0.03	-	-	0.66	2.16	0.26	1.19	-	-	-	-	0.06	0	0.01	-	0.48	-	-	-	1.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.3
H3817_001_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	660.02	9.56	643.96	651.06	966.71	3.02	188.34	306.15	312.33	2042.5	1034.92	0	0	2202.25	6755	702.15	187.11	668.13	3387.82	472.82	813.14	171.04	0	1243.07	463.66	246.16	74.05	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.55	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.5	0.08	-	-	4.03	1.65	-	1.28	-	-	-	-	-	-	2.81	0.29	0.08	0.28	-	0.2	-	-	-	-	0.19	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.42	0	0	5.5	0.08	-	-	4.03	1.65	-	1.28	-	-	-	-	-	-	2.81	0.29	0.08	0.28	-	0.2	-	-	-	-	0.19	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.42	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															7.49	0.08	0.69	0.32	0.14	0.44	0.02	0.31	0.73	0.52	1.03			1.34	1.74	0.62	0.03	0.04	0.67	2.86	0.15			0.08	0.12	0.08	0.02															19.52	250	12.18	12.99	0.16	0.69	0.32	4.17	2.09	0.02	1.59	0.73	0.52	1.03	-	-	1.34	4.55	0.91	0.11	0.32	0.67	3.06	0.15	-	-	0.08	0.31	0.08	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.94
H3817_002_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	660.02	9.56	643.96	651.06	966.71	3.02	188.34	306.15	312.33	2042.5	1034.92	0	0	2202.25	6755	702.15	187.11	668.13	3387.82	472.82	813.14	171.04	0	1243.07	463.66	246.16	74.05	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.55	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.5	0.08	-	-	4.03	1.65	-	1.28	-	-	-	-	-	-	2.81	0.29	0.08	0.28	-	0.2	-	-	-	-	0.19	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.42	0	0	5.5	0.08	-	-	4.03	1.65	-	1.28	-	-	-	-	-	-	2.81	0.29	0.08	0.28	-	0.2	-	-	-	-	0.19	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.42	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															7.49	0.08	0.69	0.32	0.14	0.44	0.02	0.31	0.73	0.52	1.03			1.34	1.74	0.62	0.03	0.04	0.67	2.86	0.15			0.08	0.12	0.08	0.02															19.52	250	12.18	12.99	0.16	0.69	0.32	4.17	2.09	0.02	1.59	0.73	0.52	1.03	-	-	1.34	4.55	0.91	0.11	0.32	0.67	3.06	0.15	-	-	0.08	0.31	0.08	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.94
H3817_003_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	660.02	9.56	643.96	651.06	966.71	3.02	188.34	306.15	312.33	2042.5	1034.92	0	0	2202.25	6755	702.15	187.11	668.13	3387.82	472.82	813.14	171.04	0	1243.07	463.66	246.16	74.05	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.55	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.5	0.08	-	-	4.03	1.65	-	1.28	-	-	-	-	-	-	2.81	0.29	0.08	0.28	-	0.2	-	-	-	-	0.19	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.42	0	0	5.5	0.08	-	-	4.03	1.65	-	1.28	-	-	-	-	-	-	2.81	0.29	0.08	0.28	-	0.2	-	-	-	-	0.19	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.42	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															7.49	0.08	0.69	0.32	0.14	0.44	0.02	0.31	0.73	0.52	1.03			1.34	1.74	0.62	0.03	0.04	0.67	2.86	0.15			0.08	0.12	0.08	0.02															19.52	250	12.18	12.99	0.16	0.69	0.32	4.17	2.09	0.02	1.59	0.73	0.52	1.03	-	-	1.34	4.55	0.91	0.11	0.32	0.67	3.06	0.15	-	-	0.08	0.31	0.08	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.94
H3818_001_0	2007	7																					1500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	P	P	V	V	V	V	V	P	V	Coin	P	T	P	V	P	V	P	P	P	P																																																				-	1500	1009.77			88.88	91.4	7.72	10.79	342.74		1930.61	25.09			180.29	4113.86	4707.82	154.42	549.01		166.93	23.16			1628.5	130.91		234.36															#1A  100/day days 1-5 0/day days 6-90	#1B 0	#2 0	#6 20	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 0 #9B 0	#8A 25	#8A 25 #8B 15	#9A 0	#12 0	#3 0 #5 100 #9C 25 #9D 15	#7A 15 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25	#7E 25 #7H 25	#7C 25 #7I 25	0 (incl in h2)	#14I 0	#15 20	#13A 0	#10B 0 n/c	#16A 12/35/8/40 #16B 45/870/200/830/50/250	#17A 25	#17B 0	#18A 20	#18B 0	0 n/c	#14A 0	#13B 0 n/c #13C 0											56.82			14.18	35.44	0.14	0.14	33.32		7.72	0.11			17.72	10.81	17.42	17.57	17.72		10.7	0.14			20.44	25		20															4.78	-	-	0.11	0.27	1.09	1.53	0.95	-	1.24	2.67	-	-	0.27	3.71	6.83	0.23	0.81	-	0.15	3.28	-	-	2.77	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.35		11.33	4.78	-	-	0.11	0.27	1.09	1.53	0.95	-	1.24	2.67	-	-	0.27	3.71	6.83	0.23	0.81	-	0.15	3.28	-	-	2.77	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.35																																																																																				-		0	4.78	-	-	0.11	0.27	1.09	1.53	0.95	-	1.24	2.67	-	-	0.27	3.71	6.83	0.23	0.81	-	0.15	3.28	-	-	2.77	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.35
H3818_002_0	2007	7																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		277.73	32.86	42.3		16.67	23.29	18.79	1096.54	30.88	21.28	18.87	4.42	0.57	34.34	22.49	27.44	8.36	4.44	20.7	80.75	17.48	0.08																				#1A mcare ffs cost share	#1B mcare ffs cost share	#2 mcare ffs cost share	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8A 20 #8B 20	#9A 20	#12 20	#3 20 #5 20 #9C 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 0 #14E 20 #14F 20 #14G 20 #14H 20 #18A 20	#7B 20 #7D 20 #7F 20 #7G 20 #16B 0 #17A 20	#7E 20 #7H 20	#7C 20 #7I 20	20 (incl in h2)	#14I 20	#15 20	#13A 20	#10B 0 n/c #13E 0	#16A 0 #16B 0	#17A 0	#17B 0	#18A 0 n/c	#18B 0 n/c	#19 0 n/c	#13D 0 #14A 0	#13B 0 n/c #13C 0											0.07	0.07	0.14		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				19.94	2.36	5.83	-	3.93	5.5	4.44	4.57	7.29	5.02	4.45	1.04	0.13	8.1	5.31	6.48	1.97	1.05	4.88	19.06	4.12	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.49	138	0	19.94	2.36	5.83	-	3.93	5.5	4.44	4.57	7.29	5.02	4.45	1.04	0.13	8.1	5.31	6.48	1.97	1.05	4.88	19.06	4.12	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.49																																																																																				-		0	19.94	2.36	5.83	-	3.93	5.5	4.44	4.57	7.29	5.02	4.45	1.04	0.13	8.1	5.31	6.48	1.97	1.05	4.88	19.06	4.12	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.49
H3818_003_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	P	Coin	P	V	V	V	V	P	P	Coin	P	T	V	V	P	V	P	P	P	P																																																				-	3000	1003.42			88.77	91.28	7.7	10.76	342.29	40.61	1928.06	25.03		0.03	893.08	4108.52	4701.7	154.21	548.28			23.1			1628.5	130.91																	#1A 200/day days 1-5 0/day days 6-90	#1B 0	#2 0	#6 20	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 50 #9B 20	#8A 30	#8A 20 #8B 20	#9A 0	#12 20	#3 0 #5 200 #9C 30 #9D 20	#7A 15 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 30 #7D 30 #7F 30 #7G 30 #17A 20	#7E 30 #7H 30	#7C 30 #7I 30	0 (incl in h2)	#14I 0	#15 20	#13A 0	#10B 0 n/c	#16A 12/35/8/40 #16B 45/870/200/830/50/250	#17A 25	#17B 0	#18A 0	#18B 0 n/c	0 n/c	#14A 0	#13B 0 n/c #13C 0											122.44			15.3	38.26	0.15	0.15	35.96	0.15	11.09	0.15		0.15	36.9	11.54	22.02	22.8	22.67			0.15			20.44	25																	10.24	-	-	0.11	0.29	1.18	1.65	1.03	6.22	1.78	3.83	-	0	2.75	3.95	8.63	0.29	1.04	-	-	3.54	-	-	2.77	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.57		14.2	10.24	-	-	0.11	0.29	1.18	1.65	1.03	6.22	1.78	3.83	-	0	2.75	3.95	8.63	0.29	1.04	-	-	3.54	-	-	2.77	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.57																																																																																				-		0	10.24	-	-	0.11	0.29	1.18	1.65	1.03	6.22	1.78	3.83	-	0	2.75	3.95	8.63	0.29	1.04	-	-	3.54	-	-	2.77	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.57
H3818_004_0	2007	4																					2500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	P	Coin	P	V	V	V	V	P	P	Coin	P	T	V	V	P	V	P	P	P	P																																																				-	2500	1006.67			88.61	91.12	7.67	10.72	341.69	40.47	1924.68	24.94	72.44	0.03	181.93	4101.47	4693.62	153.94	547.33			23.02			1628.5	130.91		234.36															#1A 200/day days 1-5 0/day days 6-90	#1B 0	#2 0	#6 20	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8A 20 #8B 20	#9A 20	#12 20	#3 0 #5 20 #9C 20 #9D 20	#7A 20 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 30 #7D 30 #7F 30 #7G 30 #17 20	#7E 30 #7H 30	#7C 30 #7I 30	0 (incl in h2)	#14I 0	#15 20	#13A 0	#10B 0 n/c	#16A 12/35/8/40 #16B 45/870/200/830/50/250	#17A 25	#17B 0	#18A 20	#18B 0	0 n/c	#14A 0	#13B 0 n/c #13C 0											117.53			14.67	36.66	0.15	0.15	34.46	0.15	10.61	0.15	65.3	0.15	53.45	11.07	21.12	21.85	21.72			0.15			20.44	25		20															9.86	-	-	0.11	0.28	1.13	1.57	0.98	5.93	1.7	3.66	0.39	0	0.81	3.79	8.26	0.28	0.99	-	-	3.38	-	-	2.77	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56		15.58	9.86	-	-	0.11	0.28	1.13	1.57	0.98	5.93	1.7	3.66	0.39	0	0.81	3.79	8.26	0.28	0.99	-	-	3.38	-	-	2.77	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56																																																																																				-		0	9.86	-	-	0.11	0.28	1.13	1.57	0.98	5.93	1.7	3.66	0.39	0	0.81	3.79	8.26	0.28	0.99	-	-	3.38	-	-	2.77	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.56
H3856_007_0	2007	3																					1500											D	D	D	P	T	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P			P	Coin																0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	965.84	14.5	0	16.78	231.17	7.8	0	323.74	234.73	83.89	0	0	0	0	4673.75	3525.96	72.87	1128.2	0	0	0	103.5	0	0	203.83	3.9	0	0	0	0	0											100 per day (days 1-8)	100 per day (days 1-8)			50	20 Coinsurance		50							20	20	20	20				20			20	20 Coinsurance																100	100			50	0.2		50							20	20	20	20				20			20	0.2																8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	N/A																																																																																			-	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29
H3856_010_0	2007	1																					1500											D	D	D	P	T	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P			P	Coin																0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	965.84	14.5	0	16.78	231.17	7.8	0	323.74	234.73	83.89	0	0	0	0	4673.75	3525.96	72.87	1128.2	0	0	0	103.5	0	0	203.83	3.9	0	0	0	0	0											100 per day (days 1-8)	100 per day (days 1-8)			50	20 Coinsurance		50							20	20	20	20				20			20	20 Coinsurance																100	100			50	0.2		50							20	20	20	20				20			20	0.2																8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	1500																																																																																			-	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29
H3856_014_0	2007	3																					1500											D	D	D	P	T	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P			P	Coin																0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	965.84	14.5	0	16.78	231.17	7.8	0	323.74	234.73	83.89	0	0	0	0	4673.75	3525.96	72.87	1128.2	0	0	0	103.5	0	0	203.83	3.9	0	0	0	0	0											100 per day (days 1-8)	100 per day (days 1-8)			50	20 Coinsurance		50							20	20	20	20				20			20	20 Coinsurance																100	100			50	0.2		50							20	20	20	20				20			20	0.2																8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	N/A																																																																																			-	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29
H3856_016_0	2007	2																					1500											D	D	D	P	T	Coin	P	P	P	P	P	P	P	P	P	P	P	P	P	P	S	P			P	Coin																0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	965.84	14.5	0	16.78	231.17	7.8	0	323.74	234.73	83.89	0	0	0	0	4673.75	3525.96	72.87	1128.2	0	0	0	103.5	0	0	203.83	3.9	0	0	0	0	0											100 per day (days 1-8)	100 per day (days 1-8)			50	20 Coinsurance		50							20	20	20	20				20			20	20 Coinsurance																100	100			50	0.2		50							20	20	20	20				20			20	0.2																8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29	N/A																																																																																			-	0	0	8.05	0.12	-	-	0.96	1.56	-	1.35	-	-	-	-	-	-	7.79	5.88	0.12	1.88	-	-	-	0.17	-	-	0.34	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29
H3864_001_0	2007	4																					None															T	Coin	Coin	V							V	V	V	V								V					V																																																				-	None					134.43	9.51	1.51	304.34							3627.59	5387.71	157.62	1416.23								15.12					83.07															50 Copay waived if admitted	20 coins up to 500 max	20 coins up to 500 max	50 Copay waived if admitted							10 Office Visit	10 Office Visit	10 Office Visit	10 Office Visit								10 Office Visit					10 Office Visit															24.56	0.17	0.17	45.81							10	10	10	10								10					10											-	-	-	-	0.28	1.6	0.25	1.16	-	-	-	-	-	-	3.02	4.49	0.13	1.18	-	-	-	-	-	-	-	0.01	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	12.2	0	0	-	-	-	-	0.28	1.6	0.25	1.16	-	-	-	-	-	-	3.02	4.49	0.13	1.18	-	-	-	-	-	-	-	0.01	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	12.2	None																																																																																			-	0	0	-	-	-	-	0.28	1.6	0.25	1.16	-	-	-	-	-	-	3.02	4.49	0.13	1.18	-	-	-	-	-	-	-	0.01	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	12.2
H3864_002_0	2007	3																					1200											D		D		T	Coin	Coin	V	V						V	V	V	V								V					V																																																				-	None	1599.08		54.62		267.96	22.25	2.69	639.25	239.5						3362.42	4516.59	857.73	790.04								17.99					78.61											100 per day to 5 days		25 per day		50 Copay waived if admitted	20 coins up to 500 max	20 coins up to 500 max	50 Copay waived if admitted	200 per visit						15 Copay per visit	15 Copay per visit	15 Copay per visit	15 Copay per visit								15 Copay per visit					15 Copay per visit											55.08		24.5		24.83	0.14	0.14	39.94	196						14.7	14.7	14.7	14.7								14.7					14.7											7.34	-	0.11	-	0.55	3.21	0.39	2.13	3.91	-	-	-	-	-	4.12	5.53	1.05	0.97	-	-	-	-	-	-	-	0.02	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	29.44	0	0.6	7.34	-	0.11	-	0.55	3.21	0.39	2.13	3.91	-	-	-	-	-	4.12	5.53	1.05	0.97	-	-	-	-	-	-	-	0.02	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	29.44	None																																																																																			-	0	0	7.34	-	0.11	-	0.55	3.21	0.39	2.13	3.91	-	-	-	-	-	4.12	5.53	1.05	0.97	-	-	-	-	-	-	-	0.02	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	29.44
H3864_006_0	2007	7																					1200											D		D		T	Coin	Coin	V	V						V	V	V	V								V					V																																																				-	None	1599.08		54.62		267.96	22.25	2.69	639.25	239.5						3362.42	4516.59	857.73	790.04								17.99					78.61											100 per day to 5 days		25 per day		50 Copay waived if admitted	20 coins up to 500 max	20 coins up to 500 max	50 Copay waived if admitted	200 per visit						15 copay per visit	15 copay per visit	15 copay per visit	15 copay per visit								15 copay per visit					15 copay per visit											55.08		24.5		24.83	0.14	0.14	39.94	196						14.7	14.7	14.7	14.7								14.7					14.7											7.34	-	0.11	-	0.55	3.21	0.39	2.13	3.91	-	-	-	-	-	4.12	5.53	1.05	0.97	-	-	-	-	-	-	-	0.02	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	29.44	0	0.6	7.34	-	0.11	-	0.55	3.21	0.39	2.13	3.91	-	-	-	-	-	4.12	5.53	1.05	0.97	-	-	-	-	-	-	-	0.02	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	29.44	None																																																																																			-	0	0	7.34	-	0.11	-	0.55	3.21	0.39	2.13	3.91	-	-	-	-	-	4.12	5.53	1.05	0.97	-	-	-	-	-	-	-	0.02	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	29.44
H3864_007_0	2007	7																					None											A				T	Coin	Coin	V							V	V	V	V									V				V																																																				-	None	241.6				134.43	9.64	1.53	304.34							3518.76	5226.08	152.89	1373.75									14.67				80.58											100 per admit				50 Copay waived if admitted	20 coins up to 500 max	20 coins up to 500 max	50 Copay waived if admitted							10 Copay per visit	15 Copay per visit	15 Copay per visit	15 Copay per visit									15 Copay per visit				15 Copay per visit											100				24.56	0.17	0.17	45.81							10	15	15	15									15				15											2.01	-	-	-	0.28	1.62	0.26	1.16	-	-	-	-	-	-	2.93	6.53	0.19	1.72	-	-	-	-	-	-	-	-	0.02	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	16.82	0	0	2.01	-	-	-	0.28	1.62	0.26	1.16	-	-	-	-	-	-	2.93	6.53	0.19	1.72	-	-	-	-	-	-	-	-	0.02	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	16.82	None																				10 coinsurance office visits only																																									0.83																						0.83	0	0	2.01	-	-	-	0.28	1.62	0.26	1.16	-	-	-	-	-	-	2.93	6.53	0.19	1.72	-	0.83	-	-	-	-	-	-	0.02	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	17.66
H3864_009_0	2007	3																																				T	Coin	Coin	V						V		P	P			P		V					V																																																								-						165.84	12.68	0.54	286.92						1427.07		1314.19	480.45			33687.54		64.74					243.97																			50 for Medicare covered ambulance services	20 coinsurance	20 coinsurance	50 for Medicare covered ER services 0 if admitted within 12 hours						10 PT/OT/ST copay		15 copay	15 copay			15 PCP/SCP copay per visit		15 copay for vision and hearing (Medicare covered)					15 copay for fit and eval 0 for routine exam																			50	0.2	0.2	34.9						0.93		15.67	15.67			3.34		15.67					2.95															-	-	-	-	0.69	2.54	0.11	0.83	-	-	-	-	-	0.11	-	1.72	0.63	-	-	9.38	-	0.08	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.14			-	-	-	-	0.69	2.54	0.11	0.83	-	-	-	-	-	0.11	-	1.72	0.63	-	-	9.38	-	0.08	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.14																																																																																				-			-	-	-	-	0.69	2.54	0.11	0.83	-	-	-	-	-	0.11	-	1.72	0.63	-	-	9.38	-	0.08	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.14
H3864_010_0	2007	3																																D	D	D		T	Coin	Coin	V	V					V		P	P			P		V					V																																																								-		1133.7	67.72	1730.62		165.59	12.66	0.54	286.48	257.41					1424.18		1267.48	491.41			33448		64.64					243.59															100 days 1-5 0 days 6-90	100 days 1-5 0 days 6-90	25 days 1-100		50 copay	20 coinsurance	20 coinsurance	50 for Medicare covered ER services 0 if admitted within 12 hours	200 copay					10 PT/OT/ST copay		20 copay	20 copay			20 PCP/SCP copay per visit		20 copay for vision and hearing (Medicare covered)					20 copay for fit and eval 0 for routine exam															62.81	62.81	13.98		50	0.2	0.2	35.75	200					0.93		20.69	20.69			4.31		20.69					20.69															5.93	0.35	2.02	-	0.69	2.53	0.11	0.85	4.29	-	-	-	-	0.11	-	2.19	0.85	-	-	12.02	-	0.11	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.47			5.93	0.35	2.02	-	0.69	2.53	0.11	0.85	4.29	-	-	-	-	0.11	-	2.19	0.85	-	-	12.02	-	0.11	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.47																																																																																				-			5.93	0.35	2.02	-	0.69	2.53	0.11	0.85	4.29	-	-	-	-	0.11	-	2.19	0.85	-	-	12.02	-	0.11	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.47
H3864_011_0	2007	2																																D	D	D		T	Coin	Coin	V	V					V		P	P			P		V					V																																																								-		1133.7	67.72	1730.62		165.59	12.66	0.54	286.48	257.41					1424.18		1267.48	491.41			33448		64.64					243.59															100 days 1-5 0 days 6-90	100 days 1-5 0 days 6-90	25 days 1-100		50 copay	20 coinsurance	20 coinsurance	50 for Medicare covered ER services 0 if admitted within 12 hours	200 copay					10 PT/OT/ST copay		15 copay	15 copay			15 PCP/SCP copay per visit		15 copay for vision and hearing (Medicare covered)					15 copay for fit and eval 0 for routine exam															62.81	62.81	13.98		50	0.2	0.2	35.75	200					0.93		15	15			3.13		15					15															5.93	0.35	2.02	-	0.69	2.53	0.11	0.85	4.29	-	-	-	-	0.11	-	1.58	0.61	-	-	8.73	-	0.08	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.2			5.93	0.35	2.02	-	0.69	2.53	0.11	0.85	4.29	-	-	-	-	0.11	-	1.58	0.61	-	-	8.73	-	0.08	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.2																																																																																				-			5.93	0.35	2.02	-	0.69	2.53	0.11	0.85	4.29	-	-	-	-	0.11	-	1.58	0.61	-	-	8.73	-	0.08	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.2
H3864_012_0	2007	2																																				T	Coin	Coin	V						V		P	P			P		V					V																																																								-						165.84	12.68	0.54	286.92						1427.07		1314.19	480.45			33687.54		64.74					243.97																			50 for Medicare covered ambulance services	20 coinsurance	20 coinsurance	50 for Medicare covered ER services 0 if admitted within 12 hours						10 PT/OT/ST copay		10 copay	10 copay			10 PCP/SCP copay per visit		10 copay for vision and hearing (Medicare covered)					10 copay for fit and eval 0 for routine exam																			50	0.2	0.2	34.9						0.93		10	10			2.14		10					1.88															-	-	-	-	0.69	2.54	0.11	0.83	-	-	-	-	-	0.11	-	1.1	0.4	-	-	6	-	0.05	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87			-	-	-	-	0.69	2.54	0.11	0.83	-	-	-	-	-	0.11	-	1.1	0.4	-	-	6	-	0.05	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87																																																																																				-			-	-	-	-	0.69	2.54	0.11	0.83	-	-	-	-	-	0.11	-	1.1	0.4	-	-	6	-	0.05	-	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87
H3864_801_0	2007	2																					None															T			V							V	V	V	V							V						V																																																				-	None					100.63			243.47							3035.32	5153.22	113.22	1406.48							19.84						126.06															50 Copay waived if admitted			50 Copay waived if admitted							10 Office visit copay	10 Office visit copay	10 Office visit copay	10 Office visit copay							10 Office visit copay						10 Office visit copay															30.23			44.62							10	10	10	10							10						10											-	-	-	-	0.25	-	-	0.91	-	-	-	-	-	-	2.53	4.29	0.09	1.17	-	-	-	-	-	-	0.02	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	9.37	0	0	-	-	-	-	0.25	-	-	0.91	-	-	-	-	-	-	2.53	4.29	0.09	1.17	-	-	-	-	-	-	0.02	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	9.37	None																																																																																			-	0	0	-	-	-	-	0.25	-	-	0.91	-	-	-	-	-	-	2.53	4.29	0.09	1.17	-	-	-	-	-	-	0.02	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	9.37
H3864_802_0	2007	4																					None															T			V							V	V	V	V							V						V																																																				-	None					100.63			243.47							3035.32	5153.22	113.22	1406.48							19.84						126.06															50 Copay waived if admitted			50 Copay waived if admitted							10 Office visit copay	10 Office visit copay	10 Office visit copay	10 Office visit copay							10 Office visit copay						10 Office visit copay															30.23			44.62							10	10	10	10							10						10											-	-	-	-	0.25	-	-	0.91	-	-	-	-	-	-	2.53	4.29	0.09	1.17	-	-	-	-	-	-	0.02	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	9.37	0	0	-	-	-	-	0.25	-	-	0.91	-	-	-	-	-	-	2.53	4.29	0.09	1.17	-	-	-	-	-	-	0.02	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	9.37	None																																																																																			-	0	0	-	-	-	-	0.25	-	-	0.91	-	-	-	-	-	-	2.53	4.29	0.09	1.17	-	-	-	-	-	-	0.02	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	9.37
H3887_001_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						2400	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		2355.58	219.34	9102.03	170.59	640.24	22.49	7.05	184.13	122.25	3803.33	169.08	33.43	4.38	284.28	127.38	1275.76	1657.27	19.58		266.38	269.91	1302.63	2137.5		133.19							108.57	0.27	0.07	285	280.44						(1a) 175/day	(1b) 175/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 35/visit	(8a) 0/visit	(8b) 0/visit	(9a) 35/visit	(12) 0/proc	(9a) 35/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 15/visit	(7e/7h) 32.5/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 15/visit	(15) 0/proc	(16b/17a) 15/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit							(4b) 35/visit (waived if admitted)	(9c) 32.5/visit 75/25 Ind/Grp Blended Copay	(9d) 35/visit	(7f1) 0/visit	(18a1) 0/visit						157	157			67	18	18	45	31			31		31		13	29			13		13										31	29	31								30.73	2.86	-	-	3.58	4.02	1.26	0.69	0.32	-	-	0.09	-	0.74	-	1.43	4.02	-	-	0.3	-	1.46	-	-	-	-	-	-	-	-	-	0.28	0	0	-	-	-	-	-	-	-	51.77		6.1	30.73	2.86	-	-	3.58	4.02	1.26	0.69	0.32	-	-	0.09	-	0.74	-	1.43	4.02	-	-	0.3	-	1.46	-	-	-	-	-	-	-	-	-	0.28	0	0	-	-	-	-	-	-	-	51.77		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						3.28	0.09	0.93	0.09	0.41	0.36	0.11	0.04	0.22	0.67	0.75	0.04	0.01	0.13	0.01	1.95	0.18	0		0.19		0.13	0.11		0.02							0.02	0	0	0.02	0.02						9.79		0	34.01	2.95	0.93	0.09	3.99	4.38	1.37	0.73	0.54	0.67	0.75	0.13	0.01	0.87	0.01	3.38	4.19	0	-	0.49	-	1.59	0.11	-	0.02	-	-	-	-	-	-	0.3	0	0	0.02	0.02	-	-	-	-	-	61.56
H3887_002_0	2007	7	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1650	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T		V		V	P		O	O	V		V	V																																																-		2578.28	370.12	1736.03		331.02	31.05	25.9	969.83	393.67	2322.25	966.77	69.13	3.49	2144.85		3657.65		531.76		842.96	19.4											340.69		149.98	254.67							(1a) 150 per Day	(1b) 150 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit		(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							84	84	20		42	11	11	20	14	6	6	14	11	14		6		6		6	11											6		6	6							18.15	2.61	2.93	-	1.17	3.5	2.92	1.64	0.46	1.09	0.45	0.08	0.39	2.52	-	1.72	-	0.25	-	0.4	2.19	-	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	42.8		33.2	18.15	2.61	2.93	-	1.17	3.5	2.92	1.64	0.46	1.09	0.45	0.08	0.39	2.52	-	1.72	-	0.25	-	0.4	2.19	-	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	42.8		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance		30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.63	0.17	0.48	0.49	0.09	0.19	0.16	0.05	0.2	0.15	0.14	0.02	0.02	0.25	0.36	0.24	0.05	0.03	0.16	0.8	0.15	0																				6.83		0	20.78	2.78	3.41	0.49	1.25	3.69	3.08	1.69	0.67	1.24	0.59	0.1	0.41	2.77	0.36	1.95	0.05	0.28	0.16	1.2	2.34	0	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	49.62
H3887_003_0	2007	4																					2950											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1887.26	164.41	898.25	0	254.03	14.21	6.13	469.89	31.51	6773.84	43.84	0	0.21	23.98	3106.47	3640.14	624.82	1.83	0	0	21.99	632.97	0	0	142.56	0	197.53	0	0	0	0											225 (1a)	225 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											125.1	125.1	69.5	0	97.3	0.17	0.19	27.8	0.17	3.34	0.13	0	0.17	0.17	5	25	37.5	0.17	0	0	0.17	25	0	0	25	0	25	0	0	0	0											19.68	1.71	5.2	-	2.06	2.37	1.17	1.09	5.26	1.88	5.57	-	0.04	4	1.29	7.58	1.95	0.31	-	-	3.67	1.32	-	-	0.3	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.86		42.85	19.68	1.71	5.2	-	2.06	2.37	1.17	1.09	5.26	1.88	5.57	-	0.04	4	1.29	7.58	1.95	0.31	-	-	3.67	1.32	-	-	0.3	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.86		295 (1a)	295 (1b)	150 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											4.03	0.35	0.98	0.78	0.81	0.94	0.4	0.43	2.77	0.99	2.93	0	0.01	2.1	1.58	2.33	0.49	0.16	0	0	1.45	0.41	0	0	0.09	0	0.13	0	0	0	0											24.16		0	23.71	2.07	6.18	0.78	2.87	3.31	1.58	1.52	8.02	2.87	8.5	-	0.05	6.11	2.87	9.91	2.44	0.47	-	-	5.12	1.72	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.03
H3887_004_0	2007	3																					2500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1887.27	164.41	898.26	0	254.03	14.21	6.13	469.89	31.51	6773.85	43.84	0	0.21	23.98	3106.48	3640.15	624.82	1.83	0	0	21.99	632.98	0	0	142.56	0	197.53	0	0	0	0											225 (1a)	225 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											115.84	115.84	64.36	0	90.1	0.15	0.18	25.74	0.15	3.09	0.12	0	0.15	0.15	5	25	37.5	0.15	0	0	0.15	25	0	0	25	0	25	0	0	0	0											18.22	1.59	4.82	-	1.91	2.2	1.11	1.01	4.87	1.74	5.16	-	0.03	3.71	1.29	7.58	1.95	0.28	-	-	3.4	1.32	-	-	0.3	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.89		46.82	18.22	1.59	4.82	-	1.91	2.2	1.11	1.01	4.87	1.74	5.16	-	0.03	3.71	1.29	7.58	1.95	0.28	-	-	3.4	1.32	-	-	0.3	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.89		295 (1a)	295 (1b)	150 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											4.03	0.35	0.98	0.78	0.81	0.94	0.4	0.43	2.77	0.99	2.93	0	0.01	2.1	1.58	2.33	0.49	0.16	0	0	1.45	0.41	0	0	0.09	0	0.13	0	0	0	0											24.16		0	22.25	1.94	5.79	0.78	2.72	3.13	1.52	1.44	7.63	2.74	8.09	-	0.05	5.81	2.87	9.91	2.44	0.44	-	-	4.85	1.72	-	-	0.39	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.06
H3887_801_0	2007	6																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1981.62	172.63	943.16	0	266.73	14.92	6.44	493.38	33.09	7112.52	46.03	0	0.22	25.18	3261.79	3822.14	656.06	1.93	0	0	23.09	664.62	0	0	149.68	0	207.41	0	0	0	0											325 (1a)	325 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											205.55	205.55	94.87	0	110.68	0.16	0.18	31.62	0.16	3.79	0.12	0	0.19	0.16	20	30	37.5	0.16	0	0	0.19	30	0	0	30	0	30	0	0	0	0											33.94	2.96	7.46	-	2.46	2.36	1.13	1.3	5.23	2.25	5.54	-	0.04	3.98	5.44	9.56	2.05	0.3	-	-	4.38	1.66	-	-	0.37	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.94		42.44	33.94	2.96	7.46	-	2.46	2.36	1.13	1.3	5.23	2.25	5.54	-	0.04	3.98	5.44	9.56	2.05	0.3	-	-	4.38	1.66	-	-	0.37	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.94		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											5.38	0.47	1.2	0.82	0.85	0.98	0.42	0.45	2.91	1.04	3.08	0	0.01	2.21	1.95	2.45	0.51	0.17	0	0	1.52	0.43	0	0	0.1	0	0.13	0	0	0	0											27.09		0	39.33	3.43	8.65	0.82	3.31	3.34	1.55	1.75	8.14	3.29	8.62	-	0.06	6.19	7.39	12	2.56	0.47	-	-	5.9	2.09	-	-	0.47	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.03
H3887_802_0	2007	3																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1981.62	172.63	943.16	0	266.73	14.92	6.44	493.38	33.09	7112.52	46.03	0	0.22	25.18	3261.79	3822.14	656.06	1.93	0	0	23.09	664.62	0	0	149.68	0	207.41	0	0	0	0											325 (1a)	325 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											205.55	205.55	94.87	0	110.68	0.16	0.18	31.62	0.16	3.79	0.12	0	0.19	0.16	20	30	37.5	0.16	0	0	0.19	30	0	0	30	0	30	0	0	0	0											33.94	2.96	7.46	-	2.46	2.36	1.13	1.3	5.23	2.25	5.54	-	0.04	3.98	5.44	9.56	2.05	0.3	-	-	4.38	1.66	-	-	0.37	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.94		42.44	33.94	2.96	7.46	-	2.46	2.36	1.13	1.3	5.23	2.25	5.54	-	0.04	3.98	5.44	9.56	2.05	0.3	-	-	4.38	1.66	-	-	0.37	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.94		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											5.38	0.47	1.2	0.82	0.85	0.98	0.42	0.45	2.91	1.04	3.08	0	0.01	2.21	1.95	2.45	0.51	0.17	0	0	1.52	0.43	0	0	0.1	0	0.13	0	0	0	0											27.09		0	39.33	3.43	8.65	0.82	3.31	3.34	1.55	1.75	8.14	3.29	8.62	-	0.06	6.19	7.39	12	2.56	0.47	-	-	5.9	2.09	-	-	0.47	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.03
H3907_002_0	2007	3																					3100											A	A	D		T	coin	coin	V	V		P			V	V	V	V	V			S	P	T		V																																																										-	N/A	331.77	9.12	266.06		203.74	9.74	2.28	483.93	502.23		1921.6			154.64	4530.97	5424.08	0.12	667.54			1303.11	1664.82	37.99		14.17																	1a:  250 per admit max 3	1b:  250 per admit max 3	2a:  50 per day day 16-100		10a:  100 per trip	11a:  15 coinsurance	11b:  15 coinsurance	4ab:  50 copay	9a-b:  150 copay		8b:  15/50 Copay depending on service			7ci:  30 Outpatient Copays	7a 14c:  10 Copay	7bdfg17a 18a:  30 Copay	7eh 9c:  30 Copay	7c7i:  30 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  100 Copay per trip		17a:  30 copay																	237.5	237.5	47.5		95	0.14	0.14	47.5	142.5		30.36			28.5	9.5	28.5	28.5	28.5			19	19	95		28.5																	6.57	0.18	1.05	-	1.61	1.36	0.32	1.92	5.96	-	4.86	-	-	0.37	3.59	12.88	0	1.59	-	-	2.06	2.64	0.3	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.29		0	6.57	0.18	1.05	-	1.61	1.36	0.32	1.92	5.96	-	4.86	-	-	0.37	3.59	12.88	0	1.59	-	-	2.06	2.64	0.3	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.29	3100																																																																																			-			6.57	0.18	1.05	-	1.61	1.36	0.32	1.92	5.96	-	4.86	-	-	0.37	3.59	12.88	0	1.59	-	-	2.06	2.64	0.3	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.29
H3907_006_0	2007	3																					3100											A	A	D		T	coin	coin	V	V		P			V		V	V	V			S	P	T	V	V		V																																																								-	N/A	360.4	10.58	183.22		178.2	16.35	2.12	460.88	476.27		1903.62			202.57		5366.86	0.2	826.35			2323.05	2967.86	29.12	0.21	9.78		6.32															1a:  100 per Admit max 3	1b:  100 per Admit max 3	2:  50 per day day 16 - 100		10a:  100 per Trip	11a:  15 Coinsurance	11b:  15 Coinsurance	4ab:  50 Copay	9ab:  60 Copay		8b:  15/50 Copay depending on type of Service			7cj:  25 Copay		7bdfg 17a 18a:  25 Copay	7eh 9c:  25 Copay	7ci:  25 Copay			15:  10/30 Copay per 30/90 day supply	11c:  10/30 Copay per 30/90 day supply	10a:  100 per Trip	16a:  25 Copay 16b:  20 coinsurance	17a:  25 copay		18a:  25 copay															95	95	47.5		95	0.14	0.14	47.5	57		29.96			23.75		23.75	23.75	23.75			9.5	9.5	95	23.75	23.75		23.75															2.85	0.08	0.73	-	1.41	2.29	0.3	1.82	2.26	-	4.75	-	-	0.4	-	10.62	0	1.64	-	-	1.84	2.35	0.23	0	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.61			2.85	0.08	0.73	-	1.41	2.29	0.3	1.82	2.26	-	4.75	-	-	0.4	-	10.62	0	1.64	-	-	1.84	2.35	0.23	0	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.61	3100																																																																																			-			2.85	0.08	0.73	-	1.41	2.29	0.3	1.82	2.26	-	4.75	-	-	0.4	-	10.62	0	1.64	-	-	1.84	2.35	0.23	0	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.61
H3907_020_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		415.84	56.92	74.86		19.95	17.48	21.23	27.01	33.71	26.61	27.94	1.35	0.59	51	21.45	34.22	10.32	2.47	22.44	131.06	19.78	0.09																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				30.96	4.24	14.16	-	4.71	4.12	5.01	6.37	7.96	6.28	6.59	0.32	0.14	12.04	5.06	8.08	2.43	0.58	5.3	30.93	4.67	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	159.97		0	30.96	4.24	14.16	-	4.71	4.12	5.01	6.37	7.96	6.28	6.59	0.32	0.14	12.04	5.06	8.08	2.43	0.58	5.3	30.93	4.67	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	159.97																																																																																				-			30.96	4.24	14.16	-	4.71	4.12	5.01	6.37	7.96	6.28	6.59	0.32	0.14	12.04	5.06	8.08	2.43	0.58	5.3	30.93	4.67	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	159.97
H3907_021_0	2007	4																					3100											A	A	D		T	coin	coin	V	V		P			V	V	V	V	V			S	P	T		V																																																										-	N/A	331.77	9.12	266.06		203.74	9.74	2.28	483.93	502.23		1921.6			154.64	4530.97	5424.08	0.12	667.54			1303.11	1664.82	37.99		14.17																	1a:  200 per admit max 3	1b:  200 per admit max 3	2a:  50 per day day 16-100		10a:  100 per trip	11a:  15 coinsurance	11b:  15 coinsurance	4ab:  50 copay	9a-b:  150 copay		8b:  15/50 Copay depending on service			7ci:  30 Outpatient Copays	7a 14c:  10 Copay	7bdfg17a 18a:  30 Copay	7eh 9c:  30 Copay	7c7i:  30 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  100 Copay per trip		17a:  30 copay																	190	190	47.5		95	0.14	0.14	47.5	142.5		30.36			28.5	9.5	28.5	28.5	28.5			19	19	95		28.5																	5.25	0.14	1.05	-	1.61	1.36	0.32	1.92	5.96	-	4.86	-	-	0.37	3.59	12.88	0	1.59	-	-	2.06	2.64	0.3	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.94		0	5.25	0.14	1.05	-	1.61	1.36	0.32	1.92	5.96	-	4.86	-	-	0.37	3.59	12.88	0	1.59	-	-	2.06	2.64	0.3	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.94	3100																																																																																			-			5.25	0.14	1.05	-	1.61	1.36	0.32	1.92	5.96	-	4.86	-	-	0.37	3.59	12.88	0	1.59	-	-	2.06	2.64	0.3	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.94
H3907_801_0	2007	2																					3100															T	coin	coin	V	V		P			V		V	V	V			S	P	T	V	V		V																																																								-	N/A					259.36	17.44	2.83	568.71	593.11		2447.14			161.86		7483.23	0.48	1168.55			896.62	801.31	20.14	0.24	0		0.12																			10a:  50 per trip	11a:  15 coinsurance	11b:  15 coinsurance	4:  50 copay	9ab:  25 copay		8b:  0/25 Copay			7ci:  15 Copay		7bdfg:15 Copay 16a17a18a:  25 Copay	7eh9c:  15 Copay	7ci:  15 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  50 Copay	16a:  25 Copay 16b:  20 coinsurance	17a:  25 Copay		18a:  25 Copay																			47.5	0.14	0.14	47.5	23.75		11.21			14.25		14.25	14.25	14.25			19	19	47.5	23.75	23.75		23.75															-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81		0	-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81	3100																																																																																			-		0	-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81
H3907_802_0	2007	2																					3100															T	coin	coin	V	V		P			V		V	V	V			S	P	T	V	V		V																																																								-	N/A					259.36	17.44	2.83	568.71	593.11		2447.14			161.86		7483.23	0.48	1168.55			896.62	801.31	20.14	0.24	0		0.12																			10a:  50 per trip	11a:  15 coinsurance	11b:  15 coinsurance	4:  50 copay	9ab:  25 copay		8b:  0/25 Copay			7ci:  15 Copay		7bdfg:15 Copay 16a17a18a:  25 Copay	7eh9c:  15 Copay	7ci:  15 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  50 Copay	16a:  25 Copay 16b:  20 coinsurance	17a:  25 Copay		18a:  25 Copay																			47.5	0.14	0.14	47.5	23.75		11.21			14.25		14.25	14.25	14.25			19	19	47.5	23.75	23.75		23.75															-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81		0	-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81	3100																																																																																			-		0	-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81
H3907_803_0	2007	2																					3100															T	coin	coin	V	V		P			V		V	V	V			S	P	T	V	V		V																																																								-	N/A					259.36	17.44	2.83	568.71	593.11		2447.14			161.86		7483.23	0.48	1168.55			896.62	801.31	20.14	0.24	0		0.12																			10a:  50 per trip	11a:  15 coinsurance	11b:  15 coinsurance	4:  50 copay	9ab:  25 copay		8b:  0/25 Copay			7ci:  15 Copay		7bdfg:15 Copay 16a17a18a:  25 Copay	7eh9c:  15 Copay	7ci:  15 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  50 Copay	16a:  25 Copay 16b:  20 coinsurance	17a:  25 Copay		18a:  25 Copay																			47.5	0.14	0.14	47.5	23.75		11.21			14.25		14.25	14.25	14.25			19	19	47.5	23.75	23.75		23.75															-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81		0	-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81	3100																																																																																			-		0	-	-	-	-	1.03	2.44	0.4	2.25	1.17	-	2.29	-	-	0.19	-	8.89	0	1.39	-	-	1.42	1.27	0.08	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.81
H3909_001_0	2007	6																																d	d	d		t	coin	coin	v	v		v			v	v	v	v	v	v	v	s																																																														-		1104.58	12.56	924.49		254.76	5.83	5.99	406.98	414.29		1087.71			550.18	4398.89	7221.2	130.42	926.7	138.54	456.35	0.48																					150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	50 per day 100 day max (PBP category 2)		100 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	150 per visit (PBP categories 9A and 9B)		40 per visit (PBP category 8B)			40 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	40 per visit (PBP categories 4B 7B 7D and 7F)	40 per visit (PBP categories 7E 7H and 9C)	40 per visit (PBP categories 7C and 7I)	40 per visit (per note in PBP category 8B)	40 per visit (PBP category 7B - vision exams)	50 per script (PBP category 15)																					150	150	50		100	0.2	0.2	50	150		40			40	25	40	40	40	40	40	50																					13.81	0.16	3.85	-	2.12	1.17	1.2	1.7	5.18	-	3.63	-	-	1.83	9.16	24.07	0.43	3.09	0.46	1.52	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.38			13.81	0.16	3.85	-	2.12	1.17	1.2	1.7	5.18	-	3.63	-	-	1.83	9.16	24.07	0.43	3.09	0.46	1.52	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.38		500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter		500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter		500 plan level oon deductible; 30 coinsurance thereafter																				0.81	0	0.03	0.03	0.69	0.8	0.64	0.03	0.08	0	0.01		0	0.02	0.12	0.4	0.33	0.27	0.22	2.02		0																				6.51	500		14.61	0.16	3.89	0.03	2.81	1.96	1.84	1.72	5.26	0	3.64	-	0	1.86	9.28	24.47	0.76	3.36	0.68	3.54	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.89
H3909_007_0	2007	3																																d	d	d		t	coin	coin	v	v		v			v	v	v	v	v	v	v	s																																																														-		1104.58	12.56	924.49		254.76	5.83	5.99	406.98	414.29		1087.71			550.18	4398.89	7221.2	130.42	926.7	138.54	456.35	0.48																					150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	50 per day 100 day max (PBP category 2)		100 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	150 per visit (PBP categories 9A and 9B)		40 per visit (PBP category 8B)			40 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	40 per visit (PBP categories 4B 7B 7D and 7F)	40 per visit (PBP categories 7E 7H and 9C)	40 per visit (PBP categories 7C and 7I)	40 per visit (per note in PBP category 8B)	40 per visit (PBP category 7B - vision exams)	50 per script (PBP category 15)																					150	150	50		100	0.2	0.2	50	150		40			40	25	40	40	40	40	40	50																					13.81	0.16	3.85	-	2.12	1.17	1.2	1.7	5.18	-	3.63	-	-	1.83	9.16	24.07	0.43	3.09	0.46	1.52	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.38			13.81	0.16	3.85	-	2.12	1.17	1.2	1.7	5.18	-	3.63	-	-	1.83	9.16	24.07	0.43	3.09	0.46	1.52	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.38		500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter		500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter	500 plan level oon deductible; 30 coinsurance thereafter		500 plan level oon deductible; 30 coinsurance thereafter																				0.81	0	0.03	0.03	0.69	0.8	0.64	0.03	0.08	0	0.01		0	0.02	0.12	0.4	0.33	0.27	0.22	2.02		0																				6.51	500		14.61	0.16	3.89	0.03	2.81	1.96	1.84	1.72	5.26	0	3.64	-	0	1.86	9.28	24.47	0.76	3.36	0.68	3.54	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.89
H3909_801_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		300		18.15	8.99	3.3	11.47		5.99	63.37	174.33					332.66						9.06	3.69																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07		0.17		0.24	0.24		0.24	0.24	0.24					0.24						0.24	0.24																				19.71	-	3.02	-	0.78	2.71	-	1.41	14.95	41.14	-	-	-	-	78.51	-	-	-	-	-	2.14	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	165.24			19.71	-	3.02	-	0.78	2.71	-	1.41	14.95	41.14	-	-	-	-	78.51	-	-	-	-	-	2.14	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	165.24		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.03	0	0.01	0	0.74	1.59	0	0.07	0.12	0.05	0	0	0	0	7.01	0	0	0	0	0	0	0																				9.6			19.74	-	3.02	-	1.52	4.3	-	1.48	15.07	41.19	-	-	-	-	85.51	-	-	-	-	-	2.14	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	174.84
H3909_802_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		300		18.15	8.99	3.3	11.47		5.99	63.37	174.33					332.66						9.06	3.69																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07		0.17	0	0.24	0.24		0.24	0.24	0.24					0.24						0.24	0.24																				19.71	-	3.02	-	0.78	2.71	-	1.41	14.95	41.14	-	-	-	-	78.51	-	-	-	-	-	2.14	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	165.24			19.71	-	3.02	-	0.78	2.71	-	1.41	14.95	41.14	-	-	-	-	78.51	-	-	-	-	-	2.14	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	165.24		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.03		0.01		0.74	1.59		0.07	0.12	0.05					7.01						0	0																				9.6			19.74	-	3.02	-	1.52	4.3	-	1.48	15.07	41.19	-	-	-	-	85.51	-	-	-	-	-	2.14	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	174.84
H3912_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		1822.58	136.1	8745.41	138.01	733.47	28.6	3.54	177.89	113.21	5064.5	176.63	26.69	19.44	304.22	26120.08	1825.2	2370.06	16.28		119.78	190.41	1041.36	1061.6		59.8							86.7	0.12	0.03	167.97	280.44						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit							(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						134	134			67	18	18	45	22			22		22		9				9		9										31		22								20.37	1.52	-	-	4.1	5.11	0.63	0.66	0.21	-	-	0.05	-	0.57	-	1.36	-	-	-	0.09	-	0.78	-	-	-	-	-	-	-	-	-	0.23	-	0	-	-	-	-	-	-	-	35.68		4.22	20.37	1.52	-	-	4.1	5.11	0.63	0.66	0.21	-	-	0.05	-	0.57	-	1.36	-	-	-	0.09	-	0.78	-	-	-	-	-	-	-	-	-	0.23	-	0	-	-	-	-	-	-	-	35.68		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						2.53	0.06	0.86	0.08	0.41	0.45	0.06	0.04	0.24	0.58	0.66	0.02	0	0.1	0.01	2.42	0.28	0		0.15		0.13	0.06		0.01							0.01	0	0	0.01	0.02						9.19		0	22.9	1.58	0.86	0.08	4.51	5.57	0.69	0.7	0.45	0.58	0.66	0.07	0	0.66	0.01	3.78	0.28	0	-	0.24	-	0.91	0.06	-	0.01	-	-	-	-	-	-	0.24	0	0	0.01	0.02	-	-	-	-	-	44.87
H3912_004_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1000	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1522.68	141.78	8128.24	152.34	571.74	1285.99	6250	164.43	109.17	3396.43	150.99	29.86	3.91	253.87	113.76	1139.27	1479.96	17.48		237.88	241.03	1163.26	2137.5		133.19	157.7		51.87				96.96	0.24	0.06	285	280.44						(1a) 125/day	(1b) 125/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						111	111			67			45	22			22		22		9				9		9										9		22								14.13	1.32	-	-	3.18	-	-	0.61	0.2	-	-	0.06	-	0.47	-	0.85	-	-	-	0.18	-	0.86	-	-	-	-	-	-	-	-	-	0.07	-	0	-	-	-	-	-	-	-	21.93		2.69	14.13	1.32	-	-	3.18	-	-	0.61	0.2	-	-	0.06	-	0.47	-	0.85	-	-	-	0.18	-	0.86	-	-	-	-	-	-	-	-	-	0.07	-	0	-	-	-	-	-	-	-	21.93		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						1.89	0.05	0.74	0.08	0.33	0.28	0.09	0.04	0.18	0.54	0.6	0.03	0.01	0.1	0.01	1.56	0.14	0		0.15		0.11	0.11		0.02							0	0	0	0.02	0.02						7.09		0	16.02	1.37	0.74	0.08	3.51	0.28	0.09	0.65	0.38	0.54	0.6	0.09	0.01	0.57	0.01	2.4	0.14	0	-	0.33	-	0.97	0.11	-	0.02	-	-	-	-	-	-	0.08	0	0	0.02	0.02	-	-	-	-	-	29.02
H3912_005_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2314.9	332.31	1558.68		297.2	25.03	20.88	870.76	353.45	2085.01	868.01	62.07	2.81	1925.74		3283.99		477.43		756.85												305.88		134.66	228.66							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							6.86	0.98	2.22	-	0.88	2.37	1.98	1.24	0.35	0.82	0.34	0.06	0.27	1.9	-	1.3	-	0.19	-	0.3	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	22.33		24.77	6.86	0.98	2.22	-	0.88	2.37	1.98	1.24	0.35	0.82	0.34	0.06	0.27	1.9	-	1.3	-	0.19	-	0.3	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	22.33		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.12	0.14	0.38	0.39	0.07	0.15	0.13	0.05	0.16	0.12	0.11	0.01	0.01	0.21	0.33	0.19	0.04	0.03	0.13	0.64	0.12	0																				5.55		0	8.98	1.12	2.6	0.39	0.95	2.53	2.11	1.28	0.51	0.95	0.45	0.08	0.28	2.11	0.33	1.49	0.04	0.22	0.13	0.94	0.12	0	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	27.88
H3912_006_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1650	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T		V	P	V	P		O	O	V		V	V																																																-		2740.53	393.42	1845.27		351.85	35.08	29.27	1030.86	418.44	2468.38	1027.61	73.48	3.94	2279.83		3887.82		565.22		896.01	21.92											362.13		159.42	270.7							(1a) 150 per Day	(1b) 150 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							82	82	20		41	11	11	20	14	5	5	14	11	14		5		5		5	11											5		5	5							18.7	2.68	3.02	-	1.2	3.83	3.19	1.69	0.48	1.12	0.47	0.08	0.43	2.59	-	1.77	-	0.26	-	0.41	2.39	-	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	44.67		37.18	18.7	2.68	3.02	-	1.2	3.83	3.19	1.69	0.48	1.12	0.47	0.08	0.43	2.59	-	1.77	-	0.26	-	0.41	2.39	-	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	44.67		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.97	0.2	0.54	0.55	0.1	0.21	0.18	0.05	0.23	0.17	0.16	0.02	0.02	0.29	0.37	0.27	0.06	0.04	0.18	0.9	0.17	0																				7.68		0	21.67	2.88	3.56	0.55	1.3	4.04	3.37	1.74	0.71	1.3	0.62	0.1	0.45	2.88	0.37	2.04	0.06	0.3	0.18	1.31	2.57	0	-	-	-	-	-	-	-	-	-	0.16	-	0.07	0.12	-	-	-	-	-	-	52.35
H3916_001_0	2007	5																																				T	Coin		V						V	V	V					S			Coin	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3100	0	0	0	0	365.94	20.4	0	231.63	0	0	0	0	0	847.77	4217.15	6019.66	0	0	0	0	179.56	0	0	8.72	239.4	0	5.12	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0	0	0	0	25	0.14	0	50	0	0	0	0	0	15	15	15	0	0	0	0	20	0	0	0.3	15	0	15	0	0	0	0											-	-	-	-	0.76	2.75	-	0.97	-	-	-	-	-	1.06	5.27	7.52	-	-	-	-	0.3	-	-	2.62	0.3	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.56	0	0	-	-	-	-	0.76	2.75	-	0.97	-	-	-	-	-	1.06	5.27	7.52	-	-	-	-	0.3	-	-	2.62	0.3	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.56		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												1.91	0	0.33	0.12	0.15	0.62	0	0.05	0.19	0	0	0	0	0.46	0.3	1.21	0	0	0	0	0.69	0	0	0.23	0.02	0	0.01	0	0	0	0											6.31	250	3.66	1.91	-	0.33	0.12	0.92	3.38	-	1.02	0.19	-	-	-	-	1.52	5.57	8.74	-	-	-	-	0.99	-	-	2.85	0.32	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.87
H3916_002_0	2007	5																																				T	Coin		V						V	V	V					S			Coin	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3100	0	0	0	0	331.72	19.56	0	255.12	0	0	0	0	0	1224.02	4173.37	5950	0	0	0	0	211.49	0	0	8.71	239.4	0	6.11	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0	0	0	0	25	0.14	0	50	0	0	0	0	0	15	15	15	0	0	0	0	20	0	0	0.3	15	0	15	0	0	0	0											-	-	-	-	0.69	2.64	-	1.06	-	-	-	-	-	1.53	5.22	7.44	-	-	-	-	0.35	-	-	2.61	0.3	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.85	0	0	-	-	-	-	0.69	2.64	-	1.06	-	-	-	-	-	1.53	5.22	7.44	-	-	-	-	0.35	-	-	2.61	0.3	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.85		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												1.78	0	0.3	0.11	0.15	0.6	0	0.06	0.2	0	0	0	0	0.55	0.27	1.09	0	0	0	0	0.52	0	0	0.23	0.02	0	0.01	0	0	0	0											5.89	250	3.06	1.78	-	0.3	0.11	0.84	3.24	-	1.12	0.2	-	-	-	-	2.08	5.48	8.53	-	-	-	-	0.87	-	-	2.85	0.32	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.74
H3916_003_0	2007	5																																				T	Coin		V						V	V	V					S			Coin	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3100	0	0	0	0	270.93	22.25	0	228.47	0	0	0	0	0	1020.44	4291.58	6039.5	0	0	0	0	182.9	0	0	8.72	239.4	0	4.16	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0	0	0	0	25	0.14	0	50	0	0	0	0	0	15	15	15	0	0	0	0	20	0	0	0.3	15	0	15	0	0	0	0											-	-	-	-	0.56	3	-	0.95	-	-	-	-	-	1.28	5.36	7.55	-	-	-	-	0.3	-	-	2.62	0.3	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.94	0	0	-	-	-	-	0.56	3	-	0.95	-	-	-	-	-	1.28	5.36	7.55	-	-	-	-	0.3	-	-	2.62	0.3	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.94		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												1.79	0	0.38	0.09	0.13	0.68	0	0.05	0.19	0	0	0	0	0.6	0.27	1.12	0	0	0	0	0.59	0	0	0.23	0.02	0	0.01	0	0	0	0											6.14	250	3.42	1.79	-	0.38	0.09	0.69	3.68	-	1	0.19	-	-	-	-	1.88	5.64	8.67	-	-	-	-	0.89	-	-	2.85	0.32	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.08
H3916_005_0	2007	5																																D		D		T	Coin	Coin	V							V	V	V	V			S			Coin	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3100	82.67	0	273.57	0	191.35	14.77	0.75	346.91	0	0	0	0	0	0	3932.09	6193.58	178.51	523.66	0	0	1072.25	0	0	8.71	382.59	0	163.97	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												40.82	0	25	0	25	0.14	0.14	50	0	0	0	0	0	0	15	15	15	15	0	0	20	0	0	0.3	15	0	15	0	0	0	0											0.28	-	0.57	-	0.4	1.99	0.1	1.45	-	-	-	-	-	-	4.92	7.74	0.22	0.65	-	-	1.79	-	-	2.61	0.48	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.41	0	0	0.28	-	0.57	-	0.4	1.99	0.1	1.45	-	-	-	-	-	-	4.92	7.74	0.22	0.65	-	-	1.79	-	-	2.61	0.48	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.41		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.66	0	0.28	0.16	0.06	0.46	0.02	0.08	0.14	0.05	0.15	0	0	0.19	0.16	0.35	0.01	0.03	0.19	0.65	0.29	0.02	0	0.33	0.03	0	0.01	0	0	0	0											5.32	250	2.29	1.94	-	0.85	0.16	0.46	2.45	0.12	1.52	0.14	0.05	0.15	-	-	0.19	5.07	8.09	0.23	0.68	0.19	0.65	2.08	0.02	-	2.94	0.51	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.73
H3916_012_0	2007	4																																A		D		T	Coin	Coin	V	V	V	V				V	V	V	V	V	V	S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3100	286.1	0	273.57	0	191.35	14.77	0.75	346.91	348.64	1600.07	797.65	0	0	0	3932.09	5623.58	178.51	523.66	2031.16	5895.47	1072.25	0	0	0	382.59	0	163.97	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												208.2	0	25	0	25	0.14	0.14	50	50	12	19	0	0	0	15	15	15	15	19	12	20	0	0	0	15	0	15	0	0	0	0											4.96	-	0.57	-	0.4	1.99	0.1	1.45	1.45	1.6	1.26	-	-	-	4.92	7.03	0.22	0.65	3.22	5.9	1.79	-	-	-	0.48	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.19	0	0	4.96	-	0.57	-	0.4	1.99	0.1	1.45	1.45	1.6	1.26	-	-	-	4.92	7.03	0.22	0.65	3.22	5.9	1.79	-	-	-	0.48	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.19		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.98	0	0.34	0.2	0.09	0.46	0.02	0.08	0.17	0.06	0.17	0	0	0.23	0.19	0.35	0.01	0.03	0.22	0.76	0.29	0.02	0	0	0.05	0	0.01	0	0	0	0											5.72	250	4.16	6.94	-	0.91	0.2	0.49	2.45	0.12	1.52	1.62	1.66	1.43	-	-	0.23	5.11	7.38	0.24	0.69	3.43	6.66	2.08	0.02	-	-	0.53	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.92
H3916_015_0	2007	5																																D		D		T	Coin	Coin	V							V	V	V	V			S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3100	82.67	0	273.57	0	191.35	14.77	0.75	346.91	0	0	0	0	0	0	3932.09	5623.58	178.51	523.66	0	0	1072.25	0	0	0	382.59	0	163.97	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												40.82	0	25	0	25	0.14	0.14	50	0	0	0	0	0	0	15	15	15	15	0	0	20	0	0	0	15	0	15	0	0	0	0											0.28	-	0.57	-	0.4	1.99	0.1	1.45	-	-	-	-	-	-	4.92	7.03	0.22	0.65	-	-	1.79	-	-	-	0.48	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.08	0	0	0.28	-	0.57	-	0.4	1.99	0.1	1.45	-	-	-	-	-	-	4.92	7.03	0.22	0.65	-	-	1.79	-	-	-	0.48	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.08		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.66	0	0.28	0.16	0.06	0.46	0.02	0.08	0.14	0.05	0.15	0	0	0.19	0.16	0.29	0.01	0.03	0.19	0.65	0.29	0.02	0	0	0.03	0	0.01	0	0	0	0											4.94	250	2.29	1.94	-	0.85	0.16	0.46	2.45	0.12	1.52	0.14	0.05	0.15	-	-	0.19	5.07	7.32	0.23	0.68	0.19	0.65	2.08	0.02	-	-	0.51	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.03
H3916_018_0	2007	5																																D		D		T	Coin	Coin	V	V	V	V				V	V	V	V	V	V	S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3100	1630.92	0	391.81	0	190.39	14.77	0.75	346.91	345.12	1558.62	776.99	0	0	0	3720.68	5334.25	168.91	495.51	1978.54	5742.74	1049.68	0	0	0	362.02	0	155.15	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												86.81	0	50	0	50	0.14	0.14	50	100	12	19	0	0	0	25	25	25	25	19	12	20	0	0	0	25	0	25	0	0	0	0											11.8	-	1.63	-	0.79	1.99	0.1	1.45	2.88	1.56	1.23	-	-	-	7.75	11.11	0.35	1.03	3.13	5.74	1.75	-	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.38	0	0	11.8	-	1.63	-	0.79	1.99	0.1	1.45	2.88	1.56	1.23	-	-	-	7.75	11.11	0.35	1.03	3.13	5.74	1.75	-	-	-	0.75	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.38		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b			PBP 3 5 9a 9c 9d 12 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.98	0	0.34	0.2	0.09	0.46	0.02	0.08	0.17	0.06	0.16	0	0	0.23	0.18	0.34	0.01	0.03	0.21	0.76	0.28	0.02	0	0	0.05	0	0.01	0	0	0	0											5.68	250	4.07	13.77	-	1.97	0.2	0.88	2.45	0.12	1.52	3.04	1.62	1.39	-	-	0.23	7.93	11.45	0.36	1.06	3.35	6.5	2.03	0.02	-	-	0.8	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.06
H3916_019_0	2007	5																																					Ded		V							V	V					S				V		V															37.57	0	6.5	2.3	1.66	0	0	0	3.8	0	0	0	0	8.96	3.29	19.84	0	0	0	0	5.47	0	0	0	0	0	0	0	0	0	0											89.4	3100	0	0	0	0	0	4207.05	0	224.68	0	0	0	0	0	0	4090.63	5784.85	0	0	0	0	151.19	0	0	0	232.22	0	4.96	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0	0	0	0	0	28.22	0	50	0	0	0	0	0	0	15	15	0	0	0	0	20	0	0	0	15	0	15	0	0	0	0											-	-	-	-	-	9.89	-	0.94	-	-	-	-	-	-	5.11	7.23	-	-	-	-	0.25	-	-	-	0.29	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.72	1500	0	37.57	-	6.5	2.3	1.66	9.89	-	0.94	3.8	-	-	-	-	8.96	8.41	27.07	-	-	-	-	5.73	-	-	-	0.29	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.12		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												2.9	0	0.5	0.18	0.13	0.77	0	0.05	0.29	0	0	0	0	0.69	0.45	1.82	0	0	0	0	0.42	0	0	0	0.02	0	0.01	0	0	0	0											8.23	1500	7.67	40.47	-	7	2.48	1.79	10.66	-	0.99	4.1	-	-	-	-	9.65	8.85	28.89	-	-	-	-	6.15	-	-	-	0.31	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.35
H3916_020_0	2007	5																																					Ded		V							V	V					S				V		V															36.25	0	6.16	2.19	1.76	0	0	0	4.12	0	0	0	0	11.17	2.63	17.88	0	0	0	0	4.56	0	0	0	0	0	0	0	0	0	0											86.72	3100	0	0	0	0	0	3800.16	0	247.47	0	0	0	0	0	0	4048.17	5708.01	0	0	0	0	175.13	0	0	0	232.22	0	5.93	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0	0	0	0	0	29.95	0	50	0	0	0	0	0	0	15	15	0	0	0	0	20	0	0	0	15	0	15	0	0	0	0											-	-	-	-	-	9.49	-	1.03	-	-	-	-	-	-	5.06	7.14	-	-	-	-	0.29	-	-	-	0.29	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.3	1500	0	36.25	-	6.16	2.19	1.76	9.49	-	1.03	4.12	-	-	-	-	11.17	7.69	25.01	-	-	-	-	4.85	-	-	-	0.29	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.02		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												2.75	0	0.47	0.17	0.13	0.74	0	0.06	0.31	0	0	0	0	0.85	0.41	1.67	0	0	0	0	0.35	0	0	0	0.02	0	0.01	0	0	0	0											7.93	1500	6.49	39	-	6.63	2.35	1.89	10.22	-	1.09	4.44	-	-	-	-	12.02	8.1	26.68	-	-	-	-	5.2	-	-	-	0.31	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	117.95
H3916_021_0	2007	5																																					Ded		V							V	V					S				V		V															35.82	0	7.57	1.73	1.43	0	0	0	3.73	0	0	0	0	12.12	2.82	18.25	0	0	0	0	4.88	0	0	0	0	0	0	0	0	0	0											88.36	3100	0	0	0	0	0	2312.02	0	221.62	0	0	0	0	0	0	4162.83	5797.76	0	0	0	0	152.88	0	0	0	232.22	0	4.03	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0	0	0	0	0	56.02	0	50	0	0	0	0	0	0	15	15	0	0	0	0	20	0	0	0	15	0	15	0	0	0	0											-	-	-	-	-	10.79	-	0.92	-	-	-	-	-	-	5.2	7.25	-	-	-	-	0.25	-	-	-	0.29	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.72	1500	0	35.82	-	7.57	1.73	1.43	10.79	-	0.92	3.73	-	-	-	-	12.12	8.02	25.5	-	-	-	-	5.14	-	-	-	0.29	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.07		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												2.74	0	0.58	0.13	0.11	0.84	0	0.05	0.28	0	0	0	0	0.93	0.42	1.69	0	0	0	0	0.37	0	0	0	0.02	0	0.01	0	0	0	0											8.17	1500	7.14	38.56	-	8.15	1.86	1.54	11.63	-	0.97	4.02	-	-	-	-	13.04	8.44	27.19	-	-	-	-	5.51	-	-	-	0.31	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.24
H3916_801_0	2007	5																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		260.84	0	38.41	0	10.21	22.29	0	4.07	31.37	0	0	0	0	76.9	45.66	186.11	0	0	0	0	46.95	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44	0	0	19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												1.03	0	0.39	0	0.13	0.28	0	0.05	0.4	0	0	0	0	0.97	0.58	2.36	0	0	0	0	0.59	0	0	0	0	0	0	0	0	0	0											6.79	0	0	20.26	-	7.63	-	2.54	5.54	-	1.01	7.8	-	-	-	-	19.12	11.35	46.28	-	-	-	-	11.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.22
H3916_802_0	2007	6																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		260.84	0	38.41	0	10.21	22.29	0	4.07	31.37	0	0	0	0	76.9	45.66	186.11	0	0	0	0	46.95	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44	0	0	19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												1.03	0	0.39	0	0.13	0.28	0	0.05	0.4	0	0	0	0	0.97	0.58	2.36	0	0	0	0	0.59	0	0	0	0	0	0	0	0	0	0											6.79	0	0	20.26	-	7.63	-	2.54	5.54	-	1.01	7.8	-	-	-	-	19.12	11.35	46.28	-	-	-	-	11.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.22
H3916_803_0	2007	5																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		260.84	0	38.41	0	10.21	22.29	0	4.07	31.37	0	0	0	0	76.9	45.66	186.11	0	0	0	0	46.95	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44	0	0	19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												1.03	0	0.39	0	0.13	0.28	0	0.05	0.4	0	0	0	0	0.97	0.58	2.36	0	0	0	0	0.59	0	0	0	0	0	0	0	0	0	0											6.79	0	0	20.26	-	7.63	-	2.54	5.54	-	1.01	7.8	-	-	-	-	19.12	11.35	46.28	-	-	-	-	11.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.22
H3916_804_0	2007	6																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		260.84	0	38.41	0	10.21	22.29	0	4.07	31.37	0	0	0	0	76.9	45.66	186.11	0	0	0	0	46.95	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44	0	0	19.23	-	7.25	-	2.41	5.26	-	0.96	7.4	-	-	-	-	18.15	10.78	43.92	-	-	-	-	11.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.44		PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												1.03	0	0.39	0	0.13	0.28	0	0.05	0.4	0	0	0	0	0.97	0.58	2.36	0	0	0	0	0.59	0	0	0	0	0	0	0	0	0	0											6.79	0	0	20.26	-	7.63	-	2.54	5.54	-	1.01	7.8	-	-	-	-	19.12	11.35	46.28	-	-	-	-	11.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.22
H3920_001_0	2007	5																																D	D	D		T	Coin	Coin	V	V					V	V	V	V	V	V	V				V																																																											-		1317.19	24.26	1202.06		242.26	7.55	5.38	272.94	264.13					368.83	7291.88	10082.72	517.41	1743.82	1175.45	777.19				901.87																		150/day - 1st 15 days	150/day - 1st 15 days	50/Day 6-14; 100/Day 15-100		150/Service	20	20 except 10 for Diabetic Supplies	50/visit	250/visit					30/visit (RT/PT/OT/ST/)	15/office visit	30/ office visit	30/office visit	30/visit	30/therapy visit	30/chiro or pod visit				50 visit (except preventive)																		150	150	91.7		150	0.2	0.16	50	250					30	15	30	30	30	30	30				50																		16.46	0.3	9.19	-	3.03	1.51	0.86	1.14	5.5	-	-	-	-	0.92	9.11	25.21	1.29	4.36	2.94	1.94	-	-	-	3.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.53		0	16.46	0.3	9.19	-	3.03	1.51	0.86	1.14	5.5	-	-	-	-	0.92	9.11	25.21	1.29	4.36	2.94	1.94	-	-	-	3.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.53																																																																																				-			16.46	0.3	9.19	-	3.03	1.51	0.86	1.14	5.5	-	-	-	-	0.92	9.11	25.21	1.29	4.36	2.94	1.94	-	-	-	3.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.53
H3920_002_0	2007	4																					2000											D	D	D		T	Coin	Coin	V	V					V	V	V	V	V	V	V				V																																																											-		1270.78	23.41	1274.06		256.77	8.01	5.7	289.29	279.95					390.92	7728.63	10686.61	548.4	1848.27	1245.86	823.74				2322.06																		75/day - 1st 10 days	75/day - 1st 10 days	50/Day 6-20; 100/Day 21-100		150/Service	20	20 except 10 diabetic supplies	50/visit	250/visit					20/visit (RT/PT/OT/ST/)	5/office visit	20/ office visit	30/office visit	20/visit	30/therapy visit	20/chiro or pod visit				20/Visit																		71.25	71.25	80.28		142.5	0.19	0.15	47.5	237.5					19	4.75	19	28.5	19	28.5	19				20																		7.55	0.14	8.52	-	3.05	1.52	0.86	1.15	5.54	-	-	-	-	0.62	3.06	16.92	1.3	2.93	2.96	1.3	-	-	-	3.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.29		3.18	7.55	0.14	8.52	-	3.05	1.52	0.86	1.15	5.54	-	-	-	-	0.62	3.06	16.92	1.3	2.93	2.96	1.3	-	-	-	3.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.29																																																																																				-			7.55	0.14	8.52	-	3.05	1.52	0.86	1.15	5.54	-	-	-	-	0.62	3.06	16.92	1.3	2.93	2.96	1.3	-	-	-	3.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.29
H3920_003_0	2007	8																																A	A	D		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																								0.16	0.41	0.26	0.84	2.86	0.3	0.86	0	0	2.89	1.1	4.89	0.08	0.18	0.85	0.84	0	0																				16.52		290.71	8.77	899.69		4.33	11.45	7.14	23.3	79.58	8.46	23.85			80.33	30.65	135.8	2.09	5.01	23.61	23.2	0																					FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare																				1014	1014	127		20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20																				24.56	0.74	9.5	-	0.87	2.29	1.43	4.66	15.92	1.69	4.77	-	-	16.07	6.13	27.16	0.42	1	4.72	4.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	126.56	138	0	24.56	0.74	9.5	-	1.02	2.7	1.68	5.5	18.78	2	5.63	-	-	18.96	7.23	32.05	0.49	1.18	5.57	5.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.08																																																																																				-			24.56	0.74	9.5	-	1.02	2.7	1.68	5.5	18.78	2	5.63	-	-	18.96	7.23	32.05	0.49	1.18	5.57	5.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.08
H3921_001_0	2007	8																					3000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1802.35	157.01	857.84	0	242.6	12.96	5.6	448.75	28.74	6469.07	39.98	0	0.2	21.87	2966.7	3476.37	596.71	1.67	0	0	20.06	604.5	0	0	136.14	0	188.65	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											167.64	167.64	85.24	0	99.45	0.17	0.19	28.41	0.11	1.14	0.09	0	0.17	0.11	15	25	37.5	0.11	0	0	0.17	25	0	0	25	0	25	0	0	0	0											25.18	2.19	6.09	-	2.01	2.21	1.09	1.06	3.27	0.61	3.58	-	0.03	2.49	3.71	7.24	1.86	0.19	-	-	3.42	1.26	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.18		40.35	25.18	2.19	6.09	-	2.01	2.21	1.09	1.06	3.27	0.61	3.58	-	0.03	2.49	3.71	7.24	1.86	0.19	-	-	3.42	1.26	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.18		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c 14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											6.04	0.21	0.7	0.54	0.78	0.85	0.37	0.41	1.89	0.95	2.08	0	0.01	1.44	1.86	5.98	0.46	0.11	0	0	1.32	0.33	0	0	0.03	0	0.07	0	0	0	0											26.44		0	31.22	2.4	6.79	0.54	2.79	3.06	1.46	1.47	5.16	1.56	5.66	-	0.05	3.93	5.57	13.22	2.33	0.3	-	-	4.74	1.59	-	-	0.32	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.62
H3921_003_0	2007	9																					2500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1833.2	159.7	872.52	0	246.76	12.77	5.51	456.43	28.32	6579.78	39.4	0	0.19	21.55	3017.47	3535.86	606.92	1.65	0	0	19.76	614.84	0	0	138.47	0	191.87	0	0	0	0											200 (1a)	200 (1b)	120 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											113.31	113.31	67.99	0	99.15	0.17	0.19	28.33	0.11	3.4	0.09	0	0.17	0.11	10	20	37.5	0.11	0	0	0.17	20	0	0	20	0	20	0	0	0	0											17.31	1.51	4.94	-	2.04	2.17	1.07	1.08	3.21	1.86	3.52	-	0.03	2.45	2.51	5.89	1.9	0.19	-	-	3.36	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.62		33.98	17.31	1.51	4.94	-	2.04	2.17	1.07	1.08	3.21	1.86	3.52	-	0.03	2.45	2.51	5.89	1.9	0.19	-	-	3.36	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.62		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c 14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											5.95	0.21	0.69	0.53	0.79	0.84	0.36	0.42	1.86	0.96	2.05	0	0.01	1.42	1.84	5.89	0.47	0.11	0	0	1.3	0.32	0	0	0.03	0	0.07	0	0	0	0											26.13		0	23.26	1.72	5.63	0.53	2.83	3.01	1.43	1.49	5.07	2.83	5.57	-	0.05	3.86	4.35	11.78	2.37	0.3	-	-	4.66	1.35	-	-	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.75
H3921_005_0	2007	5																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1802.35	157.01	857.84	0	242.6	12.96	5.6	448.75	28.74	6469.07	39.98	0	0.2	21.87	2966.7	3476.37	596.71	1.67	0	0	20.06	604.5	0	0	136.14	0	188.65	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											149.58	149.58	76.06	0	88.74	0.15	0.18	25.35	0.1	3.04	0.08	0	0.15	0.1	15	25	37.5	0.1	0	0	0.15	25	0	0	25	0	25	0	0	0	0											22.47	1.96	5.44	-	1.79	1.97	1	0.95	2.91	1.64	3.2	-	0.03	2.22	3.71	7.24	1.86	0.17	-	-	3.05	1.26	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.56		47.14	22.47	1.96	5.44	-	1.79	1.97	1	0.95	2.91	1.64	3.2	-	0.03	2.22	3.71	7.24	1.86	0.17	-	-	3.05	1.26	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.56		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c 14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											6.04	0.21	0.7	0.54	0.78	0.85	0.37	0.41	1.89	0.95	2.08	0	0.01	1.44	1.86	5.98	0.46	0.11	0	0	1.32	0.33	0	0	0.03	0	0.07	0	0	0	0											26.44		0	28.51	2.17	6.14	0.54	2.57	2.83	1.37	1.36	4.81	2.59	5.28	-	0.04	3.66	5.57	13.22	2.33	0.28	-	-	4.37	1.59	-	-	0.32	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.99
H3921_006_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1833.2	159.7	872.52	0	246.76	12.77	5.51	456.43	28.32	6579.78	39.4	0	0.19	21.55	3017.47	3535.86	606.92	1.65	0	0	19.76	614.84	0	0	138.47	0	191.87	0	0	0	0											200 (1a)	200 (1b)	120 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											102.21	102.21	61.33	0	89.44	0.15	0.18	25.55	0.1	3.07	0.08	0	0.15	0.1	10	20	37.5	0.1	0	0	0.15	20	0	0	20	0	20	0	0	0	0											15.61	1.36	4.46	-	1.84	1.96	1	0.97	2.89	1.68	3.18	-	0.03	2.21	2.51	5.89	1.9	0.17	-	-	3.03	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.26		38.34	15.61	1.36	4.46	-	1.84	1.96	1	0.97	2.89	1.68	3.18	-	0.03	2.21	2.51	5.89	1.9	0.17	-	-	3.03	1.02	-	-	0.23	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.26		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c 14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											5.95	0.21	0.69	0.53	0.79	0.84	0.36	0.42	1.86	0.96	2.05	0	0.01	1.42	1.84	5.89	0.47	0.11	0	0	1.3	0.32	0	0	0.03	0	0.07	0	0	0	0											26.13		0	21.57	1.57	5.15	0.53	2.63	2.8	1.36	1.39	4.76	2.64	5.22	-	0.04	3.63	4.35	11.78	2.37	0.28	-	-	4.33	1.35	-	-	0.27	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.39
H3921_801_0	2007	5																					3200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1860.69	162.09	885.61	0	250.46	13.16	5.68	463.27	29.17	6678.46	40.59	0	0.2	22.2	3062.73	3588.89	616.02	1.7	0	0	20.36	624.06	0	0	140.55	0	194.75	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											168.76	168.76	85.81	0	100.11	0.17	0.2	28.6	0.11	3.43	0.09	0	0.17	0.11	25	30	37.5	0.11	0	0	0.17	30	0	0	30	0	30	0	0	0	0											26.17	2.28	6.33	-	2.09	2.26	1.11	1.1	3.34	1.91	3.56	-	0.03	2.54	6.38	8.97	1.93	0.19	-	-	3.49	1.56	-	-	0.35	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.09		41.96	26.17	2.28	6.33	-	2.09	2.26	1.11	1.1	3.34	1.91	3.56	-	0.03	2.54	6.38	8.97	1.93	0.19	-	-	3.49	1.56	-	-	0.35	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.09		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c 14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											6.13	0.21	0.71	0.54	0.8	0.87	0.37	0.42	1.92	0.98	2.05	0	0.01	1.46	1.89	6.07	0.48	0.11	0	0	1.34	0.33	0	0	0.04	0	0.07	0	0	0	0											26.82		0	32.3	2.49	7.04	0.54	2.89	3.12	1.48	1.53	5.26	2.89	5.6	-	0.05	4.01	8.27	15.04	2.4	0.31	-	-	4.84	1.89	-	-	0.39	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.91
H3923_001_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											3.2	0.02	0.24	0.1	0.1	0.27	0	0.03	0.29	0.05	0.23	0	0	0.38	0.26	0.32	0.01	0.09	0	1.44	0.08	0.11	0	0	0	0	0	0	0	0	0											7.22	none	355.84	35.63	889.64	1245.22	276.61	25.24	0	254.76	1261	2572.33	632	0	0	2297.41	3740.76	4511.38	227.53	1311.61	0	50176.64	7.15	1875.88	33.53	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	38.54	100	0	100	0	0	10.41	20	30	30	30	0	0.1	0	0	50	0	0	0	0	0	0	0	0											7.41	0.74	0.98	-	1.15	5.05	-	0.82	10.51	-	5.27	-	-	1.99	6.23	11.28	0.57	3.28	-	0.42	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.85	100	0	10.61	0.76	1.22	0.1	1.25	5.32	-	0.85	10.8	0.05	5.49	-	-	2.38	6.49	11.6	0.58	3.37	-	1.87	0.08	0.11	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.06	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											5.14	0.03	0.39	0.16	0.16	0.43	0	0.05	0.46	0.08	0.37	0	0	0.62	0.42	0.51	0.02	0.15	0	2.32	0.12	0.17	0	0	0	0	0	0	0	0	0											11.61	500	6.8	15.76	0.8	1.61	0.26	1.41	5.75	-	0.9	11.26	0.13	5.86	-	-	2.99	6.91	12.11	0.6	3.53	-	4.18	0.2	0.28	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.67
H3923_002_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											2.81	0.02	0.36	0.06	0.11	0.25	0	0.04	0.28	0.19	0.3	0	0	0.32	0.29	0.31	0.02	0.08	0	1.44	0.09	0.25	0	0	0	0	0	0	0	0	0											7.21	none	308.87	35.63	1126.12	672.47	281.83	20.56	0	200.21	1020.4	11124.29	632	0	0	6865.86	3740.76	4069.35	227.53	1004.08	0	48006.99	7.35	4235.62	34.16	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	44.78	100	0	100	0	0	3.39	20	30	30	30	0	0.07	0	0	50	0	0	0	0	0	0	0	0											6.43	0.74	1.24	-	1.17	4.11	-	0.75	8.5	-	5.27	-	-	1.94	6.23	10.17	0.57	2.51	-	0.3	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.09	100	0	9.24	0.77	1.6	0.06	1.28	4.36	-	0.78	8.79	0.19	5.57	-	-	2.26	6.53	10.49	0.58	2.59	-	1.74	0.09	0.25	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.29	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											4.28	0.04	0.54	0.09	0.16	0.37	0	0.06	0.43	0.29	0.46	0	0	0.49	0.44	0.48	0.02	0.12	0	2.2	0.13	0.38	0	0	0	0	0	0	0	0	0											10.98	500	5.6	13.52	0.8	2.14	0.15	1.44	4.73	-	0.84	9.22	0.47	6.04	-	-	2.74	6.97	10.97	0.61	2.7	-	3.95	0.22	0.62	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.28
H3923_003_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											2.78	0.02	0.4	0.06	0.15	0.34	0	0.03	0.24	0.27	0.31	0	0	0.4	0.28	0.27	0.01	0.07	0	1.26	0.09	0.22	0	0	0	0	0	0	0	0	0											7.22	none	388.55	35.63	1305.61	747.98	543.75	30	0	343.27	2970.74	15012.53	632	0	0	15874.28	3740.76	3887.5	227.53	917.16	0	51935.74	8.23	2111.56	65.91	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	29.16	100	0	100	0	0	1.43	20	30	30	30	0	0.06	0	0	50	0	0	0	0	0	0	0	0											8.09	0.74	1.44	-	2.27	6	-	0.83	24.76	-	5.27	-	-	1.89	6.23	9.72	0.57	2.29	-	0.27	-	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.65	100	0	10.87	0.76	1.84	0.06	2.41	6.34	-	0.87	25	0.27	5.58	-	-	2.3	6.51	9.99	0.58	2.36	-	1.53	0.09	0.22	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.86	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											4.32	0.03	0.62	0.09	0.23	0.53	0	0.05	0.38	0.42	0.49	0	0	0.63	0.43	0.42	0.02	0.11	0	1.97	0.15	0.34	0	0	0	0	0	0	0	0	0											11.23	500	6.07	15.2	0.8	2.46	0.15	2.65	6.87	-	0.92	25.38	0.68	6.07	-	-	2.92	6.95	10.41	0.61	2.47	-	3.5	0.24	0.55	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.09
H3923_004_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											2.81	0.02	0.36	0.06	0.11	0.25	0	0.04	0.28	0.19	0.3	0	0	0.32	0.29	0.31	0.02	0.08	0	1.44	0.09	0.25	0	0	0	0	0	0	0	0	0											7.21	none	308.87	35.63	1126.12	672.47	281.83	20.56	0	200.21	1020.4	11124.29	632	0	0	6865.86	3740.76	4069.35	227.53	1004.08	0	48006.99	7.35	4235.62	34.16	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	44.78	100	0	100	0	0	3.39	20	30	30	30	0	0.07	0	0	50	0	0	0	0	0	0	0	0											6.43	0.74	1.24	-	1.17	4.11	-	0.75	8.5	-	5.27	-	-	1.94	6.23	10.17	0.57	2.51	-	0.3	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.09	100	0	9.24	0.77	1.6	0.06	1.28	4.36	-	0.78	8.79	0.19	5.57	-	-	2.26	6.53	10.49	0.58	2.59	-	1.74	0.09	0.25	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.29	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											4.28	0.04	0.54	0.09	0.16	0.37	0	0.06	0.43	0.29	0.46	0	0	0.49	0.44	0.48	0.02	0.12	0	2.2	0.13	0.38	0	0	0	0	0	0	0	0	0											10.98	500	5.6	13.52	0.8	2.14	0.15	1.44	4.73	-	0.84	9.22	0.47	6.04	-	-	2.74	6.97	10.97	0.61	2.7	-	3.95	0.22	0.62	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.28
H3923_009_0	2007	4																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											3.2	0.02	0.24	0.1	0.1	0.27	0	0.03	0.29	0.05	0.23	0	0	0.38	0.26	0.32	0.01	0.09	0	1.44	0.08	0.11	0	0	0	0	0	0	0	0	0											7.22	none	355.84	35.63	889.64	1245.22	276.61	25.24	0	254.76	1261	2572.33	632	0	0	2297.41	3740.76	4511.38	227.53	1311.61	0	50176.64	7.15	1875.88	33.53	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	38.54	100	0	100	0	0	10.41	20	30	30	30	0	0.1	0	0	50	0	0	0	0	0	0	0	0											7.41	0.74	0.98	-	1.15	5.05	-	0.82	10.51	-	5.27	-	-	1.99	6.23	11.28	0.57	3.28	-	0.42	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.85	100	0	10.61	0.76	1.22	0.1	1.25	5.32	-	0.85	10.8	0.05	5.49	-	-	2.38	6.49	11.6	0.58	3.37	-	1.87	0.08	0.11	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.06	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											5.14	0.03	0.39	0.16	0.16	0.43	0	0.05	0.46	0.08	0.37	0	0	0.62	0.42	0.51	0.02	0.15	0	2.32	0.12	0.17	0	0	0	0	0	0	0	0	0											11.61	500	6.8	15.76	0.8	1.61	0.26	1.41	5.75	-	0.9	11.26	0.13	5.86	-	-	2.99	6.91	12.11	0.6	3.53	-	4.18	0.2	0.28	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.67
H3923_010_0	2007	4																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											2.81	0.02	0.36	0.06	0.11	0.25	0	0.04	0.28	0.19	0.3	0	0	0.32	0.29	0.31	0.02	0.08	0	1.44	0.09	0.25	0	0	0	0	0	0	0	0	0											7.21	none	308.87	35.63	1126.12	672.47	281.83	20.56	0	200.21	1020.4	11124.29	632	0	0	6865.86	3740.76	4069.35	227.53	1004.08	0	48006.99	7.35	4235.62	34.16	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	44.78	100	0	100	0	0	3.39	20	30	30	30	0	0.07	0	0	50	0	0	0	0	0	0	0	0											6.43	0.74	1.24	-	1.17	4.11	-	0.75	8.5	-	5.27	-	-	1.94	6.23	10.17	0.57	2.51	-	0.3	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.09	100	0	9.24	0.77	1.6	0.06	1.28	4.36	-	0.78	8.79	0.19	5.57	-	-	2.26	6.53	10.49	0.58	2.59	-	1.74	0.09	0.25	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.29	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											4.28	0.04	0.54	0.09	0.16	0.37	0	0.06	0.43	0.29	0.46	0	0	0.49	0.44	0.48	0.02	0.12	0	2.2	0.13	0.38	0	0	0	0	0	0	0	0	0											10.98	500	5.6	13.52	0.8	2.14	0.15	1.44	4.73	-	0.84	9.22	0.47	6.04	-	-	2.74	6.97	10.97	0.61	2.7	-	3.95	0.22	0.62	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.28
H3923_011_0	2007	4																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											2.78	0.02	0.4	0.06	0.15	0.34	0	0.03	0.24	0.27	0.31	0	0	0.4	0.28	0.27	0.01	0.07	0	1.26	0.09	0.22	0	0	0	0	0	0	0	0	0											7.22	none	388.55	35.63	1305.61	747.98	543.75	30	0	343.27	2970.74	15012.53	632	0	0	15874.28	3740.76	3887.5	227.53	917.16	0	51935.74	8.23	2111.56	65.91	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	29.16	100	0	100	0	0	1.43	20	30	30	30	0	0.06	0	0	50	0	0	0	0	0	0	0	0											8.09	0.74	1.44	-	2.27	6	-	0.83	24.76	-	5.27	-	-	1.89	6.23	9.72	0.57	2.29	-	0.27	-	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.65	100	0	10.87	0.76	1.84	0.06	2.41	6.34	-	0.87	25	0.27	5.58	-	-	2.3	6.51	9.99	0.58	2.36	-	1.53	0.09	0.22	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.86	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											4.32	0.03	0.62	0.09	0.23	0.53	0	0.05	0.38	0.42	0.49	0	0	0.63	0.43	0.42	0.02	0.11	0	1.97	0.15	0.34	0	0	0	0	0	0	0	0	0											11.23	500	6.07	15.2	0.8	2.46	0.15	2.65	6.87	-	0.92	25.38	0.68	6.07	-	-	2.92	6.95	10.41	0.61	2.47	-	3.5	0.24	0.55	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.09
H3923_012_0	2007	4																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											2.81	0.02	0.36	0.06	0.11	0.25	0	0.04	0.28	0.19	0.3	0	0	0.32	0.29	0.31	0.02	0.08	0	1.44	0.09	0.25	0	0	0	0	0	0	0	0	0											7.21	none	308.87	35.63	1126.12	672.47	281.83	20.56	0	200.21	1020.4	11124.29	632	0	0	6865.86	3740.76	4069.35	227.53	1004.08	0	48006.99	7.35	4235.62	34.16	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-50: 75/Day 51-100: 100/Day		50   per Trip	20 Coins		50  (WIA)	100   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	20  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 20 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	13.21	0	50	0.2	0	44.78	100	0	100	0	0	3.39	20	30	30	30	0	0.07	0	0	50	0	0	0	0	0	0	0	0											6.43	0.74	1.24	-	1.17	4.11	-	0.75	8.5	-	5.27	-	-	1.94	6.23	10.17	0.57	2.51	-	0.3	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.09	100	0	9.24	0.77	1.6	0.06	1.28	4.36	-	0.78	8.79	0.19	5.57	-	-	2.26	6.53	10.49	0.58	2.59	-	1.74	0.09	0.25	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.29	none	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max	500 deductible 30 coinsurance 5000 OOP Max											4.28	0.04	0.54	0.09	0.16	0.37	0	0.06	0.43	0.29	0.46	0	0	0.49	0.44	0.48	0.02	0.12	0	2.2	0.13	0.38	0	0	0	0	0	0	0	0	0											10.98	500	5.6	13.52	0.8	2.14	0.15	1.44	4.73	-	0.84	9.22	0.47	6.04	-	-	2.74	6.97	10.97	0.61	2.7	-	3.95	0.22	0.62	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.28
H3923_013_0	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											1.6	0.01	0.12	0.05	0.05	0.13	0	0.02	0.14	0.02	0.11	0	0	0.19	0.13	0.16	0.01	0.05	0	0.72	0.04	0.05	0	0.01	0.01	0	0	0	0	0.02	0											3.66	none	371.4	37.19	928.53	1299.66	288.7	26.34	0	265.9	1316.12	2684.78	632	0	0	2397.85	3904.29	4844.17	242.32	1414.58	0	52453.42	7.46	1957.88	34.99	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 50/Day 51-100: 75/Day		35   per Trip	10 Coins		50  (WIA)	50   per Surgery		50   High Tech images only			25  S/A & Rehab svc Office Visit	15  Office Visit	20  Office Visit	20  Office Visit	20  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 15 Chiro Pod 30	0 Coins		35  Per Trip																			0	0	8.87	0	35	0.1	0	35.52	50	0	50	0	0	6.94	15	20	20	20	0	0.07	0	0	35	0	0	0	0	0	0	0	0											-	-	0.69	-	0.84	2.63	-	0.79	5.48	-	2.63	-	-	1.39	4.88	8.07	0.4	2.36	-	0.3	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.57	50	0	1.6	0.01	0.81	0.05	0.89	2.77	-	0.8	5.63	0.02	2.75	-	-	1.58	5.01	8.24	0.41	2.41	-	1.02	0.04	0.05	0.1	0.01	0.01	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	34.24	none	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max											3.79	0.02	0.28	0.12	0.12	0.32	0	0.04	0.34	0.06	0.27	0	0	0.45	0.31	0.39	0.02	0.12	0	1.71	0.09	0.13	0	0.03	0.03	0	0	0	0	0.04	0											8.68	250	6.96	5.39	0.04	1.09	0.17	1.01	3.09	-	0.84	5.97	0.08	3.02	-	-	2.03	5.32	8.62	0.43	2.52	-	2.73	0.13	0.18	0.1	0.05	0.05	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	-	-	42.92
H3923_014_0	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											1.4	0.01	0.18	0.03	0.05	0.12	0	0.02	0.14	0.09	0.15	0	0	0.16	0.15	0.16	0.01	0.04	0	0.72	0.04	0.12	0	0.02	0.02	0	0	0	0	0.02	0											3.65	none	322.37	37.19	1175.35	701.86	294.15	21.46	0	208.96	1065.01	11610.6	632	0	0	7166.01	3904.29	4369.38	242.32	1082.91	0	50203.23	7.68	4420.78	35.66	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 50/Day 51-100: 75/Day		35   per Trip	10 Coins		50  (WIA)	50   per Surgery		50   High Tech images only			25  S/A & Rehab svc Office Visit	15  Office Visit	20  Office Visit	20  Office Visit	20  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 15 Chiro Pod 30	0 Coins		35  Per Trip																			0	0	8.87	0	35	0.1	0	41.27	50	0	50	0	0	2.26	15	20	20	20	0	0.05	0	0	35	0	0	0	0	0	0	0	0											-	-	0.87	-	0.86	2.15	-	0.72	4.44	-	2.63	-	-	1.35	4.88	7.28	0.4	1.8	-	0.21	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.7	50	0	1.4	0.01	1.05	0.03	0.91	2.27	-	0.74	4.58	0.09	2.79	-	-	1.51	5.03	7.44	0.41	1.84	-	0.94	0.04	0.12	0.1	0.02	0.02	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	31.35	none	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max											3.16	0.03	0.4	0.07	0.12	0.28	0	0.04	0.32	0.21	0.34	0	0	0.36	0.33	0.36	0.02	0.09	0	1.63	0.1	0.28	0	0.04	0.04	0	0	0	0	0.05	0											8.23	250	5.82	4.56	0.04	1.45	0.1	1.03	2.54	-	0.78	4.9	0.3	3.13	-	-	1.87	5.35	7.81	0.43	1.93	-	2.56	0.14	0.4	0.1	0.05	0.05	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	39.59
H3923_015_0	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											1.39	0.01	0.2	0.03	0.07	0.17	0	0.02	0.12	0.13	0.16	0	0	0.2	0.14	0.14	0.01	0.04	0	0.63	0.05	0.11	0	0.02	0.02	0	0	0	0	0.02	0											3.66	none	405.54	37.19	1362.69	780.68	567.52	31.31	0	358.28	3100.6	15668.82	632	0	0	16568.24	3904.29	4176	242.32	989.16	0	54299.82	8.59	2203.86	68.79	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 50/Day 51-100: 75/Day		35   per Trip	10 Coins		50  (WIA)	50   per Surgery		50   High Tech images only			25  S/A & Rehab svc Office Visit	15  Office Visit	20  Office Visit	20  Office Visit	20  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 15 Chiro Pod 30	0 Coins		35  Per Trip																			0	0	8.87	0	35	0.1	0	26.88	50	0	50	0	0	0.95	15	20	20	20	0	0.04	0	0	35	0	0	0	0	0	0	0	0											-	-	1.01	-	1.66	3.13	-	0.8	12.92	-	2.63	-	-	1.32	4.88	6.96	0.4	1.65	-	0.19	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.75	50	0	1.39	0.01	1.21	0.03	1.73	3.3	-	0.82	13.04	0.13	2.79	-	-	1.52	5.02	7.1	0.41	1.68	-	0.82	0.05	0.11	0.2	0.02	0.02	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	41.41	none	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max											3.19	0.03	0.46	0.07	0.17	0.39	0	0.04	0.28	0.31	0.36	0	0	0.46	0.32	0.32	0.02	0.08	0	1.45	0.11	0.25	0	0.03	0.03	0	0	0	0	0.05	0											8.41	250	6.26	4.58	0.04	1.67	0.1	1.9	3.69	-	0.86	13.32	0.44	3.15	-	-	1.98	5.34	7.42	0.43	1.77	-	2.28	0.15	0.36	0.2	0.05	0.05	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	49.82
H3923_016_0	2007	9																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											1.4	0.01	0.18	0.03	0.05	0.12	0	0.02	0.14	0.09	0.15	0	0	0.16	0.15	0.16	0.01	0.04	0	0.72	0.04	0.12	0	0.02	0.02	0	0	0	0	0.02	0											3.65	none	322.37	37.19	1175.35	701.86	294.15	21.46	0	208.96	1065.01	11610.6	632	0	0	7166.01	3904.29	4369.38	242.32	1082.91	0	50203.23	7.68	4420.78	35.66	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 50/Day 51-100: 75/Day		35   per Trip	10 Coins		50  (WIA)	50   per Surgery		50   High Tech images only			25  S/A & Rehab svc Office Visit	15  Office Visit	20  Office Visit	20  Office Visit	20  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 15 Chiro Pod 30	0 Coins		35  Per Trip																			0	0	8.87	0	35	0.1	0	41.27	50	0	50	0	0	2.26	15	20	20	20	0	0.05	0	0	35	0	0	0	0	0	0	0	0											-	-	0.87	-	0.86	2.15	-	0.72	4.44	-	2.63	-	-	1.35	4.88	7.28	0.4	1.8	-	0.21	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.7	50	0	1.4	0.01	1.05	0.03	0.91	2.27	-	0.74	4.58	0.09	2.79	-	-	1.51	5.03	7.44	0.41	1.84	-	0.94	0.04	0.12	0.1	0.02	0.02	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	-	31.35	none	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max	250 deductible 25 coinsurance 3500 OOP Max											3.16	0.03	0.4	0.07	0.12	0.28	0	0.04	0.32	0.21	0.34	0	0	0.36	0.33	0.36	0.02	0.09	0	1.63	0.1	0.28	0	0.04	0.04	0	0	0	0	0.05	0											8.23	250	5.82	4.56	0.04	1.45	0.1	1.03	2.54	-	0.78	4.9	0.3	3.13	-	-	1.87	5.35	7.81	0.43	1.93	-	2.56	0.14	0.4	0.1	0.05	0.05	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	39.59
H3923_017_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	386.96	38.75	967.42	1354.1	300.79	27.45	0	277.03	1371.25	2797.23	632	0	0	2498.28	4067.82	5188.32	260.04	1521.37	0	54821.83	7.77	2039.89	36.46	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 25/Day 51-100: 50/Day		0   per Trip	5 Coins		50  (WIA)	0   per Surgery		0   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	15  Office Visit	15  Office Visit	15  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		0  Per Trip																			0	0	4.53	0	0	0.05	0	34.01	0	0	0	0	0	5.21	10	15	15	15	0	0.05	0	0	0	0	0	0	0	0	0	0	0											-	-	0.37	-	-	1.37	-	0.79	-	-	-	-	-	1.08	3.39	6.49	0.33	1.9	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.95	0	0	-	-	0.37	-	-	1.37	-	0.79	-	-	-	-	-	1.08	3.39	6.49	0.33	1.9	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.95	none	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max											2.86	0.02	0.21	0.09	0.09	0.24	0	0.03	0.26	0.04	0.2	0	0	0.34	0.23	0.3	0.01	0.09	0	1.29	0.07	0.1	0	0.02	0.02	0	0	0	0	0.03	0											6.55	150	6.3	2.86	0.02	0.58	0.09	0.09	1.61	-	0.81	0.26	0.04	0.2	-	-	1.43	3.62	6.78	0.34	1.99	-	1.54	0.07	0.1	-	0.02	0.02	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	22.5
H3923_018_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	335.88	38.75	1224.58	731.26	306.47	22.36	0	217.71	1109.61	12096.9	632	0	0	7466.16	4067.82	4679.65	260.04	1164.66	0	52507.83	8	4605.94	37.15	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 25/Day 51-100: 50/Day		0   per Trip	5 Coins		50  (WIA)	0   per Surgery		0   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	15  Office Visit	15  Office Visit	15  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		0  Per Trip																			0	0	4.53	0	0	0.05	0	39.51	0	0	0	0	0	1.69	10	15	15	15	0	0.04	0	0	0	0	0	0	0	0	0	0	0											-	-	0.46	-	-	1.12	-	0.72	-	-	-	-	-	1.05	3.39	5.85	0.33	1.46	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54	0	0	-	-	0.46	-	-	1.12	-	0.72	-	-	-	-	-	1.05	3.39	5.85	0.33	1.46	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54	none	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max											2.38	0.02	0.3	0.05	0.09	0.21	0	0.03	0.24	0.16	0.26	0	0	0.27	0.25	0.28	0.01	0.07	0	1.23	0.07	0.21	0	0.03	0.03	0	0	0	0	0.03	0											6.22	150	5.31	2.38	0.02	0.76	0.05	0.09	1.33	-	0.75	0.24	0.16	0.26	-	-	1.32	3.64	6.13	0.34	1.52	-	1.4	0.07	0.21	-	0.03	0.03	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	20.76
H3923_019_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	422.52	38.75	1419.77	813.38	591.29	32.62	0	373.28	3230.47	16325.1	632	0	0	17262.2	4067.82	4474.43	260.04	1063.84	0	56768.01	8.95	2296.17	71.67	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 25/Day 51-100: 50/Day		0   per Trip	5 Coins		50  (WIA)	0   per Surgery		0   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	15  Office Visit	15  Office Visit	15  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		0  Per Trip																			0	0	4.53	0	0	0.05	0	25.73	0	0	0	0	0	0.72	10	15	15	15	0	0.03	0	0	0	0	0	0	0	0	0	0	0											-	-	0.54	-	-	1.63	-	0.8	-	-	-	-	-	1.03	3.39	5.59	0.33	1.33	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.79	0	0	-	-	0.54	-	-	1.63	-	0.8	-	-	-	-	-	1.03	3.39	5.59	0.33	1.33	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.79	none	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max											2.4	0.02	0.35	0.05	0.13	0.3	0	0.03	0.21	0.23	0.27	0	0	0.35	0.24	0.25	0.01	0.06	0	1.1	0.08	0.19	0	0.03	0.03	0	0	0	0	0.03	0											6.35	150	5.7	2.4	0.02	0.88	0.05	0.13	1.93	-	0.83	0.21	0.23	0.27	-	-	1.38	3.63	5.84	0.34	1.39	-	1.25	0.08	0.19	-	0.03	0.03	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	21.14
H3923_020_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	335.88	38.75	1224.58	731.26	306.47	22.36	0	217.71	1109.61	12096.9	632	0	0	7466.16	4067.82	4679.65	260.04	1164.66	0	52507.83	8	4605.94	37.15	925	388.5	0	0	0	0	925	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-50: 25/Day 51-100: 50/Day		0   per Trip	5 Coins		50  (WIA)	0   per Surgery		0   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	15  Office Visit	15  Office Visit	15  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		0  Per Trip																			0	0	4.53	0	0	0.05	0	39.51	0	0	0	0	0	1.69	10	15	15	15	0	0.04	0	0	0	0	0	0	0	0	0	0	0											-	-	0.46	-	-	1.12	-	0.72	-	-	-	-	-	1.05	3.39	5.85	0.33	1.46	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54	0	0	-	-	0.46	-	-	1.12	-	0.72	-	-	-	-	-	1.05	3.39	5.85	0.33	1.46	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54	none	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max	150 deductible 20 coinsurance 2500 OOP Max											2.38	0.02	0.3	0.05	0.09	0.21	0	0.03	0.24	0.16	0.26	0	0	0.27	0.25	0.28	0.01	0.07	0	1.23	0.07	0.21	0	0.03	0.03	0	0	0	0	0.03	0											6.22	150	5.31	2.38	0.02	0.76	0.05	0.09	1.33	-	0.75	0.24	0.16	0.26	-	-	1.32	3.64	6.13	0.34	1.52	-	1.4	0.07	0.21	-	0.03	0.03	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	20.76
H3923_801_0	2007	5																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	197.87	2.19	15.13	5.45	6.26	20.85	0	4.07	32.93	12.48	26.85	0	0	35.7	27.21	36.6	1.71	11.64	0	136.12	8.12	20.25	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	0	0	14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	none	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing											1.2	0.01	0.24	0	0.12	0.4	0	0.08	0.63	0.24	0.51	0	0	0.68	0.52	0.7	0.03	0.22	0	2.6	0.16	0.39	0	0	0	0	0	0	0	0	0											8.74	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54
H3923_802_0	2007	3																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	197.87	2.19	15.13	5.45	6.26	20.85	0	4.07	32.93	12.48	26.85	0	0	35.7	27.21	36.6	1.71	11.64	0	136.12	8.12	20.25	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	0	0	14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	none	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing											1.2	0.01	0.24	0	0.12	0.4	0	0.08	0.63	0.24	0.51	0	0	0.68	0.52	0.7	0.03	0.22	0	2.6	0.16	0.39	0	0	0	0	0	0	0	0	0											8.74	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54
H3923_803_0	2007	4																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	197.87	2.19	15.13	5.45	6.26	20.85	0	4.07	32.93	12.48	26.85	0	0	35.7	27.21	36.6	1.71	11.64	0	136.12	8.12	20.25	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	0	0	14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	none	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing											1.2	0.01	0.24	0	0.12	0.4	0	0.08	0.63	0.24	0.51	0	0	0.68	0.52	0.7	0.03	0.22	0	2.6	0.16	0.39	0	0	0	0	0	0	0	0	0											8.74	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54
H3923_804_0	2007	3																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	197.87	2.19	15.13	5.45	6.26	20.85	0	4.07	32.93	12.48	26.85	0	0	35.7	27.21	36.6	1.71	11.64	0	136.12	8.12	20.25	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	0	0	14.77	0.16	3	-	1.48	4.92	-	0.96	7.77	2.94	6.34	-	-	8.42	6.42	8.64	0.4	2.75	-	32.12	1.92	4.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.8	none	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing											1.2	0.01	0.24	0	0.12	0.4	0	0.08	0.63	0.24	0.51	0	0	0.68	0.52	0.7	0.03	0.22	0	2.6	0.16	0.39	0	0	0	0	0	0	0	0	0											8.74	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54
H3924_001_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1227.81	75.88	599.3	834.64	133.75	10.03	5.68	310.81	291.47	47.41	1640.92	5.93	1.35	1031.53	3457.94	3790.22	160.61	0.15	1500.58	187.7	13.04	1.03	0	0	394.76	2.56	0	0.06	0	3.7	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	0.08	10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.75	0.04	0.3	0.11	0.16	0.12	0.07	0.19	0.57	0.55	0.48	0.01	0.02	0.27	0.42	1.51	0.03	0	0.21	0.08	0.15	0.01	0	0	0.04	0.03	0	0	0	0.04	0											8.15	250	0	12.98	0.35	1.55	1.15	1.27	2.07	1.17	1.49	1.79	1.43	2.94	0.02	0.02	1.99	6.18	7.82	0.3	0	1.19	0.39	0.35	0.01	-	-	0.7	0.03	0	0	-	0.04	-	-	-	-	-	-	-	-	-	-	-	47.24
H3924_002_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1227.81	75.88	599.3	834.64	133.75	10.03	5.68	310.81	291.47	47.41	1640.92	5.93	1.35	1031.53	3457.94	3790.22	160.61	0.15	1500.58	187.7	13.04	1.03	0	0	394.76	2.56	0	0.06	0	3.7	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	0.08	10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.75	0.04	0.3	0.11	0.16	0.12	0.07	0.19	0.57	0.55	0.48	0.01	0.02	0.27	0.42	1.51	0.03	0	0.21	0.08	0.15	0.01	0	0	0.04	0.03	0	0	0	0.04	0											8.15	250	0	12.98	0.35	1.55	1.15	1.27	2.07	1.17	1.49	1.79	1.43	2.94	0.02	0.02	1.99	6.18	7.82	0.3	0	1.19	0.39	0.35	0.01	-	-	0.7	0.03	0	0	-	0.04	-	-	-	-	-	-	-	-	-	-	-	47.24
H3924_003_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1227.81	75.88	599.3	834.64	133.75	10.03	5.68	310.81	291.47	47.41	1640.92	5.93	1.35	1031.53	3457.94	3790.22	160.61	0.15	1500.58	187.7	13.04	1.03	0	0	394.76	2.56	0	0.06	0	3.7	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	0.08	10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.75	0.04	0.3	0.11	0.16	0.12	0.07	0.19	0.57	0.55	0.48	0.01	0.02	0.27	0.42	1.51	0.03	0	0.21	0.08	0.15	0.01	0	0	0.04	0.03	0	0	0	0.04	0											8.15	250	0	12.98	0.35	1.55	1.15	1.27	2.07	1.17	1.49	1.79	1.43	2.94	0.02	0.02	1.99	6.18	7.82	0.3	0	1.19	0.39	0.35	0.01	-	-	0.7	0.03	0	0	-	0.04	-	-	-	-	-	-	-	-	-	-	-	47.24
H3924_004_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1227.81	75.88	599.3	834.64	133.75	10.03	5.68	310.81	291.47	47.41	1640.92	5.93	1.35	1031.53	3457.94	3790.22	160.61	0.15	1500.58	187.7	13.04	1.03	0	0	394.76	2.56	0	0.06	0	3.7	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	0.08	10.23	0.32	1.25	1.04	1.11	1.96	1.11	1.3	1.21	0.88	2.46	0.01	-	1.72	5.76	6.32	0.27	0	0.98	0.31	0.2	0	-	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.09	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.75	0.04	0.3	0.11	0.16	0.12	0.07	0.19	0.57	0.55	0.48	0.01	0.02	0.27	0.42	1.51	0.03	0	0.21	0.08	0.15	0.01	0	0	0.04	0.03	0	0	0	0.04	0											8.15	250	0	12.98	0.35	1.55	1.15	1.27	2.07	1.17	1.49	1.79	1.43	2.94	0.02	0.02	1.99	6.18	7.82	0.3	0	1.19	0.39	0.35	0.01	-	-	0.7	0.03	0	0	-	0.04	-	-	-	-	-	-	-	-	-	-	-	47.24
H3924_005_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1470.52	75.88	845.26	1054.31	148.7	8.84	5.01	257.81	355.21	37.65	1818.31	101.34	0.02	1123.15	4185.38	3799.7	160.61	0.1	2017.88	167.82	10.51	1.1	0	0	487.92	3.46	0	0.01	0	3.88	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	0.07	12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.29	0.04	0.42	0.14	0.18	0.1	0.06	0.16	0.7	0.44	0.53	0.13	0	0.3	0.51	1.51	0.03	0	0.28	0.07	0.12	0.01	0	0	0.05	0.04	0	0	0	0.05	0											9.15	250	0	15.54	0.35	2.18	1.46	1.42	1.83	1.04	1.23	2.18	1.14	3.26	0.34	0	2.17	7.48	7.84	0.3	0	1.59	0.35	0.28	0.01	-	-	0.86	0.04	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	52.94
H3924_006_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1470.52	75.88	845.26	1054.31	148.7	8.84	5.01	257.81	355.21	37.65	1818.31	101.34	0.02	1123.15	4185.38	3799.7	160.61	0.1	2017.88	167.82	10.51	1.1	0	0	487.92	3.46	0	0.01	0	3.88	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	0.07	12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.29	0.04	0.42	0.14	0.18	0.1	0.06	0.16	0.7	0.44	0.53	0.13	0	0.3	0.51	1.51	0.03	0	0.28	0.07	0.12	0.01	0	0	0.05	0.04	0	0	0	0.05	0											9.15	250	0	15.54	0.35	2.18	1.46	1.42	1.83	1.04	1.23	2.18	1.14	3.26	0.34	0	2.17	7.48	7.84	0.3	0	1.59	0.35	0.28	0.01	-	-	0.86	0.04	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	52.94
H3924_007_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1470.52	75.88	845.26	1054.31	148.7	8.84	5.01	257.81	355.21	37.65	1818.31	101.34	0.02	1123.15	4185.38	3799.7	160.61	0.1	2017.88	167.82	10.51	1.1	0	0	487.92	3.46	0	0.01	0	3.88	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	0.07	12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.29	0.04	0.42	0.14	0.18	0.1	0.06	0.16	0.7	0.44	0.53	0.13	0	0.3	0.51	1.51	0.03	0	0.28	0.07	0.12	0.01	0	0	0.05	0.04	0	0	0	0.05	0											9.15	250	0	15.54	0.35	2.18	1.46	1.42	1.83	1.04	1.23	2.18	1.14	3.26	0.34	0	2.17	7.48	7.84	0.3	0	1.59	0.35	0.28	0.01	-	-	0.86	0.04	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	52.94
H3924_008_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1470.52	75.88	845.26	1054.31	148.7	8.84	5.01	257.81	355.21	37.65	1818.31	101.34	0.02	1123.15	4185.38	3799.7	160.61	0.1	2017.88	167.82	10.51	1.1	0	0	487.92	3.46	0	0.01	0	3.88	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	0.07	12.25	0.32	1.76	1.32	1.24	1.72	0.98	1.07	1.48	0.7	2.73	0.21	-	1.87	6.98	6.33	0.27	0	1.31	0.28	0.16	0	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.79	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.29	0.04	0.42	0.14	0.18	0.1	0.06	0.16	0.7	0.44	0.53	0.13	0	0.3	0.51	1.51	0.03	0	0.28	0.07	0.12	0.01	0	0	0.05	0.04	0	0	0	0.05	0											9.15	250	0	15.54	0.35	2.18	1.46	1.42	1.83	1.04	1.23	2.18	1.14	3.26	0.34	0	2.17	7.48	7.84	0.3	0	1.59	0.35	0.28	0.01	-	-	0.86	0.04	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	52.94
H3924_009_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1246.76	75.88	808.33	1209.14	77.72	10.63	5.92	212.63	243.01	41.24	1101.53	38.67	0.47	846.34	3933.33	4363.61	160.61	0.04	2761.21	249.29	8.25	1.28	0	0	297.18	2.16	0	0.01	0	4.16	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	0.08	10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.79	0.04	0.41	0.16	0.09	0.12	0.07	0.13	0.48	0.48	0.32	0.05	0.01	0.22	0.48	1.73	0.03	0	0.39	0.11	0.1	0.01	0	0	0.03	0.03	0	0	0	0.05	0											8.31	250	0	13.18	0.35	2.09	1.67	0.74	2.2	1.22	1.02	1.49	1.24	1.97	0.13	0.01	1.63	7.03	9.01	0.3	0	2.18	0.52	0.22	0.01	-	-	0.53	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	48.82
H3924_010_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1246.76	75.88	808.33	1209.14	77.72	10.63	5.92	212.63	243.01	41.24	1101.53	38.67	0.47	846.34	3933.33	4363.61	160.61	0.04	2761.21	249.29	8.25	1.28	0	0	297.18	2.16	0	0.01	0	4.16	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	0.08	10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.79	0.04	0.41	0.16	0.09	0.12	0.07	0.13	0.48	0.48	0.32	0.05	0.01	0.22	0.48	1.73	0.03	0	0.39	0.11	0.1	0.01	0	0	0.03	0.03	0	0	0	0.05	0											8.31	250	0	13.18	0.35	2.09	1.67	0.74	2.2	1.22	1.02	1.49	1.24	1.97	0.13	0.01	1.63	7.03	9.01	0.3	0	2.18	0.52	0.22	0.01	-	-	0.53	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	48.82
H3924_011_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1246.76	75.88	808.33	1209.14	77.72	10.63	5.92	212.63	243.01	41.24	1101.53	38.67	0.47	846.34	3933.33	4363.61	160.61	0.04	2761.21	249.29	8.25	1.28	0	0	297.18	2.16	0	0.01	0	4.16	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	0.08	10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.79	0.04	0.41	0.16	0.09	0.12	0.07	0.13	0.48	0.48	0.32	0.05	0.01	0.22	0.48	1.73	0.03	0	0.39	0.11	0.1	0.01	0	0	0.03	0.03	0	0	0	0.05	0											8.31	250	0	13.18	0.35	2.09	1.67	0.74	2.2	1.22	1.02	1.49	1.24	1.97	0.13	0.01	1.63	7.03	9.01	0.3	0	2.18	0.52	0.22	0.01	-	-	0.53	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	48.82
H3924_012_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1246.76	75.88	808.33	1209.14	77.72	10.63	5.92	212.63	243.01	41.24	1101.53	38.67	0.47	846.34	3933.33	4363.61	160.61	0.04	2761.21	249.29	8.25	1.28	0	0	297.18	2.16	0	0.01	0	4.16	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	0.08	10.39	0.32	1.68	1.51	0.65	2.07	1.15	0.89	1.01	0.76	1.65	0.08	-	1.41	6.56	7.27	0.27	0	1.79	0.42	0.13	0	-	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.51	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.79	0.04	0.41	0.16	0.09	0.12	0.07	0.13	0.48	0.48	0.32	0.05	0.01	0.22	0.48	1.73	0.03	0	0.39	0.11	0.1	0.01	0	0	0.03	0.03	0	0	0	0.05	0											8.31	250	0	13.18	0.35	2.09	1.67	0.74	2.2	1.22	1.02	1.49	1.24	1.97	0.13	0.01	1.63	7.03	9.01	0.3	0	2.18	0.52	0.22	0.01	-	-	0.53	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	48.82
H3924_013_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1115.49	75.88	733.88	1289.38	112.18	12.25	5.64	246.71	254.57	49.82	2241.8	50.28	1.35	1149.55	3719.56	4121.95	160.61	0.11	1828.23	152.37	15.63	1.36	0	0	360.39	2.2	0	0.03	0	3.91	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	0.09	9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.49	0.04	0.37	0.17	0.13	0.14	0.07	0.15	0.5	0.58	0.65	0.07	0.02	0.3	0.45	1.64	0.03	0	0.26	0.07	0.18	0.02	0	0	0.04	0.03	0	0	0	0.05	0											8.43	250	0	11.79	0.35	1.9	1.78	1.07	2.53	1.17	1.18	1.56	1.5	4.02	0.17	0.02	2.22	6.65	8.51	0.3	0	1.44	0.32	0.42	0.02	-	-	0.64	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	49.62
H3924_014_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1115.49	75.88	733.88	1289.38	112.18	12.25	5.64	246.71	254.57	49.82	2241.8	50.28	1.35	1149.55	3719.56	4121.95	160.61	0.11	1828.23	152.37	15.63	1.36	0	0	360.39	2.2	0	0.03	0	3.91	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	0.09	9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.49	0.04	0.37	0.17	0.13	0.14	0.07	0.15	0.5	0.58	0.65	0.07	0.02	0.3	0.45	1.64	0.03	0	0.26	0.07	0.18	0.02	0	0	0.04	0.03	0	0	0	0.05	0											8.43	250	0	11.79	0.35	1.9	1.78	1.07	2.53	1.17	1.18	1.56	1.5	4.02	0.17	0.02	2.22	6.65	8.51	0.3	0	1.44	0.32	0.42	0.02	-	-	0.64	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	49.62
H3924_015_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1115.49	75.88	733.88	1289.38	112.18	12.25	5.64	246.71	254.57	49.82	2241.8	50.28	1.35	1149.55	3719.56	4121.95	160.61	0.11	1828.23	152.37	15.63	1.36	0	0	360.39	2.2	0	0.03	0	3.91	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	0.09	9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.49	0.04	0.37	0.17	0.13	0.14	0.07	0.15	0.5	0.58	0.65	0.07	0.02	0.3	0.45	1.64	0.03	0	0.26	0.07	0.18	0.02	0	0	0.04	0.03	0	0	0	0.05	0											8.43	250	0	11.79	0.35	1.9	1.78	1.07	2.53	1.17	1.18	1.56	1.5	4.02	0.17	0.02	2.22	6.65	8.51	0.3	0	1.44	0.32	0.42	0.02	-	-	0.64	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	49.62
H3924_016_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1115.49	75.88	733.88	1289.38	112.18	12.25	5.64	246.71	254.57	49.82	2241.8	50.28	1.35	1149.55	3719.56	4121.95	160.61	0.11	1828.23	152.37	15.63	1.36	0	0	360.39	2.2	0	0.03	0	3.91	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	0.09	9.3	0.32	1.53	1.61	0.93	2.39	1.1	1.03	1.06	0.92	3.36	0.1	-	1.92	6.2	6.87	0.27	0	1.19	0.25	0.24	0	-	-	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.18	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.49	0.04	0.37	0.17	0.13	0.14	0.07	0.15	0.5	0.58	0.65	0.07	0.02	0.3	0.45	1.64	0.03	0	0.26	0.07	0.18	0.02	0	0	0.04	0.03	0	0	0	0.05	0											8.43	250	0	11.79	0.35	1.9	1.78	1.07	2.53	1.17	1.18	1.56	1.5	4.02	0.17	0.02	2.22	6.65	8.51	0.3	0	1.44	0.32	0.42	0.02	-	-	0.64	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	49.62
H3924_017_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1268.42	75.88	619.49	851.97	153.59	12.57	7.65	346.25	280.93	37.17	1825.53	12.35	2.27	1062.5	3559.69	4366.34	160.61	0.78	1753.11	129.14	11.58	0.75	0	0	334.28	2.43	0	0.03	0	4.05	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	0.1	10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.84	0.04	0.31	0.11	0.18	0.15	0.09	0.22	0.55	0.43	0.53	0.02	0.03	0.28	0.43	1.73	0.03	0	0.25	0.06	0.14	0.01	0	0	0.04	0.03	0	0	0	0.05	0											8.52	250	0	13.41	0.35	1.6	1.18	1.46	2.6	1.58	1.66	1.72	1.12	3.27	0.04	0.03	2.05	6.36	9.01	0.3	0	1.39	0.27	0.31	0.01	-	-	0.59	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	50.39
H3924_018_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1268.42	75.88	619.49	851.97	153.59	12.57	7.65	346.25	280.93	37.17	1825.53	12.35	2.27	1062.5	3559.69	4366.34	160.61	0.78	1753.11	129.14	11.58	0.75	0	0	334.28	2.43	0	0.03	0	4.05	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	0.1	10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.84	0.04	0.31	0.11	0.18	0.15	0.09	0.22	0.55	0.43	0.53	0.02	0.03	0.28	0.43	1.73	0.03	0	0.25	0.06	0.14	0.01	0	0	0.04	0.03	0	0	0	0.05	0											8.52	250	0	13.41	0.35	1.6	1.18	1.46	2.6	1.58	1.66	1.72	1.12	3.27	0.04	0.03	2.05	6.36	9.01	0.3	0	1.39	0.27	0.31	0.01	-	-	0.59	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	50.39
H3924_019_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1268.42	75.88	619.49	851.97	153.59	12.57	7.65	346.25	280.93	37.17	1825.53	12.35	2.27	1062.5	3559.69	4366.34	160.61	0.78	1753.11	129.14	11.58	0.75	0	0	334.28	2.43	0	0.03	0	4.05	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	0.1	10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.84	0.04	0.31	0.11	0.18	0.15	0.09	0.22	0.55	0.43	0.53	0.02	0.03	0.28	0.43	1.73	0.03	0	0.25	0.06	0.14	0.01	0	0	0.04	0.03	0	0	0	0.05	0											8.52	250	0	13.41	0.35	1.6	1.18	1.46	2.6	1.58	1.66	1.72	1.12	3.27	0.04	0.03	2.05	6.36	9.01	0.3	0	1.39	0.27	0.31	0.01	-	-	0.59	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	50.39
H3924_020_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1268.42	75.88	619.49	851.97	153.59	12.57	7.65	346.25	280.93	37.17	1825.53	12.35	2.27	1062.5	3559.69	4366.34	160.61	0.78	1753.11	129.14	11.58	0.75	0	0	334.28	2.43	0	0.03	0	4.05	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	0.1	10.57	0.32	1.29	1.06	1.28	2.45	1.49	1.44	1.17	0.69	2.74	0.03	-	1.77	5.93	7.28	0.27	0	1.14	0.22	0.18	0	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.87	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.84	0.04	0.31	0.11	0.18	0.15	0.09	0.22	0.55	0.43	0.53	0.02	0.03	0.28	0.43	1.73	0.03	0	0.25	0.06	0.14	0.01	0	0	0.04	0.03	0	0	0	0.05	0											8.52	250	0	13.41	0.35	1.6	1.18	1.46	2.6	1.58	1.66	1.72	1.12	3.27	0.04	0.03	2.05	6.36	9.01	0.3	0	1.39	0.27	0.31	0.01	-	-	0.59	0.03	0	0	-	0.05	-	-	-	-	-	-	-	-	-	-	-	50.39
H3924_021_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1373.36	75.88	209.85	756.16	68.7	6.01	3.96	294.11	257.34	39.51	1367.63	1.58	0.01	883.96	3794.59	3329.53	160.61	0.48	2588.12	784.35	12.99	1.88	0	0	201.28	1.2	0	0	0	4.65	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	0.05	11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.07	0.04	0.11	0.1	0.08	0.07	0.05	0.18	0.5	0.46	0.4	0	0	0.23	0.46	1.32	0.03	0	0.36	0.34	0.15	0.02	0	0	0.02	0.01	0	0	0	0.05	0											8.07	250	0	14.52	0.35	0.54	1.04	0.65	1.24	0.82	1.41	1.58	1.19	2.45	0.01	0	1.71	6.78	6.87	0.3	0	2.05	1.65	0.35	0.02	-	-	0.36	0.01	0	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	45.95
H3924_022_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1373.36	75.88	209.85	756.16	68.7	6.01	3.96	294.11	257.34	39.51	1367.63	1.58	0.01	883.96	3794.59	3329.53	160.61	0.48	2588.12	784.35	12.99	1.88	0	0	201.28	1.2	0	0	0	4.65	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	0.05	11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.07	0.04	0.11	0.1	0.08	0.07	0.05	0.18	0.5	0.46	0.4	0	0	0.23	0.46	1.32	0.03	0	0.36	0.34	0.15	0.02	0	0	0.02	0.01	0	0	0	0.05	0											8.07	250	0	14.52	0.35	0.54	1.04	0.65	1.24	0.82	1.41	1.58	1.19	2.45	0.01	0	1.71	6.78	6.87	0.3	0	2.05	1.65	0.35	0.02	-	-	0.36	0.01	0	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	45.95
H3924_023_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1373.36	75.88	209.85	756.16	68.7	6.01	3.96	294.11	257.34	39.51	1367.63	1.58	0.01	883.96	3794.59	3329.53	160.61	0.48	2588.12	784.35	12.99	1.88	0	0	201.28	1.2	0	0	0	4.65	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	0.05	11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.07	0.04	0.11	0.1	0.08	0.07	0.05	0.18	0.5	0.46	0.4	0	0	0.23	0.46	1.32	0.03	0	0.36	0.34	0.15	0.02	0	0	0.02	0.01	0	0	0	0.05	0											8.07	250	0	14.52	0.35	0.54	1.04	0.65	1.24	0.82	1.41	1.58	1.19	2.45	0.01	0	1.71	6.78	6.87	0.3	0	2.05	1.65	0.35	0.02	-	-	0.36	0.01	0	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	45.95
H3924_024_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1373.36	75.88	209.85	756.16	68.7	6.01	3.96	294.11	257.34	39.51	1367.63	1.58	0.01	883.96	3794.59	3329.53	160.61	0.48	2588.12	784.35	12.99	1.88	0	0	201.28	1.2	0	0	0	4.65	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	0.05	11.44	0.32	0.44	0.95	0.57	1.17	0.77	1.23	1.07	0.73	2.05	0	-	1.47	6.32	5.55	0.27	0	1.68	1.31	0.2	0	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.07	0.04	0.11	0.1	0.08	0.07	0.05	0.18	0.5	0.46	0.4	0	0	0.23	0.46	1.32	0.03	0	0.36	0.34	0.15	0.02	0	0	0.02	0.01	0	0	0	0.05	0											8.07	250	0	14.52	0.35	0.54	1.04	0.65	1.24	0.82	1.41	1.58	1.19	2.45	0.01	0	1.71	6.78	6.87	0.3	0	2.05	1.65	0.35	0.02	-	-	0.36	0.01	0	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	45.95
H3924_025_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1065.83	75.88	411	1021.34	126.18	9.38	2.88	260.38	290.5	29.88	1385.5	5.29	1.16	710.6	3450.8	3517.22	160.61	1.32	1393.73	113.41	11.71	0.56	0	0	389.26	2.79	0	0.05	0	2.57	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	0.06	8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.38	0.04	0.21	0.13	0.15	0.11	0.03	0.16	0.57	0.35	0.4	0.01	0.01	0.19	0.42	1.4	0.03	0	0.2	0.05	0.14	0.01	0	0	0.04	0.03	0	0	0	0.03	0											7.08	250	0	11.27	0.35	1.06	1.41	1.2	1.94	0.59	1.25	1.78	0.9	2.48	0.02	0.01	1.37	6.17	7.26	0.3	0	1.1	0.24	0.31	0.01	-	-	0.69	0.03	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	41.78
H3924_026_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1065.83	75.88	411	1021.34	126.18	9.38	2.88	260.38	290.5	29.88	1385.5	5.29	1.16	710.6	3450.8	3517.22	160.61	1.32	1393.73	113.41	11.71	0.56	0	0	389.26	2.79	0	0.05	0	2.57	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	0.06	8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.38	0.04	0.21	0.13	0.15	0.11	0.03	0.16	0.57	0.35	0.4	0.01	0.01	0.19	0.42	1.4	0.03	0	0.2	0.05	0.14	0.01	0	0	0.04	0.03	0	0	0	0.03	0											7.08	250	0	11.27	0.35	1.06	1.41	1.2	1.94	0.59	1.25	1.78	0.9	2.48	0.02	0.01	1.37	6.17	7.26	0.3	0	1.1	0.24	0.31	0.01	-	-	0.69	0.03	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	41.78
H3924_027_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1065.83	75.88	411	1021.34	126.18	9.38	2.88	260.38	290.5	29.88	1385.5	5.29	1.16	710.6	3450.8	3517.22	160.61	1.32	1393.73	113.41	11.71	0.56	0	0	389.26	2.79	0	0.05	0	2.57	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	0.06	8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.38	0.04	0.21	0.13	0.15	0.11	0.03	0.16	0.57	0.35	0.4	0.01	0.01	0.19	0.42	1.4	0.03	0	0.2	0.05	0.14	0.01	0	0	0.04	0.03	0	0	0	0.03	0											7.08	250	0	11.27	0.35	1.06	1.41	1.2	1.94	0.59	1.25	1.78	0.9	2.48	0.02	0.01	1.37	6.17	7.26	0.3	0	1.1	0.24	0.31	0.01	-	-	0.69	0.03	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	41.78
H3924_028_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1065.83	75.88	411	1021.34	126.18	9.38	2.88	260.38	290.5	29.88	1385.5	5.29	1.16	710.6	3450.8	3517.22	160.61	1.32	1393.73	113.41	11.71	0.56	0	0	389.26	2.79	0	0.05	0	2.57	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	0.06	8.88	0.32	0.86	1.28	1.05	1.83	0.56	1.08	1.21	0.55	2.08	0.01	-	1.18	5.75	5.86	0.27	0	0.91	0.19	0.18	0	-	-	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.7	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											2.38	0.04	0.21	0.13	0.15	0.11	0.03	0.16	0.57	0.35	0.4	0.01	0.01	0.19	0.42	1.4	0.03	0	0.2	0.05	0.14	0.01	0	0	0.04	0.03	0	0	0	0.03	0											7.08	250	0	11.27	0.35	1.06	1.41	1.2	1.94	0.59	1.25	1.78	0.9	2.48	0.02	0.01	1.37	6.17	7.26	0.3	0	1.1	0.24	0.31	0.01	-	-	0.69	0.03	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	41.78
H3924_029_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1465.04	75.88	399.53	981.87	141.32	9.84	3.46	292.54	275.25	44.43	2173.76	6.76	1.42	618.37	3321.32	4044.44	160.61	0.77	2420.23	367.08	10.75	1.55	0	0	368.58	1.51	0	0.02	0	2.95	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	0.07	12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.28	0.04	0.2	0.13	0.17	0.11	0.04	0.18	0.54	0.52	0.63	0.01	0.02	0.16	0.4	1.61	0.03	0	0.34	0.16	0.13	0.02	0	0	0.04	0.02	0	0	0	0.03	0											8.8	250	0	15.48	0.35	1.03	1.36	1.35	2.03	0.72	1.4	1.69	1.34	3.89	0.02	0.02	1.19	5.94	8.35	0.3	0	1.91	0.77	0.29	0.02	-	-	0.65	0.02	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	50.16
H3924_030_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1465.04	75.88	399.53	981.87	141.32	9.84	3.46	292.54	275.25	44.43	2173.76	6.76	1.42	618.37	3321.32	4044.44	160.61	0.77	2420.23	367.08	10.75	1.55	0	0	368.58	1.51	0	0.02	0	2.95	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	0.07	12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.28	0.04	0.2	0.13	0.17	0.11	0.04	0.18	0.54	0.52	0.63	0.01	0.02	0.16	0.4	1.61	0.03	0	0.34	0.16	0.13	0.02	0	0	0.04	0.02	0	0	0	0.03	0											8.8	250	0	15.48	0.35	1.03	1.36	1.35	2.03	0.72	1.4	1.69	1.34	3.89	0.02	0.02	1.19	5.94	8.35	0.3	0	1.91	0.77	0.29	0.02	-	-	0.65	0.02	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	50.16
H3924_031_0	2007	5																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1465.04	75.88	399.53	981.87	141.32	9.84	3.46	292.54	275.25	44.43	2173.76	6.76	1.42	618.37	3321.32	4044.44	160.61	0.77	2420.23	367.08	10.75	1.55	0	0	368.58	1.51	0	0.02	0	2.95	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	0.07	12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.28	0.04	0.2	0.13	0.17	0.11	0.04	0.18	0.54	0.52	0.63	0.01	0.02	0.16	0.4	1.61	0.03	0	0.34	0.16	0.13	0.02	0	0	0.04	0.02	0	0	0	0.03	0											8.8	250	0	15.48	0.35	1.03	1.36	1.35	2.03	0.72	1.4	1.69	1.34	3.89	0.02	0.02	1.19	5.94	8.35	0.3	0	1.91	0.77	0.29	0.02	-	-	0.65	0.02	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	50.16
H3924_032_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1465.04	75.88	399.53	981.87	141.32	9.84	3.46	292.54	275.25	44.43	2173.76	6.76	1.42	618.37	3321.32	4044.44	160.61	0.77	2420.23	367.08	10.75	1.55	0	0	368.58	1.51	0	0.02	0	2.95	0											PBP Line 1a: 100 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 15/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b: 20 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 15/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Line 7a: 20 Line 14c: 15; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 7e 7h: 25Ind/10Grp	PBP Line 7c 7i: 15/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 0	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											100	50	25	15	100	0.2	0.2	50	50	0.02	18	25	0	20	20	20	20	15	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	0.07	12.21	0.32	0.83	1.23	1.18	1.92	0.68	1.22	1.15	0.82	3.26	0.01	-	1.03	5.54	6.74	0.27	0	1.57	0.61	0.16	0	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	None	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Not Covered	Not Covered	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.	N/A	Subject to deductible then 20 coinsurance.	Subject to deductible then 20 coinsurance.											3.28	0.04	0.2	0.13	0.17	0.11	0.04	0.18	0.54	0.52	0.63	0.01	0.02	0.16	0.4	1.61	0.03	0	0.34	0.16	0.13	0.02	0	0	0.04	0.02	0	0	0	0.03	0											8.8	250	0	15.48	0.35	1.03	1.36	1.35	2.03	0.72	1.4	1.69	1.34	3.89	0.02	0.02	1.19	5.94	8.35	0.3	0	1.91	0.77	0.29	0.02	-	-	0.65	0.02	0	0	-	0.03	-	-	-	-	-	-	-	-	-	-	-	50.16
H3931_004_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1767.76		1496.09	901.42	248.13	16.77		436.42	283.65	602.52	870.98	0	0	540.82	3259.5	4210.18	0	505.55	0	0	258.81																					350/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 125 CAT PET MRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script																					57.09		67.84	20	100	0.2		48	200	25	55.91	25	25	25	10	25	25	25	25	25	45																					8.41	-	8.46	1.5	2.07	3.35	-	1.75	4.73	1.26	4.06	-	-	1.13	2.72	8.77	-	1.05	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22			8.41	-	8.46	1.5	2.07	3.35	-	1.75	4.73	1.26	4.06	-	-	1.13	2.72	8.77	-	1.05	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22																																																																																				-			8.41	-	8.46	1.5	2.07	3.35	-	1.75	4.73	1.26	4.06	-	-	1.13	2.72	8.77	-	1.05	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.22
H3931_054_0	2007	2																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		2258.28		1452.61	1091.62	244.79	21.47		489.48	249.86	554.43	753.41	0	0	471.9	3447.95	4335.2	0	361.78	0	0	256.76																					150/day  10 day max		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	30 per visit	30 X-ray; 100 CAT PET MRI	30 per visit	30 per visit	30 per visit	0 per visit	30 per visit	30 per visit	30 per visit	30 per visit	30 per visit	45 per script																					122.46		67.84	20	100	0.2		48	200	30	53.94	30	30	30	0	30	30	30	30	30	45																					23.05	-	8.21	1.82	2.04	4.29	-	1.96	4.16	1.39	3.39	-	-	1.18	-	10.84	-	0.9	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.19			23.05	-	8.21	1.82	2.04	4.29	-	1.96	4.16	1.39	3.39	-	-	1.18	-	10.84	-	0.9	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.19																																																																																				-			23.05	-	8.21	1.82	2.04	4.29	-	1.96	4.16	1.39	3.39	-	-	1.18	-	10.84	-	0.9	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.19
H3931_055_0	2007	2																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1682.3		1423.76	857.84	236.13	16.34		415.32	269.93	573.39	828.88	0	0	514.67	3101.92	4006.64	0	481.11	0	0	246.3																					850/admission		0 days 1-8 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	35 X-ray; 125 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.1	35	35	35	35	45																					19.44	-	8.05	1.43	1.97	3.27	-	1.66	4.5	1.67	4.54	-	-	1.5	5.17	11.39	-	1.4	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.91			19.44	-	8.05	1.43	1.97	3.27	-	1.66	4.5	1.67	4.54	-	-	1.5	5.17	11.39	-	1.4	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.91																																																																																				-			19.44	-	8.05	1.43	1.97	3.27	-	1.66	4.5	1.67	4.54	-	-	1.5	5.17	11.39	-	1.4	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.91
H3931_058_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		2265.63		1457.34	1095.17	245.59	21.54		491.08	250.67	556.24	755.87	0	0	473.44	3459.18	4349.31	0	362.96	0	0	257.59																					350/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	0	20 per visit	20 X-ray; 100 CAT PET MRI	20 per visit	20 per visit	20 per visit	10 per visit	20 per visit	20 per visit	20 per visit	20 per visit	20 per visit	45 per script																					57.09		67.84	20	100	0.2		48	200	20	47.36	20	20	20	10	20	20	20	20	20	45																					10.78	-	8.24	1.83	2.05	4.31	-	1.96	4.18	0.93	2.98	-	-	0.79	2.88	7.25	-	0.6	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.74			10.78	-	8.24	1.83	2.05	4.31	-	1.96	4.18	0.93	2.98	-	-	0.79	2.88	7.25	-	0.6	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.74																																																																																				-			10.78	-	8.24	1.83	2.05	4.31	-	1.96	4.18	0.93	2.98	-	-	0.79	2.88	7.25	-	0.6	-	-	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.74
H3931_060_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	Coin	V	V	V	S			V																																																											-		2455.18		1579.27	1186.8	266.13	23.34		532.16	271.64	602.77	819.1	0	0	513.05	3748.58	4713.19	0	393.33	0	0	279.14			3822.53																		992/admission		0 days 1-20; 100 21+	0 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	400 per procedure	50 per visit	50 X-ray; 20 CAT PET MRI	50 per visit	30 per visit	50 per visit	0 per visit	50 per visit; 30 dialysis visit	20 coinsurance	50 per visit	50 per visit	50 per visit	45 per script			5 per visit																		161.82		40.15	0	100	0.2		48	400	50	67.1	50	30	50	0	46.94	50	50	50	50	45			5																		33.11	-	5.28	-	2.22	4.67	-	2.13	9.05	2.51	4.58	-	-	2.14	-	18.44	-	1.64	-	-	1.05	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.41			33.11	-	5.28	-	2.22	4.67	-	2.13	9.05	2.51	4.58	-	-	2.14	-	18.44	-	1.64	-	-	1.05	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.41																																																																																				-			33.11	-	5.28	-	2.22	4.67	-	2.13	9.05	2.51	4.58	-	-	2.14	-	18.44	-	1.64	-	-	1.05	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.41
H3931_063_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	Coin	V	V	V	S			V																																																											-		1856.15		1570.9	946.5	260.54	17.8	0	458.24	297.83	632.65	914.54	0	0	567.86	3422.49	4420.71	0	530.83	0	0	271.75			3822.53																		992/admission		0 days 1-20; 100 21+	0 per visit	100 per trip	20 coinsurance	0	50 ER; 35 UC	400 per visit	50 per visit	50 X-ray; 20 CAT PET MRI	50 per visit	30 per visit	50 per visit	0 per visit	50 per visit; 30 dialysis visit	20 coinsurance	50 per visit	50 per visit	50 per visit	45 per script			5 per visit																		161.82		40.15	0	100	0.2	0	48	400	50	67.1	50	30	50	0	46.74	0.2	50	50	50	45			5																		25.03	-	5.26	-	2.17	3.56	-	1.83	9.93	2.64	5.11	-	-	2.37	-	17.22	-	2.21	-	-	1.02	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.94			25.03	-	5.26	-	2.17	3.56	-	1.83	9.93	2.64	5.11	-	-	2.37	-	17.22	-	2.21	-	-	1.02	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.94																																																																																				-			25.03	-	5.26	-	2.17	3.56	-	1.83	9.93	2.64	5.11	-	-	2.37	-	17.22	-	2.21	-	-	1.02	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.94
H3931_064_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1630.18		1379.66	831.27	228.82	16.04		402.45	261.57	555.63	803.2	0	0	498.73	3005.83	3882.52	0	466.21	0	0	238.67																					850/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	35 X-ray; 125 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.07	35	35	35	35	45																					18.84	-	7.8	1.39	1.91	3.21	-	1.61	4.36	1.62	4.4	-	-	1.45	5.01	11.02	-	1.36	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.87			18.84	-	7.8	1.39	1.91	3.21	-	1.61	4.36	1.62	4.4	-	-	1.45	5.01	11.02	-	1.36	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.87																																																																																				-			18.84	-	7.8	1.39	1.91	3.21	-	1.61	4.36	1.62	4.4	-	-	1.45	5.01	11.02	-	1.36	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.87
H3931_065_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		2258.28		1452.61	1091.62	244.79	21.47		489.48	249.86	554.43	753.41	0	0	471.9	3447.95	4335.2	0	361.78	0	0	256.76																					150/day  10 day max		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	30 per visit	30 X-ray; 100 CAT PET MRI	30 per visit	30 per visit	30 per visit	0 per visit	30 per visit	30 per visit	30 per visit	30 per visit	30 per visit	45 per script																					122.46		67.84	20	100	0.2		48	200	30	53.94	30	30	30	0	30	30	30	30	30	45																					23.05	-	8.21	1.82	2.04	4.29	-	1.96	4.16	1.39	3.39	-	-	1.18	-	10.84	-	0.9	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.19			23.05	-	8.21	1.82	2.04	4.29	-	1.96	4.16	1.39	3.39	-	-	1.18	-	10.84	-	0.9	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.19																																																																																				-			23.05	-	8.21	1.82	2.04	4.29	-	1.96	4.16	1.39	3.39	-	-	1.18	-	10.84	-	0.9	-	-	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.19
H3931_066_0	2007	2																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1639.04		1206.48	766.63	172.7	17.12		400.17	328.06	747.45	1138.36	0	4.45	618.19	3321.81	3848.79	0	923.42	0	0	245.18																					800/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	0	35 per visit	35 X-ray; 100 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 dialysis	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					130.5		67.84	20	100	0.2		48	200	35	57.23	35	30	35	20	34.06	35	35	35	35	45																					17.82	-	6.82	1.28	1.44	3.42	-	1.6	5.47	2.18	5.43	-	0.01	1.8	5.54	10.93	-	2.69	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.35			17.82	-	6.82	1.28	1.44	3.42	-	1.6	5.47	2.18	5.43	-	0.01	1.8	5.54	10.93	-	2.69	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.35																																																																																				-			17.82	-	6.82	1.28	1.44	3.42	-	1.6	5.47	2.18	5.43	-	0.01	1.8	5.54	10.93	-	2.69	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.35
H3931_067_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1637.69		1205.49	766	172.56	17.1		399.84	327.79	746.83	1137.42	0	4.44	617.68	3319.08	3845.63	0	922.66	0	0	244.98																					800/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.0638724920851 X-ray; 100 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					130.5		67.84	20	100	0.2		48	200	35	57.23	35	30	35	20	34.06	35	35	35	35	45																					17.81	-	6.82	1.28	1.44	3.42	-	1.6	5.46	2.18	5.42	-	0.01	1.8	5.53	10.92	-	2.69	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.3			17.81	-	6.82	1.28	1.44	3.42	-	1.6	5.46	2.18	5.42	-	0.01	1.8	5.53	10.92	-	2.69	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.3																																																																																				-			17.81	-	6.82	1.28	1.44	3.42	-	1.6	5.46	2.18	5.42	-	0.01	1.8	5.53	10.92	-	2.69	-	-	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.3
H3931_068_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1661.43		1222.96	777.11	175.06	17.35		405.64	332.54	757.66	1153.91	0	4.51	626.64	3367.2	3901.39	0	936.03	0	0	248.53																					350/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	20 per visit	20 X-ray; 100 CAT PET MRI	20 per visit	20 per visit	20 per visit	10 per visit	20 per visit	20 per visit	20 per visit	20 per visit	20 per visit	45 per script																					57.09		67.84	20	100	0.2		48	200	20	47.36	20	20	20	10	20	20	20	20	20	45																					7.9	-	6.91	1.3	1.46	3.47	-	1.62	5.54	1.26	4.55	-	0.01	1.04	2.81	6.5	-	1.56	-	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.88			7.9	-	6.91	1.3	1.46	3.47	-	1.62	5.54	1.26	4.55	-	0.01	1.04	2.81	6.5	-	1.56	-	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.88																																																																																				-			7.9	-	6.91	1.3	1.46	3.47	-	1.62	5.54	1.26	4.55	-	0.01	1.04	2.81	6.5	-	1.56	-	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.88
H3931_801_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1728.91		1168.57	1136.92	220.06	18.26		389.68	309.73	11.78	59.52	0	0	585.04	2848.61	6577.84	0	594.14	0	0	7.46																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					20.7	-	9.74	3.32	2.75	5.48	-	1.62	3.87	2.36	11.9	-	-	1.71	8.31	19.19	-	1.73	-	-	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.16			20.7	-	9.74	3.32	2.75	5.48	-	1.62	3.87	2.36	11.9	-	-	1.71	8.31	19.19	-	1.73	-	-	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.16																																																																																				-			20.7	-	9.74	3.32	2.75	5.48	-	1.62	3.87	2.36	11.9	-	-	1.71	8.31	19.19	-	1.73	-	-	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.16
H3931_804_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1728.91		1168.57	1136.92	220.06	18.26		389.68	309.73	11.78	59.52	0	0	585.04	2848.61	6577.84	0	594.14	0	0	7.46																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					20.7	-	9.74	3.32	2.75	5.48	-	1.62	3.87	2.36	11.9	-	-	1.71	8.31	19.19	-	1.73	-	-	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.16			20.7	-	9.74	3.32	2.75	5.48	-	1.62	3.87	2.36	11.9	-	-	1.71	8.31	19.19	-	1.73	-	-	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.16																																																																																				-			20.7	-	9.74	3.32	2.75	5.48	-	1.62	3.87	2.36	11.9	-	-	1.71	8.31	19.19	-	1.73	-	-	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.16
H3949_002_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V																																																				-		2565.1	101.87	1618.75		214.25	10.77	8.06	282.42	48.29		56.25		1.97	3.71	693.56	9183.48	606.29	795.04			23.82				950.32																	#1A 100/day days 1-8 0/day days 9-90	#1B 100/day days 1-8 0/day days 9-90	#2 0/day days 1-20 125/day days 21-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 50	#9A 20 #9B 20	#8A 0 diag lab	#8A 20 #8B 20		#12 20	#3 20 #5 20 #9C 25 #9D 25	#7A 10 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 20 #7D 25 #7F 25 #7G 25	#7E 25 #7H 25	#7C 25 #7I 25		#14I 0	#15 20	'0	#10B 0 n/c	#16A 0 n/c #16B 0 n/c	#17A 25	#17B 0	#18A 0 n/c	#18B 0 n/c	#19 0 n/c	#14A 0 n/c	#13B 0 n/c											71.08	71.08	57.71		50	0.2	0.2	50	0.2		0.2		0.2	0.21	10	19.64	25	25			0.2				2.28																	15.19	0.6	7.78	-	0.89	2.15	1.61	1.18	9.66	-	11.25	-	0.39	0.78	0.58	15.03	1.26	1.66	-	-	4.76	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.97	0	0	15.19	0.6	7.78	-	0.89	2.15	1.61	1.18	9.66	-	11.25	-	0.39	0.78	0.58	15.03	1.26	1.66	-	-	4.76	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.97																																																																																				-		0	15.19	0.6	7.78	-	0.89	2.15	1.61	1.18	9.66	-	11.25	-	0.39	0.78	0.58	15.03	1.26	1.66	-	-	4.76	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.97
H3949_009_0	2007	6																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	Coin	P	V	P	O	O	V																																																				-		427.62	12.69	57.49		10.21	16.08	7.08	419.34	40.63	11.41	48.95	0.09	4.37	27.55	5.41	174.97	7.48	3.35	20.12	3.5	14.25	0.03																				#1A 0/day days 1-60 238/day days 61-90	#1B 0/day days 1-60 238/day days 61-90	#2 0/day days 1-20 125/day days 21-100	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 50	#9A 20 #9B 20	#8A 0-clin/diag lab 20-all other	#8A 20 #8B 20	20	#12 20	#3 20 #5 20 #9C 20 #9D 20	#7A 20 #14B 20 #14C 0 #14D 0-pap smears 20-pelvic exams #14E 20 #14F 20 #14G 20 #14H 20	#7B 20 #7D 20 #7F 20 #7G 20	#7E 20 #7H 50	#7C 20 #7I 20	20	#14I 20	#15 20	20	#10B 0	#16A 0 #16B 0	#17A 0	#17B 0	#18A 0	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											0.07	0.07	0.17		0.21	0.21	0.21	50	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21																				28.09	0.83	9.56	-	2.11	3.33	1.46	1.75	8.4	2.36	10.12	0.02	0.9	5.7	1.12	36.19	1.55	0.69	4.16	0.72	2.95	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.03	0	0	28.09	0.83	9.56	-	2.11	3.33	1.46	1.75	8.4	2.36	10.12	0.02	0.9	5.7	1.12	36.19	1.55	0.69	4.16	0.72	2.95	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.03																																																																																				-		0	28.09	0.83	9.56	-	2.11	3.33	1.46	1.75	8.4	2.36	10.12	0.02	0.9	5.7	1.12	36.19	1.55	0.69	4.16	0.72	2.95	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.03
H3949_012_0	2007	6																																D	D	D	V	T	Coin	Coin	V	V	P	P	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V	P	P	P	P	P	P	P	P	P	P																																										-		1843.85	104.54	729.07		140.54	6.89	10.17	257.06	215.72		1163.89		0.56	21.57	3748.41	6232.51	414.37	569.5			29.21				129.09																	#1A 25/day days 1-6 0/day days 7-90	#1B 25/day days 1-6 0/day days 7-90	#2 0/day days 1-20; 125/day days 21-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 25	#9A 100 #9B 0	#8A 0 diag lab	#8A 25-CAT & MRI 50-PET 15-other #8B 10		#12 20	#3 20 #5 20 #9C 20 #9D 10	#7A5 #14B 0 n/c #14C 0 #14D 0 n/c #14E 0 n/c #14F 0 n/c #14G 0 n/c #14H 0 n/c	#7B10 #7D10 #7F10 #7G10	#7E10 #7H10	#7C10 #7I10		#14I 0	#15 20	#13A 0	#10B 0 n/c	#16A 0 #16B 0	#17A 10	#17B 0	#18A 0	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											15.66	15.66	73.68		50	0.2	0.2	47.5	100		15.01		0.2	0.06	5	10	9.95	10			0.2				10																	2.41	0.14	4.48	-	0.59	1.38	2.03	1.02	1.8	-	1.46	-	0.11	1.3	1.56	5.19	0.34	0.47	-	-	5.84	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.22		0	2.41	0.14	4.48	-	0.59	1.38	2.03	1.02	1.8	-	1.46	-	0.11	1.3	1.56	5.19	0.34	0.47	-	-	5.84	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.22		.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.																																										-		0	2.41	0.14	4.48	-	0.59	1.38	2.03	1.02	1.8	-	1.46	-	0.11	1.3	1.56	5.19	0.34	0.47	-	-	5.84	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.22
H3949_013_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	P	P	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V	P	P	P	P	P	P	P	P	P	P																																										-		1852.81	105.05	732.27		141.16	6.91	10.21	258.19	323.58		1033.95		0.58	22.31	3576.64	5998.41	415.98	572			29.31				129.09																	#1A 50/day days 1-6 0/day days 7-90	#1B 50/day days 1-6 0/day days 7-90	#2 0/day days 1-20; 125/day days 21-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 35	#9A 150 #9B 50	0 diag lab	#8A 50-CAT & MRI 100-PET 25-Other #8B 15		#12 20	#3 20 #5 20 #9C 20 #9D 20	#7A 10 #14B 0 n/c #14C 0 #14D 0 n/c #14E 0 n/c #14F 0 n/c #14G 0 n/c #14H 0 n/c	#7B 20 #7D 20 #7F 20 #7G 20	#7E 20 #7H 20	#7C 20 #7I 20		#14I 0	#15 20	#13A 0	#10B 0	#16A 0 #16B 0	#17A 20	#17B 0	#18A 0	#18B 0 n/c	#19 0 n/c	#14A 0 n/c	#13B 0 n/c											31.31	31.31	72.51		50	0.2	0.2	48.5	116.96		26.74		0.2	0.01	10	20	19.91	20			0.2				20																	4.83	0.27	4.42	-	0.59	1.38	2.04	1.04	3.15	-	2.3	-	0.12	0.33	2.98	10	0.69	0.95	-	-	5.86	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.19		0	4.83	0.27	4.42	-	0.59	1.38	2.04	1.04	3.15	-	2.3	-	0.12	0.33	2.98	10	0.69	0.95	-	-	5.86	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.19		.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.																																										-		0	4.83	0.27	4.42	-	0.59	1.38	2.04	1.04	3.15	-	2.3	-	0.12	0.33	2.98	10	0.69	0.95	-	-	5.86	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.19
H3952_008_0	2007	2																																D	D	D		T	coin	coin	V	V		V			V	V	V	V	V	V	V				V	V		V																																																								-		1568.1	57.71	1241.68		267.28	14.67	3.67	424.86	325.76		1455.47			178.07	3186.17	4163.01	333.29	765.87	1.14	507.21				847.29	222.37		4															150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	25 per day 100 day max (PBP category 2)		50 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	150 per visit (PBP categories 9A and 9B)		30 per visit (PBP category 8B)			30 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	30 per visit (PBP categories 4B 7B 7D and 7F)	30 per visit (PBP categories 7E 7H and 9C)	30 per visit (PBP categories 7C and 7I)	30 per visit (per note in PBP category 8B)	30 per visit (PBP category 17A (vision exams) + remainder of category 18A not shown below)				15 per visit (PBP category 16A)	30 per visit (PBP category 17A)		30 per visit (PBP category 18A)															150	150	25		50	0.2	0.2	50	150		30			30	15	30	30	30	30	30				15	30		30															19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	10.41	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.65			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	10.41	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.65																																																																																				-			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	10.41	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.65
H3952_018_0	2007	5																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin		V	V	V	Coin	Coin	S	Coin			V		V				V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		476.57	5.12	55.37	0	4.47	20.14	0.92	8.52	30.02	17.33	45.62	0	13.13	46.79	0	6976.19	233.19	684.06	23.75	111.9	1253.66	3.01	0	0	422.86	0	162.6	0	0	0	356.2											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 7f 15											0.07	0.04	0.17	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0.2	0.14	0	14.73	20	20	0.26	0.21	25	0.17	0	0	20	0	7.7	0	0	0	20											31.31	0.19	9.21	-	0.89	4.03	0.18	1.67	6	3.47	9.12	-	2.63	6.41	-	8.56	0.39	1.14	6.16	23.47	2.61	0.51	-	-	0.7	-	0.1	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	119.36	0	0	31.31	0.19	9.21	-	0.89	4.03	0.18	1.67	6	3.47	9.12	-	2.63	6.41	-	8.56	0.39	1.14	6.16	23.47	2.61	0.51	-	-	0.7	-	0.1	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	119.36																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	31.31	0.19	9.21	-	0.89	4.03	0.18	1.67	6	3.47	9.12	-	2.63	6.41	-	8.56	0.39	1.14	6.16	23.47	2.61	0.51	-	-	0.7	-	0.1	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	119.36
H3952_020_0	2007	6																																D	D	D		T	coin	coin	V	V		V			V	V	V	V	V	V	V				V	V		V																																																								-		1568.1	57.71	1241.68		267.28	14.67	3.67	424.86	325.76		1455.47			178.07	3186.17	4163.01	333.29	765.87	1.14	507.21				847.29	222.37		4															150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	25 per day 100 day max (PBP category 2)		50 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	150 per visit (PBP categories 9A and 9B)		30 per visit (PBP category 8B)			30 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	30 per visit (PBP categories 4B 7B 7D and 7F)	30 per visit (PBP categories 7E 7H and 9C)	30 per visit (PBP categories 7C and 7I)	30 per visit (per note in PBP category 8B)	30 per visit (PBP category 17A (vision exams) + remainder of category 18A not shown below)				15 per visit (PBP category 16A)	30 per visit (PBP category 17A)		30 per visit (PBP category 18A)															150	150	25		50	0.2	0.2	50	150		30			30	15	30	30	30	30	30				15	30		30															19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	10.41	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.65			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	10.41	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.65																																																																																				-			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	10.41	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.65
H3952_026_0	2007	2																																D	D	D		T	coin	coin	V	coin		V			V	V	V	V	V	V	V	S			V	V		V																																																								-		1679.22	57.71	891.74		274.14	12.04	3.01	411.55	42.65		1298.7			187.57	3154.54	3380.33	333.19	743.05	0.01	474.14	1.35			847.29	222.37		4															150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	25 per day 100 day max (PBP category 2)		100 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	15 coinsurance (PBP categories 9A and 9B)		35 per visit (PBP category 8B)			35 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	35 per visit (PBP categories 4B 7B 7D and 7F)	35 per visit (PBP categories 7E 7H and 9C)	35 per visit (PBP categories 7C and 7I)	35 per visit (per note in PBP category 8B)	35 per visit (PBP category 17A (vision exams) + remainder of category 18A not shown below)	25 per script (PBP category 15)			15 per visit (PBP category 16A)	35 per visit (PBP category 17A)		35 per visit (PBP category 18A)															187.44	187.44	25		100	0.2	0.2	50	0.15		35			35	15	35	35	35	35	35	25			15	35		35															26.23	0.9	1.86	-	2.28	2.41	0.6	1.71	6.4	-	3.79	-	-	0.55	3.94	9.86	0.97	2.17	0	1.38	0	-	-	1.06	0.65	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.78			26.23	0.9	1.86	-	2.28	2.41	0.6	1.71	6.4	-	3.79	-	-	0.55	3.94	9.86	0.97	2.17	0	1.38	0	-	-	1.06	0.65	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.78																																																																																				-			26.23	0.9	1.86	-	2.28	2.41	0.6	1.71	6.4	-	3.79	-	-	0.55	3.94	9.86	0.97	2.17	0	1.38	0	-	-	1.06	0.65	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.78
H3952_030_0	2007	2																																D	D	D		T	coin	coin	V	V		V			V	V	V	V	V	V	V				V	V		V																																																								-		1568.1	57.71	1241.68		267.28	14.67	3.67	424.86	325.76		1455.47			178.07	3186.17	4741.9	333.29	765.87	1.14	507.21				847.29	222.37		4															150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	25 per day 100 day max (PBP category 2)		50 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	150 per visit (PBP categories 9A and 9B)		30 per visit (PBP category 8B)			30 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	30 per visit (PBP categories 4B 7B 7D and 7F)	30 per visit (PBP categories 7E 7H and 9C)	30 per visit (PBP categories 7C and 7I)	30 per visit (per note in PBP category 8B)	30 per visit (PBP category 17A (vision exams) + remainder of category 18A not shown below)				15 per visit (PBP category 16A)	30 per visit (PBP category 17A)		30 per visit (PBP category 18A)															150	150	25		50	0.2	0.2	50	150		30			30	15	30	30	30	30	30				15	30		30															19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	11.85	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.1			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	11.85	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.1																														20 coinsurance to 5000 out of pocket max																																									0.81													0.81			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	11.85	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	59.91
H3952_032_0	2007	6																																D	D	D		T	coin	coin	V	V		V			V	V	V	V	V	V	V				V	V		V																																																								-		1568.1	57.71	1241.68		267.28	14.67	3.67	424.86	325.76		1455.47			178.07	3186.17	4741.9	333.29	765.87	1.14	507.21				847.29	222.37		4															150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	25 per day 100 day max (PBP category 2)		50 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	150 per visit (PBP categories 9A and 9B)		30 per visit (PBP category 8B)			30 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	30 per visit (PBP categories 4B 7B 7D and 7F)	30 per visit (PBP categories 7E 7H and 9C)	30 per visit (PBP categories 7C and 7I)	30 per visit (per note in PBP category 8B)	30 per visit (PBP category 17A (vision exams) + remainder of category 18A not shown below)				15 per visit (PBP category 16A)	30 per visit (PBP category 17A)		30 per visit (PBP category 18A)															150	150	25		50	0.2	0.2	50	150		30			30	15	30	30	30	30	30				15	30		30															19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	11.85	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.1			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	11.85	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.1																														20 coinsurance to 5000 out of pocket max																																									0.81													0.81			19.6	0.72	2.59	-	1.11	2.93	0.73	1.77	4.07	-	3.64	-	-	0.45	3.98	11.85	0.83	1.91	0	1.27	-	-	-	1.06	0.56	-	0.01	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	59.91
H3952_040_0	2007	5																																D	D	D		T	coin	coin	V	coin		V			V	V	V	V	V	V	V	S			V	V		V																																																								-		1679.22	57.71	891.74		274.14	12.04	3.01	411.55	42.65		1298.7			187.57	3154.54	3380.33	333.19	743.05	0.01	474.14	1.35			847.29	222.37		4															150 per day 10 day max (PBP category 1A)	150 per day 10 day max (PBP category 1B)	25 per day 100 day max (PBP category 2)		100 per trip (PBP category 10A)	20 coinsurance (PBP category 11A)	20 coinsurance (PBP category 11B)	50 per visit (PBP category 4A)	15 coinsurance (PBP categories 9A and 9B)		35 per visit (PBP category 8B)			35 per visit (PBP categories 3 and 9D)	15 per visit (PBP categories 4B and 7A)	35 per visit (PBP categories 4B 7B 7D and 7F)	35 per visit (PBP categories 7E 7H and 9C)	35 per visit (PBP categories 7C and 7I)	35 per visit (per note in PBP category 8B)	35 per visit (PBP category 17A (vision exams) + remainder of category 18A not shown below)	25 per script (PBP category 15)			15 per visit (PBP category 16A)	35 per visit (PBP category 17A)		35 per visit (PBP category 18A)															187.44	187.44	25		100	0.2	0.2	50	0.15		35			35	15	35	35	35	35	35	25			15	35		35															26.23	0.9	1.86	-	2.28	2.41	0.6	1.71	6.4	-	3.79	-	-	0.55	3.94	9.86	0.97	2.17	0	1.38	0	-	-	1.06	0.65	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.78			26.23	0.9	1.86	-	2.28	2.41	0.6	1.71	6.4	-	3.79	-	-	0.55	3.94	9.86	0.97	2.17	0	1.38	0	-	-	1.06	0.65	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.78																																																																																				-			26.23	0.9	1.86	-	2.28	2.41	0.6	1.71	6.4	-	3.79	-	-	0.55	3.94	9.86	0.97	2.17	0	1.38	0	-	-	1.06	0.65	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.78
H3952_802_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		367.3		32.1	11.7	9.11	18.85		6.74	57.54	121.58					308.83						9.12	1.02																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07		0.17	0	0.24	0.24		0.24	0.24	0.24					0.24						0.24	0.24																				24.13	-	5.34	-	2.15	4.45	-	1.59	13.58	28.69	-	-	-	-	72.88	-	-	-	-	-	2.15	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.21			24.13	-	5.34	-	2.15	4.45	-	1.59	13.58	28.69	-	-	-	-	72.88	-	-	-	-	-	2.15	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.21																																																																																				-			24.13	-	5.34	-	2.15	4.45	-	1.59	13.58	28.69	-	-	-	-	72.88	-	-	-	-	-	2.15	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.21
H3952_804_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		367.3		32.1	11.7	9.11	18.85		6.74	57.54	121.58					308.83						9.12	1.02																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07		0.17	0	0.24	0.24		0.24	0.24	0.24					0.24						0.24	0.24																				24.13	-	5.34	-	2.15	4.45	-	1.59	13.58	28.69	-	-	-	-	72.88	-	-	-	-	-	2.15	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.21			24.13	-	5.34	-	2.15	4.45	-	1.59	13.58	28.69	-	-	-	-	72.88	-	-	-	-	-	2.15	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.21																																																																																				-			24.13	-	5.34	-	2.15	4.45	-	1.59	13.58	28.69	-	-	-	-	72.88	-	-	-	-	-	2.15	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.21
H3954_003_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1180.79	72.61	573.49	805.6	129.3	10.1	5.78	297.42	278.92	47.29	1570.26	5.68	1.35	493.56	4606.89	3627	153.69	0.14	1435.96	179.61	13	1.03	0	0	377.76	2.55	0	0.06	0	3.69	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22
H3954_004_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1414.22	72.61	808.86	1019.12	143.75	8.84	5.07	246.71	339.91	37.31	1740.01	96.98	0.02	537.39	5583.46	3636.07	153.69	0.09	1930.99	160.59	10.42	1.09	0	0	466.91	3.43	0	0.01	0	3.85	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42
H3954_005_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1199.01	72.61	773.52	1169.61	75.13	10.41	5.85	203.47	232.55	39.98	1054.09	37	0.46	404.95	5108.8	4175.7	153.69	0.04	2642.31	238.56	7.99	1.24	0	0	284.38	2.1	0	0.01	0	4.04	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29
H3954_006_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1072.76	72.61	702.28	1247.6	108.45	12.31	5.73	236.08	243.6	49.6	2145.26	48.12	1.35	550.02	4964.29	3944.45	153.69	0.11	1749.51	145.81	15.56	1.36	0	0	344.87	2.2	0	0.03	0	3.9	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17
H3954_007_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1219.85	72.61	592.81	822.44	148.47	12.63	7.77	331.34	268.83	36.99	1746.92	11.82	2.25	508.37	4747.33	4178.32	153.69	0.77	1677.62	123.58	11.52	0.75	0	0	319.88	2.42	0	0.03	0	4.03	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97
H3954_008_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1320.78	72.61	200.81	729.32	66.41	5.83	3.88	281.45	246.26	37.93	1308.73	1.52	0.01	422.95	4949.23	3186.15	153.69	0.47	2476.67	750.57	12.47	1.81	0	0	192.62	1.16	0	0	0	4.46	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32
H3954_009_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	229.85	72.61	25.13	810.27	93.76	10.06	5.7	266.1	48.59	45.94	39.92	0.65	1.33	22.96	5398.72	9130.24	153.69	2.61	17.46	6.89	12.75	1.02	0	0	404.05	2.55	9.33	0.06	0	3.69	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	None	26.54	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95
H3954_010_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	273.49	72.61	35.21	1025.03	104.24	8.81	4.99	220.72	58.83	36.25	43.94	11	0.02	24.83	6543.15	9153.08	153.69	1.72	23.32	6.12	10.21	1.07	0	0	499.41	3.43	0.87	0.01	0	3.85	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	None	30.74	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47
H3954_011_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	226.75	72.61	32.93	1176.39	54.48	10.36	5.77	182.04	39.36	38.83	26.04	4.1	0.45	18.3	5986.8	10511.48	153.69	0.8	31.21	8.89	7.83	1.22	0	0	304.18	2.1	0.81	0.01	0	4.04	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	None	26.96	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5
H3954_012_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.47	72.61	30.72	1254.83	78.64	12.26	5.65	211.22	42.36	48.19	54.44	5.48	1.33	25.54	5817.55	9929.36	153.69	1.98	21.23	5.58	15.26	1.34	0	0	368.87	2.2	7.19	0.03	0	3.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	None	26.72	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97
H3954_013_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	236.9	72.61	25.92	827.21	107.66	12.57	7.66	296.44	46.72	35.94	44.3	1.35	2.22	23.59	5563.3	10518.06	153.69	13.96	20.35	4.73	11.29	0.74	0	0	342.15	2.42	0.75	0.03	0	4.03	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	None	27.1	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96
H3954_014_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	247.29	72.61	8.46	733.55	48.16	5.8	3.82	251.8	41.26	36.83	32	0.17	0.01	18.92	5799.82	8020.49	153.69	8.51	28.96	27.7	12.22	1.78	0	0	206.02	1.16	1.48	0	0	4.46	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	None	28.01	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53
H3954_015_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	198.85	72.61	17.17	992.79	88.45	9.38	2.88	222.92	48.26	28.85	33.59	0.58	1.14	15.76	5396.91	8472.61	153.69	23.59	16.16	4.15	11.41	0.54	0	0	398.43	2.78	2.19	0.05	0	2.55	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	None	22.18	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91
H3954_018_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	270.38	72.61	16.52	954.21	99.06	9.73	3.43	250.45	45.24	42.44	52.13	0.73	1.37	13.57	5128.49	9742.63	153.69	13.81	27.76	13.29	10.37	1.51	0	0	377.26	1.49	1.3	0.02	0	2.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	None	29.94	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2
H3954_019_0	2007	4																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	239.83	37.52	48.84	1553.98	231.03	23.28	1.06	665.2	34.47	13.47	34.39	0	10.21	2989.99	3994.59	4633.66	146.56	458.6	20.09	87.75	16.35	2.18	0	0	321.85	0	137.93	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.02	0.08	0.08	0.11	0	0.08	8.57	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	None	38.33	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71
H3954_020_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1180.79	72.61	573.49	805.6	129.3	10.1	5.78	297.42	278.92	47.29	1570.26	5.68	1.35	493.56	4606.89	3627	153.69	0.14	1435.96	179.61	13	1.03	0	0	377.76	2.55	0	0.06	0	3.69	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22
H3954_021_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1180.79	72.61	573.49	805.6	129.3	10.1	5.78	297.42	278.92	47.29	1570.26	5.68	1.35	493.56	4606.89	3627	153.69	0.14	1435.96	179.61	13	1.03	0	0	377.76	2.55	0	0.06	0	3.69	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22
H3954_022_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1180.79	72.61	573.49	805.6	129.3	10.1	5.78	297.42	278.92	47.29	1570.26	5.68	1.35	493.56	4606.89	3627	153.69	0.14	1435.96	179.61	13	1.03	0	0	377.76	2.55	0	0.06	0	3.69	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.92	0.3	1.19	0.67	0.54	0.96	0.01	1.24	1.16	0.84	2.36	0.01	-	0.82	3.84	6.05	0.26	0	0.93	0.3	0.19	0	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.22
H3954_023_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1414.22	72.61	808.86	1019.12	143.75	8.84	5.07	246.71	339.91	37.31	1740.01	96.98	0.02	537.39	5583.46	3636.07	153.69	0.09	1930.99	160.59	10.42	1.09	0	0	466.91	3.43	0	0.01	0	3.85	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42
H3954_024_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1414.22	72.61	808.86	1019.12	143.75	8.84	5.07	246.71	339.91	37.31	1740.01	96.98	0.02	537.39	5583.46	3636.07	153.69	0.09	1930.99	160.59	10.42	1.09	0	0	466.91	3.43	0	0.01	0	3.85	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42
H3954_025_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1414.22	72.61	808.86	1019.12	143.75	8.84	5.07	246.71	339.91	37.31	1740.01	96.98	0.02	537.39	5583.46	3636.07	153.69	0.09	1930.99	160.59	10.42	1.09	0	0	466.91	3.43	0	0.01	0	3.85	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.89	0.3	1.69	0.85	0.6	0.85	0.01	1.03	1.42	0.67	2.61	0.2	-	0.9	4.65	6.06	0.26	0	1.26	0.27	0.15	0	-	-	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.42
H3954_026_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1199.01	72.61	773.52	1169.61	75.13	10.41	5.85	203.47	232.55	39.98	1054.09	37	0.46	404.95	5108.8	4175.7	153.69	0.04	2642.31	238.56	7.99	1.24	0	0	284.38	2.1	0	0.01	0	4.04	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29
H3954_027_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1199.01	72.61	773.52	1169.61	75.13	10.41	5.85	203.47	232.55	39.98	1054.09	37	0.46	404.95	5108.8	4175.7	153.69	0.04	2642.31	238.56	7.99	1.24	0	0	284.38	2.1	0	0.01	0	4.04	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29
H3954_028_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1199.01	72.61	773.52	1169.61	75.13	10.41	5.85	203.47	232.55	39.98	1054.09	37	0.46	404.95	5108.8	4175.7	153.69	0.04	2642.31	238.56	7.99	1.24	0	0	284.38	2.1	0	0.01	0	4.04	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5	0.3	1.61	0.97	0.31	1.02	0.01	0.85	0.97	0.73	1.58	0.08	-	0.67	4.26	6.96	0.26	0	1.72	0.4	0.12	0	-	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.29
H3954_029_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1072.76	72.61	702.28	1247.6	108.45	12.31	5.73	236.08	243.6	49.6	2145.26	48.12	1.35	550.02	4964.29	3944.45	153.69	0.11	1749.51	145.81	15.56	1.36	0	0	344.87	2.2	0	0.03	0	3.9	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17
H3954_030_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1072.76	72.61	702.28	1247.6	108.45	12.31	5.73	236.08	243.6	49.6	2145.26	48.12	1.35	550.02	4964.29	3944.45	153.69	0.11	1749.51	145.81	15.56	1.36	0	0	344.87	2.2	0	0.03	0	3.9	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17
H3954_031_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1072.76	72.61	702.28	1247.6	108.45	12.31	5.73	236.08	243.6	49.6	2145.26	48.12	1.35	550.02	4964.29	3944.45	153.69	0.11	1749.51	145.81	15.56	1.36	0	0	344.87	2.2	0	0.03	0	3.9	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	4.47	0.3	1.46	1.04	0.45	1.17	0.01	0.98	1.02	0.88	3.22	0.1	-	0.92	4.14	6.57	0.26	0	1.14	0.24	0.23	0	-	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.17
H3954_032_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1219.85	72.61	592.81	822.44	148.47	12.63	7.77	331.34	268.83	36.99	1746.92	11.82	2.25	508.37	4747.33	4178.32	153.69	0.77	1677.62	123.58	11.52	0.75	0	0	319.88	2.42	0	0.03	0	4.03	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97
H3954_033_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1219.85	72.61	592.81	822.44	148.47	12.63	7.77	331.34	268.83	36.99	1746.92	11.82	2.25	508.37	4747.33	4178.32	153.69	0.77	1677.62	123.58	11.52	0.75	0	0	319.88	2.42	0	0.03	0	4.03	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97
H3954_034_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1219.85	72.61	592.81	822.44	148.47	12.63	7.77	331.34	268.83	36.99	1746.92	11.82	2.25	508.37	4747.33	4178.32	153.69	0.77	1677.62	123.58	11.52	0.75	0	0	319.88	2.42	0	0.03	0	4.03	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.01	0	0	0	20	0	20	0	0	0	0											5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.08	0.3	1.24	0.69	0.62	1.2	0.01	1.38	1.12	0.66	2.62	0.02	-	0.85	3.96	6.96	0.26	0	1.09	0.21	0.17	0	-	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.97
H3954_035_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1320.78	72.61	200.81	729.32	66.41	5.83	3.88	281.45	246.26	37.93	1308.73	1.52	0.01	422.95	4949.23	3186.15	153.69	0.47	2476.67	750.57	12.47	1.81	0	0	192.62	1.16	0	0	0	4.46	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32
H3954_036_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1320.78	72.61	200.81	729.32	66.41	5.83	3.88	281.45	246.26	37.93	1308.73	1.52	0.01	422.95	4949.23	3186.15	153.69	0.47	2476.67	750.57	12.47	1.81	0	0	192.62	1.16	0	0	0	4.46	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32
H3954_037_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	V	Coin	V	D		V	V	V	V	V	V	V	Coin				V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1320.78	72.61	200.81	729.32	66.41	5.83	3.88	281.45	246.26	37.93	1308.73	1.52	0.01	422.95	4949.23	3186.15	153.69	0.47	2476.67	750.57	12.47	1.81	0	0	192.62	1.16	0	0	0	4.46	0											PBP Line 1a: 50 (days 1-5)	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 25 (days 11-100)	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 10	PBP Line 11b 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 9a: 50/day	PBP Line 8a: 15/day (MRI/CAT/PET 75/day) Line 8b: 15/day Line 9a: 50/day	PBP Line 5: 25/day Line 9a: 50/day	PBP Line 9a: 50/day Line 12: 0	PBP Line 3: 10/day Line 5: 25/day Line 9a: 50/day Line 9c: 25Ind/10Grp Line 9d: 0	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15/day (MRI/CAT/PET 75/day)	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 14a 16b:0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											50	50	25	10	50	0.1	0	50	50	0.02	18	25	0	20	10	20	20	10	7.8	20	0.02	0	0	0	20	0	20	0	0	0	0											5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.5	0.3	0.42	0.61	0.28	0.58	0.01	1.17	1.03	0.7	1.96	0	-	0.7	4.12	5.31	0.26	0	1.61	1.25	0.19	0	-	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.32
H3954_038_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	229.85	72.61	25.13	810.27	93.76	10.06	5.7	266.1	48.59	45.94	39.92	0.65	1.33	22.96	5398.72	9130.24	153.69	2.61	17.46	6.89	12.75	1.02	0	0	404.05	2.55	9.33	0.06	0	3.69	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	None	26.54	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95
H3954_039_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	229.85	72.61	25.13	810.27	93.76	10.06	5.7	266.1	48.59	45.94	39.92	0.65	1.33	22.96	5398.72	9130.24	153.69	2.61	17.46	6.89	12.75	1.02	0	0	404.05	2.55	9.33	0.06	0	3.69	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	None	26.54	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95
H3954_040_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	229.85	72.61	25.13	810.27	93.76	10.06	5.7	266.1	48.59	45.94	39.92	0.65	1.33	22.96	5398.72	9130.24	153.69	2.61	17.46	6.89	12.75	1.02	0	0	404.05	2.55	9.33	0.06	0	3.69	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	None	26.54	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.56	0.3	1.25	0.68	0.39	1.11	0.6	1.11	6.15	5.06	3.95	0.08	0.04	3.18	4.5	15.22	0.26	0	1.74	0.52	0.45	0.12	-	-	0.67	-	0.02	-	-	0	-	-	-	-	-	-	-	-	-	-	-	63.95
H3954_041_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	273.49	72.61	35.21	1025.03	104.24	8.81	4.99	220.72	58.83	36.25	43.94	11	0.02	24.83	6543.15	9153.08	153.69	1.72	23.32	6.12	10.21	1.07	0	0	499.41	3.43	0.87	0.01	0	3.85	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	None	30.74	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47
H3954_042_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	273.49	72.61	35.21	1025.03	104.24	8.81	4.99	220.72	58.83	36.25	43.94	11	0.02	24.83	6543.15	9153.08	153.69	1.72	23.32	6.12	10.21	1.07	0	0	499.41	3.43	0.87	0.01	0	3.85	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	None	30.74	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47
H3954_043_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	273.49	72.61	35.21	1025.03	104.24	8.81	4.99	220.72	58.83	36.25	43.94	11	0.02	24.83	6543.15	9153.08	153.69	1.72	23.32	6.12	10.21	1.07	0	0	499.41	3.43	0.87	0.01	0	3.85	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	None	30.74	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.84	0.3	1.77	0.85	0.43	0.98	0.53	0.92	7.49	4.02	4.38	1.41	0	3.46	5.45	15.26	0.26	0	2.33	0.46	0.36	0.12	-	-	0.83	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	71.47
H3954_044_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	226.75	72.61	32.93	1176.39	54.48	10.36	5.77	182.04	39.36	38.83	26.04	4.1	0.45	18.3	5986.8	10511.48	153.69	0.8	31.21	8.89	7.83	1.22	0	0	304.18	2.1	0.81	0.01	0	4.04	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	None	26.96	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5
H3954_045_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	226.75	72.61	32.93	1176.39	54.48	10.36	5.77	182.04	39.36	38.83	26.04	4.1	0.45	18.3	5986.8	10511.48	153.69	0.8	31.21	8.89	7.83	1.22	0	0	304.18	2.1	0.81	0.01	0	4.04	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	None	26.96	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5
H3954_046_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	226.75	72.61	32.93	1176.39	54.48	10.36	5.77	182.04	39.36	38.83	26.04	4.1	0.45	18.3	5986.8	10511.48	153.69	0.8	31.21	8.89	7.83	1.22	0	0	304.18	2.1	0.81	0.01	0	4.04	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	None	26.96	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	16.82	0.3	1.69	0.98	0.23	1.17	0.63	0.76	5.12	4.4	2.65	0.54	0.01	2.61	4.99	17.52	0.26	0	3.19	0.69	0.29	0.14	-	-	0.51	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	65.5
H3954_047_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.47	72.61	30.72	1254.83	78.64	12.26	5.65	211.22	42.36	48.19	54.44	5.48	1.33	25.54	5817.55	9929.36	153.69	1.98	21.23	5.58	15.26	1.34	0	0	368.87	2.2	7.19	0.03	0	3.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	None	26.72	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97
H3954_048_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.47	72.61	30.72	1254.83	78.64	12.26	5.65	211.22	42.36	48.19	54.44	5.48	1.33	25.54	5817.55	9929.36	153.69	1.98	21.23	5.58	15.26	1.34	0	0	368.87	2.2	7.19	0.03	0	3.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	None	26.72	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97
H3954_049_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.47	72.61	30.72	1254.83	78.64	12.26	5.65	211.22	42.36	48.19	54.44	5.48	1.33	25.54	5817.55	9929.36	153.69	1.98	21.23	5.58	15.26	1.34	0	0	368.87	2.2	7.19	0.03	0	3.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	None	26.72	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.05	0.3	1.53	1.05	0.33	1.35	0.6	0.88	5.37	5.32	5.4	0.7	0.04	3.55	4.85	16.55	0.26	0	2.11	0.42	0.54	0.15	-	-	0.61	-	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.97
H3954_050_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	236.9	72.61	25.92	827.21	107.66	12.57	7.66	296.44	46.72	35.94	44.3	1.35	2.22	23.59	5563.3	10518.06	153.69	13.96	20.35	4.73	11.29	0.74	0	0	342.15	2.42	0.75	0.03	0	4.03	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	None	27.1	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96
H3954_051_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	236.9	72.61	25.92	827.21	107.66	12.57	7.66	296.44	46.72	35.94	44.3	1.35	2.22	23.59	5563.3	10518.06	153.69	13.96	20.35	4.73	11.29	0.74	0	0	342.15	2.42	0.75	0.03	0	4.03	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	None	27.1	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96
H3954_052_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	236.9	72.61	25.92	827.21	107.66	12.57	7.66	296.44	46.72	35.94	44.3	1.35	2.22	23.59	5563.3	10518.06	153.69	13.96	20.35	4.73	11.29	0.74	0	0	342.15	2.42	0.75	0.03	0	4.03	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	None	27.1	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	17.11	0.3	1.3	0.69	0.45	1.39	0.81	1.24	5.92	3.97	4.39	0.17	0.07	3.28	4.64	17.53	0.26	0.01	2.03	0.36	0.4	0.09	-	-	0.57	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	66.96
H3954_053_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	247.29	72.61	8.46	733.55	48.16	5.8	3.82	251.8	41.26	36.83	32	0.17	0.01	18.92	5799.82	8020.49	153.69	8.51	28.96	27.7	12.22	1.78	0	0	206.02	1.16	1.48	0	0	4.46	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	None	28.01	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53
H3954_054_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	247.29	72.61	8.46	733.55	48.16	5.8	3.82	251.8	41.26	36.83	32	0.17	0.01	18.92	5799.82	8020.49	153.69	8.51	28.96	27.7	12.22	1.78	0	0	206.02	1.16	1.48	0	0	4.46	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	None	28.01	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53
H3954_055_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	247.29	72.61	8.46	733.55	48.16	5.8	3.82	251.8	41.26	36.83	32	0.17	0.01	18.92	5799.82	8020.49	153.69	8.51	28.96	27.7	12.22	1.78	0	0	206.02	1.16	1.48	0	0	4.46	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	None	28.01	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	18.53	0.3	0.44	0.61	0.2	0.66	0.42	1.05	5.43	4.22	3.29	0.02	0	2.73	4.83	13.37	0.26	0.01	2.99	2.16	0.45	0.21	-	-	0.34	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	62.53
H3954_056_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	198.85	72.61	17.17	992.79	88.45	9.38	2.88	222.92	48.26	28.85	33.59	0.58	1.14	15.76	5396.91	8472.61	153.69	23.59	16.16	4.15	11.41	0.54	0	0	398.43	2.78	2.19	0.05	0	2.55	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	None	22.18	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91
H3954_057_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	198.85	72.61	17.17	992.79	88.45	9.38	2.88	222.92	48.26	28.85	33.59	0.58	1.14	15.76	5396.91	8472.61	153.69	23.59	16.16	4.15	11.41	0.54	0	0	398.43	2.78	2.19	0.05	0	2.55	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	None	22.18	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91
H3954_058_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	198.85	72.61	17.17	992.79	88.45	9.38	2.88	222.92	48.26	28.85	33.59	0.58	1.14	15.76	5396.91	8472.61	153.69	23.59	16.16	4.15	11.41	0.54	0	0	398.43	2.78	2.19	0.05	0	2.55	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	None	22.18	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	14.38	0.3	0.86	0.83	0.37	1.04	0.3	0.93	6.13	3.19	3.34	0.07	0.03	2.19	4.5	14.12	0.26	0.02	1.61	0.31	0.4	0.06	-	-	0.66	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	55.91
H3954_059_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	270.38	72.61	16.52	954.21	99.06	9.73	3.43	250.45	45.24	42.44	52.13	0.73	1.37	13.57	5128.49	9742.63	153.69	13.81	27.76	13.29	10.37	1.51	0	0	377.26	1.49	1.3	0.02	0	2.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	None	29.94	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2
H3954_060_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	270.38	72.61	16.52	954.21	99.06	9.73	3.43	250.45	45.24	42.44	52.13	0.73	1.37	13.57	5128.49	9742.63	153.69	13.81	27.76	13.29	10.37	1.51	0	0	377.26	1.49	1.3	0.02	0	2.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	None	29.94	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2
H3954_061_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	270.38	72.61	16.52	954.21	99.06	9.73	3.43	250.45	45.24	42.44	52.13	0.73	1.37	13.57	5128.49	9742.63	153.69	13.81	27.76	13.29	10.37	1.51	0	0	377.26	1.49	1.3	0.02	0	2.9	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)		PBP Line 13b: No Cost Sharing	PBP Line 13b: Not Covered											0.07	50	0.05	10	50	0.11	0.11	50	0.13	0.11	0.1	0.13	0.03	0.14	10	20	20	10	0.1	0.08	0.04	0.12	0	0	20	0	20	0	0	0	0											19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	None	29.94	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2	2000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.76	0.3	0.84	0.8	0.41	1.09	0.37	1.04	5.8	4.74	5.23	0.09	0.04	1.91	4.27	16.24	0.26	0.01	2.8	1.01	0.37	0.18	-	-	0.63	-	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	68.2
H3954_062_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	239.83	37.52	48.84	1553.98	231.03	23.28	1.06	665.2	34.47	13.47	34.39	0	10.21	2989.99	3994.59	4633.66	146.56	458.6	20.09	87.75	16.35	2.18	0	0	321.85	0	137.93	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.02	0.08	0.08	0.11	0	0.08	8.57	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	None	38.33	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71
H3954_063_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	239.83	37.52	48.84	1553.98	231.03	23.28	1.06	665.2	34.47	13.47	34.39	0	10.21	2989.99	3994.59	4633.66	146.56	458.6	20.09	87.75	16.35	2.18	0	0	321.85	0	137.93	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.02	0.08	0.08	0.11	0	0.08	8.57	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	None	38.33	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71
H3954_064_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	239.83	37.52	48.84	1553.98	231.03	23.28	1.06	665.2	34.47	13.47	34.39	0	10.21	2989.99	3994.59	4633.66	146.56	458.6	20.09	87.75	16.35	2.18	0	0	321.85	0	137.93	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.02	0.08	0.08	0.11	0	0.08	8.57	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	None	38.33	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.53	0.16	4	1.29	0.96	1.91	0.09	2.66	2.82	1.1	3.7	-	0.84	2.14	3.33	7.72	0.24	0.38	1.74	6.82	1.34	0.18	-	-	0.54	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.71
H3954_065_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	262.07	42.97	41.47	1189.03	205.54	19.64	0.9	430.91	21.84	8.54	21.79	0	6.47	1834.61	5207.19	6214.74	217.15	679.49	31.95	127.94	23.62	3.09	0	0	419.55	0	179.81	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.01	0.08	0.08	0.1	0	0.08	8.6	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	None	41.44	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18
H3954_066_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	262.07	42.97	41.47	1189.03	205.54	19.64	0.9	430.91	21.84	8.54	21.79	0	6.47	1834.61	5207.19	6214.74	217.15	679.49	31.95	127.94	23.62	3.09	0	0	419.55	0	179.81	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.01	0.08	0.08	0.1	0	0.08	8.6	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	None	41.44	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18
H3954_067_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	262.07	42.97	41.47	1189.03	205.54	19.64	0.9	430.91	21.84	8.54	21.79	0	6.47	1834.61	5207.19	6214.74	217.15	679.49	31.95	127.94	23.62	3.09	0	0	419.55	0	179.81	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.01	0.08	0.08	0.1	0	0.08	8.6	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	None	41.44	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18
H3954_068_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	262.07	42.97	41.47	1189.03	205.54	19.64	0.9	430.91	21.84	8.54	21.79	0	6.47	1834.61	5207.19	6214.74	217.15	679.49	31.95	127.94	23.62	3.09	0	0	419.55	0	179.81	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.01	0.08	0.08	0.1	0	0.08	8.6	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	None	41.44	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	20.74	0.18	3.3	0.99	0.86	1.56	0.07	1.65	1.74	0.68	2.28	-	0.51	1.31	4.34	10.36	0.36	0.57	2.69	9.87	1.88	0.25	-	-	0.7	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18
H3954_073_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	238.7	36.11	38.21	1391.41	232.78	20.99	0.96	618.18	25.4	9.93	25.34	0	7.53	2707.24	5541.05	6258.56	178.03	557.06	29.25	111.93	21.82	2.98	0	0	446.45	0	191.33	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	47.04	0.08	0.08	0.11	0	0.08	7.02	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	None	38.43	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63
H3954_074_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	238.7	36.11	38.21	1391.41	232.78	20.99	0.96	618.18	25.4	9.93	25.34	0	7.53	2707.24	5541.05	6258.56	178.03	557.06	29.25	111.93	21.82	2.98	0	0	446.45	0	191.33	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	47.04	0.08	0.08	0.11	0	0.08	7.02	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	None	38.43	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63
H3954_075_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	238.7	36.11	38.21	1391.41	232.78	20.99	0.96	618.18	25.4	9.93	25.34	0	7.53	2707.24	5541.05	6258.56	178.03	557.06	29.25	111.93	21.82	2.98	0	0	446.45	0	191.33	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	47.04	0.08	0.08	0.11	0	0.08	7.02	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	None	38.43	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63
H3954_076_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	238.7	36.11	38.21	1391.41	232.78	20.99	0.96	618.18	25.4	9.93	25.34	0	7.53	2707.24	5541.05	6258.56	178.03	557.06	29.25	111.93	21.82	2.98	0	0	446.45	0	191.33	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	47.04	0.08	0.08	0.11	0	0.08	7.02	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	None	38.43	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	19.2	0.15	3.09	1.16	0.97	1.7	0.08	2.42	2.05	0.8	2.69	-	0.61	1.58	4.62	10.43	0.3	0.46	2.5	8.75	1.76	0.24	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.63
H3954_077_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	268.3	40.64	50.92	1561.21	213.29	20.33	0.93	492.03	24.79	9.69	24.74	0	7.35	2121.33	5267.19	6178.54	203.53	636.86	23.66	120.53	23.64	3.13	0	0	424.38	0	181.88	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.46	0.08	0.08	0.1	0	0.08	8.38	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	None	42.68	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14
H3954_078_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	268.3	40.64	50.92	1561.21	213.29	20.33	0.93	492.03	24.79	9.69	24.74	0	7.35	2121.33	5267.19	6178.54	203.53	636.86	23.66	120.53	23.64	3.13	0	0	424.38	0	181.88	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.46	0.08	0.08	0.1	0	0.08	8.38	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	None	42.68	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14
H3954_079_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	268.3	40.64	50.92	1561.21	213.29	20.33	0.93	492.03	24.79	9.69	24.74	0	7.35	2121.33	5267.19	6178.54	203.53	636.86	23.66	120.53	23.64	3.13	0	0	424.38	0	181.88	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.46	0.08	0.08	0.1	0	0.08	8.38	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	None	42.68	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14
H3954_080_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	268.3	40.64	50.92	1561.21	213.29	20.33	0.93	492.03	24.79	9.69	24.74	0	7.35	2121.33	5267.19	6178.54	203.53	636.86	23.66	120.53	23.64	3.13	0	0	424.38	0	181.88	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	46.46	0.08	0.08	0.1	0	0.08	8.38	10	20	20	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	None	42.68	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	21.03	0.17	4.01	1.3	0.89	1.6	0.07	1.91	1.95	0.76	2.56	-	0.58	1.48	4.39	10.3	0.34	0.53	1.97	9.18	1.86	0.25	-	-	0.71	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14
H3954_089_0	2007	3																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	188.3	28.4	29.18	1409.74	249.39	23.93	1.09	861.06	42.86	16.76	42.76	0	12.7	3903.9	4311.95	5001.79	158.21	495.04	20.65	90.21	16.81	2.25	0	0	347.42	0	148.89	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.35	0.08	0.08	0.11	0	0.08	8.33	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	None	35.12	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32
H3954_090_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	188.3	28.4	29.18	1409.74	249.39	23.93	1.09	861.06	42.86	16.76	42.76	0	12.7	3903.9	4311.95	5001.79	158.21	495.04	20.65	90.21	16.81	2.25	0	0	347.42	0	148.89	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.35	0.08	0.08	0.11	0	0.08	8.33	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	None	35.12	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32
H3954_091_0	2007	6																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	188.3	28.4	29.18	1409.74	249.39	23.93	1.09	861.06	42.86	16.76	42.76	0	12.7	3903.9	4311.95	5001.79	158.21	495.04	20.65	90.21	16.81	2.25	0	0	347.42	0	148.89	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.35	0.08	0.08	0.11	0	0.08	8.33	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	None	35.12	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32
H3954_092_0	2007	5																					2000											Coin	D	Coin	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	O	V	V	V	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	188.3	28.4	29.18	1409.74	249.39	23.93	1.09	861.06	42.86	16.76	42.76	0	12.7	3903.9	4311.95	5001.79	158.21	495.04	20.65	90.21	16.81	2.25	0	0	347.42	0	148.89	0	0	0	0											PBP Line 1a: 15	PBP Line 1b: 50 (days 1-5)	PBP Line 2: 15	PBP Line 6: 10/day	PBP Line 10a: 50	PBP Line 11a: 15	PBP Line 11b: 15 Line 11c: 0	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Lines 8a 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Line 3: 10/day Line 5: 25/day Line 9c: 25Ind/10Grp Line 9a 9d: 15	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: 0	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: 15	PBP Lines 14d 14e 14f 14g 14h 14i: 0 Lines 7b 7d 7f 7g: 20	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0.08	50	0.08	10	50	0.08	0.08	48.35	0.08	0.08	0.11	0	0.08	8.33	10	20	20	10	0.09	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	None	35.12	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32	2000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	15.61	0.12	2.43	1.17	1.04	1.99	0.09	3.47	3.57	1.4	4.68	-	1.06	2.71	3.59	8.34	0.26	0.41	1.82	7.14	1.4	0.19	-	-	0.58	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.32
H3954_097_0	2007	5																					None											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	371.49	4	87.84	52.94	7.71	26.4	1.21	795.82	35.15	13.74	37.35	0	10.42	36.99	28.52	43.33	1.63	4.52	30.83	117.55	22.19	2.92	0	0	0	0	0	0	0	0	0											Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	PBP Line 4a 4b: 50 Copay	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits		0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance	0 Coinsurance			0 Coinsurance											0.08	0.08	0.2	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											28.18	0.3	17.41	-	1.82	6.23	0.28	3.32	8.3	3.24	8.81	-	2.46	8.73	6.73	10.23	0.38	1.07	7.28	27.74	5.24	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.43	138	0	28.18	0.3	17.41	-	1.82	6.23	0.28	3.32	8.3	3.24	8.81	-	2.46	8.73	6.73	10.23	0.38	1.07	7.28	27.74	5.24	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.43	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	28.18	0.3	17.41	-	1.82	6.23	0.28	3.32	8.3	3.24	8.81	-	2.46	8.73	6.73	10.23	0.38	1.07	7.28	27.74	5.24	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.43
H3954_098_0	2007	4																					None												D						V							V	V	V	V							V	V	V	V														32.34	0	5.93	3	0.84	2.9	0.13	0	3.5	1.37	3.71	0	1.04	2.58	0	0	0	0	3.47	14.27	2.82	0.38	0	0	0	0	0	0	0	0	0											78.26	N/A	1739.86	38.05	1433.28	1480.9	226.03	56250.46	58.08	554.56	507.3	3317.49	1680.95	0	865.72	2389.91	5091.73	5910.57	187.45	586.55	5164.52	25283.26	1035.35	591.19	0	0	410.24	0	175.82	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.97	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.16	-	-	-	-	-	2.17	-	-	-	-	-	-	4.24	9.85	0.31	0.49	-	-	-	-	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.2	2000	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47
H3954_099_0	2007	6																					None												D						V							V	V	V	V							V	V	V	V														32.34	0	5.93	3	0.84	2.9	0.13	0	3.5	1.37	3.71	0	1.04	2.58	0	0	0	0	3.47	14.27	2.82	0.38	0	0	0	0	0	0	0	0	0											78.26	N/A	1739.86	38.05	1433.28	1480.9	226.03	56250.46	58.08	554.56	507.3	3317.49	1680.95	0	865.72	2389.91	5091.73	5910.57	187.45	586.55	5164.52	25283.26	1035.35	591.19	0	0	410.24	0	175.82	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.97	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.16	-	-	-	-	-	2.17	-	-	-	-	-	-	4.24	9.85	0.31	0.49	-	-	-	-	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.2	2000	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47
H3954_100_0	2007	6																					None												D						V							V	V	V	V							V	V	V	V														32.34	0	5.93	3	0.84	2.9	0.13	0	3.5	1.37	3.71	0	1.04	2.58	0	0	0	0	3.47	14.27	2.82	0.38	0	0	0	0	0	0	0	0	0											78.26	N/A	1739.86	38.05	1433.28	1480.9	226.03	56250.46	58.08	554.56	507.3	3317.49	1680.95	0	865.72	2389.91	5091.73	5910.57	187.45	586.55	5164.52	25283.26	1035.35	591.19	0	0	410.24	0	175.82	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.97	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.16	-	-	-	-	-	2.17	-	-	-	-	-	-	4.24	9.85	0.31	0.49	-	-	-	-	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.2	2000	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47
H3954_101_0	2007	6																					None												D						V							V	V	V	V							V	V	V	V														32.34	0	5.93	3	0.84	2.9	0.13	0	3.5	1.37	3.71	0	1.04	2.58	0	0	0	0	3.47	14.27	2.82	0.38	0	0	0	0	0	0	0	0	0											78.26	N/A	1739.86	38.05	1433.28	1480.9	226.03	56250.46	58.08	554.56	507.3	3317.49	1680.95	0	865.72	2389.91	5091.73	5910.57	187.45	586.55	5164.52	25283.26	1035.35	591.19	0	0	410.24	0	175.82	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.97	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.16	-	-	-	-	-	2.17	-	-	-	-	-	-	4.24	9.85	0.31	0.49	-	-	-	-	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.2	2000	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	32.34	0.16	5.93	3	0.84	2.9	0.13	2.17	3.5	1.37	3.71	-	1.04	2.58	4.24	9.85	0.31	0.49	3.47	14.27	2.82	0.38	-	-	0.68	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.47
H3954_102_0	2007	4																					None												D						V							V	V	V	V							V	V	V	V														34.52	0	5.35	4.65	0.96	3.33	0.15	0	3.16	1.23	3.35	0	0.94	2.32	0	0	0	0	3.93	13.84	2.73	0.36	0	0	0	0	0	0	0	0	0											80.83	N/A	1950.58	42.66	1367.05	2516.38	254.2	63260.29	65.32	487.48	443.59	2900.81	1469.82	0	756.98	2089.74	4763.29	5630.98	190.57	596.3	5409.42	25845.35	1052.57	599.72	0	0	383.78	0	164.48	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.77	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.18	-	-	-	-	-	1.9	-	-	-	-	-	-	3.97	9.38	0.32	0.5	-	-	-	-	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.16	2000	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99
H3954_103_0	2007	6																					None												D						V							V	V	V	V							V	V	V	V														34.52	0	5.35	4.65	0.96	3.33	0.15	0	3.16	1.23	3.35	0	0.94	2.32	0	0	0	0	3.93	13.84	2.73	0.36	0	0	0	0	0	0	0	0	0											80.83	N/A	1950.58	42.66	1367.05	2516.38	254.2	63260.29	65.32	487.48	443.59	2900.81	1469.82	0	756.98	2089.74	4763.29	5630.98	190.57	596.3	5409.42	25845.35	1052.57	599.72	0	0	383.78	0	164.48	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.77	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.18	-	-	-	-	-	1.9	-	-	-	-	-	-	3.97	9.38	0.32	0.5	-	-	-	-	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.16	2000	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99
H3954_104_0	2007	6																					None												D						V							V	V	V	V							V	V	V	V														34.52	0	5.35	4.65	0.96	3.33	0.15	0	3.16	1.23	3.35	0	0.94	2.32	0	0	0	0	3.93	13.84	2.73	0.36	0	0	0	0	0	0	0	0	0											80.83	N/A	1950.58	42.66	1367.05	2516.38	254.2	63260.29	65.32	487.48	443.59	2900.81	1469.82	0	756.98	2089.74	4763.29	5630.98	190.57	596.3	5409.42	25845.35	1052.57	599.72	0	0	383.78	0	164.48	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.77	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.18	-	-	-	-	-	1.9	-	-	-	-	-	-	3.97	9.38	0.32	0.5	-	-	-	-	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.16	2000	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99
H3954_105_0	2007	6																					None												D						V							V	V	V	V							V	V	V	V														34.52	0	5.35	4.65	0.96	3.33	0.15	0	3.16	1.23	3.35	0	0.94	2.32	0	0	0	0	3.93	13.84	2.73	0.36	0	0	0	0	0	0	0	0	0											80.83	N/A	1950.58	42.66	1367.05	2516.38	254.2	63260.29	65.32	487.48	443.59	2900.81	1469.82	0	756.98	2089.74	4763.29	5630.98	190.57	596.3	5409.42	25845.35	1052.57	599.72	0	0	383.78	0	164.48	0	0	0	0											PBP Line 1a: Deductible	PBP Line 1b: 50 (days 1-5)	PBP Line 2: Deductible	PBP Line 6: Deductible	PBP Line 10a: Deductible	PBP Line 11a: Deductible	PBP Line 11b 11c: Deductible	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: Deductible	PBP Lines 8a 9a: Deductible	PBP Lines 8b 9a: Deductible	PBP Lines 5 9a: Deductible	PBP Lines 9a 12: Deductible	PBP Line 3: 10/day Line 9c: 25Ind/10Grp Lines 5 9a 9d: Deductible	PBP Lines 7a 14c: 10; Lines 14b 14d 14e 14f 14g 14h 14i: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 7e 7h: 25 ind./10 grp	PBP Line 7c 7i: 10/day	PBP Line 7d: Deductible	PBP Lines 14d 14e 14f 14g 14h 14i: Deductible Lines 7b 7d 7f 7g: 20	PBP Line 15: Deductible	PBP Lines 13a 16b: Deductible Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											0	50	0	0	0	0	0	46.77	0	0	0	0	0	0	10	20	20	10	0	0	0	0	0	0	20	0	20	0	0	0	0											-	0.18	-	-	-	-	-	1.9	-	-	-	-	-	-	3.97	9.38	0.32	0.5	-	-	-	-	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.16	2000	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99	None																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	34.52	0.18	5.35	4.65	0.96	3.33	0.15	1.9	3.16	1.23	3.35	-	0.94	2.32	3.97	9.38	0.32	0.5	3.93	13.84	2.73	0.36	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.99
H3954_801_0	2007	5																					None											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	236.25	2.97	26.61	10.91	12.42	10.5	5.71	14.98	45.76	42.91	40.48	2.25	1.2	21.74	38.14	133.1	2.37	0.06	22.53	7.95	11.8	1.11	0	0	0	0	0	0	0	0	0											Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits																				0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.06	0.23	5.24	-	2.93	2.48	1.35	3.53	10.8	10.13	9.55	0.53	0.28	5.13	9	31.41	0.56	0.01	5.32	1.88	2.79	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.47	None	0	18.06	0.23	5.24	-	2.93	2.48	1.35	3.53	10.8	10.13	9.55	0.53	0.28	5.13	9	31.41	0.56	0.01	5.32	1.88	2.79	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.47	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	18.06	0.23	5.24	-	2.93	2.48	1.35	3.53	10.8	10.13	9.55	0.53	0.28	5.13	9	31.41	0.56	0.01	5.32	1.88	2.79	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.47
H3954_802_0	2007	4																					None											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	236.25	2.97	26.61	10.91	12.42	10.5	5.71	14.98	45.76	42.91	40.48	2.25	1.2	21.74	38.14	133.1	2.37	0.06	22.53	7.95	11.8	1.11	0	0	0	0	0	0	0	0	0											Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits	Medicare FFS Benefits																				0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											18.06	0.23	5.24	-	2.93	2.48	1.35	3.53	10.8	10.13	9.55	0.53	0.28	5.13	9	31.41	0.56	0.01	5.32	1.88	2.79	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.47	None	0	18.06	0.23	5.24	-	2.93	2.48	1.35	3.53	10.8	10.13	9.55	0.53	0.28	5.13	9	31.41	0.56	0.01	5.32	1.88	2.79	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.47	None	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	18.06	0.23	5.24	-	2.93	2.48	1.35	3.53	10.8	10.13	9.55	0.53	0.28	5.13	9	31.41	0.56	0.01	5.32	1.88	2.79	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.47
H3957_003_0	2007	3																																A		D		T	Coin		V	V					V	V	V					S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		429	0	680	0	385.2	21.47	0	243.82	680	0	0	0	0	892.39	4439.1	6277.65	0	0	0	0	189.01	0	0	0	252	0	5.38	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												126.41	0	25	0	25	0.14	0	50	50	0	0	0	0	20	10	20	0	0	0	0	20	0	0	0	20	0	20	0	0	0	0											4.52	-	1.42	-	0.8	2.9	-	1.02	2.83	-	-	-	-	1.49	3.7	10.46	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88	0	0	4.52	-	1.42	-	0.8	2.9	-	1.02	2.83	-	-	-	-	1.49	3.7	10.46	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.52	-	1.42	-	0.8	2.9	-	1.02	2.83	-	-	-	-	1.49	3.7	10.46	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88
H3957_006_0	2007	2																																A		D		T	Coin		V	V					V	V	V					S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		429	0	680	0	349.18	20.59	0	268.55	680	0	0	0	0	1288.44	4393.03	6194.26	0	0	0	0	222.62	0	0	0	252	0	6.44	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												126.41	0	25	0	25	0.14	0	50	50	0	0	0	0	20	10	20	0	0	0	0	20	0	0	0	20	0	20	0	0	0	0											4.52	-	1.42	-	0.73	2.78	-	1.12	2.83	-	-	-	-	2.15	3.66	10.32	-	-	-	-	0.37	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.33	0	0	4.52	-	1.42	-	0.73	2.78	-	1.12	2.83	-	-	-	-	2.15	3.66	10.32	-	-	-	-	0.37	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.33																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.52	-	1.42	-	0.73	2.78	-	1.12	2.83	-	-	-	-	2.15	3.66	10.32	-	-	-	-	0.37	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.33
H3957_016_0	2007	2																																A		D		T	Coin		V	V					V	V	V					S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		429	0	680	0	285.19	23.42	0	240.5	680	0	0	0	0	1074.14	4517.45	6291.66	0	0	0	0	192.52	0	0	0	252	0	4.38	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												126.41	0	25	0	25	0.14	0	50	50	0	0	0	0	20	10	20	0	0	0	0	20	0	0	0	20	0	20	0	0	0	0											4.52	-	1.42	-	0.59	3.16	-	1	2.83	-	-	-	-	1.79	3.76	10.49	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.32	0	0	4.52	-	1.42	-	0.59	3.16	-	1	2.83	-	-	-	-	1.79	3.76	10.49	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.32																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.52	-	1.42	-	0.59	3.16	-	1	2.83	-	-	-	-	1.79	3.76	10.49	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.32
H3957_020_0	2007	3																																A				T	Coin		V						V	V	V					S			Coin	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		425	0	0	0	385.2	21.47	0	243.82	0	0	0	0	0	892.39	4439.1	6336.48	0	0	0	0	189.01	0	0	8.39	252	0	5.38	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												81.55	0	0	0	25	0.14	0	50	0	0	0	0	0	20	10	20	0	0	0	0	20	0	0	0.4	20	0	20	0	0	0	0											2.89	-	-	-	0.8	2.9	-	1.02	-	-	-	-	-	1.49	3.7	10.56	-	-	-	-	0.32	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.45	0	0	2.89	-	-	-	0.8	2.9	-	1.02	-	-	-	-	-	1.49	3.7	10.56	-	-	-	-	0.32	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.45																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	2.89	-	-	-	0.8	2.9	-	1.02	-	-	-	-	-	1.49	3.7	10.56	-	-	-	-	0.32	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.45
H3957_021_0	2007	3																																A				T	Coin		V						V	V	V					S			Coin	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		425	0	0	0	349.18	20.59	0	268.55	0	0	0	0	0	1288.44	4393.03	6263.16	0	0	0	0	222.62	0	0	8.38	252	0	6.44	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												81.55	0	0	0	25	0.14	0	50	0	0	0	0	0	20	10	20	0	0	0	0	20	0	0	0.4	20	0	20	0	0	0	0											2.89	-	-	-	0.73	2.78	-	1.12	-	-	-	-	-	2.15	3.66	10.44	-	-	-	-	0.37	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.92	0	0	2.89	-	-	-	0.73	2.78	-	1.12	-	-	-	-	-	2.15	3.66	10.44	-	-	-	-	0.37	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.92																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	2.89	-	-	-	0.73	2.78	-	1.12	-	-	-	-	-	2.15	3.66	10.44	-	-	-	-	0.37	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.92
H3957_022_0	2007	3																																A				T	Coin		V						V	V	V					S			Coin	V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		425	0	0	0	285.19	23.42	0	240.5	0	0	0	0	0	1074.14	4517.45	6357.37	0	0	0	0	192.52	0	0	8.38	252	0	4.38	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												81.55	0	0	0	25	0.14	0	50	0	0	0	0	0	20	10	20	0	0	0	0	20	0	0	0.4	20	0	20	0	0	0	0											2.89	-	-	-	0.59	3.16	-	1	-	-	-	-	-	1.79	3.76	10.6	-	-	-	-	0.32	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.9	0	0	2.89	-	-	-	0.59	3.16	-	1	-	-	-	-	-	1.79	3.76	10.6	-	-	-	-	0.32	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.9																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	2.89	-	-	-	0.59	3.16	-	1	-	-	-	-	-	1.79	3.76	10.6	-	-	-	-	0.32	-	-	3.35	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.9
H3957_024_0	2007	1																																A		D		T	Coin		V	V					V	V	V					S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		429	0	680	0	385.2	21.47	0	243.82	680	0	0	0	0	11372.39	4439.1	6277.65	0	0	0	0	189.01	0	0	0	252	0	5.38	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												146.8	0	25	0	25	0.14	0	50	100	0	0	0	0	18	10	20	0	0	0	0	20	0	0	0	20	0	20	0	0	0	0											5.25	-	1.42	-	0.8	2.9	-	1.02	5.67	-	-	-	-	17.06	3.7	10.46	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.01	0	0	5.25	-	1.42	-	0.8	2.9	-	1.02	5.67	-	-	-	-	17.06	3.7	10.46	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.01																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.25	-	1.42	-	0.8	2.9	-	1.02	5.67	-	-	-	-	17.06	3.7	10.46	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.01
H3957_025_0	2007	1																																A		D		T	Coin		V	V					V	V	V					S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		429	0	680	0	349.18	20.59	0	268.55	680	0	0	0	0	11768.44	4393.03	6194.26	0	0	0	0	222.62	0	0	0	252	0	6.44	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												146.8	0	25	0	25	0.14	0	50	100	0	0	0	0	18	10	20	0	0	0	0	20	0	0	0	20	0	20	0	0	0	0											5.25	-	1.42	-	0.73	2.78	-	1.12	5.67	-	-	-	-	17.65	3.66	10.32	-	-	-	-	0.37	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.4	0	0	5.25	-	1.42	-	0.73	2.78	-	1.12	5.67	-	-	-	-	17.65	3.66	10.32	-	-	-	-	0.37	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.4																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.25	-	1.42	-	0.73	2.78	-	1.12	5.67	-	-	-	-	17.65	3.66	10.32	-	-	-	-	0.37	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.4
H3957_026_0	2007	1																																A		D		T	Coin		V	V					V	V	V					S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		429	0	680	0	285.19	23.42	0	240.5	680	0	0	0	0	11554.14	4517.45	6291.66	0	0	0	0	192.52	0	0	0	252	0	4.38	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												146.8	0	25	0	25	0.14	0	50	100	0	0	0	0	18	10	20	0	0	0	0	20	0	0	0	20	0	20	0	0	0	0											5.25	-	1.42	-	0.59	3.16	-	1	5.67	-	-	-	-	17.33	3.76	10.49	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.42	0	0	5.25	-	1.42	-	0.59	3.16	-	1	5.67	-	-	-	-	17.33	3.76	10.49	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.42																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.25	-	1.42	-	0.59	3.16	-	1	5.67	-	-	-	-	17.33	3.76	10.49	-	-	-	-	0.32	-	-	-	0.42	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.42
H3957_030_0	2007	6																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		427.32	0	75.33	0	18.99	33.84	0	6.9	43.93	0	0	0	0	107.43	65.74	267.52	0	0	0	0	61.7	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											31.5	-	14.12	-	4.48	7.99	-	1.63	10.37	-	-	-	-	25.35	15.51	63.14	-	-	-	-	14.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	188.65	0	0	31.5	-	14.12	-	4.48	7.99	-	1.63	10.37	-	-	-	-	25.35	15.51	63.14	-	-	-	-	14.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	188.65																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	31.5	-	14.12	-	4.48	7.99	-	1.63	10.37	-	-	-	-	25.35	15.51	63.14	-	-	-	-	14.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	188.65
H3957_805_0	2007	2																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		274.57	0	40.43	0	10.75	23.46	0	4.28	33.03	0	0	0	0	80.95	48.06	195.91	0	0	0	0	49.42	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03
H3957_806_0	2007	2																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		274.57	0	40.43	0	10.75	23.46	0	4.28	33.03	0	0	0	0	80.95	48.06	195.91	0	0	0	0	49.42	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03
H3957_807_0	2007	2																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		274.57	0	40.43	0	10.75	23.46	0	4.28	33.03	0	0	0	0	80.95	48.06	195.91	0	0	0	0	49.42	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03
H3957_808_0	2007	2																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin	Coin					Coin																					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		274.57	0	40.43	0	10.75	23.46	0	4.28	33.03	0	0	0	0	80.95	48.06	195.91	0	0	0	0	49.42	0	0	0	0	0	0	0	0	0	0											PBP 1a 1b		PBP 2	PBP 6	PBP 10a	PBP 11a 11b 11c		PBP 4a 4b	PBP 9a 9b					PBP 8a 8b 12 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b-i 14d-i 17a 18a					PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a 17b		PBP 18a 18b		PBP 19	PBP 14a												0.07	0	0.19	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0.24	0	0	0	0	0.24	0	0	0	0	0	0	0	0	0	0											20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	20.23	-	7.58	-	2.54	5.54	-	1.01	7.79	-	-	-	-	19.1	11.34	46.23	-	-	-	-	11.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.03
H3959_001_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-				981.95		304.74	11.56	6.29	305.47	495.01		1248.61				3861.14	4903.05	1362.96	659.35	1207.15	6.2	1063.69			21.48	139.38						220.3													2 40 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 10	16b 2517a 2518a 257b 257d 257f 257b 25	7d 257e 257h 259c 25	7c 157i 15	8b 25	7g 25	0.2			16a 15	17a 25						14c 107f 25													8.25		50	0.19	0.19	45	71.78		21.13				10	25	25	15	19.07	25	7.6			15	25						24.77											-	-	0.68	-	1.27	2.2	1.19	1.15	2.96	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.11			-	-	0.68	-	1.27	2.2	1.19	1.15	2.96	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.11																																																																																				-			-	-	0.68	-	1.27	2.2	1.19	1.15	2.96	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.11
H3959_002_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-				981.95		304.74	11.12	6.05	305.47	495.01		1248.61				3861.14	4903.05	1362.96	659.35	1207.15	6.2	1063.69			21.48	139.38						220.3													2 40 days 21-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 10	16b 3017a 3018a 257b 257d 307f 257b 25	7e 257h 259c 25	7c 157i 15	8b 25	7g 25	0.2			16a 15	17a 30						14c 157f 25													13.56		50	0.19	0.19	45	71.62		21.13				10	25	25	15	19.07	25	7.6			15	25						24.77											-	-	1.11	-	1.27	2.11	1.15	1.15	2.95	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.41			-	-	1.11	-	1.27	2.11	1.15	1.15	2.95	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.41																																																																																				-			-	-	1.11	-	1.27	2.11	1.15	1.15	2.95	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.41
H3959_006_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-				981.95		304.74	10	5.44	305.47	495.01						3861.14	4903.05	1362.96	659.35		6.2	1063.69			21.48	139.38						220.3													2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75						7a 10	16b 2017a 2018a 207b 207d 307f 207b 20	7e 257h 259c 25	7c 157i 15		7g 20	0.2			16a 15	17a 20						14c 157f 20													12.46		45.93	0.17	0.17	41.34	65.42						10	19.91	22.96	13.78		20	4.28			13.78	20						19.85											-	-	1.02	-	1.17	1.75	0.95	1.05	2.7	-	-	-	-	-	3.22	8.14	2.61	0.76	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.36		1.1	-	-	1.02	-	1.17	1.75	0.95	1.05	2.7	-	-	-	-	-	3.22	8.14	2.61	0.76	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.36																																																																																				-			-	-	1.02	-	1.17	1.75	0.95	1.05	2.7	-	-	-	-	-	3.22	8.14	2.61	0.76	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.36
H3959_008_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-				1066.05		330.84	12.24	6.66	331.64	537.4		1355.55				4191.82	5301.27	1363.83	715.81	1310.53	6.73	1154.79			21.48	139.4						239.17													2 40 days 21-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 10	16b 2517a 2518a 257b 257d 257f 257b 25	7e 257h 259c 25	7c 157i 15	8b 25	7g 25	0.2			16a 15	17a 25						14c 107f 25													13.69		50	0.19	0.19	45	71.67		21.13				10	25	25	15	19.07	25	7.6			15	25						24.77											-	-	1.22	-	1.38	2.32	1.26	1.24	3.21	-	2.39	-	-	-	3.49	11.04	2.84	0.89	2.08	0.01	0.73	-	-	0.03	0.29	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	34.94			-	-	1.22	-	1.38	2.32	1.26	1.24	3.21	-	2.39	-	-	-	3.49	11.04	2.84	0.89	2.08	0.01	0.73	-	-	0.03	0.29	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	34.94																																																																																				-			-	-	1.22	-	1.38	2.32	1.26	1.24	3.21	-	2.39	-	-	-	3.49	11.04	2.84	0.89	2.08	0.01	0.73	-	-	0.03	0.29	-	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	34.94
H3959_010_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2435.62	979.34	967.22		300.17	11.39	6.19	300.89	487.59		1229.88				3803.22	4833.3	1362.81	649.46	1189.04	6.11	1047.74				139.38						217											1a 225	1b 225	2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 15	16b 3017a 3018a 307b 307d 307f 30	7d 307e 257h 259c 25	7c 357i 35	8b 25	7g 30	0.2				17a 30						14c 157f 30											40.07	56.47	20.86		50	0.19	0.19	45	71.78		21.13				15	30	25	34.38	19.07	30	8.44				30						29.77											8.13	4.61	1.68	-	1.25	2.16	1.18	1.13	2.92	-	2.17	-	-	-	4.75	12.08	2.84	1.86	1.89	0.02	0.74	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	50.29			8.13	4.61	1.68	-	1.25	2.16	1.18	1.13	2.92	-	2.17	-	-	-	4.75	12.08	2.84	1.86	1.89	0.02	0.74	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	50.29																																																																																				-			8.13	4.61	1.68	-	1.25	2.16	1.18	1.13	2.92	-	2.17	-	-	-	4.75	12.08	2.84	1.86	1.89	0.02	0.74	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	50.29
H3959_011_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2423.26	979.33	962.31		298.65	10.9	5.93	299.36	485.11		1223.64				3783.92	4810.06	1362.76	646.16	1183.01	6.08	1042.42				139.38						215.9											1a 110 days 1-5	1b 110 days 1-5	2 20 days 6-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 15	16b 3017a 3018a 307b 307d 307f 307b 30	7e 257h 259c 25	7c 357i 35	8b 25	7g 30	0.2				17a 30						14c 157f 30											42.92	47.36	60.98		50	0.19	0.19	45	71.62		21.13				15	30	25	34.31	19.07	30	8.44				30						29.77											8.67	3.87	4.89	-	1.24	2.07	1.13	1.12	2.9	-	2.15	-	-	-	4.73	12.02	2.84	1.85	1.88	0.02	0.73	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	52.99			8.67	3.87	4.89	-	1.24	2.07	1.13	1.12	2.9	-	2.15	-	-	-	4.73	12.02	2.84	1.85	1.88	0.02	0.73	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	52.99																																																																																				-			8.67	3.87	4.89	-	1.24	2.07	1.13	1.12	2.9	-	2.15	-	-	-	4.73	12.02	2.84	1.85	1.88	0.02	0.73	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	52.99
H3959_012_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2435.62	979.34	967.22		300.17	10.53	5.73	300.89	487.59		1229.88				3803.22	4833.3	1362.81	649.46	1189.04	6.11	1047.74										217											1a 225	1b 225	2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 15	16b 3017a 3018a 307b 307d 307f 307b 30	7e 257h 259c 25	7c 357i 35	8b 25	7g 30	0.2										14c 157f 30											39.92	56.47	13.56		50	0.19	0.19	45	71.46		21.13				15	30	25	34.25	19.07	30	8.44										29.77											8.1	4.61	1.09	-	1.25	2	1.09	1.13	2.9	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	49.05			8.1	4.61	1.09	-	1.25	2	1.09	1.13	2.9	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	49.05																																																																																				-			8.1	4.61	1.09	-	1.25	2	1.09	1.13	2.9	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	49.05
H3959_013_0	2007	2	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	Coin																																															-		2435.62	979.34	967.22		300.17	11.39	6.19	300.89	487.59		1307.04				3803.22	4833.3	1362.81	649.46	174.86	6.11	1047.74										217					6.67						1a 250	1b 250	2 40 days 6-100		10a 50	11a 20	11b 20	4a 50	9a 1009b 100		8a 108b 50				7a 15	16b 3017a 3018a 307b 307d 307f 307b 30	7d 307e 307h 309C 20	7c 357i 35	8a 108b 50	7g 30	0.2										14c 157f 30					8a 10						44.3	62.75	34.93		50	0.19	0.19	45	94.32		11.42				15	30	30	34.38	39.87	30	8.44										29.77					0.11						8.99	5.12	2.82	-	1.25	2.16	1.18	1.13	3.83	-	1.24	-	-	-	4.75	12.08	3.41	1.86	0.58	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	0.7	-	-	-	-	-	52.4			8.99	5.12	2.82	-	1.25	2.16	1.18	1.13	3.83	-	1.24	-	-	-	4.75	12.08	3.41	1.86	0.58	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	0.7	-	-	-	-	-	52.4																																																																																				-			8.99	5.12	2.82	-	1.25	2.16	1.18	1.13	3.83	-	1.24	-	-	-	4.75	12.08	3.41	1.86	0.58	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	0.7	-	-	-	-	-	52.4
H3959_015_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2644.21	979.56	1050.06		325.88	12.05	6.56	326.66	529.34		1335.21				4128.94	5225.55	1363.67	705.08	1290.88	6.63	1137.47				139.39						235.58											1a 200	1b 200	2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 15	16b 3017a 3018a 307b 307d 307f 307b 30	7e 257h 259c 25	7c 357i 35	8b 25	7g 30	0.2				17a 30						14c 157f 30											35.78	50.2	13.56		50	0.19	0.19	45	71.67		21.13				15	30	25	34.34	19.07	30	8.44				30						29.77											7.89	4.1	1.19	-	1.36	2.29	1.25	1.22	3.16	-	2.35	-	-	-	5.16	13.06	2.84	2.02	2.05	0.02	0.8	-	-	-	0.35	-	-	-	-	-	0.58	-	-	-	-	-	-	-	-	-	-	51.68			7.89	4.1	1.19	-	1.36	2.29	1.25	1.22	3.16	-	2.35	-	-	-	5.16	13.06	2.84	2.02	2.05	0.02	0.8	-	-	-	0.35	-	-	-	-	-	0.58	-	-	-	-	-	-	-	-	-	-	51.68																																																																																				-			7.89	4.1	1.19	-	1.36	2.29	1.25	1.22	3.16	-	2.35	-	-	-	5.16	13.06	2.84	2.02	2.05	0.02	0.8	-	-	-	0.35	-	-	-	-	-	0.58	-	-	-	-	-	-	-	-	-	-	51.68
H3959_017_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-				981.95		304.74	11.1	6.04	305.47	495.01						3861.14	4903.05	1362.96	659.35		6.2	1063.69			21.48	139.38						220.3													2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75						7a 10	16b 2017a 2018a 207b 207d 207f 207b 20	7e 257h 259c 25	7c 157i 15		7g 20	0.2			16a 15	17a 20						14c 107f 20													12.39		45.67	0.17	0.17	41.1	65.4						10	19.91	22.83	13.7		20	4.28			13.7	20						19.85											-	-	1.01	-	1.16	1.93	1.05	1.05	2.7	-	-	-	-	-	3.22	8.13	2.59	0.75	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.6		1.2	-	-	1.01	-	1.16	1.93	1.05	1.05	2.7	-	-	-	-	-	3.22	8.13	2.59	0.75	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.6																																																																																				-			-	-	1.01	-	1.16	1.93	1.05	1.05	2.7	-	-	-	-	-	3.22	8.13	2.59	0.75	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.6
H3959_018_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2435.62	979.34	967.22		300.17	10.93	5.95	300.89	487.59		1229.88				3803.22	4833.3	1362.81	649.46	1189.04	6.11	1047.74										217											1a 200	1b 200	2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 15	16b 3017a 3018a 307b 307d 307f 30	7e 257h 259c 25	7c 357i 35	8b 25	7g 30	0.2										14c 157f 30											35.76	50.2	13.56		50	0.19	0.19	45	71.61		21.13				15	30	25	34.31	19.07	30	8.44										29.77											7.26	4.1	1.09	-	1.25	2.08	1.13	1.13	2.91	-	2.17	-	-	-	4.75	12.08	2.84	1.86	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	47.82			7.26	4.1	1.09	-	1.25	2.08	1.13	1.13	2.91	-	2.17	-	-	-	4.75	12.08	2.84	1.86	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	47.82																																																																																				-			7.26	4.1	1.09	-	1.25	2.08	1.13	1.13	2.91	-	2.17	-	-	-	4.75	12.08	2.84	1.86	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	47.82
H3959_019_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-				981.95		304.74	10.63	5.78	305.47	495.01		1248.61				3861.14	4903.05	1362.96	659.35	1207.15	6.2	1063.69			21.48	139.38						220.3													2 40 days 21-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 10	16b 2517a 2518a 257b 257d 257f 257b 25	7e 257h 259c 25	7c 157i 15	8b 25	7g 25	0.2			16a 15	17a 25						14c 107f 25													13.69		50	0.19	0.19	45	71.44		21.13				10	25	25	15	19.07	25	7.6			15	25						24.77											-	-	1.12	-	1.27	2.02	1.1	1.15	2.95	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.27			-	-	1.12	-	1.27	2.02	1.1	1.15	2.95	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.27																																																																																				-			-	-	1.12	-	1.27	2.02	1.1	1.15	2.95	-	2.2	-	-	-	3.22	10.21	2.84	0.82	1.92	0.01	0.67	-	-	0.03	0.29	-	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	32.27
H3959_020_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2435.62	979.34	967.22		300.17	10.47	5.7	300.89	487.59		1229.88				3803.22	4833.3	1362.81	649.46	1189.04	6.11	1047.74				139.38						217											1a 225	1b 225	2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 15	16b 3017a 3018a 307b 307d 307f 30	7e 257h 259c 25	7c 357i 35	8b 25	7g 30	0.2				17a 30						14c 157f 30											39.91	56.47	13.56		50	0.19	0.19	45	71.44		21.13				15	30	25	34.24	19.07	30	8.44				30						29.77											8.1	4.61	1.09	-	1.25	1.99	1.08	1.13	2.9	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	49.38			8.1	4.61	1.09	-	1.25	1.99	1.08	1.13	2.9	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	49.38																																																																																				-			8.1	4.61	1.09	-	1.25	1.99	1.08	1.13	2.9	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	0.35	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	49.38
H3959_021_0	2007	4	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2435.62	979.34	967.22		300.17	9.85	5.36	300.89	487.59		1229.88				3803.22	4833.3	1362.81	649.46	1189.04	6.11	1047.74										217											1a 200	1b 200	2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75		8b 25				7a 15	16b 3017a 3018a 307b 307d 307f 307b 30	7e 257h 259c 25	7c 357i 35	8b 25	7g 30	0.2										14c 157f 30											35.57	50.2	13.56		50	0.19	0.19	45	71.22		21.13				15	30	25	34.14	19.07	30	8.44										29.77											7.22	4.1	1.09	-	1.25	1.87	1.02	1.13	2.89	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	47.44			7.22	4.1	1.09	-	1.25	1.87	1.02	1.13	2.89	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	47.44																																																																																				-			7.22	4.1	1.09	-	1.25	1.87	1.02	1.13	2.89	-	2.17	-	-	-	4.75	12.08	2.84	1.85	1.89	0.02	0.74	-	-	-	-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	47.44
H3959_022_0	2007	4	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-				981.95		304.74	10.69	5.82	305.47	495.01						3861.14	4903.05	1362.96	659.35		6.2	1063.69			21.48	139.38						220.3													2 20 days 11-100		10a 50	11a 20	11b 20	4a 50	9a 759b 75						7a 10	16b 2017a 2018a 207b 207d 207f 207b 20	7e 257h 259c 25	7c 157i 15		7g 20	0.2			16a 15	17a 20						14c 107f 20													12.38		45.63	0.17	0.17	41.06	65.22						10	19.91	22.81	13.69		20	4.28			13.69	20						19.85											-	-	1.01	-	1.16	1.85	1.01	1.05	2.69	-	-	-	-	-	3.22	8.13	2.59	0.75	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.48		1.2	-	-	1.01	-	1.16	1.85	1.01	1.05	2.69	-	-	-	-	-	3.22	8.13	2.59	0.75	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.48																																																																																				-			-	-	1.01	-	1.16	1.85	1.01	1.05	2.69	-	-	-	-	-	3.22	8.13	2.59	0.75	-	0.01	0.38	-	-	0.02	0.23	-	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	24.48
H3959_023_0	2007	4	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-		2349.07	979.25	932.85		289.5	10.98	5.97	290.2	470.26		1186.18				3668.08	4670.56	1362.45	626.38	1146.79	5.89	1010.51										209.29											1a 150 days 1-5	1b 150 days 1-5	2 40 days 6-100		10a 50	11a 30	11b 30	4a 50	9a 1009b 100		8b 25				7a 20	16b 4017a 4018a 407b 407d 407f 40	7e 257h 259C 20	7c 357i 35	8b 25	7g 40	0.2										14c 20											57.91	64.58	60.98		50	0.3	0.3	45	94.32		21.13				20	40	25	34.38	19.07	40	8.44										39.58											11.34	5.27	4.74	-	1.21	3.29	1.79	1.09	3.7	-	2.09	-	-	-	6.11	15.57	2.84	1.79	1.82	0.02	0.71	-	-	-	-	-	-	-	-	-	0.69	-	-	-	-	-	-	-	-	-	-	64.07			11.34	5.27	4.74	-	1.21	3.29	1.79	1.09	3.7	-	2.09	-	-	-	6.11	15.57	2.84	1.79	1.82	0.02	0.71	-	-	-	-	-	-	-	-	-	0.69	-	-	-	-	-	-	-	-	-	-	64.07																																																																																				-			11.34	5.27	4.74	-	1.21	3.29	1.79	1.09	3.7	-	2.09	-	-	-	6.11	15.57	2.84	1.79	1.82	0.02	0.71	-	-	-	-	-	-	-	-	-	0.69	-	-	-	-	-	-	-	-	-	-	64.07
H3959_803_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		279.52	2.76	34.26		9.73	10.52	6.22	11.59	31.43	6.13	34.34	1.35	1.12	16.69	24.24	135.5	3.7	8.27	46	17.42	34.32														6.43							FFS 7.3	FFS 7.3	FFS 18.7		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71																																																																																				-			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71
H3959_804_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		279.52	2.76	34.26		9.73	10.52	6.22	11.59	31.43	6.13	34.34	1.35	1.12	16.69	24.24	135.5	3.7	8.27	46	17.42	34.32														6.43							FFS 7.3	FFS 7.3	FFS 18.7		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71																																																																																				-			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71
H3959_806_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		279.52	2.76	34.26		9.73	10.52	6.22	11.59	31.43	6.13	34.34	1.35	1.12	16.69	24.24	135.5	3.7	8.27	46	17.42	34.32														6.43							FFS 7.3	FFS 7.3	FFS 18.7		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71																																																																																				-			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71
H3959_807_0	2007	3	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		279.52	2.76	34.26		9.73	10.52	6.22	11.59	31.43	6.13	34.34	1.35	1.12	16.69	24.24	135.5	3.7	8.27	46	17.42	34.32														6.43							FFS 7.3	FFS 7.3	FFS 18.7		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71																																																																																				-			20.52	0.2	6.4	-	2.3	2.48	1.47	2.74	7.42	1.45	8.11	0.32	0.26	3.94	5.72	31.98	0.87	1.95	10.85	4.11	8.1	-	-	-	-	-	-	-	-	-	-	-	-	-	1.52	-	-	-	-	-	-	122.71
H3962_001_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	420.43	42.1	1051.12	1471.24	329.78	29.82	0	301	1489.88	3039.23	632	0	0	2714.42	4419.74	5637.18	290.76	1652.99	0	59571.49	8.44	2216.37	36.64	1000	420	0	0	0	0	1000	0											0   Adm Copay	0   Adm Copay	0/Day		0   per Trip	0 Coins		50  (WIA)	0   per Surgery		0   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	10  Office Visit	10  Office Visit	10  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		0  Per Trip																			0	0	0	0	0	0	0	32.5	0	0	0	0	0	3.47	10	10	10	10	0	0.05	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.82	-	-	-	-	-	0.79	3.68	4.7	0.24	1.38	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87	0	0	-	-	-	-	-	-	-	0.82	-	-	-	-	-	0.79	3.68	4.7	0.24	1.38	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	0.82	-	-	-	-	-	0.79	3.68	4.7	0.24	1.38	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.87
H3962_002_0	2007	7																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	364.93	42.1	1330.53	794.52	336.02	24.3	0	236.55	1205.61	13143.45	632	0	0	8112.08	4419.74	5084.51	290.76	1265.42	0	57055.3	8.69	5004.42	37.34	1000	420	0	0	0	0	1000	0											0   Adm Copay	0   Adm Copay	0/Day		0   per Trip	0 Coins		50  (WIA)	0   per Surgery		0   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	10  Office Visit	10  Office Visit	10  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		0  Per Trip																			0	0	0	0	0	0	0	37.76	0	0	0	0	0	1.13	10	10	10	10	0	0.05	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.74	-	-	-	-	-	0.76	3.68	4.24	0.24	1.05	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.97	0	0	-	-	-	-	-	-	-	0.74	-	-	-	-	-	0.76	3.68	4.24	0.24	1.05	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.97	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	0.74	-	-	-	-	-	0.76	3.68	4.24	0.24	1.05	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.97
H3962_003_0	2007	7																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	459.08	42.1	1542.59	883.75	648.28	35.44	0	405.58	3509.95	17737.45	632	0	0	18755.61	4419.74	4861.53	290.76	1155.87	0	61683.53	9.72	2494.82	72.03	1000	420	0	0	0	0	1000	0											0   Adm Copay	0   Adm Copay	0/Day		0   per Trip	0 Coins		50  (WIA)	0   per Surgery		0   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	10  Office Visit	10  Office Visit	10  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		0  Per Trip																			0	0	0	0	0	0	0	24.59	0	0	0	0	0	0.48	10	10	10	10	0	0.04	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.83	-	-	-	-	-	0.75	3.68	4.05	0.24	0.96	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.71	0	0	-	-	-	-	-	-	-	0.83	-	-	-	-	-	0.75	3.68	4.05	0.24	0.96	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.71	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	0.83	-	-	-	-	-	0.75	3.68	4.05	0.24	0.96	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.71
H3962_004_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	386.8	38.73	967.03	1353.55	303.4	27.44	0	276.92	1370.69	2796.09	632	0	0	2497.26	4066.16	5186.21	252.37	1520.75	0	54793.21	7.77	2039.06	33.71	1000	420	0	0	0	0	1000	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-100: 25/Day		35   per Trip	10 Coins		50  (WIA)	0   per Surgery		50   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	20  Office Visit	20  Office Visit	20  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		35  Per Trip																			0	0	4.34	0	35	0.1	0	35.52	0	0	50	0	0	6.94	10	20	20	20	0	0.07	0	0	35	0	0	0	0	0	0	0	0											-	-	0.35	-	0.88	2.74	-	0.82	-	-	2.63	-	-	1.44	3.39	8.64	0.42	2.53	-	0.31	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.28	0	0	-	-	0.35	-	0.88	2.74	-	0.82	-	-	2.63	-	-	1.44	3.39	8.64	0.42	2.53	-	0.31	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.28	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	0.35	-	0.88	2.74	-	0.82	-	-	2.63	-	-	1.44	3.39	8.64	0.42	2.53	-	0.31	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.28
H3962_005_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	335.74	38.73	1224.08	730.96	309.14	22.35	0	217.62	1109.16	12091.97	632	0	0	7463.12	4066.16	4677.74	252.37	1164.19	0	52481.99	7.99	4604.07	34.35	1000	420	0	0	0	0	1000	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-100: 25/Day		35   per Trip	10 Coins		50  (WIA)	0   per Surgery		50   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	20  Office Visit	20  Office Visit	20  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		35  Per Trip																			0	0	4.34	0	35	0.1	0	41.27	0	0	50	0	0	2.26	10	20	20	20	0	0.05	0	0	35	0	0	0	0	0	0	0	0											-	-	0.44	-	0.9	2.24	-	0.75	-	-	2.63	-	-	1.4	3.39	7.8	0.42	1.94	-	0.22	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.23	0	0	-	-	0.44	-	0.9	2.24	-	0.75	-	-	2.63	-	-	1.4	3.39	7.8	0.42	1.94	-	0.22	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.23	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	0.44	-	0.9	2.24	-	0.75	-	-	2.63	-	-	1.4	3.39	7.8	0.42	1.94	-	0.22	-	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	22.23
H3962_006_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	422.35	38.73	1419.19	813.05	596.42	32.6	0	373.13	3229.16	16318.45	632	0	0	17255.16	4066.16	4472.61	252.37	1063.4	0	56740.91	8.95	2295.24	66.27	1000	420	0	0	0	0	1000	0											0   Adm Copay	0   Adm Copay	0-14: 0/Day 15-100: 25/Day		35   per Trip	10 Coins		50  (WIA)	0   per Surgery		50   High Tech images only			25  S/A & Rehab svc Office Visit	10  Office Visit	20  Office Visit	20  Office Visit	20  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		35  Per Trip																			0	0	4.34	0	35	0.1	0	26.88	0	0	50	0	0	0.95	10	20	20	20	0	0.04	0	0	35	0	0	0	0	0	0	0	0											-	-	0.51	-	1.74	3.26	-	0.84	-	-	2.63	-	-	1.37	3.39	7.45	0.42	1.77	-	0.2	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.78	0	0	-	-	0.51	-	1.74	3.26	-	0.84	-	-	2.63	-	-	1.37	3.39	7.45	0.42	1.77	-	0.2	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.78	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	0.51	-	1.74	3.26	-	0.84	-	-	2.63	-	-	1.37	3.39	7.45	0.42	1.77	-	0.2	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.78
H3962_007_0	2007	8																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	369.98	37.05	924.98	1294.7	290.21	26.24	0	264.88	1311.09	2674.52	632	0	0	2388.69	3889.37	4960.72	236.57	1454.63	0	52406.89	7.43	1950.4	32.25	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-100: 50/Day		50   per Trip	20 Coins		50  (WIA)	50   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	10  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	8.68	0	50	0.2	0	38.54	50	0	100	0	0	10.41	10	30	30	30	0	0.1	0	0	50	0	0	0	0	0	0	0	0											7.71	0.77	0.67	-	1.21	5.25	-	0.85	5.46	-	5.27	-	-	2.07	3.24	12.4	0.59	3.64	-	0.44	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.71	0	0	7.71	0.77	0.67	-	1.21	5.25	-	0.85	5.46	-	5.27	-	-	2.07	3.24	12.4	0.59	3.64	-	0.44	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.71	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	7.71	0.77	0.67	-	1.21	5.25	-	0.85	5.46	-	5.27	-	-	2.07	3.24	12.4	0.59	3.64	-	0.44	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.71
H3962_008_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	321.14	37.05	1170.86	699.18	295.69	21.38	0	208.16	1060.94	11566.24	632	0	0	7138.63	3889.37	4474.36	236.57	1113.57	0	50197.33	7.65	4403.89	32.85	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-100: 50/Day		50   per Trip	20 Coins		50  (WIA)	50   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	10  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	8.68	0	50	0.2	0	44.78	50	0	100	0	0	3.39	10	30	30	30	0	0.07	0	0	50	0	0	0	0	0	0	0	0											6.69	0.77	0.85	-	1.23	4.28	-	0.78	4.42	-	5.27	-	-	2.01	3.24	11.19	0.59	2.78	-	0.31	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.55	0	0	6.69	0.77	0.85	-	1.23	4.28	-	0.78	4.42	-	5.27	-	-	2.01	3.24	11.19	0.59	2.78	-	0.31	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.55	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.69	0.77	0.85	-	1.23	4.28	-	0.78	4.42	-	5.27	-	-	2.01	3.24	11.19	0.59	2.78	-	0.31	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.55
H3962_009_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	403.99	37.05	1357.48	777.7	570.49	31.19	0	356.91	3088.76	15608.95	632	0	0	16504.94	3889.37	4278.15	236.57	1017.17	0	54271.38	8.56	2195.44	63.39	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-100: 50/Day		50   per Trip	20 Coins		50  (WIA)	50   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	10  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	8.68	0	50	0.2	0	29.16	50	0	100	0	0	1.43	10	30	30	30	0	0.06	0	0	50	0	0	0	0	0	0	0	0											8.42	0.77	0.98	-	2.38	6.24	-	0.87	12.87	-	5.27	-	-	1.97	3.24	10.7	0.59	2.54	-	0.28	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	8.42	0.77	0.98	-	2.38	6.24	-	0.87	12.87	-	5.27	-	-	1.97	3.24	10.7	0.59	2.54	-	0.28	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.42	0.77	0.98	-	2.38	6.24	-	0.87	12.87	-	5.27	-	-	1.97	3.24	10.7	0.59	2.54	-	0.28	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37
H3962_010_0	2007	6																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	369.98	37.05	924.98	1294.7	290.21	26.24	0	264.88	1311.09	2674.52	632	0	0	2388.69	3889.37	4960.72	236.57	1454.63	0	52406.89	7.43	1950.4	32.25	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-100: 50/Day		50   per Trip	20 Coins		50  (WIA)	50   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	10  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	8.68	0	50	0.2	0	38.54	50	0	100	0	0	10.41	10	30	30	30	0	0.1	0	0	50	0	0	0	0	0	0	0	0											7.71	0.77	0.67	-	1.21	5.25	-	0.85	5.46	-	5.27	-	-	2.07	3.24	12.4	0.59	3.64	-	0.44	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.71	0	0	7.71	0.77	0.67	-	1.21	5.25	-	0.85	5.46	-	5.27	-	-	2.07	3.24	12.4	0.59	3.64	-	0.44	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.71	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	7.71	0.77	0.67	-	1.21	5.25	-	0.85	5.46	-	5.27	-	-	2.07	3.24	12.4	0.59	3.64	-	0.44	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.71
H3962_011_0	2007	5																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	321.14	37.05	1170.86	699.18	295.69	21.38	0	208.16	1060.94	11566.24	632	0	0	7138.63	3889.37	4474.36	236.57	1113.57	0	50197.33	7.65	4403.89	32.85	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-100: 50/Day		50   per Trip	20 Coins		50  (WIA)	50   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	10  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	8.68	0	50	0.2	0	44.78	50	0	100	0	0	3.39	10	30	30	30	0	0.07	0	0	50	0	0	0	0	0	0	0	0											6.69	0.77	0.85	-	1.23	4.28	-	0.78	4.42	-	5.27	-	-	2.01	3.24	11.19	0.59	2.78	-	0.31	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.55	0	0	6.69	0.77	0.85	-	1.23	4.28	-	0.78	4.42	-	5.27	-	-	2.01	3.24	11.19	0.59	2.78	-	0.31	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.55	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.69	0.77	0.85	-	1.23	4.28	-	0.78	4.42	-	5.27	-	-	2.01	3.24	11.19	0.59	2.78	-	0.31	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.55
H3962_012_0	2007	5																					none											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	P	V	P	V	P	O	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	403.99	37.05	1357.48	777.7	570.49	31.19	0	356.91	3088.76	15608.95	632	0	0	16504.94	3889.37	4278.15	236.57	1017.17	0	54271.38	8.56	2195.44	63.39	0	0	0	0	0	0	0	0											250   Adm Copay	250   Adm Copay	0-14: 0/Day 15-100: 50/Day		50   per Trip	20 Coins		50  (WIA)	50   per Surgery		100   High Tech images only			30  S/A & Rehab svc Office Visit	10  Office Visit	30  Office Visit	30  Office Visit	30  Office Visit		R.Phy Bone Mass Mammogram Col. Screening Prostate Scr Pap&Pelvic 10 Chiro Pod 30	0 Coins		50  Per Trip																			250	250	8.68	0	50	0.2	0	29.16	50	0	100	0	0	1.43	10	30	30	30	0	0.06	0	0	50	0	0	0	0	0	0	0	0											8.42	0.77	0.98	-	2.38	6.24	-	0.87	12.87	-	5.27	-	-	1.97	3.24	10.7	0.59	2.54	-	0.28	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	8.42	0.77	0.98	-	2.38	6.24	-	0.87	12.87	-	5.27	-	-	1.97	3.24	10.7	0.59	2.54	-	0.28	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	8.42	0.77	0.98	-	2.38	6.24	-	0.87	12.87	-	5.27	-	-	1.97	3.24	10.7	0.59	2.54	-	0.28	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37
H3962_801_0	2007	4																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	213.92	2.36	16.36	5.89	6.76	22.54	0	4.4	35.6	13.49	29.02	0	0	38.59	29.42	39.57	1.84	12.58	0	147.15	8.78	21.9	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											15.86	0.18	3.26	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.44	0	0	15.86	0.18	3.26	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.44	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	15.86	0.18	3.26	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.44
H3962_802_0	2007	2																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	213.92	2.36	16.36	5.89	6.76	22.54	0	4.4	35.6	13.49	29.02	0	0	38.59	29.42	39.57	1.84	12.58	0	147.15	8.78	21.9	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											15.85	0.18	3.23	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.4	0	0	15.85	0.18	3.23	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.4	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	15.85	0.18	3.23	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.4
H3962_803_0	2007	4																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	213.92	2.36	16.36	5.89	6.76	22.54	0	4.4	35.6	13.49	29.02	0	0	38.59	29.42	39.57	1.84	12.58	0	147.15	8.78	21.9	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54
H3962_804_0	2007	2																					none											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	213.92	2.36	16.36	5.89	6.76	22.54	0	4.4	35.6	13.49	29.02	0	0	38.59	29.42	39.57	1.84	12.58	0	147.15	8.78	21.9	0	0	0	0	0	0	0	0	0											Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing	Consistent with Medicare Cost Sharing																				0.07	0.07	0.2	0	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0											15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54	none	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA	NA											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	15.97	0.18	3.25	-	1.6	5.32	-	1.04	8.4	3.18	6.85	-	-	9.11	6.94	9.34	0.44	2.97	-	34.73	2.07	5.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.54
H3964_001_0	2007	3																																BP	BP	Ded	Ded	T	P	P	V	P	P	P	V	P	O	V	V	V	V	V	V	O	O	T	V	V	P	V	P	O	O	O																																																				-		416.2	6.17	99.72	2625.73	365.1	654.09	274.65	447.78	148.16	6435.66	1486.02	30.73	9.88	1377.37	5742.32	11706.35	118.43	366.2	2657.17	34.19	955.22	0	124.64	273.98	202.53	409	0	6.62	0	13.24	3.31											150 per day for days 1-5	150 per day for days 1-5	0	0	0	0	0	50 per visit	150 per procedure	0	0	0	0	0	0	40 per visit	20 per visit	10 per visit	0	0	0	0	0	0	0	0	40 per visit	0	0	0	0											574	666	0	0	0	0	0	50	150	0	0	0	0	0	0	40	20	10	0	0	0	0	0	0	0	0	40	0	0	0	0											19.91	0.34	-	-	-	-	-	1.87	1.85	-	-	-	-	-	-	39.02	0.2	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.49			19.91	0.34	-	-	-	-	-	1.87	1.85	-	-	-	-	-	-	39.02	0.2	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.49																																																																																				-			19.91	0.34	-	-	-	-	-	1.87	1.85	-	-	-	-	-	-	39.02	0.2	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.49
H3964_002_0	2007	5																																BP	BP	Ded	Ded	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	P	V	P	O	O	O																																																				-		277.36	11.35	40.11	28.71	11.24	13.76	4.45	649.09	21.04	5.12	38.84	6.39	0.01	16.71	42.73	149.96	3.23	5.1	15.5	0.46	50.48	0	5.31	12.31	1.02	1.24	0	1.48	0	0.02	10.7											500 deductible per year	500 deductible per year	0	0	20 Coinsurance	20 Coinsurance	20 Coinsurance	50 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0 Coinsurance	20 Coinsurance	50 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	20 Coinsurance	0	0	0	0	0	0	0	0	0											500	500	0	0	0.2	0.2	0.2	50	0.2	0.2	0.2	0.2	0.2	0.2	0	0.2	0.5	0.2	0.2	0.2	0	0.2	0	0	0	0	0	0	0	0	0											11.56	0.47	-	-	2.25	2.75	0.89	2.7	4.21	1.02	7.77	1.28	0	3.34	-	29.99	1.61	1.02	3.1	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.06			11.56	0.47	-	-	2.25	2.75	0.89	2.7	4.21	1.02	7.77	1.28	0	3.34	-	29.99	1.61	1.02	3.1	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.06																																																																																				-			11.56	0.47	-	-	2.25	2.75	0.89	2.7	4.21	1.02	7.77	1.28	0	3.34	-	29.99	1.61	1.02	3.1	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.06
H3964_003_0	2007	4																																BP	BP	Ded	Ded	T	P	P	V	P	P	P	V	P	O	V	V	V	V	V	V	O	O	T	V	V	P	V	P	O	O	O																																																				-		416.2	6.17	99.72	2625.73	365.1	654.09	274.65	447.78	148.16	6435.66	1486.02	30.73	9.88	1377.37	5742.32	11706.35	118.43	366.2	2657.17	34.19	955.22	0	124.64	273.98	202.53	409	0	6.62	0	13.24	3.31											150 per day for days 1-5	150 per day for days 1-5	0	0	0	0	0	50 per visit	150 per procedure	0	0	0	0	0	0	40 per visit	20 per visit	10 per visit	0	0	0	0	0	0	0	0	40 per visit	0	0	0	0											574	666	0	0	0	0	0	50	150	0	0	0	0	0	0	40	20	10	0	0	0	0	0	0	0	0	40	0	0	0	0											19.91	0.34	-	-	-	-	-	1.87	1.85	-	-	-	-	-	-	39.02	0.2	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.49			19.91	0.34	-	-	-	-	-	1.87	1.85	-	-	-	-	-	-	39.02	0.2	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.49																																																																																				-			19.91	0.34	-	-	-	-	-	1.87	1.85	-	-	-	-	-	-	39.02	0.2	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.49
H4003_001_0	2007	5																					0											D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-	0						1477.95	514.12	414.53																2519.59																		0 Day	0 Day	0 Day	0 Visit	0 Trip	15 Proc or 20	15 Proc or 20	25 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Script	0 Visit	0 Visit	3 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit																14.09	14	25																3																		-	-	-	-	-	1.73	0.6	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.83		0	-	-	-	-	-	1.73	0.6	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.83																																																																																				-			-	-	-	-	-	1.73	0.6	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.83
H4003_008_0	2007	1																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	V	V	V	V	V	V	V	V	V																																																				-							1970.6	685.49	414.53																2519.59																		0 Day	0 Day	0 Day	0 Visit	0 Trip	15 Proc or 20	15 Proc or 20	25 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Script	0 Visit	0 Visit	3 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit																10.56	10.5	25																3																		-	-	-	-	-	1.73	0.6	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.83			-	-	-	-	-	1.73	0.6	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.83																																																																																				-			-	-	-	-	-	1.73	0.6	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.83
H4003_009_0	2007	5																					0											D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	V	V																																																				-	0						1825.97	636.13	476.9																3151.85																		0 Day	0 Day	0 Day	0 Visit	0 Trip	15 Proc or 20	15 Proc or 20	25 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Script	0 Visit	0 Trip	3 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit																14.08	14	25																3																		-	-	-	-	-	2.14	0.74	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.79	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.67			-	-	-	-	-	2.14	0.74	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.79	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.67																																																																																				-			-	-	-	-	-	2.14	0.74	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.79	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.67
H4003_010_0	2007	7																					0											A	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	V	V																																																				-	0	2263.79				0.21	2469.56	843.71	616.02	119.75	355.89	568.63			110.01	7568.47	5738.22	0.22	859.19				487.51		3326.08	257.6						3.03											25 Admit	0 Day	0 Day	0 Visit	25 Trip	3 Proc	3 Proc	25 ER/15 UR Visit	15 Visit	3 Visit	3 Visit 2 Mammography	0 Visit	0 Visit	3 Cardiology 5 Clinic Visit	2 PCP Visit 5 Bone Mass Screening'	5 Visit	5 Visit	2 Visit	0 Visit	0 Visit	0 Script	5 Visit	0 Trip	3 Visit	3 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	5 Visit											3.51				25	3	3	24.99	15	3	2.83			4.57	2.04	5	5	2				5		3	3						5											0.66	-	-	-	0	0.62	0.21	1.28	0.15	0.09	0.13	-	-	0.04	1.29	2.39	0	0.14	-	-	-	0.2	-	0.83	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.11		0	0.66	-	-	-	0	0.62	0.21	1.28	0.15	0.09	0.13	-	-	0.04	1.29	2.39	0	0.14	-	-	-	0.2	-	0.83	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.11																																																																																				-			0.66	-	-	-	0	0.62	0.21	1.28	0.15	0.09	0.13	-	-	0.04	1.29	2.39	0	0.14	-	-	-	0.2	-	0.83	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.11
H4003_013_0	2007	7																					0											A	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	V	V	V																																																				-	0	2263.79				0.21	2469.56	843.71	616.02	119.75	355.89	568.63			110.01	7568.47	5738.22	0.22	859.19				487.51		3326.08	257.6						3.03											25 Admit	0 Day	0 Day	0 Visit	25 Trip	3 Proc	3 Proc	25 ER/15 UR Visit	15 Visit	3 Visit	3 Visit 2 Mammography	0 Visit	0 Visit	3 Cardiology 5 Clinic Visit	2 PCP Visit 5 Bone Mass Screening'	5 Visit	5 Visit	2 Visit	0 Visit	0 Visit	0 Script	5 Visit	0 Trip	3 Visit	3 Visit	0 Visit	0 Visit	0 Visit	0 Visit	0 Visit	5 Visit											3.51				25	3	3	24.99	15	3	2.83			4.57	2.04	5	5	2				5		3	3						5											0.66	-	-	-	0	0.62	0.21	1.28	0.15	0.09	0.13	-	-	0.04	1.29	2.39	0	0.14	-	-	-	0.2	-	0.83	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.11		0	0.66	-	-	-	0	0.62	0.21	1.28	0.15	0.09	0.13	-	-	0.04	1.29	2.39	0	0.14	-	-	-	0.2	-	0.83	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.11																																																																																				-			0.66	-	-	-	0	0.62	0.21	1.28	0.15	0.09	0.13	-	-	0.04	1.29	2.39	0	0.14	-	-	-	0.2	-	0.83	0.06	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.11
H4003_801_0	2007	5																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-	0	102.53		3.86		3.12	28.32	8	6.59	10.21	1.97	6.89	0.14		5.2	69.41	174.64	6.19	8.24				7.78																				FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins																				0.16		0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24				0.24																				16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93	138		16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93																																																																																				-			16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93
H4003_802_0	2007	5																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-	0	102.53		3.86		3.12	28.32	8	6.59	10.21	1.97	6.89	0.14		5.2	69.41	174.64	6.19	8.24				7.78																				FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins																				0.16		0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24				0.24																				16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93	138		16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93																																																																																				-			16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93
H4003_803_0	2007	7																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-	0	102.53		3.86		3.12	28.32	8	6.59	10.21	1.97	6.89	0.14		5.2	69.41	174.64	6.19	8.24				7.78																				FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins																				0.16		0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24				0.24																				16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93	138		16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93																																																																																				-			16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93
H4003_804_0	2007	7																					0											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-	0	102.53		3.86		3.12	28.32	8	6.59	10.21	1.97	6.89	0.14		5.2	69.41	174.64	6.19	8.24				7.78																				FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins	FFS Medicare Ded & Coins																				0.16		0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24				0.24																				16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93	138		16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93																																																																																				-			16.87	-	0.6	-	0.74	6.68	1.89	1.56	2.41	0.47	1.63	0.03	-	1.23	16.38	41.21	1.46	1.94	-	-	-	1.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.93
H4004_001_0	2007	4																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4004_015_0	2007	6																																							V									V														coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	289	0	0	0	0	0	0	0	0	625.9	0	0	0	0	0	0	0	0	0	0	0	0	0	4.75											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0	0	0	0	0	0	0	21.81	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0.11											-	-	-	-	-	-	-	0.53	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	1.55	0	0	-	-	-	-	-	-	-	0.53	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	1.55																																																																																				-	0	0	-	-	-	-	-	-	-	0.53	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	1.55
H4004_017_0	2007	7																																																														coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	9.71											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0.05											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	0.5	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	0.5																																																																																				-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	0.5
H4004_021_0	2007	4																																coin	coin			coin	coin	coin	v	coin		coin		coin	coin	coin	coin	coin	coin	coin	coin	coin	coin			coin		coin															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		125.53	10.89	0	0	10.63	17.72	1.1	418.5	5.31	0	7.6	0	9.03	7.93	36.22	37.46	6.26	4.57	15.14	73.4	15.68	2.15	0	0	2.62	0	0.48	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0.01	0.01	0	0	0.2	0.2	0.2	23.13	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.14	0.2	0.17	0.09	0.2	0.16	0	0	0.2	0	0.2	0	0	0	0											1.25	0.11	-	-	2.13	3.54	0.22	0.81	1.06	-	1.52	-	1.81	1.59	7.05	7.49	0.87	0.91	2.53	6.3	3.14	0.35	-	-	0.52	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.29	0	0	1.25	0.11	-	-	2.13	3.54	0.22	0.81	1.06	-	1.52	-	1.81	1.59	7.05	7.49	0.87	0.91	2.53	6.3	3.14	0.35	-	-	0.52	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.29																																																																																				-			1.25	0.11	-	-	2.13	3.54	0.22	0.81	1.06	-	1.52	-	1.81	1.59	7.05	7.49	0.87	0.91	2.53	6.3	3.14	0.35	-	-	0.52	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.29
H4004_024_0	2007	6																																coin	coin						V									V														coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		104.33	5.72	0	0	0	0	0	344	0	0	0	0	0	0	0	0	702.45	0	0	0	0	0	0	0	0	0	0	0	0	0	4.79											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0.01	0.01	0	0	0	0	0	22.24	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0.1											1.04	0.06	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	2.82	0	0	1.04	0.06	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	2.82																																																																																				-	0	0	1.04	0.06	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	2.82
H4004_025_0	2007	4																																							V									V														coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	289	0	0	0	0	0	0	0	0	625.9	0	0	0	0	0	0	0	0	0	0	0	0	0	6.42											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0	0	0	0	0	0	0	21.81	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0.08											-	-	-	-	-	-	-	0.53	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	1.55	0	0	-	-	-	-	-	-	-	0.53	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	1.55																																																																																				-	0	0	-	-	-	-	-	-	-	0.53	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	0.5	-	-	-	-	-	-	-	-	-	-	1.55
H4004_029_0	2007	5																																				coin	coin	coin	V	coin		coin		coin	coin	coin	coin	coin	coin	coin	coin	coin	coin			coin		coin															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	12.15	20.25	1.25	469.69	6.37	0	9.12	0	10.84	9.51	38.46	40.24	6.24	4.56	13.23	76.65	15.63	2.18	0	0	2.84	0	0.52	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0	0	0	0	0.2	0.2	0.2	23.22	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.14	0.2	0.17	0.08	0.2	0.16	0	0	0.2	0	0.2	0	0	0	0											-	-	-	-	2.43	4.05	0.25	0.91	1.27	-	1.82	-	2.17	1.9	7.49	8.05	0.86	0.91	2.21	6.28	3.13	0.35	-	-	0.57	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.74	0	0	-	-	-	-	2.43	4.05	0.25	0.91	1.27	-	1.82	-	2.17	1.9	7.49	8.05	0.86	0.91	2.21	6.28	3.13	0.35	-	-	0.57	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.74																																																																																				-			-	-	-	-	2.43	4.05	0.25	0.91	1.27	-	1.82	-	2.17	1.9	7.49	8.05	0.86	0.91	2.21	6.28	3.13	0.35	-	-	0.57	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.74
H4004_030_0	2007	5																																D	D			T	O	O	V	P	V	V			O	V	V	V	V	V	P	S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		2995.8	590.54	0	0	461.91	1222.82	94.85	469.69	113.92	199.56	420.34	0	0	107.59	5050.78	5639.56	1026.56	668.77	374.64	2561.08	1799.69	0	0	0	447.59	0	191.82	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											25	25	0	0	25	3	3	24.11	15	3	3	0	0	2.59	2	4.78	5	2	3	3	5	0	0	0	3	0	3	0	0	0	0											6.24	1.23	-	-	0.96	0.31	0.02	0.94	0.14	0.05	0.11	-	-	0.02	0.84	2.25	0.43	0.11	0.09	0.64	0.75	-	-	-	0.11	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.3	0	0	6.24	1.23	-	-	0.96	0.31	0.02	0.94	0.14	0.05	0.11	-	-	0.02	0.84	2.25	0.43	0.11	0.09	0.64	0.75	-	-	-	0.11	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.3																																																																																				-			6.24	1.23	-	-	0.96	0.31	0.02	0.94	0.14	0.05	0.11	-	-	0.02	0.84	2.25	0.43	0.11	0.09	0.64	0.75	-	-	-	0.11	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.3
H4004_035_0	2007	5																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b	PBP 4a	PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-g 14i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d 14h	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a	PBP 1a 3 4a-b 5 6 7a-d 7f-7i 8a-b 9a-d 10a-b 11a-c 12 13a-b 14a-i 15											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4005_001_0	2007	3																																							V																							V																																																				-									341.03																							276.24																		25 copay for some services																							20 Coinsurance																		24.48																							135.75											-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	3.82			-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	3.82		Copay Per Admit	Copay Per Admit	coin	coin	coin	coin	coin	25 Copay  some Service	coin	coin	coin	coin	coin	coin/copay by service	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin															1.88	0.09	0.16	0.17	0.04	0.57	0.05	0.04	0.28	0	0.29	0	0.02	0.34	0	0	0.04	0	0.16	1.2	0.05	0	0	0.12	0.18	0.01	0.06															5.77			1.88	0.09	0.16	0.17	0.04	0.57	0.05	0.74	0.28	-	0.29	-	0.02	0.34	-	-	0.04	-	0.16	1.2	0.05	0	-	0.12	0.18	0.01	0.06	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	9.59
H4005_003_0	2007	5																																							V																							V																																																				-									341.03																							276.24																		25 copay for some services																							20 Coinsurance																		24.48																							135.75											-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	3.82			-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	3.82		Copay Per Admit	Copay Per Admit	coin	coin	coin	coin	coin	25 Copay  some Service	coin	coin	coin	coin	coin	coin/copay by service	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin															1.88	0.09	0.16	0.17	0.04	0.57	0.05	0.04	0.28	0	0.29	0	0.02	0.34	0	0	0.04	0	0.16	1.2	0.05	0	0	0.12	0.18	0.01	0.06															5.77			1.88	0.09	0.16	0.17	0.04	0.57	0.05	0.74	0.28	-	0.29	-	0.02	0.34	-	-	0.04	-	0.16	1.2	0.05	0	-	0.12	0.18	0.01	0.06	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	9.59
H4005_004_0	2007	5																																							V																																																																											-									341.03																																									25 copay for some services																																									24.48																																		-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7			-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7		Copay Per Admit	Copay Per Admit	coin	coin	coin	coin	coin	25 Copay  some Service	coin	coin	coin	coin	coin	coin/copay by service	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin															1.88	0.09	0.16	0.17	0.04	0.57	0.05	0.04	0.28	0	0.29	0	0.02	0.34	0	0	0.04	0	0.16	1.2	0.05	0	0	0.12	0	0.01	0.06															5.59			1.88	0.09	0.16	0.17	0.04	0.57	0.05	0.74	0.28	-	0.29	-	0.02	0.34	-	-	0.04	-	0.16	1.2	0.05	0	-	0.12	-	0.01	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.28
H4005_801_0	2007	2																																							V																							V																																																				-									345.61																							276.24																		25 copay for some services																							20 Coinsurance																		24.47																							135.75											-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	3.83			-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	3.83		Copay Per Admit	Copay Per Admit	coin	coin	coin	coin	coin	25 Copay  some Service	coin	coin	coin	coin	coin	coin/copay by service	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin															1.99	0.1	0.16	0.18	0.05	0.58	0.05	0.04	0.29	0	0.3	0	0.02	0.36	0	0	0.05	0	0.17	1.24	0.05	0	0	0.12	0.19	0.01	0.06															6.01			1.99	0.1	0.16	0.18	0.05	0.58	0.05	0.75	0.29	-	0.3	-	0.02	0.36	-	-	0.05	-	0.17	1.24	0.05	0	-	0.12	0.19	0.01	0.06	-	-	-	3.13	-	-	-	-	-	-	-	-	-	-	9.84
H4005_802_0	2007	3																																							V																																																																											-									354.11																																									25 copay for some services																																									24.44																																		-	-	-	-	-	-	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.72			-	-	-	-	-	-	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.72		Copay Per Admit	Copay Per Admit	coin	coin	coin	coin	coin	25 Copay  some Service	coin	coin	coin	coin	coin	coin/copay by service	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin															2.2	0.11	0.17	0.18	0.05	0.58	0.05	0.05	0.31	0	0.32	0	0.02	0.38	0	0	0.05	0	0.18	1.31	0.05	0	0	0.14	0.2	0.01	0.07															6.44			2.2	0.11	0.17	0.18	0.05	0.58	0.05	0.77	0.31	-	0.32	-	0.02	0.38	-	-	0.05	-	0.18	1.31	0.05	0	-	0.14	0.2	0.01	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.17
H4005_804_0	2007	3																																							V																																																																											-									354.11																																									25 copay for some services																																									24.44																																		-	-	-	-	-	-	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.72			-	-	-	-	-	-	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.72		Copay Per Admit	Copay Per Admit	coin	coin	coin	coin	coin	25 Copay  some Service	coin	coin	coin	coin	coin	coin/copay by service	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin															2.2	0.11	0.17	0.18	0.05	0.58	0.05	0.05	0.31	0	0.32	0	0.02	0.38	0	0	0.05	0	0.18	1.31	0.05	0	0	0.14	0.2	0.01	0.07															6.44			2.2	0.11	0.17	0.18	0.05	0.58	0.05	0.77	0.31	-	0.32	-	0.02	0.38	-	-	0.05	-	0.18	1.31	0.05	0	-	0.14	0.2	0.01	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.17
H4006_001_0	2007	5																					3100																		P									P							Coin																									0									0							0																		-									520.22									371.8							5.08																									Emerg. 25 - Urg. 5									10							25																									23.48									10							0.25																		-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	1.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.6			-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	1.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.6																																																																																				-			-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	1.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.6
H4006_007_0	2007	8																					3100																		P									P																																0									0																									-									520.22									371.8																																Emerg. 25 - Urg. 5									10																																23.48									10																									-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.33			-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.33																																																																																				-			-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.33
H4006_008_0	2007	9																					3100																		P									P							Coin					Coin																				0									0							0					0													-									520.22									371.8							5.08					8.62																				Emerg. 25 - Urg. 5									10							0.25					20																				23.48									10							0.25					0.2													-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	1.27	-	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	-	-	4.32			-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	1.27	-	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	-	-	4.32																																																																																				-			-	-	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	0.31	-	-	-	-	-	-	1.27	-	-	-	-	1.72	-	-	-	-	-	-	-	-	-	-	-	-	4.32
H4006_009_0	2007	7																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4006_013_0	2007	7																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4006_014_0	2007	6																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4006_015_0	2007	5																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4006_018_0	2007	6																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4006_803_0	2007	3																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_804_0	2007	3																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_805_0	2007	3																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_806_0	2007	5																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_807_0	2007	4																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_808_0	2007	4																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_809_0	2007	4																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_811_0	2007	4																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4006_813_0	2007	7																																Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin																					0		0		0	0		0	0					0	0						0																					-		131.14		0.61		2.07	11.64		8.01	10.71					8.67	206.58						6.89																					Medicare Cost Sharing		Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing					Medicare Cost Sharing	Medicare Cost Sharing						Medicare Cost Sharing																					0.16		0.16		0.24	0.24		0.24	0.24					0.24	0.24						0.24																					21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76																																																																																				-			21.59	-	0.1	-	0.49	2.75	-	1.89	2.53	-	-	-	-	2.05	48.75	-	-	-	-	-	1.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76
H4007_002_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	A	V	T	P	P	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		A	A	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0	0								-		220.73	2.86	37.97	3775.36	191.08	387.78	29.19	190.63	172.16	275.02	187.51	12.5	69.55	106.26	4284.78	3280.1			151.36		2.97			10	0		0					11.62	0.15	6314.59								50/admit	50/admit		0/Visit	0/ Trip	0/ Procedure	0/ Procedure	10-25/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0 Coins			0 - 0	0		0					50/admit	50/admit	0/Procedure								50	50	0	0	0	0	0	22	0	0	0	0	0	0	0	0			0		0			0	0		0					50	50	0								0.92	0.01	-	-	-	-	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.05	0	-	-	-	-	-	-	-	-	1.33	0	0	0.92	0.01	-	-	-	-	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.05	0	-	-	-	-	-	-	-	-	1.33																																																																																				-			0.92	0.01	-	-	-	-	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.05	0	-	-	-	-	-	-	-	-	1.33
H4007_005_0	2007	4																																																				Coin			Coin	Coin		Coin																																			0			0	0		0															-																						3.87			0	0		0																																			0 Coins			0 - 0	0		0																																			0			0	0		0															-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4007_008_0	2007	4																																																				Coin			Coin	Coin		Coin																																			0			0	0		0															-																						3.87			0	0		0																																			0 Coins			0	0		0																																			0			0	0		0															-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4007_801_0	2007	5	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1091.87	17.16	1060.56	3937.27	199.28	0.33	0.02	194.83	179.54	286.81	45.63	13.04	72.53	110.81	4468.54	3420.78			157.85		3.24											57.47	0.9									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									18.57	0.29	0.97	-	1.66	0.07	0	0.77	2.99	2.04	0.31	0.11	-	0.43	7.45	9.98	-	-	1.97	-	0.65	-	-	-	-	-	-	-	-	-	-	0.98	0.02	-	-	-	-	-	-	-	-	49.24	0	0	18.57	0.29	0.97	-	1.66	0.07	0	0.77	2.99	2.04	0.31	0.11	-	0.43	7.45	9.98	-	-	1.97	-	0.65	-	-	-	-	-	-	-	-	-	-	0.98	0.02	-	-	-	-	-	-	-	-	49.24																																																																																				-			18.57	0.29	0.97	-	1.66	0.07	0	0.77	2.99	2.04	0.31	0.11	-	0.43	7.45	9.98	-	-	1.97	-	0.65	-	-	-	-	-	-	-	-	-	-	0.98	0.02	-	-	-	-	-	-	-	-	49.24
H4007_802_0	2007	5	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1075.37	16.9	1044.53	3877.77	196.26	0.32	0.02	191.88	176.83	282.48	44.94	12.84	71.43	109.14	4401.01	3369.08			155.46		3.14											56.6	0.89									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									18.29	0.29	0.96	-	1.64	0.06	0	0.76	2.95	2.01	0.3	0.11	-	0.42	7.34	9.83	-	-	1.94	-	0.63	-	-	-	-	-	-	-	-	-	-	0.96	0.02	-	-	-	-	-	-	-	-	48.49	0	0	18.29	0.29	0.96	-	1.64	0.06	0	0.76	2.95	2.01	0.3	0.11	-	0.42	7.34	9.83	-	-	1.94	-	0.63	-	-	-	-	-	-	-	-	-	-	0.96	0.02	-	-	-	-	-	-	-	-	48.49																																																																																				-			18.29	0.29	0.96	-	1.64	0.06	0	0.76	2.95	2.01	0.3	0.11	-	0.42	7.34	9.83	-	-	1.94	-	0.63	-	-	-	-	-	-	-	-	-	-	0.96	0.02	-	-	-	-	-	-	-	-	48.49
H4007_803_0	2007	5	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1091.87	17.16	1060.56	3937.27	199.28	0.33	0.02	194.83	179.54	286.81	45.63	13.04	72.53	110.81	4468.54	3420.78			157.85		3.24											57.47	0.9									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									18.57	0.29	0.97	-	1.66	0.07	0	0.77	2.99	2.04	0.31	0.11	-	0.43	7.45	9.98	-	-	1.97	-	0.65	-	-	-	-	-	-	-	-	-	-	0.98	0.02	-	-	-	-	-	-	-	-	49.24	0	0	18.57	0.29	0.97	-	1.66	0.07	0	0.77	2.99	2.04	0.31	0.11	-	0.43	7.45	9.98	-	-	1.97	-	0.65	-	-	-	-	-	-	-	-	-	-	0.98	0.02	-	-	-	-	-	-	-	-	49.24																																																																																				-			18.57	0.29	0.97	-	1.66	0.07	0	0.77	2.99	2.04	0.31	0.11	-	0.43	7.45	9.98	-	-	1.97	-	0.65	-	-	-	-	-	-	-	-	-	-	0.98	0.02	-	-	-	-	-	-	-	-	49.24
H4007_804_0	2007	5	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1075.37	16.9	1044.53	3877.77	196.26	0.32	0.02	191.88	176.83	282.48	44.94	12.84	71.43	109.14	4401.01	3369.08			155.46		3.14											56.6	0.89									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									18.29	0.29	0.96	-	1.64	0.06	0	0.76	2.95	2.01	0.3	0.11	-	0.42	7.34	9.83	-	-	1.94	-	0.63	-	-	-	-	-	-	-	-	-	-	0.96	0.02	-	-	-	-	-	-	-	-	48.49	0	0	18.29	0.29	0.96	-	1.64	0.06	0	0.76	2.95	2.01	0.3	0.11	-	0.42	7.34	9.83	-	-	1.94	-	0.63	-	-	-	-	-	-	-	-	-	-	0.96	0.02	-	-	-	-	-	-	-	-	48.49																																																																																				-			18.29	0.29	0.96	-	1.64	0.06	0	0.76	2.95	2.01	0.3	0.11	-	0.42	7.34	9.83	-	-	1.94	-	0.63	-	-	-	-	-	-	-	-	-	-	0.96	0.02	-	-	-	-	-	-	-	-	48.49
H4008_001_0	2007	8	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A		V	T	P	P	V	V	V	V	V	P	V	V	V			V		Coin									Coin		A	A	Coin								0	0		0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		190.04	5.82		1966.77	109.78	27.53	2.07	213.05	404.76	1093.87	745.82	49.72	909.38	422.63	6387.4	5134.17			230.52		5.07											10	0.31	8.27								100/admit	100/admit		0/Visit	15/ Trip	0/ Procedure	0/ Procedure	0-35/ Visit	0-10/ Visit	0-10/ Visit	0-10/ Visit	10/ Visit	0/ Procedure	0-10/ Visit	0/ Visit	10/ Visit			0/ Visit		0 Coins											100/admit	100/admit	20 Coins								100	100		0	15	0	0	28	3.3	7.73	1	10	0	10	0	10			0		0											100	100	0.2								1.58	0.05	-	-	0.14	-	-	0.5	0.11	0.7	0.06	0.04	-	0.35	-	4.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	0	1.65	-	-	-	-	-	-	-	9.56	0	0	1.58	0.05	-	-	0.14	-	-	0.5	0.11	0.7	0.06	0.04	-	0.35	-	4.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	0	1.65	-	-	-	-	-	-	-	9.56																																																																																				-		0	1.58	0.05	-	-	0.14	-	-	0.5	0.11	0.7	0.06	0.04	-	0.35	-	4.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	0	1.65	-	-	-	-	-	-	-	9.56
H4008_801_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		997.05	38.07	559.83	2082.26	116.22	0.43	0.03	184.96	428.53	263.21	789.62	52.64	962.78	447.45	6762.49	5435.67			244.06		5.69											52.48	2	9.26								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								16.95	0.65	0.82	-	0.97	0.11	0.01	0.76	3.55	1.1	3.84	0.44	-	1.67	11.27	13.59	-	-	1.02	-	1.14	-	-	-	-	-	-	-	-	-	-	0.89	0.03	1.85	-	-	-	-	-	-	-	60.66	0	0	16.95	0.65	0.82	-	0.97	0.11	0.01	0.76	3.55	1.1	3.84	0.44	-	1.67	11.27	13.59	-	-	1.02	-	1.14	-	-	-	-	-	-	-	-	-	-	0.89	0.03	1.85	-	-	-	-	-	-	-	60.66																																																																																				-		0	16.95	0.65	0.82	-	0.97	0.11	0.01	0.76	3.55	1.1	3.84	0.44	-	1.67	11.27	13.59	-	-	1.02	-	1.14	-	-	-	-	-	-	-	-	-	-	0.89	0.03	1.85	-	-	-	-	-	-	-	60.66
H4008_802_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		981.99	37.5	551.37	2050.81	114.47	0.42	0.03	182.17	422.06	259.23	777.69	51.85	948.24	440.69	6660.34	5353.56			240.37		5.51											51.68	1.97	8.99								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								16.7	0.64	0.81	-	0.95	0.11	0.01	0.75	3.5	1.08	3.78	0.43	-	1.64	11.1	13.38	-	-	1	-	1.1	-	-	-	-	-	-	-	-	-	-	0.88	0.03	1.8	-	-	-	-	-	-	-	59.7	0	0	16.7	0.64	0.81	-	0.95	0.11	0.01	0.75	3.5	1.08	3.78	0.43	-	1.64	11.1	13.38	-	-	1	-	1.1	-	-	-	-	-	-	-	-	-	-	0.88	0.03	1.8	-	-	-	-	-	-	-	59.7																																																																																				-		0	16.7	0.64	0.81	-	0.95	0.11	0.01	0.75	3.5	1.08	3.78	0.43	-	1.64	11.1	13.38	-	-	1	-	1.1	-	-	-	-	-	-	-	-	-	-	0.88	0.03	1.8	-	-	-	-	-	-	-	59.7
H4008_803_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		997.05	38.07	559.83	2082.26	116.22	0.43	0.03	184.96	428.53	263.21	789.62	52.64	962.78	447.45	6762.49	5435.67			244.06		5.69											52.48	2	9.26								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								16.95	0.65	0.82	-	0.97	0.11	0.01	0.76	3.55	1.1	3.84	0.44	-	1.67	11.27	13.59	-	-	1.02	-	1.14	-	-	-	-	-	-	-	-	-	-	0.89	0.03	1.85	-	-	-	-	-	-	-	60.66	0	0	16.95	0.65	0.82	-	0.97	0.11	0.01	0.76	3.55	1.1	3.84	0.44	-	1.67	11.27	13.59	-	-	1.02	-	1.14	-	-	-	-	-	-	-	-	-	-	0.89	0.03	1.85	-	-	-	-	-	-	-	60.66																																																																																				-		0	16.95	0.65	0.82	-	0.97	0.11	0.01	0.76	3.55	1.1	3.84	0.44	-	1.67	11.27	13.59	-	-	1.02	-	1.14	-	-	-	-	-	-	-	-	-	-	0.89	0.03	1.85	-	-	-	-	-	-	-	60.66
H4008_804_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		981.99	37.5	551.37	2050.81	114.47	0.42	0.03	182.17	422.06	259.23	777.69	51.85	948.24	440.69	6660.34	5353.56			240.37		5.51											51.68	1.97	8.99								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								16.7	0.64	0.81	-	0.95	0.11	0.01	0.75	3.5	1.08	3.78	0.43	-	1.64	11.1	13.38	-	-	1	-	1.1	-	-	-	-	-	-	-	-	-	-	0.88	0.03	1.8	-	-	-	-	-	-	-	59.7	0	0	16.7	0.64	0.81	-	0.95	0.11	0.01	0.75	3.5	1.08	3.78	0.43	-	1.64	11.1	13.38	-	-	1	-	1.1	-	-	-	-	-	-	-	-	-	-	0.88	0.03	1.8	-	-	-	-	-	-	-	59.7																																																																																				-		0	16.7	0.64	0.81	-	0.95	0.11	0.01	0.75	3.5	1.08	3.78	0.43	-	1.64	11.1	13.38	-	-	1	-	1.1	-	-	-	-	-	-	-	-	-	-	0.88	0.03	1.8	-	-	-	-	-	-	-	59.7
H4009_001_0	2007	5																																D	D	D	V	T	O	O	V	V	V	P		Coin	P	P	P	V	V	P	P	Coin	V		V	P	P	P	P			O																																																				-		1148.92	19.08	644.17	1766.19	188.96	22552.9	22935.58	233.77	196.43	1660.86	704.46	0	0.36	448.36	8269.76	11745.14	183.03	552.5	3929.91	14314.65	2.47	1018.52	0	3295	491.42	328.32	210.8	21.6	0	0	357.66											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	15 copay	0 copay	0 copay	0 copay		20 coinsurance	Effective copay -- 0 or 20	0 copay	0 copay	10 copay	0 copay	0 copay	0 copay	20 coinsurance	Effective copay -- 0 or 20 coinsurance			0 copay	0 copay	0 copay	0 copay			0 copay											0	0	0	0	0	0	0	15	0	0	0	0	0.2	17.06	0	0	10	0	0	0	0.2	2.86	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.29	-	-	-	-	0.07	0.64	-	-	0.15	-	-	-	0.49	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.89			-	-	-	-	-	-	-	0.29	-	-	-	-	0.07	0.64	-	-	0.15	-	-	-	0.49	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.89																																																																																				-			-	-	-	-	-	-	-	0.29	-	-	-	-	0.07	0.64	-	-	0.15	-	-	-	0.49	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.89
H4009_002_0	2007	4																																A	A	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1153.25	19.11	650.03	1778.52	189.86	7.2	23036.33	228.49	198.02	1673.36	691.28	0	41.88	452.1	8300.52	11776.41	183.92	515.03	3953.53	14309.16	314.52	1023.8	0	3038	493.81	330.36	211.83	21.74	0	0	349.49											0 or 50 per admit	0 or 50 per admit	0 per day	0 per visit	0 per trip	20 coinsurance	Effective copay: 0 or 20 coinsurance	25 copay	0 copay	Effective copay: 0 or 10 copay	10 copay or 20 coinsurance	0 copay	10 copay	0 copay	0 copay	0-15 copay	10 copay	10 copay	0 copay	0-5 copay	0 copay	0 copay		0 copay	0 copay	0 copay	0 copay	0 copay			0 copay											1.43	1.43	0	0	0	0.2	0.3	25	0	2.25	16.84	0	10	0	0.1	0.21	10	10	0	0.25	0	0	0	0	0	0	0	0	0	0	0											0.14	0	-	-	-	1.44	0.58	0.48	-	0.31	0.97	-	0.03	-	0.07	0.2	0.15	0.43	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.1			0.14	0	-	-	-	1.44	0.58	0.48	-	0.31	0.97	-	0.03	-	0.07	0.2	0.15	0.43	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.1																																																																																				-			0.14	0	-	-	-	1.44	0.58	0.48	-	0.31	0.97	-	0.03	-	0.07	0.2	0.15	0.43	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.1
H4009_003_0	2007	9																																A	A	D	V	Coin	Coin	Coin	V	Coin	V	P	P	Coin	Coin	P	P	Coin	Coin	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1072.53	16.45	694.56	1804.48	4.11	6.79	8.62	236.48	10.23	1655.67	681.58	0	0.38	8.99	8754.47	12068.47	1.26	3.65	24.04	12923.57	330.69	989.84	0	3038	473.29	328.47	203.02	21.82	0	0	334.23											35 or 75 per day; days 1-7	35 or 75 per day; days 1-7	10 copay per day for days 8+	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	25 copay	20 coinsurance	effective copay: 10 or 20 coinsurance	effective copay: 10 or 20 coinsurance	0 copay	20 coinsurance	20 coinsurance	Effective copay: 10-20 20coinsurance	Effective copay: 10-20 20coinsurance	50 coinsurance	20 coinsurance	Effective copay: 0 or 10 or 20 coinsurance	Effective copay: 0 10 or 20 coinsurance	Effective copay: 0or 20coinsurance	Effective copay: 0or 20coinsurance	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Effective copay: 0-25											30.82	30.82	7.59	0	0.2	0.2	0.2	25	0.2	7.69	23.69	0	0.2	0.2	6.71	12.86	0.5	0.2	1299.23	4.01	18.95	3.12	0	0	0	0	0	0	0	0	0.08											2.75	0.04	0.44	-	0.82	1.36	1.72	0.49	2.05	1.06	1.35	-	0.08	1.8	4.9	12.93	0.63	0.73	2.6	4.32	0.52	0.26	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	40.85			2.75	0.04	0.44	-	0.82	1.36	1.72	0.49	2.05	1.06	1.35	-	0.08	1.8	4.9	12.93	0.63	0.73	2.6	4.32	0.52	0.26	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	40.85																																																																																				-			2.75	0.04	0.44	-	0.82	1.36	1.72	0.49	2.05	1.06	1.35	-	0.08	1.8	4.9	12.93	0.63	0.73	2.6	4.32	0.52	0.26	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	40.85
H4009_004_0	2007	5																																A	A	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1146.89	18.88	654.55	1781.93	189.2	7.17	22938.45	229.34	198.91	1678.73	712.17	0	42.12	454.45	8281.24	11767.09	183.36	526.12	3952	14269.76	316.16	1021.39	0	3835	492.28	330.39	211.17	21.76	0	0	396.28											0 or 50 per admit	0 or 50 per admit	0 copay	0 copay	0 copay	20 coinsurance	Effective copay: 0 or 20 coinsurance	25 copay	0 copay	Effective copay: 0 or 10 copay	0 copay	0 copay	10 copay	0 copay	0 copay	0 copay	10 copay	5 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											1.43	1.43	0	0	0	0.2	0.3	25	0	2.26	0	0	10	0	0	0	10	5	0	0	0	0	0	0	0	0	0	0	0	0	0											0.14	0	-	-	-	1.43	0.57	0.48	-	0.32	-	-	0.04	-	-	-	0.15	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.35			0.14	0	-	-	-	1.43	0.57	0.48	-	0.32	-	-	0.04	-	-	-	0.15	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.35																																																																																				-			0.14	0	-	-	-	1.43	0.57	0.48	-	0.32	-	-	0.04	-	-	-	0.15	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.35
H4009_005_0	2007	5																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1098.87	20.21	481.33	1469.47	174.28	21145.2	21450.79	199.87	154.83	1345.73	569.23	0	31.81	348.33	7562.74	10594.76	167.57	522.19	3421.52	13936.81	242.22	920.39	0	4601.73	450.22	283.18	193.13	18.32	0	0	398.66											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Effective copay 0 or 20	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	10 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0.3	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.68			-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.68																																																																																				-			-	-	-	-	-	-	0.54	-	-	-	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.68
H4009_006_0	2007	2																																A	A	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1513.13	25.09	851.55	2331.27	249.02	9.44	30217.59	317.82	259.48	2193.09	930.24	0	54.87	592.39	10902.67	15493.2	259.42	727.78	5183.65	18846.55	412.11	1342.66	0	4601.73	647.66	445.66	277.82	31.15	0	0	201											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0-3 copay	5 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0-3 copay	0-3 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	1.82	5	0	0	0	0	0	0	0.02	0.04	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	4.58	0.13	-	-	-	-	-	-	0.02	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79			-	-	-	-	-	-	4.58	0.13	-	-	-	-	-	-	0.02	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79																																																																																				-			-	-	-	-	-	-	4.58	0.13	-	-	-	-	-	-	0.02	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.79
H4009_007_0	2007	1																																A	A	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1452.78	23.02	891.11	2358.44	242.66	28766.44	29284.69	306.7	267.17	2184.69	921.64	0	56.99	612.69	10342.55	14857.76	241.15	702.35	5003.7	17440.32	426.29	1318.71	0	4601.73	606.59	444.06	260.2	31.04	0	0	201											25 per admit	25 per admit	0 copay	0 copay	25 copay	Effective copay 20 coinsurance	Effective copay 0 - 3	25 copay	15 copay	3 copay	3 copay	0 copay	0 copay	Effective copay 0 - 15	Effective copay 0 - 15	Effective copay 0 - 15	5 copay	2 copay	Effective copay 0 - 2	Effective copay 0 - 5	0 copay	0 copay	0 copay	3 copay	3 copay	0 copay	3 copay	0 copay	0 copay	0 copay	0 copay											4.76	4.76	0	0	25	0.76	1.82	25	15	3	3	0	0	0.73	1.56	3.52	5	2	0.98	1.27	0	0	0	3	3	0	3	0	0	0	0											0.58	0.01	-	-	0.51	1.83	4.44	0.64	0.33	0.55	0.23	-	-	0.04	1.35	4.36	0.1	0.12	0.41	1.84	-	-	-	1.15	0.15	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.69			0.58	0.01	-	-	0.51	1.83	4.44	0.64	0.33	0.55	0.23	-	-	0.04	1.35	4.36	0.1	0.12	0.41	1.84	-	-	-	1.15	0.15	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.69																																																																																				-			0.58	0.01	-	-	0.51	1.83	4.44	0.64	0.33	0.55	0.23	-	-	0.04	1.35	4.36	0.1	0.12	0.41	1.84	-	-	-	1.15	0.15	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.69
H4011_001_0	2007	6																																							V																																		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	336.59	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7	0	0	-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.52	0	0.01	0.26	0.19	0.66	0.03	0.08	0.1	0.04	0.11	0	0	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	0	0	0.18	0.06	0	0.02	0	0	0	0											6.47	0	0	0.52	-	0.01	0.26	0.19	0.66	0.03	0.78	0.1	0.04	0.11	-	-	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	-	-	0.18	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.17
H4011_003_0	2007	6																																							V																																		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	336.59	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7	0	0	-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.52	0	0.01	0.26	0.19	0.66	0.03	0.08	0.1	0.04	0.11	0	0	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	0	0	0.43	0.06	0	0.02	0	0	0	0											6.72	0	0	0.52	-	0.01	0.26	0.19	0.66	0.03	0.78	0.1	0.04	0.11	-	-	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	-	-	0.43	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.42
H4011_004_0	2007	6																																							V																																		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	336.59	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7	0	0	-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.52	0	0.01	0.26	0.19	0.66	0.03	0.08	0.1	0.04	0.11	0	0	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	0	0	0.53	0.06	0	0.02	0	0	0	0											6.81	0	0	0.52	-	0.01	0.26	0.19	0.66	0.03	0.78	0.1	0.04	0.11	-	-	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	-	-	0.53	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.51
H4011_008_0	2007	6																																							V																																		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	336.59	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7	0	0	-	-	-	-	-	-	-	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.7		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.52	0	0.01	0.26	0.19	0.66	0.03	0.08	0.1	0.04	0.11	0	0	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	0	0	0.62	0.06	0	0.02	0	0	0	0											6.9	0	0	0.52	-	0.01	0.26	0.19	0.66	0.03	0.78	0.1	0.04	0.11	-	-	0.14	0.57	1.05	0.07	0.08	0.39	1.48	0.42	-	-	0.62	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.6
H4011_801_0	2007	8																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_802_0	2007	3																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_803_0	2007	3																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_804_0	2007	3																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_805_0	2007	8																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_806_0	2007	3																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_807_0	2007	3																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_808_0	2007	3																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_809_0	2007	10																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_810_0	2007	5																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_811_0	2007	5																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4011_812_0	2007	5																																Coin		Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		71.01	0	1.8	0	8.53	29.21	1.34	3.14	4.54	1.81	4.92	0	0	6.13	24.2	43.48	1.24	3.44	17.05	69.96	16.71	1.86	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0.16	0	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01	0	0	11.66	-	0.28	-	2.01	6.89	0.32	0.74	1.07	0.43	1.16	-	-	1.45	5.71	10.26	0.29	0.81	4.02	16.51	3.94	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.01		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												1.27	0	0.02	0	0.23	0.78	0.04	0.08	0.12	0.05	0.13	0	0	0.16	0.65	1.16	0.03	0.09	0.46	1.87	0.45	0.05	0	0	0	0	0	0	0	0	0											7.65	0	0	12.94	-	0.3	-	2.24	7.68	0.35	0.83	1.19	0.48	1.29	-	-	1.61	6.36	11.43	0.33	0.9	4.48	18.38	4.39	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.66
H4012_001_0	2007	6																																																																																																																		-						249.09	2447.5	1452.91	284.95												22784.16																										25 copay	3 Average Copay	3 Average Copay	25 copay												5 Average Copay																										25	1	1	25												0.03																						-	-	-	-	0.52	0.2	0.12	0.59	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.49			-	-	-	-	0.52	0.2	0.12	0.59	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.49																																																																																				-			-	-	-	-	0.52	0.2	0.12	0.59	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.49
H4012_003_0	2007	7																																																																																																																		-						272.99	2683.8	1593.2	311.73												24119.4																										25 copay	3 Average Copay	3 Average Copay	25 copay												5 Average Copay																										25	1	1	25												0.03																						-	-	-	-	0.57	0.22	0.13	0.65	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.63			-	-	-	-	0.57	0.22	0.13	0.65	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.63																																																																																				-			-	-	-	-	0.57	0.22	0.13	0.65	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.63
H4012_004_0	2007	7																																																																																																																		-						310.06	3050.48	1810.89	353.2												26186.05																										25 copay	3 Average Copay	3 Average Copay	25 copay												5 Average Copay																										25	1	1	25												0.02																						-	-	-	-	0.65	0.25	0.15	0.74	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.84			-	-	-	-	0.65	0.25	0.15	0.74	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.84																																																																																				-			-	-	-	-	0.65	0.25	0.15	0.74	-	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.84
H4102_001_0	2007	9																					3950											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2011.15	122.6	1583.51	0	372.64	11.94	5.78	689.44	25.39	11814.8	45.2	0	0.6	29.97	4094.8	5073.12	496.13	2.63	0	0	16.39	1507.71	0	0	89.47	0	206.59	0	0	0	0											250 (1a)	250 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	13 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											159.8	159.8	89.49	0	111.86	0.19	0.22	31.96	0.13	3.32	0.1	0	0.19	0.13	10	20	37.5	0.13	0	0	0.19	20	0	0	20	0	20	0	0	0	0											26.78	1.63	11.81	-	3.47	2.29	1.28	1.84	3.25	3.27	4.59	-	0.11	3.83	3.41	8.46	1.55	0.34	-	-	3.14	2.51	-	-	0.15	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.06		37.91	26.78	1.63	11.81	-	3.47	2.29	1.28	1.84	3.25	3.27	4.59	-	0.11	3.83	3.41	8.46	1.55	0.34	-	-	3.14	2.51	-	-	0.15	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.06																																																																																				-			26.78	1.63	11.81	-	3.47	2.29	1.28	1.84	3.25	3.27	4.59	-	0.11	3.83	3.41	8.46	1.55	0.34	-	-	3.14	2.51	-	-	0.15	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.06
H4102_025_0	2007	3																					3350											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1773.56	121.12	1055.67	0	262.75	11.18	4.34	707.59	31.1	11877.82	58.31	0	0.44	38.58	4334.33	5183.75	511.11	3.34	0	0	14.96	1569.79	0	0	105.95	0	212.38	0	0	0	0											250 (1a)	250 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											154.43	154.43	86.48	0	108.1	0.19	0.22	30.89	0.12	3.71	0.1	0	0.19	0.12	10	20	37.5	0.12	0	0	0.19	20	0	0	20	0	20	0	0	0	0											22.82	1.56	7.61	-	2.37	2.07	0.95	1.82	3.84	3.67	5.73	-	0.08	4.76	3.61	8.64	1.6	0.41	-	-	2.77	2.62	-	-	0.18	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.47		37.18	22.82	1.56	7.61	-	2.37	2.07	0.95	1.82	3.84	3.67	5.73	-	0.08	4.76	3.61	8.64	1.6	0.41	-	-	2.77	2.62	-	-	0.18	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.47																																																																																				-			22.82	1.56	7.61	-	2.37	2.07	0.95	1.82	3.84	3.67	5.73	-	0.08	4.76	3.61	8.64	1.6	0.41	-	-	2.77	2.62	-	-	0.18	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.47
H4102_801_0	2007	3																					4500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1712.48	119.39	1099.71	0	260.72	10.02	5.78	718	30.61	13634.65	56.42	0	0.37	40.41	4132.64	5620.34	510.15	4.63	0	0	26.62	1719.96	0	0	103.56	0	213.02	0	0	0	0											280 (1a)	280 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											187.81	187.81	93.9	0	117.38	0.2	0.22	33.54	0.13	4.02	0.11	0	0.2	0.13	25	35	37.5	0.13	0	0	0.2	35	0	0	35	0	35	0	0	0	0											26.8	1.87	8.61	-	2.55	2.02	1.3	2.01	4.11	4.57	6.02	-	0.07	5.42	8.61	16.39	1.59	0.62	-	-	5.36	5.02	-	-	0.3	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.85		34.81	26.8	1.87	8.61	-	2.55	2.02	1.3	2.01	4.11	4.57	6.02	-	0.07	5.42	8.61	16.39	1.59	0.62	-	-	5.36	5.02	-	-	0.3	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.85																																																																																				-			26.8	1.87	8.61	-	2.55	2.02	1.3	2.01	4.11	4.57	6.02	-	0.07	5.42	8.61	16.39	1.59	0.62	-	-	5.36	5.02	-	-	0.3	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.85
H4102_802_0	2007	2																					4500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1712.48	119.39	1099.71	0	260.72	10.02	5.78	718	30.61	13634.65	56.42	0	0.37	40.41	4132.64	5620.34	510.15	4.63	0	0	26.62	1719.96	0	0	103.56	0	213.02	0	0	0	0											280 (1a)	280 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											187.81	187.81	93.9	0	117.38	0.2	0.22	33.54	0.13	4.02	0.11	0	0.2	0.13	25	35	37.5	0.13	0	0	0.2	35	0	0	35	0	35	0	0	0	0											26.8	1.87	8.61	-	2.55	2.02	1.3	2.01	4.11	4.57	6.02	-	0.07	5.42	8.61	16.39	1.59	0.62	-	-	5.36	5.02	-	-	0.3	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.85		34.81	26.8	1.87	8.61	-	2.55	2.02	1.3	2.01	4.11	4.57	6.02	-	0.07	5.42	8.61	16.39	1.59	0.62	-	-	5.36	5.02	-	-	0.3	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.85																																																																																				-			26.8	1.87	8.61	-	2.55	2.02	1.3	2.01	4.11	4.57	6.02	-	0.07	5.42	8.61	16.39	1.59	0.62	-	-	5.36	5.02	-	-	0.3	-	0.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	103.85
H4106_001_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2469.1	354.45	1662.51		317	27.9	23.28	928.76	377	2223.9	925.83	66.2	3.13	2054.02		3502.75		509.24		807.26												326.26		143.63	243.89							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							7.13	1.02	2.3	-	0.91	2.58	2.15	1.29	0.36	0.86	0.36	0.06	0.29	1.98	-	1.35	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.09	-	-	-	-	-	-	23.41		27.29	7.13	1.02	2.3	-	0.91	2.58	2.15	1.29	0.36	0.86	0.36	0.06	0.29	1.98	-	1.35	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.09	-	-	-	-	-	-	23.41																																																																																				-		0	7.13	1.02	2.3	-	0.91	2.58	2.15	1.29	0.36	0.86	0.36	0.06	0.29	1.98	-	1.35	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.09	-	-	-	-	-	-	23.41
H4152_004_0	2007	6	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									D	D	D		T	Coin		V	P		O				V	V	V	V		V	Coin	V			V		V			O		V	V																																																		-		963.3	46.1	819.6		398	10.3		280	423		440				4189	5845	536	2108		13	4.45	77			260		121			540.4		207	471									300/day subject to 3000 OOP Max	300/day subject to 3000 OOP Max	100/day subject to 3000 OOP Max		100 copay	20 of average PMPM cost for non-capitated services		50 copay	175 copay		125 copay for MRI and CAT Scans				10 copay	25 copay	25 copay	15 copay		10 copay	20 coinsurance for non-cancer drugs	25 copay			25 copay		25 copay			15 monthly		35 copay	10 copay									300	300	100		100	0.2		50	175		125				10	25	25	15		10	0.09	25			25		25			15		35	10									24.08	1.15	6.83	-	3.32	2.06	-	1.17	6.17	-	4.58	-	-	-	3.49	12.18	1.12	2.64	-	0.01	0.42	0.16	-	-	0.54	-	0.25	-	-	0.68	-	0.6	0.39	-	-	-	-	-	-	-	-	71.84			24.08	1.15	6.83	-	3.32	2.06	-	1.17	6.17	-	4.58	-	-	-	3.49	12.18	1.12	2.64	-	0.01	0.42	0.16	-	-	0.54	-	0.25	-	-	0.68	-	0.6	0.39	-	-	-	-	-	-	-	-	71.84																																																																																				-			24.08	1.15	6.83	-	3.32	2.06	-	1.17	6.17	-	4.58	-	-	-	3.49	12.18	1.12	2.64	-	0.01	0.42	0.16	-	-	0.54	-	0.25	-	-	0.68	-	0.6	0.39	-	-	-	-	-	-	-	-	71.84
H4152_005_0	2007	6	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									D	D	D		T	Coin		V	P		O				V	V	V	V		V	Coin	V			V		V			O		V	V																																																		-		992.3	55.8	964.8		406	13.3		269	458		447				4236	6283	566	2436		13	3.35	90			264		139			540.4		201	442									200/day subject to 2000 OOP Max	200/day subject to 2000 OOP Max	75/day subject to 2000 OOP Max		100 copay	20 of average PMPM cost for non-capitated services		50 copay	125 copay		100 copay for MRI and CAT Scans				10 copay	25 copay	25 copay	15 copay		10 copay	20 coinsurance for non-cancer drugs	25 copay			25 copay		25 copay			15 monthly		35 copay	10 copay									200	200	75		100	0.2		50	125		100				10	25	25	15		10	0.09	25			25		25			15		35	10									16.54	0.93	6.03	-	3.38	2.66	-	1.12	4.77	-	3.73	-	-	-	3.53	13.09	1.18	3.05	-	0.01	0.31	0.19	-	-	0.55	-	0.29	-	-	0.68	-	0.59	0.37	-	-	-	-	-	-	-	-	62.98			16.54	0.93	6.03	-	3.38	2.66	-	1.12	4.77	-	3.73	-	-	-	3.53	13.09	1.18	3.05	-	0.01	0.31	0.19	-	-	0.55	-	0.29	-	-	0.68	-	0.59	0.37	-	-	-	-	-	-	-	-	62.98																																																																																				-			16.54	0.93	6.03	-	3.38	2.66	-	1.12	4.77	-	3.73	-	-	-	3.53	13.09	1.18	3.05	-	0.01	0.31	0.19	-	-	0.55	-	0.29	-	-	0.68	-	0.59	0.37	-	-	-	-	-	-	-	-	62.98
H4152_007_0	2007	9	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									D	D	D		T	Coin		V	P		O				V	V	V	V		V	Coin	V		Coin	V		V			O		V	V																																																		-	3000	882.8	49.6	859.2		463	13.3		307	523		510				4833	7169	646	2780		15	3.82	103		8.03	301		158			540.4		229	504									75/day subject to 750 OOP Max	75/day subject to 750 OOP Max	50/day subject to 750 OOP Max		75 copay	20 of average PMPM cost for non-capitated services		50 copay	75 copay		75 copay for MRI and CAT Scans				10 copay	25 copay	25 copay	15 copay		10 copay	20 coinsurance for non-cancer drugs	25 copay		20 coinsurance for restorative services	25 copay		25 copay			15 monthly		35 copay	10 copay									75	75	50		75	0.2		50	75		75				10	25	25	15		10	0.09	25		0.2	25		25			15		35	10									5.52	0.31	3.58	-	2.89	2.66	-	1.28	3.27	-	3.19	-	-	-	4.03	14.94	1.35	3.48	-	0.01	0.36	0.21	-	1.61	0.63	-	0.33	-	-	0.68	-	0.67	0.42	-	-	-	-	-	-	-	-	51.39			5.52	0.31	3.58	-	2.89	2.66	-	1.28	3.27	-	3.19	-	-	-	4.03	14.94	1.35	3.48	-	0.01	0.36	0.21	-	1.61	0.63	-	0.33	-	-	0.68	-	0.67	0.42	-	-	-	-	-	-	-	-	51.39		20 coinsurance		20 coinsurance		20 coinsurance	20 coinsurance			20 coinsurance					20 coinsurance	20 coinsurance							20 coinsurance																				1.82		0.35		0.18	0.07			0.21					0.44	1.28							0.03																				4.37		7.39	7.34	0.31	3.93	-	3.07	2.73	-	1.28	3.48	-	3.19	-	-	0.44	5.31	14.94	1.35	3.48	-	0.01	0.36	0.24	-	1.61	0.63	-	0.33	-	-	0.68	-	0.67	0.42	-	-	-	-	-	-	-	-	55.76
H4152_012_0	2007	7	f.2.	I.7.	i.7.								OP Facility - Emergency	Professional	Professional									Urgent Care	Routine Exams	Emergency Room Professional								D	D	D		T	Coin		V	Coin		Coin			Coin	V	V	V	Coin		V	Coin	V			V		V			O		V	V	Coin																																																	-		2612.5	373.5	2867.6		1272	20.39		556	25.8		64.43			59.78	3122	4515	1902	24.36		6	14.66	92			208		126			132		179	193	44.69								117 per day for days 1-30	117 per day for days 1-30	125 per day for days 21-100		75 copay	20 coinsurance of projected average cost		50 copay	20 coinsurance of projected average cost		20 coinsurance of projected average cost			20 coinsurance of projected average cost	10 copay	20 copay	25 copay	20 coinsurance of projected average cost		10 copay	20 coinsurance of projected average cost	20 copay			20 copay		20 copay			15 monthly		25 copay	10 copay	20 coinsurance of projected average cost								117	117	125		75	0.2		50	0.2		0.2			0.2	10	20	25	0.2		10	0.2	20			20		20			15		25	10	0.2								25.47	3.64	29.87	-	7.95	4.08	-	2.32	5.16	-	12.89	-	-	11.96	2.6	7.53	3.96	4.87	-	0.01	2.93	0.15	-	-	0.35	-	0.21	-	-	0.17	-	0.37	0.16	8.94	-	-	-	-	-	-	-	135.58			25.47	3.64	29.87	-	7.95	4.08	-	2.32	5.16	-	12.89	-	-	11.96	2.6	7.53	3.96	4.87	-	0.01	2.93	0.15	-	-	0.35	-	0.21	-	-	0.17	-	0.37	0.16	8.94	-	-	-	-	-	-	-	135.58																																																																																				-			25.47	3.64	29.87	-	7.95	4.08	-	2.32	5.16	-	12.89	-	-	11.96	2.6	7.53	3.96	4.87	-	0.01	2.93	0.15	-	-	0.35	-	0.21	-	-	0.17	-	0.37	0.16	8.94	-	-	-	-	-	-	-	135.58
H4152_013_0	2007	7	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									D	D	D		T	Coin		V	P		O				V	V	V	V		V	Coin	V			V		V			O		V	V																																																		-		938.3	44.8	796.7		371	10.3		261	394		409				3897	5436	499	1961		12	4.45	71			242		113			540.4		192	438									300/day subject to 3000 OOP Max	300/day subject to 3000 OOP Max	100/day subject to 3000 OOP Max		100 copay	20 of average PMPM cost for non-capitated services		50 copay	175 copay		125 copay for MRI and CAT Scans				10 copay	25 copay	25 copay	15 copay		10 copay	20 coinsurance for non-cancer drugs	25 copay			25 copay		25 copay			15 monthly		35 copay	10 copay									300	300	100		100	0.2		50	175		125				10	25	25	15		10	0.09	25			25		25			15		35	10									23.46	1.12	6.64	-	3.09	2.06	-	1.09	5.75	-	4.26	-	-	-	3.25	11.33	1.04	2.45	-	0.01	0.42	0.15	-	-	0.5	-	0.24	-	-	0.68	-	0.56	0.37	-	-	-	-	-	-	-	-	68.44			23.46	1.12	6.64	-	3.09	2.06	-	1.09	5.75	-	4.26	-	-	-	3.25	11.33	1.04	2.45	-	0.01	0.42	0.15	-	-	0.5	-	0.24	-	-	0.68	-	0.56	0.37	-	-	-	-	-	-	-	-	68.44																																																																																				-			23.46	1.12	6.64	-	3.09	2.06	-	1.09	5.75	-	4.26	-	-	-	3.25	11.33	1.04	2.45	-	0.01	0.42	0.15	-	-	0.5	-	0.24	-	-	0.68	-	0.56	0.37	-	-	-	-	-	-	-	-	68.44
H4152_815_0	2007	5	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									A	A	D		T			V	P		O				V	V	V	V		V	Coin	V		Coin	V		V			O		V	V																																																		-	3000	370.1	12	628.8		397			263							4143	6144	554	2407		13	3.82	88		8.03	258		136			540.4		196	432									100 per admission	100 per admission	50/day for days 30-100		50 copay			25 copay							7.92 copay	13.76 copay	13.76 copay	13.76 copay		7.92 copay	20 coinsurance for non-cancer drugs	13.76 copay		20 coinsurance for restorative services	13.76 copay		13.76 copay			10 monthly		13.76 copay	7.92 copay									100	100	50		50			25							7.92	13.76	13.76	13.76		7.92	0.09	13.76		0.2	13.76		13.76			10		13.76	7.92									3.08	0.1	2.62	-	1.65	-	-	0.55	-	-	-	-	-	-	2.73	7.05	0.64	2.76	-	0.01	0.36	0.1	-	1.61	0.3	-	0.16	-	-	0.45	-	0.22	0.29	-	-	-	-	-	-	-	-	24.67			3.08	0.1	2.62	-	1.65	-	-	0.55	-	-	-	-	-	-	2.73	7.05	0.64	2.76	-	0.01	0.36	0.1	-	1.61	0.3	-	0.16	-	-	0.45	-	0.22	0.29	-	-	-	-	-	-	-	-	24.67		20 coinsurance		20 coinsurance		20 coinsurance	20 coinsurance			20 coinsurance					20 coinsurance	20 coinsurance							20 coinsurance																				1.82		0.35		0.18	0.07			0.21					0.44	1.28							0.03																				4.37		7.39	4.9	0.1	2.97	-	1.83	0.07	-	0.55	0.21	-	-	-	-	0.44	4.01	7.05	0.64	2.76	-	0.01	0.36	0.13	-	1.61	0.3	-	0.16	-	-	0.45	-	0.22	0.29	-	-	-	-	-	-	-	-	29.04
H4152_817_0	2007	5	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									A	A	D		T			V	P		O				V	V	V	V		V	Coin	V			V		V			O		V	V																																																		-		337.7	10.8	542.4		365			242							3813	5655	510	2193		12	3.82	81			238		125			540.4		181	398									100 per admission	100 per admission	50/day for days 30-100		50 average copay of anticipated group enrollees			35 average copay of anticipated group enrollees							10 average copay of anticipated group enrollees	20 average copay of anticipated group enrollees	20 average copay of anticipated group enrollees	20 average copay of anticipated group enrollees		10 average copay of anticipated group enrollees	20 coinsurance for non-cancer drugs	20 average copay of anticipated group enrollees			20 average copay of anticipated group enrollees		20 average copay of anticipated group enrollees			10 monthly		20 average copay of anticipated group enrollees	10 average copay of anticipated group enrollees									100	100	50		50			35							10	20	20	20		10	0.09	20			20		20			10		20	10									2.81	0.09	2.26	-	1.52	-	-	0.71	-	-	-	-	-	-	3.18	9.43	0.85	3.66	-	0.01	0.36	0.14	-	-	0.4	-	0.21	-	-	0.45	-	0.3	0.33	-	-	-	-	-	-	-	-	26.69			2.81	0.09	2.26	-	1.52	-	-	0.71	-	-	-	-	-	-	3.18	9.43	0.85	3.66	-	0.01	0.36	0.14	-	-	0.4	-	0.21	-	-	0.45	-	0.3	0.33	-	-	-	-	-	-	-	-	26.69																																																																																				-			2.81	0.09	2.26	-	1.52	-	-	0.71	-	-	-	-	-	-	3.18	9.43	0.85	3.66	-	0.01	0.36	0.14	-	-	0.4	-	0.21	-	-	0.45	-	0.3	0.33	-	-	-	-	-	-	-	-	26.69
H4152_818_0	2007	3	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									D	D	D		T	Coin		V	P		O				V	V	V	V		V	Coin	V			V		V			O		V	V																																																		-		963.3	46.1	819.6		398	10.3		280	423		440				4189	5845	536	2108		13	4.45	77			260		121			540.4		207	471									300/day subject to 3000 OOP Max	300/day subject to 3000 OOP Max	100/day subject to 3000 OOP Max		100 copay	20 of average PMPM cost for non-capitated services		50 copay	175 copay		125 copay for MRI and CAT Scans				10 copay	25 copay	25 copay	15 copay		10 copay	20 coinsurance for non-cancer drugs	25 copay			25 copay		25 copay			15 monthly		35 copay	10 copay									300	300	100		100	0.2		50	175		125				10	25	25	15		10	0.09	25			25		25			15		35	10									24.08	1.15	6.83	-	3.32	2.06	-	1.17	6.17	-	4.58	-	-	-	3.49	12.18	1.12	2.64	-	0.01	0.42	0.16	-	-	0.54	-	0.25	-	-	0.68	-	0.6	0.39	-	-	-	-	-	-	-	-	71.84			24.08	1.15	6.83	-	3.32	2.06	-	1.17	6.17	-	4.58	-	-	-	3.49	12.18	1.12	2.64	-	0.01	0.42	0.16	-	-	0.54	-	0.25	-	-	0.68	-	0.6	0.39	-	-	-	-	-	-	-	-	71.84																																																																																				-			24.08	1.15	6.83	-	3.32	2.06	-	1.17	6.17	-	4.58	-	-	-	3.49	12.18	1.12	2.64	-	0.01	0.42	0.16	-	-	0.54	-	0.25	-	-	0.68	-	0.6	0.39	-	-	-	-	-	-	-	-	71.84
H4152_819_0	2007	5	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									A	A	D		T			V	P		O				V	V	V	V		V	Coin	V			V		V			O		V	V																																																		-		337.7	10.8	542.4		365			242							3813	5655	510	2193		12	3.82	81			238		125			540.4		181	398									100 per admission	100 per admission	50/day for days 30-100		50 average copay of anticipated group enrollees			35 average copay of anticipated group enrollees							10 average copay of anticipated group enrollees	20 average copay of anticipated group enrollees	20 average copay of anticipated group enrollees	20 average copay of anticipated group enrollees		10 average copay of anticipated group enrollees	20 coinsurance for non-cancer drugs	20 average copay of anticipated group enrollees			20 average copay of anticipated group enrollees		20 average copay of anticipated group enrollees			10 monthly		20 average copay of anticipated group enrollees	10 average copay of anticipated group enrollees									100	100	50		50			35							10	20	20	20		10	0.09	20			20		20			10		20	10									2.81	0.09	2.26	-	1.52	-	-	0.71	-	-	-	-	-	-	3.18	9.43	0.85	3.66	-	0.01	0.36	0.14	-	-	0.4	-	0.21	-	-	0.45	-	0.3	0.33	-	-	-	-	-	-	-	-	26.69			2.81	0.09	2.26	-	1.52	-	-	0.71	-	-	-	-	-	-	3.18	9.43	0.85	3.66	-	0.01	0.36	0.14	-	-	0.4	-	0.21	-	-	0.45	-	0.3	0.33	-	-	-	-	-	-	-	-	26.69																																																																																				-			2.81	0.09	2.26	-	1.52	-	-	0.71	-	-	-	-	-	-	3.18	9.43	0.85	3.66	-	0.01	0.36	0.14	-	-	0.4	-	0.21	-	-	0.45	-	0.3	0.33	-	-	-	-	-	-	-	-	26.69
H4152_820_0	2007	5	f.2.	I.7.									OP Facility - Emergency	Professional										Urgent Care	Routine Exams									A	A	D		T			V	P		O				V	V	V	V		V	Coin	V		Coin	V		V			O		V	V																																																		-	3000	370.1	12	628.8		397			263							4143	6144	554	2407		13	3.82	88		8.03	258		136			540.4		196	432									100 per admission	100 per admission	50/day for days 30-100		50 copay			25 copay							7.92 copay	13.76 copay	13.76 copay	13.76 copay		7.92 copay	20 coinsurance for non-cancer drugs	13.76 copay		20 coinsurance for restorative services	13.76 copay		13.76 copay			10 monthly		13.76 copay	7.92 copay									100	100	50		50			25							7.92	13.76	13.76	13.76		7.92	0.09	13.76		0.2	13.76		13.76			10		13.76	7.92									3.08	0.1	2.62	-	1.65	-	-	0.55	-	-	-	-	-	-	2.73	7.05	0.64	2.76	-	0.01	0.36	0.1	-	1.61	0.3	-	0.16	-	-	0.45	-	0.22	0.29	-	-	-	-	-	-	-	-	24.67			3.08	0.1	2.62	-	1.65	-	-	0.55	-	-	-	-	-	-	2.73	7.05	0.64	2.76	-	0.01	0.36	0.1	-	1.61	0.3	-	0.16	-	-	0.45	-	0.22	0.29	-	-	-	-	-	-	-	-	24.67		20 coinsurance		20 coinsurance		20 coinsurance	20 coinsurance			20 coinsurance					20 coinsurance	20 coinsurance							20 coinsurance																				1.82		0.35		0.18	0.07			0.21					0.44	1.28							0.03																				4.37		7.39	4.9	0.1	2.97	-	1.83	0.07	-	0.55	0.21	-	-	-	-	0.44	4.01	7.05	0.64	2.76	-	0.01	0.36	0.13	-	1.61	0.3	-	0.16	-	-	0.45	-	0.22	0.29	-	-	-	-	-	-	-	-	29.04
H4204_002_0	2007	2																					5000											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1239.85	17.93	1062.3	27.17	280.23	26.08	1.25	389.35	388.4	2495.98	1283.37	0	0.24	25.75	4207.74	6302.6	152.05	491.85	0	257.14	705.17	770.76	0	0	0	0	0	0	0	0	0											150 Per Day: 1-10	150 Per Day: 1-10	0 days 1-575 days 6-100	20 coins	50 per trip	30 DME 20 Diabetes Monitoring	30 Proshetics	50 ER / 30 UC	100 ASC / 100 OP	30 per visit	30 per visit	0	20 per	30 OP SA / 30 Cardiac Rehab	20 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/20 Blood		0	0		0				0											132.56	132.56	46.82	0.18	44.19	0.25	0.27	39.28	88.37	26.49	26.51	0	0.18	0.13	17.94	28.57	26.51	24.93	0	9.36	23.81	26.23	0	0	0	0	0	0	0	0	0											13.7	0.2	4.14	4.8	1.03	6.49	0.33	1.27	2.86	5.51	2.84	-	0.04	3.3	6.29	15.01	0.34	1.02	-	0.2	1.4	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.46	0	9.55	13.7	0.2	4.14	4.8	1.03	6.49	0.33	1.27	2.86	5.51	2.84	-	0.04	3.3	6.29	15.01	0.34	1.02	-	0.2	1.4	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.46	5000																																																																																			-			13.7	0.2	4.14	4.8	1.03	6.49	0.33	1.27	2.86	5.51	2.84	-	0.04	3.3	6.29	15.01	0.34	1.02	-	0.2	1.4	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.46
H4204_003_0	2007	2																					5000											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1370.23	20.09	845.61	31.03	304.82	28.66	1.37	415.73	414.56	2665.73	1370.2	0	0.25	27.35	4231.95	6484.53	159.43	515.72	0	259.11	752.82	779.53	0	0	0	0	0	0	0	0	0											150 Per Day: 1-10	150 Per Day: 1-10	0 days 1-575 days 6-100	20 coins	50 per trip	30 DME 20 Diabetes Monitoring	30 Proshetics	50 ER / 30 UC	100 ASC / 100 OP	30 per visit	30 per visit	0	20 per	30 OP SA / 30 Cardiac Rehab	20 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/20 Blood		0	0		0				0											131.13	131.12	46.31	0.17	43.71	0.25	0.26	38.82	87.42	26.2	26.22	0	0.17	0.13	17.78	28.44	26.22	25	0	9.24	23.55	25.93	0	0	0	0	0	0	0	0	0											14.97	0.22	3.26	5.42	1.11	7.05	0.36	1.34	3.02	5.82	2.99	-	0.04	3.48	6.27	15.37	0.35	1.07	-	0.2	1.48	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.53	0	10.89	14.97	0.22	3.26	5.42	1.11	7.05	0.36	1.34	3.02	5.82	2.99	-	0.04	3.48	6.27	15.37	0.35	1.07	-	0.2	1.48	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.53	5000																																																																																			-			14.97	0.22	3.26	5.42	1.11	7.05	0.36	1.34	3.02	5.82	2.99	-	0.04	3.48	6.27	15.37	0.35	1.07	-	0.2	1.48	1.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.53
H4204_007_0	2007	4																					5000											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1199.05	17.47	878.28	30.79	263.42	26.36	1.27	334.54	333.46	2147.52	1101.45	0	0.25	25.62	4308.85	6416.46	153.85	497.49	0	263.57	605.87	776.59	0	0	0	0	0	0	0	0	0											150 Per Day: 1-10	150 Per Day: 1-10	0 days 1-575 days 6-100	20 coins	50 per trip	30 DME 20 Diabetes Monitoring	30 Proshetics	50 ER / 30 UC	100 ASC / 100 OP	30 per visit	30 per visit	0	20 per	30 OP SA / 30 Cardiac Rehab	20 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/20 Blood		0	0		0				0											133.15	133.15	47.03	0.18	44.38	0.25	0.27	39.63	88.77	26.62	26.63	0	0.18	0.12	18.04	28.98	26.63	25.86	0	9.44	23.91	26.39	0	0	0	0	0	0	0	0	0											13.3	0.19	3.44	5.47	0.97	6.59	0.34	1.1	2.47	4.76	2.44	-	0.04	3.09	6.48	15.5	0.34	1.07	-	0.21	1.21	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.72	0	8.96	13.3	0.19	3.44	5.47	0.97	6.59	0.34	1.1	2.47	4.76	2.44	-	0.04	3.09	6.48	15.5	0.34	1.07	-	0.21	1.21	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.72	5000																																																																																			-			13.3	0.19	3.44	5.47	0.97	6.59	0.34	1.1	2.47	4.76	2.44	-	0.04	3.09	6.48	15.5	0.34	1.07	-	0.21	1.21	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.72
H4204_008_0	2007	3																					5000											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1201.02	17.7	879.3	31.28	270.27	28.03	1.35	324.05	323.11	2080.57	1067.07	0	0.24	26.34	4384.36	6462.04	152.34	492.47	0	267.81	587.07	787	0	0	0	0	0	0	0	0	0											150 Per Day: 1-10	150 Per Day: 1-10	0 days 1-575 days 6-100	20 coins	50 per trip	30 DME 20 Diabetes Monitoring	30 Proshetics	50 ER / 30 UC	100 ASC / 100 OP	30 per visit	30 per visit	0	20 per	30 OP SA / 30 Cardiac Rehab	20 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/20 Blood		0	0		0				0											133	133	46.97	0.18	44.33	0.25	0.27	39.64	88.66	26.59	26.6	0	0.18	0.12	18.01	28.95	26.6	25.83	0	9.44	23.89	26.37	0	0	0	0	0	0	0	0	0											13.31	0.2	3.44	5.55	1	7	0.36	1.07	2.39	4.61	2.37	-	0.04	3.09	6.58	15.59	0.34	1.06	-	0.21	1.17	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.1	0	9.1	13.31	0.2	3.44	5.55	1	7	0.36	1.07	2.39	4.61	2.37	-	0.04	3.09	6.58	15.59	0.34	1.06	-	0.21	1.17	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.1	5000																																																																																			-			13.31	0.2	3.44	5.55	1	7	0.36	1.07	2.39	4.61	2.37	-	0.04	3.09	6.58	15.59	0.34	1.06	-	0.21	1.17	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.1
H4204_020_0	2007	2																					5000											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1169.3	16.83	783.07	29.43	277.94	30.95	1.49	259.86	258.97	1668.42	854.56	0	0.27	28.03	4650.64	7051.74	173.59	561.87	0	285.44	471	817.31	0	0	0	0	0	0	0	0	0											150 Per Day: 1-10	150 Per Day: 1-10	0 days 1-575 days 6-100	20 coins	50 per trip	30 DME 20 Diabetes Monitoring	30 Proshetics	50 ER / 30 UC	100 ASC / 100 OP	30 per visit	30 per visit	0	20 per	30 OP SA / 30 Cardiac Rehab	20 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/20 Blood		0	0		0				0											132.94	132.94	46.95	0.18	44.31	0.25	0.27	39.94	88.63	26.59	26.59	0	0.18	0.1	17.99	28.51	26.59	25.21	0	9.43	23.88	26.41	0	0	0	0	0	0	0	0	0											12.95	0.19	3.06	5.22	1.03	7.73	0.39	0.86	1.91	3.7	1.89	-	0.05	2.94	6.97	16.75	0.38	1.18	-	0.22	0.94	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.17	0	9.01	12.95	0.19	3.06	5.22	1.03	7.73	0.39	0.86	1.91	3.7	1.89	-	0.05	2.94	6.97	16.75	0.38	1.18	-	0.22	0.94	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.17	5000																																																																																			-			12.95	0.19	3.06	5.22	1.03	7.73	0.39	0.86	1.91	3.7	1.89	-	0.05	2.94	6.97	16.75	0.38	1.18	-	0.22	0.94	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.17
H4204_021_0	2007	4																					5000											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1288.66	19.06	765.6	36.51	311.21	32.83	1.57	402.05	400.72	2583.44	1324.28	0	0.24	32.61	4521.11	6640.3	152.16	492.08	0	275.71	727.95	825.05	0	0	0	0	0	0	0	0	0											150 Per Day: 1-10	150 Per Day: 1-10	0 days 1-575 days 6-100	20 coins	50 per trip	30 DME 20 Diabetes Monitoring	30 Proshetics	50 ER / 30 UC	100 ASC / 100 OP	30 per visit	30 per visit	0	20 per	30 OP SA / 30 Cardiac Rehab	20 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/20 Blood		0	0		0				0											130.37	130.37	46.05	0.17	43.46	0.24	0.26	38.76	86.91	26.06	26.07	0	0.17	0.11	17.68	28.64	26.07	25.34	0	9.27	23.41	25.81	0	0	0	0	0	0	0	0	0											14	0.21	2.94	6.35	1.13	8.03	0.41	1.3	2.9	5.61	2.88	-	0.04	3.74	6.66	15.85	0.33	1.04	-	0.21	1.42	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.83	0	11.58	14	0.21	2.94	6.35	1.13	8.03	0.41	1.3	2.9	5.61	2.88	-	0.04	3.74	6.66	15.85	0.33	1.04	-	0.21	1.42	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.83	5000																																																																																			-			14	0.21	2.94	6.35	1.13	8.03	0.41	1.3	2.9	5.61	2.88	-	0.04	3.74	6.66	15.85	0.33	1.04	-	0.21	1.42	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.83
H4204_022_0	2007	2																					5000											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1346.48	19.44	942.57	26.21	295.98	27.44	1.32	446.92	445.66	2868.18	1473.45	0	0.25	30.84	4540.26	6837.26	152.61	493.74	0	276.22	809.04	836.05	0	0	0	0	0	0	0	0	0											150 Per Day: 1-10	150 Per Day: 1-10	0 days 1-575 days 6-100	20 coins	50 per trip	30 DME 20 Diabetes Monitoring	30 Proshetics	50 ER / 30 UC	100 ASC / 100 OP	30 per visit	30 per visit	0	20 per	30 OP SA / 30 Cardiac Rehab	20 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/20 Blood		0	0		0				0											130.68	130.68	46.15	0.17	43.56	0.25	0.26	38.55	87.12	26.11	26.14	0	0.17	0.12	17.69	28.01	26.13	25.74	0	9.28	23.47	25.84	0	0	0	0	0	0	0	0	0											14.66	0.21	3.63	4.57	1.07	6.73	0.34	1.44	3.24	6.24	3.21	-	0.04	3.82	6.69	15.96	0.33	1.06	-	0.21	1.58	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.84	0	11.38	14.66	0.21	3.63	4.57	1.07	6.73	0.34	1.44	3.24	6.24	3.21	-	0.04	3.82	6.69	15.96	0.33	1.06	-	0.21	1.58	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.84	5000																																																																																			-			14.66	0.21	3.63	4.57	1.07	6.73	0.34	1.44	3.24	6.24	3.21	-	0.04	3.82	6.69	15.96	0.33	1.06	-	0.21	1.58	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.84
H4204_801_0	2007	3																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	none	294.11	2.2	41.62	0	6.92	24.61	1.17	5.68	29.53	11.45	31.3	0	0.25	30.4	44.53	131.16	1.35	4.56	29.56	25.16	8.48	6																				Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				21.32	0.16	7.52	-	1.63	5.81	0.28	1.34	6.97	2.7	7.39	-	0.06	7.17	10.51	30.95	0.32	1.08	6.98	5.94	2	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.54	0	0	21.32	0.16	7.52	-	1.63	5.81	0.28	1.34	6.97	2.7	7.39	-	0.06	7.17	10.51	30.95	0.32	1.08	6.98	5.94	2	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.54	none																																																																																			-	0	0	21.32	0.16	7.52	-	1.63	5.81	0.28	1.34	6.97	2.7	7.39	-	0.06	7.17	10.51	30.95	0.32	1.08	6.98	5.94	2	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.54
H4204_802_0	2007	2																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	none	294.11	2.2	41.62	0	6.92	24.61	1.17	5.68	29.53	11.45	31.3	0	0.25	30.4	44.53	131.16	1.35	4.56	29.56	25.16	8.48	6																				Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				21.32	0.16	7.52	-	1.63	5.81	0.28	1.34	6.97	2.7	7.39	-	0.06	7.17	10.51	30.95	0.32	1.08	6.98	5.94	2	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.54	0	0	21.32	0.16	7.52	-	1.63	5.81	0.28	1.34	6.97	2.7	7.39	-	0.06	7.17	10.51	30.95	0.32	1.08	6.98	5.94	2	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.54	none																																																																																			-	0	0	21.32	0.16	7.52	-	1.63	5.81	0.28	1.34	6.97	2.7	7.39	-	0.06	7.17	10.51	30.95	0.32	1.08	6.98	5.94	2	1.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.54
H4205_001_0	2007	4																					5000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1148.59	15.7	1042.98	26.38	276.39	24.71	1.16	381.54	23.26	2400.12	24.68	0	0.22	23.97	4091.4	6162.06	148.62	493.02	27.26	224	6.69	739.6	0	0	374.4	0	160.75	0	0	0	0											150 per day 1-7	150 per day 1-7 5/day 8-90	10/day 1-10 100/day 11-100	10 coins	100 per trip	30 DME/12 copay Diab Monit Supplies	30 coins	50 ER / 25 UC	15 coins	35 copay	15 coins		20 coins	35 OP SA 15 Cardiac Rehab	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MH	20 Therapy	15 coins Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/15 Blood		0	25		35				0											132.52	140.03	48.45	0.09	88.33	0.25	0.26	37.76	0.13	30.86	0.13	0	0.18	0.11	22.2	30.52	30.91	17.67	0.03	8.37	0.17	21.88	0	0	22.07	0	30.91	0	0	0	0											12.68	0.18	4.21	2.33	2.03	6.08	0.31	1.2	3.08	6.17	3.27	-	0.04	2.65	7.57	15.67	0.38	0.73	0.74	0.16	1.15	1.35	-	-	0.69	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.09	0	9.68	12.68	0.18	4.21	2.33	2.03	6.08	0.31	1.2	3.08	6.17	3.27	-	0.04	2.65	7.57	15.67	0.38	0.73	0.74	0.16	1.15	1.35	-	-	0.69	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.09	5000																																																																																			-			12.68	0.18	4.21	2.33	2.03	6.08	0.31	1.2	3.08	6.17	3.27	-	0.04	2.65	7.57	15.67	0.38	0.73	0.74	0.16	1.15	1.35	-	-	0.69	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.09
H4205_002_0	2007	4																					5000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1197.68	16.17	1069.43	31.28	262.75	23.54	1.11	392.73	25.41	2482.43	26.97	0	0.25	26.2	4195.86	6399.31	160.98	534.26	29.2	248.18	7.31	759.2	0	0	384.12	0	164.82	0	0	0	0											150 per day 1-7	150 per day 1-7 5/day 8-90	10/day 1-10 100/day 11-100	10 coins	100 per trip	30 DME/12 copay Diab Monit Supplies	30 coins	50 ER / 25 UC	15 coins	35 copay	15 coins		20 coins	35 OP SA 15 Cardiac Rehab	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MH	20 Therapy	15 coins Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/15 Blood		0	25		35				0											131.32	138.75	48.01	0.09	87.52	0.24	0.26	37.47	0.13	30.6	0.13	0	0.18	0.11	22	30.3	30.63	17.51	0.03	10.13	0.17	21.81	0	0	21.87	0	30.63	0	0	0	0											13.11	0.19	4.28	2.74	1.92	5.74	0.29	1.23	3.34	6.33	3.54	-	0.04	2.83	7.69	16.16	0.41	0.78	0.79	0.21	1.25	1.38	-	-	0.7	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.35	0	10.75	13.11	0.19	4.28	2.74	1.92	5.74	0.29	1.23	3.34	6.33	3.54	-	0.04	2.83	7.69	16.16	0.41	0.78	0.79	0.21	1.25	1.38	-	-	0.7	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.35	5000																																																																																			-			13.11	0.19	4.28	2.74	1.92	5.74	0.29	1.23	3.34	6.33	3.54	-	0.04	2.83	7.69	16.16	0.41	0.78	0.79	0.21	1.25	1.38	-	-	0.7	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.35
H4205_801_0	2007	2																					5000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	coin	coin	coin	coin	O			V	P	V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0															-	none	1119.67	15.39	1329.46	33.71	248.72	24.61	1.17	394.87	29.53	2517.63	31.31	0	0.26	30.45	6157.33	16112.13	177.46	4.65	30.45	25.61	8.5	761.41			389.89	102	0															150 Per Day: Days 1 to 7	150 Per Day:  1-7 5 Per Day:  8-90	10 Per Day:  1-10 100 Per Day:  11-100	10	100 Per Run	30 DME/Prosthetics 12 Diabetes	30 DME/Prosthetics 12 Diabetes	50 ER/25 UC	15	35	15	0	20	35 OP SA / 35 Cardiac Rehab/15 Other	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist/15 Other	35 MH	20 Therapy	15 OP Professional / 0 Office	35 Hearing / 0 Preventive	20	25 Vision/0 Blood			25	25 copay	0															127.24	131.04	46.52	0.08	84.82	0.24	0.25	36.15	0.13	29.69	0.13	0	0.17	0.09	17.88	16.85	29.69	0.13	0.04	0.13	0.17	21.48			25	25	0															11.87	0.17	5.15	2.86	1.76	5.81	0.3	1.19	3.76	6.23	3.98	-	0.04	2.87	9.17	22.63	0.44	0.59	1.15	3.45	1.41	1.36	-	-	0.81	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.22	0	15.42	11.87	0.17	5.15	2.86	1.76	5.81	0.3	1.19	3.76	6.23	3.98	-	0.04	2.87	9.17	22.63	0.44	0.59	1.15	3.45	1.41	1.36	-	-	0.81	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.22	5000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A			N/A	N/A	N/A															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0															-	2000	0	11.87	0.17	5.15	2.86	1.76	5.81	0.3	1.19	3.76	6.23	3.98	-	0.04	2.87	9.17	22.63	0.44	0.59	1.15	3.45	1.41	1.36	-	-	0.81	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.22
H4205_802_0	2007	2																					5000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	coin	coin	coin	coin	O			V	P	V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0															-	none	1119.67	15.39	1329.46	33.71	248.72	24.61	1.17	394.87	29.53	2517.63	31.31	0	0.26	30.45	6157.33	16112.13	177.46	4.65	30.45	25.61	8.5	761.41			389.89	102	0															150 Per Day: Days 1 to 7	150 Per Day:  1-7 5 Per Day:  8-90	10 Per Day:  1-10 100 Per Day:  11-100	10	100 Per Run	30 DME/Prosthetics 12 Diabetes	30 DME/Prosthetics 12 Diabetes	50 ER/25 UC	15	35	15	0	20	35 OP SA / 35 Cardiac Rehab/15 Other	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist/15 Other	35 MH	20 Therapy	15 OP Professional / 0 Office	35 Hearing / 0 Preventive	20	25 Vision/0 Blood			25	25 copay	0															127.24	131.04	46.52	0.08	84.82	0.24	0.25	36.15	0.13	29.69	0.13	0	0.17	0.09	17.88	16.85	29.69	0.13	0.04	0.13	0.17	21.48			25	25	0															11.87	0.17	5.15	2.86	1.76	5.81	0.3	1.19	3.76	6.23	3.98	-	0.04	2.87	9.17	22.63	0.44	0.59	1.15	3.45	1.41	1.36	-	-	0.81	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.22	0	15.42	11.87	0.17	5.15	2.86	1.76	5.81	0.3	1.19	3.76	6.23	3.98	-	0.04	2.87	9.17	22.63	0.44	0.59	1.15	3.45	1.41	1.36	-	-	0.81	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.22	5000	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A			N/A	N/A	N/A															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0	0	0															-	2000	0	11.87	0.17	5.15	2.86	1.76	5.81	0.3	1.19	3.76	6.23	3.98	-	0.04	2.87	9.17	22.63	0.44	0.59	1.15	3.45	1.41	1.36	-	-	0.81	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.22
H4206_001_0	2007	6																																D	D	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		904.11	12	918.04	0	277.25	24.92	1.25	374.44	386.37	2488.64	1273.13	0	0.21	25.21	4229.12	5267.29	136.31	439.27	0	260.49	704.06	772.96	0	0	0	0	0	0	0	0	0											150 per day 1-7	150 per day 1-7	0 days 1-5; 75 days 6-100		50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER and UC	50 ASC/ 100 OP Hosp	20 copay	20 copay		20 coins	30 OP SA/0 Cardiac Rehab	15 copay PCP	30 SCP/30 Chiro/30 Podiatrist	30 copay	30 Therapy		30 Hearing 0 Preventive	20 coins	30 vision and blood																				139.39	139.4	49.24	0	46.47	0.15	0.19	47.64	55.88	18.59	18.59	0	0.17	0.1	13.93	27.85	27.88	25.56	0	10.17	24.97	27.66	0	0	0	0	0	0	0	0	0											10.5	0.14	3.77	-	1.07	3.78	0.23	1.49	1.8	3.86	1.97	-	0.04	2.62	4.91	12.22	0.32	0.94	-	0.22	1.46	1.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.12	0	4.68	10.5	0.14	3.77	-	1.07	3.78	0.23	1.49	1.8	3.86	1.97	-	0.04	2.62	4.91	12.22	0.32	0.94	-	0.22	1.46	1.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.12	5000	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.66	0.01	0.2	0.2	0.05	0.27	0.01	0.05	0.2	0.07	0.2	0	0	0.19	0.25	0.88	0.01	0.03	0.19	0.14	0.06	0.04	0	0	0	0	0	0	0	0	0											4.72	750	0.64	12.17	0.15	3.97	0.2	1.12	4.05	0.24	1.54	2	3.93	2.17	-	0.04	2.81	5.16	13.1	0.33	0.96	0.19	0.36	1.52	1.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.84
H4206_002_0	2007	5																																A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		279.16	2.66	933.43	0	281.98	25.34	1.27	403.19	392.05	2530.31	1291.88	0	0.21	25.62	4492.98	5552.25	141.9	457.48	0	274.63	716.83	802.92	0	0	0	0	0	0	0	0	0											0	0	0 days 1-5; 75 days 6-100	0	50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER/ 20 UC	25 ASC/ 50 OP Hosp	10 copay	10 copay	0	20 coins	20 OP SA/0 Cardiac Rehab	10 PCP copay	20 SCP/20 Chiro/20 Podiatrist	20 copay	20 copay	0	20 Hearing 0 Preventive	20 coins	20 vision and blood																				0	0	47.09	0	44.45	0.15	0.18	36.51	26.72	8.89	8.89	0	0.15	0.09	8.88	17.76	17.78	17.78	0	6.65	23.01	18.36	0	0	0	0	0	0	0	0	0											0	-	3.66	-	1.04	3.68	0.23	1.23	0.87	1.87	0.96	-	0.03	2.26	3.33	8.22	0.21	0.68	-	0.15	1.37	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.03	0	5.12	0	-	3.66	-	1.04	3.68	0.23	1.23	0.87	1.87	0.96	-	0.03	2.26	3.33	8.22	0.21	0.68	-	0.15	1.37	1.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.03	2500	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.32	0.01	0.16	0.16	0.04	0.21	0.01	0.04	0.16	0.06	0.16	0	0	0.15	0.2	0.7	0.01	0.02	0.15	0.11	0.05	0.03	0	0	0	0	0	0	0	0	0											3.73	500	1.25	1.32	0.01	3.82	0.16	1.08	3.89	0.24	1.26	1.03	1.93	1.11	-	0.03	2.42	3.52	8.92	0.22	0.7	0.15	0.26	1.42	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.76
H4206_005_0	2007	6																																D	D	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		979.12	12.99	792.88	0	251.01	22.15	1.12	349.49	360.38	2323.66	1187.68	0	0.22	23	3996.75	5091.66	141.14	454.95	0	247.79	657.38	729.6	0	0	0	0	0	0	0	0	0											150 per day 1-7	150 per day 1-7	0 days 1-5; 75 days 6-100		50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER and UC	50 ASC/ 100 OP Hosp	20 copay	20 copay		20 coins	30 OP SA/0 Cardiac Rehab	15 copay PCP	30 SCP/30 Chiro/30 Podiatrist	30 copay	30 Therapy		30 Hearing 0 Preventive	20 coins	30 vision and blood																				139.86	139.86	49.4	0	46.62	0.15	0.19	47.84	56.07	18.65	18.65	0	0.17	0.11	13.98	27.94	27.98	26.17	0	10.21	25.05	27.75	0	0	0	0	0	0	0	0	0											11.41	0.15	3.26	-	0.98	3.37	0.21	1.39	1.68	3.61	1.85	-	0.04	2.42	4.66	11.85	0.33	0.99	-	0.21	1.37	1.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.48	0	4.41	11.41	0.15	3.26	-	0.98	3.37	0.21	1.39	1.68	3.61	1.85	-	0.04	2.42	4.66	11.85	0.33	0.99	-	0.21	1.37	1.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.48	5000	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.87	0.01	0.16	0.18	0.04	0.23	0.01	0.04	0.18	0.06	0.18	0	0	0.17	0.25	0.93	0.01	0.03	0.18	0.15	0.05	0.04	0	0	0	0	0	0	0	0	0											4.81	750	0.68	13.29	0.17	3.43	0.18	1.02	3.61	0.22	1.44	1.86	3.68	2.02	-	0.04	2.59	4.91	12.79	0.34	1.02	0.18	0.36	1.42	1.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.29
H4206_006_0	2007	5																																A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		288.34	2.76	806.39	0	255.37	22.53	1.14	376.47	365.74	2361.71	1205.38	0	0.22	23.37	4245.65	5361.79	146.91	473.74	0	260.81	669.55	757.84	0	0	0	0	0	0	0	0	0											0	0	0 days 1-5; 75 days 6-100	0	50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER/ 20 UC	25 ASC/ 50 OP Hosp	10 copay	10 copay	0	20 coins	20 OP SA/0 Cardiac Rehab	10 PCP copay	20 SCP/20 Chiro/20 Podiatrist	20 copay	20 copay	0	20 Hearing 0 Preventive	20 coins	20 vision and blood																				0	0	47.69	0	45.01	0.15	0.18	37.01	27.05	9	9	0	0.15	0.09	9	17.99	18.01	18.01	0	6.76	23.3	18.58	0	0	0	0	0	0	0	0	0											0	0	3.2	-	0.96	3.31	0.2	1.16	0.82	1.77	0.9	-	0.03	2.11	3.18	8.04	0.22	0.71	-	0.15	1.3	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.25	0	4.54	0	0	3.2	-	0.96	3.31	0.2	1.16	0.82	1.77	0.9	-	0.03	2.11	3.18	8.04	0.22	0.71	-	0.15	1.3	1.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.25	2500	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.48	0.01	0.13	0.14	0.03	0.19	0.01	0.03	0.14	0.05	0.14	0	0	0.14	0.2	0.74	0.01	0.02	0.14	0.12	0.04	0.03	0	0	0	0	0	0	0	0	0											3.8	500	1.3	1.48	0.01	3.33	0.14	0.99	3.5	0.21	1.19	0.97	1.82	1.04	-	0.03	2.24	3.38	8.78	0.23	0.73	0.14	0.26	1.34	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.05
H4206_007_0	2007	6																																D	D	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1004.84	12.83	733.14	0	252.03	26.8	1.35	245.73	253.66	1626.45	833.81	0	0.24	26.64	4569.65	5900.9	164.86	531.54	0	286.11	463.66	802.1	0	0	0	0	0	0	0	0	0											150 per day 1-7	150 per day 1-7	0 days 1-5; 75 days 6-100		50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER and UC	50 ASC/ 100 OP Hosp	20 copay	20 copay		20 coins	30 OP SA/0 Cardiac Rehab	15 copay PCP	30 SCP/30 Chiro/30 Podiatrist	30 copay	30 Therapy		30 Hearing 0 Preventive	20 coins	30 vision and blood																				139.36	139.37	49.23	0	46.46	0.15	0.19	48.2	55.87	18.59	18.58	0	0.17	0.09	13.93	27.86	27.88	24.95	0	10.38	24.93	27.76	0	0	0	0	0	0	0	0	0											11.67	0.15	3.01	-	0.98	4.07	0.25	0.99	1.18	2.52	1.29	-	0.04	2.44	5.31	13.7	0.38	1.11	-	0.25	0.96	1.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.13	0	4.85	11.67	0.15	3.01	-	0.98	4.07	0.25	0.99	1.18	2.52	1.29	-	0.04	2.44	5.31	13.7	0.38	1.11	-	0.25	0.96	1.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.13	5000	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.99	0.02	0.15	0.19	0.05	0.27	0.01	0.03	0.19	0.07	0.19	0	0	0.18	0.28	0.95	0.02	0.03	0.24	0.16	0.06	0.04	0	0	0	0	0	0	0	0	0											5.11	750	0.89	13.66	0.16	3.15	0.19	1.02	4.34	0.26	1.02	1.38	2.59	1.48	-	0.04	2.62	5.59	14.65	0.4	1.13	0.24	0.4	1.02	1.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.24
H4206_008_0	2007	5																																A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		282.06	2.67	744.11	0	255.77	27.21	1.37	263.5	256.94	1647.76	844.58	0	0.25	27.02	4840.34	6157.83	171.1	552.13	0	298.01	470.49	831.34	0	0	0	0	0	0	0	0	0											0	0	0 days 1-5; 75 days 6-100	0	50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER/ 20 UC	25 ASC/ 50 OP Hosp	10 copay	10 copay	0	20 coins	20 OP SA/0 Cardiac Rehab	10 PCP copay	20 SCP/20 Chiro/20 Podiatrist	20 copay	20 copay	0	20 Hearing 0 Preventive	20 coins	20 vision and blood																				0	0	47.44	0	44.77	0.15	0.18	37.3	26.91	8.95	8.95	0	0.14	0.08	8.95	17.9	17.91	17.91	0	6.77	23.14	18.3	0	0	0	0	0	0	0	0	0											0	0	2.94	-	0.95	3.98	0.25	0.82	0.58	1.23	0.63	-	0.04	2.19	3.61	9.18	0.26	0.82	-	0.17	0.91	1.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.82	0	5.08	0	0	2.94	-	0.95	3.98	0.25	0.82	0.58	1.23	0.63	-	0.04	2.19	3.61	9.18	0.26	0.82	-	0.17	0.91	1.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.82	2500	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.57	0.01	0.12	0.15	0.04	0.21	0.01	0.02	0.15	0.05	0.15	0	0	0.14	0.22	0.75	0.01	0.02	0.19	0.12	0.04	0.03	0	0	0	0	0	0	0	0	0											4.01	500	1.6	1.57	0.01	3.06	0.15	0.99	4.19	0.26	0.84	0.73	1.28	0.78	-	0.04	2.33	3.83	9.93	0.27	0.85	0.19	0.29	0.95	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.83
H4206_009_0	2007	6																																D	D	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		940	12.31	846.84	0	279.22	29.49	1.47	267.02	275.74	1769.26	907.2	0	0.2	23.83	4393	5448.21	137.31	442.5	0	270.89	503.59	777.56	0	0	0	0	0	0	0	0	0											150 per day 1-7	150 per day 1-7	0 days 1-5; 75 days 6-100		50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER and UC	50 ASC/ 100 OP Hosp	20 copay	20 copay		20 coins	30 OP SA/0 Cardiac Rehab	15 copay PCP	30 SCP/30 Chiro/30 Podiatrist	30 copay	30 Therapy		30 Hearing 0 Preventive	20 coins	30 vision and blood																				139.95	139.95	49.43	0	46.65	0.15	0.19	48.25	56.1	18.66	18.66	0	0.17	0.1	13.99	27.96	27.99	24.77	0	10.28	25.05	27.85	0	0	0	0	0	0	0	0	0											10.96	0.14	3.49	-	1.09	4.49	0.27	1.07	1.29	2.75	1.41	-	0.03	2.3	5.12	12.7	0.32	0.91	-	0.23	1.05	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.44	0	4.35	10.96	0.14	3.49	-	1.09	4.49	0.27	1.07	1.29	2.75	1.41	-	0.03	2.3	5.12	12.7	0.32	0.91	-	0.23	1.05	1.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.44	5000	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.65	0.01	0.18	0.21	0.06	0.33	0.02	0.04	0.19	0.07	0.18	0	0	0.18	0.26	0.91	0.01	0.03	0.2	0.14	0.05	0.04	0	0	0	0	0	0	0	0	0											4.74	750	0.66	12.61	0.16	3.66	0.21	1.14	4.82	0.29	1.11	1.48	2.82	1.59	-	0.04	2.47	5.39	13.61	0.33	0.94	0.2	0.37	1.1	1.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.18
H4206_010_0	2007	6																																A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		281.59	2.66	860.89	0	283.77	29.99	1.5	287.02	279.69	1796.98	920.2	0	0.2	24.2	4665.43	5729.71	142.89	460.75	0	284.94	512.01	807.86	0	0	0	0	0	0	0	0	0											0	0	0 days 1-5; 75 days 6-100	0	50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER/ 20 UC	25 ASC/ 50 OP Hosp	10 copay	10 copay	0	20 coins	20 OP SA/0 Cardiac Rehab	10 PCP copay	20 SCP/20 Chiro/20 Podiatrist	20 copay	20 copay	0	20 Hearing 0 Preventive	20 coins	20 vision and blood																				0	0	47.48	0	44.81	0.15	0.18	37.2	26.94	8.96	8.96	0	0.15	0.08	8.96	17.91	17.93	17.93	0	6.72	23.18	18.35	0	0	0	0	0	0	0	0	0											0	-	3.41	-	1.06	4.39	0.27	0.89	0.63	1.34	0.69	-	0.03	2.03	3.48	8.55	0.21	0.69	-	0.16	0.99	1.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.05	0	4.74	0	-	3.41	-	1.06	4.39	0.27	0.89	0.63	1.34	0.69	-	0.03	2.03	3.48	8.55	0.21	0.69	-	0.16	0.99	1.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.05	2500	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.3	0.01	0.14	0.17	0.04	0.26	0.01	0.03	0.15	0.05	0.14	0	0	0.14	0.21	0.72	0.01	0.02	0.15	0.11	0.04	0.03	0	0	0	0	0	0	0	0	0											3.75	500	1.27	1.3	0.01	3.55	0.17	1.1	4.65	0.28	0.92	0.78	1.39	0.83	-	0.03	2.17	3.69	9.27	0.22	0.71	0.15	0.27	1.03	1.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.8
H4206_025_0	2007	6																																A	A	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											13.68	0.09	1.39	1.77	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											16.94		313.93	2.9	27.65	0	8.38	29.49	1.51	5.81	29.05	11.1	30.46	0	0.24	30.09	51.31	138.16	1.27	4.23	32.09	24.35	8.39	6.97	0	0	0	0	0	0	0	0	0											1000 Ded; 250/day 61-999	1000 Ded; 250/day 61-999	20 coin		20 coin	20 coin	20 coin	20 coin	20 coin	20 coin	20 coin		20 coin	20 coin	0 PCP	20 coin	20 coin	20 coin	20 coin	0 Hearing / 0 Preventive	20 coin	20 coin																				64.86	64.86	0.18	0	0.19	0.19	0.19	0.19	0.19	0.19	0.19	0	0.19	0.19	0.02	0.12	0.19	0.19	0.18	0.15	0.18	0.19	0	0	0	0	0	0	0	0	0											1.7	0.02	5	-	1.55	5.46	0.28	1.07	5.38	2.05	5.64	-	0.04	5.57	1	15.89	0.23	0.78	5.81	3.71	1.55	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.02	1000	5.34	15.37	0.11	6.39	1.77	1.55	5.46	0.28	1.07	5.38	2.05	5.64	-	0.04	5.57	1	15.89	0.23	0.78	5.81	3.71	1.55	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.96	5800	1000 Ded; 250/day	1000 Ded; 250/day 61-999	20 coin		20 coin	20 per	20 per	20 coin	20 coin	20 coin	20 coin		20 coin	20 coin	20 coin	20 coin	20 coin	20 coin	20 coin	20 coin	20 coin	20 coin																				0.49	0	0.19	0.05	0.06	0.2	0.01	0.03	0.17	0.07	0.18	0	0	0.18	0.03	0.51	0.01	0.03	0.19	0.15	0.06	0.04	0	0	0	0	0	0	0	0	0											2.65	1000	0.17	15.86	0.11	6.57	1.82	1.61	5.66	0.29	1.11	5.55	2.12	5.82	-	0.05	5.75	1.03	16.41	0.24	0.81	6	3.86	1.6	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.61
H4207_001_0	2007	8																					6000											D	D	D	V	T	coin	coin	V	V	coin	coin	O	coin	coin	V	V	V	coin	coin	coin	coin	coin	T	P	Coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1184.31	17.03	988.93	0	259.11	21.81	1.07	329.06	339.67	8.85	24.14	0	0.21	23.7	5871.61	15893.37	151.68	3.82	26.15	21.29	6.61	5.62	0	0	3.35	0	161.87	0	0	0	0											1-10:  175/Day	1-10:  175/Day	1-24: 75/Day	No cost sharing	100 per trip	0	0	50 ER and UC	20 OP Hosp 100 ASC	0	0.2	0.2	0.2	0	10 PCP 20 Hosp	25 SCP/20 Chiro/20 Podiatry	45 MHSA	0	20	20 Other 20 Hearing 0 Preventive 10 Physical	0.2	20 Blood/vision			0.2		20															158.65	158.65	56.31	0	90.66	0.18	0.18	46.48	125.5	0.18	0.18	0	0.18	0.18	10.76	16.24	40.8	0.18	0.05	0.18	0.18	0.18	0	0	0.18	0	18.13	0	0	0	0											15.66	0.23	4.64	-	1.96	3.95	0.19	1.27	3.55	1.6	4.38	-	0.04	4.33	5.27	21.5	0.52	0.69	1.38	3.83	1.19	1.02	-	-	0.61	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.07	0	8.04	15.66	0.23	4.64	-	1.96	3.95	0.19	1.27	3.55	1.6	4.38	-	0.04	4.33	5.27	21.5	0.52	0.69	1.38	3.83	1.19	1.02	-	-	0.61	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.07	none	20 coins	20 coins	20 coins	20 coins	100 per trip	50 coins	50 coins	50 ER and UC	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 SCP 30 Chiro and Podiatry	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	0	30 coins	0	30 coins	0	0	0	0											1.74	0.01	0.2	0.16	0.07	0.42	0.02	0.04	0.15	0.06	0.16	0	0	0.15	0.2	0.89	0.01	0.02	0.16	0.14	0.05	0.05	0	0	0	0	0	0	0	0	0											4.71	0	0	17.4	0.24	4.84	0.16	2.03	4.37	0.21	1.32	3.7	1.66	4.54	-	0.04	4.49	5.47	22.4	0.52	0.72	1.54	3.97	1.24	1.07	-	-	0.61	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.78
H4207_002_0	2007	8																					5000											D	D	D	V	T	coin	coin	V	V	coin	coin	O	coin	coin	V	V	V	coin	coin	coin	coin	coin	T	P	Coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1191.03	16.74	1030.95	0	255.85	21.15	1.04	316.74	319.71	8.28	22.51	0	0.21	22.19	5956.29	16180.28	150.42	3.81	28.48	21.05	6.19	5.51	0	0	3.31	0	161.73	0	0	0	0											1-10:  130/Day	1-10:  130/Day	1-24: 50/Day	No cost sharing	100 per trip	0	0	50 ER and 35 UC	15 OP Hosp 75 ASC	0	0.15	0.15	0.15	0	10 PCP 15 Hosp	20 SCP/20 Chiro/20 Podiatry	35 MHSA	0	15	15 Other 20 Hearing 0 Preventive 10 Physical	0.2	15 Blood/20 vision			0.2		20															118.1	118.1	37.62	0	68.14	0.14	0.14	42	93.54	0.14	0.14	0	0.18	0.14	9.71	12.94	31.8	0.14	0.04	0.14	0.18	0.18	0	0	0.18	0	18.17	0	0	0	0											11.72	0.16	3.23	-	1.45	3.06	0.14	1.11	2.49	1.13	3.07	-	0.04	3.05	4.82	17.45	0.4	0.52	1.12	2.89	1.09	1	-	-	0.6	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.79	0	6.12	11.72	0.16	3.23	-	1.45	3.06	0.14	1.11	2.49	1.13	3.07	-	0.04	3.05	4.82	17.45	0.4	0.52	1.12	2.89	1.09	1	-	-	0.6	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.79	none	20 coins	20 coins	20 coins	20 coins	100 per trip	50 coins	50 coins	50 ER and 35 UC	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 SCP 30 Chiro and Podiatry	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	0	30 coins	0	30 coins	0	0	0	0											1.73	0.01	0.2	0.17	0.05	0.41	0.02	0.04	0.14	0.05	0.15	0	0	0.14	0.22	0.89	0.01	0.02	0.18	0.14	0.04	0.05	0	0	0	0	0	0	0	0	0											4.68	0	0	13.46	0.18	3.44	0.17	1.51	3.47	0.16	1.15	2.63	1.18	3.22	-	0.04	3.2	5.04	18.34	0.41	0.54	1.3	3.02	1.14	1.05	-	-	0.6	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.48
H4207_003_0	2007	8																					4000											D	D	D	V	T	coin	coin	V	V	coin	coin	O	coin	coin	V	V	V	coin	coin	coin	coin	coin	T	P	Coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1187.86	16.95	1055.16	0	257.48	21.4	1.06	321.15	317.06	8.39	22.82	0	0.22	22.49	6227.36	16502.81	152.31	3.95	27.7	21.87	6.27	5.59	0	0	3.36	0	163.68	0	0	0	0											1-10:  95/Day	1-10:  95/Day	1-24: 25/Day	No cost sharing	100 per trip	0	0	50 ER and 25 UC	10 OP Hosp 50 ASC	0	0.1	0.1	0.1	0	5 PCP 10 Hosp	10 SCP/20 Chiro/20 Podiatry	25 MHSA	0	10	10 Other 20 Hearing 0 Preventive 5 Physical	0.2	10 Blood/ 20 vision			0.2		20															87.55	87.55	19.08	0	46.08	0.11	0.09	39.48	64.57	0.09	0.09	0	0.18	0.09	5.42	8.62	23.04	0.09	0.03	0.1	0.17	0.18	0	0	0.18	0	18.43	0	0	0	0											8.67	0.12	1.68	-	0.99	2.33	0.1	1.06	1.71	0.77	2.1	-	0.04	2.09	2.81	11.86	0.29	0.36	0.72	2.08	1.09	1.03	-	-	0.62	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.78	0	3.64	8.67	0.12	1.68	-	0.99	2.33	0.1	1.06	1.71	0.77	2.1	-	0.04	2.09	2.81	11.86	0.29	0.36	0.72	2.08	1.09	1.03	-	-	0.62	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.78	none	20 coins	20 coins	20 coins	20 coins	100 per trip	50 coins	50 coins	50 ER and 25 UC	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 SCP 30 Chiro and Podiatry	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	0	30 coins	0	30 coins	0	0	0	0											1.74	0.01	0.21	0.16	0.04	0.42	0.02	0.04	0.14	0.06	0.15	0	0	0.15	0.22	0.89	0.01	0.02	0.17	0.14	0.05	0.05	0	0	0	0	0	0	0	0	0											4.66	0	0	10.41	0.14	1.88	0.16	1.03	2.75	0.12	1.09	1.85	0.83	2.25	-	0.04	2.24	3.03	12.74	0.3	0.39	0.89	2.22	1.14	1.07	-	-	0.62	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.44
H4207_004_0	2007	8																					6000											D	D	D	V	T	coin	coin	V	V	coin	coin	O	coin	coin	V	V	V	coin	coin	coin	coin	coin	T	P	Coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1182.07	16.82	987	0	257.58	21.52	1.06	320.09	330.4	8.59	23.39	0	0.21	23.02	5799.49	15696.26	151.23	3.78	27.03	21.08	6.42	5.57	0	0	0	0	0	0	0	0	0											1-10:  200/Day	1-10:  200/Day	1-24: 100/Day	No cost sharing	100 per trip	0	0	50 ER and UC	20 OP Hosp 100 ASC	0	0.2	0.2	0.2	0	15 PCP 20 Hosp	25 SCP/20 Chiro/20 Podiatry	45 MHSA	0	20	20 Other 20 Hearing 0 Preventive 10 Physical	0.2	20 Blood/vision	0	0	0	0	0	0	0	0	0											180.21	180.21	74.62	0	90.1	0.18	0.18	46.22	124.33	0.18	0.18	0	0.18	0.18	13.91	16.54	40.55	0.18	0.05	0.18	0.18	0.18	0	0	0	0	0	0	0	0	0											17.75	0.25	6.14	-	1.93	3.88	0.19	1.23	3.42	1.55	4.22	-	0.04	4.18	6.72	21.63	0.51	0.68	1.42	3.77	1.15	1.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.68	0	8.97	17.75	0.25	6.14	-	1.93	3.88	0.19	1.23	3.42	1.55	4.22	-	0.04	4.18	6.72	21.63	0.51	0.68	1.42	3.77	1.15	1.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.68	none	20 coins	20 coins	20 coins	20 coins	100 per trip	50 coins	50 coins	50 ER and UC	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 SCP 30 Chiro and Podiatry	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins		0		0		0	0	0	0											1.74	0.01	0.2	0.17	0.07	0.42	0.02	0.04	0.15	0.06	0.15	0	0	0.15	0.23	0.86	0.01	0.02	0.17	0.14	0.05	0.05	0	0	0	0	0	0	0	0	0											4.7	0	0	19.49	0.27	6.34	0.17	2.01	4.29	0.21	1.28	3.57	1.6	4.37	-	0.04	4.33	6.95	22.5	0.52	0.71	1.59	3.91	1.2	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.39
H4207_005_0	2007	9																					4000											D	D	D	V	T	coin	coin	V	V	coin	coin	O	coin	coin	V	V	V	coin	coin	coin	coin	coin	T	P	Coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1187.86	16.95	1055.16	0	257.48	21.4	1.06	321.15	317.06	8.39	22.82	0	0.22	22.49	6227.36	16502.81	152.31	3.95	27.7	21.87	6.27	5.59	0	0	3.36	0	163.68	0	0	0	0											1-10:  95/Day	1-10:  95/Day	1-24: 25/Day	No cost sharing	100 per trip	0	0	50 ER and 25 UC	10 OP Hosp 50 ASC	0	0.1	0.1	0.1	0	5 PCP 10 Hosp	10 SCP/20 Chiro/20 Podiatry	25 MHSA	0	10	10 Other 20 Hearing 0 Preventive 5 Physical	0.2	10 Blood/ 20 vision			0.2		20															87.55	87.55	19.08	0	46.08	0.11	0.09	39.48	64.57	0.09	0.09	0	0.18	0.09	5.42	8.62	23.04	0.09	0.03	0.1	0.17	0.18	0	0	0.18	0	18.43	0	0	0	0											8.67	0.12	1.68	-	0.99	2.33	0.1	1.06	1.71	0.77	2.1	-	0.04	2.09	2.81	11.86	0.29	0.36	0.72	2.08	1.09	1.03	-	-	0.62	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.78	0	3.64	8.67	0.12	1.68	-	0.99	2.33	0.1	1.06	1.71	0.77	2.1	-	0.04	2.09	2.81	11.86	0.29	0.36	0.72	2.08	1.09	1.03	-	-	0.62	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.78	none	20 coins	20 coins	20 coins	20 coins	100 per trip	50 coins	50 coins	50 ER and 25 UC	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 SCP 30 Chiro and Podiatry	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	0	30 coins	0	30 coins	0	0	0	0											1.74	0.01	0.21	0.16	0.04	0.42	0.02	0.04	0.14	0.06	0.15	0	0	0.15	0.22	0.89	0.01	0.02	0.17	0.14	0.05	0.05	0	0	0	0	0	0	0	0	0											4.66	0	0	10.41	0.14	1.88	0.16	1.03	2.75	0.12	1.09	1.85	0.83	2.25	-	0.04	2.24	3.03	12.74	0.3	0.39	0.89	2.22	1.14	1.07	-	-	0.62	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.44
H4208_001_0	2007	4																					none											D	D	D	V	T	coin	coin	V	V	coin	V	O	P	coin	V	V	V	V	V	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	661.47	7.19	1125.58	0	241.16	21.81	1.06	295.32	293.33	7.75	971.74	0	0	20.54	4034	6269.31	161.58	514.51	0	229.36	5.73	764.58	0	0	406.83	0	156.78	0	0	0	0											300/day up to 3 days.	300/day up to 3 days.	40 / day	0 copay	50 copay	20 coinsurance	20 coinsurance	50 ER / 30 UC	50 ASC / 20 OP	0 coins pref lab / 20 coins non-pref	0 X-Ray / 20 Radiation Therapy	0 copay	25 copay	10 Cardio / 10 Therapy/20 other services	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 copay	10 copay	0 coinsurance	25 Hearing / 0 Preventive	20 coinsurance	25 Vision	Not covered	Not covered	25 copay	Not covered	25 copay	Not covered	Not covered	Not covered	Not covered											300	300	40	0	50	0.21	0.2	43.25	84.57	0.02	5.9	0	0	0.1	10.39	27.82	25	10	0	9.2	0.2	25.07	0	0	25	0	25	0	0	0	0											16.54	0.18	3.75	-	1	4.63	0.21	1.06	2.07	0.15	0.48	-	-	2	3.49	14.53	0.34	0.43	-	0.18	1.15	1.6	-	-	0.85	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.96	0	0	16.54	0.18	3.75	-	1	4.63	0.21	1.06	2.07	0.15	0.48	-	-	2	3.49	14.53	0.34	0.43	-	0.18	1.15	1.6	-	-	0.85	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.96	none	300/day up to 10 days.	300/day up to 10 days.	Not covered	Not covered	50 copay	30 coinsurance	30 coinsurance	50 ER / 30 UC	50 ASC / 20 OP	30 coinsurance	0 X-Ray / 20 Radiation Therapy	0 copay	25 coinsurance	10 Cardio / 10 Therapy/20 other services	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	Not covered	10 copay	0 coinsurance	25 Hearing / 0 Preventive	20 coinsurance	20 coinsurance	Not covered	Not covered	Not covered	Not covered	25 copay	Not covered	Not covered	Not covered	Not covered											2.09	0.02	0	0	0.12	0.8	0.04	0.12	0.23	0.27	0.36	0	0	0.24	0.39	1.63	0	0.05	0	0.02	0.13	0.01	0	0	0	0	0.04	0	0	0	0											6.56	0	0	18.63	0.2	3.75	-	1.12	5.43	0.25	1.18	2.3	0.42	0.84	-	-	2.25	3.88	16.16	0.34	0.48	-	0.2	1.28	1.61	-	-	0.85	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.53
H4208_002_0	2007	3																					none											D	D	D	V	coin	coin	coin	V	coin	coin	coin	O	P	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	785.28	8.98	1102.37	0	6.15	21.81	1.06	292.08	19.91	7.75	21.19	0	0	20.54	3906.74	6157.39	161.58	471.63	27.96	224.64	5.73	764.58	0	0	406.83	0	0	0	0	0	0											400/day up to 4 days.	400/day up to 4 days.	65 / day	0 copay	20 coinsurance	30 coinsurance	30 coinsurance	50 ER / 40 UC	20 ASC / 20 OP	0 coins pref lab / 20 coins non-pref	0 X-Ray / 20 Radiation Therapy	0 copay	30 copay	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	50 copay	30 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	30 Vision	Not covered	Not covered	30 copay	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											400	400	65	0	0.2	0.28	0.3	46.62	0.2	0.02	0.15	0	0	0.13	15.36	32.1	50	26.98	0	11.28	0.2	29.68	0	0	30	0	0	0	0	0	0											26.18	0.3	5.97	-	1.23	6.14	0.32	1.13	3.98	0.15	3.18	-	-	2.66	5	16.47	0.67	1.06	-	0.21	1.15	1.89	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.71	0	0	26.18	0.3	5.97	-	1.23	6.14	0.32	1.13	3.98	0.15	3.18	-	-	2.66	5	16.47	0.67	1.06	-	0.21	1.15	1.89	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.71	none	400/day up to 8 days.	400/day up to 8 days.	Not covered	Not covered	20 coinsurance	50 coinsurance	50 coinsurance	50 ER / 40 UC	0 ASC / 20 OP	30 coinsurance	0 X-Ray / 20 Radiation Therapy	0 copay	30 coinsurance	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	Not covered	30 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	20 coinsurance	Not covered	Not covered	Not covered	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											3.31	0.04	0	0	0.15	1.2	0.06	0.13	0.46	0.27	0.36	0	0	0.33	0.56	1.84	0	0.12	0	0.02	0.13	0.01	0	0	0	0	0	0	0	0	0											9.01	0	0	29.49	0.34	5.97	-	1.38	7.35	0.38	1.26	4.44	0.42	3.54	-	-	2.99	5.56	18.32	0.67	1.18	-	0.23	1.28	1.91	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.72
H4208_008_0	2007	4																					none											D	D	D	V	T	coin	coin	V	V	coin	V	O	P	coin	V	V	V	V	V	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	661.47	7.19	1125.58	0	241.16	21.81	1.06	295.32	293.33	7.75	971.74	0	0	20.54	4034	6269.31	161.58	514.51	0	229.36	5.73	764.58	0	0	406.83	0	156.78	0	0	0	0											300/day up to 3 days.	300/day up to 3 days.	40 / day	0 copay	50 copay	20 coinsurance	20 coinsurance	50 ER / 30 UC	50 ASC / 20 OP	0 coins pref lab / 20 coins non-pref	0 X-Ray / 20 Radiation Therapy	0 copay	25 copay	10 Cardio / 10 Therapy/20 other services	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 copay	10 copay	0 coinsurance	25 Hearing / 0 Preventive	20 coinsurance	25 Vision	Not covered	Not covered	25 copay	Not covered	25 copay	Not covered	Not covered	Not covered	Not covered											300	300	40	0	50	0.21	0.2	43.25	84.57	0.02	5.9	0	0	0.1	10.39	27.82	25	10	0	9.2	0.2	25.07	0	0	25	0	25	0	0	0	0											16.54	0.18	3.75	-	1	4.63	0.21	1.06	2.07	0.15	0.48	-	-	2	3.49	14.53	0.34	0.43	-	0.18	1.15	1.6	-	-	0.85	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.96	0	0	16.54	0.18	3.75	-	1	4.63	0.21	1.06	2.07	0.15	0.48	-	-	2	3.49	14.53	0.34	0.43	-	0.18	1.15	1.6	-	-	0.85	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.96	none	300/day up to 10 days.	300/day up to 10 days.	Not covered	Not covered	50 copay	30 coinsurance	30 coinsurance	50 ER / 30 UC	50 ASC / 20 OP	30 coinsurance	0 X-Ray / 20 Radiation Therapy	0 copay	25 coinsurance	10 Cardio / 10 Therapy/20 other services	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	Not covered	10 copay	0 coinsurance	25 Hearing / 0 Preventive	20 coinsurance	20 coinsurance	Not covered	Not covered	Not covered	Not covered	25 copay	Not covered	Not covered	Not covered	Not covered											2.09	0.02	0	0	0.12	0.8	0.04	0.12	0.23	0.27	0.36	0	0	0.24	0.39	1.63	0	0.05	0	0.02	0.13	0.01	0	0	0	0	0.04	0	0	0	0											6.56	0	0	18.63	0.2	3.75	-	1.12	5.43	0.25	1.18	2.3	0.42	0.84	-	-	2.25	3.88	16.16	0.34	0.48	-	0.2	1.28	1.61	-	-	0.85	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.53
H4208_009_0	2007	3																					none											D	D	D	V	coin	coin	coin	V	coin	coin	coin	O	P	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	785.28	8.98	1102.37	0	6.15	21.81	1.06	292.08	19.91	7.75	21.19	0	0	20.54	3906.74	6157.39	161.58	471.63	27.96	224.64	5.73	764.58	0	0	406.83	0	0	0	0	0	0											400/day up to 4 days.	400/day up to 4 days.	65 / day	0 copay	20 coinsurance	30 coinsurance	30 coinsurance	50 ER / 40 UC	20 ASC / 20 OP	0 coins pref lab / 20 coins non-pref	0 X-Ray / 20 Radiation Therapy	0 copay	30 copay	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	50 copay	30 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	30 Vision	Not covered	Not covered	30 copay	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											400	400	65	0	0.2	0.28	0.3	46.62	0.2	0.02	0.15	0	0	0.13	15.36	32.1	50	26.98	0	11.28	0.2	29.68	0	0	30	0	0	0	0	0	0											26.18	0.3	5.97	-	1.23	6.14	0.32	1.13	3.98	0.15	3.18	-	-	2.66	5	16.47	0.67	1.06	-	0.21	1.15	1.89	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.71	0	0	26.18	0.3	5.97	-	1.23	6.14	0.32	1.13	3.98	0.15	3.18	-	-	2.66	5	16.47	0.67	1.06	-	0.21	1.15	1.89	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.71	none	400/day up to 8 days.	400/day up to 8 days.	Not covered	Not covered	20 coinsurance	50 coinsurance	50 coinsurance	50 ER / 40 UC	0 ASC / 20 OP	30 coinsurance	0 X-Ray / 20 Radiation Therapy	0 copay	30 coinsurance	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	Not covered	30 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	20 coinsurance	Not covered	Not covered	Not covered	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											3.31	0.04	0	0	0.15	1.2	0.06	0.13	0.46	0.27	0.36	0	0	0.33	0.56	1.84	0	0.12	0	0.02	0.13	0.01	0	0	0	0	0	0	0	0	0											9.01	0	0	29.49	0.34	5.97	-	1.38	7.35	0.38	1.26	4.44	0.42	3.54	-	-	2.99	5.56	18.32	0.67	1.18	-	0.23	1.28	1.91	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.72
H4208_801_0	2007	2																					none											D	D	D	V	coin	coin	coin	V	coin	coin	coin	O	P	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	752.36	8.71	1067.27	0	5.94	21.1	1.02	279.8	19.23	7.48	20.47	0	0	19.84	3742.72	5898.84	154.73	462.1	27.01	215.18	5.53	732.47	0	0	389.75	0	150.2	0	0	0	0											400/day up to 4 days.	400/day up to 4 days.	50 / day	0 copay	20 coinsurance	30 coinsurance	30 coinsurance	50 ER / 40 UC	20 ASC / 20 OP	0 coins pref lab / 20 coins non-pref	0 X-Ray / 20 Radiation Therapy	0 copay	30 copay	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	40 copay	20 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	30 Vision	Not covered	Not covered	30 copay	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											400	400	50	0	0.2	0.28	0.3	46.62	0.2	0.02	0.15	0	0	0.13	15.36	32.16	40	20	0	11.28	0.2	29.7	0	0	30	0	30	0	0	0	0											25.08	0.29	4.45	-	1.19	5.94	0.31	1.09	3.85	0.14	3.07	-	-	2.55	4.79	15.81	0.52	0.77	-	0.2	1.11	1.81	-	-	0.97	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.31	0	0	25.08	0.29	4.45	-	1.19	5.94	0.31	1.09	3.85	0.14	3.07	-	-	2.55	4.79	15.81	0.52	0.77	-	0.2	1.11	1.81	-	-	0.97	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.31	none	400/day up to 8 days.	400/day up to 8 days.	Not covered	Not covered	20 coinsurance	50 coinsurance	50 coinsurance	50 ER / 40 UC	0 ASC / 20 OP	30 coinsurance	0 X-Ray / 20 Radiation Therapy	0 copay	30 coinsurance	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	Not covered	20 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	20 coinsurance	Not covered	Not covered	Not covered	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											3.17	0.04	0	0	0.14	1.15	0.06	0.12	0.44	0.26	0.35	0	0	0.32	0.53	1.77	0	0.09	0	0.02	0.13	0.01	0	0	0	0	0.05	0	0	0	0											8.64	0	0	28.25	0.33	4.45	-	1.33	7.1	0.37	1.21	4.28	0.4	3.42	-	-	2.86	5.32	17.57	0.52	0.86	-	0.22	1.23	1.83	-	-	0.97	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.95
H4208_802_0	2007	2																					none											D	D	D	V	coin	coin	coin	V	coin	coin	coin	O	P	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	752.36	8.71	1067.27	0	5.94	21.1	1.02	279.8	19.23	7.48	20.47	0	0	19.84	3742.72	5898.84	154.73	462.1	27.01	215.18	5.53	732.47	0	0	389.75	0	150.2	0	0	0	0											400/day up to 4 days.	400/day up to 4 days.	50 / day	0 copay	20 coinsurance	30 coinsurance	30 coinsurance	50 ER / 40 UC	20 ASC / 20 OP	0 coins pref lab / 20 coins non-pref	0 X-Ray / 20 Radiation Therapy	0 copay	30 copay	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	40 copay	20 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	30 Vision	Not covered	Not covered	30 copay	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											400	400	50	0	0.2	0.28	0.3	46.62	0.2	0.02	0.15	0	0	0.13	15.36	32.16	40	20	0	11.28	0.2	29.7	0	0	30	0	30	0	0	0	0											25.08	0.29	4.45	-	1.19	5.94	0.31	1.09	3.85	0.14	3.07	-	-	2.55	4.79	15.81	0.52	0.77	-	0.2	1.11	1.81	-	-	0.97	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.31	0	0	25.08	0.29	4.45	-	1.19	5.94	0.31	1.09	3.85	0.14	3.07	-	-	2.55	4.79	15.81	0.52	0.77	-	0.2	1.11	1.81	-	-	0.97	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.31	none	400/day up to 8 days.	400/day up to 8 days.	Not covered	Not covered	20 coinsurance	50 coinsurance	50 coinsurance	50 ER / 40 UC	0 ASC / 20 OP	30 coinsurance	0 X-Ray / 20 Radiation Therapy	0 copay	30 coinsurance	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	Not covered	20 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	20 coinsurance	Not covered	Not covered	Not covered	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											3.17	0.04	0	0	0.14	1.15	0.06	0.12	0.44	0.26	0.35	0	0	0.32	0.53	1.77	0	0.09	0	0.02	0.13	0.01	0	0	0	0	0.05	0	0	0	0											8.64	0	0	28.25	0.33	4.45	-	1.33	7.1	0.37	1.21	4.28	0.4	3.42	-	-	2.86	5.32	17.57	0.52	0.86	-	0.22	1.23	1.83	-	-	0.97	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.95
H4208_803_0	2007	2																					none											D	D	D	V	coin	coin	coin	V	coin	coin	coin	O	P	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	752.36	8.71	1067.27	0	5.94	21.1	1.02	279.8	19.23	7.48	20.47	0	0	19.84	3742.72	5898.84	154.73	462.1	27.01	215.18	5.53	732.47	0	0	389.75	0	150.2	0	0	0	0											400/day up to 4 days.	400/day up to 4 days.	50 / day	0 copay	20 coinsurance	30 coinsurance	30 coinsurance	50 ER / 40 UC	20 ASC / 20 OP	0 coins pref lab / 20 coins non-pref	0 X-Ray / 20 Radiation Therapy	0 copay	30 copay	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	40 copay	20 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	30 Vision	Not covered	Not covered	30 copay	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											400	400	50	0	0.2	0.28	0.3	46.62	0.2	0.02	0.15	0	0	0.13	15.36	32.16	40	20	0	11.28	0.2	29.7	0	0	30	0	30	0	0	0	0											25.08	0.29	4.45	-	1.19	5.94	0.31	1.09	3.85	0.14	3.07	-	-	2.55	4.79	15.81	0.52	0.77	-	0.2	1.11	1.81	-	-	0.97	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.31	0	0	25.08	0.29	4.45	-	1.19	5.94	0.31	1.09	3.85	0.14	3.07	-	-	2.55	4.79	15.81	0.52	0.77	-	0.2	1.11	1.81	-	-	0.97	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.31	none	400/day up to 8 days.	400/day up to 8 days.	Not covered	Not covered	20 coinsurance	50 coinsurance	50 coinsurance	50 ER / 40 UC	0 ASC / 20 OP	30 coinsurance	0 X-Ray / 20 Radiation Therapy	0 copay	30 coinsurance	20 Cardio / 20 Therapy/20 other services	15 PCP	30 SCP / 30 Chiro / 30 Podiatrist	Not covered	20 copay	0 coinsurance	30 Hearing / 0 Preventive	20 coinsurance	20 coinsurance	Not covered	Not covered	Not covered	Not covered	30 copay	Not covered	Not covered	Not covered	Not covered											3.17	0.04	0	0	0.14	1.15	0.06	0.12	0.44	0.26	0.35	0	0	0.32	0.53	1.77	0	0.09	0	0.02	0.13	0.01	0	0	0	0	0.05	0	0	0	0											8.64	0	0	28.25	0.33	4.45	-	1.33	7.1	0.37	1.21	4.28	0.4	3.42	-	-	2.86	5.32	17.57	0.52	0.86	-	0.22	1.23	1.83	-	-	0.97	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.95
H4209_001_0	2007	5																					10000											D	D	D	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0.36	1.9	0.73	2.01	0	0	1.95	0	0	0	0	0	0	0.55	0.06	0	0	0	0	0	0	0	0	0											7.57	10000	1090.93	14.76	1014.69	24.12	277.32	21.52	1.03	328.44	22.54	8.72	23.86	0	0.22	23.26	4208.14	6256.22	156.06	516.22	23.02	256.35	6.48	751.3	0	0	378.82	0	162.21	0	0	0	0											150/day 1-7	150/day 1-7	10/day 1-10 100/day 11-100	10 coins	50 per trip	25 DME 12 Diab Monit	25 coins	50 ER / 25 UC	10 coins	10 coins	10 coins		20 coins	10 coins	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MHSA	20 Therapy	10 Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/10 Blood			25 copay		35 copay															146.76	146.76	53.66	0.1	48.92	0.23	0.24	41.97	0.1	0.1	0.1	0	0.19	0.1	24.4	31.92	34.24	19.57	0.02	11.99	0.19	24.52	0	0	24.46	0	34.24	0	0	0	0											13.34	0.18	4.54	2.36	1.13	5	0.25	1.15	2.2	0.85	2.33	-	0.04	2.31	8.56	16.64	0.45	0.84	0.46	0.26	1.2	1.54	-	-	0.77	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.87	150	1.75	13.34	0.18	4.54	2.36	1.13	5	0.25	1.51	4.1	1.59	4.35	-	0.04	4.26	8.56	16.64	0.45	0.84	0.46	0.26	1.75	1.6	-	-	0.77	-	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.44	none	20 coins	20 coins	20 coins	20 coins	50 per trip	30 coins	30 coins	20 coins	20 coins	20 coins	20 coins		20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins			30 benefit		20 coins															2.23	0.02	0.25	0.19	0.04	0.22	0.01	0.04	0.19	0.07	0.2	0	0	0.2	0.32	0.96	0.01	0.03	0.19	0.17	0.06	0.04	0	0	0.01	0.01	0.01															5.48	2000	0.27	15.57	0.2	4.79	2.55	1.17	5.23	0.26	1.55	4.29	1.66	4.55	-	0.04	4.46	8.88	17.6	0.45	0.87	0.65	0.43	1.8	1.64	-	-	0.78	0.01	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.92
H4209_002_0	2007	5																					10000											D	D	D	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0.36	1.9	0.73	2.01	0	0	1.95	0	0	0	0	0	0	0.55	0.06	0	0	0	0	0	0	0	0	0											7.56	10000	1134.63	15.19	1003.46	28.61	257.15	19.95	0.96	349.11	22.48	8.7	23.8	0	0.23	23.19	4129.28	6234.02	154.16	509.98	28.56	251.48	6.46	741.96	0	0	370.47	0	158.63	0	0	0	0											150/day 1-7	150/day 1-7	10/day 1-10 100/day 11-100	10 coins	50 per trip	25 DME 12 Diab Monit	25 coins	50 ER / 25 UC	10 coins	10 coins	10 coins		20 coins	10 coins	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MHSA	20 Therapy	10 Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/10 Blood			25 copay		35 copay															146.64	146.64	53.62	0.1	48.88	0.23	0.24	41.95	0.1	0.1	0.1	0	0.19	0.1	24.41	32.28	34.22	19.55	0.02	12.26	0.19	24.36	0	0	24.44	0	34.22	0	0	0	0											13.87	0.19	4.48	2.8	1.05	4.63	0.24	1.22	2.2	0.85	2.33	-	0.04	2.3	8.4	16.77	0.44	0.83	0.57	0.26	1.19	1.51	-	-	0.75	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.36	150	1.83	13.87	0.19	4.48	2.8	1.05	4.63	0.24	1.58	4.09	1.58	4.33	-	0.04	4.25	8.4	16.77	0.44	0.83	0.57	0.26	1.74	1.57	-	-	0.75	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.92	none	20 coins	20 coins	20 coins	20 coins	50 per trip	30 coins	30 coins	20 coins	20 coins	20 coins	20 coins		20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins			30 benefit		20 coins															2.23	0.02	0.24	0.22	0.04	0.2	0.01	0.04	0.18	0.07	0.19	0	0	0.19	0.33	1.02	0.01	0.03	0.23	0.17	0.06	0.04	0	0	0.01	0.01	0.01															5.53	2000	0.28	16.1	0.2	4.72	3.02	1.09	4.83	0.24	1.62	4.27	1.65	4.53	-	0.04	4.44	8.73	17.78	0.45	0.86	0.8	0.43	1.8	1.6	-	-	0.76	0.01	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.45
H4209_003_0	2007	5																					10000											D	D	D	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0.37	1.95	0.75	2.06	0	0	2	0	0	0	0	0	0	0.56	0.06	0	0	0	0	0	0	0	0	0											7.75	10000	1552.42	20.19	529.7	27.58	313.54	25.78	1.23	383.39	26.19	10.14	27.73	0	0.2	26.98	3791.21	5754.22	151.02	499.79	23.78	231.96	7.52	694.18	0	0	339.1	0	145.2	0	0	0	0											150/day 1-7	150/day 1-7	10/day 1-10 100/day 11-100	10 coins	50 per trip	25 DME 12 Diab Monit	25 coins	50 ER / 25 UC	10 coins	10 coins	10 coins		20 coins	10 coins	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist	35 MHSA	20 Therapy	10 Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/10 Blood			25 copay		35 copay															146.16	146.16	53.44	0.1	48.72	0.23	0.24	41.67	0.1	0.1	0.1	0	0.19	0.1	24.3	31.5	34.1	19.49	0.02	10.97	0.18	24.42	0	0	24.36	0	34.1	0	0	0	0											18.91	0.25	2.36	2.69	1.27	5.97	0.3	1.33	2.55	0.99	2.7	-	0.04	2.66	7.68	15.1	0.43	0.81	0.47	0.21	1.39	1.41	-	-	0.69	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.62	150	2.22	18.91	0.25	2.36	2.69	1.27	5.97	0.3	1.7	4.5	1.74	4.76	-	0.04	4.66	7.68	15.1	0.43	0.81	0.47	0.21	1.95	1.48	-	-	0.69	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.37	none	20 coins	20 coins	20 coins	20 coins	50 per trip	30 coins	30 coins	20 coins	20 coins	20 coins	20 coins		20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins	20 coins			30 benefit		20 coins															2.81	0.02	0.1	0.2	0.05	0.25	0.01	0.04	0.21	0.08	0.22	0	0	0.21	0.29	0.88	0.01	0.03	0.18	0.14	0.06	0.03	0	0	0.01	0.01	0.01															5.86	2000	0.35	21.72	0.27	2.46	2.89	1.32	6.22	0.31	1.74	4.7	1.82	4.98	-	0.04	4.87	7.97	15.98	0.44	0.84	0.66	0.36	2.01	1.51	-	-	0.7	0.01	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.23
H4209_004_0	2007	5																					5000											D	D	D	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0.36	1.89	0.73	2.01	0	0	1.95	0	0	0	0	0	0	0.55	0.06	0	0	0	0	0	0	0	0	0											7.55	5000	1098.18	14.81	1003.46	24.33	273.51	21.28	1.02	316.95	22.21	8.59	23.53	0	0.23	22.94	4299.34	6350.29	159.13	526.57	23.04	260.04	6.39	748.92	0	0	378.75	0	162.18	0	0	0	0											150/day 1-7	150/day 1-7	10/day 1-10 100/day 11-100	10 coins	50 per trip	25 DME 12 Diab Monit	25 coins	50 ER / 25 UC	10 coins	10 coins	10 coins		20 coins	10 coins	15 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MHSA	20 Therapy	10 Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/10 Blood			25 copay		35 copay															138.98	138.98	50.81	0.09	46.33	0.22	0.23	39.74	0.09	0.09	0.09	0	0.17	0.09	13.97	22.6	23.16	18.53	0.02	11.27	0.18	23.24	0	0	23.16	0	32.43	0	0	0	0											12.72	0.17	4.25	2.25	1.06	4.69	0.24	1.05	2.05	0.8	2.18	-	0.04	2.14	5	11.96	0.31	0.81	0.43	0.24	1.12	1.45	-	-	0.73	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.13	150	4.93	12.72	0.17	4.25	2.25	1.06	4.69	0.24	1.41	3.95	1.53	4.18	-	0.04	4.09	5	11.96	0.31	0.81	0.43	0.24	1.67	1.51	-	-	0.73	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68	none	30 coins	30 coins	30 coins	30 coins	50 per trip	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins		30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins			30 benefit		30 coins															1.31	0.01	0.14	0.11	0.03	0.16	0.01	0.02	0.11	0.04	0.12	0	0	0.11	0.19	0.57	0.01	0.02	0.11	0.1	0.03	0.03	0	0	0.01	0.01	0															3.26	1000	0.46	14.03	0.18	4.39	2.37	1.09	4.85	0.24	1.43	4.06	1.57	4.3	-	0.04	4.2	5.19	12.54	0.31	0.83	0.54	0.35	1.7	1.54	-	-	0.74	0.01	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.94
H4209_005_0	2007	5																					5000											D	D	D	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0.36	1.9	0.73	2.01	0	0	1.95	0	0	0	0	0	0	0.55	0.06	0	0	0	0	0	0	0	0	0											7.56	5000	1140.77	15.22	1019.54	28.93	255.29	19.8	0.95	346.34	22.36	8.65	23.67	0	0.23	23.07	4212.58	6312.38	154.61	511.51	28.97	254.42	6.42	740.3	0	0	369.85	0	158.37	0	0	0	0											150/day 1-7	150/day 1-7	10/day 1-10 100/day 11-100	10 coins	50 per trip	25 DME 12 Diab Monit	25 coins	50 ER / 25 UC	10 coins	10 coins	10 coins		20 coins	10 coins	15 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MHSA	20 Therapy	10 Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/10 Blood			25 copay		35 copay															138.55	138.55	50.66	0.09	46.18	0.22	0.23	39.59	0.09	0.09	0.09	0	0.17	0.09	13.96	22.85	23.09	18.47	0.02	11.49	0.17	23	0	0	23.09	0	32.33	0	0	0	0											13.17	0.18	4.3	2.67	0.98	4.35	0.22	1.14	2.06	0.8	2.18	-	0.04	2.15	4.9	12.02	0.3	0.79	0.54	0.24	1.12	1.42	-	-	0.71	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.72	150	5.18	13.17	0.18	4.3	2.67	0.98	4.35	0.22	1.5	3.96	1.53	4.19	-	0.04	4.1	4.9	12.02	0.3	0.79	0.54	0.24	1.67	1.48	-	-	0.71	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.27	none	30 coins	30 coins	30 coins	30 coins	50 per trip	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins		30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins			30 benefit		30 coins															1.3	0.01	0.14	0.13	0.03	0.14	0.01	0.02	0.1	0.04	0.11	0	0	0.11	0.19	0.6	0.01	0.02	0.14	0.1	0.03	0.03	0	0	0.01	0.01	0															3.28	1000	0.47	14.47	0.19	4.45	2.8	1.01	4.49	0.23	1.53	4.06	1.57	4.3	-	0.04	4.21	5.09	12.63	0.3	0.81	0.68	0.34	1.7	1.51	-	-	0.72	0.01	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.56
H4209_006_0	2007	5																					5000											D	D	D	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0.37	1.95	0.75	2.06	0	0	2	0	0	0	0	0	0	0.56	0.06	0	0	0	0	0	0	0	0	0											7.76	5000	1552.42	20.19	529.7	27.58	313.54	25.78	1.23	383.39	26.19	10.14	27.73	0	0.2	26.98	3874.06	5822.77	151.02	499.79	24	235.02	7.52	694.18	0	0	339.1	0	145.2	0	0	0	0											150/day 1-7	150/day 1-7	10/day 1-10 100/day 11-100	10 coins	50 per trip	25 DME 12 Diab Monit	25 coins	50 ER / 25 UC	10 coins	10 coins	10 coins		20 coins	10 coins	15 PCP	25 SCP / 25 Chiro / 25 Podiatrist	25 MHSA	20 Therapy	10 Hosp 0 Office	35 Hearing / 0 Preventive	20 coins	25 Vision/10 Blood			25 copay		35 copay															137.02	137.02	50.1	0.09	45.67	0.22	0.23	39	0.09	0.09	0.09	0	0.17	0.09	13.77	22.28	22.84	18.27	0.02	10.21	0.17	22.87	0	0	22.84	0	31.97	0	0	0	0											17.73	0.23	2.21	2.52	1.19	5.6	0.28	1.25	2.39	0.92	2.53	-	0.03	2.48	4.45	10.81	0.29	0.76	0.45	0.2	1.3	1.32	-	-	0.65	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.96	150	6.28	17.73	0.23	2.21	2.52	1.19	5.6	0.28	1.62	4.34	1.68	4.59	-	0.03	4.48	4.45	10.81	0.29	0.76	0.45	0.2	1.86	1.39	-	-	0.65	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.73	none	30 coins	30 coins	30 coins	30 coins	50 per trip	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins		30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins	30 coins			30 benefit		30 coins															1.63	0.01	0.06	0.12	0.03	0.18	0.01	0.02	0.12	0.05	0.13	0	0	0.12	0.17	0.52	0	0.02	0.11	0.08	0.04	0.03	0	0	0.01	0.01	0															3.46	1000	0.58	19.36	0.24	2.27	2.64	1.23	5.78	0.29	1.64	4.46	1.73	4.72	-	0.03	4.6	4.61	11.33	0.29	0.78	0.55	0.28	1.9	1.41	-	-	0.65	0.01	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.18
H4209_809_0	2007	4																					10000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	2.62	0	0	0	0	0.22	0.09	1.86	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											4.79	10000	1106.98	15.12	943.13	26.1	270.7	21.14	1.01	358.41	23.27	2283.83	24.9	0	0.21	24.22	5702.69	15136.23	148.27	490.59	24.86	20.76	6.77	731.16	0	0	381.48	98.94	161.52	0	0	0	0											150 Per Day: Days 1 to 7	150 Per Day: Days 1 to 7	10 Per Day:  1-10 100 Per Day:  11-100	10	50 Per Run	25 DME/Prosthetics 12 Diabetes	25 DME/Prosthetics 12 Diabetes	50 ER/25 UC	10	25 x-rays 10 therapy	10	0	20	35 OP SA / 20 Cardiac Rehab/10 Other	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist/10 Other	35 MH	20 Therapy	10 OP Professional / 0 Office	35 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	25	25 copay	35				0											145.67	145.67	53.26	0.1	48.56	0.23	0.24	41.46	0.1	24.28	0.11	0	0.19	0.08	19.46	16.11	33.99	19.42	0.01	0.11	0.18	24.28	0	0	25	25	33.99	0	0	0	0											13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	2.26	4.62	2.84	-	0.04	1.97	9.25	20.32	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.97	100	2.65	13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	4.88	4.62	2.84	-	0.04	2.19	9.34	22.18	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76	20000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0	0	25 copay	25 copay	N/A	0	0	0	0											3.32	0.03	0.34	0.31	0.06	0.32	0.01	0.05	0.29	0.11	0.31	0	0	0.3	0.47	1.47	0.01	0.05	0.31	0.25	0.09	0.06	0	0	0.02	0.01	0	0	0	0	0											8.21	2000	0.39	16.76	0.21	4.53	2.85	1.16	5.2	0.26	1.29	5.17	4.73	3.15	-	0.04	2.49	9.8	23.65	0.43	0.84	0.55	2.49	1.33	1.54	-	-	0.82	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.97
H4209_810_0	2007	4																					10000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	2.62	0	0	0	0	0.22	0.09	1.86	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											4.79	10000	1106.98	15.12	943.13	26.1	270.7	21.14	1.01	358.41	23.27	2283.83	24.9	0	0.21	24.22	5702.69	15136.23	148.27	490.59	24.86	20.76	6.77	731.16	0	0	381.48	98.94	161.52	0	0	0	0											150 Per Day: Days 1 to 7	150 Per Day: Days 1 to 7	10 Per Day:  1-10 100 Per Day:  11-100	10	50 Per Run	25 DME/Prosthetics 12 Diabetes	25 DME/Prosthetics 12 Diabetes	50 ER/25 UC	10	25 x-rays 10 therapy	10	0	20	35 OP SA / 20 Cardiac Rehab/10 Other	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist/10 Other	35 MH	20 Therapy	10 OP Professional / 0 Office	35 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	25	25 copay	35				0											145.67	145.67	53.26	0.1	48.56	0.23	0.24	41.46	0.1	24.28	0.11	0	0.19	0.08	19.46	16.11	33.99	19.42	0.01	0.11	0.18	24.28	0	0	25	25	33.99	0	0	0	0											13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	2.26	4.62	2.84	-	0.04	1.97	9.25	20.32	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.97	100	2.65	13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	4.88	4.62	2.84	-	0.04	2.19	9.34	22.18	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76	20000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0	0	25 copay	25 copay	N/A	0	0	0	0											3.32	0.03	0.34	0.31	0.06	0.32	0.01	0.05	0.29	0.11	0.31	0	0	0.3	0.47	1.47	0.01	0.05	0.31	0.25	0.09	0.06	0	0	0.02	0.01	0	0	0	0	0											8.21	2000	0.39	16.76	0.21	4.53	2.85	1.16	5.2	0.26	1.29	5.17	4.73	3.15	-	0.04	2.49	9.8	23.65	0.43	0.84	0.55	2.49	1.33	1.54	-	-	0.82	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.97
H4209_811_0	2007	3																					10000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O			V	P	V															0	0	0	0	0	0	0	0	2.62	0	0	0	0	0.22	0.09	1.86	0	0	0	0	0	0			0	0	0															4.79	10000	1106.98	15.12	943.13	26.1	270.7	21.14	1.01	358.41	23.27	2283.83	24.9	0	0.21	24.22	5702.69	15136.23	148.27	490.59	24.86	20.76	6.77	731.16			381.48	98.94	161.52															150 Per Day: Days 1 to 7	150 Per Day: Days 1 to 7	10 Per Day:  1-10 100 Per Day:  11-100	10	50 Per Run	25 DME/Prosthetics 12 Diabetes	25 DME/Prosthetics 12 Diabetes	50 ER/25 UC	10	25 x-rays 10 therapy	10	0	20	35 OP SA / 20 Cardiac Rehab/10 Other	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist/10 Other	35 MH	20 Therapy	10 OP Professional / 0 Office	35 Hearing / 0 Preventive	20	25 Vision/0 Blood			25	25 copay	35															145.67	145.67	53.26	0.1	48.56	0.23	0.24	41.46	0.1	24.28	0.11	0	0.19	0.08	19.46	16.11	33.99	19.42	0.01	0.11	0.18	24.28			25	25	33.99															13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	2.26	4.62	2.84	-	0.04	1.97	9.25	20.32	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.97	100	2.65	13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	4.88	4.62	2.84	-	0.04	2.19	9.34	22.18	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76	20000	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance			25 copay	25 copay	N/A															3.32	0.03	0.34	0.31	0.06	0.32	0.01	0.05	0.29	0.11	0.31	0	0	0.3	0.47	1.47	0.01	0.05	0.31	0.25	0.09	0.06			0.02	0.01	0															8.21	2000	0.39	16.76	0.21	4.53	2.85	1.16	5.2	0.26	1.29	5.17	4.73	3.15	-	0.04	2.49	9.8	23.65	0.43	0.84	0.55	2.49	1.33	1.54	-	-	0.82	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.97
H4209_812_0	2007	3																					10000											D	D	D	coin	T	coin	coin	V	coin	P	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O			V	P	V															0	0	0	0	0	0	0	0	2.62	0	0	0	0	0.22	0.09	1.86	0	0	0	0	0	0			0	0	0															4.79	10000	1106.98	15.12	943.13	26.1	270.7	21.14	1.01	358.41	23.27	2283.83	24.9	0	0.21	24.22	5702.69	15136.23	148.27	490.59	24.86	20.76	6.77	731.16			381.48	98.94	161.52															150 Per Day: Days 1 to 7	150 Per Day: Days 1 to 7	10 Per Day:  1-10 100 Per Day:  11-100	10	50 Per Run	25 DME/Prosthetics 12 Diabetes	25 DME/Prosthetics 12 Diabetes	50 ER/25 UC	10	25 x-rays 10 therapy	10	0	20	35 OP SA / 20 Cardiac Rehab/10 Other	25 PCP	35 SCP / 35 Chiro / 35 Podiatrist/10 Other	35 MH	20 Therapy	10 OP Professional / 0 Office	35 Hearing / 0 Preventive	20	25 Vision/0 Blood			25	25 copay	35															145.67	145.67	53.26	0.1	48.56	0.23	0.24	41.46	0.1	24.28	0.11	0	0.19	0.08	19.46	16.11	33.99	19.42	0.01	0.11	0.18	24.28			25	25	33.99															13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	2.26	4.62	2.84	-	0.04	1.97	9.25	20.32	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.97	100	2.65	13.44	0.18	4.19	2.53	1.1	4.88	0.25	1.24	4.88	4.62	2.84	-	0.04	2.19	9.34	22.18	0.42	0.79	0.24	2.24	1.24	1.48	-	-	0.79	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.76	20000	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance	30 Coinisurance			25 copay	25 copay	N/A															3.32	0.03	0.34	0.31	0.06	0.32	0.01	0.05	0.29	0.11	0.31	0	0	0.3	0.47	1.47	0.01	0.05	0.31	0.25	0.09	0.06			0.02	0.01	0															8.21	2000	0.39	16.76	0.21	4.53	2.85	1.16	5.2	0.26	1.29	5.17	4.73	3.15	-	0.04	2.49	9.8	23.65	0.43	0.84	0.55	2.49	1.33	1.54	-	-	0.82	0.21	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.97
H4406_001_0	2007	7																					3850											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	7500	1907.22	105.72	985.13	0	185.59	10.76	5.13	475.43	28.34	6735.13	38.19	0	0.13	16.33	3082.87	3098.95	365.96	1.3	0	0	19.87	618.61	0	0	119.99	143.7	184.27	0	0	0	0											275 (1a)	250 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	15 (17b1-17b5)	35 (18a)	0 (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											174.7	158.82	88.94	0	111.17	0.19	0.22	31.76	0.16	1.27	0.12	0	0.19	0.16	15	35	37.5	0.16	0	0	0.19	35	0	0	35	15	35	0	0	0	0											27.77	1.4	7.3	-	1.72	2.05	1.11	1.26	4.5	0.71	4.62	-	0.03	2.59	3.85	9.04	1.14	0.21	-	-	3.79	1.8	-	-	0.35	0.18	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.97		33.69	27.77	1.4	7.3	-	1.72	2.05	1.11	1.26	4.5	0.71	4.62	-	0.03	2.59	3.85	9.04	1.14	0.21	-	-	3.79	1.8	-	-	0.35	0.18	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.97		40 (1a)	40 (1b)	0 n/c (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											5.93	0.15	0	0.37	0.41	0.49	0.26	0.3	1.29	0.68	1.34	0	0.01	0.75	1.41	2.27	0.28	0.06	0	0	0.91	0.51	0	0	0.09	0	0.13	0	0	0	0											17.63		5.52	33.69	1.55	7.3	0.37	2.13	2.54	1.37	1.56	5.79	1.4	5.96	-	0.03	3.34	5.26	11.31	1.43	0.27	-	-	4.69	2.31	-	-	0.44	0.18	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.6
H4406_003_0	2007	6																					3250											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	6950	1907.22	105.72	985.13	0	185.59	10.76	5.13	475.43	28.34	6735.13	38.19	0	0.13	16.33	3082.87	3098.95	365.96	1.3	0	0	19.87	618.61	0	0	119.99	143.7	184.27	0	0	0	0											275 (1a)	250 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	15 (17b1-17b5)	35 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											161.22	146.56	82.07	0	102.59	0.18	0.21	29.31	0.15	3.52	0.11	0	0.18	0.15	15	35	37.5	0.15	0	0	0.18	35	0	0	35	15	35	0	0	0	0											25.62	1.29	6.74	-	1.59	1.89	1.06	1.16	4.15	1.97	4.27	-	0.02	2.39	3.85	9.04	1.14	0.19	-	-	3.49	1.8	-	-	0.35	0.18	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.75		39.15	25.62	1.29	6.74	-	1.59	1.89	1.06	1.16	4.15	1.97	4.27	-	0.02	2.39	3.85	9.04	1.14	0.19	-	-	3.49	1.8	-	-	0.35	0.18	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.75		40 (1a)	40 (1b)	0 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											6.03	0.15	0	0.26	0.42	0.5	0.24	0.31	1.32	0.69	1.36	0	0.01	0.76	0.99	1.6	0.2	0.06	0	0	0.92	0.36	0	0	0.06	0	0.1	0	0	0	0											16.32		6.83	31.65	1.44	6.74	0.26	2.01	2.39	1.29	1.47	5.47	2.67	5.63	-	0.03	3.15	4.85	10.64	1.34	0.25	-	-	4.42	2.16	-	-	0.41	0.18	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.08
H4406_004_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2335.58	369.56	1189.79		277.3	29.2	25.3	950.27	412.03	2161.74	1014.19	70.19	3.57	2134.01		3683.09		559.1		857.28												304.2		163.76	243.62							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							6.81	1.08	1.67	-	0.81	2.73	2.36	1.33	0.4	0.84	0.39	0.07	0.33	2.08	-	1.43	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.16		26.46	6.81	1.08	1.67	-	0.81	2.73	2.36	1.33	0.4	0.84	0.39	0.07	0.33	2.08	-	1.43	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.16																																																																																				-		0	6.81	1.08	1.67	-	0.81	2.73	2.36	1.33	0.4	0.84	0.39	0.07	0.33	2.08	-	1.43	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.16
H4406_801_0	2007	3																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2176.72	120.66	1034.39	0	237.64	13.78	6.57	608.79	36.29	8624.25	48.9	0	0.17	20.91	3947.58	3968.17	468.61	1.66	0	0	25.44	792.12	0	0	153.64	0	235.96	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	30 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											220.79	220.79	94.63	0	110.4	0.19	0.22	31.54	0.19	3.79	0.14	0	0.19	0.19	30	35	37.5	0.19	0	0	0.19	35	0	0	35	0	35	0	0	0	0											40.05	2.22	8.16	-	2.19	2.61	1.42	1.6	6.87	2.72	6.97	-	0.03	3.96	9.87	11.57	1.46	0.31	-	-	4.82	2.31	-	-	0.45	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.28		48.83	40.05	2.22	8.16	-	2.19	2.61	1.42	1.6	6.87	2.72	6.97	-	0.03	3.96	9.87	11.57	1.46	0.31	-	-	4.82	2.31	-	-	0.45	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.28																																																																																				-			40.05	2.22	8.16	-	2.19	2.61	1.42	1.6	6.87	2.72	6.97	-	0.03	3.96	9.87	11.57	1.46	0.31	-	-	4.82	2.31	-	-	0.45	-	0.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.28
H4407_001_0	2007	3											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	1011.958448	371.4346771	242.6998569		78.81102741	7.981278111		257.9947438	240.5448297		402.625086	23.97549042			7136.044729	3058.304884	263.0257388				25.29772278	2.389974858	431.2566428		192.1052318							2.778496937										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										12.65	4.64	1.01	-	0.66	1.6	-	1.07	5.01	-	2.52	0.3	-	-	8.92	7.65	0.66	-	-	-	5.06	0.03	0.13	-	0.48	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	52.44		0	12.65	4.64	1.01	-	0.66	1.6	-	1.07	5.01	-	2.52	0.3	-	-	8.92	7.65	0.66	-	-	-	5.06	0.03	0.13	-	0.48	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	52.44	2000																																																																																			-		0	12.65	4.64	1.01	-	0.66	1.6	-	1.07	5.01	-	2.52	0.3	-	-	8.92	7.65	0.66	-	-	-	5.06	0.03	0.13	-	0.48	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	52.44
H4407_002_0	2007	3																					2000											D	D	D	V	T	Coin	Coin	V	P	O	V	O	V	O	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-	0	1391.35	43.72	404.48		79.76	8.52		327.94	221.46						4331.42	3690.46	113.99		110.64		17.77					427.93																150 per day for 1st 10 days	170 per day for 1st 10 days	95 for days 1 to 100		160 per trip	20 coinsurance		50 per visit	270 per visit						5 per visit	15 per visit	15 per visit		15 per visit		10 per Script					100 limit on eyewear																150	170	95		160	0.2		50	270						5	15	15		15		0.1					100																17.39	0.62	3.2	-	1.06	1.7	-	1.37	4.98	-	-	-	-	-	1.8	4.61	0.14	-	0.14	-	1.78	-	-	-	-	3.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.37	0	0	17.39	0.62	3.2	-	1.06	1.7	-	1.37	4.98	-	-	-	-	-	1.8	4.61	0.14	-	0.14	-	1.78	-	-	-	-	3.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.37	2000																																																																																			-	0	0	17.39	0.62	3.2	-	1.06	1.7	-	1.37	4.98	-	-	-	-	-	1.8	4.61	0.14	-	0.14	-	1.78	-	-	-	-	3.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.37
H4407_003_0	2007	2																					0																																																																																													-	0																																																																																																																												-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0																																																																																			-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4407_004_0	2007	3																					0											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		0		0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0	0					0											0 copay	0 copay	0 copay		0 per trip	0 coins	0 coins	0 copay	0 copay		0 copay		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0	0	0 copay		0 copay	100 limit on eyewear					0 copay											0	0	0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0						0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4407_005_0	2007	3											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	885.46	325.01	212.36		68.96	6.98		225.75	210.48		352.3	20.98			6244.04	2676.02	230.15				22.14	2.09	377.35		168.09							2.43										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88	2000																																																																																			-		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88
H4407_007_0	2007	5																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4407_008_0	2007	4																																D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	Coin	T	V	V	V				O	V																																																				-		0		0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0	0		0			0											0 copay	0 copay	0 copay		0 per trip	0 coins	0 coins	0 copay	0 copay		0 copay		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0	0	0 copay		0 copay	100 limit on eyewear		500 once every 3 years			0 copay											0	0	0		0	0	0	0	0		0		0	0	0	0	0	0	0	0	0	0	0		0			0			0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4407_009_0	2007	4	0										Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	885.46	325.01	212.36		68.96	6.98		225.75	210.48		352.3	20.98			6363.89	2727.38	241.65				22.14	2.09	377.35		168.09							2.4										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	200 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	200		75	150			15	30	30				0.2	150	3.5		30							250										11.07	4.06	0.88	-	0.57	1.4	-	0.94	3.51	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.31			11.07	4.06	0.88	-	0.57	1.4	-	0.94	3.51	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.31	2000																																																																																			-			11.07	4.06	0.88	-	0.57	1.4	-	0.94	3.51	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.31
H4407_802_0	2007	3	0										Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	885.46	325.01	212.36		68.96	6.98		225.75	210.48		352.3	20.98			6244.04	2676.02	230.15				22.14	2.09	377.35		168.09							2.43										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88	2000																																																																																			-		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88
H4407_807_0	2007	6	0										Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	885.46	325.01	212.36		68.96	6.98		225.75	210.48		352.3	20.98			6363.89	2727.38	241.65				22.14	2.09	377.35		168.09							2.4										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.19		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.19	2000																																																																																			-		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.19
H4407_808_0	2007	3	0										Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T										0	0	0		0	0		0	0		0	0			0	0	0				0	0	0		0							0										-	0	885.46	325.01	212.36		68.96	6.98		225.75	210.48		352.3	20.98			6244.04	2676.02	230.15				22.14	2.09	377.35		168.09							2.43										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88	2000																																																																																			-		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.81	6.69	0.58	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.88
H4407_809_0	2007	6	0	0	0	0	0	0	0	0	0	0	Ambulance	0	0	0	0	0	0	0	0	0	2000	Air	0	0	0	0	0	0	0	0	0	D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	885.46	325.01	212.36		68.96	6.98		225.75	210.48		352.3	20.98			6363.89	2727.38	241.65				22.14	2.09	377.35		168.09							2.4										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.19		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.19	2000																																																																																			-		0	11.07	4.06	0.88	-	0.57	1.4	-	0.94	4.38	-	2.2	0.26	-	-	7.95	6.82	0.6	-	-	-	4.43	0.03	0.11	-	0.42	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.19
H4408_001_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1281.66	9.35	459.8	2193.77	127.92	0.74	0.06	207.57	452.47	834.43	568.93	37.93	388.94	322.39	7333.23	8698.53			320.76		10.27											67.46	0.49	16.71								190/day (1-5)	190/day (1-5)	0/day (1-10) 100/day (11-100)	15/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125-200/ Visit	0-90/ Visit	50-90/ Visit	50/ Visit	0/ Procedure	35-90/ Visit	15/ Visit	35/ Visit			50/ Visit		20 Coins											190/day (1-5)	190/day (1-5)	20 Coins								129.24	129.24	20.37	15	100	0.2	0.2	49.63	149.75	69.55	56.67	50	0	44.71	15	35			50		0.2											129.24	129.24	0.2								13.8	0.1	0.78	2.74	1.07	0.15	0.01	0.86	5.65	4.84	2.69	0.16	-	1.2	9.17	25.37	-	-	1.34	-	2.05	-	-	-	-	-	-	-	-	-	-	0.73	0.01	3.34	-	-	-	-	-	-	-	76.04	0	0	13.8	0.1	0.78	2.74	1.07	0.15	0.01	0.86	5.65	4.84	2.69	0.16	-	1.2	9.17	25.37	-	-	1.34	-	2.05	-	-	-	-	-	-	-	-	-	-	0.73	0.01	3.34	-	-	-	-	-	-	-	76.04		30 Coins	30 Coins	30 Coins	30 Coins	100/Trip	40 Coins		50/Visit	30 Coins	30 Coins			0/Procedure		30 Coins	30 Coins					20 Coins													30 Coins								11.68	0.05	0.39	0.53	0.34	0.05		0.34	4.83	5.7			0		3.62	4.35					0.78													1.24								33.89	1000	0	25.49	0.15	1.17	3.27	1.41	0.2	0.01	1.19	10.48	10.54	2.69	0.16	-	1.2	12.78	29.72	-	-	1.34	-	2.83	-	-	-	-	-	-	-	-	-	-	0.73	0.01	4.58	-	-	-	-	-	-	-	109.93
H4408_002_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1268.21	9.26	454.97	2170.75	126.58	0.72	0.05	205.39	447.72	825.67	562.96	37.53	384.86	319.01	7256.26	8607.24			317.4		10.05											66.75	0.49	16.36								190/day (1-5)	190/day (1-5)	0/day (1-10) 100/day (11-100)	15/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125-200/ Visit	0-90/ Visit	50-90/ Visit	50/ Visit	0/ Procedure	35-90/ Visit	15/ Visit	35/ Visit			50/ Visit		20 Coins											190/day (1-5)	190/day (1-5)	20 Coins								129.24	129.24	20.37	15	100	0.2	0.2	49.63	149.75	69.55	56.67	50	0	44.71	15	35			50		0.2											129.24	129.24	0.2								13.66	0.1	0.77	2.71	1.05	0.14	0.01	0.85	5.59	4.79	2.66	0.16	-	1.19	9.07	25.1	-	-	1.32	-	2.01	-	-	-	-	-	-	-	-	-	-	0.72	0.01	3.27	-	-	-	-	-	-	-	75.18	0	0	13.66	0.1	0.77	2.71	1.05	0.14	0.01	0.85	5.59	4.79	2.66	0.16	-	1.19	9.07	25.1	-	-	1.32	-	2.01	-	-	-	-	-	-	-	-	-	-	0.72	0.01	3.27	-	-	-	-	-	-	-	75.18		30 Coins	30 Coins	30 Coins	30 Coins	100/Trip	40 Coins		50/Visit	30 Coins	30 Coins			0/Procedure		30 Coins	30 Coins					20 Coins													30 Coins								10.33	0.04	0.34	0.47	0.32	0.04		0.32	4.27	5.04			0		3.2	3.84					0.69													1.1								29.99	1000	2.04	23.99	0.14	1.12	3.18	1.37	0.19	0.01	1.16	9.86	9.82	2.66	0.16	-	1.19	12.27	28.95	-	-	1.32	-	2.7	-	-	-	-	-	-	-	-	-	-	0.72	0.01	4.37	-	-	-	-	-	-	-	105.17
H4408_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1283.12	9.36	460.32	2196.26	128.07	0.74	0.06	253.42	452.98	835.38	569.57	37.97	389.39	322.76	7341.55	8708.4			321.13		10.29											13.63	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									121.11	125.13	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.95	0.1	0.34	1.83	1.07	0.19	0.01	0.95	7.55	2.44	2.18	0.32	-	1.01	15.29	25.4	-	-	0.94	-	2.06	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.3	0	0	12.95	0.1	0.34	1.83	1.07	0.19	0.01	0.95	7.55	2.44	2.18	0.32	-	1.01	15.29	25.4	-	-	0.94	-	2.06	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.3		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.3	0.02	0.41	0.56	0.27	0.05		0.26	5.07	5.98			0		1.9	4.56					0.61																					21.98	0	0	15.25	0.11	0.74	2.39	1.33	0.23	0.01	1.22	12.62	8.42	2.18	0.32	-	1.01	17.19	29.96	-	-	0.94	-	2.67	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	97.28
H4408_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		255.07	1.92	453.33	2162.9	126.12	0.72	0.05	249.57	446.1	822.69	560.92	37.39	383.47	317.86	7230.03	8576.13			316.25		9.98											13.42	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.75	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.44	2.4	2.14	0.31	-	1	15.06	25.01	-	-	0.92	-	2	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.13	0	0	12.75	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.44	2.4	2.14	0.31	-	1	15.06	25.01	-	-	0.92	-	2	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.13		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.27	0.02	0.39	0.54	0.26	0.05		0.26	4.91	5.8			0		1.84	4.42					0.59																					21.36	0	0	15.02	0.11	0.73	2.34	1.31	0.23	0.01	1.2	12.35	8.2	2.14	0.31	-	1	16.9	29.44	-	-	0.92	-	2.59	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.49
H4408_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		259	1.95	460.32	2196.26	128.07	0.74	0.06	253.42	452.98	835.38	569.57	37.97	389.39	322.76	7341.55	8708.4			321.13		10.29											13.63	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.95	0.1	0.34	1.83	1.07	0.19	0.01	0.95	7.55	2.44	2.18	0.32	-	1.01	15.29	25.4	-	-	0.94	-	2.06	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.3	0	0	12.95	0.1	0.34	1.83	1.07	0.19	0.01	0.95	7.55	2.44	2.18	0.32	-	1.01	15.29	25.4	-	-	0.94	-	2.06	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.3		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.3	0.02	0.41	0.56	0.27	0.05		0.26	5.07	5.98			0		1.9	4.56					0.61																					21.98	0	0	15.25	0.11	0.74	2.39	1.33	0.23	0.01	1.22	12.62	8.42	2.18	0.32	-	1.01	17.19	29.96	-	-	0.94	-	2.67	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	97.28
H4408_805_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		255.07	1.92	453.33	2162.9	126.12	0.72	0.05	249.57	446.1	822.69	560.92	37.39	383.47	317.86	7230.03	8576.13			316.25		9.98											13.42	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.75	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.44	2.4	2.14	0.31	-	1	15.06	25.01	-	-	0.92	-	2	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.13	0	0	12.75	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.44	2.4	2.14	0.31	-	1	15.06	25.01	-	-	0.92	-	2	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.13		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.27	0.02	0.39	0.54	0.26	0.05		0.26	4.91	5.8			0		1.84	4.42					0.59																					21.36	0	0	15.02	0.11	0.73	2.34	1.31	0.23	0.01	1.2	12.35	8.2	2.14	0.31	-	1	16.9	29.44	-	-	0.92	-	2.59	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.49
H4449_002_0	2007	6	h.1.	h.2.									OP Facility - Other	OP Facility - Other									500	Complex diag	PET scans											D		T	Coin	Coin	V							V	V	V	V	V	V												P	V																																																		-	N/A			1580.39		106.65	27.19	6.8	775							6999.99	3018.58	267.54	4396.38	1480.81	11324.82												45.29	3.8											50/Days 20 - 100		100	0	0	50							5	5	5	5	5	5												50	200											46.71		93.41	0.19	0.19	46.71							4.67	4.67	4.67	4.67	4.67	4.67												46.71	186.82									-	-	6.15	-	0.83	5.08	1.27	3.02	-	-	-	-	-	-	2.72	1.17	0.1	1.71	0.58	4.41	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	27.28	0	1.84	-	-	6.15	-	0.83	5.08	1.27	3.02	-	-	-	-	-	-	2.72	1.17	0.1	1.71	0.58	4.41	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	27.28	500																																																																																			-	0	0	-	-	6.15	-	0.83	5.08	1.27	3.02	-	-	-	-	-	-	2.72	1.17	0.1	1.71	0.58	4.41	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	27.28
H4449_003_0	2007	3	h.1.	h.2.									OP Facility - Other	OP Facility - Other									500	Complex diag	PET scans											D		T	Coin	Coin	V							V	V	V	V	V	V												P	V																																																		-	N/A			1619.32		108.18	28.4	7.1	786.12							7172.42	3092.94	274.13	4504.68	1517.28	11603.78												45.29	3.8											50/Days 20 - 100		100	20	20	50							5	5	5	5	5	5												50	200											46.71		93.41	0.19	0.19	46.71							4.67	4.67	4.67	4.67	4.67	4.67												46.71	186.82									-	-	6.3	-	0.84	5.31	1.33	3.06	-	-	-	-	-	-	2.79	1.2	0.11	1.75	0.59	4.52	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	28.04	0	1.84	-	-	6.3	-	0.84	5.31	1.33	3.06	-	-	-	-	-	-	2.79	1.2	0.11	1.75	0.59	4.52	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	28.04	500																																																																																			-	0	0	-	-	6.3	-	0.84	5.31	1.33	3.06	-	-	-	-	-	-	2.79	1.2	0.11	1.75	0.59	4.52	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	28.04
H4449_004_0	2007	2																					3000											D	D	D		T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	N/A	1690.09	40	1567.16		105.76	22.92	7.64	768.51	774.65	8.72	6.98	6.98	3.49	2.91	6941.37	2993.31	265.3	4359.57	6.79	108.4	7.31	0.76																				125 per Day days 1 - 5	125 per Day days 1 - 5	125 per day for days 25 -100	None	100 per one way trip	20	20	50 per visit	50 per surgery	20	20	20	20	20	10	20	20	20	20	20	20	20																				78.11	78.11	25.22		99.3	0.2	0.2	49.65	49.65	0.2	0.2	0.2	0.2	0.2	9.93	19.86	19.86	19.86	0.2	0.2	0.2	0.2																				11	0.26	3.29	-	0.88	4.55	1.52	3.18	3.21	1.73	1.39	1.39	0.69	0.58	5.74	4.95	0.44	7.22	1.35	21.53	1.45	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.49	0	1.56	11	0.26	3.29	-	0.88	4.55	1.52	3.18	3.21	1.73	1.39	1.39	0.69	0.58	5.74	4.95	0.44	7.22	1.35	21.53	1.45	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.49	3000																																																																																			-			11	0.26	3.29	-	0.88	4.55	1.52	3.18	3.21	1.73	1.39	1.39	0.69	0.58	5.74	4.95	0.44	7.22	1.35	21.53	1.45	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.49
H4449_006_0	2007	3																					3000											D	D	D		T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	N/A	1746.38	41.33	1619.35		109.28	26.63	8.88	794.1	800.45	10.72	8.57	8.57	4.29	3.57	7172.56	3093	274.13	4504.77	6.79	108.4	8.49	0.88																				125 per Day	125 per Day	125 per day for days 20 -100	None	100 per one way trip	20	20	50 per visit	100 per surgery	20	20	20	20	20	10	20	20	20	20	20	20	20																				118.79	118.79	44.19		95.76	0.19	0.19	47.88	95.76	0.19	0.19	0.19	0.19	0.19	9.58	19.15	19.15	19.15	0.19	0.19	0.19	0.19																				17.29	0.41	5.96	-	0.87	5.1	1.7	3.17	6.39	2.05	1.64	1.64	0.82	0.68	5.72	4.94	0.44	7.19	1.3	20.76	1.63	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.87	0	4.53	17.29	0.41	5.96	-	0.87	5.1	1.7	3.17	6.39	2.05	1.64	1.64	0.82	0.68	5.72	4.94	0.44	7.19	1.3	20.76	1.63	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.87	3000																																																																																			-			17.29	0.41	5.96	-	0.87	5.1	1.7	3.17	6.39	2.05	1.64	1.64	0.82	0.68	5.72	4.94	0.44	7.19	1.3	20.76	1.63	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.87
H4449_007_0	2007	3																					3000											D	D	D		T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	N/A	1736.02	41.09	1609.75		108.63	29.83	9.94	789.39	795.71	12.44	9.95	9.95	4.98	4.15	7130.02	3074.66	272.51	4478.05	6.79	108.4	9.51	0.99																				125 per Day	125 per Day	125 per day for days 20 -100	None	100 per one way trip	20	20	50 per visit	100 per surgery	20	20	20	20	20	10	20	20	20	20	20	20	20																				118.79	118.79	44.19		95.76	0.19	0.19	47.88	95.76	0.19	0.19	0.19	0.19	0.19	9.58	19.15	19.15	19.15	0.19	0.19	0.19	0.19																				17.19	0.41	5.93	-	0.87	5.71	1.9	3.15	6.35	2.38	1.91	1.91	0.95	0.79	5.69	4.91	0.43	7.15	1.3	20.76	1.82	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.69	0	4.53	17.19	0.41	5.93	-	0.87	5.71	1.9	3.15	6.35	2.38	1.91	1.91	0.95	0.79	5.69	4.91	0.43	7.15	1.3	20.76	1.82	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.69	3000																																																																																			-			17.19	0.41	5.93	-	0.87	5.71	1.9	3.15	6.35	2.38	1.91	1.91	0.95	0.79	5.69	4.91	0.43	7.15	1.3	20.76	1.82	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.69
H4449_008_0	2007	4																					3000											D	D	D		T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	N/A	1653.29	39.13	1533.03		103.45	22.56	7.52	751.77	757.78	8.53	6.82	6.82	3.41	2.84	6790.21	2928.12	259.52	4264.63	6.79	108.4	7.19	0.75																				125 per Day	125 per Day	125 per day for days 20 -100	None	100 per one way trip	20	20	50	100	20	20	20	20	20	10	35	35	35	20	20	20	20																				121.11	121.11	45.06		97.63	0.2	0.2	48.82	97.63	0.2	0.2	0.2	0.2	0.2	9.76	34.17	34.17	34.17	0.2	0.2	0.2	0.2																				16.69	0.39	5.76	-	0.84	4.4	1.47	3.06	6.17	1.67	1.33	1.33	0.67	0.56	5.52	8.34	0.74	12.14	1.32	21.17	1.4	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.11	0	2.35	16.69	0.39	5.76	-	0.84	4.4	1.47	3.06	6.17	1.67	1.33	1.33	0.67	0.56	5.52	8.34	0.74	12.14	1.32	21.17	1.4	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.11	3000																																																																																			-			16.69	0.39	5.76	-	0.84	4.4	1.47	3.06	6.17	1.67	1.33	1.33	0.67	0.56	5.52	8.34	0.74	12.14	1.32	21.17	1.4	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.11
H4449_009_0	2007	4	h.1.	h.2.									OP Facility - Other	OP Facility - Other									500	Complex diag	PET scans											D		T	Coin	Coin	V							V	V	V	V	V	V												P	V																																																		-	N/A			1567.16		105.76	24.2	6.05	768.51							6941.37	2993.31	265.3	4359.57	1468.41	11229.98												45.29	3.8											50/Days 20 - 100		100	20	20	50							5	5	5	5	5	5												50	200											46.71		93.41	0.19	0.19	46.71							4.67	4.67	4.67	4.67	4.67	4.67												46.71	186.82									-	-	6.1	-	0.82	4.52	1.13	2.99	-	-	-	-	-	-	2.7	1.17	0.1	1.7	0.57	4.37	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	26.41	0	1.84	-	-	6.1	-	0.82	4.52	1.13	2.99	-	-	-	-	-	-	2.7	1.17	0.1	1.7	0.57	4.37	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	26.41	500																																																																																			-			-	-	6.1	-	0.82	4.52	1.13	2.99	-	-	-	-	-	-	2.7	1.17	0.1	1.7	0.57	4.37	-	-	-	-	-	-	-	-	-	-	-	0.18	0.06	-	-	-	-	-	-	-	-	26.41
H4449_010_0	2007	3																					3000											D	D	D		T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	N/A	1704.36	40.34	1580.39		106.65	25.49	8.5	775	781.19	10.11	8.09	8.09	4.04	3.37	6999.99	3018.58	267.54	4396.38	6.79	108.4	8.13	0.84																				125 per Day	125 per Day	125 per day for days 20 -100	None	100 per one way trip	20	20	50 per visit	100 per surgery	20	20	20	20	20	10	20	20	20	20	20	20	20																				118.79	118.79	44.19		95.76	0.19	0.19	47.88	95.76	0.19	0.19	0.19	0.19	0.19	9.58	19.15	19.15	19.15	0.19	0.19	0.19	0.19																				16.87	0.4	5.82	-	0.85	4.88	1.63	3.09	6.23	1.94	1.55	1.55	0.77	0.65	5.59	4.82	0.43	7.02	1.3	20.76	1.56	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.86	0	4.53	16.87	0.4	5.82	-	0.85	4.88	1.63	3.09	6.23	1.94	1.55	1.55	0.77	0.65	5.59	4.82	0.43	7.02	1.3	20.76	1.56	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.86	3000																																																																																			-			16.87	0.4	5.82	-	0.85	4.88	1.63	3.09	6.23	1.94	1.55	1.55	0.77	0.65	5.59	4.82	0.43	7.02	1.3	20.76	1.56	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.86
H4449_011_0	2007	2	h.1.	h.2.									OP Facility - Other	OP Facility - Other									3000	Complex diag	PET scans									D	D	D		T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	Coin										P	V																																																		-	N/A	1571.48	37.19	1457.18		98.34	20.17	6.72	714.57	720.29	7.24	5.8	5.8	2.9	2.41	6454.23	2783.24	246.68	4053.62	6.79	108.4	6.43	0.67										50.9	3.46									180 per Day Days 1 - 5	180 per Day Days 1 - 5	180 per day for days 12 -100	None	100 per one way trip	20	20	50 per visit	100 per Surgery	20	20	20	20	20	12	40 per visit	40 per visit	40 per visit	20	20	20	20										50	200									107.61	107.61	108.55		95	0.19	0.19	47.5	95	0.19	0.19	0.19	0.19	0.19	11.4	38	38	38	0.19	0.19	0.19	0.19										47.5	190									14.09	0.33	13.18	-	0.78	3.83	1.28	2.83	5.7	1.38	1.1	1.1	0.55	0.46	6.13	8.81	0.78	12.84	1.29	20.6	1.22	0.13	-	-	-	-	-	-	-	-	-	0.2	0.05	-	-	-	-	-	-	-	-	98.67	0	3.75	14.09	0.33	13.18	-	0.78	3.83	1.28	2.83	5.7	1.38	1.1	1.1	0.55	0.46	6.13	8.81	0.78	12.84	1.29	20.6	1.22	0.13	-	-	-	-	-	-	-	-	-	0.2	0.05	-	-	-	-	-	-	-	-	98.67	3000																																																																																			-			14.09	0.33	13.18	-	0.78	3.83	1.28	2.83	5.7	1.38	1.1	1.1	0.55	0.46	6.13	8.81	0.78	12.84	1.29	20.6	1.22	0.13	-	-	-	-	-	-	-	-	-	0.2	0.05	-	-	-	-	-	-	-	-	98.67
H4454_002_0	2007	4											Ambulance		Utilization was trended fwd	by the respective categorical	increases from 2005 to 2007	(Before this change the	Memb. Cost Share PMPM	was 35.43 6.43 increase).			2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	1064.1	390.57	255.2		75.06	7.49		271.29	252.94		423.37	25.21			6796.23	2912.67	250.5				24.09	2.28	410.72		182.96							2.61										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	190 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	190		75	150			15	30	30				0.2	150	3.5		30							250										13.3	4.88	1.06	-	0.63	1.5	-	1.13	4	-	2.65	0.32	-	-	8.5	7.28	0.63	-	-	-	4.82	0.03	0.12	-	0.46	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	51.35		2.65	13.3	4.88	1.06	-	0.63	1.5	-	1.13	4	-	2.65	0.32	-	-	8.5	7.28	0.63	-	-	-	4.82	0.03	0.12	-	0.46	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	51.35	2000																																																																																			-	0	0	13.3	4.88	1.06	-	0.63	1.5	-	1.13	4	-	2.65	0.32	-	-	8.5	7.28	0.63	-	-	-	4.82	0.03	0.12	-	0.46	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	51.35
H4454_007_0	2007	4											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	931.09	341.75	223.3		65.68	6.56		237.38	221.32		370.45	22.06			5946.7	2548.59	219.19				21.08	1.99	359.38		160.09							2.28										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	200 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	200		75	150			15	30	30				0.2	150	3.5		30							250										11.64	4.27	0.93	-	0.55	1.31	-	0.99	3.69	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.12		1.87	11.64	4.27	0.93	-	0.55	1.31	-	0.99	3.69	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.12	2000																																																																																			-		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	3.69	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	45.12
H4454_008_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4454_012_0	2007	3											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	931.09	341.75	223.3		65.68	6.56		237.38	221.32		370.45	22.06			5946.7	2548.59	219.19				21.08	1.99	359.38		160.09							2.28										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04	2000																																																																																			-		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04
H4454_013_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4454_014_0	2007	3											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	931.09	341.75	223.3		65.68	6.56		237.38	221.32		370.45	22.06			5946.7	2548.59	219.19				21.08	1.99	359.38		160.09							2.28										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04	2000																																																																																			-		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04
H4454_803_0	2007	4											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	931.09	341.75	223.3		65.68	6.56		237.38	221.32		370.45	22.06			5946.7	2548.59	219.19				21.08	1.99	359.38		160.09							2.28										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04	2000																																																																																			-		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04
H4454_805_0	2007	8											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	931.09	341.75	223.3		65.68	6.56		237.38	221.32		370.45	22.06			5946.7	2548.59	219.19				21.08	1.99	359.38		160.09							2.28										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04	2000																																																																																			-		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04
H4454_806_0	2007	5											Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	931.09	341.75	223.3		65.68	6.56		237.38	221.32		370.45	22.06			5946.7	2548.59	219.19				21.08	1.99	359.38		160.09							2.28										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04			11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04	2000																																																																																			-			11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04
H4454_807_0	2007	7	0										Ambulance										2000	Air										D	D	D		T	Coin		P	P		P	O			V	V	V				Coin	O	T		V							T																																																			-	0	931.09	341.75	223.3		65.68	6.56		237.38	221.32		370.45	22.06			5946.7	2548.59	219.19				21.08	1.99	359.38		160.09							2.28										150/D first 10 Days; 2K OP	150/D first 10 Days; 2K OP	50/D (0-20 Days); 0 (21-100 Days)		100 CP/Trip (0 admit)	20 Coins. 1K OP max		50 CP / Visit	250 CP / Surg		75 CP / (MRI CT Test)	150/Admit; 2K OP			15 CP / Visit	30 CP / Visit	30 CP / Visit				20 Coins. 1K OP max	150/D first 10 Days; 2K OP	3.50 / Trip		30 CP / Visit							250 CP / Trip										150	150	50		100	0.2		50	250		75	150			15	30	30				0.2	150	3.5		30							250										11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04	2000																																																																																			-		0	11.64	4.27	0.93	-	0.55	1.31	-	0.99	4.61	-	2.32	0.28	-	-	7.43	6.37	0.55	-	-	-	4.22	0.02	0.1	-	0.4	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	46.04
H4456_010_0	2007	6																																D	D	D		T	Coin		V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	Coin		V	Coin	coin			V		V																																																								-		1264.95	167	584.52		203	16.68		226.34	23.75	1124.88	19.3	0.36	0.36	3.88	3799.64	3108.64	180	4.14		694	20.49				129.91		233															PBP line 1a - 250 per day	PBP line 1b - 250 per day	PBP line 2 - 125 per day	PBP line 6 - no cost share	PBP line10a - 150 per trip	PBP line 11a - 30 coinsurance	PBP line 11b - 30 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 20 coinsurance	BPB line 8a - 15 per visit	PBP line 8a & 8b - 15 per visit	PBP line 5 - 20 coinsurance	PBP line 12 - 30	PBP line 9a - 20	PBP line 7a - 10 per visit	PBP line 7d - 20 per visit	PBP line 7e - 40 per visit	PBP line 7c and 7i - 20	PBP line 8a & 8b - no cost share	PBP line 7g - 10/20 per visit	PBP line 15 - 30 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 20 per visit	PBP line 17b - benefit max	PBP line 18a - 20 per visit	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											175	175	87.5	0	105	0.21	0	35	0.14	4.2	0.1	0.14	0.21	0.14	10	20	40	0.2	0	15	0.21	0	0	0	20	0	20															18.45	2.44	4.26	-	1.78	3.5	-	0.66	3.32	0.39	1.89	0.05	0.08	0.54	3.17	5.18	0.6	0.83	-	0.87	4.3	-	-	-	0.22	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.91		17.92	18.45	2.44	4.26	-	1.78	3.5	-	0.66	3.32	0.39	1.89	0.05	0.08	0.54	3.17	5.18	0.6	0.83	-	0.87	4.3	-	-	-	0.22	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.91																																																																																				-			18.45	2.44	4.26	-	1.78	3.5	-	0.66	3.32	0.39	1.89	0.05	0.08	0.54	3.17	5.18	0.6	0.83	-	0.87	4.3	-	-	-	0.22	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.91
H4456_013_0	2007	5																																D	D	D		T	Coin		V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	Coin		V	Coin				V		V																																																								-		1330.83	141.5	614.96		211.46	17.3		235.77	33.31	1171.75	20.11	0.36	0.37	6.13	3957.96	3238.17	180	4.58		694	21.35				129.91		233															PBP line 1a - 295 per day	PBP line 1b - 295 per day	PBP line 2 - 140 per day	PBP line 6 - no cost share	PBP line10a - 150 per trip	PBP line 11a - 30 coinsurance	PBP line 11b - 30 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 30 coinsurance	BPB line 8a - 15 per visit	PBP line 8a & 8b - 15 per visit	PBP line 5 - 30 coinsurance	PBP line 12 - 30	PBP line 9a - 30	PBP line 7a - 10 per visit	PBP line 7d - 25 per visit	PBP line 7e - 40 per visit	PBP line 7c and 7i - 30	PBP line 8a & 8b - no cost share	PBP line 7g - 10/25 per visit	PBP line 15 - 30 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 25 per visit	PBP line 17b	PBP line 18a - 25 per visit	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											211.52	211.52	100.38		107.55	0.22		35.85	0.22	4.3	0.15	0.22	0.22	0.22	10	25	40	0.3		15	0.22				25		25															23.46	2.49	5.14	-	1.9	3.72	-	0.7	7.17	0.42	3.03	0.08	0.08	1.32	3.3	6.75	0.6	1.38	-	0.87	4.59	-	-	-	0.27	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.74		21.16	23.46	2.49	5.14	-	1.9	3.72	-	0.7	7.17	0.42	3.03	0.08	0.08	1.32	3.3	6.75	0.6	1.38	-	0.87	4.59	-	-	-	0.27	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.74																																																																																				-			23.46	2.49	5.14	-	1.9	3.72	-	0.7	7.17	0.42	3.03	0.08	0.08	1.32	3.3	6.75	0.6	1.38	-	0.87	4.59	-	-	-	0.27	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.74
H4456_015_0	2007	3																																A	A	A			Coin		V	V		Coin	V			V	V	V	V		V	Coin				V																																																										-		283.79	6.48	8			17.39		257.22	449.18		7.33	6.88			4318.08	3532.8	180	776.64		666.24	23.29				124.72																	PBP line 1a - 50 per admit	PBP line 1b - 50 per admit	PBP line 2 - 150 one-time payment if days exceed 20	PBP line 6 - no cost share	PBP line10a - no cost share	PBP line 11a - 20 coinsurance	PBP line 11b - 20 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 50 per visit	BPB line 8a - no cost share	PBP line 8a & 8b - 20 coinsurance (complex radiology services only)	PBP line 5 - 50 per visit	PBP line 12 - no cost share	PBP line 9a - no cost share	PBP line 7a - 15 per visit	PBP line 7d - 15 per visit	PBP line 7e - 15 per visit	PBP line 7c and 7i - 15 per visit	PBP line 8a & 8b - no cost share	PBP line 7g - 15 per visit	PBP line 15 - 20 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 15 per visit	PBP line 17b - 100 benefit max over 2 years	PBP line 18a	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											50	50	150			0.2		50	50		0.2	50			15	15	15	15		15	0.2				15																	1.18	0.03	0.1	-	-	3.48	-	1.07	1.87	-	1.47	0.03	-	-	5.4	4.42	0.23	0.97	-	0.83	4.66	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.88			1.18	0.03	0.1	-	-	3.48	-	1.07	1.87	-	1.47	0.03	-	-	5.4	4.42	0.23	0.97	-	0.83	4.66	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.88																																																																																				-			1.18	0.03	0.1	-	-	3.48	-	1.07	1.87	-	1.47	0.03	-	-	5.4	4.42	0.23	0.97	-	0.83	4.66	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.88
H4456_016_0	2007	1																																A	A	A			Coin		V	V		Coin	V			V	V	V	V		V	Coin				V																																																										-		283.79	6.48	8			17.39		257.22	449.18		7.33	6.88			4318.08	3532.8	180	776.64		666.24	23.29				124.72																	PBP line 1a - 50 per admit	PBP line 1b - 50 per admit	PBP line 2 - 150 one-time payment if days exceed 20	PBP line 6 - no cost share	PBP line10a - no cost share	PBP line 11a - 20 coinsurance	PBP line 11b - 20 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 50 per visit	BPB line 8a - no cost share	PBP line 8a & 8b - 20 coinsurance (complex radiology services only)	PBP line 5 - 50 per visit	PBP line 12 - no cost share	PBP line 9a - no cost share	PBP line 7a - 15 per visit	PBP line 7d - 15 per visit	PBP line 7e - 15 per visit	PBP line 7c and 7i - 15 per visit	PBP line 8a & 8b - no cost share	PBP line 7g - 15 per visit	PBP line 15 - 20 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 15 per visit	PBP line 17b - 100 benefit max over 2 years	PBP line 18a	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											50	50	150			0.2		50	50		0.2	50			15	15	15	15		15	0.2				15																	1.18	0.03	0.1	-	-	3.48	-	1.07	1.87	-	1.47	0.03	-	-	5.4	4.42	0.23	0.97	-	0.83	4.66	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.88			1.18	0.03	0.1	-	-	3.48	-	1.07	1.87	-	1.47	0.03	-	-	5.4	4.42	0.23	0.97	-	0.83	4.66	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.88																																																																																				-			1.18	0.03	0.1	-	-	3.48	-	1.07	1.87	-	1.47	0.03	-	-	5.4	4.42	0.23	0.97	-	0.83	4.66	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.88
H4456_017_0	2007	3																																	A	A			Coin		V			Coin						V	V			Coin				V																																																										-			6.48	8			21.17		308.67			8.79						180	931.97			27.95				149.66																	PBP line 1a - no cost share	PBP line 1b - no cost share amount displayed attributed to capitated service cost sharing	PBP line 2 - 100 one-time payment if days exceed 20	PBP line 6 - no cost share	PBP line10a - no cost share	PBP line 11a - 20 coinsurance	PBP line 11b - 20 coinsurance - PMPM included above	PBP line 4a - 50 per visit	PBP lines 9a and 9b - no cost share	PBP line 8a - no cost share	PBP line 8a & 8b - 20 coinsurance (complex radiology services only)	PBP line 5 - no cost share	PBP line 12 - no cost share	PBP line 9a - no cost share	PBP line 7a - no cost share	PBP line 7d - no cost share	PBP line 7e - 15 per visit	PBP line 7c and 7i - 15 per visit	PBP line 8a & 8b - no cost share	PBP line 7g - no cost share	PBP line 15 - 20 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 15 per visit	PBP line 17b - 100 benefit max over 2 years	PBP line 18a	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c												50	100			0.2		50			0.2						15	15			0.2				15																	-	0.03	0.07	-	-	4.23	-	1.29	-	-	1.76	-	-	-	-	-	0.23	1.16	-	-	5.59	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54			-	0.03	0.07	-	-	4.23	-	1.29	-	-	1.76	-	-	-	-	-	0.23	1.16	-	-	5.59	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54																																																																																				-			-	0.03	0.07	-	-	4.23	-	1.29	-	-	1.76	-	-	-	-	-	0.23	1.16	-	-	5.59	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.54
H4456_019_0	2007	4																																A	A	A			Coin		V	V		Coin	V			V	V	V	V		V	Coin				V																																																										-		295.89	6.48	8			18.18		267.94	467.89		7.63	7.16			4498	3680	180	809		694	24.26				129.91																	PBP line 1a - 50 per admit	PBP line 1b - 50 per admit	PBP line 2 - 150 one-time payment if days exceed 20	PBP line 6 - no cost share	PBP line10a - no cost share	PBP line 11a - 20 coinsurance	PBP line 11b - 20 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 50 per visit	BPB line 8a - no cost share	PBP line 8a & 8b - 20 coinsurance (complex radiology services only)	PBP line 5 - 50 per visit	PBP line 12 - no cost share	PBP line 9a - no cost share	PBP line 7a - 15 per visit	PBP line 7d - 15 per visit	PBP line 7e - 15 per visit	PBP line 7c and 7i - 15 per visit	PBP line 8a & 8b - no cost share	PBP line 7g - 15 per visit	PBP line 15 - 20 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 15 per visit	PBP line 17b - 100 benefit max over 2 years	PBP line 18a	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											50	50	150			0.2		50	50		0.2	50			15	15	15	15		15	0.2				15																	1.23	0.03	0.1	-	-	3.64	-	1.12	1.95	-	1.53	0.03	-	-	5.62	4.6	0.23	1.01	-	0.87	4.85	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.96			1.23	0.03	0.1	-	-	3.64	-	1.12	1.95	-	1.53	0.03	-	-	5.62	4.6	0.23	1.01	-	0.87	4.85	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.96																																																																																				-			1.23	0.03	0.1	-	-	3.64	-	1.12	1.95	-	1.53	0.03	-	-	5.62	4.6	0.23	1.01	-	0.87	4.85	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.96
H4456_020_0	2007	2																																A	A	A			Coin		V	V		Coin	V			V	V	V	V		V	Coin				V																																																										-		295.89	6.48	8			18.18		267.94	467.89		7.63	7.16			4498	3680	180	809		694	24.26				129.91																	PBP line 1a - 50 per admit	PBP line 1b - 50 per admit	PBP line 2 - 150 one-time payment if days exceed 20	PBP line 6 - no cost share	PBP line10a - no cost share	PBP line 11a - 20 coinsurance	PBP line 11b - 20 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 50 per visit	BPB line 8a - no cost share	PBP line 8a & 8b - 20 coinsurance (complex radiology services only)	PBP line 5 - 50 per visit	PBP line 12 - no cost share	PBP line 9a - no cost share	PBP line 7a - 15 per visit	PBP line 7d - 15 per visit	PBP line 7e - 15 per visit	PBP line 7c and 7i - 15 per visit	PBP line 8a & 8b - no cost share	PBP line 7g - 15 per visit	PBP line 15 - 20 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 15 per visit	PBP line 17b - 100 benefit max over 2 years	PBP line 18a	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											50	50	150			0.2		50	50		0.2	50			15	15	15	15		15	0.2				15																	1.23	0.03	0.1	-	-	3.64	-	1.12	1.95	-	1.53	0.03	-	-	5.62	4.6	0.23	1.01	-	0.87	4.85	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.96			1.23	0.03	0.1	-	-	3.64	-	1.12	1.95	-	1.53	0.03	-	-	5.62	4.6	0.23	1.01	-	0.87	4.85	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.96																																																																																				-			1.23	0.03	0.1	-	-	3.64	-	1.12	1.95	-	1.53	0.03	-	-	5.62	4.6	0.23	1.01	-	0.87	4.85	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.96
H4456_021_0	2007	4																																A	A	A			Coin		V	V		Coin	V					V	V			Coin				V																																																										-		356.36	6.48	8			22.11		321.53	561.47		9.16	8.6					180	970.8			29.11				155.9																	PBP line 1a - 50 per admit	PBP line 1b - 50 per admit	PBP line 2 - 100 one-time payment if days exceed 20	PBP line 6 - no cost share	PBP line10a - no cost share	PBP line 11a - 20 coinsurance	PBP line 11b - 20 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 50 per visit	BPB line 8a - no cost share	PBP line 8a & 8b - 20 coinsurance (complex radiology services only)	PBP line 5 - 50 per visit	PBP line 12 - no cost share	PBP line 9a - no cost share	PBP line 7a - no cost share	PBP line 7d - no cost share	PBP line 7e - 15 per visit	PBP line 7c and 7i - 15 per visit	PBP line 8a & 8b - no cost share	PBP line 7g - no cost share	PBP line 15 - 20 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 15 per visit	PBP line 17b - 100 benefit max over 2 years	PBP line 18a	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											50	50	100			0.2		50	50		0.2	50					15	15			0.2				15																	1.48	0.03	0.07	-	-	4.42	-	1.34	2.34	-	1.83	0.04	-	-	-	-	0.23	1.21	-	-	5.82	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19			1.48	0.03	0.07	-	-	4.42	-	1.34	2.34	-	1.83	0.04	-	-	-	-	0.23	1.21	-	-	5.82	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19																																																																																				-			1.48	0.03	0.07	-	-	4.42	-	1.34	2.34	-	1.83	0.04	-	-	-	-	0.23	1.21	-	-	5.82	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19
H4456_801_0	2007	4																																D	D	D		T	Coin		V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	Coin		V	Coin				V		V																																																								-		1663.66	141.5	1048.31		13.28	20.95		10.82	43.54	1531.38	26.28	0.36	0.49	7.05	5172.7	4232	180	5.99		798.1	22.78				129.91		214.43															PBP line 1a - 295 per day	PBP line 1b - 295 per day	PBP line 2 - 140 per day	PBP line 6 - no cost share	PBP line10a - 150 per trip	PBP line 11a - 30 coinsurance	PBP line 11b - 30 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 30 coinsurance	BPB line 8a - 15 per visit	PBP line 8a & 8b - 15 per visit	PBP line 5 - 30 coinsurance	PBP line 12 - 30	PBP line 9a - 30	PBP line 7a - 10 per visit	PBP line 7d - 25 per visit	PBP line 7e - 40 per visit	PBP line 7c and 7i - 30	PBP line 8a & 8b - no cost share	PBP line 7g - 10/25 per visit	PBP line 15 - 30 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 25 per visit	PBP line 17b	PBP line 18a - 25 per visit	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											188.75	188.75	89.58	0	95.98	0.19	0	31.99	0.19	3.84	0.13	0.19	0.19	0.19	10	25	40	0.3	0	15	0.19	0	0	0	25	0	25	0	0	0	0											26.17	2.23	7.83	-	0.11	4.02	-	0.03	8.36	0.49	3.53	0.07	0.09	1.35	4.31	8.82	0.6	1.8	-	1	4.37	-	-	-	0.27	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.88		34.59	26.17	2.23	7.83	-	0.11	4.02	-	0.03	8.36	0.49	3.53	0.07	0.09	1.35	4.31	8.82	0.6	1.8	-	1	4.37	-	-	-	0.27	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.88																																																																																				-			26.17	2.23	7.83	-	0.11	4.02	-	0.03	8.36	0.49	3.53	0.07	0.09	1.35	4.31	8.82	0.6	1.8	-	1	4.37	-	-	-	0.27	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.88
H4456_805_0	2007	3																																D	D	D		T	Coin		V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	Coin		V	Coin				V		V																																																								-		1663.66	141.5	1048.31		13.28	20.95		10.82	43.54	1531.38	26.28	0.36	0.49	7.05	5172.7	4232	180	5.99		798.1	22.78				129.91		214.43															PBP line 1a - 295 per day	PBP line 1b - 295 per day	PBP line 2 - 140 per day	PBP line 6 - no cost share	PBP line10a - 150 per trip	PBP line 11a - 30 coinsurance	PBP line 11b - 30 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 30 coinsurance	BPB line 8a - 15 per visit	PBP line 8a & 8b - 15 per visit	PBP line 5 - 30 coinsurance	PBP line 12 - 30	PBP line 9a - 30	PBP line 7a - 10 per visit	PBP line 7d - 25 per visit	PBP line 7e - 40 per visit	PBP line 7c and 7i - 30	PBP line 8a & 8b - no cost share	PBP line 7g - 10/25 per visit	PBP line 15 - 30 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 25 per visit	PBP line 17b	PBP line 18a - 25 per visit	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											188.75	188.75	89.58	0	95.98	0.19	0	31.99	0.19	3.84	0.13	0.19	0.19	0.19	10	25	40	0.3	0	15	0.19	0	0	0	25	0	25	0	0	0	0											26.17	2.23	7.83	-	0.11	4.02	-	0.03	8.36	0.49	3.53	0.07	0.09	1.35	4.31	8.82	0.6	1.8	-	1	4.37	-	-	-	0.27	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.88		34.59	26.17	2.23	7.83	-	0.11	4.02	-	0.03	8.36	0.49	3.53	0.07	0.09	1.35	4.31	8.82	0.6	1.8	-	1	4.37	-	-	-	0.27	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.88																																																																																				-			26.17	2.23	7.83	-	0.11	4.02	-	0.03	8.36	0.49	3.53	0.07	0.09	1.35	4.31	8.82	0.6	1.8	-	1	4.37	-	-	-	0.27	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.88
H4456_806_0	2007	3																																D	D	D		T	Coin		V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	Coin		V	Coin				V		V																																																								-		1530.57	141.5	964.44		12.22	19.28		7.47	30.04	1408.87	24.18	0.36	0.49	4.86	4758.88	3893.44	180	5.24		734.25	20.96				129.91		197.28															PBP line 1a - 250 per day	PBP line 1b - 250 per day	PBP line 2 - 125 per day	PBP line 6 - no cost share	PBP line10a - 150 per trip	PBP line 11a - 30 coinsurance	PBP line 11b - 30 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 20 coinsurance	BPB line 8a - 15 per visit	PBP line 8a & 8b - 15 per visit	PBP line 5 - 20 coinsurance	PBP line 12 - 30	PBP line 9a - 20	PBP line 7a - 10 per visit	PBP line 7d - 20 per visit	PBP line 7e - 40 per visit	PBP line 7c and 7i - 20	PBP line 8a & 8b - no cost share	PBP line 7g - 10/20 per visit	PBP line 15 - 30 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 20 per visit	PBP line 17b - benefit max	PBP line 18a - 20 per visit	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											165.05	165.05	82.52		99.03	0.2		33.01	0.13	3.96	0.09	0.13	0.2	0.13	10	20	40	0.2		15	0.2				20		20															21.05	1.95	6.63	-	0.1	3.82	-	0.02	3.97	0.47	2.23	0.05	0.1	0.64	3.97	6.49	0.6	1.05	-	0.92	4.15	-	-	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.74		31.63	21.05	1.95	6.63	-	0.1	3.82	-	0.02	3.97	0.47	2.23	0.05	0.1	0.64	3.97	6.49	0.6	1.05	-	0.92	4.15	-	-	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.74																																																																																				-			21.05	1.95	6.63	-	0.1	3.82	-	0.02	3.97	0.47	2.23	0.05	0.1	0.64	3.97	6.49	0.6	1.05	-	0.92	4.15	-	-	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.74
H4456_807_0	2007	2																																D	D	D		T	Coin		V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	Coin		V	Coin				V		V																																																								-		1530.57	141.5	964.44		12.22	19.28		7.47	30.04	1408.87	24.18	0.36	0.49	4.86	4758.88	3893.44	180	5.24		734.25	20.96				129.91		197.28															PBP line 1a - 250 per day	PBP line 1b - 250 per day	PBP line 2 - 125 per day	PBP line 6 - no cost share	PBP line10a - 150 per trip	PBP line 11a - 30 coinsurance	PBP line 11b - 30 coinsurance - PMPM included above	BPB line 4a - 50 per visit	BPB lines 9a and 9b - 20 coinsurance	BPB line 8a - 15 per visit	PBP line 8a & 8b - 15 per visit	PBP line 5 - 20 coinsurance	PBP line 12 - 30	PBP line 9a - 20	PBP line 7a - 10 per visit	PBP line 7d - 20 per visit	PBP line 7e - 40 per visit	PBP line 7c and 7i - 20	PBP line 8a & 8b - no cost share	PBP line 7g - 10/20 per visit	PBP line 15 - 30 coinsurance	PBP line 13a - no cost share	PBP line 10b	PBP line 16a	PBP line 17a - 20 per visit	PBP line 17b - benefit max	PBP line 18a - 20 per visit	PBP line 18b	PBP line 19	PBP line 14a	PBP line 13c											165.05	165.05	82.52		99.03	0.2		33.01	0.13	3.96	0.09	0.13	0.2	0.13	10	20	40	0.2		15	0.2				20		20															21.05	1.95	6.63	-	0.1	3.82	-	0.02	3.97	0.47	2.23	0.05	0.1	0.64	3.97	6.49	0.6	1.05	-	0.92	4.15	-	-	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.74		31.63	21.05	1.95	6.63	-	0.1	3.82	-	0.02	3.97	0.47	2.23	0.05	0.1	0.64	3.97	6.49	0.6	1.05	-	0.92	4.15	-	-	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.74																																																																																				-			21.05	1.95	6.63	-	0.1	3.82	-	0.02	3.97	0.47	2.23	0.05	0.1	0.64	3.97	6.49	0.6	1.05	-	0.92	4.15	-	-	-	0.22	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.74
H4461_001_0	2007	8																																	A				coin	coin	V						V			V			V		V			V		V																																																								-			63.17				10.13	1.51	327.41						3355.66			192.99			30586.1		82.32			306.26		43.69																100 per admission copayment				20 cost sharing	20 cost sharing	50 ER 10 Urgent Care						20 PT/OT/ST 10 CORF 10 Mental Health			10 MH/SA			10/Visit PCP 20/Visit Specialist		10 Vision 10 Hearing			10 per exam		10 per exam																11.03				0.2	0.2	28.29						0.97			10			3.37		10			10		10															-	0.06	-	-	-	2.03	0.3	0.77	-	-	-	-	-	0.27	-	-	0.16	-	-	8.6	-	0.07	-	-	0.26	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.55			-	0.06	-	-	-	2.03	0.3	0.77	-	-	-	-	-	0.27	-	-	0.16	-	-	8.6	-	0.07	-	-	0.26	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.55																																																																																				-			-	0.06	-	-	-	2.03	0.3	0.77	-	-	-	-	-	0.27	-	-	0.16	-	-	8.6	-	0.07	-	-	0.26	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.55
H4461_004_0	2007	6																																	A				coin	coin	V						V			V			V		V			V		V																																																								-			58.13				8.93	1.26	313.69						3077.71			148.3			28484.21		80.26			298.57		45.47																100 per admission copayment				20 cost sharing	20 cost sharing	50 ER 10 Urgent Care						20 PT/OT/ST 10 CORF 10 Mental Health			10 MH/SA			10/Visit PCP 20/Visit Specialist		10 Vision 10 Hearing			10 per exam		10 per exam																10.52				0.2	0.2	28.29						0.99			10			3.47		10			10		10															-	0.05	-	-	-	1.79	0.25	0.74	-	-	-	-	-	0.25	-	-	0.12	-	-	8.24	-	0.07	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.79			-	0.05	-	-	-	1.79	0.25	0.74	-	-	-	-	-	0.25	-	-	0.12	-	-	8.24	-	0.07	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.79																																																																																				-			-	0.05	-	-	-	1.79	0.25	0.74	-	-	-	-	-	0.25	-	-	0.12	-	-	8.24	-	0.07	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.79
H4461_007_0	2007	3																																	A				coin	coin	V						V			V			V		V			V		V																																																								-			85.08				10.07	0.85	367.29						4907.36			174.95			25824.36		71.21			264.83		36.24																100 per admission copayment				20 cost sharing	20 cost sharing	50 ER 10 Urgent Care						20 PT/OT/ST 10 CORF 10 Mental Health			10 MH/SA			10/Visit PCP 20/Visit Specialist		10 Vision 10 Hearing			10 per exam		10 per exam																5.91				0.2	0.2	28.29						0.57			10			3.69		10			10		10															-	0.04	-	-	-	2.01	0.17	0.87	-	-	-	-	-	0.23	-	-	0.15	-	-	7.93	-	0.06	-	-	0.22	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.71			-	0.04	-	-	-	2.01	0.17	0.87	-	-	-	-	-	0.23	-	-	0.15	-	-	7.93	-	0.06	-	-	0.22	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.71																																																																																				-			-	0.04	-	-	-	2.01	0.17	0.87	-	-	-	-	-	0.23	-	-	0.15	-	-	7.93	-	0.06	-	-	0.22	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.71
H4461_011_0	2007	14																																																					V																																																													-																							88.63																																									10 Vision copay																																									10																				-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07
H4461_012_0	2007	6																																	A				coin	coin	V						V			V			V		V			V		V																																																								-			85.08				10.07	0.85	367.29						4907.36			174.95			25824.36		71.21			264.83		36.24																100 per admission copayment				20 cost sharing	20 cost sharing	50 ER 10 Urgent Care						20 PT/OT/ST 10 CORF 10 Mental Health			10 MH/SA			10/Visit PCP 20/Visit Specialist		10 Vision 10 Hearing			10 per exam		10 per exam																5.91				0.2	0.2	28.29						0.57			10			3.69		10			10		10															-	0.04	-	-	-	2.01	0.17	0.87	-	-	-	-	-	0.23	-	-	0.15	-	-	7.93	-	0.06	-	-	0.22	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.71			-	0.04	-	-	-	2.01	0.17	0.87	-	-	-	-	-	0.23	-	-	0.15	-	-	7.93	-	0.06	-	-	0.22	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.71																																																																																				-			-	0.04	-	-	-	2.01	0.17	0.87	-	-	-	-	-	0.23	-	-	0.15	-	-	7.93	-	0.06	-	-	0.22	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.71
H4461_013_0	2007	11																																																					V																																																													-																							88.63																																									10 Vision copay																																									10																				-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07
H4461_014_0	2007	7																																A	A	D	coin	coin	coin	coin	V	coin					coin			V		coin	coin	coin	V			V		V																																																								-		241.29	6.65	667.68	4.9	6.45	8.96	1.27	314.95	25.69					54.15			148.89		21.55	191.17	7.03	80.58			299.77		45.66															500 per admission copayment	500 per admission copayment	75 Copay days 21-100	10 cost sharing	10 cost sharing	20 cost sharing	20 cost sharing	50 ER 10 Urgent Care	10 cost sharing					20 PT/OT/ST 10 CORF 10 Mental Health 10 coin all other			25 MH/SA		10 cost sharing	10 lab 10/Visit PCP 20/Visit Specialist	20 cost sharing	25 Vision 25 Hearing			25 per exam		25 per exam															496.82	474.8	22.3	0.1	0.1	0.2	0.2	31.15	0.1					0.1			25		0.1	0.11	0.2	25			25		25															9.99	0.26	1.24	0.49	0.64	1.79	0.25	0.82	2.57	-	-	-	-	5.38	-	-	0.31	-	2.16	20.25	1.41	0.17	-	-	0.62	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.45			9.99	0.26	1.24	0.49	0.64	1.79	0.25	0.82	2.57	-	-	-	-	5.38	-	-	0.31	-	2.16	20.25	1.41	0.17	-	-	0.62	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.45																																																																																				-			9.99	0.26	1.24	0.49	0.64	1.79	0.25	0.82	2.57	-	-	-	-	5.38	-	-	0.31	-	2.16	20.25	1.41	0.17	-	-	0.62	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.45
H4461_015_0	2007	12																																A	A	D	coin	coin	coin	coin	V	coin					coin			V		coin	coin	coin	V			V		V																																																								-		279.17	7.25	1403.44	6.04	8.21	10.2	1.52	329.47	27.89					58.47			194.2		22.36	202.13	7.1	82.84			308.19		43.96															500 per admission copayment	500 per admission copayment	75 Copay days 21-100	10 cost sharing	10 cost sharing	20 cost sharing	20 cost sharing	50 ER 10 Urgent Care	10 cost sharing					20 PT/OT/ST 10 CORF 10 Mental Health 10 coin all other			25 MH/SA		10 cost sharing	10 lab 10/Visit PCP 20/Visit Specialist	20 cost sharing	25 Vision 25 Hearing			25 per exam		25 per exam															496.82	474.8	22.3	0.1	0.1	0.2	0.2	31.15	0.1					0.1			25		0.1	0.11	0.2	25			25		25															11.56	0.29	2.61	0.6	0.82	2.04	0.3	0.86	2.79	-	-	-	-	5.78	-	-	0.4	-	2.24	21.24	1.42	0.17	-	-	0.64	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86			11.56	0.29	2.61	0.6	0.82	2.04	0.3	0.86	2.79	-	-	-	-	5.78	-	-	0.4	-	2.24	21.24	1.42	0.17	-	-	0.64	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86																																																																																				-			11.56	0.29	2.61	0.6	0.82	2.04	0.3	0.86	2.79	-	-	-	-	5.78	-	-	0.4	-	2.24	21.24	1.42	0.17	-	-	0.64	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86
H4461_016_0	2007	9																																	A				coin	coin	V						V			V			V		V			V		V																																																								-			63.17				10.13	1.51	327.41						3355.66			192.99			30586.1		82.32			306.26		43.69																100 per admission copayment				20 cost sharing	20 cost sharing	50 ER 10 Urgent Care						20 PT/OT/ST 10 CORF 10 Mental Health			10 MH/SA			10/Visit PCP 20/Visit Specialist		10 Vision 10 Hearing			10 per exam		10 per exam																11.03				0.2	0.2	28.29						0.97			10			3.37		10			10		10															-	0.06	-	-	-	2.03	0.3	0.77	-	-	-	-	-	0.27	-	-	0.16	-	-	8.6	-	0.07	-	-	0.26	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.55			-	0.06	-	-	-	2.03	0.3	0.77	-	-	-	-	-	0.27	-	-	0.16	-	-	8.6	-	0.07	-	-	0.26	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.55																																																																																				-			-	0.06	-	-	-	2.03	0.3	0.77	-	-	-	-	-	0.27	-	-	0.16	-	-	8.6	-	0.07	-	-	0.26	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.55
H4461_017_0	2007	15																																A	A	D	coin	coin	coin	coin	V	coin					coin			V		coin	coin	coin	V			V		V																																																								-		279.17	7.25	1403.44	6.04	8.21	10.2	1.52	329.47	27.89					58.47			194.2		22.36	202.13	7.1	82.84			308.19		43.96															500 per admission copayment	500 per admission copayment	75 Copay days 21-100	10 cost sharing	10 cost sharing	20 cost sharing	20 cost sharing	50 ER 10 Urgent Care	10 cost sharing					20 PT/OT/ST 10 CORF 10 Mental Health 10 coin all other			25 MH/SA		10 cost sharing	10 lab 10/Visit PCP 20/Visit Specialist	20 cost sharing	25 Vision 25 Hearing			25 per exam		25 per exam															496.82	474.8	22.3	0.1	0.1	0.2	0.2	31.15	0.1					0.1			25		0.1	0.11	0.2	25			25		25															11.56	0.29	2.61	0.6	0.82	2.04	0.3	0.86	2.79	-	-	-	-	5.78	-	-	0.4	-	2.24	21.24	1.42	0.17	-	-	0.64	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86			11.56	0.29	2.61	0.6	0.82	2.04	0.3	0.86	2.79	-	-	-	-	5.78	-	-	0.4	-	2.24	21.24	1.42	0.17	-	-	0.64	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86																																																																																				-			11.56	0.29	2.61	0.6	0.82	2.04	0.3	0.86	2.79	-	-	-	-	5.78	-	-	0.4	-	2.24	21.24	1.42	0.17	-	-	0.64	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.86
H4461_802_0	2007	5																																	A				coin	coin	V						V			V			V		V			V		V																																																								-			58.85				11	1.51	323.35						3377.77			176.49			32032.47		86.9			323.3		44.92																100 per admission copayment				20 cost sharing	20 cost sharing	50 ER 10 Urgent Care						20 PT/OT/ST 10 CORF 10 Mental Health			10 MH/SA			10/Visit PCP 20/Visit Specialist		10 Vision 10 Hearing			10 per exam		10 per exam																9.5				0.2	0.2	28.29						0.98			10			3.36		10			10		10															-	0.05	-	-	-	2.2	0.3	0.76	-	-	-	-	-	0.28	-	-	0.15	-	-	8.98	-	0.07	-	-	0.27	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.09			-	0.05	-	-	-	2.2	0.3	0.76	-	-	-	-	-	0.28	-	-	0.15	-	-	8.98	-	0.07	-	-	0.27	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.09																																																																																				-			-	0.05	-	-	-	2.2	0.3	0.76	-	-	-	-	-	0.28	-	-	0.15	-	-	8.98	-	0.07	-	-	0.27	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.09
H4506_003_0	2007	3																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-		229.01	0.84	152.12		236.6	7.79	0.42	542.22	441.93		186.19		16.81	491.29	4179.94	4168.99	0.41	215.44			12.79				87.57																	1a: 300	1b: 300	2a: 0 Days 1-20 and 100 Days 21-100 2a2: 300 per admit plus 100 Days 21-100	6:00	10a: 100	11a: 10	11b 11c: 20	4a 4b: 50	9a: 150 9b: 100	8a: 0/25/50/125/200/300	8b: 0	(incl in h5)	12:50	3 5 9d: 25 9c: 35/20	7a 14c: 5; 14d 14e 14f 14g 14h: 0	7b 7d 7f 7g 17a 18a: 25	7e 7h: 35/20	7c 7i: 25	8b: 0	14i: 10	15:10	13a 14b: 0	10b: 0 (n/c)	16a 16b: 0 (n/c)	17a: 25	17b: 0 (n/c)	18a: 0 (n/c)	18b: 0 (n/c)	0 (n/c)	14a: 0	13b: 0 (n/c)											300	300	63.01		100	0.1	0.2	50	150		56.96		50	17.93	5	22.6	31.25	24.78			0.1				25																	5.73	0.02	0.8	-	1.97	0.78	0.08	2.26	5.52	-	0.88	-	0.07	0.73	1.74	7.85	0	0.44	-	-	1.28	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.35		0	5.73	0.02	0.8	-	1.97	0.78	0.08	2.26	5.52	-	0.88	-	0.07	0.73	1.74	7.85	0	0.44	-	-	1.28	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.35																																																																																				-		0	5.73	0.02	0.8	-	1.97	0.78	0.08	2.26	5.52	-	0.88	-	0.07	0.73	1.74	7.85	0	0.44	-	-	1.28	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.35
H4506_004_0	2007	3																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-		242.13	0.38	26.8		343.55	30.07	0.26	598.95	535.54		548.4		10.36	387.61		4437.57	2.34	739.96			7.27				60.81																	1a: 300	1b: 300	2a: 0 Days 1-20 100 Days 21-100 2a2: 300 per admit plus 100 Days 21-100	6:00	10a: 100	11a: 10	11b 11c: 20	4a 4b: 50	9a: 150 9b: 100	8a: 0/25/50/125/200/300	8b: 0	(incl in h5)	12:50	3 5 9d: 25 9c: 35/20	7a 14c 14d 14e 14f 14g 14h: 0	7b 7d 7f 7g 17a 18a: 25	7e 7h: 35/20	7c 7i: 25	8b: 0	14i: 10	15:10	13a 14b: 0	10b: 0 (n/c)	16a 16b: 0 (n/c)	17a: 25	17b: 0 (n/c)	18a: 0 (n/c)	18b: 0 (n/c)	0 (n/c)	14a: 0	13b: 0 (n/c)											300	300	63.22		100	0.1	0.2	50	150		61.31		50	13.74		23.29	31.25	12.5			0.1				25																	6.05	0.01	0.14	-	2.86	3.01	0.05	2.5	6.69	-	2.8	-	0.04	0.44	-	8.61	0.01	0.77	-	-	0.73	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.85		0	6.05	0.01	0.14	-	2.86	3.01	0.05	2.5	6.69	-	2.8	-	0.04	0.44	-	8.61	0.01	0.77	-	-	0.73	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.85																																																																																				-		0	6.05	0.01	0.14	-	2.86	3.01	0.05	2.5	6.69	-	2.8	-	0.04	0.44	-	8.61	0.01	0.77	-	-	0.73	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.85
H4506_010_0	2007	1																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-		229.01	0.84	152.12		236.6	7.79	0.42	542.22	441.93		186.19		16.81	491.29	4179.94	4168.99	0.41	215.44			12.79				87.57																	1a: 300	1b: 300	2a: 0 Days 1-20 and 100 Days 21-100 2a2: 300 per admit and 100 Days 21-100	6:00	10a: 75	11a: 10	11b 11c: 20	4a 4b: 50	9a: 150 9b: 100	8a: 0/25/50/125/200/300	8b: 0	(incl in h5)	12:50	3 5 9d: 25 9c: 35/20	7a 14c: 5; 14d 14e 14f 14g 14h: 0	7b 7d 7f 7g 17a 18a: 25	7e 7h: 35/20	7c 7i: 25	8b: 0	14i: 10	15:10	13a 14b: 0	10b: 0 (n/c)	16a 16b: 0 (n/c)	17a: 25	17b: 0 (n/c)	18a: 0 (n/c)	18b: 0 (n/c)	0 (n/c)	14a: 0	13b: 0 (n/c)											300	300	63.01		75	0.1	0.2	50	150		56.96		50	17.93	5	22.6	31.25	24.78			0.1				25																	5.73	0.02	0.8	-	1.48	0.78	0.08	2.26	5.52	-	0.88	-	0.07	0.73	1.74	7.85	0	0.44	-	-	1.28	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.86		0	5.73	0.02	0.8	-	1.48	0.78	0.08	2.26	5.52	-	0.88	-	0.07	0.73	1.74	7.85	0	0.44	-	-	1.28	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.86																																																																																				-		0	5.73	0.02	0.8	-	1.48	0.78	0.08	2.26	5.52	-	0.88	-	0.07	0.73	1.74	7.85	0	0.44	-	-	1.28	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.86
H4506_011_0	2007	1																																A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-		242.13	0.38	26.8		343.55	30.07	0.26	598.95	535.54		548.4		10.36	387.61		4437.57	2.34	739.96			7.27				60.81																	1a: 300	1b: 300	2a: 0 Days 1-20 and 100 Days 21-100 2a2: 300 per admit and 100 Days 21-100	6:00	10a: 75	11a: 10	11b 11c: 20	4a 4b: 50	9a: 150 9b: 100	8a: 0/25/50/125/200/300	8b: 0	(incl in h5)	12:50	3 5 9d: 25 9c: 35/20	7a 14c 14d 14e 14f 14g: 0	7b 7d 7f 7g 17a 18a: 25	7e 7h: 35/20	7c 7i: 25	8b: 0	14i: 10	15:10	13a 14b: 0	10b: 0 (n/c)	16a 16b: 0 (n/c)	17a: 25	17b: 0 (n/c)	18a: 0 (n/c)	18b: 0 (n/c)	0 (n/c)	14a: 0	13b: 0 (n/c)											300	300	63.22		75	0.1	0.2	50	150		61.31		50	13.74		23.29	31.25	12.5			0.1				25																	6.05	0.01	0.14	-	2.15	3.01	0.05	2.5	6.69	-	2.8	-	0.04	0.44	-	8.61	0.01	0.77	-	-	0.73	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.13		0	6.05	0.01	0.14	-	2.15	3.01	0.05	2.5	6.69	-	2.8	-	0.04	0.44	-	8.61	0.01	0.77	-	-	0.73	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.13																																																																																				-		0	6.05	0.01	0.14	-	2.15	3.01	0.05	2.5	6.69	-	2.8	-	0.04	0.44	-	8.61	0.01	0.77	-	-	0.73	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.13
H4506_012_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		514.86	49.56	24.56		17.4	41.29	25.14	25.62	32.84	26.24	24.07	2.84	6.95	37.51	31.96	44.25	10.16	4.86	32.37	151.69	33.5	0.12																				Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin											0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				34.38	3.31	4.67	-	4.11	9.74	5.93	6.05	7.75	6.19	5.68	0.67	1.64	8.85	7.54	10.44	2.4	1.15	7.64	35.8	7.91	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.88	138	0	34.38	3.31	4.67	-	4.11	9.74	5.93	6.05	7.75	6.19	5.68	0.67	1.64	8.85	7.54	10.44	2.4	1.15	7.64	35.8	7.91	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.88		FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share																																																				-		0	34.38	3.31	4.67	-	4.11	9.74	5.93	6.05	7.75	6.19	5.68	0.67	1.64	8.85	7.54	10.44	2.4	1.15	7.64	35.8	7.91	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.88
H4506_013_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		498.98	31.22	588.23		34.77	16.52	20.07	13.19	19.23	43.27	12.32	2.3	2.31	135.22	11.5	37.21	28.78	3.88	30.96	207.72	39.17	0.08																				Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin	Med FFS Ded/Coin											0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				33.08	2.07	110.94	-	8.21	3.9	4.74	3.11	4.54	10.21	2.91	0.54	0.55	31.91	2.71	8.78	6.79	0.92	7.31	49.02	9.25	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	301.5	138	0	33.08	2.07	110.94	-	8.21	3.9	4.74	3.11	4.54	10.21	2.91	0.54	0.55	31.91	2.71	8.78	6.79	0.92	7.31	49.02	9.25	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	301.5		FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share	FFS Cost Share																																																				-		0	33.08	2.07	110.94	-	8.21	3.9	4.74	3.11	4.54	10.21	2.91	0.54	0.55	31.91	2.71	8.78	6.79	0.92	7.31	49.02	9.25	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	301.5
H4506_015_0	2007	3																																A	A	D	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	Coin	Coin	V	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-		242.13	0.38	26.8	6.8	15.7	30.07	0.26	598.95	49.67	3.76	44.27	30.74	2.77	20.27	5343.24	4437.57	0.04	6.07			7.27				60.81																	1a: 175 Days 1-5	1b: 175 Days 1-5	2a: 0 Days 1-20 and 100 Days 21-100 2a2: 175 Days 1-5 and 100 Days 21-100	6:20	10a: 20	11a: 20	11b 11c: 20	4a 4b: 50	9a 9b: 20	8a: 20	8b: 20	(incl in h5)	12:20	3 9c: 20; 5 9d: 40	7a 14c: 15; 14d 14e 14f 14g 14h: 0	7b 7c 7d 7f 7g 17a 18a: 40	7e 7h: 20	7c 7i: 20	8b: 20	14i: 40	15:20	13a: 20; 14b: 0	0 (n/c)	16a 16b: 0 (n/c)	17a: 40	17b: 0 (n/c)	18a: 0 (n/c)	18b: 0 (n/c)	0 (n/c)	14a: 0	13b: 0 (n/c)											624.02	624.02	63.72	0.2	0.2	0.2	0.2	50	0.2	0.2	0.2	0.2	0.2	0.2	15	31.33	0.2	0.2			0.2				40																	12.59	0.02	0.14	1.36	3.14	6.01	0.05	2.5	9.93	0.75	8.85	6.15	0.55	4.05	6.68	11.59	0.01	1.24	-	-	1.45	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.28		0	12.59	0.02	0.14	1.36	3.14	6.01	0.05	2.5	9.93	0.75	8.85	6.15	0.55	4.05	6.68	11.59	0.01	1.24	-	-	1.45	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.28																																																																																				-		0	12.59	0.02	0.14	1.36	3.14	6.01	0.05	2.5	9.93	0.75	8.85	6.15	0.55	4.05	6.68	11.59	0.01	1.24	-	-	1.45	-	-	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.28
H4506_801_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		270.34	0.39	8.28		9.74	12.78	0.38	19.09	34.79	25.98	18.97	12.31	1	11.47	31.19	37	0.01	3.59	37.34	128.4	11.42	12.78																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co											0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116	138	0	18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116																																																																																				-		0	18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116
H4506_806_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		270.34	0.39	8.28		9.74	12.78	0.38	19.09	34.79	25.98	18.97	12.31	1	11.47	31.19	37	0.01	3.59	37.34	128.4	11.42	12.78																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co											0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116	138	0	18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116																																																																																				-		0	18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116
H4506_808_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		270.34	0.39	8.28		9.74	12.78	0.38	19.09	34.79	25.98	18.97	12.31	1	11.47	31.19	37	0.01	3.59	37.34	128.4	11.42	12.78																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co											0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116	138	0	18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116																																																																																				-		0	18.05	0.03	1.57	-	2.3	3.02	0.09	4.51	8.21	6.13	4.48	2.91	0.24	2.71	7.36	8.73	0	0.85	8.81	30.3	2.69	3.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116
H4510_012_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								2000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin							A	A	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-		273.42	0.63	1408.72	2594.2	303.97	0.97	0.07	338	248.69	180.42	123.01	8.2	34.23	69.71	6248.96	5757.35			240.22		5.01			2.04	0							14.39	0.03	31746.67								50 admit/ LTAC 950/admit	950/admit	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	40-50/ Visit	0-50/ Visit	25-100/ Visit	50/ Visit	0/ Procedure	30-100/ Visit	5/ Visit	15/ Visit			100/ Visit		20 Coins			0 coinsurance	0							50 admit/ LTAC 950/admit	950/admit	0/Procedure								78.27	782.73	9.07	0	82.39	0.16	0.16	37.9	35.68	31.83	34.33	41.2	0	30.53	4.12	12.36			82.39		0.16			0	0							78.27	782.73	0								1.78	0.04	1.06	-	2.09	0.16	0.01	1.07	0.74	0.48	0.35	0.03	-	0.18	2.15	5.93	-	-	1.65	-	0.83	-	-	-	-	-	-	-	-	-	-	0.09	0	-	-	-	-	-	-	-	-	18.64	0	3.98	1.78	0.04	1.06	-	2.09	0.16	0.01	1.07	0.74	0.48	0.35	0.03	-	0.18	2.15	5.93	-	-	1.65	-	0.83	-	-	-	-	-	-	-	-	-	-	0.09	0	-	-	-	-	-	-	-	-	18.64	2000																																																																																			-			1.78	0.04	1.06	-	2.09	0.16	0.01	1.07	0.74	0.48	0.35	0.03	-	0.18	2.15	5.93	-	-	1.65	-	0.83	-	-	-	-	-	-	-	-	-	-	0.09	0	-	-	-	-	-	-	-	-	18.64
H4510_015_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								3750	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin					Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-		311.8	1.06	1519.08	2348.73	348.39	0.73	0.06	322.76	261.19	313.22	213.56	14.24	31.31	121.02	7531.38	5277.34			256.28		6.74			2.04	0							16.41	0.06	16.44								65 admit/ LTAC 950/admit	950/admit	0/day (1-20) 125/day (21-100)	0/Visit	50/ Trip	20 Coins	20 Coins	35-50/ Visit	40-50/ Visit	0-50/ Visit	0-100/ Visit	50/ Visit	0/ Procedure	15-100/ Visit	5/ Visit	20/ Visit			100/ Visit		20 Coins			Dental (#756)	see PBP							65 admit/ LTAC 950/admit	950/admit	20 Coins								96.8	843.66	9.77	0	44.4	0.18	0.18	41.74	38.45	34.31	17.76	44.4	0	22.72	4.44	17.76			88.81		0.18			0	0							96.8	843.66	0.18								2.52	0.07	1.24	-	1.29	0.13	0.01	1.12	0.84	0.9	0.32	0.05	-	0.23	2.79	7.81	-	-	1.9	-	1.2	-	-	-	-	-	-	-	-	-	-	0.13	0	2.92	-	-	-	-	-	-	-	25.46	0	3.21	2.52	0.07	1.24	-	1.29	0.13	0.01	1.12	0.84	0.9	0.32	0.05	-	0.23	2.79	7.81	-	-	1.9	-	1.2	-	-	-	-	-	-	-	-	-	-	0.13	0	2.92	-	-	-	-	-	-	-	25.46	3750																																																																																			-			2.52	0.07	1.24	-	1.29	0.13	0.01	1.12	0.84	0.9	0.32	0.05	-	0.23	2.79	7.81	-	-	1.9	-	1.2	-	-	-	-	-	-	-	-	-	-	0.13	0	2.92	-	-	-	-	-	-	-	25.46
H4510_016_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S			Coin	Coin					Coin		A	A	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-		328.25	0.76	912.51	3114.48	364.94	340.71	25.64	405.79	298.57	216.6	147.68	9.85	41.09	83.69	7502.21	6912.02			288.4		295.66			4.6	0							17.28	0.04	38113.61								0/admit	0/admit	0/admit 0/day (21-100)	0/Visit	0/ Trip	0/ Procedure	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts			0 to 50	Vision capitated benefit							0/admit	0/admit	0/Procedure								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4510_017_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	P	P	V	V	V	V	V	P	V	V	V			V		S			Coin	Coin							A	A	P								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-		384.46	1.3	1873.04	2896.01	429.57	340.8	25.65	397.97	322.05	386.2	263.32	17.55	38.61	149.21	9286.26	6507			315.99		527.16			4.6	0							20.23	0.07	27591.96								0/admit	0/admit	0/day (1-20) 0/day (21-100)	0/Visit	0/ Trip	0/ Procedure	0/ Procedure	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Visit	0/ Procedure	0/ Visit	0/ Visit	0/ Visit			0/ Visit		0/ Scripts			0 to 50	Capitated - see PBP							0/admit	0/admit	0/Procedure								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0							0	0	0								-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4510_801_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0									-		1775.43	6.84	1558.09	2409.05	357.34	0.77	0.06	324.43	267.9	321.26	51.11	14.6	32.12	124.12	7724.8	5412.87			262.86		7.09			0	0		0					93.44	0.36									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									30.19	0.12	1.43	-	2.98	0.15	0.01	1.28	4.46	2.28	0.35	0.12	-	0.48	12.87	15.79	-	-	3.29	-	1.42	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.82	0	0	30.19	0.12	1.43	-	2.98	0.15	0.01	1.28	4.46	2.28	0.35	0.12	-	0.48	12.87	15.79	-	-	3.29	-	1.42	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.82																																																																																				-			30.19	0.12	1.43	-	2.98	0.15	0.01	1.28	4.46	2.28	0.35	0.12	-	0.48	12.87	15.79	-	-	3.29	-	1.42	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.82
H4510_802_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1614.76	12.32	1589.19	2418.69	233.74	0.86	0.06	346.65	270.55	223.92	35.62	10.18	79.94	86.52	5672.43	4707.19			207.68		7.5											84.99	0.65									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									27.46	0.21	1.46	-	1.95	0.17	0.01	1.36	4.51	1.59	0.24	0.08	-	0.34	9.45	13.73	-	-	2.6	-	1.5	-	-	-	-	-	-	-	-	-	-	1.45	0.01	-	-	-	-	-	-	-	-	68.12	0	0	27.46	0.21	1.46	-	1.95	0.17	0.01	1.36	4.51	1.59	0.24	0.08	-	0.34	9.45	13.73	-	-	2.6	-	1.5	-	-	-	-	-	-	-	-	-	-	1.45	0.01	-	-	-	-	-	-	-	-	68.12																																																																																				-			27.46	0.21	1.46	-	1.95	0.17	0.01	1.36	4.51	1.59	0.24	0.08	-	0.34	9.45	13.73	-	-	2.6	-	1.5	-	-	-	-	-	-	-	-	-	-	1.45	0.01	-	-	-	-	-	-	-	-	68.12
H4510_803_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	Coin		Coin			Coin		D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0	0		0					0	0									-		1775.43	6.84	1558.09	2409.05	357.34	0.77	0.06	324.43	267.9	321.26	51.11	14.6	32.12	124.12	7724.8	5412.87			262.86		7.09			0	0		0					93.44	0.36									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins			0	0		0					300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2			0	0		0					204.06	204.06									30.19	0.12	1.43	-	2.98	0.15	0.01	1.28	4.46	2.28	0.35	0.12	-	0.48	12.87	15.79	-	-	3.29	-	1.42	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.82	0	0	30.19	0.12	1.43	-	2.98	0.15	0.01	1.28	4.46	2.28	0.35	0.12	-	0.48	12.87	15.79	-	-	3.29	-	1.42	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.82																																																																																				-			30.19	0.12	1.43	-	2.98	0.15	0.01	1.28	4.46	2.28	0.35	0.12	-	0.48	12.87	15.79	-	-	3.29	-	1.42	-	-	-	-	-	-	-	-	-	-	1.59	0.01	-	-	-	-	-	-	-	-	78.82
H4510_804_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		1614.76	12.32	1589.19	2418.69	233.74	0.86	0.06	346.65	270.55	223.92	35.62	10.18	79.94	86.52	5672.43	4707.19			207.68		7.5											84.99	0.65									300/day (1-5)	300/day (1-5)	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	200/ Visit	35-100/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	35-100/ Visit	20/ Visit	35/ Visit			150/ Visit		20 Coins											300/day (1-5)	300/day (1-5)									204.06	204.06	11.01	0	100	0.2	0.2	47.24	200	85.23	81.43	100	0	46.47	20	35			150		0.2											204.06	204.06									27.46	0.21	1.46	-	1.95	0.17	0.01	1.36	4.51	1.59	0.24	0.08	-	0.34	9.45	13.73	-	-	2.6	-	1.5	-	-	-	-	-	-	-	-	-	-	1.45	0.01	-	-	-	-	-	-	-	-	68.12	0	0	27.46	0.21	1.46	-	1.95	0.17	0.01	1.36	4.51	1.59	0.24	0.08	-	0.34	9.45	13.73	-	-	2.6	-	1.5	-	-	-	-	-	-	-	-	-	-	1.45	0.01	-	-	-	-	-	-	-	-	68.12																																																																																				-			27.46	0.21	1.46	-	1.95	0.17	0.01	1.36	4.51	1.59	0.24	0.08	-	0.34	9.45	13.73	-	-	2.6	-	1.5	-	-	-	-	-	-	-	-	-	-	1.45	0.01	-	-	-	-	-	-	-	-	68.12
H4513_001_0	2007	7																					3000											A	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	253.89	94.35	34.09	1243.16	170.43	10.01	0.6	562.03	275.25	147.03	0	0	14.78	296.94	4490.16	7457.29	62.19	215.55	2009.84	184.19	2.59	0	533.37	0	64.54	0	0	0	0	0	0											275 per admit	100 per day Days 1-10	Days 1-10 0 per day; Days 11-100 25 per day	No Cost Sharing	50 per trip unless being admitted for same condition w/in 3 days	10 Coinsurance	10 Coinsurance	50 per visit	150 per visit	25 copay	25 copay	No Cost Sharing	25 copay	25 copay	10 copay	25 copay	25 copay	25 copay	25 copay	25 copay	15 Coinsurance	No Cost Sharing	No Cost Sharing		25 copay	1 pair of eyeglasses after cataract surgery																275	100	25	0	50	0.1	0.1	50	150	25	25	0	25	25	10	25	25	25	25	25	0.09	0	0	0	25	0	0	0	0	0	0											5.82	0.79	0.07	-	0.71	1	0.06	2.34	3.44	0.31	-	-	0.03	0.62	3.74	15.54	0.13	0.45	4.19	0.38	0.24	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.98		0	5.82	0.79	0.07	-	0.71	1	0.06	2.34	3.44	0.31	-	-	0.03	0.62	3.74	15.54	0.13	0.45	4.19	0.38	0.24	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.98	3000																																																																																			-		0	5.82	0.79	0.07	-	0.71	1	0.06	2.34	3.44	0.31	-	-	0.03	0.62	3.74	15.54	0.13	0.45	4.19	0.38	0.24	-	-	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.98
H4513_006_0	2007	4																					3000											A	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	170.54	63.38	179.89	586.15	124.42	5.69	0.34	262.25	168.39	89.45	0	0	8.99	180.64	3572.04	5932.47	49.47	171.48	1598.88	146.53	1.47	0	0	0	64.54	0	0	0	0	0	0											450 per admit	150 per day Days 1-10	Days 1-10 0 per day; Days 11-100 25 per day	No Cost Sharing	50 per trip unless being admitted for same condition w/in 3 days	10 Coinsurance	10 Coinsurance	50 per visit	150 per visit	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	10 copay	30 copay	30 copay	30 copay	30 copay	30 copay	15 copay	No Cost Sharing	No Cost Sharing		30 copay	1 pair of eyeglasses after cataract surgery																450	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	10	30	30	30	30	30	0.09	0	0	0	30	0	0	0	0	0	0											6.4	0.79	0.37	-	0.52	0.57	0.03	1.09	2.1	0.22	-	-	0.02	0.45	2.98	14.83	0.12	0.43	4	0.37	0.13	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.6			6.4	0.79	0.37	-	0.52	0.57	0.03	1.09	2.1	0.22	-	-	0.02	0.45	2.98	14.83	0.12	0.43	4	0.37	0.13	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.6	3000																																																																																			-			6.4	0.79	0.37	-	0.52	0.57	0.03	1.09	2.1	0.22	-	-	0.02	0.45	2.98	14.83	0.12	0.43	4	0.37	0.13	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.6
H4513_009_0	2007	3																					3000											A	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	225.83	83.92	161.27	827.09	179.24	5.24	0.31	482.28	179.77	118.32	0	0	11.89	238.95	3572.61	5933.42	49.48	171.5	1599.14	146.55	1.83	0	0	0	64.54																	500 per admit	150 per day Days 1-10	25 per Day	No Cost Sharing	50 per trip	10 Coinsurance	10 Coinsurance	50 per trip	150 copay	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	10 copay	30 copay	30 copay	30 copay	30 copay	30 copay	No Cost Sharing	No Cost Sharing	No Cost Sharing		30 copay	1 pair of eyeglasses after cataract surgery																500	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	10	30	30	30	30	30	0.09	0	0	0	30	0																9.41	1.05	0.34	-	0.75	0.52	0.03	2.01	2.25	0.3	-	-	0.03	0.6	2.98	14.83	0.12	0.43	4	0.37	0.16	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.33			9.41	1.05	0.34	-	0.75	0.52	0.03	2.01	2.25	0.3	-	-	0.03	0.6	2.98	14.83	0.12	0.43	4	0.37	0.16	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.33	3000																																																																																			-			9.41	1.05	0.34	-	0.75	0.52	0.03	2.01	2.25	0.3	-	-	0.03	0.6	2.98	14.83	0.12	0.43	4	0.37	0.16	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.33
H4513_010_0	2007	4																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4513_014_0	2007	4																					3000											A	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	167.67	62.31	175.51	563.49	122.83	5.63	0.34	251.91	164.71	87.46	0	0	8.79	176.63	3545.9	5889.07	49.11	170.22	1587.19	145.45	1.43				64.54																	450 per admit	150 per day Days 1-10	Days 1-10 0 per day; Days 11-100 25 per day	No Cost Sharing	50 per trip unless being admitted for same condition w/in 3 days	10 Coinsurance	10 Coinsurance	50 per visit	150 per visit	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	10 copay	30 copay	30 copay	30 copay	30 copay	30 copay	15 copay	No Cost Sharing	No Cost Sharing		30 copay	1 pair of eyeglasses after cataract surgery																450	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	10	30	30	30	30	30	0.09				30																	6.29	0.78	0.37	-	0.51	0.56	0.03	1.05	2.06	0.22	-	-	0.02	0.44	2.95	14.72	0.12	0.43	3.97	0.36	0.13	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.18			6.29	0.78	0.37	-	0.51	0.56	0.03	1.05	2.06	0.22	-	-	0.02	0.44	2.95	14.72	0.12	0.43	3.97	0.36	0.13	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.18	v																																																																																			-			6.29	0.78	0.37	-	0.51	0.56	0.03	1.05	2.06	0.22	-	-	0.02	0.44	2.95	14.72	0.12	0.43	3.97	0.36	0.13	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.18
H4513_015_0	2007	4																					3000																																																																																													-	0																																																																																																																												-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3000																																																																																			-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H4513_017_0	2007	3																					3000											A	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	228.41	84.88	164.39	839.78	180.99	5.32	0.32	488.07	182.15	119.82	0	0	12.05	241.99	3616.89	6006.97	50.09	173.63	1618.96	148.37	1.88	0	0	0	64.54																	500 per admit	150 per day Days 1-10	25 per Day	No Cost Sharing	50 per trip	10 Coinsurance	10 Coinsurance	50 per trip	150 copay	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	10 copay	30 copay	30 copay	30 copay	30 copay	30 copay	No Cost Sharing	No Cost Sharing	No Cost Sharing		30 copay	1 pair of eyeglasses after cataract surgery																500	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	10	30	30	30	30	30	0.09	0	0	0	30	0																9.52	1.06	0.34	-	0.75	0.53	0.03	2.03	2.28	0.3	-	-	0.03	0.6	3.01	15.02	0.13	0.43	4.05	0.37	0.17	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.82			9.52	1.06	0.34	-	0.75	0.53	0.03	2.03	2.28	0.3	-	-	0.03	0.6	3.01	15.02	0.13	0.43	4.05	0.37	0.17	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.82	3000																																																																																			-			9.52	1.06	0.34	-	0.75	0.53	0.03	2.03	2.28	0.3	-	-	0.03	0.6	3.01	15.02	0.13	0.43	4.05	0.37	0.17	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.82
H4513_802_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	1808.28	94.35	34.09	1243.16	170.43	10.01	0.6	562.03	275.25	147.03	0	0	14.78	296.94	4512.06	7493.67	62.49	216.6	2019.65	185.09	2.59		533.37		64.54																	150 per Day	150 per Day	25 per Day	No Cost Sharing	50 per trip	10 Coinsurance	10 Coinsurance	50 per trip	150 copay	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	20 copay	30 copay	30 copay	30 copay	30 copay	30 copay	15 Coinsurance	No Cost Sharing	3.50 per trip		30 copay	1 pair of eyeglasses after cataract surgery																150	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	20	30	30	30	30	30	0.09		3.5		30																	22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57																																																																																				-			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57
H4513_804_0	2007	7																					3000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	1808.28	94.35	34.09	1243.16	170.43	10.01	0.6	562.03	275.25	147.03	0	0	14.78	296.94	4512.06	7493.67	62.49	216.6	2019.65	185.09	2.59	0	533.37		64.54																	150 per Day	150 per Day	25 per Day	No Cost Sharing	50 per trip	10 Coinsurance	10 Coinsurance	50 per trip	150 copay	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	20 copay	30 copay	30 copay	30 copay	30 copay	30 copay	15 Coinsurance	No Cost Sharing	3.50 per trip		30 copay	1 pair of eyeglasses after cataract surgery																150	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	20	30	30	30	30	30	0.09	0	3.5		30																	22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57	3000																																																																																			-			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57
H4513_805_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	1808.28	94.35	34.09	1243.16	170.43	10.01	0.6	562.03	275.25	147.03	0	0	14.78	296.94	4512.06	7493.67	62.49	216.6	2019.65	185.09	2.59	0	533.37		64.54																	150 per Day	150 per Day	25 per Day	No Cost Sharing	50 per trip	10 Coinsurance	10 Coinsurance	50 per trip	150 copay	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	20 copay	30 copay	30 copay	30 copay	30 copay	30 copay	15 Coinsurance	No Cost Sharing	3.50 per trip		30 copay	1 pair of eyeglasses after cataract surgery																150	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	20	30	30	30	30	30	0.09	0	3.5		30																	22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57	3000																																																																																			-			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57
H4513_806_0	2007	7																					3000											D	D	D	V	T	Coin	Coin	P	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	V	V	V	O	O	O																																																				-	0	1808.28	94.35	34.09	1243.16	170.43	10.01	0.6	562.03	275.25	147.03	0	0	14.78	296.94	4512.06	7493.67	62.49	216.6	2019.65	185.09	2.59	0	533.37	0	64.54																	150 per Day	150 per Day	25 per Day	No Cost Sharing	50 per trip	10 Coinsurance	10 Coinsurance	50 per trip	150 copay	30 copay	30 copay	No Cost Sharing	30 copay	30 copay	20 copay	30 copay	30 copay	30 copay	30 copay	30 copay	15 Coinsurance	No Cost Sharing	3.50 per trip		30 copay	1 pair of eyeglasses after cataract surgery																150	150	25	0	50	0.1	0.1	50	150	30	30	0	30	30	20	30	30	30	30	30	0.09	0	3.5		30																	22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57	3000																																																																																			-			22.6	1.18	0.07	-	0.71	1	0.06	2.34	3.44	0.37	-	-	0.04	0.74	7.52	18.73	0.16	0.54	5.05	0.46	0.24	-	0.16	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57
H4514_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						2500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V		V	Coin	P	T	P	V	P	V	P				V	V	V	V	V																																															-		3288.81	20.66	450.32	859.56	690.29	32.97	9.52	917.9	163.5	1426.38	610.58	36.63	0.69	2002.22	7062.18	3087.31	7321.02	227.43		0.33	786.97	666.23	2088.5	1042	10.16	293.3		41.6				2366.67			38	225.2						(1a) 125/day	(1b) 125/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 30/visit	(8a) 30/visit	(8b) 30/visit	(9a) 30/visit	(12) 20 coins	(9a) 30/visit	(7a 14b-14i) 10/visit	(7b/7d/7f) 30/visit	(7e/7h) 32.5/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 30/visit		(7g) 30/visit	(15) 0/proc	(16b/17a) 30/proc (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip	(16a) 0/proc	(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 30/visit (waived if admitted)			(7f1) 0/visit	(18a1) 0/visit						99	99			39	16	16	39	24	24	24	24	16	24	8	24	26	24		24		24										24										27.01	0.17	-	-	2.27	5.2	1.5	3.02	0.32	2.81	1.2	0.07	0.11	3.95	4.64	6.08	15.63	0.45	-	0	-	1.31	-	-	-	-	-	-	-	-	-	4.66	-	-	-	-	-	-	-	-	-	80.41		21.58	27.01	0.17	-	-	2.27	5.2	1.5	3.02	0.32	2.81	1.2	0.07	0.11	3.95	4.64	6.08	15.63	0.45	-	0	-	1.31	-	-	-	-	-	-	-	-	-	4.66	-	-	-	-	-	-	-	-	-	80.41																																																																																				-		0	27.01	0.17	-	-	2.27	5.2	1.5	3.02	0.32	2.81	1.2	0.07	0.11	3.95	4.64	6.08	15.63	0.45	-	0	-	1.31	-	-	-	-	-	-	-	-	-	4.66	-	-	-	-	-	-	-	-	-	80.41
H4514_004_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		2696.8	244.68	1124.08		249.51	31.06	35.86	691.86	537.83	2699.45	1142.39	86.14	1.66	1623.76		5904.02		557.53		1092.87												315.3		304.65	308.92							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						39	39	19		39	8	10	19	13	3	5	13	10	13		5		5		5												5		5	5							8.78	0.8	1.76	-	0.81	2.43	3.73	1.08	0.58	0.59	0.5	0.09	0.17	1.76	-	2.56	-	0.24	-	0.47	-	-	-	-	-	-	-	-	-	-	-	0.14	-	0.13	0.13	-	-	-	-	-	-	26.75		24.63	8.78	0.8	1.76	-	0.81	2.43	3.73	1.08	0.58	0.59	0.5	0.09	0.17	1.76	-	2.56	-	0.24	-	0.47	-	-	-	-	-	-	-	-	-	-	-	0.14	-	0.13	0.13	-	-	-	-	-	-	26.75																																																																																				-		0	8.78	0.8	1.76	-	0.81	2.43	3.73	1.08	0.58	0.59	0.5	0.09	0.17	1.76	-	2.56	-	0.24	-	0.47	-	-	-	-	-	-	-	-	-	-	-	0.14	-	0.13	0.13	-	-	-	-	-	-	26.75
H4514_005_0	2007	3	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1000	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		2426.23	225.92	9232.98	180.33	676.79	1522.28	7398.39	194.64	129.23	4020.5	178.74	35.34	4.63	300.52	131.74	1348.6	1751.9	20.69		281.59	271.05	1377	2250		140.2							114.77	0.29	0.07	300	295.2						(1a) 125/day	(1b) 125/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit							(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						102	102			61			41	20			20		20		8				8		8										8		20								20.62	1.92	-	-	3.45	-	-	0.66	0.22	-	-	0.06	-	0.51	-	0.92	-	-	-	0.19	-	0.94	-	-	-	-	-	-	-	-	-	0.08	-	0	-	-	-	-	-	-	-	29.56		6.68	20.62	1.92	-	-	3.45	-	-	0.66	0.22	-	-	0.06	-	0.51	-	0.92	-	-	-	0.19	-	0.94	-	-	-	-	-	-	-	-	-	0.08	-	0	-	-	-	-	-	-	-	29.56																																																																																				-		0	20.62	1.92	-	-	3.45	-	-	0.66	0.22	-	-	0.06	-	0.51	-	0.92	-	-	-	0.19	-	0.94	-	-	-	-	-	-	-	-	-	0.08	-	0	-	-	-	-	-	-	-	29.56
H4514_006_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					2100	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		2686.65	385.68			333.17	30.82	25.72	959.45	389.46	2297.4	956.43	68.39	3.4	2121.91	9505.48	3824.88	558.29	547.87		881.5												337.04	122.11	156.83	266.32	429.32						(1a) 125 per Day	(1b) 125 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 50 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/30 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 30 per Visit	(8a) 30 per Visit	(8b) 30 per Visit	(9a) 30 per Visit	(12) 20 Coinsurance	(9a) 30 per Visit	(7a) 10 per Visit	(7d) 30 per Visit	(7h) 35/25 per Visit	(7c) 30 per Visit	0 per Visit	(7g) 30 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 30 per Visit	(9c) 35/25 per Visit	(7b) 30 per Visit	(7f) 30 per Visit	(7e) 35/25 per Visit						74	74			29	12	12	25	18	18	18	18	12	18	6	18	19	18		18												18	19	18	18	19						16.48	2.37	-	-	0.82	3.63	3.03	2.02	0.57	3.38	1.41	0.1	0.4	3.12	4.71	5.63	0.89	0.81	-	1.3	-	-	-	-	-	-	-	-	-	-	-	0.5	0.19	0.23	0.39	0.68	-	-	-	-	-	52.67		36.7	16.48	2.37	-	-	0.82	3.63	3.03	2.02	0.57	3.38	1.41	0.1	0.4	3.12	4.71	5.63	0.89	0.81	-	1.3	-	-	-	-	-	-	-	-	-	-	-	0.5	0.19	0.23	0.39	0.68	-	-	-	-	-	52.67																																																																																				-		0	16.48	2.37	-	-	0.82	3.63	3.03	2.02	0.57	3.38	1.41	0.1	0.4	3.12	4.71	5.63	0.89	0.81	-	1.3	-	-	-	-	-	-	-	-	-	-	-	0.5	0.19	0.23	0.39	0.68	-	-	-	-	-	52.67
H4514_007_0	2007	6																					2950											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2188.71	190.67	1041.73	0	330.54	19.73	8.52	611.4	43.75	8813.84	60.86	0	0.3	33.29	4042.01	4736.4	812.99	2.55	0	0	30.53	823.64	0	0	185.49	0	257.02	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											147.17	147.17	74.83	0	87.3	0.15	0.18	24.94	0.15	2.99	0.11	0	0.15	0.15	5	20	37.5	0.15	0	0	0.15	20	0	0	20	0	20	0	0	0	0											26.84	2.34	6.5	-	2.4	2.95	1.51	1.27	6.55	2.2	6.94	-	0.04	4.99	1.68	7.89	2.54	0.38	-	-	4.57	1.37	-	-	0.31	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.71		69.31	26.84	2.34	6.5	-	2.4	2.95	1.51	1.27	6.55	2.2	6.94	-	0.04	4.99	1.68	7.89	2.54	0.38	-	-	4.57	1.37	-	-	0.31	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.71																																																																																				-			26.84	2.34	6.5	-	2.4	2.95	1.51	1.27	6.55	2.2	6.94	-	0.04	4.99	1.68	7.89	2.54	0.38	-	-	4.57	1.37	-	-	0.31	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.71
H4514_008_0	2007	3																					2350											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2188.71	190.67	1041.73	0	330.54	19.73	8.52	611.4	43.75	8813.84	60.86	0	0.3	33.29	4042.01	4736.4	812.99	2.55	0	0	30.53	823.64	0	0	185.49	0	257.02	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											131.26	131.26	66.74	0	77.87	0.13	0.16	22.25	0.13	2.67	0.1	0	0.13	0.13	5	20	37.5	0.13	0	0	0.13	20	0	0	20	0	20	0	0	0	0											23.94	2.09	5.79	-	2.14	2.63	1.4	1.13	5.84	1.96	6.19	-	0.04	4.45	1.68	7.89	2.54	0.34	-	-	4.08	1.37	-	-	0.31	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.25		76.77	23.94	2.09	5.79	-	2.14	2.63	1.4	1.13	5.84	1.96	6.19	-	0.04	4.45	1.68	7.89	2.54	0.34	-	-	4.08	1.37	-	-	0.31	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.25																																																																																				-			23.94	2.09	5.79	-	2.14	2.63	1.4	1.13	5.84	1.96	6.19	-	0.04	4.45	1.68	7.89	2.54	0.34	-	-	4.08	1.37	-	-	0.31	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.25
H4514_801_0	2007	4																					4400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2298.15	200.2	1093.82	0	347.06	20.72	8.94	641.97	45.93	9254.54	63.91	0	0.31	34.95	4244.11	4973.22	853.64	2.67	0	0	32.06	864.82	0	0	194.76	0	269.87	0	0	0	0											350 (1a)	350 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 40 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											198.47	198.47	85.06	0	99.24	0.17	0.19	28.35	0.17	3.4	0.13	0	0.17	0.17	35	40	37.5	0.17	0	0	0.17	40	0	0	40	0	40	0	0	0	0											38.01	3.31	7.75	-	2.87	3.52	1.74	1.52	7.81	2.62	8.28	-	0.05	5.95	12.38	16.58	2.67	0.45	-	-	5.45	2.88	-	-	0.65	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.41		67.83	38.01	3.31	7.75	-	2.87	3.52	1.74	1.52	7.81	2.62	8.28	-	0.05	5.95	12.38	16.58	2.67	0.45	-	-	5.45	2.88	-	-	0.65	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.41																																																																																				-			38.01	3.31	7.75	-	2.87	3.52	1.74	1.52	7.81	2.62	8.28	-	0.05	5.95	12.38	16.58	2.67	0.45	-	-	5.45	2.88	-	-	0.65	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.41
H4520_001_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		254.33	1.92	452.01	2156.63	125.76	0.73	0.05	204.06	444.81	820.3	559.3	37.29	382.36	316.93	7209.06	8551.25			315.33		10.13			4.44								13.39	0.1	16.48								75/day (days 1-5)/LTAC 950/admit	950/admit	0/day (1-20) 125/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	50-75/ Visit	0-75/ Visit	25-100/ Visit	75/ Visit	0/ Procedure	15-100/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins			25 - 75								75/day (days 1-5)/LTAC 950/admit	950/admit	20 Coins								300	950	11.01	0	100	0.2	0.2	49.51	58.25	57.95	43.33	75	0	34.41	15	30			100		0.2			0.35								300	950	0.2								6.36	0.15	0.41	-	1.05	0.15	0.01	0.84	2.16	3.96	2.02	0.23	-	0.91	9.01	21.38	-	-	2.63	-	2.03	-	-	1.57	-	-	-	-	-	-	-	0.33	0.01	3.3	-	-	-	-	-	-	-	58.51	0	0	6.36	0.15	0.41	-	1.05	0.15	0.01	0.84	2.16	3.96	2.02	0.23	-	0.91	9.01	21.38	-	-	2.63	-	2.03	-	-	1.57	-	-	-	-	-	-	-	0.33	0.01	3.3	-	-	-	-	-	-	-	58.51		950/stay	950/admit	0/day (1-20)	20 Coins	100/Trip	20 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		20 Coins	20 Coins					20 Coins			50-80										20 Coins								2.47	0.02	0.05	0.28	0.27	0.02		0.27	2.55	3.01			0		1.91	2.3					0.62			1.63										0.66								16.05	0	0	8.82	0.17	0.46	0.28	1.32	0.17	0.01	1.11	4.71	6.97	2.02	0.23	-	0.91	10.92	23.67	-	-	2.63	-	2.64	-	-	3.2	-	-	-	-	-	-	-	0.33	0.01	3.95	-	-	-	-	-	-	-	74.56
H4520_002_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		275.44	2.08	489.54	2335.69	136.2	0.82	0.06	221	481.74	888.41	605.73	40.38	414.11	343.25	7807.62	9261.25			341.51		11.35			4.44								14.5	0.11	18.46								75/day (1-5)/LTAC 950/admit	950/admit	0/day (1-20) 100/day (21-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	100/ Visit	0-100/ Visit	30-100/ Visit	100/ Visit	0/ Procedure	15-100/ Visit	15/ Visit	30/ Visit			100/ Visit		20 Coins			25 - 75								75/day (1-5)/LTAC 950/admit	950/admit	20 Coins								300	950	8.81	0	100	0.2	0.2	49.51	100	77.27	44	100	0	38.53	15	30			100		0.2			0.35								300	950	0.2								6.89	0.16	0.36	-	1.13	0.16	0.01	0.91	4.01	5.72	2.22	0.34	-	1.1	9.76	23.15	-	-	2.85	-	2.27	-	-	1.57	-	-	-	-	-	-	-	0.36	0.01	3.69	-	-	-	-	-	-	-	66.69	0	0	6.89	0.16	0.36	-	1.13	0.16	0.01	0.91	4.01	5.72	2.22	0.34	-	1.1	9.76	23.15	-	-	2.85	-	2.27	-	-	1.57	-	-	-	-	-	-	-	0.36	0.01	3.69	-	-	-	-	-	-	-	66.69		950/admit /LTAC 950/admit	950/admit	20 Coins	20 Coins	100/Trip	20 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		20 Coins	20 Coins					20 Coins			50-80										20 Coins								2.55	0.02	0.22	0.3	0.28	0.02		0.28	2.73	3.22			0		2.04	2.46					0.66			1.63										0.7								17.11	0	0	9.44	0.18	0.58	0.3	1.42	0.18	0.01	1.19	6.74	8.94	2.22	0.34	-	1.1	11.8	25.61	-	-	2.85	-	2.93	-	-	3.2	-	-	-	-	-	-	-	0.36	0.01	4.39	-	-	-	-	-	-	-	83.8
H4520_003_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin	V					V		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1257.16	9.17	451	2151.83	125.48	0.75	0.06	203.6	443.82	818.47	558.05	37.2	381.51	316.23	7193.01	8532.21			314.63		10.35											13.36	0.1	16.84								175 (1-7)/LTAC 950 per admit	950/admit	0/day (1-6) 75/day (7-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-50/ Visit	30-100/ Visit	50/ Visit	0/ Procedure	15-100/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins											175 (1-7)/LTAC 950 per admit	950/admit	15 Coins								143.92	198.12	21.82	10	100	0.2	0.2	49.63	116.5	38.64	45.33	50	0	36.18	10	35			100		0.2											713	950	0.15								15.08	0.15	0.82	1.79	1.05	0.15	0.01	0.84	4.31	2.64	2.11	0.16	-	0.95	5.99	24.89	-	-	2.62	-	2.07	-	-	-	-	-	-	-	-	-	-	0.79	0.01	2.53	-	-	-	-	-	-	-	68.95	0	0	15.08	0.15	0.82	1.79	1.05	0.15	0.01	0.84	4.31	2.64	2.11	0.16	-	0.95	5.99	24.89	-	-	2.62	-	2.07	-	-	-	-	-	-	-	-	-	-	0.79	0.01	2.53	-	-	-	-	-	-	-	68.95		950/admit	950/admit	15 Coins	20 Coins	100/Trip	40 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		20 Coins	20 Coins					20 Coins													20 Coins								2.46	0.02	0.15	0.28	0.27	0.04		0.27	2.54	3			0		1.9	2.29					0.61													0.65								14.49	0	0	17.54	0.17	0.97	2.07	1.32	0.19	0.01	1.11	6.85	5.63	2.11	0.16	-	0.95	7.9	27.17	-	-	2.62	-	2.68	-	-	-	-	-	-	-	-	-	-	0.79	0.01	3.18	-	-	-	-	-	-	-	83.44
H4520_005_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1424.4	10.39	511	2438.09	142.17	0.91	0.07	230.69	502.86	927.36	632.29	42.15	432.26	358.3	8149.92	9667.27			356.49		12.69											15.13	0.11	20.64								175 (1-5)/LTAC 950 per admit	950/admit	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-50/ Visit	30-100/ Visit	50/ Visit	0/ Procedure	15-100/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins											175 (1-5)/LTAC 950 per admit	950/admit	15 Coins								121.11	198.12	11.79	10	100	0.2	0.2	49.63	116.5	38.64	45.33	50	0	36.18	10	35			100		0.2											600	950	0.15								14.38	0.17	0.5	2.03	1.18	0.18	0.01	0.95	4.88	2.99	2.39	0.18	-	1.08	6.79	28.2	-	-	2.97	-	2.54	-	-	-	-	-	-	-	-	-	-	0.76	0.01	3.1	-	-	-	-	-	-	-	75.29	0	0	14.38	0.17	0.5	2.03	1.18	0.18	0.01	0.95	4.88	2.99	2.39	0.18	-	1.08	6.79	28.2	-	-	2.97	-	2.54	-	-	-	-	-	-	-	-	-	-	0.76	0.01	3.1	-	-	-	-	-	-	-	75.29		950/admit	950/admit	15 Coins	15 Coins	100/Trip	40 Coins		50/Visit	15 Coins	15 Coins			0/Procedure		15 Coins	15 Coins					20 Coins													15 Coins								2.66	0.02	0.18	0.24	0.3	0.05		0.29	2.23	2.63			0		1.67	2.01					0.72													0.57								13.57	0	0	17.04	0.19	0.68	2.28	1.48	0.23	0.01	1.25	7.11	5.62	2.39	0.18	-	1.08	8.46	30.2	-	-	2.97	-	3.26	-	-	-	-	-	-	-	-	-	-	0.76	0.01	3.67	-	-	-	-	-	-	-	88.86
H4520_006_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		262.76	1.98	467.01	2228.17	129.93	0.8	0.06	210.83	459.57	847.51	577.85	38.52	395.04	327.45	7448.22	8834.93			325.79		11.09			4.44								13.83	0.1	18.05								125/day (days 1-5)/LTAC 950 per admit	950/admit	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-125/ Visit	0-50/ Visit	30-100/ Visit	50/ Visit	0/ Procedure	15-100/ Visit	10/ Visit	35/ Visit			100/ Visit		20 Coins			25 - 75								125/day (days 1-5)/LTAC 950 per admit	950/admit	15 Coins								450	950	11.79	10	100	0.2	0.2	49.63	108.25	38.64	45.33	50	0	36.18	10	35			100		0.2			0.37								450	950	0.15								9.85	0.16	0.46	1.86	1.08	0.16	0.01	0.87	4.15	2.73	2.18	0.16	-	0.99	6.21	25.77	-	-	2.71	-	2.22	-	-	1.63	-	-	-	-	-	-	-	0.52	0.01	2.71	-	-	-	-	-	-	-	66.43	0	0	9.85	0.16	0.46	1.86	1.08	0.16	0.01	0.87	4.15	2.73	2.18	0.16	-	0.99	6.21	25.77	-	-	2.71	-	2.22	-	-	1.63	-	-	-	-	-	-	-	0.52	0.01	2.71	-	-	-	-	-	-	-	66.43		200/day (days 1-5)/LTAC 950 per admit	950/admit	20 Coins	20 Coins	100/Trip	40 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		15 Coins	15 Coins					20 Coins			50-80										15 Coins								1.88	0.02	0.22	0.3	0.28	0.04		0.28	2.72	3.21			0		1.53	1.84					0.66			1.63										0.53								15.14	0	0	11.73	0.18	0.68	2.16	1.37	0.2	0.01	1.15	6.87	5.94	2.18	0.16	-	0.99	7.74	27.61	-	-	2.71	-	2.88	-	-	3.26	-	-	-	-	-	-	-	0.52	0.01	3.23	-	-	-	-	-	-	-	81.57
H4520_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		274.96	2.07	488.69	2331.61	135.96	0.85	0.06	269.04	480.9	886.86	604.67	40.31	413.38	342.65	7793.98	9245.07			340.92		11.86											14.47	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.75	0.1	0.36	1.94	1.13	0.21	0.02	1.01	8.01	2.59	2.31	0.34	-	1.07	16.24	26.96	-	-	0.99	-	2.37	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	80.15	0	0	13.75	0.1	0.36	1.94	1.13	0.21	0.02	1.01	8.01	2.59	2.31	0.34	-	1.07	16.24	26.96	-	-	0.99	-	2.37	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	80.15		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.56	0.02	0.48	0.66	0.3	0.06		0.29	5.97	7.05			0		2.24	5.38					0.72																					25.72	0	0	16.31	0.12	0.84	2.6	1.43	0.27	0.02	1.31	13.99	9.64	2.31	0.34	-	1.07	18.47	32.34	-	-	0.99	-	3.1	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	105.87
H4520_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		273.35	2.06	485.82	2317.94	135.16	0.84	0.06	267.46	478.08	881.66	601.13	40.08	410.96	340.64	7748.3	9190.88			338.92		11.73											14.39	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.67	0.1	0.36	1.93	1.13	0.21	0.02	1.01	7.97	2.57	2.3	0.33	-	1.07	16.14	26.81	-	-	0.99	-	2.35	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	79.66	0	0	13.67	0.1	0.36	1.93	1.13	0.21	0.02	1.01	7.97	2.57	2.3	0.33	-	1.07	16.14	26.81	-	-	0.99	-	2.35	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	79.66		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.54	0.02	0.47	0.65	0.29	0.06		0.29	5.9	6.97			0		2.21	5.31					0.71																					25.44	0	0	16.21	0.12	0.83	2.58	1.42	0.27	0.02	1.3	13.87	9.54	2.3	0.33	-	1.07	18.35	32.12	-	-	0.99	-	3.06	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	105.11
H4520_805_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		274.96	2.07	488.69	2331.61	135.96	0.85	0.06	269.04	480.9	886.86	604.67	40.31	413.38	342.65	7793.98	9245.07			340.92		11.86											14.47	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.75	0.1	0.36	1.94	1.13	0.21	0.02	1.01	8.01	2.59	2.31	0.34	-	1.07	16.24	26.96	-	-	0.99	-	2.37	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	80.15	0	0	13.75	0.1	0.36	1.94	1.13	0.21	0.02	1.01	8.01	2.59	2.31	0.34	-	1.07	16.24	26.96	-	-	0.99	-	2.37	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	80.15		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.56	0.02	0.48	0.66	0.3	0.06		0.29	5.97	7.05			0		2.24	5.38					0.72																					25.72	0	0	16.31	0.12	0.84	2.6	1.43	0.27	0.02	1.31	13.99	9.64	2.31	0.34	-	1.07	18.47	32.34	-	-	0.99	-	3.1	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	105.87
H4520_806_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		273.35	2.06	485.82	2317.94	135.16	0.84	0.06	267.46	478.08	881.66	601.13	40.08	410.96	340.64	7748.3	9190.88			338.92		11.73											14.39	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.67	0.1	0.36	1.93	1.13	0.21	0.02	1.01	7.97	2.57	2.3	0.33	-	1.07	16.14	26.81	-	-	0.99	-	2.35	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	79.66	0	0	13.67	0.1	0.36	1.93	1.13	0.21	0.02	1.01	7.97	2.57	2.3	0.33	-	1.07	16.14	26.81	-	-	0.99	-	2.35	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	79.66		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.54	0.02	0.47	0.65	0.29	0.06		0.29	5.9	6.97			0		2.21	5.31					0.71																					25.44	0	0	16.21	0.12	0.83	2.58	1.42	0.27	0.02	1.3	13.87	9.54	2.3	0.33	-	1.07	18.35	32.12	-	-	0.99	-	3.06	-	-	-	-	-	-	-	-	-	-	0.72	0.01	-	-	-	-	-	-	-	-	105.11
H4521_001_0	2007	2																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1448.22	47.12	403.1		189.3	12.01	4.04	245.61	298.81		13.14			140.58	4343.81	4719.06	189.99	557.51		3.28	40.87				129.91		232.59															100 per admit	100 per admit	25 per day 25-100		50	0	0	50 - Emergency 25 - Urgent	75		25 - Radiation Therapy			10 - OP Rehab	10	25	25	10		25 Specialist	5				25 for 1 exam		25 for 1 exam															14.81	10.16	14.1		45.32	0.18	0.18	40.79	67.99		22.66			9.28	9.07	22.66	22.66	9.06		0.35	0.05				22.66		22.66															1.79	0.04	0.47	-	0.71	2.18	0.73	0.83	1.69	-	0.02	-	-	0.11	3.28	8.91	0.36	0.42	-	1.16	1.85	-	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.25		2.61	1.79	0.04	0.47	-	0.71	2.18	0.73	0.83	1.69	-	0.02	-	-	0.11	3.28	8.91	0.36	0.42	-	1.16	1.85	-	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.25																																																																																				-		0	1.79	0.04	0.47	-	0.71	2.18	0.73	0.83	1.69	-	0.02	-	-	0.11	3.28	8.91	0.36	0.42	-	1.16	1.85	-	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.25
H4521_002_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		2437.97	122.14	664.88		447.34	31.17	22.96	540.96	320.11	18671.6	670.69	40.44	11.32	1404.22	7869.38	8004.34	472.33	1026.58	45.54	165.28	44.31	41.58																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																					123.09	45.8	84.89		74.58	0.24	0.24	89.65	338.27	5.01	74.64	215.37	651.52	36.49	15.64	17.18	15.71	25.14	0.24	0.24	0.24	16.08																				25.01	0.47	4.7	-	2.78	7.36	5.42	4.04	9.02	7.79	4.17	0.73	0.61	4.27	10.26	11.46	0.62	2.15	10.75	39.01	10.46	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	161.13		0	25.01	0.47	4.7	-	2.78	7.36	5.42	4.04	9.02	7.79	4.17	0.73	0.61	4.27	10.26	11.46	0.62	2.15	10.75	39.01	10.46	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	161.13																																																																																				-		0	25.01	0.47	4.7	-	2.78	7.36	5.42	4.04	9.02	7.79	4.17	0.73	0.61	4.27	10.26	11.46	0.62	2.15	10.75	39.01	10.46	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	161.13
H4521_004_0	2007	2																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1411.05	45.91	392.76		189.29	12	4.04	240.08	292.09		12.85			137.41	4253.38	4619.06	185.96	545.7		3.21	40	28.66			129.91		232.59															1a: 250 per day up to 1500	1b: 250 per day up to 1500	2a: 25 per day 25-100		10a: 100	11a: 20	11b-c: 20	4a-b: 50 - Emergency 30 - Urgent	9a-b: 150		8: 35 - Radiation Therapy		12:35	35 - OP Rehab	7a: 15	7bdfg: 35	7e 7h 9c: 35	3 7c 7i: 35		25 Specialist	15:15	30 Medicare-covered-Eyewear			17a: 35 for 1 exam		18a: 35 for 1 exam															94.94	94.94	12.35		79.44	0.16	0.16	36.54	119.17		27.81			27.81	11.92	27.81	27.81	27.81		0.43	0.12	23.83			27.81		27.81															11.16	0.36	0.4	-	1.25	1.91	0.64	0.73	2.9	-	0.03	-	-	0.32	4.22	10.7	0.43	1.26	-	1.39	4.77	0.06	-	-	0.3	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.39		11.23	11.16	0.36	0.4	-	1.25	1.91	0.64	0.73	2.9	-	0.03	-	-	0.32	4.22	10.7	0.43	1.26	-	1.39	4.77	0.06	-	-	0.3	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.39																																																																																				-		0	11.16	0.36	0.4	-	1.25	1.91	0.64	0.73	2.9	-	0.03	-	-	0.32	4.22	10.7	0.43	1.26	-	1.39	4.77	0.06	-	-	0.3	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.39
H4521_801_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		240.57	2.66	12.35		5.24	12	11.44	8.97	39.71	23.25	14.38	2.75		12.48	24.27	38.1	1.2	5.61	35.13	111.98	40	0.17																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.22		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16		0	16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16																																																																																				-		0	16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H4521_802_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		240.57	2.66	12.35		5.24	12	11.44	8.97	39.71	23.25	14.38	2.75		12.48	24.27	38.1	1.2	5.61	35.13	111.98	40	0.17																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.22		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16		0	16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16																																																																																				-		0	16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H4521_803_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		240.57	2.66	12.35		5.24	12	11.44	8.97	39.71	23.25	14.38	2.75		12.48	24.27	38.1	1.2	5.61	35.13	111.98	40	0.17																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.22		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16		0	16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16																																																																																				-		0	16.02	0.18	2.71	-	1.24	2.83	2.7	2.12	9.37	5.49	3.39	0.65	-	2.95	5.73	8.99	0.28	1.32	8.29	26.43	9.44	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H4522_001_0	2007	7																					2900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3600	1690.02	127.86	507.83	0	145.87	10.87	4.75	414.89	43.43	6616.08	40.18	0	0.06	18.11	3157.13	3572.88	489.74	3.23	0	0	15.66	940.26	0	0	116.05	0	173.92	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											155.99	155.99	85.09	0	99.27	0.17	0.19	28.36	0.17	1.13	0.13	0	0.17	0.17	10	25	37.5	0.17	0	0	0.17	25	0	0	25	0	25	0	0	0	0											21.97	1.66	3.6	-	1.21	1.85	0.91	0.98	7.39	0.63	5.16	-	0.01	3.08	2.63	7.44	1.53	0.55	-	-	2.67	1.96	-	-	0.24	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.83		39.24	21.97	1.66	3.6	-	1.21	1.85	0.91	0.98	7.39	0.63	5.16	-	0.01	3.08	2.63	7.44	1.53	0.55	-	-	2.67	1.96	-	-	0.24	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.83		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.45	0.19	0.34	0.43	0.25	0.38	0.19	0.2	2.04	0.52	1.42	0	0	0.85	1.53	2.29	0.38	0.15	0	0	0.55	0.61	0	0	0.07	0	0.11	0	0	0	0											14.96		8.28	24.42	1.85	3.94	0.43	1.46	2.23	1.1	1.18	9.43	1.14	6.58	-	0.01	3.93	4.16	9.73	1.91	0.7	-	-	3.22	2.57	-	-	0.32	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.79
H4522_005_0	2007	4																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3000	1690.02	127.86	507.83	0	145.87	10.87	4.75	414.89	43.43	6616.08	40.18	0	0.06	18.11	3157.13	3572.88	489.74	3.23	0	0	15.66	940.26	0	0	116.05	0	173.92	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											141.39	141.39	77.12	0	89.98	0.15	0.18	25.71	0.15	3.08	0.12	0	0.15	0.15	10	25	37.5	0.15	0	0	0.15	25	0	0	25	0	25	0	0	0	0											19.91	1.51	3.26	-	1.09	1.68	0.84	0.89	6.7	1.7	4.68	-	0.01	2.79	2.63	7.44	1.53	0.5	-	-	2.42	1.96	-	-	0.24	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.15		45.12	19.91	1.51	3.26	-	1.09	1.68	0.84	0.89	6.7	1.7	4.68	-	0.01	2.79	2.63	7.44	1.53	0.5	-	-	2.42	1.96	-	-	0.24	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.15		375 (1a)	375 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.35	0.18	0.33	0.22	0.24	0.37	0.16	0.19	1.95	0.49	1.36	0	0	0.81	0.78	1.17	0.19	0.15	0	0	0.53	0.31	0	0	0.04	0	0.06	0	0	0	0											11.88		11.36	22.26	1.68	3.59	0.22	1.33	2.04	1	1.08	8.65	2.2	6.04	-	0.01	3.61	3.41	8.61	1.73	0.64	-	-	2.94	2.27	-	-	0.28	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.03
H4522_007_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2213.04	350.17	1127.36		262.75	26.75	23.17	900.41	390.41	2048.32	960.98	66.51	3.27	2022.05		3489.86		529.76		812.3												288.24		155.16	230.84							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							6.59	1.04	1.61	-	0.78	2.55	2.21	1.29	0.39	0.81	0.38	0.07	0.31	2.01	-	1.39	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	22.22		24.43	6.59	1.04	1.61	-	0.78	2.55	2.21	1.29	0.39	0.81	0.38	0.07	0.31	2.01	-	1.39	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	22.22		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.19	0.15	0.29	0.37	0.07	0.16	0.14	0.05	0.19	0.13	0.13	0.02	0.02	0.21	0.34	0.21	0.04	0.03	0.14	0.68	0.14	0																				5.71		0	8.77	1.19	1.9	0.37	0.85	2.71	2.35	1.33	0.58	0.95	0.51	0.08	0.33	2.22	0.34	1.6	0.04	0.24	0.14	1	0.14	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	27.93
H4522_801_0	2007	5																					3400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	4000	1774.52	134.26	533.22	0	153.16	11.41	4.99	435.63	45.61	6946.88	42.19	0	0.06	19.02	3314.99	3751.52	514.23	3.39	0	0	16.44	987.27	0	0	121.85	0	182.61	0	0	0	0											280 (1a)	280 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											163.95	163.95	87.83	0	102.47	0.18	0.2	29.28	0.18	3.51	0.13	0	0.18	0.18	25	35	37.5	0.18	0	0	0.18	35	0	0	35	0	35	0	0	0	0											24.24	1.83	3.9	-	1.31	2	0.97	1.06	8.01	2.03	5.59	-	0.01	3.34	6.91	10.94	1.61	0.6	-	-	2.89	2.88	-	-	0.36	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.03		40.75	24.24	1.83	3.9	-	1.31	2	0.97	1.06	8.01	2.03	5.59	-	0.01	3.34	6.91	10.94	1.61	0.6	-	-	2.89	2.88	-	-	0.36	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.03		380 (1a)	380 (1b)	175 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.7	0.2	0.37	0.25	0.27	0.41	0.18	0.22	2.21	0.56	1.54	0	0	0.92	1.55	1.51	0.22	0.16	0	0	0.6	0.41	0	0	0.05	0	0.07	0	0	0	0											14.43		11.72	26.94	2.04	4.28	0.25	1.58	2.42	1.16	1.28	10.22	2.59	7.14	-	0.01	4.26	8.46	12.46	1.83	0.76	-	-	3.49	3.29	-	-	0.4	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.46
H4523_001_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-20101.50/Day 21-100	0	50	0.2	0.2	50   (Waived if Admitted; Worldwide)  30	175	0	0  100	30	25	25	10	25	30	25	25	25	45	0	Not Covered	Not Covered	0	150 Every 2 Years	0	500 Every 3 Years														121.34	121.34	40.74	0	50	0.2	0.2	47.4	175	0	34.2	30	25	25	10	25	30	25	25	25	45	0	0	0	0	0	0	0														15.74	0.31	4.32	-	0.96	3.14	0.2	1.65	5.02	-	3.2	-	-	-	4.52	13.97	0.49	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.63			15.74	0.31	4.32	-	0.96	3.14	0.2	1.65	5.02	-	3.2	-	-	-	4.52	13.97	0.49	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.63																																																																																				-			15.74	0.31	4.32	-	0.96	3.14	0.2	1.65	5.02	-	3.2	-	-	-	4.52	13.97	0.49	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.63
H4523_005_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	18.07	0	0	0	0	317.28	0	22.16														100/Day 1-5	100/Day 1-5	0/Day 1-20100/Day 21-100	0	75	0.2	0.2	50	100	0	0  100	10	0	15	5	10	10	10	10	10	0.2	0	Not Covered	Not Covered	0	150 Every 2 Years	0	500 Every 3 Years														60.67	60.67	40.15	0	75	0.2	0.2	46.75	100	0	34.2	10	0	15	5	10	10	10	10	10	0.2	0	0	0	0	0	0	0														7.87	0.15	4.25	-	1.44	3.14	0.2	1.63	2.87	-	3.2	-	-	-	2.26	5.59	0.16	0.48	0.78	1.18	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.83			7.87	0.15	4.25	-	1.44	3.14	0.2	1.63	2.87	-	3.2	-	-	-	2.26	5.59	0.16	0.48	0.78	1.18	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.83																																																																																				-			7.87	0.15	4.25	-	1.44	3.14	0.2	1.63	2.87	-	3.2	-	-	-	2.26	5.59	0.16	0.48	0.78	1.18	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.83
H4523_006_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-20101.50/Day 21-100	0	50	0.2	0.2	50   (Waived if Admitted; Worldwide)  30	175	0	0  100	30	25	25	10	25	30	25	25	25	45	0	Not Covered	Not Covered	0	150 Every 2 Years	0	500 Every 3 Years														121.34	121.34	40.74	0	50	0.2	0.2	47.4	175	0	34.2	30	25	25	10	25	30	25	25	25	45	0	0	0	0	0	0	0														15.74	0.31	4.32	-	0.96	3.14	0.2	1.65	5.02	-	3.2	-	-	-	4.52	13.97	0.49	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.63			15.74	0.31	4.32	-	0.96	3.14	0.2	1.65	5.02	-	3.2	-	-	-	4.52	13.97	0.49	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.63																																																																																				-			15.74	0.31	4.32	-	0.96	3.14	0.2	1.65	5.02	-	3.2	-	-	-	4.52	13.97	0.49	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.63
H4523_007_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														100/Day 1-5	100/Day 1-5	0/Day 1-20100/Day 21-100	0	75	0.2	0.2	50   (Waived if Admitted; Worldwide)	100	0	0  100	10	0	10	5	10	10	10	10	10	45	0	Not Covered	Not Covered	0	150 Every 2 Years	0	500 Every 3 Years														60.67	60.67	40.15	0	75	0.2	0.2	46.75	100	0	34.2	10	0	10	5	10	10	10	10	10	45	0	0	0	0	0	0	0														7.87	0.15	4.25	-	1.44	3.14	0.2	1.63	2.87	-	3.2	-	-	-	2.26	5.59	0.16	0.48	0.78	1.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.22			7.87	0.15	4.25	-	1.44	3.14	0.2	1.63	2.87	-	3.2	-	-	-	2.26	5.59	0.16	0.48	0.78	1.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.22																																																																																				-			7.87	0.15	4.25	-	1.44	3.14	0.2	1.63	2.87	-	3.2	-	-	-	2.26	5.59	0.16	0.48	0.78	1.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.22
H4523_009_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														75/Day 1-5	75/Day 1-5	0/Day 1-20100/Day 21-100	15	75	0.2	0.2	50   (Waived if Admitted; Worldwide)	50	0	0  100	15	0	15	5	15	15	15	15	15	45	0	Not Covered	Not Covered	0	150 Every 2 Years	0	500 Every 3 Years														45.5	45.5	40.15	15	75	0.2	0.2	46.75	50	0	34.2	15	0	15	5	15	15	15	15	15	45	0	0	0	0	0	0	0														5.9	0.11	4.25	2.61	1.44	3.14	0.2	1.63	1.43	-	3.2	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.48			5.9	0.11	4.25	2.61	1.44	3.14	0.2	1.63	1.43	-	3.2	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.48																																																																																				-			5.9	0.11	4.25	2.61	1.44	3.14	0.2	1.63	1.43	-	3.2	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.48
H4523_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0	0	0			200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	0.3	0.3	50 50	150	0.2	0.2 0.2	35	35	35	35	35	35	35	35	35	0.2	0	N/A	Not Covered	0	Not Covered	0	Not Covered	N/A	Not Covered	0	0	0	0	0	0	0	0	0			143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H4523_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0	0	0			200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	0.3	0.3	50 50	150	0.2	0.2 0.2	35	35	35	35	35	35	35	35	35	0.2	0	N/A	Not Covered	0	Not Covered	0	Not Covered	N/A	Not Covered	0	0	0	0	0	0	0	0	0			143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H4524_001_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5														200/day 1-5	200/day 1-5	0/day 1-20101.50/day 21-100	0	50	0.2	0.2	50 (Waived if Admitted; Worldwide)	200	0	0  100	30	25	25	10	25	30	25	25	25	45	0	Not Covered	Not Covered	0	150 Every 2 Years	0	300 Every 3 Years														121.34	121.34	40.74	0	50	0.2	0.2	47.4	200	0	34.2	30	25	25	10	25	30	25	25	25	45	0	0	0	0	0	0	0														13.85	0.27	3.8	-	0.84	2.77	0.18	1.45	5.05	-	2.82	-	-	-	3.98	12.3	0.43	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.11			13.85	0.27	3.8	-	0.84	2.77	0.18	1.45	5.05	-	2.82	-	-	-	3.98	12.3	0.43	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.11		0.2	0.2	0.2	0.2	50	0.2	0.2	50 (Waived if Admitted; Worldwide)	0.2	0	0.20 0.20	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	Not Covered	Not Covered	0.2	0	0.2	0														2.87	0	0.47	0.42	0.07	0.24	0	0.12	0.29	0.01	0.29	0	0.09	0.32	0.37	0.47	0.02	0.05	0.35	1.26	0.27	0	0	0	0.05	0	0.01	0														8.03			16.72	0.27	4.26	0.42	0.92	3	0.18	1.57	5.34	0.01	3.11	-	0.09	0.32	4.35	12.76	0.45	1.1	2.07	3.86	0.27	-	-	-	0.05	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.14
H4524_002_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5														200/day 1-5	200/day 1-5	0/day 1-20101.50/day 21-100	0	50	0.2	0.2	50 (Waived if Admitted; Worldwide)	200	0	0  100	30	25	25	10	25	30	25	25	25	45	0	Not Covered	Not Covered	0	150 Every 2 Years	0	300 Every 3 Years														121.34	121.34	40.74	0	50	0.2	0.2	47.4	200	0	34.2	30	25	25	10	25	30	25	25	25	45	0	0	0	0	0	0	0														13.85	0.27	3.8	-	0.84	2.77	0.18	1.45	5.05	-	2.82	-	-	-	3.98	12.3	0.43	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.11			13.85	0.27	3.8	-	0.84	2.77	0.18	1.45	5.05	-	2.82	-	-	-	3.98	12.3	0.43	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.11		0.2	0.2	0.2	0.2	50	0.2	0.2	50 (Waived if Admitted; Worldwide)	0.2	0	0.20 0.20	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	Not Covered	Not Covered	0.2	0	0.2	0														3.93	0	0.64	0.57	0.1	0.32	0	0.15	0.4	0.03	0.39	0	0.13	0.43	0.51	0.64	0.02	0.07	0.47	1.72	0.37	0	0	0	0.07	0	0.02	0														10.98			17.78	0.27	4.43	0.57	0.94	3.09	0.18	1.61	5.45	0.03	3.21	-	0.13	0.43	4.49	12.93	0.46	1.12	2.19	4.32	0.37	-	-	-	0.07	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.09
H4524_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H4524_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30	30	30	0	150	0	0	50	0	0	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54				0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H4525_001_0	2007	4																																																																																																																		-		1962.06	117.2	1102.02		217.8	33422.37	173.88	338.74	478.74		1303.26						488.77			38358.22																						67.50 Average Copay	67.50 Average Copay	72.85 Average Copay		100 Copay	80 Coinsurance	80 Coinsurance	45.30 Average Copay	100 Copay		39.25 Average Copay						24.16 Average Copay			7.14 Average Copay																						67.5	67.5	72.85		100	1.23	16.59	45.3	100		39.25						24.16			7.49																						11.04	0.66	6.69	-	1.81	3.44	0.24	1.28	3.99	-	4.26	-	-	-	-	-	0.98	-	-	23.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.34			11.04	0.66	6.69	-	1.81	3.44	0.24	1.28	3.99	-	4.26	-	-	-	-	-	0.98	-	-	23.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.34																																																																																				-			11.04	0.66	6.69	-	1.81	3.44	0.24	1.28	3.99	-	4.26	-	-	-	-	-	0.98	-	-	23.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.34
H4525_002_0	2007	4																																																																																																																		-		2030.08	121.26	1650.24		141.85	47949.28	249.45	381.76	633.62		1308.9						525.47			40778.93																						67.50 Average Copay	67.50 Average Copay	72.85 Average Copay		100 Copay	80 Coinsurance	80 Coinsurance	45.30 Average Copay	100 Copay		39.25 Average Copay						24.16 Average Copay			7.14 Average Copay																						67.5	67.5	72.85		100	1.15	15.53	45.83	100		39.25						24.16			7.43																						11.42	0.68	10.02	-	1.18	4.61	0.32	1.46	5.28	-	4.28	-	-	-	-	-	1.06	-	-	25.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57			11.42	0.68	10.02	-	1.18	4.61	0.32	1.46	5.28	-	4.28	-	-	-	-	-	1.06	-	-	25.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57																																																																																				-			11.42	0.68	10.02	-	1.18	4.61	0.32	1.46	5.28	-	4.28	-	-	-	-	-	1.06	-	-	25.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.57
H4525_003_0	2007	4																																																																																																																		-		3005.98	179.55	2496.31		207.07	71109.1	369.94	557.29	924.95		1910.72		37.55	5433.56			753.46		8906.99	58248.65		1085.93			246.33																	Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits	Medicare Benefits	Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits		Medicare Benefits	Medicare Benefits			Medicare Benefits		Medicare Benefits	Medicare Benefits		Medicare Benefits			Medicare Benefits																	126.26	59.23	67.05		73.9	1.36	18.32	68.3	133.44		75.9		155.73	32.07			16.52		10.58	16.68		20.1			23.24																	31.63	0.89	13.95	-	1.28	8.07	0.56	3.17	10.29	-	12.08	-	0.49	14.52	-	-	1.04	-	7.85	80.95	-	1.82	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	189.06			31.63	0.89	13.95	-	1.28	8.07	0.56	3.17	10.29	-	12.08	-	0.49	14.52	-	-	1.04	-	7.85	80.95	-	1.82	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	189.06																																																																																				-			31.63	0.89	13.95	-	1.28	8.07	0.56	3.17	10.29	-	12.08	-	0.49	14.52	-	-	1.04	-	7.85	80.95	-	1.82	-	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	189.06
H4525_004_0	2007	2																																																																																																																		-		1962.06	117.2	1102.02		217.8	33422.37	173.88	338.74	478.74		1303.26						488.77			38358.22																						67.50 Average Copay	67.50 Average Copay	72.85 Average Copay		100 Copay	80 Coinsurance	80 Coinsurance	45.30 Average Copay	100 Copay		39.25 Average Copay						24.16 Average Copay			7.14 Average Copay																						67.5	67.5	72.85		100	1.23	16.59	45.3	100		39.25						24.16			7.14																						11.04	0.66	6.69	-	1.81	3.44	0.24	1.28	3.99	-	4.26	-	-	-	-	-	0.98	-	-	22.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.22			11.04	0.66	6.69	-	1.81	3.44	0.24	1.28	3.99	-	4.26	-	-	-	-	-	0.98	-	-	22.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.22																																																																																				-			11.04	0.66	6.69	-	1.81	3.44	0.24	1.28	3.99	-	4.26	-	-	-	-	-	0.98	-	-	22.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.22
H4525_005_0	2007	2																																																																																																																		-		2030.08	121.26	1650.24		141.85	47949.28	249.45	381.76	633.62		1308.9						525.47			40778.93																						67.50 Average Copay	67.50 Average Copay	72.85 Average Copay		100 Copay	80 Coinsurance	80 Coinsurance	45.30 Average Copay	100 Copay		39.25 Average Copay						24.16 Average Copay			7.14 Average Copay																						67.5	67.5	72.85		100	1.15	15.53	45.83	100		39.25						24.16			7.08																						11.42	0.68	10.02	-	1.18	4.61	0.32	1.46	5.28	-	4.28	-	-	-	-	-	1.06	-	-	24.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.37			11.42	0.68	10.02	-	1.18	4.61	0.32	1.46	5.28	-	4.28	-	-	-	-	-	1.06	-	-	24.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.37																																																																																				-			11.42	0.68	10.02	-	1.18	4.61	0.32	1.46	5.28	-	4.28	-	-	-	-	-	1.06	-	-	24.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.37
H4525_006_0	2007	5																																																																																																																		-				1124.06		219.97	35093.49	182.57	356.13	488.32		1303.26						484.58			38496.57																								15.62 Average Copay		50 Copay	90 Coinsurance	90 Coinsurance	44.71 Average Copay	50 Copay		27.48 Average Copay						19.33 Average Copay			6.64 Average Copay																								36.71		50	0.62	8.3	44.71	50		27.48						19.33	0		7.29																						-	-	3.44	-	0.92	1.8	0.13	1.33	2.03	-	2.98	-	-	-	-	-	0.78	-	-	23.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.81			-	-	3.44	-	0.92	1.8	0.13	1.33	2.03	-	2.98	-	-	-	-	-	0.78	-	-	23.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.81																																																																																				-			-	-	3.44	-	0.92	1.8	0.13	1.33	2.03	-	2.98	-	-	-	-	-	0.78	-	-	23.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.81
H4525_007_0	2007	5																																																																																																																		-				1683.25		143.97	50798.06	264.27	401.09	649.46		1315.31						526.23			40935.07																								15.62 Average Copay		50 Copay	90 Coinsurance	90 Coinsurance	45.28 Average Copay	50 Copay		27.48 Average Copay						19.33 Average Copay			6.60 Average Copay																								36.71		50	0.58	7.76	45.33	50		27.48						19.33			6.93																						-	-	5.15	-	0.6	2.44	0.17	1.52	2.71	-	3.01	-	-	-	-	-	0.85	-	-	23.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.07			-	-	5.15	-	0.6	2.44	0.17	1.52	2.71	-	3.01	-	-	-	-	-	0.85	-	-	23.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.07																																																																																				-			-	-	5.15	-	0.6	2.44	0.17	1.52	2.71	-	3.01	-	-	-	-	-	0.85	-	-	23.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.07
H4525_801_0	2007	2																																																																																																																		-		2207.21	131.84	1832.97		152.04	52213.57	271.63	409.19	679.14		1402.94		27.57	3989.6			553.25		6540.17	42770.47		67.02																				Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits	Medicare Benefits	Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits		Medicare Benefits	Medicare Benefits			Medicare Benefits		Medicare Benefits	Medicare Benefits		Medicare Benefits																				121.23	56.88	66.8		73.9	1.41	19.01	68.3	133.44		75.9		172.65	32.07			18.32	0	11.73	18.49		17.76																				22.3	0.62	10.2	-	0.94	6.15	0.43	2.33	7.55	-	8.87	-	0.4	10.66	-	-	0.84	-	6.39	65.89	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.69			22.3	0.62	10.2	-	0.94	6.15	0.43	2.33	7.55	-	8.87	-	0.4	10.66	-	-	0.84	-	6.39	65.89	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.69																																																																																				-			22.3	0.62	10.2	-	0.94	6.15	0.43	2.33	7.55	-	8.87	-	0.4	10.66	-	-	0.84	-	6.39	65.89	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.69
H4525_802_0	2007	5																																																																																																																		-		2207.21	131.84	1832.97		152.04	52213.57	271.63	409.19	679.14		1402.94		27.57	3989.6			553.25		6540.17	42770.47		67.02																				Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits	Medicare Benefits	Medicare Benefits	Medicare Benefits	Medicare Benefits		Medicare Benefits		Medicare Benefits	Medicare Benefits			Medicare Benefits		Medicare Benefits	Medicare Benefits		Medicare Benefits																				121.23	56.88	66.8		73.9	1.41	19.01	68.3	133.44		75.9		172.65	32.07			18.32	0	11.73	18.49		17.76																				22.3	0.62	10.2	-	0.94	6.15	0.43	2.33	7.55	-	8.87	-	0.4	10.66	-	-	0.84	-	6.39	65.89	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.69			22.3	0.62	10.2	-	0.94	6.15	0.43	2.33	7.55	-	8.87	-	0.4	10.66	-	-	0.84	-	6.39	65.89	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.69																																																																																				-			22.3	0.62	10.2	-	0.94	6.15	0.43	2.33	7.55	-	8.87	-	0.4	10.66	-	-	0.84	-	6.39	65.89	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	143.69
H4527_001_0	2007	3																																A	D	D	V	T	Coin	Coin	V	P	V	Coin	V	V	V	V	V	V	V	Coin	P	Coin	P	P	P	V	P	V	P	P	P	P																																																				-			39.17	840.82		291.86	10.54	14.43	340.81			16.71			121.8	4843.36	4061.44	244.72	253.15	24.65		17.83				252		232.59															No cost sharing	Medicare Cost Share	50 / Days 11-100	No cost sharing	100 / Trip	20 / Item	20 / Item	50 / Visit	No cost sharing	No cost sharing	20 for Therapeutic	No cost sharing	No cost sharing	20 / Visit	5 / Visit	20 / Visit	20 / Visit Ind or Grp	20 / Visit	20 - MRI CT PET	No cost sharing	20 / Script	No cost sharing	Not covered	No cost sharing for preventive services	No cost sharing	No copay up to 150 per year	No cost sharing	No copay up to 400	Not covered	No cost sharing	Not covered												138.38	31.09		100	0.2	0.2	46.98			0.2			20	5	20	19.39	20	0.15		0.2				0		0															-	0.45	2.18	-	2.43	2.11	2.89	1.33	-	-	3.34	-	-	0.2	2.02	6.77	0.4	0.42	3.6	-	3.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.71		0	-	0.45	2.18	-	2.43	2.11	2.89	1.33	-	-	3.34	-	-	0.2	2.02	6.77	0.4	0.42	3.6	-	3.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.71																																																																																				-		0	-	0.45	2.18	-	2.43	2.11	2.89	1.33	-	-	3.34	-	-	0.2	2.02	6.77	0.4	0.42	3.6	-	3.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.71
H4527_002_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	Coin	V	V	V	V	V	V	V	Coin	P	Coin	P	P	P	V	P	V	P	P	P	P																																																				-		1365.26	37.03	440		259.57	9.69	14.62	293.46	262.28		14.62			104.6	4315.93	3612.06	217.64	225.14	22.34		16.16				252																	150 / days 1-5	Medicare Cost Share	75 / Days 11-100	No cost sharing	100 / Trip	20 / Item	20 / Item	100 / Visit	125 / Procedure	No cost sharing	20 for Therapeutic	No cost sharing	No cost sharing	30 / Visit	15 / Visit	30 / Visit	30 / Visit Ind or Grp	320 / Visit	20 - MRI CT PET	No cost sharing	20 / Script	No cost sharing	Not covered	Not covered	20 / Exam	No copay up to 150 per year	Not covered	Not covered	Not covered	No cost sharing	Not covered											63.98	141.82	46.64		100	0.2	0.2	93.93	125		0.2			30	15	30	29.39	30	0.15		0.2				20																	7.28	0.44	1.71	-	2.16	1.94	2.92	2.3	2.73	-	2.92	-	-	0.26	5.39	9.03	0.53	0.56	3.26	-	3.23	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.1		0	7.28	0.44	1.71	-	2.16	1.94	2.92	2.3	2.73	-	2.92	-	-	0.26	5.39	9.03	0.53	0.56	3.26	-	3.23	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.1																																																																																				-		0	7.28	0.44	1.71	-	2.16	1.94	2.92	2.3	2.73	-	2.92	-	-	0.26	5.39	9.03	0.53	0.56	3.26	-	3.23	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.1
H4527_003_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	Coin	V	V	V	V	V	V	V	Coin	P	Coin	P	P	P	V	P	V	P	P	P	P																																																				-			43.51	495		305.02	14.82	26.56	344.73			17.09			125.15		4190.35	245.43	318.75	24.04		21.79			328.42			232.59															No Cost Sharing	Medicare Cost Share	75 / days 11-100	No cost sharing	100 / Trip	20 / Item	20 / Item	50 / Visit	No Cost Sharing	No cost sharing	20 for Therapeutic	No cost sharing	No cost sharing	10 / Visit	0 copay	10 / Visit	10 / Visit ind or group	10 / Visit	20 on most services	No cost sharing	0 for Diab. Items 20 for rest	No cost sharing	No cost sharing	10 / Exam	No cost sharing	No copay up to 150 per year	10 / Exam	No copay up to 400	Not covered	No cost sharing	Not covered												133.34	46.64		100	0.2	0.2	46.99			0.2			10		10	10	10	0.15		0.15			10			10															-	0.48	1.92	-	2.54	2.96	5.21	1.35	-	-	3.42	-	-	0.1	-	3.49	0.2	0.27	3.51	-	3.36	-	-	0.27	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.3		0	-	0.48	1.92	-	2.54	2.96	5.21	1.35	-	-	3.42	-	-	0.1	-	3.49	0.2	0.27	3.51	-	3.36	-	-	0.27	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.3																																																																																				-		0	-	0.48	1.92	-	2.54	2.96	5.21	1.35	-	-	3.42	-	-	0.1	-	3.49	0.2	0.27	3.51	-	3.36	-	-	0.27	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.3
H4527_004_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	Coin	V	V	V	V	V	V	V	Coin	P	Coin	P	P	P	V	P	V	P	P	P	P																																																				-			45.67	983.14		341.26	16.04	26.23	398.38			19.42			40.29			274.59		26.37		23.91						232.59				16250											No cost sharing	Medicare Cost Share	50 / days 11-100	No cost sharing	50 / Trip	0 for diabetic suppliers 10 for other	0 for diabetic suppliers 10 for other	50 / Visit	No cost sharing	No cost sharing	20 for Therapeutic	No cost sharing	No cost sharing	No cost sharing	No cost sharing	No cost sharing	10 / Visit	No cost sharing	10 - MRI CT PET	No cost sharing	20 / Script	No cost sharing	No cost sharing	No cost sharing for preventive services	No copay for exams	No copay up to 150 per year	No cost sharing	No copay up to 800	Not covered	No cost sharing	1 / Meal												133.53	31.09		50	0.1	0.1	46.98			0.13			10			10		0.09		0.16						0				1											-	0.51	2.55	-	1.42	1.6	2.57	1.56	-	-	2.59	-	-	0.03	-	-	0.23	-	2.35	-	3.78	-	-	-	-	-	-	-	-	-	1.35	-	-	-	-	-	-	-	-	-	-	20.55		0	-	0.51	2.55	-	1.42	1.6	2.57	1.56	-	-	2.59	-	-	0.03	-	-	0.23	-	2.35	-	3.78	-	-	-	-	-	-	-	-	-	1.35	-	-	-	-	-	-	-	-	-	-	20.55																																																																																				-		0	-	0.51	2.55	-	1.42	1.6	2.57	1.56	-	-	2.59	-	-	0.03	-	-	0.23	-	2.35	-	3.78	-	-	-	-	-	-	-	-	-	1.35	-	-	-	-	-	-	-	-	-	-	20.55
H4527_005_0	2007	3																																D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V	V	V	V	V	V	V	Coin	P	Coin	P	P	P	V	P	V	P	P	P	P																																																				-		1710.44	46.4	840.82		282.1	10.14	13.47	331.43	28.09		15.76			119.42	4684.03	3925.69	236.54	244.69	21.78		15.83				252		232.59															150/ days 1-5 unlimited days	Medicare Cost Share	75 / days 11-100	No cost sharing	100 / Trip	20 / Item	20 / Item	100 / Visit	20 / Procedure	No cost sharing	20 for Therapeutic	No cost sharing	No cost sharing	30 / Visit	10 / Visit	30 / Visit	30 / Visit Ind or Grp	30 / Visit	20 - MRI CT PET	No cost sharing	20 / Script	No cost sharing	Not covered	Not covered	20 / Exam	No copay up to 150 per year	20 / Exam	No copay up to 400	Not covered	No cost sharing	Not covered											63.98	141.82	46.64		100	0.2	0.2	93.94	0.2		0.2			30	10	30	29.19	30	0.15		0.2				20		20															9.12	0.55	3.27	-	2.35	2.03	2.69	2.59	5.62	-	3.15	-	-	0.3	3.9	9.81	0.58	0.61	3.18	-	3.17	-	-	-	0.42	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.73		0	9.12	0.55	3.27	-	2.35	2.03	2.69	2.59	5.62	-	3.15	-	-	0.3	3.9	9.81	0.58	0.61	3.18	-	3.17	-	-	-	0.42	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.73																																																																																				-		0	9.12	0.55	3.27	-	2.35	2.03	2.69	2.59	5.62	-	3.15	-	-	0.3	3.9	9.81	0.58	0.61	3.18	-	3.17	-	-	-	0.42	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.73
H4527_006_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	Coin	V	V	V	V	V	V	V	Coin	P	Coin	P	P	P	V	P	V	P	P	P	P																																																				-			52.46	950.64		318.95	14.43	23.51	374.64			17.13			137.47		4381.73	256.64	333.31	21.79		19.93			328.42			232.59															No Cost Sharing	Medicare Cost Share	75 for days 11-100	No cost sharing	100 / Trip	20 / Item	20 / Item	50 / Visit	No Cost Sharing	No Cost Sharing	20 for Therapeutic	No cost sharing	No cost sharing	10 / Visit	0 copay	10 / Visit	10 / Visit	10 / Visit	20 - MRI CT PET	No cost sharing	0 for Diab. Items 20 for rest	No cost sharing	No cost sharing	10 / Exam	No cost sharing	No copay up to 150 per year	10 / Exam	No copay up to 400	Not covered	No cost sharing	Not covered												133.34	46.64		100	0.2	0.2	46.99			0.2			10		10	10	10	0.15		0.15			10			10															-	0.58	3.69	-	2.66	2.89	4.6	1.47	-	-	3.43	-	-	0.11	-	3.65	0.21	0.28	3.18	-	2.99	-	-	0.27	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.21		0	-	0.58	3.69	-	2.66	2.89	4.6	1.47	-	-	3.43	-	-	0.11	-	3.65	0.21	0.28	3.18	-	2.99	-	-	0.27	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.21																																																																																				-		0	-	0.58	3.69	-	2.66	2.89	4.6	1.47	-	-	3.43	-	-	0.11	-	3.65	0.21	0.28	3.18	-	2.99	-	-	0.27	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.21
H4527_008_0	2007	3																																A	D	D	V	P	P	P	V	V	V	V	V	V	V	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		2010.95	54.55	1036.47		359.77	1232.73	3307.03	419.85	228.1		293.86			154.08	5952.53	4702.96	301.14	341.66	34.67		26.22				252		232.59				65000											75 per Admit	Medicare Cost Share	50 for days 11-100	No cost sharing	100 / Trip	20 / Item	20 / Item	50 / Visit	50 for Hosp 0 for ASC	No cost sharing	20 for Therapeutic	No cost sharing	No cost sharing	30 / Visit	5 / visit	30 / Visit	30 / Visit	30 / Visit	20 - MRI CT PET	No cost sharing	0 for Diab. Items 20 for rest	No cost sharing	No cost sharing	No cost sharing for preventive services	No cost sharing	No copay up to 150 per year	No cost sharing	No copay up to 400	Not covered	No cost sharing	2 / Meal											12.33	138.38	31.09		100	31.68	28.26	46.98	50		205.68			30	5	30	29.03	30	0.15		0.14				0		0				2											2.07	0.63	2.69	-	3	3.25	7.79	1.64	0.95	-	5.04	-	-	0.39	2.48	11.76	0.73	0.85	5.06	-	3.64	-	-	-	-	-	-	-	-	-	10.83	-	-	-	-	-	-	-	-	-	-	62.8		0	2.07	0.63	2.69	-	3	3.25	7.79	1.64	0.95	-	5.04	-	-	0.39	2.48	11.76	0.73	0.85	5.06	-	3.64	-	-	-	-	-	-	-	-	-	10.83	-	-	-	-	-	-	-	-	-	-	62.8																																																																																				-		0	2.07	0.63	2.69	-	3	3.25	7.79	1.64	0.95	-	5.04	-	-	0.39	2.48	11.76	0.73	0.85	5.06	-	3.64	-	-	-	-	-	-	-	-	-	10.83	-	-	-	-	-	-	-	-	-	-	62.8
H4528_001_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	P	P	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V	P	P	P	P	P	P	P	P	P	P																																										-		1697.69	52.1	635.5		133.75	14.36	12.28	295.43	362.44		712.14		0.09	18.48	3471.73	5267.98	201.61	286.08			28.16				129.91																	#1A 50/day days 1-6 0/day days 7-90	#1B 50/day days 1-6 0/day days 7-90	#2 0/day days 1-20; 125/day days 21-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 35	#9A 150 #9B 50	0 diag lab	#8A 50-CAT & MRI 100-PET 25-Other #8B 15		#12 20	#3 20 #5 20 #9C 20 #9D 20	#7A 10 #14B 0 n/c #14C 0 #14D 0 n/c #14E 0 n/c #14F 0 n/c #14G 0 n/c #14H 0 n/c	#7B 20 #7D 20 #7F 20 #7G 20	#7E 20 #7H 20	#7C 20 #7I 20		#14I 0	#15 20	#13A 0	#10B 0	#16A 0 #16B 0	#17A 20	#17B 0	#18A 0	#18B 0 n/c	#19 0 n/c	#14A 0 n/c	#13B 0 n/c											33.61	33.61	79.06		50	0.2	0.2	48.5	98.12		26.75		0.2	0.08	10	20	19.63	20			0.2				20																	4.75	0.15	4.19	-	0.56	2.87	2.46	1.19	2.96	-	1.59	-	0.02	1.41	2.89	8.78	0.33	0.48	-	-	5.63	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.48		0	4.75	0.15	4.19	-	0.56	2.87	2.46	1.19	2.96	-	1.59	-	0.02	1.41	2.89	8.78	0.33	0.48	-	-	5.63	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.48		.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.																																										-		0	4.75	0.15	4.19	-	0.56	2.87	2.46	1.19	2.96	-	1.59	-	0.02	1.41	2.89	8.78	0.33	0.48	-	-	5.63	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.48
H4528_002_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	P	Coin	P	P	P	V	V	V	V	V	V	O	O	T	P	P	P	P	P	O	O	V	P	P	P	P	P	P	P	P	P	P																																										-			251.85	1063.96		315.98	35.07	22.25	680.58			14.67			31.08											129.09																		800 Deductible; 0 days 1-60 200 days 61-90	#2 0/day days 1-20; 125/day days 21-100		50	20	#11B 20 #11C 0	#4A 50 #4B 0		Clinical/Diagnositic 0; Therapeutic 20	Standard X-Rays 0; CT MRI PET 20			#3 0 #5 0 #9C 10 #9D 0	#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 0 #7D 0 #7F 0 #7G 0	#7E 10 #7H 0	#7C 0 #7I 0						#16A 0 #16B 0	5				0 n/c														51.35	77.06		50	0.2	0.2	50			0.18			10											5																	-	1.08	6.83	-	1.32	7.01	4.45	2.84	-	-	2.61	-	-	0.03	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.21		0	-	1.08	6.83	-	1.32	7.01	4.45	2.84	-	-	2.61	-	-	0.03	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.21		.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.																																										-		0	-	1.08	6.83	-	1.32	7.01	4.45	2.84	-	-	2.61	-	-	0.03	-	-	-	-	-	-	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.21
H4528_005_0	2007	6																																D	D	D	V	T	Coin	Coin	V	V	P	P	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V	P	P	P	P	P	P	P	P	P	P																																										-		1697.69	52.1	635.5		133.75	14.36	12.28	295.43	174.39		712.14		0.09	18.48	3585.29	5385.31	198.18	280.67			29.52				129.09																	#1A 25/day days 1-6 0/day days 7-90	#1B 25/day days 1-6 0/day days 7-90	#2 0/day days 1-20; 125/day days 21-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 20	#4A 50 #4B 25	#9A 100 #9B 0	#8A 0 diag lab	#8A 25-CAT & MRI 50-PET 15-other #8B 10		#12 20	#3 20 #5 20 #9C 20 #9D 10	#7A5 #14B 0 n/c #14C 0 #14D 0 n/c #14E 0 n/c #14F 0 n/c #14G 0 n/c #14H 0 n/c	#7B10 #7D10 #7F10 #7G10	#7E10 #7H10	#7C10 #7I10		#14I 0	#15 20	#13A 0	#10B 0 n/c	#16A 0 #16B 0	#17A 10	#17B 0	#18A 0 n/c	#18B 0 n/c	#19 0 n/c	#14A 0	#13B 0 n/c											16.81	16.81	79.06		50	0.2	0.2	47.5	100		15.3		0.2	0.08	5	10	9.81	10			0.2				10																	2.38	0.07	4.19	-	0.56	2.87	2.46	1.17	1.45	-	0.91	-	0.02	1.42	1.49	4.49	0.16	0.23	-	-	5.9	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88		0	2.38	0.07	4.19	-	0.56	2.87	2.46	1.17	1.45	-	0.91	-	0.02	1.42	1.49	4.49	0.16	0.23	-	-	5.9	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88		.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.																																										-		0	2.38	0.07	4.19	-	0.56	2.87	2.46	1.17	1.45	-	0.91	-	0.02	1.42	1.49	4.49	0.16	0.23	-	-	5.9	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88
H4529_001_0	2007	7																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1720.01	72.54	650.44		135.85	8.32	7.62	269.97	34.17		14.55	2.65	0.15	13.27	3715.06	5291.13	286.17	462.44	17.8	6.39	28.1				129.91		116.29															#1A: 50 days 1-5	#1B: 100 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 15	#11B/11C: 15	#4: 50	#9A OP Hosp: 10 NTE 200; #9B ASC: 10 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 10; #5: 30; #9A OP Hosp 15 / Chemo 20; #9C: 20; #9D: 10	#7A: 5; #14C: 5	#7B : 5; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 30	#7C/#7I: 10	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 5	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 125 Allowance every two years	#18A: 20	#18B: 600 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	28.58	57.15	12.54		93.25	0.14	0.14	46.63	0.06		0.11	0.14	0.19	0.14	4.67	17.84	27.97	9.32	0.09	0.09	0.19				25		20															4.1	0.35	0.68	-	1.06	1.16	1.07	1.05	2.22	-	1.55	0.37	0.03	1.81	1.45	7.86	0.67	0.36	1.66	0.6	5.24	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.72		2.41	4.1	0.35	0.68	-	1.06	1.16	1.07	1.05	2.22	-	1.55	0.37	0.03	1.81	1.45	7.86	0.67	0.36	1.66	0.6	5.24	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.72																																																																																				-		0	4.1	0.35	0.68	-	1.06	1.16	1.07	1.05	2.22	-	1.55	0.37	0.03	1.81	1.45	7.86	0.67	0.36	1.66	0.6	5.24	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.72
H4529_002_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1643.08	69.29	621.36	2031.91	129.78	7.95	7.28	257.91	32.64		13.9	2.53	0.15	12.68	3552.3	5054.44	273.37	441.76	17	6.1	26.84				129.91		116.29															#1A: 105 days 1-5	#1B: 200 days 1-5	#2: 30 days 11-100	#6: 10	#10A: 125	#11A: 20	#11B/11C: 20	#4: 50	#9A OP Hosp: 15 NTE 400; #9B ASC: 15 NTE 200	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 10; #5: 45; #9A OP Hosp 15 / Chemo 20; #9C: 25; #9D: 10	#7A: 10; #14C: 10	#7B : 5; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 45	#7C: 15; #7I: 10	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 10	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 500 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	64.36	122.59	16.14	10	125	0.2	0.2	50	0.11		0.16	0.15	0.2	0.15	10	23.84	45	10.63	0.15	0.15	0.2				25		30															8.81	0.71	0.84	1.69	1.35	1.59	1.46	1.07	3.62	-	2.18	0.38	0.03	1.87	2.96	10.04	1.03	0.39	2.55	0.92	5.37	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.41		0	8.81	0.71	0.84	1.69	1.35	1.59	1.46	1.07	3.62	-	2.18	0.38	0.03	1.87	2.96	10.04	1.03	0.39	2.55	0.92	5.37	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.41																																																																																				-		0	8.81	0.71	0.84	1.69	1.35	1.59	1.46	1.07	3.62	-	2.18	0.38	0.03	1.87	2.96	10.04	1.03	0.39	2.55	0.92	5.37	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.41
H4529_003_0	2007	5																					7500											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1820.33	76.77	688.34	2251.11	143.78	9.32	8.53	285.7	38.27		16.3	2.96	0.17	14.86	3927.27	5599.71	302.86	489.41	19.94	7.16	31.47				129.91		116.29															#1A: 100 days 1-5	#1B: 200 days 1-5	#2: 30 days 11-100	#6: 5	#10A: 105	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 300; #9B ASC: 15 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 15; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 15	#7A: 10; #14C: 10	#7B : 20; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 40	#7C/#7I: 15	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 100 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	57.4	114.8	15.11	4.68	98.33	0.19	0.15	46.83	0.09		0.11	0.14	0.19	0.14	9.38	23.14	37.46	14.05	0.09	0.09	0.19				25		30															8.71	0.73	0.87	0.88	1.18	1.75	1.27	1.11	3.53	-	1.74	0.42	0.03	2.05	3.07	10.8	0.95	0.57	1.87	0.67	5.89	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.65		3.26	8.71	0.73	0.87	0.88	1.18	1.75	1.27	1.11	3.53	-	1.74	0.42	0.03	2.05	3.07	10.8	0.95	0.57	1.87	0.67	5.89	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.65																																																																																				-		0	8.71	0.73	0.87	0.88	1.18	1.75	1.27	1.11	3.53	-	1.74	0.42	0.03	2.05	3.07	10.8	0.95	0.57	1.87	0.67	5.89	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.65
H4529_004_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1807.6	93.77	686.46	2359.18	149.51	9.69	8.62	284.1	35.65		15.37	2.79	0.38	14.63	3575.28	4957.32	308.61	446.36	17.79	6.42	28.11				126.92																	#1A: 150 days 1-5	#1B: 225 days 1-5	#2: 50 days 11-100	#6: 15	#10A: 140	#11A: 25	#11B Pros: 25; #11B Supplies: 20; #11C: 20	#4: 50	#9A OP Hosp: 15 NTE 450; #9B ASC: 15 NTE 275	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 25; #5: 45; #9A OP Hosp 15 / Chemo 20; #9C: 45; #9D: 25	#7A: 15; #14C: 35	#7B : 20; #7D/7F/7G #16B #17A #18A: 32	#7E/#7H: 45	#7C/#7I: 25	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	91.94	137.91	26.89	15	140	0.25	0.21	50	0.1		0.16	0.15	0.2	0.15	15.42	31.32	45	25	0.15	0.15	0.2				25																	13.85	1.08	1.54	2.95	1.74	2.42	1.8	1.18	3.73	-	2.41	0.42	0.08	2.15	4.59	12.94	1.16	0.93	2.67	0.96	5.62	-	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.5		0	13.85	1.08	1.54	2.95	1.74	2.42	1.8	1.18	3.73	-	2.41	0.42	0.08	2.15	4.59	12.94	1.16	0.93	2.67	0.96	5.62	-	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.5																																																																																				-		0	13.85	1.08	1.54	2.95	1.74	2.42	1.8	1.18	3.73	-	2.41	0.42	0.08	2.15	4.59	12.94	1.16	0.93	2.67	0.96	5.62	-	-	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.5
H4529_007_0	2007	7																																D	D	D	V	T	Coin	Coin	V	V	V	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		3153.69	429.82	2790.91		458.84	19.66	14.65	638.71	281.76		14.64	2.72	4.17	24.57	4547.01	4683.28	1706.25	614.71	16.68	6.08	28.17				127.73		114.34															#1A: 50 days 1-5	#1B: 200 days 1-5	#2: 30 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 10; #11C: 10	#4: 50	#9B ASC: 100; #9A OP Hosp: 200	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 10; #5: 45; #9A OP Hosp 15 / Chemo 20; #9C: 25; #9D: 10	#7A: 3; #14C: 10	#7B : 8; #7D/7F/7G #16B #17A #18A: 10	#7E/#7H: 45	#7C: 15; #7I: 10	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 10	Part B Rx: 15	0 Copay	0 Copay	0 Copay	#17A: 5	#17B: 100 Allowance	#18A: 20	#18B: 500 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	30.65	122.59	16.14		100	0.2	0.13	50	155.86		0.16	0.15	0.2	0.13	3.12	9.95	45	10.8	0.15	0.15	0.15				5		20															8.05	4.39	3.75	-	3.82	3.93	1.83	2.66	3.66	-	2.29	0.41	0.83	3.17	1.18	3.88	6.4	0.55	2.5	0.91	4.23	-	-	-	0.05	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.7		0	8.05	4.39	3.75	-	3.82	3.93	1.83	2.66	3.66	-	2.29	0.41	0.83	3.17	1.18	3.88	6.4	0.55	2.5	0.91	4.23	-	-	-	0.05	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.7																																																																																				-		0	8.05	4.39	3.75	-	3.82	3.93	1.83	2.66	3.66	-	2.29	0.41	0.83	3.17	1.18	3.88	6.4	0.55	2.5	0.91	4.23	-	-	-	0.05	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.7
H4529_014_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1746.52	84.68	663.67		142.27	9.37	8.42	270.38	35.61		15.29	2.78	0.3	14.33	3397.14	5070.25	288.11	434.61			27.99				126.91		113.6															#1A: 75 days 1-5	#1B: 125 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 10; #11C: 10	#4: 50 / Worldwide: 40	#9A OP Hosp: 15 NTE 200; #9B ASC: 15 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 10	#12: 20	#3: 15; #5: 50; #9A OP Hosp 10 / Chemo 20; #9C: 50; #9D: 15	#7A: 8; #14C: 0	#7B : 8; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 50	#7C/#7I: 15	#8B: 0	#7A/#7D Cardio. Testing: 0; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 100 Allowance every two years	#18A: 20	#18B: 600 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	45.97	76.62	13.45		100	0.2	0.12	49.99	0.09		0.16	0.1	0.2	0.11	8	18.84	50	15			0.2				10		20															6.69	0.54	0.74	-	1.19	1.87	1	1.13	3.03	-	2.4	0.28	0.06	1.57	2.26	7.96	1.2	0.54	-	-	5.6	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.36		0	6.69	0.54	0.74	-	1.19	1.87	1	1.13	3.03	-	2.4	0.28	0.06	1.57	2.26	7.96	1.2	0.54	-	-	5.6	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.36																																																																																				-		0	6.69	0.54	0.74	-	1.19	1.87	1	1.13	3.03	-	2.4	0.28	0.06	1.57	2.26	7.96	1.2	0.54	-	-	5.6	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.36
H4529_015_0	2007	7																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1741.3	73.44	658.46		137.54	9.03	8.27	273.31	37.1		15.8	2.87	0.16	14.41	3683.61	5575.57	289.71	468.16			30.51				129.91		116.29															#1A: 50 days 1-5	#1B: 100 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 75	#11A: 15	#11B Pros: 15; #11B Supplies: 10; #11C: 10	#4: 50	#9A OP Hosp: 10 NTE 150; #9B ASC: 10 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 12	#12: 20	#3: 10; #5: 35; #9A OP Hosp 12 / Chemo 20; #9C: 20; #9D: 10	#7A: 5; #14C: 0	#7B : 5; #7D/7F/7G #16B #17A #18A: 15	#7E/#7H: 35	#7C/#7I: 10	#8B: 0	#7A/#7D Cardio. Testing: 0; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 5	#17B: 150 Allowance every two years	#18A: 15	#18B: 700 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	28.96	57.91	10.16		70.87	0.14	0.1	47.24	0.06		0.11	0.11	0.19	0.12	4.72	13.28	33.07	9.45			0.19				5		15															4.2	0.35	0.56	-	0.81	1.28	0.85	1.08	2.12	-	1.7	0.33	0.03	1.69	1.45	6.17	0.8	0.37	-	-	5.77	-	-	-	0.05	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.75		1.72	4.2	0.35	0.56	-	0.81	1.28	0.85	1.08	2.12	-	1.7	0.33	0.03	1.69	1.45	6.17	0.8	0.37	-	-	5.77	-	-	-	0.05	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.75																																																																																				-		0	4.2	0.35	0.56	-	0.81	1.28	0.85	1.08	2.12	-	1.7	0.33	0.03	1.69	1.45	6.17	0.8	0.37	-	-	5.77	-	-	-	0.05	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.75
H4529_018_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1687.57	81.82	641.16		137.47	8.75	7.86	261.27	33.25		14.27	2.59	0.28	13.38	3282.49	4906.35	278.39	419.95			26.13				126.91		113.6															#1A: 75 days 1-5	#1B: 125 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 10; #11C: 10	#4: 50 / Worldwide: 40	#9A OP Hosp: 10 NTE 200; #9B ASC: 10 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 15; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 30; #9D: 15	#7A: 8; #14C: 0	#7B : 8; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 40	#7C/#7I: 15	#8B: 0	#7A/#7D Cardio. Testing: 0; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 100 Allowance every two years	#18A: 20	#18B: 600 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	45.97	76.62	13.45		100	0.2	0.12	49.99	0.07		0.16	0.15	0.2	0.15	8	18.69	40	15			0.2				10		20															6.46	0.52	0.72	-	1.15	1.75	0.93	1.09	2.21	-	2.24	0.39	0.06	1.96	2.19	7.64	0.93	0.52	-	-	5.23	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.28		0	6.46	0.52	0.72	-	1.15	1.75	0.93	1.09	2.21	-	2.24	0.39	0.06	1.96	2.19	7.64	0.93	0.52	-	-	5.23	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.28																																																																																				-		0	6.46	0.52	0.72	-	1.15	1.75	0.93	1.09	2.21	-	2.24	0.39	0.06	1.96	2.19	7.64	0.93	0.52	-	-	5.23	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.28
H4529_019_0	2007	7																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1682.52	70.96	636.26		132.89	8.43	7.72	264.09	34.63		14.75	2.68	0.15	13.45	3559.27	5394.76	279.94	452.36			28.48				129.91		116.29															#1A: 50 days 1-5	#1B: 100 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 75	#11A: 15	#11B Pros: 15; #11B Supplies: 10; #11C: 10	#4: 50	#9A OP Hosp: 10 NTE 150; #9B ASC: 10 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 12	#12: 20	#3: 10; #5: 30; #9A OP Hosp 12 / Chemo 20; #9C: 20; #9D: 10	#7A: 5; #14C: 0	#7B : 5; #7D/7F/7G #16B #17A #18A: 15	#7E/#7H: 30	#7C/#7I: 10	#8B: 0	#7A/#7D Cardio. Testing: 0; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 5	#17B: 150 Allowance every two years	#18A: 15	#18B: 700 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	29.1	58.19	10.21		71.2	0.14	0.1	47.46	0.06		0.11	0.11	0.19	0.12	4.75	13.34	28.48	9.49			0.19				5		15															4.08	0.34	0.54	-	0.79	1.2	0.8	1.04	2.06	-	1.6	0.31	0.03	1.58	1.41	6	0.66	0.36	-	-	5.41	-	-	-	0.05	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.4		1.5	4.08	0.34	0.54	-	0.79	1.2	0.8	1.04	2.06	-	1.6	0.31	0.03	1.58	1.41	6	0.66	0.36	-	-	5.41	-	-	-	0.05	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.4																																																																																				-		0	4.08	0.34	0.54	-	0.79	1.2	0.8	1.04	2.06	-	1.6	0.31	0.03	1.58	1.41	6	0.66	0.36	-	-	5.41	-	-	-	0.05	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.4
H4531_001_0	2007	4																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin			V		V				V																																																				-	5000	291.82		1173.84	2786.4	363	28.15		268.67	437.19	296.59	594.88	35.48		1199.43	5385.6	3970.93	257.43	965.51	27.62	12.34	16.71	15.62			612		88.2				577.8											275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.			25 per visit		25 per visit				15/25											246.31		17.91	8.96	89.57	0.09		44.78	44.78	44.78	44.78	22.39		44.78	8.96	26.87	22.39	22.39	0.09	0.09	0.09	0.09			25		25				20											5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	1.28	-	0.18	-	-	-	0.96	-	-	-	-	-	-	-	-	-	-	49.65	0	5.5	5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	1.28	-	0.18	-	-	-	0.96	-	-	-	-	-	-	-	-	-	-	49.65	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			50 copay		50 copay				20 coinsurance											5.36		1.22	0.58		0.52			0.66	0.16	0.34	0.01		0.42	0.49	0.51	0.04	0.04	0.55	0.36	0.33	0.31			0.28		0.04				0.14											12.35	500	4.05	11.35	-	2.97	2.66	2.71	3.04	-	1	2.29	1.26	2.56	0.08	-	4.9	4.51	9.4	0.52	1.84	3.02	1.47	1.83	1.71	-	-	1.56	-	0.22	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	61.99
H4531_802_0	2007	2																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	291.82		1173.84	2786.4	363	28.15		268.67	437.19	296.59	594.88	35.48		1199.43	5385.6	3970.93	257.43	965.51	27.62	12.34	16.71	15.62																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				246.31		17.91	8.96	89.57	0.09		44.78	44.78	44.78	44.78	22.39		44.78	8.96	26.87	22.39	22.39	0.09	0.09	0.09	0.09																				5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	0	5.5	5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				5.36		1.22	0.58		0.52			0.66	0.16	0.34	0.01		0.42	0.49	0.51	0.04	0.04	0.55	0.36	0.33	0.31																				11.88	500	4.01	11.35	-	2.97	2.66	2.71	3.04	-	1	2.29	1.26	2.56	0.08	-	4.9	4.51	9.4	0.52	1.84	3.02	1.47	1.83	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.11
H4531_803_0	2007	2																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	291.82		1173.84	2786.4	363	28.15		268.67	437.19	296.59	594.88	35.48		1199.43	5385.6	3970.93	257.43	965.51	27.62	12.34	16.71	15.62																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				246.31		17.91	8.96	89.57	0.09		44.78	44.78	44.78	44.78	22.39		44.78	8.96	26.87	22.39	22.39	0.09	0.09	0.09	0.09																				5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	0	5.5	5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				5.36		1.22	0.58		0.52			0.66	0.16	0.34	0.01		0.42	0.49	0.51	0.04	0.04	0.55	0.36	0.33	0.31																				11.88	500	4.01	11.35	-	2.97	2.66	2.71	3.04	-	1	2.29	1.26	2.56	0.08	-	4.9	4.51	9.4	0.52	1.84	3.02	1.47	1.83	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.11
H4531_804_0	2007	2																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	291.82		1173.84	2786.4	363	28.15		268.67	437.19	296.59	594.88	35.48		1199.43	5385.6	3970.93	257.43	965.51	27.62	12.34	16.71	15.62																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				246.31		17.91	8.96	89.57	0.09		44.78	44.78	44.78	44.78	22.39		44.78	8.96	26.87	22.39	22.39	0.09	0.09	0.09	0.09																				5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	0	5.5	5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				5.36		1.22	0.58		0.52			0.66	0.16	0.34	0.01		0.42	0.49	0.51	0.04	0.04	0.55	0.36	0.33	0.31																				11.88	500	4.01	11.35	-	2.97	2.66	2.71	3.04	-	1	2.29	1.26	2.56	0.08	-	4.9	4.51	9.4	0.52	1.84	3.02	1.47	1.83	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.11
H4531_805_0	2007	3																					2700											A		D	V	T	Coin		V	V	V	V	V		V	V	V	V	V	Coin	Coin	Coin	Coin																																																													-	5000	291.82		1173.84	2786.4	363	28.15		268.67	437.19	296.59	594.88	35.48		1199.43	5385.6	3970.93	257.43	965.51	27.62	12.34	16.71	15.62																				275 per admission.		20 per day.	10 per day.	100 per trip.	10 coinsurance.		50 emrg/20 Urgent	50 per visit.	50 per visit.	50 per visit.	25 per visit.		50 per visit.	10 per visit.  0 additional copay for colorectal screening mamograms bone mass measurements and PSA's.	30 per visit	25 per visit	25 per visit	10 coinsurance	10 coinsurance except sustitute 0 copay for colorectal screening mamograms bone mass measurements and PSA's.	10 coinsurance.	10 coinsurance.																				246.31		17.91	8.96	89.57	0.09		44.78	44.78	44.78	44.78	22.39		44.78	8.96	26.87	22.39	22.39	0.09	0.09	0.09	0.09																				5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	0	5.5	5.99	-	1.75	2.08	2.71	2.52	-	1	1.63	1.11	2.22	0.07	-	4.48	4.02	8.89	0.48	1.8	2.47	1.11	1.5	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.23	7700	20 coinsurance		20 coinsurance	20 coinsurance		20 coinsurance			20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance																				5.36		1.22	0.58		0.52			0.66	0.16	0.34	0.01		0.42	0.49	0.51	0.04	0.04	0.55	0.36	0.33	0.31																				11.88	500	4.01	11.35	-	2.97	2.66	2.71	3.04	-	1	2.29	1.26	2.56	0.08	-	4.9	4.51	9.4	0.52	1.84	3.02	1.47	1.83	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.11
H4577_001_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2004.81	42.32	1544.91	2498.64	10.32	27.79	4.54	5.6	30.46	3102.54	30.47	0	9.03	19.73	21.73	50.35	1.71	1223.05	26.68	32189.2	9.72	6059.96	0	699.2	338.4	260.8	48.3	6.1	0	284.49	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0	0exam;10-20/20-50 compreh dent;1000max bft	0	1pr glasses/cont per yr 140 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											110.84	40.39	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	3.96	0.2	0	0	7.37	0	10	0	10	0	0	0											18.52	0.14	3.48	-	2.06	5.56	0.91	1.12	6.09	-	6.09	-	1.81	3.95	4.2	10.07	0.86	-	4.54	10.62	1.94	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	82.6		0	18.52	0.14	3.48	-	2.06	5.56	0.91	1.12	6.09	-	6.09	-	1.81	3.95	4.2	10.07	0.86	-	4.54	10.62	1.94	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	82.6	0																								50 (500 max bft)	50 coinsurance; 70 max bft	50 coinsurance; 70 max bft	50 coinsurance	50 coinsurance																																					1.61	0.18	0.18	0.03	0.06														2.06		0	18.52	0.14	3.48	-	2.06	5.56	0.91	1.12	6.09	-	6.09	-	1.81	3.95	4.2	10.07	0.86	-	4.54	10.62	1.94	-	-	2.04	0.18	0.4	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	84.66
H4577_002_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2248.29	47.46	1401.38	2562.81	9.4	25.31	4.54	5.97	32.48	2677.31	32.02	0	9.63	21.04	22.47	53.84	1.98	1305.87	32.6	34643.08	10.36	6426.47	0	699.2	338.4	260.8	48.3	6.1	0	291.71	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0	0exam;10-20/20-50 compreh dent;1000max bft	0	1pr glasses/cont per yr 260 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											108.12	39.4	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	4.16	0.2	0	0	7.37	0	10	0	10	0	0	0											20.26	0.16	3.15	-	1.88	5.06	0.91	1.19	6.5	-	6.4	-	1.93	4.21	4.33	10.77	0.99	-	5.54	12.02	2.07	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	88.02		0	20.26	0.16	3.15	-	1.88	5.06	0.91	1.19	6.5	-	6.4	-	1.93	4.21	4.33	10.77	0.99	-	5.54	12.02	2.07	-	-	0.43	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	88.02	0																								50 (500 max bft)	50 coinsurance; 100 max bft	50 coinsurance; 100 max bft	50 coinsurance	50 coinsurance																																					1.61	0.18	0.26	0.03	0.06														2.14		0	20.26	0.16	3.15	-	1.88	5.06	0.91	1.19	6.5	-	6.4	-	1.93	4.21	4.33	10.77	0.99	-	5.54	12.02	2.07	-	-	2.04	0.18	0.48	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	90.16
H4577_003_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1897.96	40.06	1652.09	1570.81	8.28	22.31	4.37	6.05	32.9	3412.31	32.83	0	9.75	21.32	21.63	51.28	1.77	1271.43	26.59	30881.89	10.5	6274.08	0	648.8	338.4	260.8	48.3	6.1	0	284.47	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0	0exam;10-20/20-50 compreh dent;1000max bft	0	1pr glasses/cont per yr 260 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											121.39	44.23	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	4.1	0.2	0	0	8.19	0	10	0	10	0	0	0											19.2	0.15	3.72	-	1.66	4.46	0.87	1.21	6.58	-	6.57	-	1.95	4.26	4.18	10.26	0.89	-	4.52	10.56	2.1	-	-	0.44	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	83.79		0	19.2	0.15	3.72	-	1.66	4.46	0.87	1.21	6.58	-	6.57	-	1.95	4.26	4.18	10.26	0.89	-	4.52	10.56	2.1	-	-	0.44	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	83.79	0																								50 (500 max bft)	50 coinsurance; 100 max bft	50 coinsurance; 100 max bft	50 coinsurance	50 coinsurance																																					1.87	0.18	0.26	0.03	0.06														2.4		0	19.2	0.15	3.72	-	1.66	4.46	0.87	1.21	6.58	-	6.57	-	1.95	4.26	4.18	10.26	0.89	-	4.52	10.56	2.1	-	-	2.31	0.18	0.48	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	86.19
H4577_004_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1894.17	39.98	1350.71	1644.63	10	26.94	4.56	5.77	31.4	3141.7	31.34	0	9.3	20.34	26.74	65.28	2.38	1498.25	33.22	36983.49	10.02	7277.9	0	0	338.4	260.8	48.3	6.1	0	323.87	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0		0	1pr glasses/cont per yr 260 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											134.08	48.85	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	4.14	0.2	0	0	0	0	10	0	10	0	0	0											21.16	0.16	3.04	-	2	5.39	0.91	1.15	6.28	-	6.27	-	1.86	4.07	5.15	13.06	1.19	-	5.65	12.75	2	-	-	-	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	92.32		0	21.16	0.16	3.04	-	2	5.39	0.91	1.15	6.28	-	6.27	-	1.86	4.07	5.15	13.06	1.19	-	5.65	12.75	2	-	-	-	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	92.32	0																								0	50 coinsurance; 100 max bft	50 coinsurance; 100 max bft	50 coinsurance	50 coinsurance																																					0	0.18	0.26	0.03	0.06														0.53		0	21.16	0.16	3.04	-	2	5.39	0.91	1.15	6.28	-	6.27	-	1.86	4.07	5.15	13.06	1.19	-	5.65	12.75	2	-	-	-	0.18	0.48	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	92.85
H4577_005_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1148.92	24.25	1140.06	1127.47	6.99	18.83	3.61	557.23	431.27	2989.47	28.39	0	7.97	799.24	4364.36	9255.6	1	914.11	21.06	98.99	8.58	14.28	0	0	0	0	0	0	0	208.09	549.33											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.4	3.77	0.72	-	-	-	1.42	-	1.59	-	-	-	0	-	0.67	0.92	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.49		0	-	-	-	-	1.4	3.77	0.72	-	-	-	1.42	-	1.59	-	-	-	0	-	0.67	0.92	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.49	0																																																																																			-		0	-	-	-	-	1.4	3.77	0.72	-	-	-	1.42	-	1.59	-	-	-	0	-	0.67	0.92	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.49
H4577_006_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1407.84	29.72	1133.24	1163.55	7.33	19.74	3.52	462.3	357.8	2480.17	26.42	0	7.42	663.08	4921.67	10509.92	1.16	1047.88	25.74	117.59	7.99	17.76	0	0	0	0	0	0	0	234.66	549.38											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.47	3.95	0.7	-	-	-	1.32	-	1.48	-	-	-	0.01	-	0.82	1.17	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.92		0	-	-	-	-	1.47	3.95	0.7	-	-	-	1.32	-	1.48	-	-	-	0.01	-	0.82	1.17	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.92	0																																																																																			-		0	-	-	-	-	1.47	3.95	0.7	-	-	-	1.32	-	1.48	-	-	-	0.01	-	0.82	1.17	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.92
H4577_007_0	2007	5																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1443.74	30.48	1238.89	1471.83	7.78	20.94	3.61	480.95	372.23	2580.2	26.56	0	7.46	689.82	4887.86	10376.47	1.18	1026.27	26.56	120.15	8.03	17.34	0	0	0	0	0	0	0	233.05	549.36											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.56	4.19	0.72	-	-	-	1.33	-	1.49	-	-	-	0.01	-	0.85	1.14	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.28		0	-	-	-	-	1.56	4.19	0.72	-	-	-	1.33	-	1.49	-	-	-	0.01	-	0.85	1.14	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.28	0																																																																																			-		0	-	-	-	-	1.56	4.19	0.72	-	-	-	1.33	-	1.49	-	-	-	0.01	-	0.85	1.14	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.28
H4577_008_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1440.92	30.42	1177.5	1477.55	8.17	22.02	3.89	564.7	437.05	3029.53	29.09	0	8.16	809.95	4936.81	10614.74	1.23	1068.17	24.9	119.59	8.79	18.63	0	0	0	0	0	0	0	235.39	549.38											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.63	4.4	0.78	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.79	1.23	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.93		0	-	-	-	-	1.63	4.4	0.78	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.79	1.23	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.93	0																																																																																			-		0	-	-	-	-	1.63	4.4	0.78	-	-	-	1.45	-	1.63	-	-	-	0.01	-	0.79	1.23	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.93
H4577_009_0	2007	4																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1501.87	31.7	1227.21	1326.15	7.95	21.42	3.88	486.19	376.29	2608.35	29.39	0	8.29	697.35	5295.79	11452.74	1.34	1161.41	26.67	131.44	8.92	21.28	0	0	0	0	0	0	0	252.5	549.44											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.59	4.28	0.78	-	-	-	1.47	-	1.66	-	-	-	0.01	-	0.85	1.4	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.04		0	-	-	-	-	1.59	4.28	0.78	-	-	-	1.47	-	1.66	-	-	-	0.01	-	0.85	1.4	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.04	0																																																																																			-		0	-	-	-	-	1.59	4.28	0.78	-	-	-	1.47	-	1.66	-	-	-	0.01	-	0.85	1.4	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.04
H4577_010_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1781.84	37.61	1476.12	1745.04	8.57	23.08	4.1	559.95	433.37	3004.02	30.68	0	8.63	803.14	5210	11214.66	1.29	1130.23	26.94	130.21	9.29	20.12	0	0	0	0	0	0	0	248.41	549.44											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.71	4.62	0.82	-	-	-	1.53	-	1.73	-	-	-	0.01	-	0.86	1.31	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.59		0	-	-	-	-	1.71	4.62	0.82	-	-	-	1.53	-	1.73	-	-	-	0.01	-	0.86	1.31	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.59	0																																																																																			-		0	-	-	-	-	1.71	4.62	0.82	-	-	-	1.53	-	1.73	-	-	-	0.01	-	0.86	1.31	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.59
H4577_011_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1556.47	32.74	1316.32	1531.49	7.72	20.79	3.69	434.62	443.4	10.42	26.32	0	7.78	821.72	4384.95	9150.59	209.3	877.37	4499.38	115.43	8.37	18.91	0	0	438	0	187.71	0	0	233.6	2.21											250  Days 1 - 5	250  Days 1 - 5	119  days 21 - 100	0	0.2	0.3	0.3	50	75-ASC/ 150-OP/ 150-Non Surg	0.2	0.2		0.2	40 to 150	15	40	30 to 40	40	Phy. Off. 10-40 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	50											146.25	146.25	24.77	0	0.18	0.28	0.28	45.85	130.68	0.18	0.18	0	0.18	86.11	11.57	36.68	29.8	36.68	14.95	0.1	0.18	0	0	0	18.34	0	18.34	0	0	0	45.85											18.97	0.4	2.72	-	1.42	5.72	1.02	1.66	4.83	1.91	4.83	-	1.43	5.9	4.23	27.97	0.52	2.68	5.61	11.84	1.54	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	106.14		9.6	18.97	0.4	2.72	-	1.42	5.72	1.02	1.66	4.83	1.91	4.83	-	1.43	5.9	4.23	27.97	0.52	2.68	5.61	11.84	1.54	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	106.14	3650																																																																																			-		0	18.97	0.4	2.72	-	1.42	5.72	1.02	1.66	4.83	1.91	4.83	-	1.43	5.9	4.23	27.97	0.52	2.68	5.61	11.84	1.54	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	106.14
H4577_012_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1437.99	30.35	1160.74	1257.37	6.95	18.71	3.58	401.14	409.24	10.48	26.55	0	7.89	758.43	4298.98	8776.48	194.63	815.86	4427.91	113.84	8.49	16.41	0	0	429.41	0	184.03	0	0	229.02	549.37											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											132.14	132.14	26.53	0	0.18	0.23	0.23	46.03	106.33	0.18	0.18	0	0.18	70.57	7.74	32.22	25.32	32.22	14.06	0.09	0.18	0	0	0	18.41	0	18.41	0	0	0	0.31											15.83	0.33	2.57	-	1.28	4.31	0.82	1.54	3.63	1.93	4.89	-	1.45	4.46	2.77	23.57	0.41	2.19	5.19	9.76	1.56	-	-	-	0.66	-	0.28	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	89.44		7.82	15.83	0.33	2.57	-	1.28	4.31	0.82	1.54	3.63	1.93	4.89	-	1.45	4.46	2.77	23.57	0.41	2.19	5.19	9.76	1.56	-	-	-	0.66	-	0.28	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	89.44	3650																																																																																			-		0	15.83	0.33	2.57	-	1.28	4.31	0.82	1.54	3.63	1.93	4.89	-	1.45	4.46	2.77	23.57	0.41	2.19	5.19	9.76	1.56	-	-	-	0.66	-	0.28	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	89.44
H4577_013_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1509.38	31.86	1115.77	1537.79	8.18	22.04	3.83	395.64	403.63	10.57	26.81	0	7.96	748.02	4640.03	9699.3	222.37	932.14	4631.96	125.66	8.57	20.84	0	0	463.48	0	198.63	0	0	247.19	549.44											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.4	131.4	26.38	0	0.18	0.23	0.23	45.77	105.74	0.18	0.18	0	0.18	70.17	7.7	32.04	25.18	32.04	14.08	0.09	0.18	0	0	0	18.31	0	18.31	0	0	0	0.31											16.53	0.35	2.45	-	1.5	5.04	0.88	1.51	3.56	1.93	4.91	-	1.46	4.37	2.98	25.9	0.47	2.49	5.43	11.01	1.57	-	-	-	0.71	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	95.36		8.9	16.53	0.35	2.45	-	1.5	5.04	0.88	1.51	3.56	1.93	4.91	-	1.46	4.37	2.98	25.9	0.47	2.49	5.43	11.01	1.57	-	-	-	0.71	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	95.36	3650																																																																																			-		0	16.53	0.35	2.45	-	1.5	5.04	0.88	1.51	3.56	1.93	4.91	-	1.46	4.37	2.98	25.9	0.47	2.49	5.43	11.01	1.57	-	-	-	0.71	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	95.36
H4577_014_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1525.3	32.2	1235.42	1500.09	8.2	22.08	3.95	393.51	401.46	11.03	28.14	0	8.35	744.01	4587.12	9461.92	212.95	892.66	4719.42	128.49	8.99	19.15	0	0	458.19	0	196.37	0	0	244.37	549.41											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.34	131.34	26.36	0	0.18	0.23	0.23	45.75	105.69	0.18	0.18	0	0.18	70.14	7.7	32.03	25.16	32.03	14.63	0.08	0.18	0	0	0	18.3	0	18.3	0	0	0	0.31											16.69	0.35	2.71	-	1.5	5.05	0.9	1.5	3.54	2.02	5.15	-	1.53	4.35	2.94	25.25	0.45	2.38	5.75	10.85	1.65	-	-	-	0.7	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	95.58		8.9	16.69	0.35	2.71	-	1.5	5.05	0.9	1.5	3.54	2.02	5.15	-	1.53	4.35	2.94	25.25	0.45	2.38	5.75	10.85	1.65	-	-	-	0.7	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	95.58	3650																																																																																			-		0	16.69	0.35	2.71	-	1.5	5.05	0.9	1.5	3.54	2.02	5.15	-	1.53	4.35	2.94	25.25	0.45	2.38	5.75	10.85	1.65	-	-	-	0.7	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	95.58
H4577_015_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1720.52	36.32	1223.55	1499.01	8.73	23.52	4.11	369.15	376.61	11.27	28.7	0	8.56	697.95	4686.23	9817.49	225.76	946.35	5128.75	136.05	9.22	21.8	0	0	468.09	0	200.61	0	0	249.65	549.41											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.01	131.01	26.3	0	0.18	0.23	0.23	45.64	105.42	0.18	0.18	0	0.18	69.96	7.68	31.95	25.1	31.95	14.21	0.09	0.18	0	0	0	18.26	0	18.26	0	0	0	0.3											18.78	0.4	2.68	-	1.59	5.37	0.94	1.4	3.31	2.06	5.24	-	1.56	4.07	3	26.14	0.47	2.52	6.07	12.01	1.68	-	-	-	0.71	-	0.31	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.33		9.66	18.78	0.4	2.68	-	1.59	5.37	0.94	1.4	3.31	2.06	5.24	-	1.56	4.07	3	26.14	0.47	2.52	6.07	12.01	1.68	-	-	-	0.71	-	0.31	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.33	3650																																																																																			-		0	18.78	0.4	2.68	-	1.59	5.37	0.94	1.4	3.31	2.06	5.24	-	1.56	4.07	3	26.14	0.47	2.52	6.07	12.01	1.68	-	-	-	0.71	-	0.31	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.33
H4577_801_0	2007	5																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1783.43	37.65	1202.12	1894.63	7.79	20.97	3.67	4.76	25.87	2673.35	25.83	0	7.67	16.76	19.25	47.49	1.66	2.11	4871.92	118.92	8.26	17.89	0	0	0	0	0	0	0	237.14	0											952  0 (1-60) 238 (61 - 90) 476 (91+)	952  0 (1-60) 238 (61 - 90) 476 (91+)	119  Days 21-100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2		0.2	0.2	0.2	0.2	0.5 to 0.5	0.2	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0.2	0	Not covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.8	52.03	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0.2	10.45	0.1	0.2	0.2	0	0	0	0	0	0	0	0	0											21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9	0																																																																																			-		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9
H4577_802_0	2007	5																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1783.43	37.65	1202.12	1894.63	7.79	20.97	3.67	4.76	25.87	2673.35	25.83	0	7.67	16.76	19.25	47.49	1.66	2.11	4871.92	118.92	8.26	17.89	0	0	0	0	0	0	0	237.14	0											952  0 (1-60) 238 (61 - 90) 476 (91+)	952  0 (1-60) 238 (61 - 90) 476 (91+)	119  Days 21-100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2		0.2	0.2	0.2	0.2	0.5 to 0.5	0.2	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0.2	0	Not covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.8	52.03	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0.2	10.45	0.1	0.2	0.2	0	0	0	0	0	0	0	0	0											21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9	0																																																																																			-		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9
H4590_010_0	2007	7																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1399.9	37.92	917.05	1921.16	153.29	22.63	1.58	416.45	386.19	604.24	37.19	29.86	5.14	619.08	7548.64	4732.06	177.06	394.01	38.44	22340.84	39.88	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											100 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	5	20	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	25 1/yr	20	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											17.42	109.69	39	0	100	0.2	0.2	48.99	100	0	0.15	0	0	69.59	8.9	21.49	30	20	0.09	0	0.2	0	0	0	25	20	0	0	0	0	0											2.03	0.35	2.98	-	1.28	4.45	0.32	1.7	3.22	-	5.73	-	-	3.59	5.6	8.47	0.44	0.66	3.32	0.01	7.98	-	-	-	0.23	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.75	0	0	2.03	0.35	2.98	-	1.28	4.45	0.32	1.7	3.22	-	5.73	-	-	3.59	5.6	8.47	0.44	0.66	3.32	0.01	7.98	-	-	-	0.23	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.75	None																																																																																			-	0	0	2.03	0.35	2.98	-	1.28	4.45	0.32	1.7	3.22	-	5.73	-	-	3.59	5.6	8.47	0.44	0.66	3.32	0.01	7.98	-	-	-	0.23	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.75
H4590_012_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1899.42	51.45	861.46	1814.64	159.13	17.99	1.26	371.26	400.78	550.86	25	30.99	4.64	642.46	6989.19	4041.62	155.13	364.84	26.23	21434.2	39.88	0	0	0	119.04	269.05	212.75	38.17	0	0	678.81											100 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	5	25	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											65.26	109.69	62	0	100	0.2	0.2	48.99	100	0	0.15	0	0	69.59	8.95	25.74	30	25	0.26	0	0.2	0	0	0	30	30	0	0	0	0	0											10.33	0.47	4.45	-	1.33	3.53	0.25	1.52	3.34	-	3.85	-	-	3.73	5.21	8.67	0.39	0.76	6.9	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68	0	0	10.33	0.47	4.45	-	1.33	3.53	0.25	1.52	3.34	-	3.85	-	-	3.73	5.21	8.67	0.39	0.76	6.9	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68	None																																																																																			-	0	0	10.33	0.47	4.45	-	1.33	3.53	0.25	1.52	3.34	-	3.85	-	-	3.73	5.21	8.67	0.39	0.76	6.9	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68
H4590_020_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	2621.9	71.02	1206.55	2517.34	220.75	24.27	1.69	518.76	565.96	777.91	33.85	43.76	6.28	907.27	9830.95	5684.91	160.24	513.18	35.39	30149.17	54.31	0	0	1538.5	119.04	269.05	212.75	38.17	0	0	678.81											0 per admit	812 Copay Per Stay	No copay Day(s) 1-20; 120 [Day(s) 21-100]	Covered in Full	50 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0.2	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Office Visit2 teeth cleanings/year and preventative care	Exam 5/12 months	materials copay 5/12 months	5 Exam/12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	97.67	47	0	50	0.2	0.2	23.74	0	0	0.15	0	0.2	0	0	0	10	0	0.09	0	0.2	0	0	1.77	5	5	5	0	0	0	0											-	0.58	4.73	-	0.92	4.77	0.34	1.03	-	-	5.21	-	1.26	-	-	-	0.13	-	3.05	-	10.86	-	-	0.23	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.35	0	0	-	0.58	4.73	-	0.92	4.77	0.34	1.03	-	-	5.21	-	1.26	-	-	-	0.13	-	3.05	-	10.86	-	-	0.23	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.35	None																																																																																			-	0	0	-	0.58	4.73	-	0.92	4.77	0.34	1.03	-	-	5.21	-	1.26	-	-	-	0.13	-	3.05	-	10.86	-	-	0.23	0.05	0.11	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.35
H4590_022_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1776.39	48.12	1112.57	2400.01	191.5	26.16	1.82	508.83	457.27	715.47	42.49	35.36	5.87	733.03	9041.59	5667.95	160.24	471.93	44.42	26759.33	52.78	0	0	1538.5	111.57	252.17	199.41	35.78	0	0	640.54											0 per admit	812 Copay Per Stay	No copay Day(s) 1-20; 120 [Day(s) 21-100]	Covered in Full	50 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0.2	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Office Visit2 teeth cleanings/year and preventative care	Exam 5/12 months	materials copay 5/12 months	5 Exam/12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	97.67	47	0	50	0.2	0.2	23.74	0	0	0.15	0	0.2	0	0	0	10	0	0.09	0	0.2	0	0	1.77	5	5	5	0	0	0	0											-	0.39	4.36	-	0.8	5.14	0.36	1.01	-	-	6.54	-	1.17	-	-	-	0.13	-	3.83	-	10.56	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.76	0	0	-	0.39	4.36	-	0.8	5.14	0.36	1.01	-	-	6.54	-	1.17	-	-	-	0.13	-	3.83	-	10.56	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.76	None																																																																																			-	0	0	-	0.39	4.36	-	0.8	5.14	0.36	1.01	-	-	6.54	-	1.17	-	-	-	0.13	-	3.83	-	10.56	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.76
H4590_025_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1389.87	37.65	817.3	1751.83	146.21	20.19	1.41	380.26	333.16	536.67	32.67	25.76	4.51	534.07	6613.64	4145.93	155.13	355.35	34.28	19899.83	39.88	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											50 per admit	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	5	15	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											8.71	109.69	62	0	100	0.2	0.2	48.99	50	0	0.15	0	0	36.59	8.9	17.23	30	15	0.24	0	0.2	0	0	0	30	30	0	0	0	0	0											1.01	0.34	4.22	-	1.22	3.96	0.28	1.55	1.39	-	5.03	-	-	1.63	4.9	5.95	0.39	0.44	8.14	0.01	7.98	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.39	0	0	1.01	0.34	4.22	-	1.22	3.96	0.28	1.55	1.39	-	5.03	-	-	1.63	4.9	5.95	0.39	0.44	8.14	0.01	7.98	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.39	None																																																																																			-	0	0	1.01	0.34	4.22	-	1.22	3.96	0.28	1.55	1.39	-	5.03	-	-	1.63	4.9	5.95	0.39	0.44	8.14	0.01	7.98	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.39
H4590_027_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1899.42	51.45	861.46	1814.64	159.13	18	1.26	371.26	400.78	550.86	25	30.99	4.64	642.46	6989.19	4041.62	155.13	364.84	26.24	21434.2	39.88	0	0	0	119.04	269.05	212.75	38.17	0	0	678.81											100 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	5	25	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											65.26	109.69	62	0	100	0.2	0.2	48.99	100	0	0.15	0	0	69.59	8.95	25.74	30	25	0.26	0	0.2	0	0	0	30	30	0	0	0	0	0											10.33	0.47	4.45	-	1.33	3.53	0.25	1.52	3.34	-	3.85	-	-	3.73	5.21	8.67	0.39	0.76	6.9	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68	0	0	10.33	0.47	4.45	-	1.33	3.53	0.25	1.52	3.34	-	3.85	-	-	3.73	5.21	8.67	0.39	0.76	6.9	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68	None																																																																																			-	0	0	10.33	0.47	4.45	-	1.33	3.53	0.25	1.52	3.34	-	3.85	-	-	3.73	5.21	8.67	0.39	0.76	6.9	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.68
H4590_028_0	2007	8																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1401.43	37.96	918.05	1923.26	153.46	22.64	1.58	416.91	386.61	604.9	37.2	29.89	5.14	619.75	7556.88	4737.23	177.06	394.44	38.44	22365.22	39.88	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											50 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	5	10	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	25 1/yr	20	25 1/yr	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											8.71	109.69	39	0	100	0.2	0.2	48.99	50	0	0.15	0	0	36.59	8.9	12.97	30	10	0.09	0	0.2	0	0	0	25	20	25	0	0	0	0											1.02	0.35	2.98	-	1.28	4.45	0.32	1.7	1.61	-	5.73	-	-	1.89	5.6	5.12	0.44	0.33	3.32	0	7.98	-	-	-	0.23	0.42	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.18	0	0	1.02	0.35	2.98	-	1.28	4.45	0.32	1.7	1.61	-	5.73	-	-	1.89	5.6	5.12	0.44	0.33	3.32	0	7.98	-	-	-	0.23	0.42	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.18	None																																																																																			-	0	0	1.02	0.35	2.98	-	1.28	4.45	0.32	1.7	1.61	-	5.73	-	-	1.89	5.6	5.12	0.44	0.33	3.32	0	7.98	-	-	-	0.23	0.42	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.18
H4590_029_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1399.9	37.92	917.05	1921.16	153.29	22.18	1.55	416.45	386.19	604.24	36.44	29.86	5.03	619.08	7548.64	4732.06	177.06	394.01	37.66	22340.84	39.88	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											0 per admit	912 per admit	No copay [Day(s) 1-20]; 100 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	20 2 visits/yr	0 1/yr	0	0 exam /yr	800 3/yrs	Not Covered	0	Acupuncture: 10 12 visits/yr; Routine Chiropractic: 10 12 visits/yr											0	109.69	39	0	100	0.2	0.2	48.99	0	0	0.15	0	0	3.58	4.68	4.46	30	0	0.09	0	0.2	0	0	0	0	0	0	0	0	0	8.93											-	0.35	2.98	-	1.28	4.36	0.31	1.7	-	-	5.61	-	-	0.18	2.94	1.76	0.44	-	3.25	-	7.98	-	-	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	33.61	0	0	-	0.35	2.98	-	1.28	4.36	0.31	1.7	-	-	5.61	-	-	0.18	2.94	1.76	0.44	-	3.25	-	7.98	-	-	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	33.61	None																																																																																			-	0	0	-	0.35	2.98	-	1.28	4.36	0.31	1.7	-	-	5.61	-	-	0.18	2.94	1.76	0.44	-	3.25	-	7.98	-	-	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	33.61
H4590_030_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	2034.88	55.12	922.9	1944.06	170.48	19.41	1.35	397.74	429.36	590.15	26.97	33.2	5.01	688.28	7487.65	4329.86	155.13	390.86	28.3	22962.84	39.88	0	0	0	119.04	269.05	212.75	38.17	0	0	678.81											100 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	5	25	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	0 1/yr	500/3 yrs	Not Covered	0	Acupuncture: 10 12 visits/yr; Routine Chiropractic: 10 12 visits/yr											65.26	109.69	62	0	100	0.2	0.2	48.99	100	0	0.15	0	0	69.59	8.95	25.74	30	25	0.26	0	0.2	0	0	0	30	30	0	0	0	0	8.99											11.07	0.5	4.77	-	1.42	3.81	0.27	1.62	3.58	-	4.15	-	-	3.99	5.58	9.29	0.39	0.81	7.41	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	0.51	-	-	-	-	-	-	-	-	-	-	68.13	0	0	11.07	0.5	4.77	-	1.42	3.81	0.27	1.62	3.58	-	4.15	-	-	3.99	5.58	9.29	0.39	0.81	7.41	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	0.51	-	-	-	-	-	-	-	-	-	-	68.13	None																																																																																			-	0	0	11.07	0.5	4.77	-	1.42	3.81	0.27	1.62	3.58	-	4.15	-	-	3.99	5.58	9.29	0.39	0.81	7.41	0.01	7.98	-	-	-	0.3	0.67	-	-	-	-	0.51	-	-	-	-	-	-	-	-	-	-	68.13
H4590_031_0	2007	6																					1650											D	D	D	V	T	Coin	Coin	V	P	P	P	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	1650	3599.8	132.69	10719.14	3249.66	994.45	10.65	1.52	587.36	235.44	1600.59	695.99	26.15	6.62	755.97	1851.75	3834.13	654.65	186.85	32.11	42426.86	36.16	0	0	1538.5	54.04	122.13	78.62	14.11	0	0	122.99											150	15000	0	0	75	0	Prosthetic Devices: 0.2; Diabetes Monitoring Supplies: 0.2	ER Copay (per visit): 50; Urgent Care: 35	Ambulatory Surgical Center Copay: 25; Outpatient Hospital Copay: 25	0	Radiation Therapy: 0; Compex Radiology (MRIMRACTPETSpec): 0	0	0	Cardiac Rehabilitation: 25; Pulmonary Rehabilitation: 25; Ambulatory Surgical Center Copay: 25; Outpatient Hospital Copay: 25	0	10	0	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 0; Compex Radiology (MRIMRACTPETSpec): 0	0	Inhalation Solutions: 0; Oral Chemo: 0; Anti-Emetics: 0; Outpatient Injectables  -Self Administered: 0	0	12 OW	N	0	0	0	600 /2 years	Not Covered	0	Acupuncture: N; Routine Chiropractic: N											83.23	96.87	0	0	48.49	0.2	0.2	31.84	16.16	0	0	0	0	13.97	0	6.47	0	6.47	0	0	0	0	0	0	0	0	0	0	0	0	0											24.97	1.07	-	-	4.02	2.13	0.3	1.56	0.32	-	-	-	-	0.88	-	2.07	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.41	0	20.46	24.97	1.07	-	-	4.02	2.13	0.3	1.56	0.32	-	-	-	-	0.88	-	2.07	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.41	1650																																																																																			-	0	0	24.97	1.07	-	-	4.02	2.13	0.3	1.56	0.32	-	-	-	-	0.88	-	2.07	-	0.1	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.41
H4590_032_0	2007	4																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	3599.8	132.69	10719.14	3249.66	994.45	17.28	2.46	587.36	235.44	1600.59	17.7	26.15	10.74	755.97	1851.75	3834.13	654.65	186.85	52.1	42426.86	69.92	0	0	1538.5	54.04	122.13	78.62	14.11	0	0	122.99											100 [Day(s) 1-5]	912 per admit	No copay [Day(s) 1-20]; 50 [Day(s) 21-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	0 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 5 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	25	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 0; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0 24 one-way trips per year	0 Office Visit2 teeth cleanings/year and preventative care	Exam 0/1 yr	Materials copay 0/1 yr	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											65.26	109.69	20	0	100	0.2	0.2	48.99	50	0	0.13	0	0	36.37	0	25	30	25	0.09	0	0.2	0	0	1.77	0	0	0	0	0	0	0											19.58	1.21	17.87	-	8.29	3.39	0.49	2.4	0.98	-	2.35	-	-	2.29	-	7.99	1.64	0.39	4.63	0	13.98	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.71	0	0	19.58	1.21	17.87	-	8.29	3.39	0.49	2.4	0.98	-	2.35	-	-	2.29	-	7.99	1.64	0.39	4.63	0	13.98	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.71	None																																																																																			-	0	0	19.58	1.21	17.87	-	8.29	3.39	0.49	2.4	0.98	-	2.35	-	-	2.29	-	7.99	1.64	0.39	4.63	0	13.98	-	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.71
H4590_033_0	2007	6																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1801.52	48.8	1128.31	2433.97	194.21	26.6	1.86	516.03	463.74	725.59	43.22	35.86	5.97	743.41	9169.52	5748.15	160.24	478.61	45.18	27137.97	53.53	0	0	1538.5	111.57	252.17	199.41	35.78	0	0	640.54											0 per admit	812 Copay Per Stay	No copay Day(s) 1-20; 120 [Day(s) 21-100]	Covered in Full	50 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 0 PCP/In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0.2	Cardiac Rehabilitation: 0; Pulmonary Rehabilitation: 0; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	10	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 20; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	0/24 one-way trips/year	5 Office Visit2 teeth cleanings/year and preventative care	Exam 5/12 months	materials copay 5/12 months	5 Exam/12 months	400 3/yrs	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	97.67	47	0	50	0.2	0.2	23.74	0	0	0.15	0	0.2	0	0	0	10	0	0.09	0	0.2	0	0	1.77	5	5	5	0	0	0	0											-	0.4	4.42	-	0.81	5.22	0.37	1.02	-	-	6.65	-	1.19	-	-	-	0.13	-	3.9	-	10.71	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.29	0	0	-	0.4	4.42	-	0.81	5.22	0.37	1.02	-	-	6.65	-	1.19	-	-	-	0.13	-	3.9	-	10.71	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.29	None																																																																																			-	0	0	-	0.4	4.42	-	0.81	5.22	0.37	1.02	-	-	6.65	-	1.19	-	-	-	0.13	-	3.9	-	10.71	-	-	0.23	0.05	0.11	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.29
H4590_034_0	2007	4																					2800											D	D	D	V	T	Coin	Coin	V	P	P	P	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2800	5164.09	190.35	11298.29	3312.85	1114.17	10.69	1.52	582.01	283.23	1691.44	623	31.46	7.67	909.4	1956.91	3737.67	654.65	197.48	27.69	49800.66	35.32	0	0	1538.5	57.65	130.31	83.89	15.05	0	0	126.62											200	20000	0	0	75	0	Prosthetic Devices: 0.2; Diabetes Monitoring Supplies: 0.2	ER Copay (per visit): 50; Urgent Care: 35	Ambulatory Surgical Center Copay: 35; Outpatient Hospital Copay: 35	0	Radiation Therapy: 0; Compex Radiology (MRIMRACTPETSpec): 0	0	0	Cardiac Rehabilitation: 35; Pulmonary Rehabilitation: 35; Ambulatory Surgical Center Copay: 35; Outpatient Hospital Copay: 35	0	15	35/25	Occupational Therapy: 0; PT and Speech/Language Therapy: 0	Routine Outpatient X-Ray: 0; Radiation Therapy: 0; Compex Radiology (MRIMRACTPETSpec): 0	0	Inhalation Solutions: 0; Oral Chemo: 0; Anti-Emetics: 0; Outpatient Injectables  -Self Administered: 0	0	24 OW	N	0	0	Not Covered	Not Covered	Not Covered	0	Acupuncture: N; Routine Chiropractic: N											113.57	126.16	0	0	47.36	0.2	0.2	31.1	22.1	0	0	0	0	19.11	0	9.47	22.1	9.47	0	0	0	0	0	0	0	0	0	0	0	0	0											48.87	2	-	-	4.4	2.14	0.3	1.51	0.52	-	-	-	-	1.45	-	2.95	1.21	0.16	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.51	0	38.23	48.87	2	-	-	4.4	2.14	0.3	1.51	0.52	-	-	-	-	1.45	-	2.95	1.21	0.16	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.51	2800																																																																																			-	0	0	48.87	2	-	-	4.4	2.14	0.3	1.51	0.52	-	-	-	-	1.45	-	2.95	1.21	0.16	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.51
H4590_801_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1715.69	46.48	887.71	1861.89	157.59	10.72	0.75	390.16	399.42	575.42	15.93	30.88	2.64	640.29	7249.9	4325.53	164.37	378.44	16.6	21940.14	45.5	0	0	0	116.12	262.45	207.53	37.24	0	0	663.85											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											190.86	190.82	87.23	0	95.41	0.3	0.3	7.84	235.95	0	0.23	0	0.3	54.28	55.27	65.42	21.81	65.42	0.3	3.08	0.3	0	0	0	0	0	0	0	0	0	0											27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	0	115.3	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	5000																																																																																			-	0	0	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22
H4590_802_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1715.69	46.48	887.71	1861.89	157.59	10.72	0.75	390.16	399.42	575.42	15.93	30.88	2.64	640.29	7249.9	4325.53	164.37	378.44	16.6	21940.14	45.5	0	0	0	116.12	262.45	207.53	37.24	0	0	663.85											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											190.86	190.82	87.23	0	95.41	0.3	0.3	7.84	235.95	0	0.23	0	0.3	54.28	55.27	65.42	21.81	65.42	0.3	3.08	0.3	0	0	0	0	0	0	0	0	0	0											27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	0	115.3	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	5000																																																																																			-	0	0	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22
H4590_803_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1715.69	46.48	887.71	1861.89	157.59	10.72	0.75	390.16	399.42	575.42	15.93	30.88	2.64	640.29	7249.9	4325.53	164.37	378.44	16.6	21940.14	45.5	0	0	0	116.12	262.45	207.53	37.24	0	0	663.85											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											190.86	190.82	87.23	0	95.41	0.3	0.3	7.84	235.95	0	0.23	0	0.3	54.28	55.27	65.42	21.81	65.42	0.3	3.08	0.3	0	0	0	0	0	0	0	0	0	0											27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	0	115.3	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	5000																																																																																			-	0	0	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22
H4590_804_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1715.69	46.48	887.71	1861.89	157.59	10.72	0.75	390.16	399.42	575.42	15.93	30.88	2.64	640.29	7249.9	4325.53	164.37	378.44	16.6	21940.14	45.5	0	0	0	116.12	262.45	207.53	37.24	0	0	663.85											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											190.86	190.82	87.23	0	95.41	0.3	0.3	7.84	235.95	0	0.23	0	0.3	54.28	55.27	65.42	21.81	65.42	0.3	3.08	0.3	0	0	0	0	0	0	0	0	0	0											27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	0	115.3	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22	5000																																																																																			-	0	0	27.29	0.74	6.45	-	1.25	3.21	0.22	0.26	7.85	-	3.68	-	0.79	2.9	33.39	23.58	0.3	2.06	4.95	5.64	13.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	138.22
H4604_003_0	2007	7																					2900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3000	1155.18	105.87	522.52	0	156.93	13.14	4.73	458.86	24.12	0	27.99	0	1.14	15.16	3392.3	3092.65	487.23	2.25	0	0	15.37	728.91	0	0	82.96	0	188.6	0	0	0	0											275 (1a)	275 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	0 (8a 8b)	0/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											172.82	172.82	94.27	0	109.98	0.19	0.21	31.42	0.16	0	0.11	0	0.19	0.16	5	25	37.5	0.16	0	0	0.19	25	0	0	25	0	25	0	0	0	0											16.64	1.52	4.1	-	1.44	2.48	1	1.2	3.79	-	3.16	-	0.22	2.38	1.41	6.44	1.52	0.35	-	-	2.9	1.52	-	-	0.17	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.65		24.17	16.64	1.52	4.1	-	1.44	2.48	1	1.2	3.79	-	3.16	-	0.22	2.38	1.41	6.44	1.52	0.35	-	-	2.9	1.52	-	-	0.17	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.65		300 (1a)	300 (1b)	175 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	30 (8a 8b)	30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											4.57	0.42	1.21	0.29	0.26	0.44	0.18	0.3	1.15	0.2	0.03	0	0.05	0.72	1.24	1.59	0.3	0.08	0	0	0.52	0.38	0	0	0.04	0	0.1	0	0	0	0											14.06		5.83	21.21	1.94	5.31	0.29	1.69	2.92	1.18	1.5	4.94	0.2	3.19	-	0.27	3.1	2.65	8.03	1.83	0.43	-	-	3.41	1.89	-	-	0.22	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.71
H4604_005_0	2007	5																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	2400	1155.18	105.87	522.52	0	156.93	13.14	4.73	458.86	24.12	0	27.99	0	1.14	15.16	3392.3	3092.65	487.23	2.25	0	0	15.37	728.91	0	0	82.96	0	188.6	0	0	0	0											265 (1a)	265 (1b)	100 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	15 (9b)	0 (8a 8b)	0/15 (8a 8b)	15 (incl in h5)	30 (12)	15 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	15 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											164.32	164.32	62.01	0	108.51	0.19	0.21	31	0.09	0	0.07	0	0.19	0.09	5	20	37.5	0.09	0	0	0.19	20	0	0	20	0	20	0	0	0	0											15.82	1.45	2.7	-	1.42	2.44	0.99	1.19	2.24	-	1.87	-	0.21	1.41	1.41	5.15	1.52	0.21	-	-	2.86	1.21	-	-	0.14	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57		21.15	15.82	1.45	2.7	-	1.42	2.44	0.99	1.19	2.24	-	1.87	-	0.21	1.41	1.41	5.15	1.52	0.21	-	-	2.86	1.21	-	-	0.14	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.57		350 (1a)	350 (1b)	150 (2a)	20 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	20 (8a 8b)	20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 75 (5); 45/35 (9c)	15 (7a 14c); 20 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	20 (7c 7i)	20 (incl in h2)	20 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 20 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											4.86	0.45	0.94	0.11	0.23	0.4	0.14	0.28	0.7	0.12	0.02	0	0.05	0.44	0.52	0.79	0.18	0.05	0	0	0.47	0.19	0	0	0.02	0	0.05	0	0	0	0											10.99		8.07	20.68	1.89	3.64	0.11	1.65	2.85	1.14	1.46	2.94	0.12	1.89	-	0.26	1.85	1.94	5.94	1.7	0.26	-	-	3.33	1.4	-	-	0.16	-	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.56
H4604_006_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2152.34	340.57	1096.44		255.54	25.3	21.92	875.72	379.71	1992.14	934.63	64.69	3.09	1966.59		3394.14		515.23		790.03												280.34		150.91	224.5							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							36	36	17		36	10	10	17	12	5	5	12	10	12		5		5		5												5		5	5							6.52	1.03	1.59	-	0.77	2.45	2.12	1.27	0.38	0.8	0.38	0.07	0.3	1.98	-	1.37	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.84		23.25	6.52	1.03	1.59	-	0.77	2.45	2.12	1.27	0.38	0.8	0.38	0.07	0.3	1.98	-	1.37	-	0.21	-	0.32	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	21.84		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.07	0.14	0.28	0.35	0.06	0.15	0.13	0.05	0.18	0.13	0.12	0.02	0.02	0.2	0.33	0.2	0.04	0.03	0.14	0.64	0.13	0																				5.41		0	8.58	1.18	1.87	0.35	0.84	2.61	2.26	1.32	0.56	0.93	0.5	0.08	0.32	2.18	0.33	1.57	0.04	0.24	0.14	0.96	0.13	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	27.25
H4604_007_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		2371.09	220.78	8303.02	155.61	584.03	1313.64	6384.39	167.96	111.52	3469.46	154.24	30.5	3.99	259.33	116.2	1163.77	1511.79	17.86		243	246.21	1188.28	1140		133.19	157.7		51.87				99.04	0.25	0.06	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						60	60			60			40	20			20		20																		8										11.92	1.11	-	-	2.94	-	-	0.56	0.19	-	-	0.05	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	17.26		4.21	11.92	1.11	-	-	2.94	-	-	0.56	0.19	-	-	0.05	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	17.26		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						3.01	0.08	0.77	0.08	0.34	0.3	0.09	0.04	0.19	0.56	0.63	0.04	0.01	0.1	0.01	1.62	0.15	0		0.16		0.11	0.06		0.02							0	0	0	0.02	0.02						8.4		0	14.92	1.19	0.77	0.08	3.28	0.3	0.09	0.6	0.37	0.56	0.63	0.09	0.01	0.54	0.01	1.62	0.15	0	-	0.16	-	0.11	0.06	-	0.02	-	-	-	-	-	-	0.07	0	0	0.02	0.02	-	-	-	-	-	25.66
H4604_801_0	2007	3																					4000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1516.18	138.96	685.8	0	193.86	16.23	5.84	602.25	31.66	8053.64	36.74	0	1.5	19.9	4190.49	3820.33	601.88	2.78	0	0	18.99	900.42	0	0	102.48	0	232.98	0	0	0	0											300 (1a)	300 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	35 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											199.19	199.19	99.59	0	116.19	0.2	0.22	33.2	0.2	3.98	0.15	0	0.2	0.2	35	35	37.5	0.2	0	0	0.2	35	0	0	35	0	35	0	0	0	0											25.17	2.31	5.69	-	1.88	3.23	1.29	1.67	6.31	2.67	5.61	-	0.3	3.96	12.22	11.14	1.88	0.55	-	-	3.78	2.63	-	-	0.3	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.26		32.41	25.17	2.31	5.69	-	1.88	3.23	1.29	1.67	6.31	2.67	5.61	-	0.3	3.96	12.22	11.14	1.88	0.55	-	-	3.78	2.63	-	-	0.3	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.26																																																																																				-			25.17	2.31	5.69	-	1.88	3.23	1.29	1.67	6.31	2.67	5.61	-	0.3	3.96	12.22	11.14	1.88	0.55	-	-	3.78	2.63	-	-	0.3	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.26
H4605_001_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	668.33	9.68	1091.43	2594.7	1113.38	3.47	216.92	323.89	330.43	2160.85	1094.88	0	0	2329.86	6314.22	695.16	214.73	661.48	3518.44	468.12	849.53	196.99	0	1316.31	532.09	299.38	84.98	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.59	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.57	0.08	-	-	4.64	2.05	-	1.35	-	-	-	-	-	-	2.63	0.29	0.09	0.28	-	0.2	-	-	-	-	0.22	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.42	0	0	5.57	0.08	-	-	4.64	2.05	-	1.35	-	-	-	-	-	-	2.63	0.29	0.09	0.28	-	0.2	-	-	-	-	0.22	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.42	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.42	0.04	0.49	0.32	0.09	0.27	0.01	0.15	0.34	0.24	0.48			0.62	0.73	0.28	0.02	0.02	0.31	1.62	0.07			0.04	0.07	0.05	0.02															9.7	250	6.05	8.99	0.12	0.49	0.32	4.73	2.32	0.01	1.5	0.34	0.24	0.48	-	-	0.62	3.36	0.57	0.11	0.3	0.31	1.82	0.07	-	-	0.04	0.29	0.05	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.12
H4605_002_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	668.33	9.68	1091.43	2594.7	1113.38	3.47	216.92	323.89	330.43	2160.85	1094.88	0	0	2329.86	6314.22	695.16	214.73	661.48	3518.44	468.12	849.53	196.99	0	1316.31	532.09	299.38	84.98	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.59	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.57	0.08	-	-	4.64	2.05	-	1.35	-	-	-	-	-	-	2.63	0.29	0.09	0.28	-	0.2	-	-	-	-	0.22	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.42	0	0	5.57	0.08	-	-	4.64	2.05	-	1.35	-	-	-	-	-	-	2.63	0.29	0.09	0.28	-	0.2	-	-	-	-	0.22	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.42	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.42	0.04	0.49	0.32	0.09	0.27	0.01	0.15	0.34	0.24	0.48			0.62	0.73	0.28	0.02	0.02	0.31	1.62	0.07			0.04	0.07	0.05	0.02															9.7	250	6.05	8.99	0.12	0.49	0.32	4.73	2.32	0.01	1.5	0.34	0.24	0.48	-	-	0.62	3.36	0.57	0.11	0.3	0.31	1.82	0.07	-	-	0.04	0.29	0.05	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.12
H4605_004_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	668.33	9.68	1091.43	2594.7	1113.38	3.47	216.92	323.89	330.43	2160.85	1094.88	0	0	2329.86	6314.22	695.16	214.73	661.48	3518.44	468.12	849.53	196.99	0	1316.31	532.09	299.38	84.98	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.59	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.57	0.08	-	-	4.64	2.05	-	1.35	-	-	-	-	-	-	2.63	0.29	0.09	0.28	-	0.2	-	-	-	-	0.22	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.42	0	0	5.57	0.08	-	-	4.64	2.05	-	1.35	-	-	-	-	-	-	2.63	0.29	0.09	0.28	-	0.2	-	-	-	-	0.22	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.42	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.42	0.04	0.49	0.32	0.09	0.27	0.01	0.15	0.34	0.24	0.48			0.62	0.73	0.28	0.02	0.02	0.31	1.62	0.07			0.04	0.07	0.05	0.02															9.7	250	6.05	8.99	0.12	0.49	0.32	4.73	2.32	0.01	1.5	0.34	0.24	0.48	-	-	0.62	3.36	0.57	0.11	0.3	0.31	1.82	0.07	-	-	0.04	0.29	0.05	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.12
H4606_001_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1199.07	8.75	430.16	2052.39	119.68	0.65	0.05	194.19	423.31	780.65	532.26	35.48	363.88	301.62	6860.63	8137.94			300.09		8.99											63.11	0.46	14.62								135/day (1-7)	135/day (1-7)	0/day (1-6) 100/day (7-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125/ Visit	0-50/ Visit	50-125/ Visit	125/ Visit	0/ Procedure	15-125/ Visit	10/ Visit	35/ Visit			125/ Visit		20 Coins											135/day (1-7)	135/day (1-7)	20 Coins								105.25	105.25	29.09	10	100	0.2	0.2	49.63	125	38.64	65	125	0	46.18	10	35			125		0.2											105.25	105.25	0.2								10.52	0.08	1.04	1.71	1	0.13	0.01	0.8	4.41	2.51	2.88	0.37	-	1.16	5.72	23.74	-	-	3.13	-	1.8	-	-	-	-	-	-	-	-	-	-	0.55	0	2.92	-	-	-	-	-	-	-	64.48	0	0	10.52	0.08	1.04	1.71	1	0.13	0.01	0.8	4.41	2.51	2.88	0.37	-	1.16	5.72	23.74	-	-	3.13	-	1.8	-	-	-	-	-	-	-	-	-	-	0.55	0	2.92	-	-	-	-	-	-	-	64.48		950/admit	950/admit	20 Coins	40 Coins	100/Trip	40 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		40 Coins	40 Coins					20 Coins													40 Coins								2.24	0.02	0.17	0.46	0.25	0.03		0.25	4.21	4.97			0		3.16	3.79					0.51													1.08								21.15	0	0	12.76	0.09	1.21	2.17	1.25	0.16	0.01	1.05	8.62	7.49	2.88	0.37	-	1.16	8.87	27.53	-	-	3.13	-	2.31	-	-	-	-	-	-	-	-	-	-	0.55	0	4.01	-	-	-	-	-	-	-	85.63
H4606_003_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1250.67	9.13	448.68	2140.72	124.83	0.7	0.05	202.55	441.53	814.25	555.17	37.01	379.54	314.6	7155.87	8488.16			313.01		9.78											65.82	0.48	15.91								175/day (1-7)	175/day (1-7)	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	125/ Visit	0-50/ Visit	50-150/ Visit	125/ Visit	0/ Procedure	15-150/ Visit	10/ Visit	35/ Visit			150/ Visit		20 Coins											175/day (1-7)	175/day (1-7)	20 Coins								136.43	136.43	11.79	10	100	0.2	0.2	49.63	125	38.64	70	125	0	46.18	10	35			150		0.2											136.43	136.43	0.2								14.22	0.1	0.44	1.78	1.04	0.14	0.01	0.84	4.6	2.62	3.24	0.39	-	1.21	5.96	24.76	-	-	3.91	-	1.96	-	-	-	-	-	-	-	-	-	-	0.75	0.01	3.18	-	-	-	-	-	-	-	71.16	0	0	14.22	0.1	0.44	1.78	1.04	0.14	0.01	0.84	4.6	2.62	3.24	0.39	-	1.21	5.96	24.76	-	-	3.91	-	1.96	-	-	-	-	-	-	-	-	-	-	0.75	0.01	3.18	-	-	-	-	-	-	-	71.16		950/admit	950/admit	20 Coins	40 Coins	100/Trip	40 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		40 Coins	40 Coins					40 Coins													40 Coins								2.34	0.02	0.18	0.5	0.26	0.04		0.26	4.58	5.41			0		3.43	4.13					1.11													1.18								23.44	0	0	16.56	0.12	0.63	2.29	1.3	0.18	0.01	1.1	9.18	8.03	3.24	0.39	-	1.21	9.4	28.88	-	-	3.91	-	3.06	-	-	-	-	-	-	-	-	-	-	0.75	0.01	4.36	-	-	-	-	-	-	-	94.59
H4606_004_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1199.08	8.75	430.17	2052.41	119.68	0.65	0.05	194.2	423.32	780.66	532.27	35.48	363.88	301.62	6860.7	8138.03			300.09		8.99			4.37								63.11	0.46	14.62								75/day (1-5)	75/day (1-5)	0/day (1-13) 75/day (14-100)	10/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	75/ Visit	0-50/ Visit	30-75/ Visit	75/ Visit	0/ Procedure	15-75/ Visit	5/ Visit	15/ Visit			75/ Visit		20 Coins			25 to 75								75/day (1-5)	75/day (1-5)	20 Coins								51.02	51.02	11.79	10	100	0.2	0.2	49.63	75	38.64	39	75	0	28.53	5	15			75		0.2			0.35								51.02	51.02	0.2								5.1	0.04	0.42	1.71	1	0.13	0.01	0.8	2.65	2.51	1.73	0.22	-	0.72	2.86	10.17	-	-	1.88	-	1.8	-	-	1.54	-	-	-	-	-	-	-	0.27	0	2.92	-	-	-	-	-	-	-	38.48	0	0	5.1	0.04	0.42	1.71	1	0.13	0.01	0.8	2.65	2.51	1.73	0.22	-	0.72	2.86	10.17	-	-	1.88	-	1.8	-	-	1.54	-	-	-	-	-	-	-	0.27	0	2.92	-	-	-	-	-	-	-	38.48		950/admit	950/admit	20 Coins	20 Coins	100/Trip	40 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		25 Coins	25 Coins					20 Coins			50 to 80										25 Coins								2.24	0.02	0.17	0.23	0.25	0.03		0.25	2.11	2.49			0		1.97	2.37					0.51			1.6										0.68								14.91	0	0	7.34	0.05	0.59	1.94	1.25	0.16	0.01	1.05	4.75	5	1.73	0.22	-	0.72	4.83	12.54	-	-	1.88	-	2.31	-	-	3.14	-	-	-	-	-	-	-	0.27	0	3.6	-	-	-	-	-	-	-	53.39
H4606_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		250.39	1.89	445.02	2123.28	123.81	0.69	0.05	245	437.93	807.62	550.65	36.71	376.45	312.03	7097.6	8419.03			310.46		9.62											13.18	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.79	24.56	-	-	0.91	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.73	0	0	12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.79	24.56	-	-	0.91	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.73		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.23	0.02	0.36	0.5	0.26	0.04		0.26	4.51	5.33			0		1.69	4.06					0.55																					19.79	0	0	14.75	0.11	0.69	2.26	1.29	0.22	0.01	1.18	11.81	7.68	2.1	0.31	-	0.98	16.48	28.62	-	-	0.91	-	2.47	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	92.52
H4606_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		246.59	1.86	438.26	2091.01	121.93	0.67	0.05	241.28	431.28	795.34	542.28	36.15	370.73	307.29	6989.73	8291.08			305.74		9.33											12.98	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.33	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.19	2.32	2.07	0.3	-	0.96	14.56	24.18	-	-	0.89	-	1.87	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.59	0	0	12.33	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.19	2.32	2.07	0.3	-	0.96	14.56	24.18	-	-	0.89	-	1.87	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.59		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.19	0.02	0.35	0.48	0.25	0.04		0.25	4.38	5.16			0		1.64	3.94					0.53																					19.24	0	0	14.52	0.11	0.67	2.22	1.27	0.21	0.01	1.16	11.56	7.48	2.07	0.3	-	0.96	16.2	28.12	-	-	0.89	-	2.4	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	90.83
H4606_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		250.39	1.89	445.02	2123.28	123.81	0.69	0.05	245	437.93	807.62	550.65	36.71	376.45	312.03	7097.6	8419.03			310.46		9.62											13.18	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.79	24.56	-	-	0.91	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.73	0	0	12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.79	24.56	-	-	0.91	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.73		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.23	0.02	0.36	0.5	0.26	0.04		0.26	4.51	5.33			0		1.69	4.06					0.55																					19.79	0	0	14.75	0.11	0.69	2.26	1.29	0.22	0.01	1.18	11.81	7.68	2.1	0.31	-	0.98	16.48	28.62	-	-	0.91	-	2.47	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	92.52
H4606_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		246.59	1.86	438.26	2091.01	121.93	0.67	0.05	241.28	431.28	795.34	542.28	36.15	370.73	307.29	6989.73	8291.08			305.74		9.33											12.98	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.33	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.19	2.32	2.07	0.3	-	0.96	14.56	24.18	-	-	0.89	-	1.87	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.59	0	0	12.33	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.19	2.32	2.07	0.3	-	0.96	14.56	24.18	-	-	0.89	-	1.87	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.59		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.19	0.02	0.35	0.48	0.25	0.04		0.25	4.38	5.16			0		1.64	3.94					0.53																					19.24	0	0	14.52	0.11	0.67	2.22	1.27	0.21	0.01	1.16	11.56	7.48	2.07	0.3	-	0.96	16.2	28.12	-	-	0.89	-	2.4	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	90.83
H4720_001_0	2007	5																					3900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1563.01	100.95	499.14	0	100.2	13.54	7.78	609.8	31.93	10208.22	39.4	0	0.01	30.08	4184.45	4888.95	401.43	2.7	0	0	22.7	1142.81	0	0	118.92	0	212.42	0	0	0	0											375 (1a)	375 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	13 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											235.61	235.61	100.53	0	109.95	0.19	0.21	31.41	0.19	3.27	0.15	0	0.19	0.19	15	30	37.5	0.19	0	0	0.19	30	0	0	30	0	30	0	0	0	0											30.69	1.98	4.18	-	0.92	2.55	1.63	1.6	6.02	2.78	5.92	-	0	5.67	5.23	12.22	1.25	0.51	-	-	4.28	2.86	-	-	0.3	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.12		40.39	30.69	1.98	4.18	-	0.92	2.55	1.63	1.6	6.02	2.78	5.92	-	0	5.67	5.23	12.22	1.25	0.51	-	-	4.28	2.86	-	-	0.3	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.12																																																																																				-			30.69	1.98	4.18	-	0.92	2.55	1.63	1.6	6.02	2.78	5.92	-	0	5.67	5.23	12.22	1.25	0.51	-	-	4.28	2.86	-	-	0.3	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.12
H4720_801_0	2007	5																					4500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1656.39	106.98	528.96	0	106.18	14.48	8.32	646.23	34.15	10818.1	42.14	0	0.01	32.17	4434.44	5181.03	425.42	2.89	0	0	24.28	1211.08	0	0	126.02	0	225.11	0	0	0	0											350 (1a)	350 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											234.21	234.21	107.07	0	117.11	0.17	0.18	33.46	0.17	4.02	0.13	0	0.2	0.17	25	35	37.5	0.17	0	0	0.2	35	0	0	35	0	35	0	0	0	0											32.33	2.09	4.72	-	1.04	2.42	1.53	1.8	5.71	3.62	5.62	-	0	5.38	9.24	15.11	1.33	0.48	-	-	4.88	3.53	-	-	0.37	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.85		35.2	32.33	2.09	4.72	-	1.04	2.42	1.53	1.8	5.71	3.62	5.62	-	0	5.38	9.24	15.11	1.33	0.48	-	-	4.88	3.53	-	-	0.37	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.85																																																																																				-			32.33	2.09	4.72	-	1.04	2.42	1.53	1.8	5.71	3.62	5.62	-	0	5.38	9.24	15.11	1.33	0.48	-	-	4.88	3.53	-	-	0.37	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.85
H4720_803_0	2007	6																					4500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1656.39	106.98	528.96	0	106.18	14.48	8.32	646.23	34.15	10818.1	42.14	0	0.01	32.17	4434.44	5181.03	425.42	2.89	0	0	24.28	1211.08	0	0	126.02	0	225.11	0	0	0	0											350 (1a)	350 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											234.21	234.21	107.07	0	117.11	0.17	0.18	33.46	0.17	4.02	0.13	0	0.2	0.17	25	35	37.5	0.17	0	0	0.2	35	0	0	35	0	35	0	0	0	0											32.33	2.09	4.72	-	1.04	2.42	1.53	1.8	5.71	3.62	5.62	-	0	5.38	9.24	15.11	1.33	0.48	-	-	4.88	3.53	-	-	0.37	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.85		35.2	32.33	2.09	4.72	-	1.04	2.42	1.53	1.8	5.71	3.62	5.62	-	0	5.38	9.24	15.11	1.33	0.48	-	-	4.88	3.53	-	-	0.37	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.85																																																																																				-			32.33	2.09	4.72	-	1.04	2.42	1.53	1.8	5.71	3.62	5.62	-	0	5.38	9.24	15.11	1.33	0.48	-	-	4.88	3.53	-	-	0.37	-	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.85
H4779_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							13.78	15.22	401.6	467.44		316.31	59.37		1057.66		6428.05	151.58			1041.47					137.43		289.34						14.1	429.79		111.18	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.42	2.68	1.21	1.71	-	0.46	0.22	-	3.88	-	9.42	0.22	-	-	1.53	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.63	-	0.16	0.23	-	-	-	-	25.5		3.37	-	-	-	-	-	2.42	2.68	1.21	1.71	-	0.46	0.22	-	3.88	-	9.42	0.22	-	-	1.53	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.63	-	0.16	0.23	-	-	-	-	25.5		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.23	0.03	0.28	0.28	0.05	0.08	0.09	0.03	0.3	0.17	0.18	0.02	0	0.16		0.32	0.01	0.03	0.2	0.72	0.17	0			0.01		0.01															5.4		0	2.23	0.03	0.28	0.28	0.05	2.51	2.77	1.23	2.01	0.17	0.65	0.24	0	4.04	-	9.74	0.24	0.03	0.2	2.25	0.17	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.63	-	0.16	0.23	-	-	-	-	30.9
H4779_002_0	2007	2	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							13.78	15.22	401.61	467.45		316.32	59.38		1057.68		6428.2	151.59			1041.49					137.43		289.34						14.1	429.8		111.18	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.42	2.68	1.21	1.71	-	0.46	0.22	-	3.88	-	9.42	0.22	-	-	1.53	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.63	-	0.16	0.23	-	-	-	-	25.5		3.37	-	-	-	-	-	2.42	2.68	1.21	1.71	-	0.46	0.22	-	3.88	-	9.42	0.22	-	-	1.53	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.63	-	0.16	0.23	-	-	-	-	25.5		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.23	0.03	0.28	0.28	0.05	0.08	0.09	0.03	0.3	0.17	0.18	0.02	0	0.16		0.32	0.01	0.03	0.2	0.72	0.17	0			0.01		0.01															5.4		0	2.23	0.03	0.28	0.28	0.05	2.51	2.77	1.23	2.01	0.17	0.65	0.24	0	4.04	-	9.74	0.24	0.03	0.2	2.25	0.17	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.63	-	0.16	0.23	-	-	-	-	30.9
H4779_003_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								33.96	766.46	595.82		452.42	95.43		1798.85		7204.17	462.09			1536.96							289.34						70.77	371.74		299.7	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit											16	34	41		16	41		41		16	16			17							20						16	16		16	20					-	-	-	-	-	-	5.59	2.16	2.05	-	0.62	0.33	-	6.17	-	9.89	0.63	-	-	2.17	-	-	-	-	-	-	0.48	-	-	-	-	-	0.1	0.51	-	0.41	0.23	-	-	-	-	31.34		6.48	-	-	-	-	-	-	5.59	2.16	2.05	-	0.62	0.33	-	6.17	-	9.89	0.63	-	-	2.17	-	-	-	-	-	-	0.48	-	-	-	-	-	0.1	0.51	-	0.41	0.23	-	-	-	-	31.34		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						3.3	0.13	0.33	0.41	0.07	0.18	0.21	0.05	0.36	0.21	0.22	0.03	0.01	0.25		0.38	0.04	0.03	0.24	0.91	0.21	0			0.01		0.01															7.58		0	3.3	0.13	0.33	0.41	0.07	0.18	5.8	2.2	2.41	0.21	0.85	0.36	0.01	6.42	-	10.27	0.67	0.03	0.24	3.08	0.21	0	-	-	0.01	-	0.49	-	-	-	-	-	0.1	0.51	-	0.41	0.23	-	-	-	-	38.93
H4908_001_0	2007	1	s.	t.									DME/Prosthetics/Supplies	Outpatient Radiology										Diabetic Visit/Supplies	MRI CT & PET Scan									A	A	A	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin				V							V	P																																																		-		313.61	19.96	97.76	1828.35	387.74	15.92	5.35	430.89	304.43	5977.82	1230.45	57.65	0	5308.2	4570.14	4159.83	534.54	997.82	3012.34		3				177.93							656.07	217.14									0	0	0	0	50 per trip	0	0	50 per visit	0	0	0	0	0	0	10 per office visit	10 per office visit	10 per visit	10 per visit	10 per visit		10				10							10 per visit	50 per service									0	0	0	0	49.75	0	0	49.75	0	0	0	0	0	0	8.34	6.11	9.95	9.95	9.95		0.1				9.95							9.95	49.75									-	-	-	-	1.61	-	-	1.79	-	-	-	-	-	-	3.18	2.12	0.44	0.83	2.5	-	0.3	-	-	-	0.15	-	-	-	-	-	-	0.54	0.9	-	-	-	-	-	-	-	-	14.35		0.07	-	-	-	-	1.61	-	-	1.79	-	-	-	-	-	-	3.18	2.12	0.44	0.83	2.5	-	0.3	-	-	-	0.15	-	-	-	-	-	-	0.54	0.9	-	-	-	-	-	-	-	-	14.35	3000	500 per admit	500 per admit	150 per admit	15 per visit	50 per trip	20	20	50 per visit	250 per visit	OP Facility - Other	OP Facility - Other	OP Facility - Other	OP Facility - Other	OP Facility - Other	15 per office visit	15 per office visit	15 per office visit	15 per office visit	15 per office visit		20											15 per visit	100 per service									1.44	0.09	0.14	0.23	0.18	0.35	0.12	0.2	0.7	0.83	0.17	0.01	0	0.73	0.53	0.35	0.07	0.14	0.42		0.07											0.09	0.2									7.05		0.04	1.44	0.09	0.14	0.23	1.79	0.35	0.12	1.98	0.7	0.83	0.17	0.01	0	0.73	3.7	2.47	0.52	0.97	2.91	-	0.37	-	-	-	0.15	-	-	-	-	-	-	0.63	1.1	-	-	-	-	-	-	-	-	21.4
H4908_002_0	2007	3	s.	t.									DME/Prosthetics/Supplies	Outpatient Radiology										Diabetic Visit/Supplies	MRI CT & PET Scan									A	A	A	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin				V							V	P																																																		-		313.61	19.96	97.76	1828.35	387.74	15.92	5.35	430.89	304.43	5977.82	1230.45	57.65	0	5308.2	4570.14	4159.83	534.54	997.82	3012.34		3				177.93							656.07	217.14									0	0	0	0	50 per trip	0	0	50 per visit	0	0	0	0	0	0	10 per office visit	10 per office visit	10 per visit	10 per visit	10 per visit		10				10							10 per visit	50 per service									0	0	0	0	49.75	0	0	49.75	0	0	0	0	0	0	8.34	6.11	9.95	9.95	9.95		0.1				9.95							9.95	49.75									-	-	-	-	1.61	-	-	1.79	-	-	-	-	-	-	3.18	2.12	0.44	0.83	2.5	-	0.3	-	-	-	0.15	-	-	-	-	-	-	0.54	0.9	-	-	-	-	-	-	-	-	14.35		0.07	-	-	-	-	1.61	-	-	1.79	-	-	-	-	-	-	3.18	2.12	0.44	0.83	2.5	-	0.3	-	-	-	0.15	-	-	-	-	-	-	0.54	0.9	-	-	-	-	-	-	-	-	14.35	3000	500 per admit	500 per admit	150 per admit	15 per visit	50 per trip	20	20	50 per visit	250 per visit	OP Facility - Other	OP Facility - Other	OP Facility - Other	OP Facility - Other	OP Facility - Other	15 per office visit	15 per office visit	15 per office visit	15 per office visit	15 per office visit		20											15 per visit	100 per service									1.44	0.09	0.14	0.23	0.18	0.35	0.12	0.2	0.7	0.83	0.17	0.01	0	0.73	0.53	0.35	0.07	0.14	0.42		0.07											0.09	0.2									7.05		0.04	1.44	0.09	0.14	0.23	1.79	0.35	0.12	1.98	0.7	0.83	0.17	0.01	0	0.73	3.7	2.47	0.52	0.97	2.91	-	0.37	-	-	-	0.15	-	-	-	-	-	-	0.63	1.1	-	-	-	-	-	-	-	-	21.4
H4908_003_0	2007	2	s.	t.									DME/Prosthetics/Supplies	Outpatient Lab										Diabetic Visit/Supplies	MRI CT & PET Scan									A	A	A	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin											V	P																																																		-		305.36	19.44	95.18	1780.24	377.54	15.5	5.21	419.55	296.42	5820.51	1198.07	56.13	0	5168.51	4449.88	4050.36	520.47	971.56	2933.06		2.93											638.8	211.42									500 per admit	500 per admit	500 per admit	0	50 per trip	10	10	50 per visit	250 per visit	10 per visit	10 per visit	10 per visit	10 per visit	10 per visit	10 per office visit 50 Urg Care	10 per office visit 50 Urg Care	10 per  visit	20 per  visit	10 per  visit		10											10 per  visit	100 per service									497.5	497.5	497.5	0	49.75	0.1	0.1	49.75	248.75	9.95	9.95	9.95	9.95	9.95	10.01	5.8	9.95	19.9	9.95		0.1											9.95	99.5									12.66	0.81	3.95	-	1.57	1.54	0.52	1.74	6.14	4.83	0.99	0.05	0	4.29	3.71	1.96	0.43	1.61	2.43	-	0.29	-	-	-	-	-	-	-	-	-	-	0.53	1.75	-	-	-	-	-	-	-	-	51.79		0.26	12.66	0.81	3.95	-	1.57	1.54	0.52	1.74	6.14	4.83	0.99	0.05	0	4.29	3.71	1.96	0.43	1.61	2.43	-	0.29	-	-	-	-	-	-	-	-	-	-	0.53	1.75	-	-	-	-	-	-	-	-	51.79	3500	1000 per admit	1000 per admit	1000 per admit	20 per visit	20	20	20	20	250 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit	20 OV 20 Urg Care	30 OV 20 Urg Care	30 per office visit	20	30 per office visit		20											20 per visit	150 per service									2.8	0.18	0.87	0.3	0.1	0.34	0.12	0.11	0.68	0.8	0.16	0.01	0	0.71	0.78	0.65	0.14	0.08	0		0.06											0.12	0.29									9.3		0.05	15.46	0.98	4.82	0.3	1.67	1.88	0.63	1.85	6.82	5.63	1.16	0.05	0	5	4.49	2.61	0.57	1.69	2.43	-	0.36	-	-	-	-	-	-	-	-	-	-	0.65	2.04	-	-	-	-	-	-	-	-	61.09
H4908_004_0	2007	3	s.	t.									DME/Prosthetics/Supplies	Outpatient Radiology										Diabetic Visit/Supplies	MRI CT & PET Scan									A	A	A	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin											V	P																																																		-		305.36	19.44	95.18	1780.24	377.54	15.5	5.21	419.55	296.42	5820.51	1198.07	56.13	0	5168.51	4449.88	4050.36	520.47	971.56	2933.06		2.93											638.8	211.42									500 per admit	500 per admit	500 per admit	0	50 per trip	10	10	50 per visit	250 per visit	10 per visit	10 per visit	10 per visit	10 per visit	10 per visit	10 per office visit 50 Urg Care	10 per office visit 50 Urg Care	10 per  visit	20 per  visit	10 per  visit		10											10 per visit	100 per service									497.5	497.5	497.5	0	49.75	0.1	0.1	49.75	248.75	9.95	9.95	9.95	9.95	9.95	10.01	5.8	9.95	19.9	9.95		0.1											9.95	99.5									12.66	0.81	3.95	-	1.57	1.54	0.52	1.74	6.14	4.83	0.99	0.05	0	4.29	3.71	1.96	0.43	1.61	2.43	-	0.29	-	-	-	-	-	-	-	-	-	-	0.53	1.75	-	-	-	-	-	-	-	-	51.79		0.26	12.66	0.81	3.95	-	1.57	1.54	0.52	1.74	6.14	4.83	0.99	0.05	0	4.29	3.71	1.96	0.43	1.61	2.43	-	0.29	-	-	-	-	-	-	-	-	-	-	0.53	1.75	-	-	-	-	-	-	-	-	51.79	3500	1000 per admit	1000 per admit	1000 per admit	20 per visit	20	20	20	20	250 per visit	15 per visit	15 per visit	15 per visit	15 per visit	15 per visit	20 OV 20 Urg Care	30 OV 20 Urg Care	30 per office visit	20	30 per office visit		20											20 per visit	150 per service									2.8	0.18	0.87	0.3	0.1	0.34	0.12	0.11	0.68	0.8	0.16	0.01	0	0.71	0.78	0.65	0.14	0.08	0		0.06											0.12	0.29									9.3		0.05	15.46	0.98	4.82	0.3	1.67	1.88	0.63	1.85	6.82	5.63	1.16	0.05	0	5	4.49	2.61	0.57	1.69	2.43	-	0.36	-	-	-	-	-	-	-	-	-	-	0.65	2.04	-	-	-	-	-	-	-	-	61.09
H4908_801_0	2007	1	s.	t.																														Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin						Coin																																																														-		266.72		58.03		5.25	29.34		5.59	15.62	57.2					190.19						3.25																					FFS Medicare Actl. Equiv Cost		FFS Medicare Actl. Equiv Cost		FFS Medicare Actl. Equiv Cost	FFS Medicare Actl. Equiv Cost		FFS Medicare Actl. Equiv Cost	FFS Medicare Actl. Equiv Cost	FFS Medicare Actl. Equiv Cost					FFS Medicare Actl. Equiv Cost						FFS Medicare Actl. Equiv Cost																					0.08		0.19		0.24	0.24		0.24	0.24	0.24					0.24						0.24																					22.28	-	10.9	-	1.24	6.92	-	1.32	3.69	13.5	-	-	-	-	44.88	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.5		0	22.28	-	10.9	-	1.24	6.92	-	1.32	3.69	13.5	-	-	-	-	44.88	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.5																																																																																				-		0	22.28	-	10.9	-	1.24	6.92	-	1.32	3.69	13.5	-	-	-	-	44.88	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.5
H4908_802_0	2007	2	s.	t.																														Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin						Coin																																																														-		266.72		58.03		5.25	29.34		5.59	15.62	57.2					190.19						3.25																					FFS Medicare Actl. Equiv Cost		FFS Medicare Actl. Equiv Cost		FFS Medicare Actl. Equiv Cost	FFS Medicare Actl. Equiv Cost		FFS Medicare Actl. Equiv Cost	FFS Medicare Actl. Equiv Cost	FFS Medicare Actl. Equiv Cost					FFS Medicare Actl. Equiv Cost						FFS Medicare Actl. Equiv Cost																					0.08		0.19		0.24	0.24		0.24	0.24	0.24					0.24						0.24																					22.28	-	10.9	-	1.24	6.92	-	1.32	3.69	13.5	-	-	-	-	44.88	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.5		0	22.28	-	10.9	-	1.24	6.92	-	1.32	3.69	13.5	-	-	-	-	44.88	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.5																																																																																				-		0	22.28	-	10.9	-	1.24	6.92	-	1.32	3.69	13.5	-	-	-	-	44.88	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.5
H4909_001_0	2007	7																																A	A	D		T	Coin	Coin	V	V		V		V	V	V	V	V		V		S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1169.31	24.68	270.91	0	175.88	15.7	0.72	268.47	234.8	0	487.21	0	28.4	75.21	3860.79	3805.7	129.32	0	691.15	0	711.95	0	0	0	310.51	0	133.07	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												166.64	166.64	71.42	0	71.42	0.19	0.19	45.51	166.64	0	47.61	0	32.93	28.57	14.28	28.57	28.57	0	47.61	0	33.33	0	0	0	28.57	0	28.57	0	0	0	0											16.24	0.34	1.61	-	1.05	2.99	0.14	1.02	3.26	-	1.93	-	0.08	0.18	4.6	9.06	0.31	-	2.74	-	1.98	-	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57	0	2.44	16.24	0.34	1.61	-	1.05	2.99	0.14	1.02	3.26	-	1.93	-	0.08	0.18	4.6	9.06	0.31	-	2.74	-	1.98	-	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												5.62	0.12	1.03	0	0.27	1.28	0.06	0.27	1.2	0	0.91	0	0.02	0.06	1.97	3.11	0.11	0	0.73	0	0.51	0	0	0	0.24	0	0.1	0	0	0	0											17.58	0	1.55	21.86	0.46	2.64	-	1.32	4.27	0.2	1.29	4.46	-	2.84	-	0.1	0.24	6.56	12.17	0.41	-	3.47	-	2.49	-	-	-	0.98	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.15
H4909_004_0	2007	7																																A	A	D		T	Coin	Coin	V	V		V		V	V	V	V	V		V		S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1178.27	24.87	270.91	0	175.88	15.7	0.72	269.16	235.71	0	487.21	0	28.4	75.41	3985.33	3894.61	132.33	0	691.15	0	711.95	0	0	0	317.73	0	136.17	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												120.57	120.57	72.34	0	72.34	0.19	0.19	45.51	144.68	0	48.23	0	33.35	24.11	9.65	24.11	24.11	0	48.23	0	33.76	0	0	0	24.11	0	24.11	0	0	0	0											11.84	0.25	1.63	-	1.06	3.03	0.14	1.02	2.84	-	1.96	-	0.08	0.15	3.2	7.83	0.27	-	2.78	-	2	-	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.99	0	1.51	11.84	0.25	1.63	-	1.06	3.03	0.14	1.02	2.84	-	1.96	-	0.08	0.15	3.2	7.83	0.27	-	2.78	-	2	-	-	-	0.64	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.99	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												4.58	0.1	1.04	0	0.27	1.29	0.06	0.27	1.21	0	0.92	0	0.02	0.05	1.64	2.81	0.1	0	0.73	0	0.51	0	0	0	0.22	0	0.09	0	0	0	0											15.91	0	1.22	16.42	0.35	2.67	-	1.33	4.32	0.2	1.29	4.06	-	2.88	-	0.1	0.21	4.85	10.64	0.36	-	3.51	-	2.52	-	-	-	0.85	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.9
H4909_801_0	2007	5																																A	A	D		T	Coin	Coin	V	V		V		V	V	V	V	V		V		S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1169.48	24.69	271.12	0	175.85	15.69	0.72	268.45	234.78	0	487.18	0	28.4	75.21	3860.52	3805.55	129.33	0	690.99	0	711.99	0	0	0	310.49	0	133.07	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												166.64	166.64	71.42	0	71.42	0.19	0.19	45.51	166.64	0	47.61	0	32.93	28.57	14.28	28.57	28.57	0	47.61	0	33.33	0	0	0	28.57	0	28.57	0	0	0	0											16.24	0.34	1.61	-	1.05	2.99	0.14	1.02	3.26	-	1.93	-	0.08	0.18	4.6	9.06	0.31	-	2.74	-	1.98	-	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57	0	2.44	16.24	0.34	1.61	-	1.05	2.99	0.14	1.02	3.26	-	1.93	-	0.08	0.18	4.6	9.06	0.31	-	2.74	-	1.98	-	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												5.62	0.12	1.03	0	0.27	1.28	0.06	0.27	1.2	0	0.91	0	0.02	0.06	1.97	3.11	0.11	0	0.73	0	0.51	0	0	0	0.24	0	0.1	0	0	0	0											17.58	0	1.55	21.86	0.46	2.64	-	1.32	4.27	0.2	1.29	4.46	-	2.84	-	0.1	0.24	6.56	12.17	0.41	-	3.47	-	2.49	-	-	-	0.98	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.15
H4909_803_0	2007	2																																A	A	D		T	Coin	Coin	V	V		V		V	V	V	V	V		V		S				V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		1169.48	24.69	271.12	0	175.85	15.69	0.72	268.45	234.78	0	487.18	0	28.4	75.21	3860.52	3805.55	129.33	0	690.99	0	711.99	0	0	0	310.49	0	133.07	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												166.64	166.64	71.42	0	71.42	0.19	0.19	45.51	166.64	0	47.61	0	32.93	28.57	14.28	28.57	28.57	0	47.61	0	33.33	0	0	0	28.57	0	28.57	0	0	0	0											16.24	0.34	1.61	-	1.05	2.99	0.14	1.02	3.26	-	1.93	-	0.08	0.18	4.6	9.06	0.31	-	2.74	-	1.98	-	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57	0	2.44	16.24	0.34	1.61	-	1.05	2.99	0.14	1.02	3.26	-	1.93	-	0.08	0.18	4.6	9.06	0.31	-	2.74	-	1.98	-	-	-	0.74	-	0.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.57	4000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												5.62	0.12	1.03	0	0.27	1.28	0.06	0.27	1.2	0	0.91	0	0.02	0.06	1.97	3.11	0.11	0	0.73	0	0.51	0	0	0	0.24	0	0.1	0	0	0	0											17.58	0	1.55	21.86	0.46	2.64	-	1.32	4.27	0.2	1.29	4.46	-	2.84	-	0.1	0.24	6.56	12.17	0.41	-	3.47	-	2.49	-	-	-	0.98	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.15
H4910_001_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.46 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.46	35	35	35	35	45				0		0															17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09																																																																																				-			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09
H4910_002_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															350 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 125 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															57.09		67.84	20	100	0.2		48	200	25	59.2	25	25	25	10	25	25	25	25	25	45				0		0															7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65			7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65																																																																																				-			7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65
H4910_004_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.46 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.46	35	35	35	35	45				0		0															17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09																																																																																				-			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09
H4910_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H4910_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H4911_002_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	5000	1369.62		1118.74	1836.48	202.67	13.83		367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0				0		0															350 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 100 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															57.09		67.84	20	100	0.2		48	200	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															6.52	-	6.32	3.06	1.69	2.77	-	1.47	5.05	4.01	4.18	-	-	-	3.98	12.3	0.36	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.07	0	0	6.52	-	6.32	3.06	1.69	2.77	-	1.47	5.05	4.01	4.18	-	-	-	3.98	12.3	0.36	1.05	1.72	2.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.07		20 150 ded 5000 OOP max		20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	100 per trip	20 150 ded 5000 OOP max		50 ER; 35 UC	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	45 per script				20 150 ded 5000 OOP max		20 150 ded 5000 OOP max															3.51		0.57	0.51	0.17	0.42		0.08	0.36	0.12	0.35	0	0.11	0.39	0.46	0.57	0.02	0.06	0.42	1.54	0.03				0.06		0.02															9.77	150	6.03	10.03	-	6.89	3.57	1.86	3.19	-	1.55	5.41	4.14	4.53	-	0.11	0.39	4.44	12.87	0.38	1.11	2.14	4.14	0.03	-	-	-	0.06	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.84
H4911_003_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	7500	1369.62		1118.74	1836.48	202.67	13.83		367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.4 X-ray; 100 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	57.23	35	30	35	20	34.4	35	35	35	35	45				0		0															15.83	-	6.32	3.06	1.69	2.77	-	1.47	5.05	5.62	4.72	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.42	0	0	15.83	-	6.32	3.06	1.69	2.77	-	1.47	5.05	5.62	4.72	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.42		30 500 ded 7500 OOP max		30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	100 per trip	30 500 ded 7500 OOP max		50 ER; 35 UC	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	45 per script				30 500 ded 7500 OOP max		30 500 ded 7500 OOP max															5.75		0.93	0.84	0.19	0.48		0.12	0.59	0.2	0.57	0	0.19	0.63	0.75	0.93	0.04	0.1	0.69	2.52	0.09				0.1		0.03															15.73	500	9.23	21.57	-	7.26	3.9	1.87	3.24	-	1.6	5.64	5.82	5.29	-	0.19	0.63	8.71	17.85	0.54	1.57	3.1	6.15	0.09	-	-	-	0.1	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.15
H4911_004_0	2007	6																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	7500	1369.62		1118.74	1836.48	202.67	13.83		367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0				0		0															800 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	30 per visit	34.4 X-ray; 100 CATPETMRI	30 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															130.5		67.84	20	100	0.2		48	200	30	57.23	30	30	35	20	34.4	35	35	35	35	45				0		0															14.89	-	6.32	3.06	1.69	2.77	-	1.47	5.05	4.81	4.72	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.69	0	0	14.89	-	6.32	3.06	1.69	2.77	-	1.47	5.05	4.81	4.72	-	-	-	7.96	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.69		30 500 ded 7500 OOP max		30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	100 per trip	30 500 ded 7500 OOP max		50 ER; 35 UC	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	45 per script				30 500 ded 7500 OOP max		30 500 ded 7500 OOP max															6.83		1.11	0.99	0.21	0.57		0.15	0.7	0.24	0.68	0	0.22	0.75	0.89	1.11	0.04	0.12	0.82	2.99	0.19				0.12		0.03															18.77	500	9.23	21.73	-	7.43	4.05	1.9	3.33	-	1.62	5.75	5.06	5.4	-	0.22	0.75	8.85	18.03	0.55	1.59	3.23	6.63	0.19	-	-	-	0.12	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.46
H4911_801_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	150 per trip	30 500 ded unlimited OOP max	0	50 ER; 50 UC	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	20 coinsurance	0			30 500 ded unlimited OOP max		30 500 ded unlimited OOP max															5.49	0	0.89	0.8	0.26	0.45	0	0.16	0.56	0.2	0.55	0	0.18	0.61	0.71	0.89	0.03	0.09	0.66	2.4	0.37	0			0.09		0.03															15.44	500		21.89	0.32	10.21	6.15	2.79	4.6	0.26	1.69	4.35	1.38	3.88	-	0.18	0.61	14.64	18.56	0.54	3.03	4.68	9.68	3.55	-	-	-	0.09	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.15
H4911_802_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	150 per trip	30 500 ded unlimited OOP max	0	50 ER; 50 UC	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	20 coinsurance	0			30 500 ded unlimited OOP max		30 500 ded unlimited OOP max															5.49	0	0.89	0.8	0.26	0.45	0	0.16	0.56	0.2	0.55	0	0.18	0.61	0.71	0.89	0.03	0.09	0.66	2.4	0.37	0			0.09		0.03															15.44	500		21.89	0.32	10.21	6.15	2.79	4.6	0.26	1.69	4.35	1.38	3.88	-	0.18	0.61	14.64	18.56	0.54	3.03	4.68	9.68	3.55	-	-	-	0.09	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.15
H5005_001_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1291.6	34.99	1597.48	1824.41	256.14	17.8	1.24	387.59	435.86	592.87	30.04	33.7	5.65	698.71	6180.04	3649.16	160.14	367.87	29.46	19925.86	69.33	0	0	0	119.04	269.05	212.75	38.17	0	0	678.81											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.2	200	0	0.15	0	0	135.61	15	30	30	30	0.24	0.01	0.2	0	0	0	30	30	0	0	0	0	0											14.05	0.32	8.25	-	2.13	3.5	0.25	1.59	7.26	-	4.63	-	-	7.9	7.73	9.12	0.4	0.92	7.19	0.01	13.87	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.08	0	0	14.05	0.32	8.25	-	2.13	3.5	0.25	1.59	7.26	-	4.63	-	-	7.9	7.73	9.12	0.4	0.92	7.19	0.01	13.87	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.08	None																																																																																			-	0	0	14.05	0.32	8.25	-	2.13	3.5	0.25	1.59	7.26	-	4.63	-	-	7.9	7.73	9.12	0.4	0.92	7.19	0.01	13.87	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.08
H5005_010_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1366.34	37.01	953.68	1693.76	281.6	15.63	1.09	381.65	389.28	569.44	28.52	30.1	5.03	624.03	5275.58	3387.82	160.14	348.07	27.97	18905.76	69.33	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	0 1/yr	500/3 yrs	Not Covered	0	Acupuncture: 10 / 12 visits yr; Routine Chiropractic: 10 / 12 visits yr											130.52	109.69	62	0	100	0.2	0.2	49.2	200	0	0.15	0	0	135.61	15	30	30	30	0.24	0.01	0.2	0	0	0	30	30	0	0	0	0	8.93											14.86	0.34	4.93	-	2.35	3.07	0.22	1.56	6.49	-	4.39	-	-	7.05	6.59	8.47	0.4	0.87	6.85	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	83.7	0	0	14.86	0.34	4.93	-	2.35	3.07	0.22	1.56	6.49	-	4.39	-	-	7.05	6.59	8.47	0.4	0.87	6.85	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	83.7	None																																																																																			-	0	0	14.86	0.34	4.93	-	2.35	3.07	0.22	1.56	6.49	-	4.39	-	-	7.05	6.59	8.47	0.4	0.87	6.85	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	83.7
H5005_011_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1306.78	35.4	1384.49	1761.27	272.97	15.38	1.07	387.59	454.25	577.52	27.42	35.12	5.52	728.19	5691.27	3588.86	160.14	358.3	26.89	19651.27	69.33	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	0 1/yr	500/3 yrs	Not Covered	0	Acupuncture: 10 / 12 visits yr; Routine Chiropractic: 10 / 12 visits yr											130.52	109.69	62	0	100	0.2	0.2	49.2	200	0	0.15	0	0	135.61	15	30	30	30	0.25	0.01	0.2	0	0	0	30	30	0	0	0	0	8.96											14.21	0.32	7.15	-	2.27	3.02	0.21	1.59	7.57	-	4.22	-	-	8.23	7.11	8.97	0.4	0.9	6.85	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	88.36	0	0	14.21	0.32	7.15	-	2.27	3.02	0.21	1.59	7.57	-	4.22	-	-	8.23	7.11	8.97	0.4	0.9	6.85	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	88.36	None																																																																																			-	0	0	14.21	0.32	7.15	-	2.27	3.02	0.21	1.59	7.57	-	4.22	-	-	8.23	7.11	8.97	0.4	0.9	6.85	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	88.36
H5005_013_0	2007	5																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1263.63	34.23	1419.9	1693.76	225.66	15.67	1.09	381.65	432.44	563.01	26.21	33.44	5.13	693.23	5885.12	3754.75	160.14	348.07	25.71	19426.66	69.33	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	68	0	100	0.2	0.2	49.2	200	0	0.15	0	0	135.61	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											13.74	0.31	8.05	-	1.88	3.08	0.22	1.56	7.21	-	4.04	-	-	7.83	7.36	9.39	0.4	0.87	6.65	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.37	0	0	13.74	0.31	8.05	-	1.88	3.08	0.22	1.56	7.21	-	4.04	-	-	7.83	7.36	9.39	0.4	0.87	6.65	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.37	None																																																																																			-	0	0	13.74	0.31	8.05	-	1.88	3.08	0.22	1.56	7.21	-	4.04	-	-	7.83	7.36	9.39	0.4	0.87	6.65	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.37
H5005_015_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1306.78	35.4	1419.9	1761.27	225.66	17.23	1.2	387.59	432.44	577.52	29.47	33.44	5.64	693.23	5885.12	3754.75	160.14	358.3	28.9	19743.18	69.33	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.2	200	0	0.15	0	0	135.61	15	30	30	30	0.24	0.01	0.2	0	0	0	30	30	0	0	0	0	0											14.21	0.32	7.34	-	1.88	3.38	0.24	1.59	7.21	-	4.54	-	-	7.83	7.36	9.39	0.4	0.9	7.03	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.43	0	0	14.21	0.32	7.34	-	1.88	3.38	0.24	1.59	7.21	-	4.54	-	-	7.83	7.36	9.39	0.4	0.9	7.03	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.43	None																																																																																			-	0	0	14.21	0.32	7.34	-	1.88	3.38	0.24	1.59	7.21	-	4.54	-	-	7.83	7.36	9.39	0.4	0.9	7.03	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.43
H5005_018_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1263.63	34.23	1419.9	1693.76	225.66	15.67	1.09	381.65	432.44	563.01	26.21	33.44	5.13	693.23	5885.12	3754.75	160.14	348.07	25.71	19426.66	69.33	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											200 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											130.52	109.69	62	0	100	0.2	0.2	49.2	200	0	0.15	0	0	135.61	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											13.74	0.31	7.34	-	1.88	3.08	0.22	1.56	7.21	-	4.04	-	-	7.83	7.36	9.39	0.4	0.87	6.65	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.66	0	0	13.74	0.31	7.34	-	1.88	3.08	0.22	1.56	7.21	-	4.04	-	-	7.83	7.36	9.39	0.4	0.87	6.65	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.66	None																																																																																			-	0	0	13.74	0.31	7.34	-	1.88	3.08	0.22	1.56	7.21	-	4.04	-	-	7.83	7.36	9.39	0.4	0.87	6.65	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.66
H5005_019_0	2007	7																					2850											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2850	1263.63	34.23	1419.9	1824.41	270.14	7.48	0.52	387.59	432.44	592.87	13.37	33.44	2.49	693.23	5745.1	3649.16	160.14	367.87	13.11	19772.28	43.4	0	0	0	119.04	269.05	212.75	38.17	0	0	678.81											295 Day	295 Day	160 Day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 10 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	10	30	40 Ind/30 Grp	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											161.57	161.57	87.63	0	95.84	0.3	0.3	26.95	205.7	0	0.23	0	0.3	47.32	5.48	16.43	21.91	16.43	0.32	3.32	0.3	0	0	0	30	30	0	0	0	0	0											17.01	0.46	10.37	-	2.16	2.24	0.16	0.87	7.41	-	3.09	-	0.75	2.73	2.62	5	0.29	0.5	4.24	5.47	13.02	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.37	0	64.75	17.01	0.46	10.37	-	2.16	2.24	0.16	0.87	7.41	-	3.09	-	0.75	2.73	2.62	5	0.29	0.5	4.24	5.47	13.02	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.37	2850																																																																																			-	0	0	17.01	0.46	10.37	-	2.16	2.24	0.16	0.87	7.41	-	3.09	-	0.75	2.73	2.62	5	0.29	0.5	4.24	5.47	13.02	-	-	-	0.3	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.37
H5005_020_0	2007	4																					4000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	4000	1306.78	35.4	1419.9	1761.27	225.66	12.69	0.89	387.59	432.44	577.52	21.71	33.44	4.16	693.23	5885.12	3754.75	160.14	358.3	21.29	19743.18	56.01	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											79.09	88.62	59.78	0	80.79	0.2	0.2	39.75	80.79	0	0.15	0	0	56.22	12.12	24.24	24.24	24.24	0.26	0	0.2	0	0	0	30	30	0	0	0	0	0											8.61	0.26	7.07	-	1.52	2.49	0.18	1.28	2.91	-	3.34	-	-	3.25	5.94	7.58	0.32	0.72	5.5	0.01	11.2	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.14	0	14.79	8.61	0.26	7.07	-	1.52	2.49	0.18	1.28	2.91	-	3.34	-	-	3.25	5.94	7.58	0.32	0.72	5.5	0.01	11.2	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.14	4000																																																																																			-	0	0	8.61	0.26	7.07	-	1.52	2.49	0.18	1.28	2.91	-	3.34	-	-	3.25	5.94	7.58	0.32	0.72	5.5	0.01	11.2	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.14
H5005_021_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1306.78	35.4	1419.9	1761.27	270.14	15.42	1.08	387.59	432.44	577.52	27.13	33.44	5.2	693.23	5745.1	3522.85	160.14	358.3	26.61	19456.9	69.33	0	0	0	115.43	260.89	206.3	37.01	0	0	660.31											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	62	0	100	0.2	0.2	49.2	100	0	0.15	0	0	69.59	15	30	30	30	0.26	0.01	0.2	0	0	0	30	30	0	0	0	0	0											10.66	0.32	7.34	-	2.25	3.03	0.22	1.59	3.6	-	4.18	-	-	4.02	7.18	8.81	0.4	0.9	6.83	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.13	0	0	10.66	0.32	7.34	-	2.25	3.03	0.22	1.59	3.6	-	4.18	-	-	4.02	7.18	8.81	0.4	0.9	6.83	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.13	None																																																																																			-	0	0	10.66	0.32	7.34	-	2.25	3.03	0.22	1.59	3.6	-	4.18	-	-	4.02	7.18	8.81	0.4	0.9	6.83	0.01	13.87	-	-	-	0.29	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.13
H5005_022_0	2007	4																					4000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	4000	1263.63	34.23	1419.9	1693.76	225.66	13.28	0.93	381.65	432.44	563.01	22.22	33.44	4.35	693.23	5885.12	3754.75	160.14	348.07	21.79	19426.66	56.06	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											79.16	88.7	59.84	0	80.86	0.2	0.2	39.78	80.86	0	0.15	0	0	56.27	12.13	24.26	24.26	24.26	0.25	0	0.2	0	0	0	30	30	0	0	0	0	0											8.34	0.25	7.08	-	1.52	2.61	0.19	1.27	2.91	-	3.42	-	-	3.25	5.95	7.59	0.32	0.7	5.46	0.01	11.21	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.99	0	14.69	8.34	0.25	7.08	-	1.52	2.61	0.19	1.27	2.91	-	3.42	-	-	3.25	5.95	7.59	0.32	0.7	5.46	0.01	11.21	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.99	4000																																																																																			-	0	0	8.34	0.25	7.08	-	1.52	2.61	0.19	1.27	2.91	-	3.42	-	-	3.25	5.95	7.59	0.32	0.7	5.46	0.01	11.21	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.99
H5005_023_0	2007	3																					None											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	None	1263.63	34.23	1419.9	1693.76	270.14	16.06	1.12	381.65	432.44	563.01	27.68	33.44	5.42	693.23	5745.1	3510.36	160.14	348.07	27.14	19125.66	69.33	0	0	0	111.57	252.17	199.41	35.78	0	0	640.54											150 [Day(s) 1-5]	912 per admit	0 [Day(s) 1-10]; 100 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	100 per trip	20 Coinsurance	Prosthetic Devices: 20 Coinsurance; Diabetes Monitoring Supplies: 0 Coinsurance	ER Copay (per visit): 50; Urgent Care: 15 PCP Copay;30 In Area/In Network;50 Other	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	0	Cardiac Rehabilitation: 0 visits 1-1230 visits 13+; Pulmonary Rehabilitation: 0 visits 1-1230 visits 13+; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	15	30	30	Occupational Therapy: 0 visits 1-1230 visits 13+; PT and Speech/Language Therapy: 0 visits 1-1230 visits 13+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	30 2/yrs	30	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											97.89	109.69	62	0	100	0.2	0.2	49.2	100	0	0.15	0	0	69.59	15	30	30	30	0.25	0.01	0.2	0	0	0	30	30	0	0	0	0	0											10.31	0.31	7.34	-	2.25	3.15	0.22	1.56	3.6	-	4.26	-	-	4.02	7.18	8.78	0.4	0.87	6.77	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.82	0	0	10.31	0.31	7.34	-	2.25	3.15	0.22	1.56	3.6	-	4.26	-	-	4.02	7.18	8.78	0.4	0.87	6.77	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.82	None																																																																																			-	0	0	10.31	0.31	7.34	-	2.25	3.15	0.22	1.56	3.6	-	4.26	-	-	4.02	7.18	8.78	0.4	0.87	6.77	0.01	13.87	-	-	-	0.28	0.63	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.82
H5005_801_0	2007	5																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1296.09	35.11	1430.69	1775.61	243.98	8.7	0.61	379.12	420.66	615.03	14.7	32.53	2.79	674.34	5863.31	3667.59	157.65	453.5	14.65	20193.82	75.15	0	0	0	117.18	264.84	209.43	37.57	0	0	669.28											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											207.82	207.78	94.98	0	103.89	0.3	0.3	8.31	236.38	0	0.23	0	0.3	54.38	40.54	50.46	23.75	50.46	0.31	3.72	0.3	0	0	0	0	0	0	0	0	0	0											22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	0	86.22	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	5000																																																																																			-	0	0	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96
H5005_802_0	2007	5																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1296.09	35.11	1430.69	1775.61	243.98	8.7	0.61	379.12	420.66	615.03	14.7	32.53	2.79	674.34	5863.31	3667.59	157.65	453.5	14.65	20193.82	75.15	0	0	0	117.18	264.84	209.43	37.57	0	0	669.28											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											207.82	207.78	94.98	0	103.89	0.3	0.3	8.31	236.38	0	0.23	0	0.3	54.38	40.54	50.46	23.75	50.46	0.31	3.72	0.3	0	0	0	0	0	0	0	0	0	0											22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	0	86.22	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	5000																																																																																			-	0	0	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96
H5005_803_0	2007	6																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1296.09	35.11	1430.69	1775.61	243.98	8.7	0.61	379.12	420.66	615.03	14.7	32.53	2.79	674.34	5863.31	3667.59	157.65	453.5	14.65	20193.82	75.15	0	0	0	117.18	264.84	209.43	37.57	0	0	669.28											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											207.82	207.78	94.98	0	103.89	0.3	0.3	8.31	236.38	0	0.23	0	0.3	54.38	40.54	50.46	23.75	50.46	0.31	3.72	0.3	0	0	0	0	0	0	0	0	0	0											22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	0	86.22	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	5000																																																																																			-	0	0	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96
H5005_804_0	2007	6																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	1296.09	35.11	1430.69	1775.61	243.98	8.7	0.61	379.12	420.66	615.03	14.7	32.53	2.79	674.34	5863.31	3667.59	157.65	453.5	14.65	20193.82	75.15	0	0	0	117.18	264.84	209.43	37.57	0	0	669.28											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											207.82	207.78	94.98	0	103.89	0.3	0.3	8.31	236.38	0	0.23	0	0.3	54.38	40.54	50.46	23.75	50.46	0.31	3.72	0.3	0	0	0	0	0	0	0	0	0	0											22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	0	86.22	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96	5000																																																																																			-	0	0	22.45	0.61	11.32	-	2.11	2.61	0.18	0.26	8.29	-	3.4	-	0.84	3.06	19.81	15.42	0.31	1.91	4.58	6.26	22.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.96
H5006_010_0	2007	10																																D	D	D	Coin	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	Coin	Coin	V	Coin	Coin																																																													-		809.76	9.01	428.62	10.8	139.71	7.27	5.22	310.59	66.07	29.57	3.34	0.5	0.08	0.02	3638.4	2360.84	1.38	3.3	0	0	21.24	0.46	0	0	0	0	0	0	0	0	0	0										150 day for 1st 5 days	150 day for 1st 5 days	35 day for days 11+	15 Coinsurance	150 Copay	20 Coinsurance	20 Coinsurance	50 per visit	15 Coinsurance	15 Coinsurance	15 Coinsurance	50 Coinsurance	15 Coinsurance	50 Coinsurance	10 Per Visit	35 Per Visit	50 Coinsurance	15 Coinsurance	15 Coinsurance	35 Per Visit	20 Coinsurance	15 Coinsurance																				150	150	35	0.15	150	0.2	0.2	50	0.15	0.15	0.15	0.5	0.15	0.5	10	35	0.5	0.15	0.15	35	0.2	0.15																				10.12	0.11	1.25	1.62	1.75	1.45	1.04	1.29	9.91	4.43	0.5	0.25	0.01	0.01	3.03	6.89	0.69	0.5	-	-	4.25	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.18			10.12	0.11	1.25	1.62	1.75	1.45	1.04	1.29	9.91	4.43	0.5	0.25	0.01	0.01	3.03	6.89	0.69	0.5	-	-	4.25	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.18																																																																																				-			10.12	0.11	1.25	1.62	1.75	1.45	1.04	1.29	9.91	4.43	0.5	0.25	0.01	0.01	3.03	6.89	0.69	0.5	-	-	4.25	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.18
H5006_011_0	2007	2																																D	D	D	Coin	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	Coin	Coin	V	Coin	Coin																																																													-		809.76	9.01	428.62	10.8	139.71	7.27	5.22	310.29	66.07	29.57	3.34	0.5	0.08	0.02	3638.4	2394.97	1.38	3.3	0	0	21.24	0.46	0	0	0	0	0	0	0	0	0	0										100 day for 1st 5 days	100 day for 1st 5 days	30 day for days 11+	10 Coinsurance	100 Copay	20 Coinsurance	20 Coinsurance	50 per visit	10 Coinsurance	10 Coinsurance	10 Coinsurance	50 Coinsurance	10 Coinsurance	50 Coinsurance	10 Per Visit	30 Per Visit	50 Coinsurance	10 Coinsurance	10 Coinsurance	30 Per Visit	20 Coinsurance	10 Coinsurance																				100	100	30	0.1	100	0.2	0.2	50	0.1	0.1	0.1	0.5	0.1	0.5	10	30	0.5	0.1	0.1	0.3	0.2	0.1																				6.75	0.08	1.07	1.08	1.16	1.45	1.04	1.29	6.61	2.96	0.33	0.25	0.01	0.01	3.03	5.99	0.69	0.33	-	-	4.25	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.43			6.75	0.08	1.07	1.08	1.16	1.45	1.04	1.29	6.61	2.96	0.33	0.25	0.01	0.01	3.03	5.99	0.69	0.33	-	-	4.25	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.43																																																																																				-			6.75	0.08	1.07	1.08	1.16	1.45	1.04	1.29	6.61	2.96	0.33	0.25	0.01	0.01	3.03	5.99	0.69	0.33	-	-	4.25	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.43
H5006_801_0	2007	3																																D	D	D	Coin	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	Coin	Coin	V	Coin	Coin																																																													-		850.23	9.46	854.43	12.53	146.69	8.33	6.02	326.9	73	33.81	3.82	0.54	0.09	0.03	4013.63	2773.76	1.63	3.9	0	0	19.9	2.61	0	0	0	0	0	0	0	0	0	0										250 day for 1st 5 days	250 day for 1st 5 days	75 day	20 Coinsurance	150 Copay	20 Coinsurance	20 Coinsurance	50 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	50 Coinsurance	20 Coinsurance	20 Coinsurance	20 Per Visit	40 Per Visit	50 Coinsurance	20 Coinsurance	20 Coinsurance	40 Per Visit	25 Coinsurance	20 Coinsurance																				250	250	75	0.2	150	0.2	0.2	50	0.2	0.2	0.2	0.5	0.2	0.2	20	40	0.5	0.2	0.2	40	0.25	0.2																				17.71	0.2	5.34	2.51	1.83	1.67	1.2	1.36	14.6	6.76	0.76	0.27	0.02	0.01	6.69	9.25	0.82	0.78	-	-	4.97	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.27			17.71	0.2	5.34	2.51	1.83	1.67	1.2	1.36	14.6	6.76	0.76	0.27	0.02	0.01	6.69	9.25	0.82	0.78	-	-	4.97	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.27																																																																																				-			17.71	0.2	5.34	2.51	1.83	1.67	1.2	1.36	14.6	6.76	0.76	0.27	0.02	0.01	6.69	9.25	0.82	0.78	-	-	4.97	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.27
H5008_001_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1814.98	169	8528.8	166.58	625.17	20.37	6.39	179.79	119.37	3713.86	165.11	32.65	4.27	277.6	121.7	1245.75	1618.28	19.12		260.11	250.38	1271.98	1200		140.2	166		54.6				106.02	0.27	0.07	300	295.2						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						135	135			67	18	18	45	22			22		22		9				9		9										31		22								20.4	1.9	-	-	3.51	3.66	1.15	0.67	0.22	-	-	0.06	-	0.52	-	0.93	-	-	-	0.19	-	0.95	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	34.47		3.86	20.4	1.9	-	-	3.51	3.66	1.15	0.67	0.22	-	-	0.06	-	0.52	-	0.93	-	-	-	0.19	-	0.95	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	34.47																																																																																				-		0	20.4	1.9	-	-	3.51	3.66	1.15	0.67	0.22	-	-	0.06	-	0.52	-	0.93	-	-	-	0.19	-	0.95	-	-	-	-	-	-	-	-	-	0.28	-	0	-	-	-	-	-	-	-	34.47
H5008_002_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2442.21	350.59			313.55	27.3	22.78	918.64	372.89	2199.68	915.74	65.48	3.07	2031.65		3464.6		503.69		798.47												322.71		142.06	241.23							(1a) 75 per Day	(1b) 75 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							37	37			37	10	10	18	12	5	5	12	10	12		5		5		5												5		5	5							7.46	1.07	-	-	0.96	2.67	2.23	1.35	0.38	0.9	0.37	0.07	0.3	2.07	-	1.41	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.1	-	-	-	-	-	-	22.05		23.05	7.46	1.07	-	-	0.96	2.67	2.23	1.35	0.38	0.9	0.37	0.07	0.3	2.07	-	1.41	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.1	-	-	-	-	-	-	22.05																																																																																				-		0	7.46	1.07	-	-	0.96	2.67	2.23	1.35	0.38	0.9	0.37	0.07	0.3	2.07	-	1.41	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.06	0.1	-	-	-	-	-	-	22.05
H5009_001_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	649.58	9.41	675.76	571.44	930.05	2.9	181.2	346.81	353.82	2313.77	1172.37	0	0	2494.75	6803.47	798.14	171.73	759.48	3536.55	537.47	938.83	164.56	0	1433.16	425.54	263.19	67.96	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.62	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.41	0.08	-	-	3.88	1.81	-	1.45	-	-	-	-	-	-	2.83	0.33	0.07	0.32	-	0.22	-	-	-	-	0.18	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.61	0	0	5.41	0.08	-	-	3.88	1.81	-	1.45	-	-	-	-	-	-	2.83	0.33	0.07	0.32	-	0.22	-	-	-	-	0.18	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.61	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.63	0.04	0.24	0.1	0.07	0.23	0.01	0.16	0.37	0.26	0.52			0.68	0.87	0.34	0.02	0.02	0.4	1.52	0.08			0.06	0.06	0.04	0.01															9.73	250	6.07	9.04	0.12	0.24	0.1	3.95	2.04	0.01	1.61	0.37	0.26	0.52	-	-	0.68	3.7	0.67	0.09	0.34	0.4	1.74	0.08	-	-	0.06	0.24	0.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.34
H5009_002_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	649.58	9.41	675.76	571.44	930.05	2.9	181.2	346.81	353.82	2313.77	1172.37	0	0	2494.75	6803.47	798.14	171.73	759.48	3536.55	537.47	938.83	164.56	0	1433.16	425.54	263.19	67.96	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.62	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.41	0.08	-	-	3.88	1.81	-	1.45	-	-	-	-	-	-	2.83	0.33	0.07	0.32	-	0.22	-	-	-	-	0.18	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.61	0	0	5.41	0.08	-	-	3.88	1.81	-	1.45	-	-	-	-	-	-	2.83	0.33	0.07	0.32	-	0.22	-	-	-	-	0.18	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.61	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.63	0.04	0.24	0.1	0.07	0.23	0.01	0.16	0.37	0.26	0.52			0.68	0.87	0.34	0.02	0.02	0.4	1.52	0.08			0.06	0.06	0.04	0.01															9.73	250	6.07	9.04	0.12	0.24	0.1	3.95	2.04	0.01	1.61	0.37	0.26	0.52	-	-	0.68	3.7	0.67	0.09	0.34	0.4	1.74	0.08	-	-	0.06	0.24	0.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.34
H5009_004_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	649.58	9.41	675.76	571.44	930.05	2.9	181.2	346.81	353.82	2313.77	1172.37	0	0	2494.75	6803.47	798.14	171.73	759.48	3536.55	537.47	938.83	164.56	0	1433.16	425.54	263.19	67.96	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.62	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.41	0.08	-	-	3.88	1.81	-	1.45	-	-	-	-	-	-	2.83	0.33	0.07	0.32	-	0.22	-	-	-	-	0.18	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.61	0	0	5.41	0.08	-	-	3.88	1.81	-	1.45	-	-	-	-	-	-	2.83	0.33	0.07	0.32	-	0.22	-	-	-	-	0.18	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.61	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.63	0.04	0.24	0.1	0.07	0.23	0.01	0.16	0.37	0.26	0.52			0.68	0.87	0.34	0.02	0.02	0.4	1.52	0.08			0.06	0.06	0.04	0.01															9.73	250	6.07	9.04	0.12	0.24	0.1	3.95	2.04	0.01	1.61	0.37	0.26	0.52	-	-	0.68	3.7	0.67	0.09	0.34	0.4	1.74	0.08	-	-	0.06	0.24	0.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.34
H5010_001_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	691.58	10.02	770.74	668.14	1288.47	4.02	251.03	189.62	193.45	1265.04	640.98	0	0	1363.98	7212.39	915.4	241.58	871.05	4171.02	616.42	709.55	227.97	0	1424.33	598.63	345.22	95.61	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.59	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.76	0.08	-	-	5.37	2.37	-	0.79	-	-	-	-	-	-	3.01	0.38	0.1	0.36	-	0.26	-	-	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.77	0	0	5.76	0.08	-	-	5.37	2.37	-	0.79	-	-	-	-	-	-	3.01	0.38	0.1	0.36	-	0.26	-	-	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.77	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.92	0.04	0.33	0.12	0.09	0.28	0.02	0.1	0.27	0.19	0.38			0.5	0.88	0.37	0.02	0.02	0.61	1.8	0.07			0.06	0.07	0.05	0.02															10.21	250	6.4	9.68	0.12	0.33	0.12	5.46	2.65	0.02	0.89	0.27	0.19	0.38	-	-	0.5	3.89	0.75	0.12	0.38	0.61	2.06	0.07	-	-	0.06	0.32	0.05	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.98
H5010_002_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	691.58	10.02	770.74	668.14	1288.47	4.02	251.03	189.62	193.45	1265.04	640.98	0	0	1363.98	7212.39	915.4	241.58	871.05	4171.02	616.42	709.55	227.97	0	1424.33	598.63	345.22	95.61	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.59	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.76	0.08	-	-	5.37	2.37	-	0.79	-	-	-	-	-	-	3.01	0.38	0.1	0.36	-	0.26	-	-	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.77	0	0	5.76	0.08	-	-	5.37	2.37	-	0.79	-	-	-	-	-	-	3.01	0.38	0.1	0.36	-	0.26	-	-	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.77	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.92	0.04	0.33	0.12	0.09	0.28	0.02	0.1	0.27	0.19	0.38			0.5	0.88	0.37	0.02	0.02	0.61	1.8	0.07			0.06	0.07	0.05	0.02															10.21	250	6.4	9.68	0.12	0.33	0.12	5.46	2.65	0.02	0.89	0.27	0.19	0.38	-	-	0.5	3.89	0.75	0.12	0.38	0.61	2.06	0.07	-	-	0.06	0.32	0.05	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.98
H5010_004_0	2007	4																					1000											D	D			T	Coin		V							V	V	V	V		V					V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	691.58	10.02	770.74	668.14	1288.47	4.02	251.03	189.62	193.45	1265.04	640.98	0	0	1363.98	7212.39	915.4	241.58	871.05	4171.02	616.42	709.55	227.97	0	1424.33	598.63	345.22	95.61	0	0	0	0											100/day (days 1-3)	100/day (days 1-3)			50	10		50 ER 5 Urgent							5	5	5	5		5 chiro					5		5															100	100	0	0	50	0.59	0	50	0	0	0	0	0	0	5	5	5	5	0	5	0	0	0	0	5	0	5	0	0	0	0											5.76	0.08	-	-	5.37	2.37	-	0.79	-	-	-	-	-	-	3.01	0.38	0.1	0.36	-	0.26	-	-	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.77	0	0	5.76	0.08	-	-	5.37	2.37	-	0.79	-	-	-	-	-	-	3.01	0.38	0.1	0.36	-	0.26	-	-	-	-	0.25	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.77	N/A	Coin	Coin	Coin	Coin	T	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			Coin	Coin	O	Coin															3.92	0.04	0.33	0.12	0.09	0.28	0.02	0.1	0.27	0.19	0.38			0.5	0.88	0.37	0.02	0.02	0.61	1.8	0.07			0.06	0.07	0.05	0.02															10.21	250	6.4	9.68	0.12	0.33	0.12	5.46	2.65	0.02	0.89	0.27	0.19	0.38	-	-	0.5	3.89	0.75	0.12	0.38	0.61	2.06	0.07	-	-	0.06	0.32	0.05	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.98
H5050_001_0	2007	3																					1000											D	D			T	Coin	Coin	V	V						V	V	V	V	V	V		V	T		V		V		Coin																																																						-		389.75	5.94	0	0	255.44	6.38	3.19	142.92	105.74	0	0	0	0	0	3797.06	2209.2	138.08	207.11	0	552.3	0	656.72	17.13	0	583.53	0	280.89	0	0.26	0	0											100 per day for 1st 3 days	100 per day for 1st 3 days	0 Copay	0 Copay	75 per trip	20 coinsurance	20 coinsurance	50 per visit	100 per visit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	0 Copay	15 Copay	75 per trip	0 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 coinsurance	0 Copay	0 Copay											95	95	0	0	71.25	0.19	0.19	47.5	95	0	0	0	0	0	14.25	14.25	14.25	14.25	0	14.25	0	14.25	71.25	0	14.25	0	14.25	0	0.19	0	0											3.09	0.05	-	-	1.52	1.21	0.61	0.57	0.84	-	-	-	-	-	4.51	2.62	0.16	0.25	-	0.66	-	0.78	0.1	-	0.69	-	0.33	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	18.02		0.95	3.09	0.05	-	-	1.52	1.21	0.61	0.57	0.84	-	-	-	-	-	4.51	2.62	0.16	0.25	-	0.66	-	0.78	0.1	-	0.69	-	0.33	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	18.02																																																																																				-			3.09	0.05	-	-	1.52	1.21	0.61	0.57	0.84	-	-	-	-	-	4.51	2.62	0.16	0.25	-	0.66	-	0.78	0.1	-	0.69	-	0.33	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	18.02
H5050_002_0	2007	2																					1000											D	D			T	Coin	Coin	V	V						V	V	V	V	V	V		V	T		V		V		Coin																																																						-		588.55	8.96	0	0	252.02	6.06	3.03	176.31	260.87	0	0	0	0	0	4307.33	2506.08	156.63	234.95	0	626.52	0	756.92	4.98	0	1431.4	0	291.31	0	0.33	0	0											100 per day for 1st 3 days	100 per day for 1st 3 days	0 Copay	0 Copay	75 per trip	20 coinsurance	20 coinsurance	50 per visit	100 per visit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	0 Copay	15 Copay	75 per trip	0 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 coinsurance	0 Copay	0 Copay											95	95	0	0	71.25	0.19	0.19	47.5	95	0	0	0	0	0	14.25	14.25	14.25	14.25	0	14.25	0	14.25	71.25	0	14.25	0	14.25	0	0.19	0	0											4.66	0.07	-	-	1.5	1.15	0.58	0.7	2.07	-	-	-	-	-	5.11	2.98	0.19	0.28	-	0.74	-	0.9	0.03	-	1.7	-	0.35	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	23.05		1.21	4.66	0.07	-	-	1.5	1.15	0.58	0.7	2.07	-	-	-	-	-	5.11	2.98	0.19	0.28	-	0.74	-	0.9	0.03	-	1.7	-	0.35	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	23.05																																																																																				-			4.66	0.07	-	-	1.5	1.15	0.58	0.7	2.07	-	-	-	-	-	5.11	2.98	0.19	0.28	-	0.74	-	0.9	0.03	-	1.7	-	0.35	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	23.05
H5050_004_0	2007	5																					1000											D	D			T	Coin	Coin	V	V						V	V	V	V	V	V		V	T		V		V		Coin																																																						-		733.95	11.18	0	0	548.67	12	6	271.52	109.82	0	0	0	0	0	5020.96	2921.29	182.58	273.87	0	730.32	0	823.77	24.33	0	1183.98	0	310.27	0	0.25	0	120											100 per day for 1st 3 days	100 per day for 1st 3 days	0 Copay	0 Copay	75 per trip	20 coinsurance	20 coinsurance	50 per visit	100 per visit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	0 Copay	15 Copay	75 per trip	0 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 coinsurance	0 Copay	15 Copay - Alternative Care											95	95	0	0	71.25	0.19	0.19	47.5	95	0	0	0	0	0	14.25	14.25	14.25	14.25	0	14.25	0	14.25	71.25	0	14.25	0	14.25	0	0.19	0	14.25											5.81	0.09	-	-	3.26	2.28	1.14	1.07	0.87	-	-	-	-	-	5.96	3.47	0.22	0.33	-	0.87	-	0.98	0.14	-	1.41	-	0.37	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	28.45		1.5	5.81	0.09	-	-	3.26	2.28	1.14	1.07	0.87	-	-	-	-	-	5.96	3.47	0.22	0.33	-	0.87	-	0.98	0.14	-	1.41	-	0.37	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	28.45																																																																																				-			5.81	0.09	-	-	3.26	2.28	1.14	1.07	0.87	-	-	-	-	-	5.96	3.47	0.22	0.33	-	0.87	-	0.98	0.14	-	1.41	-	0.37	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	28.45
H5050_009_0	2007	5																					1000											D	D			T	Coin	Coin	V	V						V	V	V	V	V	V		V	T		V		V		Coin																																																						-		494.97	7.54	0	0	324.41	8.1	4.05	181.5	134.28	0	0	0	0	0	4816.35	2802.24	175.14	262.71	0	700.56	0	834.01	21.76	0	741.07	0	356.71	0	0.33	0	0											100 per day for 1st 3 days	100 per day for 1st 3 days	0 Copay	0 Copay	75 per trip	20 coinsurance	20 coinsurance	50 per visit	100 per visit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	0 Copay	15 Copay	75 per trip	0 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 coinsurance	0 Copay	0 Copay											95	95	0	0	71.25	0.19	0.19	47.5	95	0	0	0	0	0	14.25	14.25	14.25	14.25	0	14.25	0	14.25	71.25	0	14.25	0	14.25	0	0.19	0	0											3.92	0.06	-	-	1.93	1.54	0.77	0.72	1.06	-	-	-	-	-	5.72	3.33	0.21	0.31	-	0.83	-	0.99	0.13	-	0.88	-	0.42	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	22.88		1.2	3.92	0.06	-	-	1.93	1.54	0.77	0.72	1.06	-	-	-	-	-	5.72	3.33	0.21	0.31	-	0.83	-	0.99	0.13	-	0.88	-	0.42	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	22.88																																																																																				-			3.92	0.06	-	-	1.93	1.54	0.77	0.72	1.06	-	-	-	-	-	5.72	3.33	0.21	0.31	-	0.83	-	0.99	0.13	-	0.88	-	0.42	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	22.88
H5050_010_0	2007	6																					1000											D	D			T	Coin	Coin	V	V						V	V	V	V	V	V		V	T		V		V		Coin																																																						-		746.22	11.36	0	0	319.54	7.68	3.84	223.54	330.76	0	0	0	0	0	5455.5	3174.11	198.38	297.57	0	793.53	0	959.69	6.32	0	1814.86	0	369.35	0	0.42	0	0											100 per day for 1st 3 days	100 per day for 1st 3 days	0 Copay	0 Copay	75 per trip	20 coinsurance	20 coinsurance	50 per visit	100 per visit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	0 Copay	15 Copay	75 per trip	0 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 coinsurance	0 Copay	0 Copay											95	95	0	0	71.25	0.19	0.19	47.5	95	0	0	0	0	0	14.25	14.25	14.25	14.25	0	14.25	0	14.25	71.25	0	14.25	0	14.25	0	0.19	0	0											5.91	0.09	-	-	1.9	1.46	0.73	0.88	2.62	-	-	-	-	-	6.48	3.77	0.24	0.35	-	0.94	-	1.14	0.04	-	2.16	-	0.44	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	29.22		1.54	5.91	0.09	-	-	1.9	1.46	0.73	0.88	2.62	-	-	-	-	-	6.48	3.77	0.24	0.35	-	0.94	-	1.14	0.04	-	2.16	-	0.44	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	29.22																																																																																				-			5.91	0.09	-	-	1.9	1.46	0.73	0.88	2.62	-	-	-	-	-	6.48	3.77	0.24	0.35	-	0.94	-	1.14	0.04	-	2.16	-	0.44	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	29.22
H5050_801_0	2007	2																					1000											D	D			T	Coin	Coin	V	V						V	V	V	V	V	V		V	T		V		V		Coin																																																						-		519.72	7.91	0	0	280.49	7.51	3.76	164.69	189.85	0	0	0	0	0	4914.79	2859.51	178.72	268.08	0	714.88	0	866.92	11.33	0	766.91	0	318	0	0.28	0	0											100 per day for 1st 3 days	100 per day for 1st 3 days	0 Copay	0 Copay	75 per trip	20 coinsurance	20 coinsurance	50 per visit	100 per visit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	0 Copay	15 Copay	75 per trip	0 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 coinsurance	0 Copay	0 Copay											95	95	0	0	71.25	0.19	0.19	47.5	95	0	0	0	0	0	14.25	14.25	14.25	14.25	0	14.25	0	14.25	71.25	0	14.25	0	14.25	0	0.19	0	0											4.11	0.06	-	-	1.67	1.43	0.71	0.65	1.5	-	-	-	-	-	5.84	3.4	0.21	0.32	-	0.85	-	1.03	0.07	-	0.91	-	0.38	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	23.19		1.22	4.11	0.06	-	-	1.67	1.43	0.71	0.65	1.5	-	-	-	-	-	5.84	3.4	0.21	0.32	-	0.85	-	1.03	0.07	-	0.91	-	0.38	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	23.19																																																																																				-			4.11	0.06	-	-	1.67	1.43	0.71	0.65	1.5	-	-	-	-	-	5.84	3.4	0.21	0.32	-	0.85	-	1.03	0.07	-	0.91	-	0.38	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	23.19
H5050_802_0	2007	2																					1000											D	D			T	Coin	Coin	V	V						V	V	V	V	V	V		V	T		V		V		Coin																																																						-		494.4	7.53	0	0	266.82	7.15	3.57	156.67	180.6	0	0	0	0	0	4676.45	2720.84	170.05	255.08	0	680.21	0	824.7	10.78	0	729.56	0	302.51	0	0.26	0	0											100 per day for 1st 3 days	100 per day for 1st 3 days	0 Copay	0 Copay	75 per trip	20 coinsurance	20 coinsurance	50 per visit	100 per visit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15 Copay	15 Copay	15 Copay	15 Copay	0 Copay	15 Copay	0 Copay	15 Copay	75 per trip	0 Copay	15 Copay	0 Copay	15 Copay	0 Copay	20 coinsurance	0 Copay	0 Copay											95	95	0	0	71.25	0.19	0.19	47.5	95	0	0	0	0	0	14.25	14.25	14.25	14.25	0	14.25	0	14.25	71.25	0	14.25	0	14.25	0	0.19	0	0											3.91	0.06	-	-	1.58	1.36	0.68	0.62	1.43	-	-	-	-	-	5.55	3.23	0.2	0.3	-	0.81	-	0.98	0.06	-	0.87	-	0.36	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	22.06		1.16	3.91	0.06	-	-	1.58	1.36	0.68	0.62	1.43	-	-	-	-	-	5.55	3.23	0.2	0.3	-	0.81	-	0.98	0.06	-	0.87	-	0.36	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	22.06																																																																																				-			3.91	0.06	-	-	1.58	1.36	0.68	0.62	1.43	-	-	-	-	-	5.55	3.23	0.2	0.3	-	0.81	-	0.98	0.06	-	0.87	-	0.36	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	22.06
H5106_013_0	2007	5																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											4.26	0.03	0.58	0.33	0.11	0.39	0.02	0.08	0.42	0.16	0.44	0	0	0.43	0	0	0	0	0	0	0.12	0.01	0	0	0	0.04	0	0.01	0	0	0											7.44	2000	247.22	1.85	33.64	19.37	257.01	22.84	1.07	363.17	24.18	9.35	25.57	0	0.17	24.9	5251.19	12556.55	124.45	411.59	20.75	16.81	6.95	630.47	0	0	337.96	0	123.01	0	0	0	0											10 / Admit	10 / Admit	10 / Admit	10 Coinsurance	100 Copay	10 Coinsurance	10 Coinsurance	50 ER / 25 UC	10 ASC / 10 OP	10 Pathology	10 X-Rays / 10 Radiation Therapy	No cost sharing	10 Coinsurance	20 Cardio / 20 Therapy/10 other services	20 PCP/0 Preventive	20 SCP / 20 Chiro / 20 Podiatrist/0 Preventive	30 MH	20 Therapy	10 Coinsurance for All except 0 for Office Visits	20 Hearing &Vision / 0 Preventive/10coinsurance on all other	10 Coinsurance	20 Copay Vision & Hearing Exams/10Coinsurance for Other		0	20 Copay	100 Allowance per year	20 Hearing & Speech	300 Allowance every 3 years			0											0.06	0.06	0.06	0.06	62.04	0.06	0.06	25.81	0.06	0.06	0.06	0	0.1	0.05	15.62	11.66	30	20	0.03	0.11	0.06	18.61	0	0	20	0	20	0	0	0	0											15.4	0.12	2.09	1.21	1.33	1.42	0.07	0.78	1.51	0.58	1.59	-	0.02	1.3	6.83	12.2	0.31	0.69	0.61	1.79	0.43	0.98	-	-	0.56	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.02	150	24.42	19.66	0.15	2.67	1.54	1.44	1.82	0.09	0.86	1.92	0.74	2.03	-	0.02	1.72	6.83	12.2	0.31	0.69	0.61	1.79	0.55	0.99	-	-	0.56	0.04	0.21	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	59.46	2000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											6	0.05	0.81	0.45	0.17	0.58	0.03	0.11	0.6	0.23	0.64	0	0	0.62	0.81	2.18	0.02	0.07	0.49	0.39	0.17	0.11	0	0	0	0	0	0	0	0	0											14.51	250	7.54	25.65	0.19	3.49	1.99	1.61	2.39	0.11	0.97	2.52	0.98	2.67	-	0.02	2.34	7.64	14.39	0.33	0.76	1.1	2.17	0.73	1.1	-	-	0.56	0.04	0.21	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	73.97
H5106_014_0	2007	6																					1000											A	A	coin	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	coin	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	1250	336.11	3.38	35.34	21.04	270.63	24.02	1.13	387.2	381.73	0	0	0	0.18	26.15	3662.48	4684.7	128.23	437.92	21.8	211.46	0	602.18	0	0	364.84	0	132.79	0	0	0	0											150 / Admit	150 / Admit	150 / Admit	0 Coinsurance	100 Copay	0 Coinsurance	0 Coinsurance	50 ER / 25 UC	100 ASC / 100 OP	0 Pathology	0 X-Rays / 0 Radiation Therapy	No cost sharing	0 Coinsurance	15 Cardio / 15 Therapy/0 other services	15 PCP/0 Preventive	15 SCP / 15 Chiro / 15 Podiatrist/0 Preventive	30 MH	15 Therapy	0 Coinsurance for All except 0 for Office Visits	15 Hearing &Vision / 0 Preventive/0coinsurance on all other	0 Coinsurance	15 Copay Vision & Hearing Exams/0Coinsurance for Other		0	15 Copay	100 Allowance per year	15 Hearing & Speech	300 Allowance every 3 years			0											91.97	91.97	0.27	0	61.31	0	0	25.47	61.31	0	0	0	0	0.04	9.17	9.2	18.39	9.2	0	3.55	0	9.2	0	0	9.2	0	9.2	0	0	0	0											2.58	0.03	9.62	-	1.38	-	-	0.82	1.95	-	-	-	-	1.16	2.8	3.59	0.2	0.34	-	0.06	-	0.46	-	-	0.28	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.36	0	25.4	2.58	0.03	9.62	-	1.38	-	-	0.82	1.95	-	-	-	-	1.16	2.8	3.59	0.2	0.34	-	0.06	-	0.46	-	-	0.28	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.36	1250	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	20 Coinsurance	20 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											5.51	0.04	0.76	0.4	0.15	0.38	0.02	0.1	0.55	0.21	0.58	0	0	0.56	0.75	2.02	0.02	0.06	0.45	0.35	0.16	0.1	0	0	0	0	0	0	0	0	0											13.19	250	9.4	8.09	0.07	10.38	0.4	1.54	0.38	0.02	0.92	2.5	0.21	0.58	-	0	1.72	3.55	5.61	0.22	0.4	0.45	0.42	0.16	0.56	-	-	0.28	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.55
H5106_015_0	2007	5																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											4.31	0.03	0.56	0.4	0.11	0.38	0.02	0.08	0.43	0.17	0.46	0	0	0.44	0	0	0	0	0	0	0.12	0.01	0	0	0	0.04	0	0.01	0	0	0											7.58	2000	283.46	2.13	36.54	26.26	266.93	25.28	1.18	546.52	28.58	11.06	30.17	0	0.19	29.34	6030.89	12362.61	136.38	451.12	19.91	19.09	8.2	711.73	0	0	365.69	0	133.1	0	0	0	0											10 / Admit	10 / Admit	10 / Admit	10 Coinsurance	100 Copay	10 Coinsurance	10 Coinsurance	50 ER / 25 UC	10 ASC / 10 OP	10 Pathology	10 X-Rays / 10 Radiation Therapy	No cost sharing	10 Coinsurance	20 Cardio / 20 Therapy/10 other services	20 PCP/0 Preventive	20 SCP / 20 Chiro / 20 Podiatrist/0 Preventive	30 MH	20 Therapy	10 Coinsurance for All except 0 for Office Visits	20 Hearing &Vision / 0 Preventive/10coinsurance on all other	10 Coinsurance	20 Copay Vision & Hearing Exams/10Coinsurance for Other		0	20 Copay	100 Allowance per year	20 Hearing & Speech	300 Allowance every 3 years			0											0.06	0.06	0.06	0.06	57.88	0.06	0.06	24.02	0.06	0.06	0.06	0	0.1	0.06	15.22	13.29	30	20	0.03	0.11	0.06	17.82	0	0	20	0	20	0	0	0	0											16.47	0.12	2.12	1.53	1.29	1.47	0.07	1.09	1.66	0.64	1.75	-	0.02	1.64	7.65	13.7	0.34	0.75	0.59	2.02	0.48	1.06	-	-	0.61	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.29	150	31.24	20.78	0.16	2.68	1.93	1.4	1.85	0.09	1.18	2.1	0.81	2.21	-	0.02	2.08	7.65	13.7	0.34	0.75	0.59	2.02	0.6	1.07	-	-	0.61	0.04	0.22	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	64.87	2000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											6.58	0.05	0.85	0.59	0.17	0.61	0.03	0.15	0.68	0.26	0.72	0	0	0.7	0.92	2.39	0.02	0.08	0.45	0.42	0.2	0.11	0	0	0	0	0	0	0	0	0											15.97	250	9.34	27.36	0.21	3.53	2.52	1.56	2.46	0.11	1.32	2.78	1.08	2.94	-	0.02	2.78	8.57	16.09	0.36	0.83	1.04	2.44	0.8	1.19	-	-	0.61	0.04	0.22	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	80.85
H5106_016_0	2007	5																					1000											A	A	coin	coin	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	coin	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	1250	379.1	3.79	36.62	28.1	264.83	25.23	1.18	509.43	502.1	0	0	0	0.19	28.08	3559.41	4620.82	131.6	449.8	19.84	205.59	0	585.16	0	0	354.77	0	129.12	0	0	0	0											150 / Admit	150 / Admit	150 / Admit	0 Coinsurance	100 Copay	0 Coinsurance	0 Coinsurance	50 ER / 25 UC	100 ASC / 100 OP	0 Pathology	0 X-Rays / 0 Radiation Therapy	No cost sharing	0 Coinsurance	15 Cardio / 15 Therapy/0 other services	15 PCP/0 Preventive	15 SCP / 15 Chiro / 15 Podiatrist/0 Preventive	30 MH	15 Therapy	0 Coinsurance for All except 0 for Office Visits	15 Hearing &Vision / 0 Preventive/0coinsurance on all other	0 Coinsurance	15 Copay Vision & Hearing Exams/0Coinsurance for Other		0	15 Copay	100 Allowance per year	15 Hearing & Speech	300 Allowance every 3 years			0											88.95	88.95	0.28	0	59.3	0	0	24.63	59.3	0	0	0	0	0.05	8.87	8.89	17.79	8.89	0	3.43	0	8.89	0	0	8.89	0	8.89	0	0	0	0											2.81	0.03	10.13	-	1.31	-	-	1.05	2.48	-	-	-	-	1.32	2.63	3.43	0.2	0.33	-	0.06	-	0.43	-	-	0.26	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.56	0	28.62	2.81	0.03	10.13	-	1.31	-	-	1.05	2.48	-	-	-	-	1.32	2.63	3.43	0.2	0.33	-	0.06	-	0.43	-	-	0.26	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.56	1250	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	20 Coinsurance	20 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											5.78	0.04	0.78	0.54	0.15	0.39	0.02	0.12	0.58	0.23	0.62	0	0	0.6	0.8	2.08	0.02	0.07	0.4	0.36	0.17	0.1	0	0	0	0	0	0	0	0	0											13.84	250	10.39	8.59	0.07	10.91	0.54	1.46	0.39	0.02	1.17	3.06	0.23	0.62	-	0	1.92	3.43	5.51	0.21	0.4	0.4	0.42	0.17	0.53	-	-	0.26	-	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.41
H5106_017_0	2007	4																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											4.25	0.03	0.57	0.34	0.11	0.39	0.02	0.08	0.43	0.16	0.45	0	0	0.44	0	0	0	0	0	0	0.12	0.01	0	0	0	0.04	0	0.01	0	0	0											7.45	2000	247.54	1.86	33.22	19.61	256.88	22.88	1.07	365.94	24.81	9.6	26.23	0	0.17	25.55	5232.25	12664.69	125.3	414.17	20.59	16.8	7.13	629.07	0	0	336.67	0	122.54	0	0	0	0											10 / Admit	10 / Admit	10 / Admit	10 Coinsurance	100 Copay	10 Coinsurance	10 Coinsurance	50 ER / 25 UC	10 ASC / 10 OP	10 Pathology	10 X-Rays / 10 Radiation Therapy	No cost sharing	10 Coinsurance	20 Cardio / 20 Therapy/10 other services	20 PCP/0 Preventive	20 SCP / 20 Chiro / 20 Podiatrist/0 Preventive	30 MH	20 Therapy	10 Coinsurance for All except 0 for Office Visits	20 Hearing &Vision / 0 Preventive/10coinsurance on all other	10 Coinsurance	20 Copay Vision & Hearing Exams/10Coinsurance for Other		0	20 Copay	100 Allowance per year	20 Hearing & Speech	300 Allowance every 3 years			0											0.06	0.06	0.06	0.06	61.87	0.06	0.06	25.74	0.06	0.06	0.06	0	0.1	0.05	15.61	11.6	30	20	0.03	0.11	0.06	18.61	0	0	20	0	20	0	0	0	0											15.37	0.12	2.06	1.22	1.32	1.42	0.07	0.79	1.54	0.6	1.63	-	0.02	1.31	6.81	12.24	0.31	0.69	0.61	1.79	0.44	0.98	-	-	0.56	-	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.09	150	24.61	19.62	0.15	2.63	1.55	1.43	1.81	0.09	0.87	1.97	0.76	2.08	-	0.02	1.75	6.81	12.24	0.31	0.69	0.61	1.79	0.57	0.99	-	-	0.56	0.04	0.2	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	59.54	2000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											5.99	0.05	0.8	0.45	0.17	0.58	0.03	0.11	0.61	0.24	0.65	0	0	0.63	0.8	2.18	0.02	0.07	0.48	0.38	0.18	0.11	0	0	0	0	0	0	0	0	0											14.53	250	7.57	25.61	0.19	3.43	2.01	1.6	2.39	0.11	0.98	2.58	1	2.73	-	0.02	2.38	7.6	14.42	0.33	0.76	1.09	2.17	0.74	1.09	-	-	0.56	0.04	0.2	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	74.07
H5106_018_0	2007	4																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											4.32	0.03	0.44	0.4	0.11	0.39	0.02	0.08	0.4	0.15	0.42	0	0	0.41	0	0	0	0	0	0	0.11	0.01	0	0	0	0.04	0	0.01	0	0	0											7.36	2000	229.11	1.74	23.55	21.39	229.95	20.74	0.97	371.79	21.18	8.2	22.38	0	0.14	21.78	4582.83	10607.2	114.12	377.44	15.14	14.44	6.08	549.88	0	0	288.14	0	104.87	0	0	0	0											10 / Admit	10 / Admit	10 / Admit	10 Coinsurance	100 Copay	10 Coinsurance	10 Coinsurance	50 ER / 25 UC	10 ASC / 10 OP	10 Pathology	10 X-Rays / 10 Radiation Therapy	No cost sharing	10 Coinsurance	20 Cardio / 20 Therapy/10 other services	20 PCP/0 Preventive	20 SCP / 20 Chiro / 20 Podiatrist/0 Preventive	30 MH	20 Therapy	10 Coinsurance for All except 0 for Office Visits	20 Hearing &Vision / 0 Preventive/10coinsurance on all other	10 Coinsurance	20 Copay Vision & Hearing Exams/10Coinsurance for Other		0	20 Copay	100 Allowance per year	20 Hearing & Speech	300 Allowance every 3 years			0											0.06	0.06	0.06	0.06	64.5	0.06	0.06	26.81	0.06	0.06	0.06	0	0.1	0.06	15.32	12.16	30	20	0.03	0.11	0.06	18.25	0	0	20	0	20	0	0	0	0											14.83	0.11	1.52	1.38	1.24	1.34	0.06	0.83	1.37	0.53	1.45	-	0.01	1.29	5.85	10.75	0.29	0.63	0.45	1.54	0.39	0.84	-	-	0.48	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.35	150	20.7	19.15	0.15	1.97	1.79	1.35	1.73	0.08	0.91	1.77	0.69	1.87	-	0.01	1.7	5.85	10.75	0.29	0.63	0.45	1.54	0.51	0.85	-	-	0.48	0.04	0.17	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	54.71	2000	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											5.83	0.04	0.59	0.52	0.16	0.54	0.03	0.11	0.55	0.21	0.58	0	0	0.56	0.7	1.97	0.02	0.06	0.37	0.34	0.16	0.09	0	0	0	0	0	0	0	0	0											13.43	250	6.32	24.98	0.19	2.56	2.31	1.5	2.28	0.11	1.02	2.32	0.9	2.45	-	0.02	2.26	6.55	12.72	0.3	0.69	0.81	1.88	0.67	0.94	-	-	0.48	0.04	0.17	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	68.14
H5106_805_0	2007	4																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											3.8	0.03	0.51	0.27	0.11	0.38	0.02	0.07	0.35	0.14	0.37	0	0	0.36	0.17	0.64	0	0	0.1	0	0.1	0.01	0	0	0	0.04	0	0.01	0	0	0											7.47	7500	256.35	1.94	34.19	17.95	285.75	25.78	1.21	377.18	23.65	9.15	25.01	0	0.18	24.43	5700.33	13194.47	137.8	445.44	23	18.38	6.8	684	0	0	369.32	0	134.42	0	0	0	0											20 / Admit	20 / Admit	20 / Admit	20 Coinsurance	100 Copay	20 Coinsurance	20 Coinsurance	50 ER / 25 UC	20 ASC / 20 OP	20 Pathology	20 X-Rays / 20 Radiation Therapy	No cost sharing	20 Coinsurance	25 Cardio / 25 Therapy/20 other services	25 PCP/0 Preventive	25 SCP / 25 Chiro / 25 Podiatrist/0 Preventive	30 MH	25 Therapy	20 Coinsurance for All except 0 for Office Visits	25 Hearing &Vision / 0 Preventive/20coinsurance on all other	20 Coinsurance	25 Copay Vision & Hearing Exams/20Coinsurance for Other		0	25 Copay	100 Allowance per year	25 Hearing & Speech	300 Allowance every 3 years			0											0.1	0.1	0.1	0.1	50.76	0.1	0.1	21.13	0.1	0.1	0.1	0	0.2	0.07	19.22	14.6	30	25	0.03	0.21	0.1	23.6	0	0	25	0	25	0	0	0	0											26.2	0.2	3.49	1.83	1.21	2.63	0.12	0.66	2.42	0.93	2.56	-	0.04	1.7	9.13	16.06	0.34	0.93	0.68	3.8	0.7	1.35	-	-	0.77	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.02	150	51.87	30	0.23	4	2.1	1.32	3.02	0.14	0.73	2.77	1.07	2.93	-	0.04	2.06	9.3	16.7	0.34	0.93	0.78	3.8	0.8	1.36	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	85.5	7500	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											9.09	0.07	1.21	0.62	0.27	0.93	0.04	0.16	0.84	0.33	0.89	0	0.01	0.86	1.28	3.39	0.03	0.11	0.78	0.61	0.24	0.17	0	0	0	0	0	0	0	0	0											21.94	500	3.03	39.09	0.3	5.21	2.72	1.59	3.95	0.18	0.89	3.61	1.4	3.82	-	0.04	2.92	10.59	20.09	0.38	1.04	1.56	4.41	1.04	1.52	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	107.43
H5106_806_0	2007	4																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											3.8	0.03	0.51	0.27	0.11	0.38	0.02	0.07	0.35	0.14	0.37	0	0	0.36	0.17	0.64	0	0	0.1	0	0.1	0.01	0	0	0	0.04	0	0.01	0	0	0											7.47	7500	256.35	1.94	34.19	17.95	285.75	25.78	1.21	377.18	23.65	9.15	25.01	0	0.18	24.43	5700.33	13194.47	137.8	445.44	23	18.38	6.8	684	0	0	369.32	0	134.42	0	0	0	0											20 / Admit	20 / Admit	20 / Admit	20 Coinsurance	100 Copay	20 Coinsurance	20 Coinsurance	50 ER / 25 UC	20 ASC / 20 OP	20 Pathology	20 X-Rays / 20 Radiation Therapy	No cost sharing	20 Coinsurance	25 Cardio / 25 Therapy/20 other services	25 PCP/0 Preventive	25 SCP / 25 Chiro / 25 Podiatrist/0 Preventive	30 MH	25 Therapy	20 Coinsurance for All except 0 for Office Visits	25 Hearing &Vision / 0 Preventive/20coinsurance on all other	20 Coinsurance	25 Copay Vision & Hearing Exams/20Coinsurance for Other		0	25 Copay	100 Allowance per year	25 Hearing & Speech	300 Allowance every 3 years			0											0.1	0.1	0.1	0.1	50.76	0.1	0.1	21.13	0.1	0.1	0.1	0	0.2	0.07	19.22	14.6	30	25	0.03	0.21	0.1	23.6	0	0	25	0	25	0	0	0	0											26.2	0.2	3.49	1.83	1.21	2.63	0.12	0.66	2.42	0.93	2.56	-	0.04	1.7	9.13	16.06	0.34	0.93	0.68	3.8	0.7	1.35	-	-	0.77	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.02	150	51.87	30	0.23	4	2.1	1.32	3.02	0.14	0.73	2.77	1.07	2.93	-	0.04	2.06	9.3	16.7	0.34	0.93	0.78	3.8	0.8	1.36	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	85.5	7500	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											9.09	0.07	1.21	0.62	0.27	0.93	0.04	0.16	0.84	0.33	0.89	0	0.01	0.86	1.28	3.39	0.03	0.11	0.78	0.61	0.24	0.17	0	0	0	0	0	0	0	0	0											21.94	500	3.03	39.09	0.3	5.21	2.72	1.59	3.95	0.18	0.89	3.61	1.4	3.82	-	0.04	2.92	10.59	20.09	0.38	1.04	1.56	4.41	1.04	1.52	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	107.43
H5106_807_0	2007	5																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											3.8	0.03	0.51	0.27	0.11	0.38	0.02	0.07	0.35	0.14	0.37	0	0	0.36	0.17	0.64	0	0	0.1	0	0.1	0.01	0	0	0	0.04	0	0.01	0	0	0											7.47	7500	256.35	1.94	34.19	17.95	285.75	25.78	1.21	377.18	23.65	9.15	25.01	0	0.18	24.43	5700.33	13194.47	137.8	445.44	23	18.38	6.8	684	0	0	369.32	0	134.42	0	0	0	0											20 / Admit	20 / Admit	20 / Admit	20 Coinsurance	100 Copay	20 Coinsurance	20 Coinsurance	50 ER / 25 UC	20 ASC / 20 OP	20 Pathology	20 X-Rays / 20 Radiation Therapy	No cost sharing	20 Coinsurance	25 Cardio / 25 Therapy/20 other services	25 PCP/0 Preventive	25 SCP / 25 Chiro / 25 Podiatrist/0 Preventive	30 MH	25 Therapy	20 Coinsurance for All except 0 for Office Visits	25 Hearing &Vision / 0 Preventive/20coinsurance on all other	20 Coinsurance	25 Copay Vision & Hearing Exams/20Coinsurance for Other		0	25 Copay	100 Allowance per year	25 Hearing & Speech	300 Allowance every 3 years			0											0.1	0.1	0.1	0.1	50.76	0.1	0.1	21.13	0.1	0.1	0.1	0	0.2	0.07	19.22	14.6	30	25	0.03	0.21	0.1	23.6	0	0	25	0	25	0	0	0	0											26.2	0.2	3.49	1.83	1.21	2.63	0.12	0.66	2.42	0.93	2.56	-	0.04	1.7	9.13	16.06	0.34	0.93	0.68	3.8	0.7	1.35	-	-	0.77	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.02	150	51.87	30	0.23	4	2.1	1.32	3.02	0.14	0.73	2.77	1.07	2.93	-	0.04	2.06	9.3	16.7	0.34	0.93	0.78	3.8	0.8	1.36	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	85.5	7500	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											9.09	0.07	1.21	0.62	0.27	0.93	0.04	0.16	0.84	0.33	0.89	0	0.01	0.86	1.28	3.39	0.03	0.11	0.78	0.61	0.24	0.17	0	0	0	0	0	0	0	0	0											21.94	500	3.03	39.09	0.3	5.21	2.72	1.59	3.95	0.18	0.89	3.61	1.4	3.82	-	0.04	2.92	10.59	20.09	0.38	1.04	1.56	4.41	1.04	1.52	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	107.43
H5106_808_0	2007	5																					1500											coin	coin	coin	coin	T	coin	coin	V	coin	coin	coin	O	coin	coin	V	V	V	V	coin	coin	coin	O	T	P	V	P	V	P	O	O	V											3.8	0.03	0.51	0.27	0.11	0.38	0.02	0.07	0.35	0.14	0.37	0	0	0.36	0.17	0.64	0	0	0.1	0	0.1	0.01	0	0	0	0.04	0	0.01	0	0	0											7.47	7500	256.35	1.94	34.19	17.95	285.75	25.78	1.21	377.18	23.65	9.15	25.01	0	0.18	24.43	5700.33	13194.47	137.8	445.44	23	18.38	6.8	684	0	0	369.32	0	134.42	0	0	0	0											20 / Admit	20 / Admit	20 / Admit	20 Coinsurance	100 Copay	20 Coinsurance	20 Coinsurance	50 ER / 25 UC	20 ASC / 20 OP	20 Pathology	20 X-Rays / 20 Radiation Therapy	No cost sharing	20 Coinsurance	25 Cardio / 25 Therapy/20 other services	25 PCP/0 Preventive	25 SCP / 25 Chiro / 25 Podiatrist/0 Preventive	30 MH	25 Therapy	20 Coinsurance for All except 0 for Office Visits	25 Hearing &Vision / 0 Preventive/20coinsurance on all other	20 Coinsurance	25 Copay Vision & Hearing Exams/20Coinsurance for Other		0	25 Copay	100 Allowance per year	25 Hearing & Speech	300 Allowance every 3 years			0											0.1	0.1	0.1	0.1	50.76	0.1	0.1	21.13	0.1	0.1	0.1	0	0.2	0.07	19.22	14.6	30	25	0.03	0.21	0.1	23.6	0	0	25	0	25	0	0	0	0											26.2	0.2	3.49	1.83	1.21	2.63	0.12	0.66	2.42	0.93	2.56	-	0.04	1.7	9.13	16.06	0.34	0.93	0.68	3.8	0.7	1.35	-	-	0.77	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.02	150	51.87	30	0.23	4	2.1	1.32	3.02	0.14	0.73	2.77	1.07	2.93	-	0.04	2.06	9.3	16.7	0.34	0.93	0.78	3.8	0.8	1.36	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	85.5	7500	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	100 Copay	30 Coinsurance	30 Coinsurance	50 ER / 30 UC	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		0	0	0	0	0	0	0	0											9.09	0.07	1.21	0.62	0.27	0.93	0.04	0.16	0.84	0.33	0.89	0	0.01	0.86	1.28	3.39	0.03	0.11	0.78	0.61	0.24	0.17	0	0	0	0	0	0	0	0	0											21.94	500	3.03	39.09	0.3	5.21	2.72	1.59	3.95	0.18	0.89	3.61	1.4	3.82	-	0.04	2.92	10.59	20.09	0.38	1.04	1.56	4.41	1.04	1.52	-	-	0.77	0.04	0.28	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	107.43
H5151_002_0	2007	6																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	2178.4	56.7	2340	2183.2	414.2	18.93	0	410.4	393.9	16493	1886.5	653.7	655.6	2270.7	4468.2	3914.7	177.5	4.8	129.2	0	14.68	0	0	0	236.5	195.5	18.1	0	0	0.5	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	100	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.97	45.97	0	0	25	20	20	50	85	0	0	0	0	11.2	15	15	20	20	0	0	20	0	0	0	15	15	0	0	0	0	0											8.35	0.22	-	-	0.86	3.79	-	1.71	2.79	-	-	-	-	2.12	5.59	4.89	0.3	0.01	-	-	2.94	-	-	-	0.3	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.09			8.35	0.22	-	-	0.86	3.79	-	1.71	2.79	-	-	-	-	2.12	5.59	4.89	0.3	0.01	-	-	2.94	-	-	-	0.3	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.09	N/A																																																																																			-			8.35	0.22	-	-	0.86	3.79	-	1.71	2.79	-	-	-	-	2.12	5.59	4.89	0.3	0.01	-	-	2.94	-	-	-	0.3	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.09
H5151_003_0	2007	6																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1936.3	50.4	2079.9	1940.6	368.1	16.83	0	364.8	350.1	14660	1676.8	581.1	582.7	2018.3	3971.6	3479.6	157.7	4.3	114.9	0	13.05	0	0	0	210.2	173.8	16.1	0	0	0.4	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	100	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.97	45.97	0	0	0	20	20	50	85	0	0	0	0	11.2	15	15	20	20	0	0	20	0	0	0	15	15	0	0	0	0	0											7.42	0.19	-	-	-	3.37	-	1.52	2.48	-	-	-	-	1.88	4.96	4.35	0.26	0.01	-	-	2.61	-	-	-	0.26	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.53			7.42	0.19	-	-	-	3.37	-	1.52	2.48	-	-	-	-	1.88	4.96	4.35	0.26	0.01	-	-	2.61	-	-	-	0.26	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.53	N/A																																																																																			-			7.42	0.19	-	-	-	3.37	-	1.52	2.48	-	-	-	-	1.88	4.96	4.35	0.26	0.01	-	-	2.61	-	-	-	0.26	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.53
H5151_004_0	2007	2																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	2023.5	52.6	2173.7	2028	384.7	17.59	0	381.2	365.9	15320.4	1752.4	607.3	609	2109.2	4150.5	3636.4	164.9	4.5	120	0	13.64	0	0	0	219.7	181.6	16.8	0	0	0.4	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	0	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.97	45.97	0	0	0	20	20	50	0	0	0	0	0	11.2	15	15	20	20	0	0	20	0	0	0	15	15	0	0	0	0	0											7.75	0.2	-	-	-	3.52	-	1.59	-	-	-	-	-	1.97	5.19	4.55	0.27	0.01	-	-	2.73	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.27			7.75	0.2	-	-	-	3.52	-	1.59	-	-	-	-	-	1.97	5.19	4.55	0.27	0.01	-	-	2.73	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.27	N/A																																																																																			-			7.75	0.2	-	-	-	3.52	-	1.59	-	-	-	-	-	1.97	5.19	4.55	0.27	0.01	-	-	2.73	-	-	-	0.27	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.27
H5151_005_0	2007	2																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	1761.5	45.8	1892.2	1765.4	334.9	15.31	0	331.8	318.5	13336.6	1525.5	528.6	530.1	1836.1	3613.1	3165.5	143.5	3.9	104.5	0	11.87	0	0	0	191.2	158.1	14.6	0	0	0.4	0											50 / days 1-10	50 / days 1-10	0	0	25	0	0	50	0	0	50	0	35	25	15	25	25	25	0	0	0.2	0	0	0	15	15	0	0	0	0	0											45.97	45.97	0	0	0	0.2	0.2	50	0	0	0	0	0	11.2	15	15	20	20	0	0	0.2	0	0	0	15	15	0	0	0	0	0											6.75	0.18	-	-	-	3.06	-	1.38	-	-	-	-	-	1.71	4.52	3.96	0.24	0.01	-	-	2.37	-	-	-	0.24	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.61			6.75	0.18	-	-	-	3.06	-	1.38	-	-	-	-	-	1.71	4.52	3.96	0.24	0.01	-	-	2.37	-	-	-	0.24	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.61	N/A																																																																																			-			6.75	0.18	-	-	-	3.06	-	1.38	-	-	-	-	-	1.71	4.52	3.96	0.24	0.01	-	-	2.37	-	-	-	0.24	0.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.61
H5151_802_0	2007	2																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	2192.7	102.2	2333.9	2514.7	454.8	16.18	0	361.3	317.2	12761.1	1326.9	462.5	305.5	2345.2	3434.5	3176.3	90.7	14.5	100.4	0	20.49	0	0	0	73.2	54.4	6	0	0	0	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	0	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.97	45.97	0	0	0	20	20	50	0	0	0	0	0	4.82	15	15	20	20	0	0	20	0	0	0	15	15	0	0	0	0	0											8.4	0.39	-	-	-	3.24	-	1.51	-	-	-	-	-	0.94	4.29	3.97	0.15	0.02	-	-	4.1	-	-	-	0.09	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.17			8.4	0.39	-	-	-	3.24	-	1.51	-	-	-	-	-	0.94	4.29	3.97	0.15	0.02	-	-	4.1	-	-	-	0.09	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.17	N/A																																																																																			-			8.4	0.39	-	-	-	3.24	-	1.51	-	-	-	-	-	0.94	4.29	3.97	0.15	0.02	-	-	4.1	-	-	-	0.09	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.17
H5151_803_0	2007	2																					N/A											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	O	T	V	V	P	V	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	2192.7	102.2	2333.9	2514.7	454.8	16.18	0	361.3	317.2	12761.1	1326.9	462.5	305.5	2345.2	3434.5	3176.3	90.7	14.5	100.4	0	20.49	0	0	0	73.2	54.4	6	0	0	0	0											50 / days 1-10	50 / days 1-10	0	0	25	20	20	50	0	0	50	0	35	25	15	25	25	25	0	0	20	0	0	0	15	15	0	0	0	0	0											45.97	45.97	0	0	0	20	20	50	0	0	0	0	0	4.82	15	15	20	20	0	0	20	0	0	0	15	15	0	0	0	0	0											8.4	0.39	-	-	-	3.24	-	1.51	-	-	-	-	-	0.94	4.29	3.97	0.15	0.02	-	-	4.1	-	-	-	0.09	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.17			8.4	0.39	-	-	-	3.24	-	1.51	-	-	-	-	-	0.94	4.29	3.97	0.15	0.02	-	-	4.1	-	-	-	0.09	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.17	N/A																																																																																			-			8.4	0.39	-	-	-	3.24	-	1.51	-	-	-	-	-	0.94	4.29	3.97	0.15	0.02	-	-	4.1	-	-	-	0.09	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.17
H5204_002_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		517.81	119.31	219.89		50.36	29.19	36.82	28.01	34.54	57.6	19.36	2.48	3.18	178.73	14.89	35.97	59.2	2.86	24.25	238.29	37.46	0.03																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co																				0.08	0.08	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				42.15	9.71	37.16	-	11.88	6.89	8.69	6.61	8.15	13.59	4.57	0.58	0.75	42.18	3.51	8.49	13.97	0.68	5.72	56.24	8.84	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	290.38		0	42.15	9.71	37.16	-	11.88	6.89	8.69	6.61	8.15	13.59	4.57	0.58	0.75	42.18	3.51	8.49	13.97	0.68	5.72	56.24	8.84	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	290.38																																																																																				-		0	42.15	9.71	37.16	-	11.88	6.89	8.69	6.61	8.15	13.59	4.57	0.58	0.75	42.18	3.51	8.49	13.97	0.68	5.72	56.24	8.84	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	290.38
H5206_002_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		628.88	63.49	340.88		41.28	26.02	39.43	36	22.39	40.03	11.48	1.75	3.41	126.48	9.14	34.22	38.37	2.13	28.3	240.46	35.63	0.04																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co																				0.08	0.08	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				51.19	5.17	57.61	-	9.74	6.14	9.31	8.5	5.28	9.45	2.71	0.41	0.8	29.85	2.16	8.07	9.06	0.5	6.68	56.75	8.41	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	287.8	138	0	51.19	5.17	57.61	0	9.74	6.14	9.31	8.5	5.28	9.45	2.71	0.41	0.8	29.85	2.16	8.07	9.06	0.5	6.68	56.75	8.41	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	287.8																																																																																				-		0	51.19	5.17	57.61	0	9.74	6.14	9.31	8.5	5.28	9.45	2.71	0.41	0.8	29.85	2.16	8.07	9.06	0.5	6.68	56.75	8.41	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	287.8
H5206_003_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		541.41	54.66	466.99		61.89	15.33	23.23	31.56	24.28	55.88	16.02	2.44	4.75	176.5	11.02	39.55	44.4	2.47	32.74	283.04	55.27	0.09																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co																				0.08	0.08	0.15		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				41.04	4.14	69.16	-	14.61	3.62	5.48	7.45	5.73	13.19	3.78	0.58	1.12	41.66	2.6	9.33	10.48	0.58	7.73	66.8	13.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	322.13	138	0	41.04	4.14	69.16	-	14.61	3.62	5.48	7.45	5.73	13.19	3.78	0.58	1.12	41.66	2.6	9.33	10.48	0.58	7.73	66.8	13.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	322.13																																																																																				-		0	41.04	4.14	69.16	-	14.61	3.62	5.48	7.45	5.73	13.19	3.78	0.58	1.12	41.66	2.6	9.33	10.48	0.58	7.73	66.8	13.04	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	322.13
H5207_001_0	2007	1																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		521.47	42	302.37		51.37	32.48	52.13	41.68	14.96	65.3	18.29	2.84	5.79	207.71	10.63	42.35	43.51	2.59	36.39	304.17	47.44	0.05																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				38.43	3.1	52.44	-	12.12	7.67	12.3	9.84	3.53	15.41	4.32	0.67	1.37	49.02	2.51	9.99	10.27	0.61	8.59	71.78	11.2	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	325.17	138	0	38.43	3.1	52.44	-	12.12	7.67	12.3	9.84	3.53	15.41	4.32	0.67	1.37	49.02	2.51	9.99	10.27	0.61	8.59	71.78	11.2	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	325.17																																																																																				-		0	38.43	3.1	52.44	-	12.12	7.67	12.3	9.84	3.53	15.41	4.32	0.67	1.37	49.02	2.51	9.99	10.27	0.61	8.59	71.78	11.2	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	325.17
H5209_002_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		452.51	34.36	310.86		38.13	17.27	27.29	25.71	18.8	47.09	12.91	2.05	4.51	147.98	8.09	32.79	32.81	1.93	28.35	236.71	25.06	0.04																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co																				0.08	0.08	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				36.83	2.8	52.53	-	9	4.08	6.44	6.07	4.44	11.11	3.05	0.48	1.06	34.92	1.91	7.74	7.74	0.46	6.69	55.86	5.91	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	259.14	138	0	36.83	2.8	52.53	-	9	4.08	6.44	6.07	4.44	11.11	3.05	0.48	1.06	34.92	1.91	7.74	7.74	0.46	6.69	55.86	5.91	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	259.14																																																																																				-		0	36.83	2.8	52.53	-	9	4.08	6.44	6.07	4.44	11.11	3.05	0.48	1.06	34.92	1.91	7.74	7.74	0.46	6.69	55.86	5.91	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	259.14
H5211_001_0	2007	1																					500 on all but ER; no limit on ER																		V							V	V	V								V		V																																																								-	500 on all but ER; no limit on ER								280.78							3352.78	5294.87	73.41								2.13		0															no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	50 per visit if not admitted	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	15 per visit	15 per visit	15 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	15 per visit	no cost sharing	15 per visit	no cost sharing	an optional benefit (see wkst 7)	no cost sharing	no cost sharing																		50							14.06	14.06	14.06								14.06		14.06															-	-	-	-	-	-	-	1.17	-	-	-	-	-	-	3.93	6.2	0.09	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.39	0	0.69	-	-	-	-	-	-	-	1.17	-	-	-	-	-	-	3.93	6.2	0.09	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.39	500 on all but ER; no limit on ER																																																																																			-		0.39	-	-	-	-	-	-	-	1.17	-	-	-	-	-	-	3.93	6.2	0.09	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.39
H5211_002_0	2007	5																					2500 on all but ER; no limit on ER											D	D	D		T	Coin	Coin	V	V						V	V	V								V		V																																																								-		819.41	17.33	795.43		97.28	2.61	5.96	165.57	333.69					133.13	1960.51	3060.94	43.89								2.13		0															150 each of days 1-5/admit	150 each of days 1-5/admit	50 for each of days 1-20/admit	no cost sharing	50 per trip	20 coinsurance	20 coinsurance	50 per visit if not admitted	50 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing	ASC 50/visit	30 per visit	30 per visit	30 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	30 per visit	no cost sharing	30 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing											97.32	71.82	44.57		45.2	0.18	0.18	50	45.2					45.2	27.12	27.12	27.12								27.12		27.12															6.65	0.1	2.95	-	0.37	0.47	1.08	0.69	1.26	-	-	-	-	0.5	4.43	6.92	0.1	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.52		2.64	6.65	0.1	2.95	-	0.37	0.47	1.08	0.69	1.26	-	-	-	-	0.5	4.43	6.92	0.1	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.52																																																																																				-			6.65	0.1	2.95	-	0.37	0.47	1.08	0.69	1.26	-	-	-	-	0.5	4.43	6.92	0.1	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.52
H5211_003_0	2007	2																					2500 on all but ER; no limit on ER											D	D	D		T	Coin	Coin	V	V					V	V	V	V								V		V																																																								-		802.1	16.97	778.63		95.22	2.55	5.83	162.08	326.64					130.32	1919.1	2996.29	42.96								2.13		0															150 each of days 1-5/admit	150 each of days 1-5/admit	50 for each of days 1-20/admit	no cost sharing	50 per trip	20 coinsurance	20 coinsurance	50 per visit if not admitted	50 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing	ASC 50/visit	30 per visit	30 per visit	30 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	30 per visit	no cost sharing	30 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing											97.32	71.82	44.57		45.2	0.18	0.18	50	45.2					45.2	27.12	27.12	27.12								27.12		27.12															6.51	0.1	2.89	-	0.36	0.46	1.05	0.68	1.23	-	-	-	-	0.49	4.34	6.77	0.1	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.98		2.58	6.51	0.1	2.89	-	0.36	0.46	1.05	0.68	1.23	-	-	-	-	0.49	4.34	6.77	0.1	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.98																																																																																				-			6.51	0.1	2.89	-	0.36	0.46	1.05	0.68	1.23	-	-	-	-	0.49	4.34	6.77	0.1	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.98
H5211_004_0	2007	4																					500 on all but ER; no limit on ER																		V							V	V	V								V		V																																																								-	500 on all but ER; no limit on ER								286.84							3425.12	5409.11	74.99								2.13		0															no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	50 per visit if not admitted	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	15 per visit	15 per visit	15 per visit	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	no cost sharing	15 per visit	no cost sharing	15 per visit	no cost sharing	an optional benefit (see wkst 7)	no cost sharing	no cost sharing																		50							14.06	14.06	14.06								14.06		14.06															-	-	-	-	-	-	-	1.2	-	-	-	-	-	-	4.01	6.34	0.09	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.63	0	0.7	-	-	-	-	-	-	-	1.2	-	-	-	-	-	-	4.01	6.34	0.09	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.63	500 on all but ER; no limit on ER																																																																																			-		0.39	-	-	-	-	-	-	-	1.2	-	-	-	-	-	-	4.01	6.34	0.09	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.63
H5214_003_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin									Coin		D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1218.91	8.9	437.28	2086.36	121.66	0.67	0.05	197.41	430.32	793.57	541.07	36.07	369.9	306.61	6974.18	8272.64			305.06		9.29											64.15	0.47	15.11								175/day (1-5)	175/day (1-5)	0/day (1-13) 75/day (14-100)	15/Visit	100/ Trip	20 Coins	20 Coins	35-50/ Visit	100-150/ Visit	0-75/ Visit	50-75/ Visit	50/ Visit	0/ Procedure	35-75/ Visit	5/ Visit	35/ Visit			50/ Visit		20 Coins											175/day (1-5)	175/day (1-5)	20 Coins								119.04	119.04	11.79	15	100	0.2	0.2	49.63	116.5	57.95	54.17	50	0	42.06	5	35			50		0.2											119.04	119.04	0.2								12.09	0.09	0.43	2.61	1.01	0.13	0.01	0.82	4.18	3.83	2.44	0.15	-	1.07	2.91	24.13	-	-	1.27	-	1.86	-	-	-	-	-	-	-	-	-	-	0.64	0	3.02	-	-	-	-	-	-	-	62.7	0	0	12.09	0.09	0.43	2.61	1.01	0.13	0.01	0.82	4.18	3.83	2.44	0.15	-	1.07	2.91	24.13	-	-	1.27	-	1.86	-	-	-	-	-	-	-	-	-	-	0.64	0	3.02	-	-	-	-	-	-	-	62.7		25 Coins	25 Coins	25 Coins	25 Coins	100/Trip	40 Coins		50/Visit	25 Coins	25 Coins			0/Procedure		25 Coins	25 Coins					20 Coins													25 Coins								8.29	0.03	0.28	0.38	0.3	0.04		0.3	3.43	4.04			0		2.56	3.08					0.66													0.88								24.28	500	0	20.38	0.12	0.7	2.98	1.32	0.18	0.01	1.12	7.6	7.88	2.44	0.15	-	1.07	5.47	27.21	-	-	1.27	-	2.52	-	-	-	-	-	-	-	-	-	-	0.64	0	3.9	-	-	-	-	-	-	-	86.98
H5214_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		250.34	1.89	222.47	2122.85	123.79	0.69	0.05	244.95	437.84	807.45	550.54	36.7	376.37	311.97	7096.16	8417.33			310.39		9.62											13.18	0.1									600/admit	600/admit	100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35-50/ Visit		20 Coins											600/admit	600/admit									600	600	17.61	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			43.14		0.2											600	600									12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.78	24.55	-	-	1.12	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.92	0	0	12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.78	24.55	-	-	1.12	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.92		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.23	0.02	0.38	0.52	0.26	0.05		0.26	4.73	5.59			0		1.77	4.26					0.57																					20.63	0	0	14.74	0.11	0.71	2.29	1.29	0.22	0.01	1.18	12.03	7.94	2.1	0.31	-	0.98	16.56	28.81	-	-	1.12	-	2.5	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	93.55
H5214_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		246.48	1.86	438.08	2090.14	121.88	0.67	0.05	241.18	431.1	795.01	542.05	36.14	370.57	307.16	6986.81	8287.62			305.61		9.32											12.97	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.32	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.18	2.32	2.07	0.3	-	0.96	14.56	24.17	-	-	0.89	-	1.86	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.56	0	0	12.32	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.18	2.32	2.07	0.3	-	0.96	14.56	24.17	-	-	0.89	-	1.86	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.56		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.19	0.02	0.37	0.5	0.25	0.04		0.25	4.59	5.42			0		1.72	4.13					0.55																					20.04	0	0	14.52	0.11	0.69	2.25	1.27	0.21	0.01	1.16	11.77	7.73	2.07	0.3	-	0.96	16.27	28.3	-	-	0.89	-	2.42	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	91.6
H5214_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		250.34	1.89	222.47	2122.85	123.79	0.69	0.05	244.95	437.84	807.45	550.54	36.7	376.37	311.97	7096.16	8417.33			310.39		9.62											13.18	0.1									600/admit	600/admit	100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35-50/ Visit		20 Coins											600/admit	600/admit									600	600	17.61	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			43.14		0.2											600	600									12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.78	24.55	-	-	1.12	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.92	0	0	12.52	0.09	0.33	1.77	1.03	0.17	0.01	0.92	7.3	2.36	2.1	0.31	-	0.98	14.78	24.55	-	-	1.12	-	1.92	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	72.92		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.23	0.02	0.38	0.52	0.26	0.05		0.26	4.73	5.59			0		1.77	4.26					0.57																					20.63	0	0	14.74	0.11	0.71	2.29	1.29	0.22	0.01	1.18	12.03	7.94	2.1	0.31	-	0.98	16.56	28.81	-	-	1.12	-	2.5	-	-	-	-	-	-	-	-	-	-	0.66	0	-	-	-	-	-	-	-	-	93.55
H5214_805_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		246.48	1.86	438.08	2090.14	121.88	0.67	0.05	241.18	431.1	795.01	542.05	36.14	370.57	307.16	6986.81	8287.62			305.61		9.32											12.97	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.32	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.18	2.32	2.07	0.3	-	0.96	14.56	24.17	-	-	0.89	-	1.86	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.56	0	0	12.32	0.09	0.32	1.74	1.02	0.17	0.01	0.91	7.18	2.32	2.07	0.3	-	0.96	14.56	24.17	-	-	0.89	-	1.86	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	71.56		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.19	0.02	0.37	0.5	0.25	0.04		0.25	4.59	5.42			0		1.72	4.13					0.55																					20.04	0	0	14.52	0.11	0.69	2.25	1.27	0.21	0.01	1.16	11.77	7.73	2.07	0.3	-	0.96	16.27	28.3	-	-	0.89	-	2.42	-	-	-	-	-	-	-	-	-	-	0.65	0	-	-	-	-	-	-	-	-	91.6
H5215_001_0	2007	4																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	153.52	7.41	4.52	317.76	0	0	260.04	0	0	74.29	2926.67	2615.06	146.11	396.62	0	1210.9	6.12	452.79	0	0	0	230.33	0	0	0	0	0											PBP: 1A IP Acute: 0	1B IP Psych: 0	2 SNF: 0	6 Home Health: 0	10A Ambulance: 25	11A DME: 10	11B Prosthetics/Medical Supplies: 10 11C Diabetes Monitoring Supplies: 10	4A ER: 50 4B Urgent Care: 10	9B ASC Services: 0	8A: See Radiology	8A: CAT MRI = 50; 8B OP X-Ray: 5	9A OP Hospital: 0	12 Renal Dialysis: 10 copay (not for facility)	3 CORF: 10 9C OP Sub Abuse:  10 9D Cardiac Rehab: 10	7A PCP: 5 14B Immunizations: 0 14C Routine Physical Exams: 0 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 10 7D Physician Specialist: 10 7F Podiatry: 10	7E Mental Health: 10 7H Psychiatric: 10	7C Occupational Therapy: 10 7I Physical and Speech Therapy: 10	Included in i.2.	7G Other Health Care: 5 18A Medicare Covered Hearing Exams: 5	15 Part B Drugs: 5 coins 1000 OOP max	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10 17A Medicare Covered Eye Exams: 10	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A: Eye Exams: Not Covered	17B Eye Wear: 10 100 Annual max plan coverage	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0	0	0	0	25	0.1	0.1	48.73	0	0	34.25	0	0	10	5.05	10	10	10	0	10	0.05	10	0	0	0	10	0	0	0	0	0											-	-	-	-	0.32	0.74	0.45	1.29	-	-	0.74	-	-	0.06	1.23	2.18	0.12	0.33	-	1.01	0.31	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.35	0	0	-	-	-	-	0.32	0.74	0.45	1.29	-	-	0.74	-	-	0.06	1.23	2.18	0.12	0.33	-	1.01	0.31	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.35	2000	75/Day (days 1-7)	75/Day (days 1-7) with preauthorization 125/day (days 1-7) otherwise	50/Day (days 21-100)	15 Copay	25 Copay	10 Coinsurance with preauth 20 otherwise	10 Coinsurance with preauth 20 otherwise	50 ER Copay 10 UC Copay	75 Copay	No Cost Share	10 to 100 Copay	10 Copay	No Cost Share	10 -15 Copay	10 Copay	15 Copay for Chiropractic Physician Specialist Podiatrist	15 Copay	15 Copay	Included in i.2.	15 Copay	20 Coins 2000 OOP Max	15 Copay eye exams 10 copay comp. Dental	Not Covered	Not Covered	Not Covered	15 Copay (100 Allowance)	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											0.6	0.01	0.44	0.14	0.06	0.18	0.11	0.26	0.38	0	0.29	0	0	0.01	0.51	0.67	0.04	0.1	0	0.31	0.12	0.12	0	0	0	0.06	0	0	0	0	0											4.42	0	0.27	0.6	0.01	0.44	0.14	0.38	0.92	0.56	1.56	0.38	-	1.03	0	0	0.07	1.74	2.85	0.16	0.43	-	1.32	0.43	0.5	-	-	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.78
H5215_002_0	2007	5																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	153.52	7.41	4.52	317.76	0	0	260.04	0	0	74.29	2926.7	2615.08	146.11	396.62	0	1210.93	6.11	452.79	0	0	0	230.33	0	0	0	0	0											PBP: 1A IP Acute: 0	1B IP Psych: 0	2 SNF: 0	6 Home Health: 0	10A Ambulance: 25	11A DME: 10	11B Prosthetics/Medical Supplies: 10 11C Diabetes Monitoring Supplies: 10	4A ER: 50 4B Urgent Care: 10	9B ASC Services: 0	8A: See Radiology	8A: CAT MRI = 50; 8B OP X-Ray: 5	9A OP Hospital: 0	12 Renal Dialysis: 10 copay (not for facility)	3 CORF: 10 9C OP Sub Abuse:  10 9D Cardiac Rehab: 10	7A PCP: 5 14B Immunizations: 0 14C Routine Physical Exams: 0 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7B Chiropractic: 10 7D Physician Specialist: 10 7F Podiatry: 10	7E Mental Health: 10 7H Psychiatric: 10	7C Occupational Therapy: 10 7I Physical and Speech Therapy: 10	Included in i.2.	7G Other Health Care: 5 18A Medicare Covered Hearing Exams: 5	15 Part B Drugs: 5 coins 1000 OOP max	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10 17A Medicare Covered Eye Exams: 10	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A: Eye Exams: Not Covered	17B Eye Wear: 10 100 Annual max plan coverage	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0	0	0	0	25	0.1	0.1	48.73	0	0	34.25	0	0	10	5.05	10	10	10	0	10	0.05	10	0	0	0	10	0	0	0	0	0											-	-	-	-	0.32	0.74	0.45	1.29	-	-	0.74	-	-	0.06	1.23	2.18	0.12	0.33	-	1.01	0.31	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.35	0	0	-	-	-	-	0.32	0.74	0.45	1.29	-	-	0.74	-	-	0.06	1.23	2.18	0.12	0.33	-	1.01	0.31	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.35	2000	75/Day (days 1-7)	75/Day (days 1-7) with preauthorization 125/day (days 1-7) otherwise	50/Day (days 21-100)	15 Copay	25 Copay	10 Coinsurance with preauth 20 otherwise	10 Coinsurance with preauth 20 otherwise	50 ER Copay 10 UC Copay	75 Copay	No Cost Share	10 to 100 Copay	10 Copay	No Cost Share	10 -15 Copay	10 Copay	15 Copay for Chiropractic Physician Specialist Podiatrist	15 Copay	15 Copay	Included in i.2.	15 Copay	20 Coins 2000 OOP Max	15 Copay eye exams 10 copay comp. Dental	Not Covered	Not Covered	Not Covered	15 Copay (100 Allowance)	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											0.6	0.01	0.44	0.14	0.06	0.18	0.11	0.26	0.38	0	0.29	0	0	0.01	0.51	0.67	0.04	0.1	0	0.31	0.12	0.12	0	0	0	0.06	0	0	0	0	0											4.42	0	0.27	0.6	0.01	0.44	0.14	0.38	0.92	0.56	1.56	0.38	-	1.03	0	0	0.07	1.74	2.85	0.16	0.43	-	1.32	0.43	0.5	-	-	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.77
H5215_005_0	2007	7																					0											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	Not Covered	Not Covered	No Cost Share	100 Benefit Annually	No Cost Share	100 Benefit Annually	Not Covered	Not Covered	Not Covered											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1000	75/Day (days 1-7)	125/Day (days 1-7)	25/Day (days 21-100)	15 Copay	25 Copay	5 Coinsurance	5 Coinsurance	50 Copay	75 Copay	No Cost Share	10 to 25 Copay	10 Copay	No Cost Share	10 Copay	5 Copay	10 Copay	10 Copay	10 Copay	No Cost Share	5 to 10 Copay	10 Coins 1000 OOP Max	10 Copay	Not Covered	Not Covered	Not Covered	10 Copay 100 Annual Benefit	Not Covered	100 Benefit Annually	Not Covered	Not Covered	Not Covered											0.27	0.03	0.26	0.17	0.08	0.09	0.06	0	0.47	0	0.09	0	0	0.01	0.31	0.54	0.03	0.08	0	0.24	0.07	0.1	0	0	0	0.04	0	0	0	0	0											2.94	0	0.29	0.27	0.03	0.26	0.17	0.08	0.09	0.06	0	0.47	-	0.09	0	0	0.01	0.31	0.54	0.03	0.08	-	0.24	0.07	0.1	-	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.94
H5215_006_0	2007	7																					0											D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	Not Covered	Not Covered	No Cost Share	100 Benefit Annually	No Cost Share	100 Benefit Annually	Not Covered	Not Covered	Not Covered											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1000	75/Day (days 1-7)	125/Day (days 1-7)	25/Day (days 21-100)	15 Copay	25 Copay	5 Coinsurance	5 Coinsurance	50 Copay	75 Copay	No Cost Share	10 to 25 Copay	10 Copay	No Cost Share	10 Copay	5 Copay	10 Copay	10 Copay	10 Copay	No Cost Share	5 to 10 Copay	10 Coins 1000 OOP Max	10 Copay	Not Covered	Not Covered	Not Covered	10 Copay 100 Annual Benefit	Not Covered	100 Benefit Annually	Not Covered	Not Covered	Not Covered											0.27	0.03	0.26	0.17	0.08	0.09	0.06	0	0.47	0	0.09	0	0	0.01	0.31	0.54	0.03	0.08	0	0.24	0.07	0.1	0	0	0	0.05	0	0	0	0	0											2.95	0	0.29	0.27	0.03	0.26	0.17	0.08	0.09	0.06	0	0.47	-	0.09	0	0	0.01	0.31	0.54	0.03	0.08	-	0.24	0.07	0.1	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.95
H5215_801_0	2007	2																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	155.88	1.67	36.76	0	3.33	7.41	4.52	3.82	20.53	8.03	21.83	0.56	0.07	20.52	21.83	62.03	0.9	2.32	15.26	24.55	6.11	3.15	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											0.08	0.08	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.22	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											12.69	0.14	6.21	-	0.79	1.75	1.07	0.9	4.85	1.9	5.15	0.13	0.02	4.84	4.89	14.23	0.21	0.55	3.6	5.79	1.44	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.9	0	0	12.69	0.14	6.21	-	0.79	1.75	1.07	0.9	4.85	1.9	5.15	0.13	0.02	4.84	4.89	14.23	0.21	0.55	3.6	5.79	1.44	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.9	0	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											2.47	0.03	1.2	0	0.16	0.35	0.22	0.18	0.98	0.39	1.04	0.03	0	0.99	1.01	3.01	0.04	0.11	0.75	1.21	0.29	0.16	0	0	0	0	0	0	0	0	0											14.63	0	0	15.16	0.16	7.41	-	0.94	2.1	1.29	1.09	5.83	2.28	6.19	0.16	0.02	5.83	5.9	17.25	0.26	0.66	4.35	7	1.73	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.53
H5215_804_0	2007	2																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	155.88	1.67	36.76	0	3.33	7.41	4.52	3.82	20.53	8.03	21.83	0.56	0.07	20.52	21.83	62.03	0.9	2.32	15.26	24.55	6.11	3.15	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											0.08	0.08	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.22	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											12.69	0.14	6.21	-	0.79	1.75	1.07	0.9	4.85	1.9	5.15	0.13	0.02	4.84	4.89	14.23	0.21	0.55	3.6	5.79	1.44	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.9	0	0	12.69	0.14	6.21	-	0.79	1.75	1.07	0.9	4.85	1.9	5.15	0.13	0.02	4.84	4.89	14.23	0.21	0.55	3.6	5.79	1.44	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.9	0	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											2.47	0.03	1.2	0	0.16	0.35	0.22	0.18	0.98	0.39	1.04	0.03	0	0.99	1.01	3.01	0.04	0.11	0.75	1.21	0.29	0.16	0	0	0	0	0	0	0	0	0											14.63	0	0	15.16	0.16	7.41	-	0.94	2.1	1.29	1.09	5.83	2.28	6.19	0.16	0.02	5.83	5.9	17.25	0.26	0.66	4.35	7	1.73	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.53
H5215_805_0	2007	2																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	159.33	1.71	38.06	0	3.44	7.66	4.67	4	21.54	8.42	22.89	0.59	0.07	21.51	22.58	64.26	0.93	2.39	15.8	25.43	6.4	3.28	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											0.08	0.08	0.17	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.22	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											12.97	0.14	6.43	-	0.81	1.81	1.1	0.94	5.08	1.99	5.4	0.14	0.02	5.08	5.07	14.75	0.22	0.56	3.73	6	1.51	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.53	0	0	12.97	0.14	6.43	-	0.81	1.81	1.1	0.94	5.08	1.99	5.4	0.14	0.02	5.08	5.07	14.75	0.22	0.56	3.73	6	1.51	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.53	0	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											2.52	0.03	1.24	0	0.16	0.37	0.22	0.19	1.03	0.41	1.09	0.03	0	1.04	1.05	3.12	0.05	0.12	0.77	1.25	0.31	0.16	0	0	0	0	0	0	0	0	0											15.15	0	0	15.49	0.17	7.67	-	0.98	2.17	1.32	1.14	6.11	2.4	6.5	0.17	0.02	6.12	6.11	17.87	0.27	0.68	4.5	7.25	1.82	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	89.68
H5216_001_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						V		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		1204.55	8.79	432.13	2061.78	120.22	0.65	0.05	237.91	425.25	784.22	534.7	35.65	365.54	303	6892.02	8175.18			301.46		9.07			7.94								12.8	0.1	14.76								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			25 - 75								550/admit	550/admit	20 Coins								111.02	114.7	34.66	0	100	0.2	0.2	46	81.6	38.64	50	50	50	33.53	10	30			100		0.2			0.25								550	550	0.2								11.14	0.08	1.25	-	1	0.13	0.01	0.91	2.89	2.52	2.23	0.15	1.52	0.85	5.74	20.44	-	-	2.51	-	1.81	-	-	2	-	-	-	-	-	-	-	0.59	0	2.95	-	-	-	-	-	-	-	60.75	0	0	11.14	0.08	1.25	-	1	0.13	0.01	0.91	2.89	2.52	2.23	0.15	1.52	0.85	5.74	20.44	-	-	2.51	-	1.81	-	-	2	-	-	-	-	-	-	-	0.59	0	2.95	-	-	-	-	-	-	-	60.75		800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50 - 80										30 Coins								2.2	0.02	0.3	0.41	0.29	0.03		0.29	3.7	4.36			0.03		4.11	4.87					0.6			2.08										0.95								24.22	500	0.96	13.34	0.1	1.54	0.41	1.29	0.16	0.01	1.2	6.59	6.89	2.23	0.15	1.56	0.85	9.85	25.31	-	-	2.51	-	2.41	-	-	4.08	-	-	-	-	-	-	-	0.59	0	3.9	-	-	-	-	-	-	-	84.97
H5216_801_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.26	1.92	451.9	2156.09	125.72	0.71	0.05	248.79	444.7	820.09	559.16	37.28	382.26	316.85	7207.26	8549.11			315.25		9.92											13.38	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.71	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.93	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.89	0	0	12.71	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.93	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.89		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.65	5.49			0		1.74	4.19					0.56																					20.36	0	0	14.97	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.06	7.88	2.14	0.31	-	0.99	16.76	29.12	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.25
H5216_802_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.26	1.92	451.9	2156.09	125.72	0.71	0.05	248.79	444.7	820.09	559.16	37.28	382.26	316.85	7207.26	8549.11			315.25		9.92											13.38	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.71	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.93	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.89	0	0	12.71	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.93	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.89		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.65	5.49			0		1.74	4.19					0.56																					20.36	0	0	14.97	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.06	7.88	2.14	0.31	-	0.99	16.76	29.12	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.25
H5216_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.31	1.92	451.99	2156.52	125.75	0.71	0.05	248.84	444.79	820.26	559.27	37.28	382.34	316.92	7208.7	8550.83			315.32		9.92											13.38	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.9	0	0	12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.9		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.65	5.49			0		1.74	4.19					0.56																					20.37	0	0	14.98	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.07	7.88	2.14	0.31	-	0.99	16.76	29.13	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.27
H5216_804_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.31	1.92	451.98	2156.46	125.75	0.71	0.05	248.83	444.77	820.24	559.25	37.28	382.33	316.91	7208.49	8550.58			315.31		9.92											13.38	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.9	0	0	12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.98	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.9		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.65	5.49			0		1.74	4.19					0.56																					20.36	0	0	14.98	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.07	7.88	2.14	0.31	-	0.99	16.76	29.13	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.26
H5227_001_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V	Coin	Coin	P	P	V	Coin	Coin	P	Coin	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-		1576.19	107.81	659.81		108.29	8.2	9.65	287.09	41.1	9639.31	23.06		0.46	6.62	3911.11	4921.39	393.05	5.85	27.99		21.16			6.84	131.15	0.82	234.81															265/day days 1-11	265/day days 1-11	125/day days 1-24		150 Copay	20 Coins	20 Coins	50 Copay waived if admitted	20 Coins	5 Copay	20 Coins		20 Coins	20 Coins	15 Copay	25 Copay Spec 35 Copay Chiro	35 Group 40 Individual	20 Coins	20 Coins		20 Coins			50 Coins	25 Copay	20 Coins	25 Copay															153.92	153.92	56.78		104.34	0.14	0.14	34.78	0.14	3.48	0.12		0.14	0.14	10.43	17.89	26.09	0.14	0.02		0.14			0.35	17.39	0.14	17.39															20.22	1.38	3.12	-	0.94	1.14	1.34	0.83	5.72	2.79	2.66	-	0.06	0.92	3.4	7.34	0.85	0.81	0.66	-	2.94	-	-	2.38	0.19	0.11	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.17		26.33	20.22	1.38	3.12	-	0.94	1.14	1.34	0.83	5.72	2.79	2.66	-	0.06	0.92	3.4	7.34	0.85	0.81	0.66	-	2.94	-	-	2.38	0.19	0.11	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.17																																																																																				-			20.22	1.38	3.12	-	0.94	1.14	1.34	0.83	5.72	2.79	2.66	-	0.06	0.92	3.4	7.34	0.85	0.81	0.66	-	2.94	-	-	2.38	0.19	0.11	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.17
H5227_801_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H5227_802_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H5253_004_0	2007	8																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1494.59	134.1	708.3	0	166.04	6.79	3.29	370.73	35.09	6964.99	43.43	0	0.73	25.11	2890.56	2945.98	484.65	1.9	0	0	17.47	719.63	0	0	98.19	354.6	185.65	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											198.95	198.95	101.16	0	118.02	0.17	0.2	32.28	0.17	1.35	0.13	0	0.2	0.17	15	30	37.5	0.17	0	0	0.2	30	0	0	30	15	30	0	0	0	0											24.78	2.22	5.97	-	1.63	1.15	0.66	1	5.92	0.78	5.64	-	0.15	4.23	3.61	7.36	1.51	0.32	-	-	3.54	1.8	-	-	0.25	0.44	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.43		27.84	24.78	2.22	5.97	-	1.63	1.15	0.66	1	5.92	0.78	5.64	-	0.15	4.23	3.61	7.36	1.51	0.32	-	-	3.54	1.8	-	-	0.25	0.44	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.43	4350	325 (1a)	325 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	40 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.37	0.21	0.52	0.49	0.36	0.3	0.17	0.23	1.56	0.69	1.5	0	0.03	1.11	1.35	1.89	0.38	0.08	0	0	0.78	0.46	0	0	0.06	0	0.12	0	0	0	0											14.66		4.75	27.15	2.44	6.49	0.49	1.99	1.45	0.83	1.23	7.47	1.47	7.14	-	0.18	5.35	4.96	9.25	1.89	0.41	-	-	4.31	2.26	-	-	0.31	0.44	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.08
H5253_007_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1766.81	137.6	8912.15	116.45	1105.5	16.3	6.33	223.42	173.36	2639.23	232.69	22.82	2.99	303.51	29492.07	1415.1	1500.32	13.36		278.76	257.12	1006.47	1576.13		140.2	177.18		54.6				191.39	0.19	0.05	260.72	295.2						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						134	134			67	18	18	45	22			22		22		9				9		9										31		22								19.74	1.54	-	-	6.18	2.91	1.13	0.83	0.32	-	-	0.04	-	0.57	-	1.05	-	-	-	0.21	-	0.75	-	-	-	-	-	-	-	-	-	0.5	-	0	-	-	-	-	-	-	-	35.77		4.25	19.74	1.54	-	-	6.18	2.91	1.13	0.83	0.32	-	-	0.04	-	0.57	-	1.05	-	-	-	0.21	-	0.75	-	-	-	-	-	-	-	-	-	0.5	-	0	-	-	-	-	-	-	-	35.77																																																																																				-		0	19.74	1.54	-	-	6.18	2.91	1.13	0.83	0.32	-	-	0.04	-	0.57	-	1.05	-	-	-	0.21	-	0.75	-	-	-	-	-	-	-	-	-	0.5	-	0	-	-	-	-	-	-	-	35.77
H5253_011_0	2007	10																					2700											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3500	1629.93	141.99	829.28	0	254.64	12.88	5.56	450.08	27.29	6488.22	37.97	0	0.19	20.77	3113.88	3236.8	626.31	1.66	0	0	19.93	634.52	0	0	142.9	255.4	198	0	0	0	0											250 (1a)	250 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	5 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	15 (17b1-17b5)	20 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											145.09	145.09	72.54	0	101.56	0.17	0.2	29.02	0.12	1.16	0.09	0	0.17	0.12	10	20	37.5	0.12	0	0	0.17	20	0	0	20	15	20	0	0	0	0											19.71	1.72	5.01	-	2.16	2.24	1.1	1.09	3.17	0.63	3.44	-	0.03	2.41	2.59	5.39	1.96	0.19	-	-	3.47	1.06	-	-	0.24	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.26		33.3	19.71	1.72	5.01	-	2.16	2.24	1.1	1.09	3.17	0.63	3.44	-	0.03	2.41	2.59	5.39	1.96	0.19	-	-	3.47	1.06	-	-	0.24	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.26		325 (1a)	325 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	15 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											3.87	0.34	0.46	0.27	0.24	0.25	0.12	0.18	0.78	0.41	0.84	0	0.01	0.6	0.58	0.9	0.25	0.03	0	0	0.39	0.18	0	0	0.04	0	0.06	0	0	0	0											10.79		5.98	23.58	2.05	5.47	0.27	2.4	2.49	1.22	1.27	3.95	1.04	4.28	-	0.04	3.01	3.18	6.29	2.2	0.23	-	-	3.86	1.23	-	-	0.28	0.32	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.05
H5253_021_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-		1498.46	132.99	727.42	0	164.81	7.09	3.33	362.21	35.79	7121.08	45.94	0	0.73	25.96	2919.38	3004.02	481.81	2.02	0	0	18.13	727.84	0	0	98.73	354.96	184.74	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50/40 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	15 (17b1-17b5)	30 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											186.37	186.37	94.76	0	110.56	0.16	0.19	30.27	0.16	3.79	0.12	0	0.19	0.16	15	30	37.5	0.16	0	0	0.19	30	0	0	30	15	30	0	0	0	0											23.27	2.07	5.74	-	1.52	1.12	0.65	0.91	5.65	2.25	5.59	-	0.14	4.1	3.65	7.51	1.51	0.32	-	-	3.44	1.82	-	-	0.25	0.44	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.4		32.89	23.27	2.07	5.74	-	1.52	1.12	0.65	0.91	5.65	2.25	5.59	-	0.14	4.1	3.65	7.51	1.51	0.32	-	-	3.44	1.82	-	-	0.25	0.44	0.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.4	3800	325 (1a)	325 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	40 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.23	0.2	0.5	0.3	0.33	0.29	0.14	0.21	1.49	0.66	1.48	0	0.03	1.08	0.86	1.22	0.24	0.08	0	0	0.75	0.29	0	0	0.04	0	0.07	0	0	0	0											12.5		7.29	25.5	2.26	6.24	0.3	1.85	1.41	0.78	1.12	7.14	2.91	7.07	-	0.17	5.18	4.51	8.73	1.74	0.4	-	-	4.19	2.11	-	-	0.29	0.44	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.9
H5253_022_0	2007	4																					2200											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3000	1629.93	141.99	829.28	0	254.64	12.88	5.56	450.08	27.29	6488.22	37.97	0	0.19	20.77	3113.88	3236.8	626.31	1.66	0	0	19.93	634.52	0	0	142.9	255.4	198	0	0	0	0											250 (1a)	250 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	15 (17b1-17b5)	20 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											130.87	130.87	65.43	0	91.61	0.16	0.18	26.17	0.1	3.14	0.08	0	0.16	0.1	10	20	37.5	0.1	0	0	0.16	20	0	0	20	15	20	0	0	0	0											17.78	1.55	4.52	-	1.94	2.02	1.02	0.98	2.86	1.7	3.1	-	0.03	2.18	2.59	5.39	1.96	0.17	-	-	3.13	1.06	-	-	0.24	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.88		38.84	17.78	1.55	4.52	-	1.94	2.02	1.02	0.98	2.86	1.7	3.1	-	0.03	2.18	2.59	5.39	1.96	0.17	-	-	3.13	1.06	-	-	0.24	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.88		325 (1a)	325 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	15 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											3.68	0.32	0.44	0.15	0.23	0.24	0.1	0.17	0.74	0.39	0.8	0	0.01	0.57	0.33	0.5	0.14	0.03	0	0	0.37	0.1	0	0	0.02	0	0.03	0	0	0	0											9.36		7.41	21.46	1.87	4.96	0.15	2.17	2.26	1.12	1.15	3.6	2.09	3.91	-	0.03	2.74	2.92	5.9	2.09	0.2	-	-	3.5	1.16	-	-	0.26	0.32	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.24
H5253_024_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2415.36	346.74	1626.32		310.1	26.7	22.28	908.55	368.79	2175.5	905.68	64.76	3	2009.32		3426.51		498.15		789.69												319.16		140.5	238.58							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							7.06	1.01	2.28	-	0.91	2.5	2.08	1.28	0.36	0.85	0.35	0.06	0.28	1.96	-	1.34	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	23.1		26.27	7.06	1.01	2.28	-	0.91	2.5	2.08	1.28	0.36	0.85	0.35	0.06	0.28	1.96	-	1.34	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	23.1																																																																																				-		0	7.06	1.01	2.28	-	0.91	2.5	2.08	1.28	0.36	0.85	0.35	0.06	0.28	1.96	-	1.34	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.05	0.09	-	-	-	-	-	-	23.1
H5253_801_0	2007	3																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1382.06	148.99	661.26	0	159.06	8.76	4.09	419.21	46.71	9083.18	54.28	0	0.52	30.54	3654.37	4059.28	594.49	2.16	0	0	16.8	968.47	0	0	90.18	0	228.51	0	0	0	0											325 (1a)	325 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	30 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											229.68	229.68	113.07	0	123.67	0.18	0.21	35.34	0.18	4.24	0.14	0	0.21	0.18	30	35	37.5	0.18	0	0	0.21	35	0	0	35	0	35	0	0	0	0											26.45	2.85	6.23	-	1.64	1.55	0.85	1.23	8.25	3.21	7.39	-	0.11	5.39	9.14	11.84	1.86	0.38	-	-	3.56	2.82	-	-	0.26	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.69		28.5	26.45	2.85	6.23	-	1.64	1.55	0.85	1.23	8.25	3.21	7.39	-	0.11	5.39	9.14	11.84	1.86	0.38	-	-	3.56	2.82	-	-	0.26	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.69																																																																																				-			26.45	2.85	6.23	-	1.64	1.55	0.85	1.23	8.25	3.21	7.39	-	0.11	5.39	9.14	11.84	1.86	0.38	-	-	3.56	2.82	-	-	0.26	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.69
H5253_802_0	2007	4																					4800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1382.06	148.99	661.26	0	159.06	8.76	4.09	419.21	46.71	9083.18	54.28	0	0.52	30.54	3654.37	4059.28	594.49	2.16	0	0	16.8	968.47	0	0	90.18	0	228.51	0	0	0	0											325 (1a)	325 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	30 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											229.68	229.68	113.07	0	123.67	0.18	0.21	35.34	0.18	4.24	0.14	0	0.21	0.18	30	35	37.5	0.18	0	0	0.21	35	0	0	35	0	35	0	0	0	0											26.45	2.85	6.23	-	1.64	1.55	0.85	1.23	8.25	3.21	7.39	-	0.11	5.39	9.14	11.84	1.86	0.38	-	-	3.56	2.82	-	-	0.26	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.69		28.5	26.45	2.85	6.23	-	1.64	1.55	0.85	1.23	8.25	3.21	7.39	-	0.11	5.39	9.14	11.84	1.86	0.38	-	-	3.56	2.82	-	-	0.26	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.69																																																																																				-			26.45	2.85	6.23	-	1.64	1.55	0.85	1.23	8.25	3.21	7.39	-	0.11	5.39	9.14	11.84	1.86	0.38	-	-	3.56	2.82	-	-	0.26	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.69
H5262_001_0	2007	2	f.										OP Facility - Urgent Care										2500											A	A	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	V	V	V	V	V	V	V										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0			21.76			9.34	1.15	226.81							2336.3	4007.57	89.89	360.85		1.89	5.82	10.09			0.6							234.03												10 for days 1 - 20 (PBP#2base2 #2base4)			10 of the cost (PBP #11Abase1)	10 of the cost (PBP #11Bbase1 #11Bbase2)	50 per visit (PBP #4Abase2)							15 for office visits & specialty (PBP #7Abase1)	15 for group therapy or visits (PBP #7Bbase3 #7Dbase1 #7Fbase2 #14Ibase2)	15 per visit (PBP #7Ebase4#7Hbase4 #9Cbase4)	15 rehab 10 cardiac or pulmonary rehab (PBP #7Cbase1 #7Ibase1 #9Dbase2)		15 per visit (PBP #7Gbase1)	10 per Diabetic supply (PBP #11Cbase1)	15 per visit (PBP #16Bbase7 #17Abase2)			15 per visit (PBP #17A base2)							15 per visit (PBP #4Bbase2)												0.1			0.1	0.1	50							15	15	15	14.7		15	0.1	15			15							15										-	-	2.18	-	-	0.93	0.12	0.95	-	-	-	-	-	-	2.92	5.01	0.11	0.44	-	0	0.58	0.01	-	-	0	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	13.55	0	0.03	-	-	2.18	-	-	0.93	0.12	0.95	-	-	-	-	-	-	2.92	5.01	0.11	0.44	-	0	0.58	0.01	-	-	0	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	13.55	2500																																																																																			-	0	0	-	-	2.18	-	-	0.93	0.12	0.95	-	-	-	-	-	-	2.92	5.01	0.11	0.44	-	0	0.58	0.01	-	-	0	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	13.55
H5262_003_0	2007	2	f.										OP Facility - Urgent Care										2500											A	A	Coin			Coin	Coin	V	V	Coin	Coin				V	V	V	V	Coin	V	Coin	V			V							V										0	0	0			0	0	0	0	0	0				0	0	0	0	0		0	0			0							0										-	0	180.52	3.52	15.44			6.63	0.82	113.7	171.97	10	4.45				1667.57	2852.18	65.48	256.77	19.06	1.34	4.14	7.63			296.9							175.84										200 for each stay (PBP #1Abase6)	200 for each stay (PBP #1Bbase6)	10 Coins for days 1 - 20 (PBP #2base2 #2base4)			20 coins (PBP # 11Abase1)	20 coins (PBP # 11Bbase1 #11Bbase2)	50 per visit (PBP #4Abase2)	75 per visit (PBP #9Abase2#9Bbase2)	10 coins (PBP # 8Abase2 #9Abase1 #9Bbase1)	10 coins (PBP # 8Abase2 #8Bbase1 #9Abase1 #9Bbase1)				30 per visit (PBP #7Abase1)	30 per visit (PBP #7Bbase3 #7Dbase1 7Fbase2 14Ibase2)	30 per visit (PBP #7Ebase4 #7Hbase4 #9Cbase4)	30 per  rehab 15 per cardiac or pulmonary visit (PBP #7Cbase1 #7Ibase1 #9Dbase2)	10 coins (PBP # 8Abase2)	30 per exam of existing cond (7Gbase1)	20 Coins for diabetic supplies (PBP # 11Cbase1)	30 per Visit (PBP #16Bbase7 #17Abase2)			30 per Visit (PBP #17Abase2)							30 per visit (PBP #4Bbase2)										200	200	0.1			0.2	0.2	50	75	0.1	0.1				30	30	30	29.06	0.1	30	0.2	30			30							30										3.01	0.06	1.54	-	-	1.33	0.16	0.47	1.07	1	0.44	-	-	-	4.17	7.13	0.16	0.62	1.91	0	0.83	0.02	-	-	0.74	-	-	-	-	-	-	0.44	-	-	-	-	-	-	-	-	-	25.12	0	1.26	3.01	0.06	1.54	-	-	1.33	0.16	0.47	1.07	1	0.44	-	-	-	4.17	7.13	0.16	0.62	1.91	0	0.83	0.02	-	-	0.74	-	-	-	-	-	-	0.44	-	-	-	-	-	-	-	-	-	25.12	2500																																																																																			-		0	3.01	0.06	1.54	-	-	1.33	0.16	0.47	1.07	1	0.44	-	-	-	4.17	7.13	0.16	0.62	1.91	0	0.83	0.02	-	-	0.74	-	-	-	-	-	-	0.44	-	-	-	-	-	-	-	-	-	25.12
H5262_004_0	2007	1	f.										OP Facility - Urgent Care										2500											A	A	Coin			Coin	Coin	V	V	Coin	Coin				V	V	V	V	Coin	V	Coin	V			V							V										0	0	0			0	0	0	0	0	0				0	0	0	0	0	0	0	0			0							0										-	0	180.52	3.52	15.44			6.63	0.82	113.7	171.97	10	4.45				1667.57	2852.18	65.48	256.77	19.06	1.34	4.14	7.63			296.9							175.84										200 for each stay (PBP #1Abase6)	200 for each stay (PBP #1Bbase6)	10 Coins for days 1 - 20 (PBP #2base2 #2base4)			20 coins (PBP # 11Abase1)	20 coins (PBP # 11Bbase1 #11Bbase2)	50 per visit (PBP #4Abase2)	75 per visit (PBP #9Abase2#9Bbase2)	10 coins (PBP # 8Abase2 #9Abase1 #9Bbase1)	10 coins (PBP # 8Abase2 #8Bbase1 #9Abase1 #9Bbase1)				30 per visit (PBP #7Abase1)	30 per visit (PBP #7Bbase3 #7Dbase1 7Fbase2 14Ibase2)	30 per visit (PBP #7Ebase4 #7Hbase4 #9Cbase4)	30 per  rehab 15 per cardiac or pulmonary visit (PBP #7Cbase1 #7Ibase1 #9Dbase2)	10 coins (PBP # 8Abase2)	30 per exam of existing cond (7Gbase1)	20 Coins for diabetic supplies (PBP # 11Cbase1)	30 per Visit (PBP #16Bbase7 #17Abase2)			30 per Visit (PBP #17Abase2)							30 per visit (PBP #4Bbase2)										200	200	0.1			0.2	0.2	50	75	0.1	0.1				30	30	30	29.06	0.1	30	0.2	30			30							30										3.01	0.06	1.54	-	-	1.33	0.16	0.47	1.07	1	0.44	-	-	-	4.17	7.13	0.16	0.62	1.91	0	0.83	0.02	-	-	0.74	-	-	-	-	-	-	0.44	-	-	-	-	-	-	-	-	-	25.12	0	1.26	3.01	0.06	1.54	-	-	1.33	0.16	0.47	1.07	1	0.44	-	-	-	4.17	7.13	0.16	0.62	1.91	0	0.83	0.02	-	-	0.74	-	-	-	-	-	-	0.44	-	-	-	-	-	-	-	-	-	25.12	2500																																																																																			-		0	3.01	0.06	1.54	-	-	1.33	0.16	0.47	1.07	1	0.44	-	-	-	4.17	7.13	0.16	0.62	1.91	0	0.83	0.02	-	-	0.74	-	-	-	-	-	-	0.44	-	-	-	-	-	-	-	-	-	25.12
H5262_005_0	2007	1	f.										OP Facility - Urgent Care										2500											A	A	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	V	V	V	V	V	V	V										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	0			21.76			9.34	1.15	226.81							2336.3	4007.57	89.89	360.85		1.89	5.82	10.09			0.6							234.03												10 for days 1 - 20 (PBP#2base2 #2base4)			10 of the cost (PBP #11Abase1)	10 of the cost (PBP #11Bbase1 #11Bbase2)	50 per visit (PBP #4Abase2)							15 for office visits & specialty (PBP #7Abase1)	15 for group therapy or visits (PBP #7Bbase3 #7Dbase1 #7Fbase2 #14Ibase2)	15 per visit (PBP #7Ebase4#7Hbase4 #9Cbase4)	15 rehab 10 cardiac or pulmonary rehab (PBP #7Cbase1 #7Ibase1 #9Dbase2)		15 per visit (PBP #7Gbase1)	10 per Diabetic supply (PBP #11Cbase1)	15 per visit (PBP #16Bbase7 #17Abase2)			15 per visit (PBP #17A base2)							15 per visit (PBP #4Bbase2)												0.1			0.1	0.1	50							15	15	15	14.7		15	0.1	15			15							15										-	-	2.18	-	-	0.93	0.12	0.95	-	-	-	-	-	-	2.92	5.01	0.11	0.44	-	0	0.58	0.01	-	-	0	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	13.55	0	0.03	-	-	2.18	-	-	0.93	0.12	0.95	-	-	-	-	-	-	2.92	5.01	0.11	0.44	-	0	0.58	0.01	-	-	0	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	13.55	2500																																																																																			-		0	-	-	2.18	-	-	0.93	0.12	0.95	-	-	-	-	-	-	2.92	5.01	0.11	0.44	-	0	0.58	0.01	-	-	0	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	13.55
H5302_003_0	2007	3																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1584.91	83.6	445.37		91.76	1015.92	948.35	335.37	393.19	872.8	591.55		1.74	173.45	3584.33	6377.2	265.88	392.59			22.59																					180/day days 1-5	180/day days 1-5	100 Copay days 11-100		50 Copay	25 Coin	20 Diab Supplies 25 All Other	50 Copay	125 OP Hospital 75 ASC	30 Copay	30 Copay		20 Coin	30 Copay PTSTOT 50 MH/SA	10 Copay	50 Copay	50 Copay	30 Copay			20 Coin																					95.27	95.27	46.55		43.17	30.54	29.96	43.17	88.55	25.9	25.9		393.83	26.28	8.63	25.9	43.17	25.9			0.17																					12.58	0.66	1.73	-	0.33	2.59	2.37	1.21	2.9	1.88	1.28	-	0.06	0.38	2.58	13.77	0.96	0.85	-	-	3.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.02		7.91	12.58	0.66	1.73	-	0.33	2.59	2.37	1.21	2.9	1.88	1.28	-	0.06	0.38	2.58	13.77	0.96	0.85	-	-	3.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.02	5000	30		30		30			30	30		30	30		30		30		30	30	30											30											2.06		0.14		0.05			0	0.42		0.1	0.02		0.14		0.3		0.03	0.29	0.84											0											4.4		3.22	14.64	0.66	1.87	-	0.38	2.59	2.37	1.21	3.33	1.88	1.38	0.02	0.06	0.52	2.58	14.07	0.96	0.88	0.29	0.84	3.9	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	54.42
H5302_004_0	2007	7																																A	A	D	V	P	Coin	Coin	V	V	V	V	V	Coin	V	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	Coin	P	P	P																																																				-		1647.39	87.88	454.27		93.6	12.22	11.4	342.55	401.05	890.25	601.17		0.34	176.92	3579.7	6504.74	271.2	404.97			23.04				127.09		227.53	1.63														200/admit	100/admit	100 Copay days 6+		50 Copay	20 Coin	20 Coin	50 ER 20 UC	50 OP Hospital 25 ASC	20 Copay	20 Copay		20 Coin	20 Copay	10 Copay	20 Copay	20 Copay	20 Copay			20 Coin				30 Copay		30 Copay	20 Coin														27.81	19.42	62.02		40.34	0.16	0.16	40.32	31.28	16.14	16.14		0.16	16.14	8.07	16.48	16.14	16.14			0.16				24.2		24.2	0.16														3.82	0.14	2.35	-	0.31	1.97	1.84	1.15	1.05	1.2	0.81	-	0.05	0.24	2.41	8.93	0.36	0.54	-	-	3.72	-	-	-	0.26	-	0.46	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	31.87		7.63	3.82	0.14	2.35	-	0.31	1.97	1.84	1.15	1.05	1.2	0.81	-	0.05	0.24	2.41	8.93	0.36	0.54	-	-	3.72	-	-	-	0.26	-	0.46	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	31.87	2500	20 Coin		20 Coin		20 Coin			20 Coin	20 Coin		20 Coin	20 Coin		20 Coin		20 Coin		20 Coin	20 Coin	20 Coin								20 Coin			20 Coin											1.21		0.08		0.03			0	0.25		0.06	0.01		0.08		0.18		0.02	0.17	0.49								0.01			0											2.59		2.51	5.02	0.14	2.43	-	0.34	1.97	1.84	1.15	1.29	1.2	0.87	0.01	0.05	0.32	2.41	9.11	0.36	0.56	0.17	0.49	3.72	-	-	-	0.26	-	0.46	0.27	-	-	0	-	-	-	-	-	-	-	-	-	-	34.46
H5302_805_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		266.52	6.84	15.39		4.49	12.97	13.05	15.33	41.89	22.43	21.99	2.49	0.2	17.28	20.78	38.43	1.97	2.82	27.22	97.49	26.37	0.13																				Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.08	0.08	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75			20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75		Medicare FFS		Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				1.02		0.17		0.06	0.18	0.18		0.57	0.19	0.18	0.03		0.22	0.28	0.48	0	0.04	0.37	1.33	0.02	0																				5.33			21.54	0.53	3.18	-	1.12	3.24	3.26	3.62	10.46	5.48	5.37	0.62	0.05	4.3	5.19	9.55	0.46	0.71	6.8	24.34	6.24	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.08
H5302_806_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		266.52	6.84	15.39		4.49	12.97	13.05	15.33	41.89	22.43	21.99	2.49	0.2	17.28	20.78	38.43	1.97	2.82	27.22	97.49	26.37	0.13																				Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.08	0.08	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75			20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75		Medicare FFS		Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				1.02		0.17		0.06	0.18	0.18		0.57	0.19	0.18	0.03		0.22	0.28	0.48	0	0.04	0.37	1.33	0.02	0																				5.33			21.54	0.53	3.18	-	1.12	3.24	3.26	3.62	10.46	5.48	5.37	0.62	0.05	4.3	5.19	9.55	0.46	0.71	6.8	24.34	6.24	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.08
H5302_807_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		266.52	6.84	15.39		4.49	12.97	13.05	15.33	41.89	22.43	21.99	2.49	0.2	17.28	20.78	38.43	1.97	2.82	27.22	97.49	26.37	0.13																				Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.08	0.08	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75			20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75		Medicare FFS		Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				1.02		0.17		0.06	0.18	0.18		0.57	0.19	0.18	0.03		0.22	0.28	0.48	0	0.04	0.37	1.33	0.02	0																				5.33			21.54	0.53	3.18	-	1.12	3.24	3.26	3.62	10.46	5.48	5.37	0.62	0.05	4.3	5.19	9.55	0.46	0.71	6.8	24.34	6.24	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.08
H5302_808_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		266.52	6.84	15.39		4.49	12.97	13.05	15.33	41.89	22.43	21.99	2.49	0.2	17.28	20.78	38.43	1.97	2.82	27.22	97.49	26.37	0.13																				Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.08	0.08	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75			20.52	0.53	3.01	-	1.06	3.06	3.08	3.62	9.89	5.29	5.19	0.59	0.05	4.08	4.91	9.07	0.46	0.67	6.42	23.01	6.22	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.75		Medicare FFS		Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				1.02		0.17		0.06	0.18	0.18		0.57	0.19	0.18	0.03		0.22	0.28	0.48	0	0.04	0.37	1.33	0.02	0																				5.33			21.54	0.53	3.18	-	1.12	3.24	3.26	3.62	10.46	5.48	5.37	0.62	0.05	4.3	5.19	9.55	0.46	0.71	6.8	24.34	6.24	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	116.08
H5304_001_0	2007	6																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	974.52	12.31	1506.4	23.21	239.37	26.82	1.32	558.4	552.92	0	1820.16	0	0.25	1041.67	4200.04	5253.94	1.16	479.78	0	254.34	9.41	662.42	0	0	2.74	0	138.13	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.77	10	24.96	0.5	25	0	8.66	0.2	25	0	0	0.5	0	25	0	0	0	0											16.24	0.18	2.99	3.48	2.99	8.04	0.4	1.93	4.61	-	1.12	-	0.04	2.15	3.5	10.93	0.58	1	-	0.18	1.92	1.38	-	-	1.37	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.33	0	0	16.24	0.18	2.99	3.48	2.99	8.04	0.4	1.93	4.61	-	1.12	-	0.04	2.15	3.5	10.93	0.58	1	-	0.18	1.92	1.38	-	-	1.37	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.33	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	16.24	0.18	2.99	3.48	2.99	8.04	0.4	1.93	4.61	-	1.12	-	0.04	2.15	3.5	10.93	0.58	1	-	0.18	1.92	1.38	-	-	1.37	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.33
H5304_801_0	2007	8																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H5304_802_0	2007	3																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H5304_803_0	2007	7																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H5402_007_0	2007	5	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	Coin	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1532.57	13.62	2569.08	473.55	227.39	8.02	0.21	288.97	26.63	36.71	31.56	2.4	1.07	2.41	3997.37	15163.09	0.21	460.67	3864.94	0	7.45	0.01	0	540	584.26	0	115.95	10.11	0	13.95	0	0	185.71									110/Day 1-5; 0/Day 6-90	125/Day 1-5; 0/Day 6-90	0/Day 1-10; 100/Day 11-100	0	100/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	HOSP 20 Coinsurance	150/Visit	X-rays 5; Thera Rad 35; CT 100; MRIPETNM 150	20 Coinsurance	30/Visit	OP Rehab 15/Visit	Prostate Screen 50; Chemo 35; Hep B 20 Coinsurance	5/Visit SPC Routine Foot Care; Chiropractic	25/Visit	0	5/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Routine 0/Visit; Non-Routine 10/Visit	10 Eyewear	15/Procedure	0	0	0	0	25/Visit	75/Visit									46.92	74.16	60.3	0	90.43	0.1	0.2	44.45	0.18	135.64	64.53	0.18	27.13	0	0.22	0.39	22.61	0	4.52	0	0.2	0	0	0	0	0	13.56	0	0	0	0	0	67.82									5.99	0.08	12.91	-	1.71	0.8	0.04	1.07	4.82	0.41	0.17	0.43	0	-	0.07	0.5	0	-	1.46	-	1.49	-	-	-	-	-	0.13	-	-	-	-	-	1.05	-	-	-	-	-	-	-	-	33.14		2.05	5.99	0.08	12.91	-	1.71	0.8	0.04	1.07	4.82	0.41	0.17	0.43	0	-	0.07	0.5	0	-	1.46	-	1.49	-	-	-	-	-	0.13	-	-	-	-	-	1.05	-	-	-	-	-	-	-	-	33.14	3450																																																																																			-		0	5.99	0.08	12.91	-	1.71	0.8	0.04	1.07	4.82	0.41	0.17	0.43	0	-	0.07	0.5	0	-	1.46	-	1.49	-	-	-	-	-	0.13	-	-	-	-	-	1.05	-	-	-	-	-	-	-	-	33.14
H5402_010_0	2007	6	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	Coin	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1768.56	15.72	2964.67	506.51	262.4	8.29	0.24	333.47	30.73	42.37	36.42	2.76	1.24	2.73	4612.88	17266.04	0.24	531.6	4460.06	0	8.59	0.01	0	540	674.22	0	108.36	11.66	0	16.1	0	0	214.3									100/Day 1-5; 0/Day 6-90	100/Day 1-5; 0/Day 6-90	0/Day 1-10; 75/Day 11-100	0	100/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	20 Coinsurance	100/Visit	X-rays 5; Thera Rad 35; CTMRIPETNM 100	20 Coinsurance	35/Visit	OP Rehab 15/Visit	Prostate Screen 50; Chemo 35; Hep B 20 Coinsurance	5/Visit SPC Routine Foot Care; Chiropractic	25/Visit	0	5/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Routine 0/Visit; Non-Routine 10/Visit	10 Eyewear	10/Procedure	0	0	0	0	25/Visit	50/Visit									42.65	59.33	45.23	0	92.86	0.1	0.2	45.64	0.19	92.86	53.95	0.19	32.5	0	0.22	0.4	23.22	0	4.64	0	0.2	0	0	0	0	0	9.29	0	0	0	0	0	46.43									6.29	0.08	11.17	-	2.03	0.83	0.05	1.27	5.71	0.33	0.16	0.51	0	-	0.08	0.58	0	-	1.73	-	1.72	-	-	-	-	-	0.08	-	-	-	-	-	0.83	-	-	-	-	-	-	-	-	33.45		1.01	6.29	0.08	11.17	-	2.03	0.83	0.05	1.27	5.71	0.33	0.16	0.51	0	-	0.08	0.58	0	-	1.73	-	1.72	-	-	-	-	-	0.08	-	-	-	-	-	0.83	-	-	-	-	-	-	-	-	33.45	3450																																																																																			-		0	6.29	0.08	11.17	-	2.03	0.83	0.05	1.27	5.71	0.33	0.16	0.51	0	-	0.08	0.58	0	-	1.73	-	1.72	-	-	-	-	-	0.08	-	-	-	-	-	0.83	-	-	-	-	-	-	-	-	33.45
H5402_011_0	2007	5	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3950	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	Coin	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1486.63	13.22	2492.07	496.48	220.57	7.97	0.2	280.31	25.83	35.61	30.61	2.32	1.04	2.31	3877.55	14750.76	0.2	446.86	3749.08	0	7.22	0.01	0	540	566.74	0	87.14	9.8	0	13.54	0	0	180.14									275/Day 1-7; 0/Day 8-90	275/Day 1-7; 0/Day 8-90	0/Day 1-7; 100/Day 8-100	35/Visit	100/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	20 Coinsurance	175/Visit	Diag. Rad. And X-rays 15; Thera Rad 40; CT 150MRIPETNM 175	20 Coinsurance	40/Visit	20 Coinsurance; OP Rehab 25/Visit	Prostate Screen 100; Chemo 45; Hep B 20 Coinsurance	25/Visit SPC Routine Foot Care; Chiropractic	30/Visit	0	10/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Not Covered	Not Covered	Not Covered	0	0	0	0	25/Visit	100/Visit									143.92	196.44	65.71	30.57	87.35	0.1	0.2	42.93	0.17	152.86	68.27	0.17	34.94	0.05	1.56	1.38	26.2	0	8.73	0	0.2	0	0	0	0	0	0	0	0	0	0	0	87.35									17.83	0.22	13.65	1.26	1.61	0.8	0.04	1	4.51	0.45	0.17	0.41	0	0.13	0.5	1.7	0	-	2.73	-	1.44	-	-	-	-	-	-	-	-	-	-	-	1.31	-	-	-	-	-	-	-	-	49.76		2.26	17.83	0.22	13.65	1.26	1.61	0.8	0.04	1	4.51	0.45	0.17	0.41	0	0.13	0.5	1.7	0	-	2.73	-	1.44	-	-	-	-	-	-	-	-	-	-	-	1.31	-	-	-	-	-	-	-	-	49.76	3950																																																																																			-		0	17.83	0.22	13.65	1.26	1.61	0.8	0.04	1	4.51	0.45	0.17	0.41	0	0.13	0.5	1.7	0	-	2.73	-	1.44	-	-	-	-	-	-	-	-	-	-	-	1.31	-	-	-	-	-	-	-	-	49.76
H5402_012_0	2007	4	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	Coin	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1526.2	13.57	2558.4	472.66	226.44	8.02	0.21	287.77	26.52	36.56	31.43	2.39	1.07	2.26	3980.74	15044.33	0.21	458.75	3848.86	0	7.41	0.01	0	540	581.83	0	115.72	10.06	0	13.9	0	0	184.94									135/Day 1-5; 0/Day 6-90	150/Day 1-5; 0/Day 6-90	0/Day 1-7; 100/Day 8-100	0	100/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	HOSP 20 Coinsurance	150/Visit	X-rays 5; Thera Rad 35; CT 100; MRIPETNM 150	20 Coinsurance	30/Visit	OP Rehab 15/Visit	Colorectal Screen 100; Chemo 35; Hep B 20 Coinsurance	5/Visit SPC Routine Foot Care 10; Chiropractic 10	25/Visit	0	5/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Routine 0/Visit; Non-Routine 20/Visit	25 Eyewear	15/Procedure	0	0	0	0	25/Visit	50/Visit									57.58	89	65.71	0	90.14	0.1	0.2	44.3	0.18	135.21	64.32	0.18	0	0	0.39	0.77	0	0	4.51	0	0.2	0	0	0	0	0	13.52	0	0	0	0	0	45.07									7.32	0.1	14.01	-	1.7	0.8	0.04	1.06	4.78	0.41	0.17	0.43	-	-	0.13	0.96	-	-	1.45	-	1.48	-	-	-	-	-	0.13	-	-	-	-	-	0.69	-	-	-	-	-	-	-	-	35.67		2.13	7.32	0.1	14.01	-	1.7	0.8	0.04	1.06	4.78	0.41	0.17	0.43	-	-	0.13	0.96	-	-	1.45	-	1.48	-	-	-	-	-	0.13	-	-	-	-	-	0.69	-	-	-	-	-	-	-	-	35.67	3450																																																																																			-		0	7.32	0.1	14.01	-	1.7	0.8	0.04	1.06	4.78	0.41	0.17	0.43	-	-	0.13	0.96	-	-	1.45	-	1.48	-	-	-	-	-	0.13	-	-	-	-	-	0.69	-	-	-	-	-	-	-	-	35.67
H5402_013_0	2007	4	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	Coin	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1713.32	15.23	2872.07	498.8	254.2	8.23	0.23	323.06	29.77	41.04	35.28	2.68	1.2	2.54	4468.8	16748.88	0.24	515	4320.75	0	8.32	0.01	0	540	653.16	0	107.23	11.3	0	15.6	0	0	207.61									100/Day 1-5; 0/Day 6-90	100/Day 1-5; 0/Day 6-90	0/Day 1-7; 75/Day 8-100	0	50/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	50	50/Visit	X-rays 5; Thera Rad 35; CTMRIPETNM 50	20 Coinsurance	30/Visit	OP Rehab 15/Visit	Colorectal Screen 100; Chemo 35; Hep B 20 Coinsurance	0/Visit SPC Routine Foot Care 5; Chiropractic 5	20/Visit	0	5/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Routine 0/Visit; Non-Routine 15/Visit	15 Eyewear	10/Procedure	0	0	0	0	20/Visit	50/Visit									42.65	59.33	52.1	0	91.63	0.1	0.2	45.04	0.18	91.63	53.24	0.18	0	0	0.39	2.28	0	0	4.58	0	0.2	0	0	0	0	0	9.16	0	0	0	0	0	45.82									6.09	0.08	12.47	-	1.94	0.82	0.05	1.21	5.46	0.31	0.16	0.49	-	-	0.15	3.18	-	-	1.65	-	1.66	-	-	-	-	-	0.08	-	-	-	-	-	0.79	-	-	-	-	-	-	-	-	36.59		1.41	6.09	0.08	12.47	-	1.94	0.82	0.05	1.21	5.46	0.31	0.16	0.49	-	-	0.15	3.18	-	-	1.65	-	1.66	-	-	-	-	-	0.08	-	-	-	-	-	0.79	-	-	-	-	-	-	-	-	36.59	3450																																																																																			-		0	6.09	0.08	12.47	-	1.94	0.82	0.05	1.21	5.46	0.31	0.16	0.49	-	-	0.15	3.18	-	-	1.65	-	1.66	-	-	-	-	-	0.08	-	-	-	-	-	0.79	-	-	-	-	-	-	-	-	36.59
H5402_015_0	2007	4	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	Coin	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1624.18	14.44	2722.65	486.35	240.98	8.13	0.22	306.25	28.22	38.91	33.45	2.54	1.14	2.41	4236.31	15933.11	0.22	488.2	4095.96	0	7.89	0.01	0	540	619.18	0	117.35	10.71	0	14.79	0	0	196.81									110/Day 1-5; 0/Day 6-90	125/Day 1-5; 0/Day 6-90	0/Day 1-10; 100/Day 11-100	0	100/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	HOSP 20 Coinsurance	150/Visit	X-rays 5; Thera Rad 35; CT 100; MRIPETNM 150	20 Coinsurance	30/Visit	OP Rehab 15/Visit	Chemo 35; Hep B 20 Coinsurance	5/Visit SPC Routine Foot Care; Chiropractic	25/Visit	0	5/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Routine 0/Visit; Non-Routine 10/Visit	10 Eyewear	15/Procedure	0	0	0	0	25/Visit	75/Visit									46.92	74.16	60.3	0	90.43	0.1	0.2	44.45	0.18	135.64	64.53	0.18	0	0	0.22	0.28	0	0	4.52	0	0.2	0	0	0	0	0	13.56	0	0	0	0	0	67.82									6.35	0.09	13.68	-	1.82	0.81	0.04	1.13	5.1	0.44	0.18	0.46	-	-	0.08	0.37	-	-	1.54	-	1.58	-	-	-	-	-	0.13	-	-	-	-	-	1.11	-	-	-	-	-	-	-	-	34.93		2.17	6.35	0.09	13.68	-	1.82	0.81	0.04	1.13	5.1	0.44	0.18	0.46	-	-	0.08	0.37	-	-	1.54	-	1.58	-	-	-	-	-	0.13	-	-	-	-	-	1.11	-	-	-	-	-	-	-	-	34.93	3450																																																																																			-		0	6.35	0.09	13.68	-	1.82	0.81	0.04	1.13	5.1	0.44	0.18	0.46	-	-	0.08	0.37	-	-	1.54	-	1.58	-	-	-	-	-	0.13	-	-	-	-	-	1.11	-	-	-	-	-	-	-	-	34.93
H5402_017_0	2007	5	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	Coin	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1823.31	16.21	3056.46	514.16	270.52	8.35	0.25	343.8	31.68	43.68	37.55	2.85	1.28	2.7	4755.7	17763	0.25	548.06	4598.14	0	8.86	0.01	0	540	695.09	0	109.19	12.02	0	16.6	0	0	220.94									100/Day 1-5; 0/Day 6-90	100/Day 1-5; 0/Day 6-90	0/Day 1-10; 75/Day 11-100	0	100/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	20 Coinsurance	100/Visit	X-rays 5; Thera Rad 35; CTMRIPETNM 100	20 Coinsurance	30/Visit	OP Rehab 15/Visit	Chemo 35; Hep B 20 Coinsurance	5/Visit SPC Routine Foot Care; Chiropractic	25/Visit	0	5/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Routine 0/Visit; Non-Routine 10/Visit	10 Eyewear	10/Procedure	0	0	0	0	25/Visit	50/Visit									42.65	59.33	45.23	0	92.86	0.1	0.2	45.64	0.19	92.86	53.95	0.19	0	0	0.22	0.29	0	0	4.64	0	0.2	0	0	0	0	0	9.29	0	0	0	0	0	46.43									6.48	0.08	11.52	-	2.09	0.84	0.05	1.31	5.88	0.34	0.17	0.53	-	-	0.09	0.43	-	-	1.78	-	1.77	-	-	-	-	-	0.08	-	-	-	-	-	0.85	-	-	-	-	-	-	-	-	34.29		1.04	6.48	0.08	11.52	-	2.09	0.84	0.05	1.31	5.88	0.34	0.17	0.53	-	-	0.09	0.43	-	-	1.78	-	1.77	-	-	-	-	-	0.08	-	-	-	-	-	0.85	-	-	-	-	-	-	-	-	34.29	3450																																																																																			-		0	6.48	0.08	11.52	-	2.09	0.84	0.05	1.31	5.88	0.34	0.17	0.53	-	-	0.09	0.43	-	-	1.78	-	1.77	-	-	-	-	-	0.08	-	-	-	-	-	0.85	-	-	-	-	-	-	-	-	34.29
H5402_024_0	2007	5	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	V	V	V	V	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	2141.69	19.04	3590.15	558.62	317.76	8.09	0.29	403.83	128.41	51.3	44.1	21.3	1.5	3.28	5586.1	20746.01	0.29	643.76	5401.04	0	10.4	0.01	0	540	816.47	0	115.55	14.12	0	19.5	0	0	259.52									25/Day 1-10; 0 Days 11-90	25/Day 1-10; 0 Days 11-90	0 Days 1-25; 40 Days 26-100	No Cost Sharing	100/Trip	No Cost Sharing	No Cost Sharing	ER 50/Visit UC No Cost Sharing	100/Visit	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing	No Cost Sharing									15.7	22.78	12.44	0	99.29	0	0	48.4	99.29	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									2.8	0.04	3.72	-	2.63	-	-	1.63	1.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.88		0.04	2.8	0.04	3.72	-	2.63	-	-	1.63	1.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.88	3450																																																																																			-		0	2.8	0.04	3.72	-	2.63	-	-	1.63	1.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.88
H5402_025_0	2007	5	h.6.	g.1.									OP Facility - Other	OP Facility - Surgery									3450	MH Substance Abuse	Ambulatory Surgical Center									D	D	D	P	T	Coin	Coin	V	Coin	V	V	V	V	Coin	P	P	V	P	P	P	Coin	Coin	T	P	P	P	P	P	O	V	Coin	V	V									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0									-	0	1643.56	14.61	2755.12	489.05	243.85	8.15	0.23	309.9	28.55	39.37	33.85	16.35	1.15	2.55	4286.84	16136.04	0.23	494.03	4144.82	0	7.98	0.01	0	540	626.57	0	117.64	10.84	0	14.97	0	0	199.16									115/Day 1-5; 0/Day 6-90	125/Day 1-5; 0/Day 6-90	0/Day 1-10; 75/Day 11-100	0	100/Trip	10 Coinsurance	20 Coinsurance	ER 50/Visit; UC 20/Visit	HOSP 20 Coinsurance	150/Visit	X-rays 5; Thera Rad 35; CT 100; MRIPETNM 150	20 Coinsurance	30/Visit	OP Rehab 15/Visit	Chemo 35; Hep B 20 Coinsurance	5/Visit SPC Routine Foot Care; Chiropractic	25/Visit	0	5/Visit	0	20 Coinsurance	20 Coinsurance	0	0	Routine 0/Visit; Non-Routine 10/Visit	10 Eyewear	15/Procedure	0	0	0	0	25/Visit	75/Visit									49.05	74.16	45.23	0	90.43	0.1	0.2	44.45	0.18	135.64	64.53	0.18	0	0	0.22	0.28	0	0	4.52	0	0.2	0	0	0	0	0	13.56	0	0	0	0	0	67.82									6.72	0.09	10.38	-	1.84	0.81	0.05	1.15	5.16	0.45	0.18	0	-	-	0.08	0.38	-	-	1.56	-	1.6	-	-	-	-	-	0.13	-	-	-	-	-	1.13	-	-	-	-	-	-	-	-	31.7		1.27	6.72	0.09	10.38	-	1.84	0.81	0.05	1.15	5.16	0.45	0.18	0	-	-	0.08	0.38	-	-	1.56	-	1.6	-	-	-	-	-	0.13	-	-	-	-	-	1.13	-	-	-	-	-	-	-	-	31.7	3450																																																																																			-		0	6.72	0.09	10.38	-	1.84	0.81	0.05	1.15	5.16	0.45	0.18	0	-	-	0.08	0.38	-	-	1.56	-	1.6	-	-	-	-	-	0.13	-	-	-	-	-	1.13	-	-	-	-	-	-	-	-	31.7
H5404_001_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V						Coin	V	V	S																																															-		1427.04	131.02	403.21	667.69	219.03	6	0.5	362.67	35.84	3809.38	10.54	64.11		4883.57	2075.07	1383.38	236.7	726.83	11.32					498.53	402.2	198.1	145.73					9329.74	19.3	635.7	1180.58	3418.45						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	0-20				10 Urgent Care else 0	20	20	20	0-20					0-75	10	10	10						10	20	20	0-75						156.79	156.79	39.64	19.95	124.68	0.2	0.2	49.93	0.25	14.98	0.07	0		0	1	19.97	19.97	19.97	0.07					4.99	9.99	9.99	9.99					0	0.1	19.97	19.97	14.98						18.65	1.71	1.33	1.11	2.28	1.2	0.1	1.51	8.95	4.76	0.79	-	-	-	0.17	2.3	0.39	1.21	0.85	-	-	-	-	0.21	0.33	0.16	0.12	-	-	-	-	-	1.93	1.06	1.96	4.27	-	-	-	-	-	57.35		0.08	18.65	1.71	1.33	1.11	2.28	1.2	0.1	1.51	8.95	4.76	0.79	-	-	-	0.17	2.3	0.39	1.21	0.85	-	-	-	-	0.21	0.33	0.16	0.12	-	-	-	-	-	1.93	1.06	1.96	4.27	-	-	-	-	-	57.35																																																																																				-			18.65	1.71	1.33	1.11	2.28	1.2	0.1	1.51	8.95	4.76	0.79	-	-	-	0.17	2.3	0.39	1.21	0.85	-	-	-	-	0.21	0.33	0.16	0.12	-	-	-	-	-	1.93	1.06	1.96	4.27	-	-	-	-	-	57.35
H5404_002_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	S																																															-		1301.02	119.45	367.6	608.73	199.69	5.47	0.46	330.65	32.67	3472.99	9.61	58.45		4452.32	1891.83	1261.22	215.8	662.65	10.32					454.51	366.69	180.61	132.86					8505.87	17.59	579.56	1076.33	3116.58						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	0-20				10 Urgent Care else 0	25	25	25	20					0-75	10	10	10						10	20	20	0-75						156.79	156.79	39.64	19.95	124.68	0.2	0.2	49.93	0.25	14.98	0.07	0		0	1	24.97	24.97	24.97	0.07					4.99	9.99	9.99	9.99					0	0.1	19.97	19.97	14.98						17	1.56	1.21	1.01	2.07	1.09	0.09	1.38	8.16	4.34	0.72	-	-	-	0.16	2.62	0.45	1.38	0.77	-	-	-	-	0.19	0.31	0.15	0.11	-	-	-	-	-	1.76	0.96	1.79	3.89	-	-	-	-	-	53.17		0.07	17	1.56	1.21	1.01	2.07	1.09	0.09	1.38	8.16	4.34	0.72	-	-	-	0.16	2.62	0.45	1.38	0.77	-	-	-	-	0.19	0.31	0.15	0.11	-	-	-	-	-	1.76	0.96	1.79	3.89	-	-	-	-	-	53.17																																																																																				-			17	1.56	1.21	1.01	2.07	1.09	0.09	1.38	8.16	4.34	0.72	-	-	-	0.16	2.62	0.45	1.38	0.77	-	-	-	-	0.19	0.31	0.15	0.11	-	-	-	-	-	1.76	0.96	1.79	3.89	-	-	-	-	-	53.17
H5404_003_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	S																																															-		1342.17	123.23	379.23	627.98	206	5.65	0.47	341.1	33.71	3582.83	9.91	60.29		4593.13	1951.66	1301.1	222.63	683.61	10.64					468.88	378.28	186.32	137.07					8774.87	18.15	597.89	1110.37	3215.14						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	0-20				10 Urgent Care else 0	25	25	25	20					0-75	10	10	10						10	20	20	0-75						156.79	156.79	39.64	19.95	124.68	0.2	0.2	49.93	0.25	14.98	0.07	0		0	1	24.97	24.97	24.97	0.07					4.99	9.99	9.99	9.99					0	0.1	19.97	19.97	14.98						17.54	1.61	1.25	1.04	2.14	1.13	0.09	1.42	8.42	4.47	0.74	-	-	-	0.16	2.71	0.46	1.42	0.8	-	-	-	-	0.2	0.31	0.16	0.11	-	-	-	-	-	1.81	1	1.85	4.01	-	-	-	-	-	54.86		0.07	17.54	1.61	1.25	1.04	2.14	1.13	0.09	1.42	8.42	4.47	0.74	-	-	-	0.16	2.71	0.46	1.42	0.8	-	-	-	-	0.2	0.31	0.16	0.11	-	-	-	-	-	1.81	1	1.85	4.01	-	-	-	-	-	54.86																																																																																				-			17.54	1.61	1.25	1.04	2.14	1.13	0.09	1.42	8.42	4.47	0.74	-	-	-	0.16	2.71	0.46	1.42	0.8	-	-	-	-	0.2	0.31	0.16	0.11	-	-	-	-	-	1.81	1	1.85	4.01	-	-	-	-	-	54.86
H5404_004_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V			V	V	V	V	Coin					V	V	V	V						Coin	V	V	S																																															-		1266.35	116.27	357.8	592.5	194.37	5.33	0.44	321.83	31.8	3380.44	9.35	56.89		4333.67	1841.41	1227.61	210.05	644.99	10.04					442.39	356.91	175.79	129.32					8279.2	17.12	564.12	1047.65	3033.53						250 (Days 1-7)	250 (Days 1-7)	100 (Days 6-100)	20	125	20	20	50	25	0-75	0-20				10 Urgent Care else 0	25	25	25	20					0-75	10	10	10						5	25	25	0-75						195.99	195.99	63.75	19.97	124.8	0.2	0.2	49.92	0.25	14.98	0.07	0		0	1	24.96	24.96	24.96	0.07					4.99	9.98	9.98	9.98					0	0.05	24.96	24.96	14.98						20.68	1.9	1.9	0.99	2.02	1.06	0.09	1.34	7.94	4.22	0.7	-	-	-	0.15	2.55	0.44	1.34	0.75	-	-	-	-	0.18	0.3	0.15	0.11	-	-	-	-	-	0.85	1.17	2.18	3.79	-	-	-	-	-	56.8		0.09	20.68	1.9	1.9	0.99	2.02	1.06	0.09	1.34	7.94	4.22	0.7	-	-	-	0.15	2.55	0.44	1.34	0.75	-	-	-	-	0.18	0.3	0.15	0.11	-	-	-	-	-	0.85	1.17	2.18	3.79	-	-	-	-	-	56.8																																																																																				-			20.68	1.9	1.9	0.99	2.02	1.06	0.09	1.34	7.94	4.22	0.7	-	-	-	0.15	2.55	0.44	1.34	0.75	-	-	-	-	0.18	0.3	0.15	0.11	-	-	-	-	-	0.85	1.17	2.18	3.79	-	-	-	-	-	56.8
H5404_013_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	V	V	V	P																																															-		1434.64	131.72	405.35	671.24	220.2	6.04	0.5	364.6	36.03	3829.68	10.6	64.45		4909.58	2086.12	1390.75	237.97	730.7	11.38					501.18	404.35	199.16	146.51					9379.44	438.19	639.08	1186.87	3436.66						225 (Days 1-7)	225 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	25	25	25	20					0-75	10	10	10						50	25	25	0-75						176.39	176.39	39.61	19.95	124.68	0.2	0.2	49.89	0.25	14.97	0.07	0		0	1	24.95	24.95	24.95	0.07					4.99	9.98	9.98	9.98					0	49.89	24.95	24.95	14.97						21.09	1.94	1.34	1.12	2.29	1.2	0.1	1.52	8.99	4.78	0.79	-	-	-	0.17	2.89	0.49	1.52	0.85	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	1.82	1.33	2.47	4.29	-	-	-	-	-	61.81		0.14	21.09	1.94	1.34	1.12	2.29	1.2	0.1	1.52	8.99	4.78	0.79	-	-	-	0.17	2.89	0.49	1.52	0.85	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	1.82	1.33	2.47	4.29	-	-	-	-	-	61.81																																																																																				-			21.09	1.94	1.34	1.12	2.29	1.2	0.1	1.52	8.99	4.78	0.79	-	-	-	0.17	2.89	0.49	1.52	0.85	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	1.82	1.33	2.47	4.29	-	-	-	-	-	61.81
H5404_016_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1208.98	111	341.59	565.66	185.56	5.09	0.42	307.25	30.36	3227.29	8.93	54.31		4137.33	1757.98	1171.99	200.53	615.77	9.59					422.35	340.74	167.83	123.46					7904.1	16.35	538.56	1000.18	2896.09						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	100	20	20	50	20	0-75	20				10 Urgent Care else 0	15	20	20	20					0-75	10	10	10						10	15	15	0-75						156.79	156.79	39.64	19.95	124.68	0.2	0.2	49.93	0.25	14.98	0.07	0		0	1	19.97	19.97	19.97	0.07					4.99	9.99	9.99	9.99					0	9.99	19.97	19.97	14.98						15.8	1.45	1.13	0.94	1.93	1.02	0.08	1.28	7.58	4.03	0.67	-	-	-	0.15	1.95	0.33	1.02	0.72	-	-	-	-	0.18	0.28	0.14	0.1	-	-	-	-	-	163.27	0.9	1.66	3.62	-	-	-	-	-	210.22		0.28	15.8	1.45	1.13	0.94	1.93	1.02	0.08	1.28	7.58	4.03	0.67	-	-	-	0.15	1.95	0.33	1.02	0.72	-	-	-	-	0.18	0.28	0.14	0.1	-	-	-	-	-	163.27	0.9	1.66	3.62	-	-	-	-	-	210.22																																																																																				-			15.8	1.45	1.13	0.94	1.93	1.02	0.08	1.28	7.58	4.03	0.67	-	-	-	0.15	1.95	0.33	1.02	0.72	-	-	-	-	0.18	0.28	0.14	0.1	-	-	-	-	-	163.27	0.9	1.66	3.62	-	-	-	-	-	210.22
H5404_022_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	V	V	V	P																																															-		1536.67	141.09	434.18	718.98	235.86	6.47	0.54	390.53	38.59	4102.03	11.35	69.03		5258.74	2234.48	1489.65	254.89	782.67	12.18					536.83	433.1	213.32	156.93					10046.48	469.35	684.53	1271.28	3681.07						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	20	20	20	20					0-75	10	10	10						10	20	20	0-75						156.79	156.79	39.64	19.95	124.68	0.2	0.2	49.93	0.25	14.98	0.07	0		0	1	19.97	19.97	19.97	0.07					4.99	9.99	9.99	9.99					0	9.99	19.97	19.97	14.98						20.08	1.84	1.43	1.2	2.45	1.29	0.11	1.63	9.63	5.12	0.85	-	-	-	0.19	2.48	0.42	1.3	0.91	-	-	-	-	0.22	0.36	0.18	0.13	-	-	-	-	-	0.39	1.14	2.12	4.6	-	-	-	-	-	60.07		0.08	20.08	1.84	1.43	1.2	2.45	1.29	0.11	1.63	9.63	5.12	0.85	-	-	-	0.19	2.48	0.42	1.3	0.91	-	-	-	-	0.22	0.36	0.18	0.13	-	-	-	-	-	0.39	1.14	2.12	4.6	-	-	-	-	-	60.07																																																																																				-			20.08	1.84	1.43	1.2	2.45	1.29	0.11	1.63	9.63	5.12	0.85	-	-	-	0.19	2.48	0.42	1.3	0.91	-	-	-	-	0.22	0.36	0.18	0.13	-	-	-	-	-	0.39	1.14	2.12	4.6	-	-	-	-	-	60.07
H5404_025_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		P	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	S																																															-		1412.13	129.65	398.99	660.71	216.74	5.94	0.5	358.88	35.46	3769.58	10.43	63.44		4832.54	2053.38	1368.92	234.23	719.24	11.2					493.32	398	196.03	144.21					9232.25	19.1	629.05	1168.24	3382.73						300 (Days 1-7)	300 (Days 1-7)	100 (Days 6-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	15	20	20	20					0-75	10	10	10						10	20	20	0-75						235.19	235.19	63.63	19.95	124.68	0.2	0.2	49.83	0.25	14.95	0.07	0		0	1	14.95	19.93	19.93	0.07					4.98	9.97	9.97	9.97					0	0.1	19.93	19.93	14.95						27.68	2.54	2.12	1.1	2.25	1.18	0.1	1.49	8.84	4.7	0.78	-	-	-	0.17	1.71	0.39	1.19	0.84	-	-	-	-	0.2	0.33	0.16	0.12	-	-	-	-	-	1.9	1.04	1.94	4.21	-	-	-	-	-	66.98		0.23	27.68	2.54	2.12	1.1	2.25	1.18	0.1	1.49	8.84	4.7	0.78	-	-	-	0.17	1.71	0.39	1.19	0.84	-	-	-	-	0.2	0.33	0.16	0.12	-	-	-	-	-	1.9	1.04	1.94	4.21	-	-	-	-	-	66.98																																																																																				-			27.68	2.54	2.12	1.1	2.25	1.18	0.1	1.49	8.84	4.7	0.78	-	-	-	0.17	1.71	0.39	1.19	0.84	-	-	-	-	0.2	0.33	0.16	0.12	-	-	-	-	-	1.9	1.04	1.94	4.21	-	-	-	-	-	66.98
H5404_028_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	V	V	V	P																																															-		1496.32	137.38	422.78	700.1	229.67	6.3	0.52	380.28	37.58	3994.33	11.05	67.22		5120.67	2175.81	1450.54	248.2	762.12	11.87					522.73	421.73	207.72	152.81					9782.7	457.03	666.56	1237.9	3584.42						300 (Days 1-7)	300 (Days 1-7)	100 (Days 6-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	20	20	20	20					0-75	10	10	10						50	20	20	0-75						235.19	235.19	63.63	19.95	124.68	0.2	0.2	49.83	0.25	14.95	0.07	0		0	1	19.93	19.93	19.93	0.07					4.98	9.97	9.97	9.97					0	49.83	19.93	19.93	14.95						29.33	2.69	2.24	1.16	2.39	1.25	0.1	1.58	9.36	4.98	0.83	-	-	-	0.18	2.41	0.41	1.27	0.89	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	1.9	1.11	2.06	4.47	-	-	-	-	-	71.46		0.25	29.33	2.69	2.24	1.16	2.39	1.25	0.1	1.58	9.36	4.98	0.83	-	-	-	0.18	2.41	0.41	1.27	0.89	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	1.9	1.11	2.06	4.47	-	-	-	-	-	71.46																																																																																				-			29.33	2.69	2.24	1.16	2.39	1.25	0.1	1.58	9.36	4.98	0.83	-	-	-	0.18	2.41	0.41	1.27	0.89	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	1.9	1.11	2.06	4.47	-	-	-	-	-	71.46
H5404_031_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1370.03	125.79	387.1	641.01	210.28	5.76	0.48	348.18	34.41	3657.21	10.12	61.55		4688.48	1992.18	1328.12	227.25	697.8	10.86					478.61	386.14	190.19	139.91					8957.04	18.53	610.3	1133.42	3281.89						300 (Days 1-7)	300 (Days 1-7)	100 (Days 6-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	20	20	20	20					0-75	10	10	10						10	20	20	0-75						235.19	235.19	63.63	19.95	124.68	0.2	0.2	49.83	0.25	14.95	0.07	0		0	1	19.93	19.93	19.93	0.07					4.98	9.97	9.97	9.97					0	0.1	19.93	19.93	14.95						26.85	2.47	2.05	1.07	2.18	1.15	0.1	1.45	8.57	4.56	0.76	-	-	-	0.17	2.21	0.38	1.16	0.81	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	1.85	1.01	1.88	4.09	-	-	-	-	-	65.54		0.23	26.85	2.47	2.05	1.07	2.18	1.15	0.1	1.45	8.57	4.56	0.76	-	-	-	0.17	2.21	0.38	1.16	0.81	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	1.85	1.01	1.88	4.09	-	-	-	-	-	65.54																																																																																				-			26.85	2.47	2.05	1.07	2.18	1.15	0.1	1.45	8.57	4.56	0.76	-	-	-	0.17	2.21	0.38	1.16	0.81	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	1.85	1.01	1.88	4.09	-	-	-	-	-	65.54
H5404_034_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1726.19	158.49	487.73	807.65	264.95	7.26	0.61	438.7	43.35	4607.94	12.75	77.55		5907.31	2510.07	1673.38	286.33	879.2	13.69					603.04	486.52	239.63	176.28					11285.54	23.34	768.96	1428.07	4135.06						200 (Days 1-7)	200 (Days 1-7)	75 (Days 7-100)	20	100	20	20	50	25	0-75	20				Urgent care 10	20	25	25	20					0-75	10	10	10						10	25	25	0-75						156.79	156.79	43.37	19.95	99.74	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	19.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.1	24.98	24.98	14.99						22.55	2.07	1.76	1.34	2.2	1.45	0.12	1.83	10.83	5.76	0.96	-	-	-	0.21	2.79	0.6	1.83	1.03	-	-	-	-	0.25	0.41	0.2	0.15	-	-	-	-	-	2.33	1.6	2.97	5.16	-	-	-	-	-	70.39		0.05	22.55	2.07	1.76	1.34	2.2	1.45	0.12	1.83	10.83	5.76	0.96	-	-	-	0.21	2.79	0.6	1.83	1.03	-	-	-	-	0.25	0.41	0.2	0.15	-	-	-	-	-	2.33	1.6	2.97	5.16	-	-	-	-	-	70.39																																																																																				-			22.55	2.07	1.76	1.34	2.2	1.45	0.12	1.83	10.83	5.76	0.96	-	-	-	0.21	2.79	0.6	1.83	1.03	-	-	-	-	0.25	0.41	0.2	0.15	-	-	-	-	-	2.33	1.6	2.97	5.16	-	-	-	-	-	70.39
H5404_037_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	V	V	V	P																																															-		1464.67	134.48	413.84	685.29	224.81	6.16	0.51	372.24	36.78	3909.84	10.82	65.8		5012.36	2129.79	1419.86	242.95	746	11.61					511.68	412.81	203.32	149.58					9575.78	447.36	652.46	1211.71	3508.6						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	20	20	20	20					0-75	10	10	10						10	20	20	0-75						156.79	156.79	39.64	19.95	124.68	0.2	0.2	49.93	0.25	14.98	0.07	0		0	1	19.97	19.97	19.97	0.07					4.99	9.99	9.99	9.99					0	9.99	19.97	19.97	14.98						19.14	1.76	1.37	1.14	2.34	1.23	0.1	1.55	9.18	4.88	0.81	-	-	-	0.18	2.36	0.4	1.24	0.87	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	0.37	1.09	2.02	4.38	-	-	-	-	-	57.26		0.08	19.14	1.76	1.37	1.14	2.34	1.23	0.1	1.55	9.18	4.88	0.81	-	-	-	0.18	2.36	0.4	1.24	0.87	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	0.37	1.09	2.02	4.38	-	-	-	-	-	57.26																																																																																				-			19.14	1.76	1.37	1.14	2.34	1.23	0.1	1.55	9.18	4.88	0.81	-	-	-	0.18	2.36	0.4	1.24	0.87	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	0.37	1.09	2.02	4.38	-	-	-	-	-	57.26
H5404_043_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1481.06	135.98	418.47	692.96	227.32	6.23	0.52	376.4	37.2	3953.6	10.94	66.53		5068.45	2153.62	1435.75	245.67	754.35	11.74					517.4	417.43	205.6	151.25					9682.94	20.03	659.76	1225.27	3547.86						200 (Days 1-7)	200 (Days 1-7)	75 (Days 7-100)	20	125	20	20	50	25	0-75	20				Urgent care 10	25	25	25	20					0-75	10	10	10						10	25	25	0-75						156.79	156.79	43.37	19.95	124.68	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	24.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.1	24.98	24.98	14.99						19.35	1.78	1.51	1.15	2.36	1.25	0.1	1.57	9.29	4.94	0.82	-	-	-	0.18	2.99	0.51	1.57	0.88	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	2	1.37	2.55	4.43	-	-	-	-	-	61.47		0.05	19.35	1.78	1.51	1.15	2.36	1.25	0.1	1.57	9.29	4.94	0.82	-	-	-	0.18	2.99	0.51	1.57	0.88	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	2	1.37	2.55	4.43	-	-	-	-	-	61.47																																																																																				-			19.35	1.78	1.51	1.15	2.36	1.25	0.1	1.57	9.29	4.94	0.82	-	-	-	0.18	2.99	0.51	1.57	0.88	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	2	1.37	2.55	4.43	-	-	-	-	-	61.47
H5404_053_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						4000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		2805.85	257.61	792.78	1312.81	430.66	11.81	0.98	713.09	70.47	7490.03	20.72	126.05		9602.1	4080.01	2720.01	465.41	1429.1	22.25					980.21	790.81	389.51	286.54					18344.2	37.94	1249.91	2321.27	6721.38						25 (Days 1-7)	25 (Days 1-7)	25 (Days 11-100)	20	50	20	20	25	25	0-75	20				0	0	0	0	20					0-75	10	10	10						5	0	0	0-75						19.6	19.6	9.92	19.95	49.87	0.2	0.2	25	0.25	15	0.08	0		0	0	0	0	0	0.08					5	10	10	10					0	0.05	0	0	15						4.58	0.42	0.66	2.18	1.79	2.36	0.2	1.49	17.62	9.36	1.55	-	-	-	-	-	-	-	1.67	-	-	-	-	0.41	0.66	0.32	0.24	-	-	-	-	-	1.9	-	-	8.4	-	-	-	-	-	55.81		0	4.58	0.42	0.66	2.18	1.79	2.36	0.2	1.49	17.62	9.36	1.55	-	-	-	-	-	-	-	1.67	-	-	-	-	0.41	0.66	0.32	0.24	-	-	-	-	-	1.9	-	-	8.4	-	-	-	-	-	55.81																																																																																				-			4.58	0.42	0.66	2.18	1.79	2.36	0.2	1.49	17.62	9.36	1.55	-	-	-	-	-	-	-	1.67	-	-	-	-	0.41	0.66	0.32	0.24	-	-	-	-	-	1.9	-	-	8.4	-	-	-	-	-	55.81
H5404_056_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin				V	V	V	V	Coin					V	V	V	V					S	D	V	V	S																																															-		1757.02	161.32	496.44	822.08	269.68	7.39	0.62	446.53	44.13	4690.25	12.98	78.93		6012.83	2554.9	1703.27	291.44	894.9	13.93					613.81	495.21	243.91	179.43					11487.12	536.65	782.69	1453.57	4208.92						150 (Days 1-7)	150 (Days 1-7)	50 (Days 7-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	15	20	20	20					0-75	10	10	10						10	20	20	0-75						117.6	117.6	28.93	19.99	124.97	0.2	0.2	49.99	0.25	15	0.07	0		0	1	15	19.99	19.99	0.07					5	10	10	10					0	10	19.99	19.99	15						17.22	1.58	1.2	1.37	2.81	1.48	0.12	1.86	11.03	5.86	0.97	-	-	-	0.21	2.13	0.49	1.49	1.04	-	-	-	-	0.26	0.41	0.2	0.15	-	-	-	-	-	0.45	1.3	2.42	5.26	-	-	-	-	-	61.32		0.02	17.22	1.58	1.2	1.37	2.81	1.48	0.12	1.86	11.03	5.86	0.97	-	-	-	0.21	2.13	0.49	1.49	1.04	-	-	-	-	0.26	0.41	0.2	0.15	-	-	-	-	-	0.45	1.3	2.42	5.26	-	-	-	-	-	61.32																																																																																				-			17.22	1.58	1.2	1.37	2.81	1.48	0.12	1.86	11.03	5.86	0.97	-	-	-	0.21	2.13	0.49	1.49	1.04	-	-	-	-	0.26	0.41	0.2	0.15	-	-	-	-	-	0.45	1.3	2.42	5.26	-	-	-	-	-	61.32
H5404_059_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin				V	V	V	V	Coin					V	V	V	V					S	D	V	V	S																																															-		2026.76	186.08	572.65	948.29	311.08	8.53	0.71	515.09	50.9	5410.3	14.97	91.05		6935.91	2947.13	1964.75	336.18	1032.29	16.07					708.04	571.23	281.35	206.98					13250.61	619.04	902.85	1676.73	4855.07						150 (Days 1-7)	150 (Days 1-7)	50 (Days 7-100)	20	125	20	20	50	25	0-75	0-20				10 Urgent Care else 0	15	20	20	0-20					0-75	10	10	10						10	20	20	0-75						117.6	117.6	28.93	19.99	124.97	0.2	0.2	49.99	0.25	15	0.07	0		0	1	15	19.99	19.99	0.07					5	10	10	10					0	10	19.99	19.99	15						19.86	1.82	1.38	1.58	3.24	1.71	0.14	2.15	12.72	6.76	1.12	-	-	-	0.25	2.46	0.56	1.72	1.21	-	-	-	-	0.29	0.48	0.23	0.17	-	-	-	-	-	0.52	1.5	2.79	6.07	-	-	-	-	-	70.73		0.02	19.86	1.82	1.38	1.58	3.24	1.71	0.14	2.15	12.72	6.76	1.12	-	-	-	0.25	2.46	0.56	1.72	1.21	-	-	-	-	0.29	0.48	0.23	0.17	-	-	-	-	-	0.52	1.5	2.79	6.07	-	-	-	-	-	70.73																																																																																				-			19.86	1.82	1.38	1.58	3.24	1.71	0.14	2.15	12.72	6.76	1.12	-	-	-	0.25	2.46	0.56	1.72	1.21	-	-	-	-	0.29	0.48	0.23	0.17	-	-	-	-	-	0.52	1.5	2.79	6.07	-	-	-	-	-	70.73
H5404_062_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1374.94	126.24	388.48	643.31	211.03	5.78	0.48	349.43	34.53	3670.3	10.15	61.77		4705.27	1999.31	1332.87	228.06	700.3	10.9					480.33	387.52	190.87	140.41					8989.11	18.59	612.49	1137.48	3293.64						250 (Days 1-7)	250 (Days 1-7)	100 (Days 6-100)	20	125	20	20	50	25	0-75	20				Urgent care 10	20	20	20	20					0-75	10	10	10						10	20	20	0-75						195.99	195.99	63.65	19.95	124.68	0.2	0.2	49.84	0.25	14.95	0.07	0		0	1	19.94	19.94	19.94	0.07					4.98	9.97	9.97	9.97					0	0.1	19.94	19.94	14.95						22.46	2.06	2.06	1.07	2.19	1.15	0.1	1.45	8.61	4.57	0.76	-	-	-	0.17	2.21	0.38	1.16	0.82	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	1.85	1.02	1.89	4.1	-	-	-	-	-	60.88		0.19	22.46	2.06	2.06	1.07	2.19	1.15	0.1	1.45	8.61	4.57	0.76	-	-	-	0.17	2.21	0.38	1.16	0.82	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	1.85	1.02	1.89	4.1	-	-	-	-	-	60.88																																																																																				-			22.46	2.06	2.06	1.07	2.19	1.15	0.1	1.45	8.61	4.57	0.76	-	-	-	0.17	2.21	0.38	1.16	0.82	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	1.85	1.02	1.89	4.1	-	-	-	-	-	60.88
H5404_086_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V					Coin				Coin	V	V	S																																															-		1292.96	118.71	365.32	604.95	198.45	5.44	0.45	328.6	32.47	3451.47	9.55	58.08		4424.73	1880.11	1253.4	214.47	658.54	10.25					451.69					79.81			8453.17	17.48	575.97	1069.66	3097.27						300 (Days 1-7)	300 (Days 1-7)	150 (Days 1-100)	20	125	20	20	50	25	0-75	0-20				10 Urgent Care else 0	30	30	25	0-20					0-75					copays & coins as percent pmpm				5	30	30	0-75						235.19	235.19	95.43	19.95	124.66	0.2	0.2	49.82	0.25	14.95	0.07	0		0	1	29.89	29.89	24.91	0.07					4.98					0.18			0	0.05	29.89	29.89	14.95						25.34	2.33	2.91	1.01	2.06	1.08	0.09	1.36	8.09	4.3	0.71	-	-	-	0.16	3.12	0.53	1.37	0.77	-	-	-	-	0.19	-	-	-	-	14.62	-	-	-	0.87	1.43	2.66	3.86	-	-	-	-	-	78.86		0.29	25.34	2.33	2.91	1.01	2.06	1.08	0.09	1.36	8.09	4.3	0.71	-	-	-	0.16	3.12	0.53	1.37	0.77	-	-	-	-	0.19	-	-	-	-	14.62	-	-	-	0.87	1.43	2.66	3.86	-	-	-	-	-	78.86																																																																																				-			25.34	2.33	2.91	1.01	2.06	1.08	0.09	1.36	8.09	4.3	0.71	-	-	-	0.16	3.12	0.53	1.37	0.77	-	-	-	-	0.19	-	-	-	-	14.62	-	-	-	0.87	1.43	2.66	3.86	-	-	-	-	-	78.86
H5404_087_0	2007	8	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V					Coin				Coin	V	V	S																																															-		1550.6	142.37	438.12	725.5	238	6.52	0.54	394.07	38.94	4139.23	11.45	69.66		5306.43	2254.74	1503.16	257.2	789.77	12.3					541.7					82.23			10137.58	20.97	690.74	1282.8	3714.45						325 (Days 1-7)	325 (Days 1-7)	150 (Days 7-100)	20	125	20	20	50	25	0-75	0-20				10 Urgent Care else 0	25	25	25	0-20					0-75					copays & coins as percent pmpm				10	25	25	0-75						254.79	254.79	95.35	19.95	124.66	0.2	0.2	49.78	0.25	14.93	0.07	0		0	1	24.89	24.89	24.89	0.07					4.98					0.19			0	0.1	24.89	24.89	14.93						32.92	3.02	3.48	1.21	2.47	1.3	0.11	1.63	9.69	5.15	0.86	-	-	-	0.19	3.12	0.53	1.64	0.92	-	-	-	-	0.22	-	-	-	-	15.6	-	-	-	2.09	1.43	2.66	4.62	-	-	-	-	-	94.87		0.43	32.92	3.02	3.48	1.21	2.47	1.3	0.11	1.63	9.69	5.15	0.86	-	-	-	0.19	3.12	0.53	1.64	0.92	-	-	-	-	0.22	-	-	-	-	15.6	-	-	-	2.09	1.43	2.66	4.62	-	-	-	-	-	94.87																																																																																				-			32.92	3.02	3.48	1.21	2.47	1.3	0.11	1.63	9.69	5.15	0.86	-	-	-	0.19	3.12	0.53	1.64	0.92	-	-	-	-	0.22	-	-	-	-	15.6	-	-	-	2.09	1.43	2.66	4.62	-	-	-	-	-	94.87
H5404_093_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1407.1	129.19	397.57	658.36	215.97	5.92	0.49	357.6	35.34	3756.16	10.39	63.21		4815.33	2046.07	1364.05	233.4	716.68	11.16					491.56	396.58	195.33	143.7					9199.38	19.03	626.82	1164.09	3370.69						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				Urgent care 10	25	25	25	20					0-75	10	10	10						5	25	25	0-75						156.79	156.79	39.67	19.95	124.68	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	24.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.05	24.98	24.98	14.99						18.39	1.69	1.31	1.09	2.24	1.18	0.1	1.49	8.83	4.69	0.78	-	-	-	0.17	2.84	0.49	1.49	0.84	-	-	-	-	0.2	0.33	0.16	0.12	-	-	-	-	-	0.95	1.3	2.42	4.21	-	-	-	-	-	57.32		0.04	18.39	1.69	1.31	1.09	2.24	1.18	0.1	1.49	8.83	4.69	0.78	-	-	-	0.17	2.84	0.49	1.49	0.84	-	-	-	-	0.2	0.33	0.16	0.12	-	-	-	-	-	0.95	1.3	2.42	4.21	-	-	-	-	-	57.32																																																																																				-			18.39	1.69	1.31	1.09	2.24	1.18	0.1	1.49	8.83	4.69	0.78	-	-	-	0.17	2.84	0.49	1.49	0.84	-	-	-	-	0.2	0.33	0.16	0.12	-	-	-	-	-	0.95	1.3	2.42	4.21	-	-	-	-	-	57.32
H5404_094_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		P	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	S																																															-		1286.3	118.1	363.44	601.84	197.43	5.41	0.45	326.9	32.3	3433.69	9.5	57.78		4401.93	1870.42	1246.94	213.36	655.15	10.2					449.36	362.54	178.56	131.36					8409.6	17.39	573	1064.15	3081.31						300 (Days 1-7)	300 (Days 1-7)	100 (Days 6-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	15	25	25	20					0-75	10	10	10						10	25	25	0-75						235.19	235.19	63.63	19.95	124.68	0.2	0.2	49.83	0.25	14.95	0.07	0		0	1	14.95	24.91	24.91	0.07					4.98	9.97	9.97	9.97					0	0.1	24.91	24.91	14.95						25.21	2.31	1.93	1	2.05	1.08	0.09	1.36	8.05	4.28	0.71	-	-	-	0.16	1.55	0.44	1.36	0.76	-	-	-	-	0.19	0.3	0.15	0.11	-	-	-	-	-	1.73	1.19	2.21	3.84	-	-	-	-	-	62.06		0.21	25.21	2.31	1.93	1	2.05	1.08	0.09	1.36	8.05	4.28	0.71	-	-	-	0.16	1.55	0.44	1.36	0.76	-	-	-	-	0.19	0.3	0.15	0.11	-	-	-	-	-	1.73	1.19	2.21	3.84	-	-	-	-	-	62.06																																																																																				-			25.21	2.31	1.93	1	2.05	1.08	0.09	1.36	8.05	4.28	0.71	-	-	-	0.16	1.55	0.44	1.36	0.76	-	-	-	-	0.19	0.3	0.15	0.11	-	-	-	-	-	1.73	1.19	2.21	3.84	-	-	-	-	-	62.06
H5404_096_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1437.78	132.01	406.24	672.71	220.68	6.05	0.5	365.4	36.11	3838.04	10.62	64.59		4920.31	2090.68	1393.79	238.49	732.3	11.4					502.28	405.23	199.59	146.83					9399.94	19.44	640.48	1189.46	3444.17						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				Urgent care 10	25	25	25	20					0-75	10	10	10						5	25	25	0-75						156.79	156.79	39.67	19.95	124.68	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	24.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.05	24.98	24.98	14.99						18.79	1.72	1.34	1.12	2.29	1.21	0.1	1.52	9.02	4.79	0.8	-	-	-	0.17	2.9	0.5	1.52	0.85	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	0.97	1.33	2.48	4.3	-	-	-	-	-	58.57		0.05	18.79	1.72	1.34	1.12	2.29	1.21	0.1	1.52	9.02	4.79	0.8	-	-	-	0.17	2.9	0.5	1.52	0.85	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	0.97	1.33	2.48	4.3	-	-	-	-	-	58.57																																																																																				-			18.79	1.72	1.34	1.12	2.29	1.21	0.1	1.52	9.02	4.79	0.8	-	-	-	0.17	2.9	0.5	1.52	0.85	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	0.97	1.33	2.48	4.3	-	-	-	-	-	58.57
H5404_101_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1222.29	112.22	345.35	571.89	187.61	5.14	0.43	310.64	30.7	3262.83	9.03	54.91		4182.89	1777.35	1184.9	202.74	622.55	9.69					427	344.5	169.68	124.82					7991.14	16.53	544.49	1011.2	2927.98						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				Urgent care 10	25	25	25	20					0-75	10	10	10						5	25	25	0-75						156.79	156.79	39.67	19.95	124.68	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	24.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.05	24.98	24.98	14.99						15.97	1.47	1.14	0.95	1.95	1.03	0.09	1.29	7.67	4.08	0.68	-	-	-	0.15	2.47	0.42	1.3	0.73	-	-	-	-	0.18	0.29	0.14	0.1	-	-	-	-	-	0.83	1.13	2.11	3.66	-	-	-	-	-	49.8		0.04	15.97	1.47	1.14	0.95	1.95	1.03	0.09	1.29	7.67	4.08	0.68	-	-	-	0.15	2.47	0.42	1.3	0.73	-	-	-	-	0.18	0.29	0.14	0.1	-	-	-	-	-	0.83	1.13	2.11	3.66	-	-	-	-	-	49.8																																																																																				-			15.97	1.47	1.14	0.95	1.95	1.03	0.09	1.29	7.67	4.08	0.68	-	-	-	0.15	2.47	0.42	1.3	0.73	-	-	-	-	0.18	0.29	0.14	0.1	-	-	-	-	-	0.83	1.13	2.11	3.66	-	-	-	-	-	49.8
H5404_102_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1419.69	130.35	401.13	664.25	217.9	5.97	0.5	360.8	35.65	3789.75	10.49	63.78		4858.4	2064.37	1376.25	235.48	723.09	11.26					495.96	400.13	197.08	144.98					9281.66	19.2	632.42	1174.5	3400.83						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	0-20				Urgent care 10	25	25	25	20					0-75	10	10	10						5	25	25	0-75						156.79	156.79	39.67	19.95	124.68	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	24.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.05	24.98	24.98	14.99						18.55	1.7	1.33	1.1	2.26	1.19	0.1	1.5	8.91	4.73	0.79	-	-	-	0.17	2.86	0.49	1.51	0.84	-	-	-	-	0.21	0.33	0.16	0.12	-	-	-	-	-	0.96	1.32	2.44	4.25	-	-	-	-	-	57.84		0.04	18.55	1.7	1.33	1.1	2.26	1.19	0.1	1.5	8.91	4.73	0.79	-	-	-	0.17	2.86	0.49	1.51	0.84	-	-	-	-	0.21	0.33	0.16	0.12	-	-	-	-	-	0.96	1.32	2.44	4.25	-	-	-	-	-	57.84																																																																																				-			18.55	1.7	1.33	1.1	2.26	1.19	0.1	1.5	8.91	4.73	0.79	-	-	-	0.17	2.86	0.49	1.51	0.84	-	-	-	-	0.21	0.33	0.16	0.12	-	-	-	-	-	0.96	1.32	2.44	4.25	-	-	-	-	-	57.84
H5404_105_0	2007	7	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	V	V	V	P																																															-		1471.89	135.14	415.88	688.67	225.91	6.19	0.52	374.07	36.96	3929.1	10.87	66.12		5037.04	2140.28	1426.85	244.14	749.67	11.67					514.2	414.84	204.33	150.31					9622.94	449.56	655.67	1217.68	3525.88						300 (Days 1-7)	300 (Days 1-7)	100 (Days 6-100)	20	125	20	20	50	25	0-75	20				10 Urgent Care else 0	20	25	25	20					0-75	10	10	10						50	25	25	0-75						235.19	235.19	63.63	19.95	124.68	0.2	0.2	49.83	0.25	14.95	0.07	0		0	1	19.93	24.91	24.91	0.07					4.98	9.97	9.97	9.97					0	49.83	24.91	24.91	14.95						28.85	2.65	2.21	1.14	2.35	1.23	0.1	1.55	9.21	4.89	0.81	-	-	-	0.18	2.37	0.51	1.56	0.87	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	1.87	1.36	2.53	4.39	-	-	-	-	-	71.48		0.25	28.85	2.65	2.21	1.14	2.35	1.23	0.1	1.55	9.21	4.89	0.81	-	-	-	0.18	2.37	0.51	1.56	0.87	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	1.87	1.36	2.53	4.39	-	-	-	-	-	71.48																																																																																				-			28.85	2.65	2.21	1.14	2.35	1.23	0.1	1.55	9.21	4.89	0.81	-	-	-	0.18	2.37	0.51	1.56	0.87	-	-	-	-	0.21	0.34	0.17	0.12	-	-	-	-	-	1.87	1.36	2.53	4.39	-	-	-	-	-	71.48
H5404_106_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1498.55	137.59	423.41	701.15	230.01	6.31	0.53	380.85	37.63	4000.29	11.07	67.32		5128.3	2179.06	1452.71	248.57	763.26	11.88					523.51	422.36	208.03	153.04					9797.29	20.26	667.55	1239.74	3589.76						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				Urgent care 10	25	25	25	20					0-75	10	10	10						5	25	25	0-75						156.79	156.79	39.67	19.95	124.68	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	24.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.05	24.98	24.98	14.99						19.58	1.8	1.4	1.17	2.39	1.26	0.11	1.59	9.4	5	0.83	-	-	-	0.18	3.02	0.52	1.59	0.89	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	1.01	1.39	2.58	4.48	-	-	-	-	-	61.05		0.05	19.58	1.8	1.4	1.17	2.39	1.26	0.11	1.59	9.4	5	0.83	-	-	-	0.18	3.02	0.52	1.59	0.89	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	1.01	1.39	2.58	4.48	-	-	-	-	-	61.05																																																																																				-			19.58	1.8	1.4	1.17	2.39	1.26	0.11	1.59	9.4	5	0.83	-	-	-	0.18	3.02	0.52	1.59	0.89	-	-	-	-	0.22	0.35	0.17	0.13	-	-	-	-	-	1.01	1.39	2.58	4.48	-	-	-	-	-	61.05
H5404_108_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V		V	V	V	V	V	Coin					V	V	V	V					S	Coin	V	V	P																																															-		1377.43	126.47	389.19	644.47	211.42	5.8	0.48	350.06	34.59	3676.94	10.17	61.88		4713.78	2002.92	1335.28	228.48	701.56	10.92					481.2	388.22	191.21	140.67					9005.37	18.63	613.6	1139.54	3299.6						200 (Days 1-7)	200 (Days 1-7)	100 (Days 11-100)	20	125	20	20	50	25	0-75	20				Urgent care 10	25	25	25	20					0-75	10	10	10						5	25	25	0-75						156.79	156.79	39.67	19.95	124.68	0.2	0.2	49.96	0.25	14.99	0.07	0		0	1	24.98	24.98	24.98	0.07					5	9.99	9.99	9.99					0	0.05	24.98	24.98	14.99						18	1.65	1.29	1.07	2.2	1.16	0.1	1.46	8.64	4.59	0.76	-	-	-	0.17	2.78	0.48	1.46	0.82	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	0.93	1.28	2.37	4.12	-	-	-	-	-	56.12		0.04	18	1.65	1.29	1.07	2.2	1.16	0.1	1.46	8.64	4.59	0.76	-	-	-	0.17	2.78	0.48	1.46	0.82	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	0.93	1.28	2.37	4.12	-	-	-	-	-	56.12																																																																																				-			18	1.65	1.29	1.07	2.2	1.16	0.1	1.46	8.64	4.59	0.76	-	-	-	0.17	2.78	0.48	1.46	0.82	-	-	-	-	0.2	0.32	0.16	0.12	-	-	-	-	-	0.93	1.28	2.37	4.12	-	-	-	-	-	56.12
H5404_110_0	2007	4	s.	t.									Outpatient Facility - Surgery	Durable Medical Equipment									1500	ASC	Diabetes Supplies									D	D	D	V	T	Coin	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	Ded	V	Ded	O	O	O	V	Coin																																																		-	none	3803	841	2206	7812	1071	57	4.75	429	442	8845	1256	105	-	436	4626	5323	968	1839	4753	26075	-	240	-	421	412	103	106	19	-	15641	9000	238	33.25									100 days 1 to 5	100 days 1 to 5	50 days 1 to 10; 25 11 to 100		100 per trip	30 of covered charges	30 of covered charges	50 per visit	125 per visit to Hospital		0 to 50 per visit				10 Urgent care copay									0-75	10	10	10	10				25 per visit to ASC	30 of covered charges									68.65	68.65	30.15	0	100	30	30	50	125	0	25	0	0	0	1	0	0	0	0	0	0	0	0	7	10	10	10	10	0	0	0	25	30									21.76	4.81	5.54	-	8.92	17.1	1.42	1.79	4.61	-	2.62	-	-	-	0.39	-	-	-	-	-	-	-	-	0.25	0.34	0.09	0.09	0.02	-	-	-	0.5	9.97	-	-	-	-	-	-	-	-	80.21	0	0.05	21.76	4.81	5.54	-	8.92	17.1	1.42	1.79	4.61	-	2.62	-	-	-	0.39	-	-	-	-	-	-	-	-	0.25	0.34	0.09	0.09	0.02	-	-	-	0.5	9.97	-	-	-	-	-	-	-	-	80.21	none																																																																																			-			21.76	4.81	5.54	-	8.92	17.1	1.42	1.79	4.61	-	2.62	-	-	-	0.39	-	-	-	-	-	-	-	-	0.25	0.34	0.09	0.09	0.02	-	-	-	0.5	9.97	-	-	-	-	-	-	-	-	80.21
H5404_111_0	2007	4	s.	t.									Outpatient Facility - Surgery	Durable Medical Equipment									1500	ASC	Diabetes Supplies									D	D	D	V	T	Coin	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	Ded	V	Ded	O	O	O	V	Coin																																																		-	none	2502	553	1917	1157	554	26.93	2.24	808	531	5716	811	68	-	281	2956	3402	618	1175	3038	16663	-	240	-	421	412	103	106	19	-	10000	9000	286	15.71									100 days 1 to 5	100 days 1 to 5	50 days 1 to 10; 25 11 to 100		100 per trip	30 of covered charges	30 of covered charges	50 per visit	125 per visit to Hospital		0 to 50 per visit				10 Urgent care copay									0-70	10	10	10	10				25 per visit to ASC	30 of covered charges									68.65	68.65	30.15	0	100	0.3	0.3	50	125	0	25	0	0	0	1	0	0	0	0	0	0	0	0	7	10	10	10	10	0	0	0	25	0.3									14.31	3.17	4.82	-	4.62	8.08	0.67	3.37	5.53	-	1.69	-	-	-	0.25	-	-	-	-	-	-	-	-	0.25	0.34	0.09	0.09	0.02	-	-	-	0.6	4.71	-	-	-	-	-	-	-	-	52.58	0	0.03	14.31	3.17	4.82	-	4.62	8.08	0.67	3.37	5.53	-	1.69	-	-	-	0.25	-	-	-	-	-	-	-	-	0.25	0.34	0.09	0.09	0.02	-	-	-	0.6	4.71	-	-	-	-	-	-	-	-	52.58	none																																																																																			-			14.31	3.17	4.82	-	4.62	8.08	0.67	3.37	5.53	-	1.69	-	-	-	0.25	-	-	-	-	-	-	-	-	0.25	0.34	0.09	0.09	0.02	-	-	-	0.6	4.71	-	-	-	-	-	-	-	-	52.58
H5404_112_0	2007	4																					none											D	D	D	V	T	P	Coin	V	V	P	V	V	V	V	V	V	V	V	P																																																																-	none	18302	755	25507	22106	5522	227003	18917	781	898	14477	2216	247	-	828	10918	17487	1292	2678	13433	53083	-	240	-	421	412	103	106	19	-	10000	9000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	none																																																																																			-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5404_113_0	2007	4																					none											D	D	D	V	T	P	Coin	V	V	P	V	V	V	V	V	V	V	V	P																																																																-	none	14426	595	23298	11950	3734	99085	8257	972	898	13136	2011	224	-	752	10183	16310	1205	2498	12528	49509	-	240	-	1710	442	110	102	18	-	10000	9000																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	none																																																																																			-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5407_001_0	2007	6																					2800											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-		1516.98	297.91	504.59	528.72	94.43		5.22	219	304.88	41.53	53.68	70.9	2.03	139.78		3056.87	151.93	49.63		91.16																						150/ day 1st 5 days	150/day 1st 5 days	75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter		20 per visit	35 ind/25 group	25 per visit		20 chiro/podiatry																						94.56	62.09	8.6	1.06	143.28		0.19	47.32	129.95	95.52	54.45	143.28	143.28	143.28		19.1	32.95	23.88		19.1																						11.95	1.54	0.36	0.05	1.13	-	1	0.86	3.3	0.33	0.24	0.85	0.02	1.67	-	4.87	0.42	0.1	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.84	0	1.35	11.95	1.54	0.36	0.05	1.13	-	1	0.86	3.3	0.33	0.24	0.85	0.02	1.67	-	4.87	0.42	0.1	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.84	2800								50 ER 40 urgent care												25 non par lab																													0.29												1.25																						1.53	0	0.07	11.95	1.54	0.36	0.05	1.13	-	1	1.15	3.3	0.33	0.24	0.85	0.02	1.67	-	4.87	0.42	0.1	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.37
H5407_004_0	2007	6																					2800											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-		1369.27	268.9	455.46	477.24	85.24		4.65	219	275.19	37.48	48.46	64	1.83	126.17		2759.22	137.14	44.8		91.16																						150/ day 1st 5 days	150/day 1st 5 days	75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter		20 per visit	35 ind/25 group	25 per visit		20 chiro/podiatry																						94.56	62.09	8.6	1.06	143.28		0.19	47.32	129.95	95.52	54.45	143.28	143.28	143.28		19.1	32.95	23.88		19.1																						10.79	1.39	0.33	0.04	1.02	-	0.89	0.86	2.98	0.3	0.22	0.76	0.02	1.51	-	4.39	0.38	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.11	0	1.23	10.79	1.39	0.33	0.04	1.02	-	0.89	0.86	2.98	0.3	0.22	0.76	0.02	1.51	-	4.39	0.38	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.11	2800								50 ER 40 urgent care												25 non par lab																													0.29												1.25																						1.53	0	0.07	10.79	1.39	0.33	0.04	1.02	-	0.89	1.15	2.98	0.3	0.22	0.76	0.02	1.51	-	4.39	0.38	0.09	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.65
H5407_005_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1369.27	268.9	455.46	477.24	85.24		4.65	219	275.19	37.48	48.46	64	1.83	126.17	6948.33	2538.48	137.14	44.8		91.16																						200/ day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						21.3	4.18	1.38	0.22	0.99	-	0.87	0.84	3.01	0.29	0.21	0.75	0.02	1.47	5.4	6.91	0.37	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.56	0	3.84	21.3	4.18	1.38	0.22	0.99	-	0.87	0.84	3.01	0.29	0.21	0.75	0.02	1.47	5.4	6.91	0.37	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.56	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.22																						1.5	0	0.14	21.3	4.18	1.38	0.22	0.99	-	0.87	1.12	3.01	0.29	0.21	0.75	0.02	1.47	5.4	6.91	0.37	0.09	-	1.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.05
H5407_006_0	2007	6																					2800													D	V	T		Coin	V	V	V	V	V	V	V			V	V																								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-				481.77	504.81	90.16		7.04	219	291.09	39.65	51.25	67.69	1.93	133.46			145.06	47.39																										75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter			35 ind/25 group	25 per visit																										8.98	1.11	149.67		0.2	49.44	135.75	99.78	56.88	149.67	149.67	149.67			34.42	24.95																								-	-	0.36	0.05	1.12	-	1.4	0.9	3.29	0.33	0.24	0.84	0.02	1.66	-	-	0.42	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.75	0	0.02	-	-	0.36	0.05	1.12	-	1.4	0.9	3.29	0.33	0.24	0.84	0.02	1.66	-	-	0.42	0.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.75	2800								50 ER 40 urgent care												25 non par lab																													0.3												1.3																						1.6	0	0	-	-	0.36	0.05	1.12	-	1.4	1.2	3.29	0.33	0.24	0.84	0.02	1.66	-	-	0.42	0.1	-	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.35
H5407_007_0	2007	6																					2800											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-		1448.37	284.43	481.77	504.81	90.16		5.97	219	291.09	39.65	51.25	67.69	1.93	133.46		2918.62	145.06	47.39		91.16																						150/ day 1st 5 days	150/day 1st 5 days	75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter		20 per visit	35 ind/25 group	25 per visit		20 chiro/podiatry																						94.56	62.09	8.6	1.06	143.28		0.19	47.32	129.95	95.52	54.45	143.28	143.28	143.28		19.1	32.95	23.88		19.1																						11.41	1.47	0.35	0.04	1.08	-	1.14	0.86	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.76	0	1.3	11.41	1.47	0.35	0.04	1.08	-	1.14	0.86	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.76	2800								50 ER 40 urgent care												25 non par lab																													0.29												1.25																						1.53	0	0.07	11.41	1.47	0.35	0.04	1.08	-	1.14	1.15	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.3
H5407_008_0	2007	6																					2800											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-		1557.78	305.92	518.16	542.94	96.97		5.65	219	313.08	42.64	55.13	72.81	2.08	143.54		3139.08	156.02	50.97		91.16																						150/ day 1st 5 days	150/day 1st 5 days	75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter		20 per visit	35 ind/25 group	25 per visit		20 chiro/podiatry																						94.56	62.09	8.6	1.06	143.28		0.19	47.32	129.95	95.52	54.45	143.28	143.28	143.28		19.1	32.95	23.88		19.1																						12.28	1.58	0.37	0.05	1.16	-	1.08	0.86	3.39	0.34	0.25	0.87	0.02	1.71	-	5	0.43	0.1	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.64	0	1.39	12.28	1.58	0.37	0.05	1.16	-	1.08	0.86	3.39	0.34	0.25	0.87	0.02	1.71	-	5	0.43	0.1	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.64	2800								50 ER 40 urgent care												25 non par lab																													0.29												1.25																						1.53	0	0.07	12.28	1.58	0.37	0.05	1.16	-	1.08	1.15	3.39	0.34	0.25	0.87	0.02	1.71	-	5	0.43	0.1	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.17
H5407_009_0	2007	6																					2500											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	2500			518.16	542.94	96.97		5.65	219	313.08	42.64	55.13		2.08	143.54		3139.08	156.02	50.97		91.16																								50/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	0 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++		150 per encounter	150 per encounter		5 per visit	35 ind/25 group	25 per visit		5 chiro/podiatry																								8.37	1.03	139.51		0.19	46.08	113.56	93.01	53.02		139.51	139.51		4.65	32.09	23.25		4.65																						-	-	0.36	0.05	1.13	-	1.05	0.84	2.96	0.33	0.24	-	0.02	1.67	-	1.22	0.42	0.1	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.43	0	0.78	-	-	0.36	0.05	1.13	-	1.05	0.84	2.96	0.33	0.24	-	0.02	1.67	-	1.22	0.42	0.1	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.43	2500								50 ER 40 urgent care												25 non par lab																													0.28												1.21																						1.49	0	0.11	-	-	0.36	0.05	1.13	-	1.05	1.12	2.96	0.33	0.24	-	0.02	1.67	-	1.22	0.42	0.1	-	1.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.92
H5407_010_0	2007	6																					2800											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-		1393.49	273.65	463.51	485.68	86.75		4.72	219	280.06	38.15	49.31	65.13	1.86	128.4		2808.02	139.56	45.59		91.16																						150/ day 1st 5 days	150/day 1st 5 days	75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter		20 per visit	35 ind/25 group	25 per visit		20 chiro/podiatry																						94.56	62.09	8.6	1.06	143.28		0.19	47.32	129.95	95.52	54.45	143.28	143.28	143.28		19.1	32.95	23.88		19.1																						10.98	1.42	0.33	0.04	1.04	-	0.9	0.86	3.03	0.3	0.22	0.78	0.02	1.53	-	4.47	0.38	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.56	0	1.25	10.98	1.42	0.33	0.04	1.04	-	0.9	0.86	3.03	0.3	0.22	0.78	0.02	1.53	-	4.47	0.38	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.56	2800								50 ER 40 urgent care												25 non par lab																													0.29												1.25																						1.53	0	0.07	10.98	1.42	0.33	0.04	1.04	-	0.9	1.15	3.03	0.3	0.22	0.78	0.02	1.53	-	4.47	0.38	0.09	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.09
H5407_011_0	2007	6																					2800																																																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2800																																																																																			-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5407_012_0	2007	5																					2800											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-		1448.37	284.43	481.77	504.81	90.16		5.55	219	291.09	39.65	51.25	67.69	1.93	133.46		2918.62	145.06	47.39		91.16																						150/ day 1st 5 days	150/day 1st 5 days	75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter		20 per visit	35 ind/25 group	25 per visit		20 chiro/podiatry																						94.56	62.09	8.6	1.06	143.28		0.19	47.32	129.95	95.52	54.45	143.28	143.28	143.28		19.1	32.95	23.88		19.1																						11.41	1.47	0.35	0.04	1.08	-	1.06	0.86	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.68	0	1.3	11.41	1.47	0.35	0.04	1.08	-	1.06	0.86	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.68	2800								50 ER 40 urgent care												25 non par lab																													0.29												1.25																						1.53	0	0.07	11.41	1.47	0.35	0.04	1.08	-	1.06	1.15	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.22
H5407_013_0	2007	5																					2800											D	D	D	V	T		Coin	V	V	V	V	V	V	V		V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-		1448.37	284.43	481.77	504.81	90.16		5.71	219	291.09	39.65	51.25	67.69	1.93	133.46		2918.62	145.06	47.39		91.16																						150/ day 1st 5 days	150/day 1st 5 days	75/day days 15-30 100 thereafter	25/visit after 1st 25 visits	150 per trip		20 of allowed charges	50 ER 25 Urgent care	75 ASC 150 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter		20 per visit	35 ind/25 group	25 per visit		20 chiro/podiatry																						94.56	62.09	8.6	1.06	143.28		0.19	47.32	129.95	95.52	54.45	143.28	143.28	143.28		19.1	32.95	23.88		19.1																						11.41	1.47	0.35	0.04	1.08	-	1.09	0.86	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.72	0	1.3	11.41	1.47	0.35	0.04	1.08	-	1.09	0.86	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.72	2800								50 ER 40 urgent care												25 non par lab																													0.29												1.25																						1.53	0	0.07	11.41	1.47	0.35	0.04	1.08	-	1.09	1.15	3.15	0.32	0.23	0.81	0.02	1.59	-	4.65	0.4	0.09	-	1.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.25
H5407_014_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1516.98	297.91	504.59	528.72	94.43		5.22	219	304.88	41.53	53.68	70.9	2.03	139.78	7697.88	2812.32	151.93	49.63		91.16																						200/day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						23.59	4.63	1.53	0.24	1.1	-	0.97	0.84	3.34	0.32	0.24	0.83	0.02	1.63	5.99	7.65	0.41	0.1	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.69	0	3.84	23.59	4.63	1.53	0.24	1.1	-	0.97	0.84	3.34	0.32	0.24	0.83	0.02	1.63	5.99	7.65	0.41	0.1	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.69	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.7																						1.98	0	0.14	23.59	4.63	1.53	0.24	1.1	-	0.97	1.12	3.34	0.32	0.24	0.83	0.02	1.63	5.99	7.65	0.41	0.1	-	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.67
H5407_015_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1448.37	284.43	481.77	504.81	90.16		7.04	219	291.09	39.65	51.25	67.69	1.93	133.46	7349.74	2685.13	145.06	47.39		91.16																						200/day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						22.53	4.42	1.46	0.23	1.05	-	1.31	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.7	0	3.7	22.53	4.42	1.46	0.23	1.05	-	1.31	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.7	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.22																						1.5	0	0.11	22.53	4.42	1.46	0.23	1.05	-	1.31	1.12	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	1.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.19
H5407_016_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1448.37	284.43	481.77	504.81	90.16		5.97	219	291.09	39.65	51.25	67.69	1.93	133.46	7349.74	2685.13	145.06	47.39		91.16																						200/day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						22.53	4.42	1.46	0.23	1.05	-	1.11	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.5	0	3.7	22.53	4.42	1.46	0.23	1.05	-	1.11	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.5	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.22																						1.5	0	0.11	22.53	4.42	1.46	0.23	1.05	-	1.11	1.12	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	1.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.99
H5407_017_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1557.78	305.92	518.16	542.94	96.97		5.65	219	313.08	42.64	55.13	72.81	2.08	143.54	7904.9	2887.95	156.02	50.97		91.16																						200/day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						24.23	4.76	1.57	0.25	1.13	-	1.05	0.84	3.43	0.33	0.24	0.85	0.02	1.67	6.15	7.86	0.42	0.1	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.16	0	3.95	24.23	4.76	1.57	0.25	1.13	-	1.05	0.84	3.43	0.33	0.24	0.85	0.02	1.67	6.15	7.86	0.42	0.1	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.16	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.22																						1.5	0	0.11	24.23	4.76	1.57	0.25	1.13	-	1.05	1.12	3.43	0.33	0.24	0.85	0.02	1.67	6.15	7.86	0.42	0.1	-	1.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.66
H5407_018_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1393.49	273.65	463.51	485.68	86.75		4.72	219	280.06	38.15	49.31	65.13	1.86	128.4	7071.22	2583.38	139.56	45.59		91.16																						200/day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						21.67	4.26	1.41	0.22	1.01	-	0.88	0.84	3.06	0.3	0.22	0.76	0.02	1.5	5.5	7.03	0.37	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.39	0	3.54	21.67	4.26	1.41	0.22	1.01	-	0.88	0.84	3.06	0.3	0.22	0.76	0.02	1.5	5.5	7.03	0.37	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.39	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.7																						1.98	0	0.14	21.67	4.26	1.41	0.22	1.01	-	0.88	1.12	3.06	0.3	0.22	0.76	0.02	1.5	5.5	7.03	0.37	0.09	-	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.38
H5407_019_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1448.37	284.43	481.77	504.81	90.16		5.55	219	291.09	39.65	51.25	67.69	1.93	133.46	7349.74	2685.13	145.06	47.39		91.16																						200/day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						22.53	4.42	1.46	0.23	1.05	-	1.04	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.42	0	3.68	22.53	4.42	1.46	0.23	1.05	-	1.04	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.42	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.22																						1.5	0	0.11	22.53	4.42	1.46	0.23	1.05	-	1.04	1.12	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	1.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.91
H5407_020_0	2007	6																					3100											D	D	D	V	T		Coin	V	V	V	V	V	V	V	V	V	V	V		V																						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																						-	3100	1448.37	284.43	481.77	504.81	90.16		5.71	219	291.09	39.65	51.25	67.69	1.93	133.46	7349.74	2685.13	145.06	47.39		91.16																						200/day	200/day	100/day days 7-30 150 thereafter	5/1st 25 visits then 25/visit	150 per trip		20 of allowed charges	50 ER 25 Urgent care	100 ASC 200 hospital	100 per encounter	25 freest.100 hosp major ++	150 per encounter	150 per encounter	150 per encounter	10 per visit	35 per visit	35 ind/25 group	25 per visit		35 chiro/podiatry 35 lab																						186.64	186.64	36.39	5.5	139.98		0.19	46.23	131.3	93.32	53.19	139.98	139.98	139.98	9.33	32.66	32.19	23.33		32.66																						22.53	4.42	1.46	0.23	1.05	-	1.07	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.45	0	3.68	22.53	4.42	1.46	0.23	1.05	-	1.07	0.84	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.45	3100								50 ER 40 urgent care												25 non par lab																													0.28												1.7																						1.98	0	0.14	22.53	4.42	1.46	0.23	1.05	-	1.07	1.12	3.18	0.31	0.23	0.79	0.02	1.56	5.72	7.31	0.39	0.09	-	1.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.43
H5410_001_0	2007	3																																Coin	A	D	P	P	O	O	V	V	V	V	V	V	V	P	Coin	P	P	P	P	S	O	P	P	P	P	P	P	O	P	P																																																				-	0	0.03															0.01								4		2.42																30 Gastric Bypass Surgery															30 Gastric Bypass Surgery								Various Copays		150 Copay for contact lenses																0.3															0.3								94.5		150																0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	0.03	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07	0		0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	0.03	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07																																																																																				-			0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	0.03	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.07
H5411_001_0	2007	3																																	A	A					V	V	V	V	V		V																												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-			9.04						184.38	64.88	158.91	258.59	76.17		162.68																													25/day for 1st 5 days						50 copay per visit	50 copay per visit	25 per visit	25 per visit	50 copay per visit		50 per visit																													100						50	50	25	25	50		50																												-	0.08	-	-	-	-	-	0.77	0.27	0.33	0.54	0.32	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98	0	0	-	0.08	-	-	-	-	-	0.77	0.27	0.33	0.54	0.32	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98			0																																									0																																								-	0	0	-	0.08	-	-	-	-	-	0.77	0.27	0.33	0.54	0.32	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98
H5411_002_0	2007	3																																	A	A					V	V	V	V	V		V																												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-			9.04						184.38	64.88	158.91	258.59	76.17		162.68																													25/day for 1st 5 days						50 copay per visit	50 copay per visit	25 per visit	25 per visit	50 copay per visit		50 per visit																													100						50	50	25	25	50		50																												-	0.08	-	-	-	-	-	0.77	0.27	0.33	0.54	0.32	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98	0	0	-	0.08	-	-	-	-	-	0.77	0.27	0.33	0.54	0.32	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98			0																																									0																																								-	0	0	-	0.08	-	-	-	-	-	0.77	0.27	0.33	0.54	0.32	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.98
H5411_003_0	2007	3																																	A						V	V	V	V	V		V																												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-			13.13						267.92	94.28	230.92	375.76	110.68		236.39																													25/day for 1st 5 days						25 copay per visit	50 copay per visit	25 per visit	25 per visit	50 copay per visit		50 per visit																													100						25	50	25	25	50		50																												-	0.11	-	-	-	-	-	0.56	0.39	0.48	0.78	0.46	-	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.77	0	0	-	0.11	-	-	-	-	-	0.56	0.39	0.48	0.78	0.46	-	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.77			0																																									0																																								-	0	0	-	0.11	-	-	-	-	-	0.56	0.39	0.48	0.78	0.46	-	0.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.77
H5414_002_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	30	100 Complex Rad 30 Routine Rad	30	30	30	15	30	30	30	30	30	45	0																				122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	30	53.94	30	30	30	15	30	30	30	30	30	45	0																				15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68																																																																																				-			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68
H5414_004_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				75/day 1-10	75/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	20	100 Complex Rad 20 Routine Rad	20	20	20	10	20	20	20	20	20	45	0																				61.23	61.23	65.39	20	100	0.2	0.2	46.75	150	20	47.36	20	20	20	10	20	20	20	20	20	45	0																				7.94	0.15	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	4.52	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.69			7.94	0.15	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	4.52	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.69																																																																																				-			7.94	0.15	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	4.52	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.69
H5414_006_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				225/day 1-10	225/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	35	100 Complex Rad 35 Routine Rad	35	30	35	25	35 Specialist; 30 Renal Dialysis	35	35	35	35	45	0																				183.69	183.69	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	25	34.46	35	35	35	35	45	0																				23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32			23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32																																																																																				-			23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32
H5414_007_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	30	100 Complex Rad 30 Routine Rad	30	30	30	15	30	30	30	30	30	45	0																				122.46	122.46	65.39	20	100	0.2	0.2	46.75	150	30	53.94	30	30	30	15	30	30	30	30	30	45	0																				15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68																																																																																				-			15.88	0.31	6.93	3.48	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.68
H5414_008_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0																		50/day 1-10	50/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	20	100 Complex Rad 20 Routine Rad	20	20	20	0	20	20	20	20	20	45	0	Not Covered																			40.82	40.82	65.39	20	100	0.2	0.2	46.75	150	20	47.36	20	20	20	0	20	20	20	20	20	45	0	0	0																		5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47																																																																																				-			5.29	0.1	6.93	3.48	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.47
H5414_009_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16	0	0	0											225/day 1-10	225/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 Urgent Care	150	35	100 Complex Rad 35 Routine Rad	35	30	35	25	35 Specialist; 30 Renal Dialysis	35	35	35	35	45	0	Not Covered		35	100 Every 2 Years	35	500 Every 3 Yrs	N/A	Fitness	0											183.69	183.69	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	25	34.46	35	35	35	35	45	0	0	0	35	0	35	0	0	0	0											23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32			23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32																																																																																				-			23.82	0.46	6.93	3.48	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	11.31	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.32
H5414_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5414_803_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07				0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				0		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5415_039_0	2007	4	s.	t.	u.	v.	w.	x.	y.				Inpatient Facility	Inpatient Facility	Professional	OP Facility - Surgery	OP Facility - Other	OP Facility - Other	OP Facility - Other				3500	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles		Radiology	Other	Lab -- Other				D	D	D	Coin	T	Coin	Coin	V	V	V	V	Coin	Coin	V	V	V			V		S			Coin								D	D	Coin	Coin	Coin	Coin	Coin				2.84	0.02	0.27	0.27	0.26	0.02	0	0.21	0.69	1.18	0.44	0.07	0.01	0.24	1.5	4.46			0.2		0			0								0.15	0	0.39	0.51	0.17	0.1	1.18				15.18		1228.44	8.96	440.7	10.4	122.61	0.68	0.05	198.95	290.57	181.77	454.42	2.7	0.41	254.47	7028.68	8337.28			307.44		1091.69			0								64.65	0.47	15.35	19.69	6.74	4.04	45.82				125/day (1-10)	125/day (1-7)	0/day (1-6) 100/day (7-100)	10 Coins	100/ Trip	10 Coins	10 Coins	25-50/ Visit	30/ Visit	0/ Visit	0-30/ Visit	10 Coins	10 Coins	25-30/ Visit	10/ Visit	25/ Visit			30/ Visit		0/ Scripts			See PBP for details								125/day (1-10)	125/day (1-7)	10 Coins	10 Coins	10 Coins	10 Coins	10 Coins				76.51	76.51	20.63	0.07	70.9	0.07	0.07	35.02	0.39	-77.64	15	0.07	0.07	12.83	7.09	17.73			21.27		0			0								76.51	69.22	0.07	0.07	0.07	0.07	0.07				7.83	0.06	0.76	0.74	0.72	0.05	0	0.58	0.01	-1.18	0.57	0.19	0.03	0.27	4.15	12.32	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	0.41	0	1.09	1.4	0.48	0.29	3.25	-	-	-	34.56	200	14.99	10.67	0.08	1.03	1	0.99	0.07	0	0.79	0.7	-	1.01	0.26	0.04	0.51	5.66	16.77	-	-	0.74	-	-	-	-	-	-	-	-	-	-	-	-	0.56	0	1.48	1.9	0.65	0.39	4.42	-	-	-	49.74	3500	200/day (1-10)	200/day (1-10)	20 Coins	20 Coins	100/Trip	20 Coins		50/Visit	20 Coins	20 Coins			0/Procedure		35/Visit	35/Visit					20 Coins			See PBP for details										20 Coins				20 Coins				2.29	0.02	0.2	0.27	0.28	0.02		0.28	0	0			0		4.01	4.75					0.59			0										0.63	2.4			2.89				18.62	200	0	12.96	0.09	1.23	1.27	1.27	0.08	0	1.07	0.7	-	1.01	0.26	0.04	0.51	9.66	21.52	-	-	0.74	-	0.59	-	-	-	-	-	-	-	-	-	-	0.56	0	2.11	4.3	0.65	0.39	7.31	-	-	-	68.36
H5415_801_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		284.47	2.14	252.79	2412.21	140.66	0.82	0.06	278.34	497.52	917.51	625.58	41.71	427.67	354.49	8063.4	9564.65			352.7		11.42											14.97	0.11	18.59								600/admit	600/admit	100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	35/ Visit	35/ Visit			35-50/ Visit		20 Coins											600/admit	600/admit	0 Coins								408.12	408.12	17.61	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	35	35			43.14		0.2											408.12	408.12	0								9.67	0.07	0.37	2.01	1.17	0.21	0.02	1.05	8.29	2.68	2.39	0.35	-	1.11	23.52	27.9	-	-	1.27	-	2.28	-	-	-	-	-	-	-	-	-	-	0.51	0	-	-	-	-	-	-	-	-	84.87	0	0	9.67	0.07	0.37	2.01	1.17	0.21	0.02	1.05	8.29	2.68	2.39	0.35	-	1.11	23.52	27.9	-	-	1.27	-	2.28	-	-	-	-	-	-	-	-	-	-	0.51	0	-	-	-	-	-	-	-	-	84.87		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.53	0.02	0.43	0.59	0.29	0.05		0.29	5.36	6.32			0		2.01	4.82					0.65																					23.35	0	0	12.2	0.09	0.8	2.6	1.47	0.26	0.02	1.34	13.65	9	2.39	0.35	-	1.11	25.52	32.72	-	-	1.27	-	2.93	-	-	-	-	-	-	-	-	-	-	0.51	0	-	-	-	-	-	-	-	-	108.22
H5415_803_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		288.58	2.18	512.9	2447.13	142.7	0.82	0.06	282.37	504.73	930.8	634.63	42.31	433.86	359.63	8180.14	9703.13			357.81		11.41											15.19	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									14.43	0.11	0.38	2.04	1.19	0.21	0.02	1.06	8.41	2.71	2.42	0.35	-	1.13	17.04	28.3	-	-	1.04	-	2.28	-	-	-	-	-	-	-	-	-	-	0.76	0.01	-	-	-	-	-	-	-	-	83.89	0	0	14.43	0.11	0.38	2.04	1.19	0.21	0.02	1.06	8.41	2.71	2.42	0.35	-	1.13	17.04	28.3	-	-	1.04	-	2.28	-	-	-	-	-	-	-	-	-	-	0.76	0.01	-	-	-	-	-	-	-	-	83.89		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.57	0.02	0.43	0.59	0.3	0.05		0.29	5.35	6.32			0		2	4.82					0.65																					23.38	0	0	16.99	0.13	0.81	2.63	1.49	0.26	0.02	1.36	13.76	9.03	2.42	0.35	-	1.13	19.05	33.12	-	-	1.04	-	2.93	-	-	-	-	-	-	-	-	-	-	0.76	0.01	-	-	-	-	-	-	-	-	107.27
H5415_804_0	2007	2	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		284.47	2.14	252.79	2412.21	140.66	0.82	0.06	278.34	497.52	917.51	625.58	41.71	427.67	354.49	8063.4	9564.65			352.7		11.42											14.97	0.11	18.59								600/admit	600/admit	100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	35/ Visit	35/ Visit			35-50/ Visit		20 Coins											600/admit	600/admit	0 Coins								408.12	408.12	17.61	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	35	35			43.14		0.2											408.12	408.12	0								9.67	0.07	0.37	2.01	1.17	0.21	0.02	1.05	8.29	2.68	2.39	0.35	-	1.11	23.52	27.9	-	-	1.27	-	2.28	-	-	-	-	-	-	-	-	-	-	0.51	0	-	-	-	-	-	-	-	-	84.87	0	0	9.67	0.07	0.37	2.01	1.17	0.21	0.02	1.05	8.29	2.68	2.39	0.35	-	1.11	23.52	27.9	-	-	1.27	-	2.28	-	-	-	-	-	-	-	-	-	-	0.51	0	-	-	-	-	-	-	-	-	84.87		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.53	0.02	0.43	0.59	0.29	0.05		0.29	5.36	6.32			0		2.01	4.82					0.65																					23.35	0	0	12.2	0.09	0.8	2.6	1.47	0.26	0.02	1.34	13.65	9	2.39	0.35	-	1.11	25.52	32.72	-	-	1.27	-	2.93	-	-	-	-	-	-	-	-	-	-	0.51	0	-	-	-	-	-	-	-	-	108.22
H5415_805_0	2007	1	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		288.58	2.18	512.9	2447.13	142.7	0.82	0.06	282.37	504.73	930.8	634.63	42.31	433.86	359.63	8180.14	9703.13			357.81		11.41											15.19	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									14.43	0.11	0.38	2.04	1.19	0.21	0.02	1.06	8.41	2.71	2.42	0.35	-	1.13	17.04	28.3	-	-	1.04	-	2.28	-	-	-	-	-	-	-	-	-	-	0.76	0.01	-	-	-	-	-	-	-	-	83.89	0	0	14.43	0.11	0.38	2.04	1.19	0.21	0.02	1.06	8.41	2.71	2.42	0.35	-	1.13	17.04	28.3	-	-	1.04	-	2.28	-	-	-	-	-	-	-	-	-	-	0.76	0.01	-	-	-	-	-	-	-	-	83.89		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.57	0.02	0.43	0.59	0.3	0.05		0.29	5.35	6.32			0		2	4.82					0.65																					23.38	0	0	16.99	0.13	0.81	2.63	1.49	0.26	0.02	1.36	13.76	9.03	2.42	0.35	-	1.13	19.05	33.12	-	-	1.04	-	2.93	-	-	-	-	-	-	-	-	-	-	0.76	0.01	-	-	-	-	-	-	-	-	107.27
H5416_001_0	2007	6																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		982.27	33.49	533.7		82.38	7.61	7.08	323.93	35.76		7.74	3.16	0.06	10.12	6022.71	7204.92	403.19	1507.82	42	12.33	16.24				190.65		116.29															#1A: 50 days 1-5	#1B: 100 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 75	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 200; #9B ASC: 15 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 10; #5: 35; #9A OP Hosp 15 / Chemo 20; #9C: 20; #9D: 10	#7A: 5; #14C: 5	#7B : 8; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 35	#7C/#7I: 10	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 150 Allowance every two years	#18A: 20	#18B: 600 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	28.52	57.05	10.01		69.81	0.19	0.15	46.54	0.1		0.12	0.14	0.19	0.15	4.66	17.62	32.58	9.26	0.14	0.12	0.19				25		20															2.33	0.16	0.45	-	0.48	1.42	1.05	1.26	3.45	-	0.93	0.44	0.01	1.5	2.34	10.58	1.09	1.16	5.86	1.51	3.02	-	-	-	0.4	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.63		3.19	2.33	0.16	0.45	-	0.48	1.42	1.05	1.26	3.45	-	0.93	0.44	0.01	1.5	2.34	10.58	1.09	1.16	5.86	1.51	3.02	-	-	-	0.4	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.63																																																																																				-		0	2.33	0.16	0.45	-	0.48	1.42	1.05	1.26	3.45	-	0.93	0.44	0.01	1.5	2.34	10.58	1.09	1.16	5.86	1.51	3.02	-	-	-	0.4	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.63
H5416_002_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		929.29	44.27	528.1	710.84	82.93	7.24	6.69	309.72	33.26		7.53	3.07	0.07	9.98	5291.73	6026.54	231.6	1083.32	35.39	8.8	14.82				173.57		113.6															#1A: 125 days 1-5	#1B: 200 days 1-5	#2: 35 days 11-100	#6: 12	#10A: 110	#11A: 20	#11B/11C: 20	#4: 50	#9A OP Hosp: 15 NTE 400; #9B ASC: 15 NTE 300	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 20; #5: 50; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 20	#7A: 10; #14C: 10	#7B : 12; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 50	#7C/#7I: 20	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	76.62	122.59	18.83	12	110	0.2	0.2	50	0.13		0.16	0.15	0.2	0.16	10	24.03	47.97	20	0.15	0.12	0.2				25		30															5.93	0.45	0.83	0.71	0.76	1.45	1.34	1.29	4.35	-	1.24	0.46	0.01	1.64	4.41	12.07	0.93	1.81	5.31	1.08	2.96	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.67		0.24	5.93	0.45	0.83	0.71	0.76	1.45	1.34	1.29	4.35	-	1.24	0.46	0.01	1.64	4.41	12.07	0.93	1.81	5.31	1.08	2.96	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.67																																																																																				-		0	5.93	0.45	0.83	0.71	0.76	1.45	1.34	1.29	4.35	-	1.24	0.46	0.01	1.64	4.41	12.07	0.93	1.81	5.31	1.08	2.96	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.67
H5416_003_0	2007	8																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		927.24	32.22	517.62		78.81	7.17	6.68	302.29	33.49		7.32	2.99	0.05	9.55	5562.08	6357.87	211.99	1135.12	37.05	9.23	15.57				180.68		116.29															#1A: 150 days 1-5	#1B: 175 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B/11C: 20	#4: 50	#9A OP Hosp: 15 NTE 400; #9B ASC: 15 NTE 200	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 20; #5: 50; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 20	#7A: 15; #14C: 15	#7B : 15; #7D/7F/7G #16B #17A #18A: 30	#7E/#7H: 50	#7C/#7I: 20	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	91.94	107.26	13.45		100	0.2	0.2	50	0.13		0.16	0.15	0.2	0.16	15	28.87	49.74	20	0.15	0.12	0.2				25		30															7.1	0.29	0.58	-	0.66	1.43	1.34	1.26	4.42	-	1.21	0.45	0.01	1.57	6.95	15.29	0.88	1.89	5.56	1.13	3.11	-	-	-	0.38	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.8		0.26	7.1	0.29	0.58	-	0.66	1.43	1.34	1.26	4.42	-	1.21	0.45	0.01	1.57	6.95	15.29	0.88	1.89	5.56	1.13	3.11	-	-	-	0.38	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.8																																																																																				-		0	7.1	0.29	0.58	-	0.66	1.43	1.34	1.26	4.42	-	1.21	0.45	0.01	1.57	6.95	15.29	0.88	1.89	5.56	1.13	3.11	-	-	-	0.38	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.8
H5416_004_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		946.33	94.6	815.54	1277.6	114.25	5.74	5.7	292.29	37.86		14.57	5.93	0.17	18	3390.14	4585.91	310.82	759.6	14.72	4.39	18.93				126.91		113.61															#1A: 125 days 1-5	#1B: 200 days 1-5	#2: 35 days 11-100	#6: 12	#10A: 120	#11A: 25	#11B Pros: 25; #11B Supplies: 20; #11C: 20	#4: 50	#9A OP Hosp: 15 NTE 325; #9B ASC: 15 NTE 200	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 20; #5: 50; #9A OP Hosp 15 / Chemo 20; #9C: 50; #9D: 20	#7A: 20; #14C: 20	#7B : 15; #7D/7F/7G #16B #17A #18A: 30	#7E/#7H: 50	#7C/#7I: 20	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	76.62	122.59	18.83	12	120	0.25	0.21	50	0.1		0.16	0.15	0.2	0.16	20	28.17	50	20	0.15	0.15	0.2				25		30															6.04	0.97	1.28	1.28	1.14	1.43	1.2	1.22	3.86	-	2.38	0.89	0.03	2.86	5.65	10.76	1.3	1.27	2.21	0.66	3.79	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.75		0	6.04	0.97	1.28	1.28	1.14	1.43	1.2	1.22	3.86	-	2.38	0.89	0.03	2.86	5.65	10.76	1.3	1.27	2.21	0.66	3.79	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.75																																																																																				-		0	6.04	0.97	1.28	1.28	1.14	1.43	1.2	1.22	3.86	-	2.38	0.89	0.03	2.86	5.65	10.76	1.3	1.27	2.21	0.66	3.79	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.75
H5416_005_0	2007	6																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		990.13	65.35	848.22		103.83	5.26	5.48	267.72	40.73		15.45	6.32	0.12	18.41	3747.24	5186.1	244.34	844.45	16.45	4.95	21.14				129.91		116.29															#1A: 100 days 1-5	#1B: 125 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 250; #9B ASC: 15 NTE 125	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 15; #5: 35; #9A OP Hosp 15 / Chemo 20; #9C: 35; #9D: 15	#7A: 10; #14C: 15	#7B : 15; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 35	#7C/#7I: 15	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 20	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	55.89	69.87	12.26		91.19	0.18	0.15	45.6	0.09		0.15	0.14	0.18	0.15	9.24	21.66	31.92	13.68	0.14	0.14	0.18				25		20															4.61	0.38	0.87	-	0.79	0.96	0.8	1.02	3.48	-	2.3	0.86	0.02	2.67	2.89	9.36	0.65	0.96	2.25	0.68	3.86	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.87		3.8	4.61	0.38	0.87	-	0.79	0.96	0.8	1.02	3.48	-	2.3	0.86	0.02	2.67	2.89	9.36	0.65	0.96	2.25	0.68	3.86	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.87																																																																																				-		0	4.61	0.38	0.87	-	0.79	0.96	0.8	1.02	3.48	-	2.3	0.86	0.02	2.67	2.89	9.36	0.65	0.96	2.25	0.68	3.86	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.87
H5417_001_0	2007	6	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1000	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		1669.68	146.59	9231.48	10.68	277.24	658.03	3791.23	179.25	114.24	5711.46	117.02	25.08	3.25	577.28	26412.13	1710.25	2391.73	67.75		507.23	83.59	1440.52	1353.68		78							21.83	0.46		104.74	280.44						(1a) 25/day	(1b) 25/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit							(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay		(7f1) 0/visit	(18a1) 0/visit						25	25			75			50																								10										3.46	0.3	-	-	1.72	-	-	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	6.25		0.04	3.46	0.3	-	-	1.72	-	-	0.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	6.25		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30		30	30						2.32	0.03	0.88	0	0.16	0.17	0.11	0.04	0.24	0.69	0.7	0.03	0	0.05	0.01	2.53	0.22	0.01		0.25		0.13	0.13		0							0	0		0.01	0.02						8.76		0	5.78	0.34	0.88	0	1.88	0.17	0.11	0.78	0.24	0.69	0.7	0.03	0	0.05	0.01	2.53	0.22	0.01	-	0.25	-	0.13	0.13	-	0	-	-	-	-	-	-	0.02	0	-	0.01	0.02	-	-	-	-	-	15
H5417_005_0	2007	5	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T	V	V	P	V	P		O	O	V	V	V	V	V																																															-		2477.35	224.77	995.34		220.92	24.85	28.69	612.59	476.21	2390.15	1011.5	76.27	1.32	1437.72		5227.56		493.65		967.65												279.18		269.75	273.52							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0/20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0/10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c/7i) 10/10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit	(9c) 0 per Visit	(7b) 10 per Visit	(7f) 10 per Visit	(7e) 0 per Visit						41	41	20		41	8	11	20	14	3	6	14	11	14		6		6		6												6		6	6							8.56	0.78	1.65	-	0.76	2.06	3.17	1.02	0.55	0.55	0.47	0.09	0.15	1.65	-	2.41	-	0.23	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.13	-	-	-	-	-	-	24.9		20.17	8.56	0.78	1.65	-	0.76	2.06	3.17	1.02	0.55	0.55	0.47	0.09	0.15	1.65	-	2.41	-	0.23	-	0.45	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0.12	0.13	-	-	-	-	-	-	24.9		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	(16a/16b) 0 per Visit	30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.8	0.11	0.28	0.35	0.06	0.15	0.18	0.04	0.3	0.19	0.19	0.02	0.01	0.21	0.37	0.32	0.03	0.03	0.22	0.94	0.2	0	0.04		0.01		0.01															7.05		0	11.36	0.88	1.93	0.35	0.82	2.21	3.35	1.05	0.85	0.74	0.66	0.11	0.15	1.86	0.37	2.73	0.03	0.26	0.22	1.39	0.2	0	0.04	-	0.01	-	0.01	-	-	-	-	0.13	-	0.12	0.13	-	-	-	-	-	-	31.96
H5417_006_0	2007	9																					2500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	7500	1661.83	40.03	612.27	0	153.63	14.61	5.47	185.88	16.57	6152.21	32.87	0	0.18	11.45	27864.55	3179.82	149.87	4.17	0	0	14.52	786.76	0	0	55.36	0	160.37	0	0	0	0											250/325 (1a)	250 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20/30 (9b)	5 (8a 8b)	15/20/30 (8a 8b)	20/30 (incl in h5)	30 (12)	20/30 (3 9d 9a); 60 (5); 40/30 (9c)	3 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20/30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											151.2	151.2	75.6	0	105.84	0.18	0.22	30.24	0.12	1.21	0.09	0	0.18	0.12	3	25	37.5	0.12	0	0	0.18	25	0	0	25	0	25	0	0	0	0											20.94	0.5	3.86	-	1.36	2.65	1.2	0.47	2	0.62	3.08	-	0.03	1.38	6.97	6.62	0.47	0.5	-	-	2.63	1.64	-	-	0.12	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.38		26.6	20.94	0.5	3.86	-	1.36	2.65	1.2	0.47	2	0.62	3.08	-	0.03	1.38	6.97	6.62	0.47	0.5	-	-	2.63	1.64	-	-	0.12	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.38		375 (1a)	375 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	30 (16a)/0 n/c (16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.52	0.08	0.52	0.39	0.38	0.75	0.31	0.13	0.85	0.7	1.3	0	0.01	0.59	20.53	2.33	0.12	0.21	0	0	0.74	0.59	0	0	0.04	0	0.12	0	0	0	0											34.21		2.84	24.46	0.59	4.38	0.39	1.74	3.4	1.5	0.6	2.85	1.32	4.38	-	0.04	1.97	27.49	8.95	0.58	0.72	-	-	3.38	2.23	-	0	0.16	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.59
H5418_001_0	2007	9																																D	D	D	V	T	Coin	P	V	V	V	V	V	V	V	V	P	P	P	P	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1106.98	62.19			122.95	6.48		187.51	314.89					9.31	3203.26	4875.47					26.92			1947.75		124																100/day up to 400 max 800	150/admit deductible 0 days 91-150			50 Copay waived if admitted	20 Coin on amts over 500		50 Copay waived if admitted	75 Copay					30 SA Copay	5 Copay	10 Copay					20 Coins on drugs over 200 max 550			up to 20 depending on svc		25 Copay																46.15	16.55			5	0.05		25.03	75					1.5	5	10					0.17			6.78		25																4.26	0.09	-	-	0.05	0.32	-	0.39	1.97	-	-	-	-	0	1.33	4.06	-	-	-	-	4.58	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.41			4.26	0.09	-	-	0.05	0.32	-	0.39	1.97	-	-	-	-	0	1.33	4.06	-	-	-	-	4.58	-	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.41		Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				1.06	0.02	0.28		0.08	0.1	0.1	0.11	0.52	0.41	0.32	0.04	0.01	0.2	0.36	0.82	0.05	0.18	0.48	1.79	0.43	0																				7.37			5.32	0.11	0.28	-	0.13	0.43	0.1	0.5	2.49	0.41	0.32	0.04	0.01	0.2	1.69	4.89	0.05	0.18	0.48	1.79	5	0	-	1.1	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	25.78
H5419_001_0	2007	1																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	635.99	8.21	722.65	14.5	179.61	15.79	0.77	275.14	265.3	0	897.52	0	0.26	525.32	3758.42	4921.91	1.16	502.77	0	232	0	642.58	0	0	2.64	0	140.31	0	0	0	0											150/day; days 1-5	300/admit	25/day; days 21-100	15	100	30	30	50 ER / 10 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /10 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											150	60	5.96	0.15	100	0.3	0.3	36.46	100	0	7.38	0	0.18	10	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											7.95	0.04	0.36	2.17	1.5	4.74	0.23	0.84	2.21	-	0.55	-	0.05	0.44	3.13	4.1	0.58	0.42	-	0.07	-	0.54	-	-	1.32	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.34	0	0	7.95	0.04	0.36	2.17	1.5	4.74	0.23	0.84	2.21	-	0.55	-	0.05	0.44	3.13	4.1	0.58	0.42	-	0.07	-	0.54	-	-	1.32	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.34	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	7.95	0.04	0.36	2.17	1.5	4.74	0.23	0.84	2.21	-	0.55	-	0.05	0.44	3.13	4.1	0.58	0.42	-	0.07	-	0.54	-	-	1.32	-	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.34
H5419_004_0	2007	6																					none											D	D	D	coin	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	coin	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	648.48	8.61	719.91	13.38	183.93	16.31	0.76	275.9	270.97	0	922.93	0	0.27	531.82	3675.32	4837.8	1.21	483.05	0	223.4	8.77	600.86	0	0	2.75	0	146.49	0	0	0	0											200/day; days 1-5	900/admit	100/day; days 21-100	15	150	30	30	50 ER / 25 UC	100	0	25 for Hi Tech/Radiation Therapy		25	10 OP SA /25 Cardiac	10 PCP	25 SCP / 25 Chiro / 25 Podiatrist	50 MH	25 Therapy		25 Hearing / 0 Preventive	20	25 Vision/0 Blood		0	50		25				0											200	180	23.83	0.15	150	0.3	0.3	41.53	100	0	7.38	0	0.17	24.51	10	24.96	0.5	25	0	8.6	0.2	25	0	0	0.5	0	25	0	0	0	0											10.81	0.13	1.43	2.01	2.3	4.89	0.23	0.95	2.26	-	0.57	-	0.05	1.09	3.06	10.06	0.6	1.01	-	0.16	1.79	1.25	-	-	1.38	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.32	0	0	10.81	0.13	1.43	2.01	2.3	4.89	0.23	0.95	2.26	-	0.57	-	0.05	1.09	3.06	10.06	0.6	1.01	-	0.16	1.79	1.25	-	-	1.38	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.32	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.81	0.13	1.43	2.01	2.3	4.89	0.23	0.95	2.26	-	0.57	-	0.05	1.09	3.06	10.06	0.6	1.01	-	0.16	1.79	1.25	-	-	1.38	-	0.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.32
H5419_009_0	2007	6																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	224.06	2.35	0	0	187.1	16.69	0.75	307.21	275.06	0	941.16	0	0.27	536.56	3858.19	5208.18	1.23	540.95	0	237.56	0	664.88	0	0	3.27	0	173.88	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.15	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											0.93	0.01	-	-	0.39	3.34	0.15	0.51	0.57	-	0.58	-	0.02	0.77	3.21	4.34	0.62	0.45	-	0.07	-	0.55	-	-	1.63	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.29	0	0	0.93	0.01	-	-	0.39	3.34	0.15	0.51	0.57	-	0.58	-	0.02	0.77	3.21	4.34	0.62	0.45	-	0.07	-	0.55	-	-	1.63	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.29	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0.93	0.01	-	-	0.39	3.34	0.15	0.51	0.57	-	0.58	-	0.02	0.77	3.21	4.34	0.62	0.45	-	0.07	-	0.55	-	-	1.63	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.29
H5419_013_0	2007	3																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	coin	V	P	V	S	O	T	P	coin	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	221.79	2.28	0	0	183.43	16.25	0.76	300.25	270.33	0	919.89	0	0.27	531.06	3809.28	5068.67	1.2	522.37	0	234.79	0	653.97	0	0	2.96	0	157.5	0	0	0	0											50/admit	50/admit	0	0	25	20	20	25 ER / 10 UC	25	0	25 for Hi Tech/Radiation Therapy		10	10 OP SA /25 Cardiac	10 PCP	10 SCP / 10 Chiro / 10 Podiatrist	50 MH	10 Therapy		10 Hearing / 0 Preventive		10 Vision/0 Blood		0	50		10				0											50	50	0	0	25	0.2	0.2	19.92	25	0	7.38	0	0.07	17.1	10	9.99	0.5	10	0	3.55	0	10	0	0	0.5	0	10	0	0	0	0											0.92	0.01	-	-	0.38	3.25	0.15	0.5	0.56	-	0.57	-	0.02	0.76	3.17	4.22	0.6	0.44	-	0.07	-	0.54	-	-	1.48	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.77	0	0	0.92	0.01	-	-	0.38	3.25	0.15	0.5	0.56	-	0.57	-	0.02	0.76	3.17	4.22	0.6	0.44	-	0.07	-	0.54	-	-	1.48	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.77	none																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0.92	0.01	-	-	0.38	3.25	0.15	0.5	0.56	-	0.57	-	0.02	0.76	3.17	4.22	0.6	0.44	-	0.07	-	0.54	-	-	1.48	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.77
H5419_805_0	2007	4																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H5419_806_0	2007	3																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H5419_807_0	2007	4																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	270.65	2.07	38.19	0	6.38	22.8	1.05	5.03	26.42	10.28	28.12	0	0.23	27.23	41.09	118.51	1.21	4.12	26.65	21.9	7.6	5.38	0	0	0	0	0	0	0	0	0											Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare	Similar to 2007 FFS Medicare																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.26	0.2	0	0	0	0	0	0	0	0	0											19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16	none	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.59	0.15	6.89	-	1.51	5.38	0.25	1.19	6.24	2.43	6.64	-	0.05	6.43	9.7	27.97	0.28	0.97	6.29	5.17	1.99	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.16
H5420_001_0	2007	4																					1500															T		O	V							V																																																																				-						217.47		2240.31	166.81							11670.04																															50		25 for non-preferred supplies	50 (waived if admitted)							25 Urgent Care Copay																															50		3.75	40							2.5																											-	-	-	-	0.91	-	0.7	0.56	-	-	-	-	-	-	2.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.59			-	-	-	-	0.91	-	0.7	0.56	-	-	-	-	-	-	2.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.59																																																																																				-			-	-	-	-	0.91	-	0.7	0.56	-	-	-	-	-	-	2.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.59
H5420_003_0	2007	4											DME/Prosthetics/Supplies											Supplies												D		T	Coin	Coin	V			V		Coin		V		V	V	V		Coin											S																																																			-				426.03		162.68	0.93	0.19	124.78			164.36		4.2		10005.14		2608.46	7393.17	9211.35		1.77											1675.81												25 Days 7-21 (0 Days 1-622-100)		75	20 (high cost items only)	20	50 (waived if admitted)			0-25 Varying by Service		20		25 Urgent Care Copay		10	10	0-25 Varying by Service		20											25 non-preferred supplies												10.12		75	0.03	0.2	40			6.72		0.2		2.5		10	10	6.72		0.2											3.75										-	-	0.36	-	1.02	0.03	0.04	0.42	-	-	0.09	-	0.84	-	2.08	-	2.17	6.16	5.16	-	0.35	-	-	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	19.24			-	-	0.36	-	1.02	0.03	0.04	0.42	-	-	0.09	-	0.84	-	2.08	-	2.17	6.16	5.16	-	0.35	-	-	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	19.24																																																																																				-			-	-	0.36	-	1.02	0.03	0.04	0.42	-	-	0.09	-	0.84	-	2.08	-	2.17	6.16	5.16	-	0.35	-	-	-	-	-	-	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	19.24
H5420_004_0	2007	3											Professional	Professional									2500	Podiatry	Chiro													T		O	V							V																																																																				-						262.42		1952.66	201.28							3063.41																															50		25 non-preferred supplies	50 (waived if admitted)							25 Urgent Care else 0																															50		3.75	40			6.72				2.5																											-	-	-	-	1.09	-	0.61	0.67	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.01		0	-	-	-	-	1.09	-	0.61	0.67	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.01																																																																																				-			-	-	-	-	1.09	-	0.61	0.67	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.01
H5420_005_0	2007	3											Professional	Professional									3500	Podiatry	Chiro									D	D	D		T	Coin	Coin	V	V		V		Coin		V	V	V	V	V		Coin				V							V	V	O																																																	-		1688.41	304.11	496.41		189.55	6.32	0.19	145.39	168.97		191.52		2.83		2543.15	1406.03	459.66	429.13	725.61		4.8				488.33							314.25	47.5	1952.66									175 days 1-5 then 0	0 days 1-6; 25 days 7-100		100	20 (high cost items only)	20	50 (waived if admitted)	100		0-50 varies by service		20		25 Urgent Care Copay	25	25	25	0-50 varies by service		20				25							25	25	25 for non-preferred supplies									120.14	14.47		100	0.03	0.2	40	100		13.44		0.2		2.5	25	25	25	13.44		0.2				25							25	25	3.75								-	3.04	0.6	-	1.58	0.19	0.04	0.48	1.41	-	0.21	-	0.57	-	0.53	2.93	0.96	0.89	0.81	-	0.96	-	-	-	1.02	-	-	-	-	-	-	0.65	0.1	0.61	-	-	-	-	-	-	-	17.59		0	-	3.04	0.6	-	1.58	0.19	0.04	0.48	1.41	-	0.21	-	0.57	-	0.53	2.93	0.96	0.89	0.81	-	0.96	-	-	-	1.02	-	-	-	-	-	-	0.65	0.1	0.61	-	-	-	-	-	-	-	17.59																																																																																				-			-	3.04	0.6	-	1.58	0.19	0.04	0.48	1.41	-	0.21	-	0.57	-	0.53	2.93	0.96	0.89	0.81	-	0.96	-	-	-	1.02	-	-	-	-	-	-	0.65	0.1	0.61	-	-	-	-	-	-	-	17.59
H5420_006_0	2007	4																																				T		O	V																																																																											-						300.77		3098.43	230.7																																						50		0-25 by vendor	25 (waived if admitted)																																						50		2.5	20																																		-	-	-	-	1.25	-	0.65	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.28			-	-	-	-	1.25	-	0.65	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.28																																																																																				-			-	-	-	-	1.25	-	0.65	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.28
H5421_032_0	2007	2																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1680.03	80.46	681.69	31.13	101.82	10.49	12.41	325.89	395.1		24.2		1.3	258	3777.57	5118.85	2.29	450.35	29.38	454.59	27.55	27.16			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															47.5	47.41	29.86	0.11	74.19	0.15	0.15	37.1	115.02		0.15		37.01	31.67	11.12	22.68	0.37	22.16	0.15	22.18	0.15	22.21			22.24		22.24															6.65	0.32	1.7	3.46	0.63	1.56	1.84	1.01	3.79	-	3.59	-	0	0.68	3.5	9.67	0.85	0.83	4.35	0.84	4.08	0.05	-	-	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.07		17.5	6.65	0.32	1.7	3.46	0.63	1.56	1.84	1.01	3.79	-	3.59	-	0	0.68	3.5	9.67	0.85	0.83	4.35	0.84	4.08	0.05	-	-	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.07																																																																																				-		0	6.65	0.32	1.7	3.46	0.63	1.56	1.84	1.01	3.79	-	3.59	-	0	0.68	3.5	9.67	0.85	0.83	4.35	0.84	4.08	0.05	-	-	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.07
H5421_034_0	2007	2																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1696.03	81.23	688.18	31.42	102.79	10.59	12.53	328.98	398.86		24.43		1.31	260.46	3813.53	5167.58	2.31	454.64	29.66	458.91	27.81	27.42			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															22.53	25.37	32.49	0.12	40.34	0.16	0.16	28.24	31.28		0.08		40.28	23.01	4.03	12.6	0.4	12.07	0.08	12.08	0.16	12.09			12.1		12.1															3.18	0.17	1.86	3.8	0.35	1.71	2.02	0.77	1.04	-	1.97	-	0	0.5	1.28	5.42	0.93	0.46	2.39	0.46	4.48	0.03	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.21		7.98	3.18	0.17	1.86	3.8	0.35	1.71	2.02	0.77	1.04	-	1.97	-	0	0.5	1.28	5.42	0.93	0.46	2.39	0.46	4.48	0.03	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.21																																																																																				-		0	3.18	0.17	1.86	3.8	0.35	1.71	2.02	0.77	1.04	-	1.97	-	0	0.5	1.28	5.42	0.93	0.46	2.39	0.46	4.48	0.03	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.21
H5421_035_0	2007	3																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1518.46	75.6	657.67	24.94	97.04	10.55	11.96	331.83	391.08		23.6		1.39	237.77	3761.85	4712.19	1.82	327.87	25.15	381.92	24.47	26.5			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															48.67	48.57	30.63	0.11	75.99	0.15	0.15	38.01	116.67		0.15		38	33.6	11.4	23.29	0.38	22.8	0.15	22.8	0.15	22.8			22.8		22.8															6.16	0.31	1.68	2.84	0.61	1.6	1.82	1.05	3.8	-	3.59	-	0	0.67	3.57	9.15	0.69	0.62	3.82	0.73	3.72	0.05	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.18		14.9	6.16	0.31	1.68	2.84	0.61	1.6	1.82	1.05	3.8	-	3.59	-	0	0.67	3.57	9.15	0.69	0.62	3.82	0.73	3.72	0.05	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.18																																																																																				-		0	6.16	0.31	1.68	2.84	0.61	1.6	1.82	1.05	3.8	-	3.59	-	0	0.67	3.57	9.15	0.69	0.62	3.82	0.73	3.72	0.05	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.18
H5421_037_0	2007	3																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1532.91	76.32	663.93	25.18	97.97	10.65	12.08	334.98	394.8		23.83		1.4	240.04	3797.66	4757.04	1.84	330.99	25.39	385.56	24.71	26.75			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															23.25	25.86	33.17	0.12	41.15	0.16	0.16	28.82	31.59		0.08		41.16	24.58	4.12	12.88	0.41	12.35	0.08	12.35	0.16	12.35			12.35		12.35															2.97	0.16	1.84	3.11	0.34	1.75	1.99	0.8	1.04	-	1.96	-	0	0.49	1.3	5.11	0.76	0.34	2.09	0.4	4.07	0.03	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.91		6.64	2.97	0.16	1.84	3.11	0.34	1.75	1.99	0.8	1.04	-	1.96	-	0	0.49	1.3	5.11	0.76	0.34	2.09	0.4	4.07	0.03	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.91																																																																																				-		0	2.97	0.16	1.84	3.11	0.34	1.75	1.99	0.8	1.04	-	1.96	-	0	0.49	1.3	5.11	0.76	0.34	2.09	0.4	4.07	0.03	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.91
H5421_038_0	2007	2																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1341.82	73.38	652.68	21.35	92.84	9.51	11.44	327.21	348.51		22.2		1.05	225.92	3841.18	4461.6	1.74	344.09	20.83	348.26	22.14	25.1			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															49.66	49.52	31.25	0.12	77.49	0.16	0.16	38.77	126.64		0.16		38.77	31.89	11.63	23.81	0.39	23.24	0.16	23.26	0.16	23.28			23.26		23.26															5.55	0.3	1.7	2.48	0.6	1.47	1.77	1.06	3.68	-	3.44	-	0	0.6	3.72	8.85	0.67	0.67	3.23	0.68	3.43	0.05	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.67		12.95	5.55	0.3	1.7	2.48	0.6	1.47	1.77	1.06	3.68	-	3.44	-	0	0.6	3.72	8.85	0.67	0.67	3.23	0.68	3.43	0.05	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.67																																																																																				-		0	5.55	0.3	1.7	2.48	0.6	1.47	1.77	1.06	3.68	-	3.44	-	0	0.6	3.72	8.85	0.67	0.67	3.23	0.68	3.43	0.05	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.67
H5421_039_0	2007	2																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1354.6	74.07	658.89	21.55	93.73	9.6	11.55	330.32	351.83		22.41		1.06	228.07	3877.74	4504.06	1.76	347.36	21.02	351.57	22.35	25.34			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															24.19	26.55	33.8	0.13	41.9	0.17	0.17	29.35	34.25		0.08		41.93	22.62	4.19	13.18	0.42	12.57	0.08	12.58	0.17	12.59			12.58		12.58															2.73	0.16	1.86	2.71	0.33	1.61	1.94	0.81	1	-	1.88	-	0	0.43	1.36	4.95	0.74	0.36	1.76	0.37	3.75	0.03	-	-	0.14	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.15		5.61	2.73	0.16	1.86	2.71	0.33	1.61	1.94	0.81	1	-	1.88	-	0	0.43	1.36	4.95	0.74	0.36	1.76	0.37	3.75	0.03	-	-	0.14	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.15																																																																																				-		0	2.73	0.16	1.86	2.71	0.33	1.61	1.94	0.81	1	-	1.88	-	0	0.43	1.36	4.95	0.74	0.36	1.76	0.37	3.75	0.03	-	-	0.14	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.15
H5421_040_0	2007	6																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1680.03	80.46	681.69	31.13	101.82	10.49	12.41	325.89	395.1		24.2		1.3	258	3777.57	5118.85	2.29	450.35	29.38	454.59	27.55	27.16			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															47.5	47.41	29.86	0.11	74.19	0.15	0.15	37.1	115.02		0.15		37.01	31.67	11.12	22.68	0.37	22.16	0.15	22.18	0.15	22.21			22.24		22.24															6.65	0.32	1.7	3.46	0.63	1.56	1.84	1.01	3.79	-	3.59	-	0	0.68	3.5	9.67	0.85	0.83	4.35	0.84	4.08	0.05	-	-	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.07		17.5	6.65	0.32	1.7	3.46	0.63	1.56	1.84	1.01	3.79	-	3.59	-	0	0.68	3.5	9.67	0.85	0.83	4.35	0.84	4.08	0.05	-	-	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.07																																																																																				-		0	6.65	0.32	1.7	3.46	0.63	1.56	1.84	1.01	3.79	-	3.59	-	0	0.68	3.5	9.67	0.85	0.83	4.35	0.84	4.08	0.05	-	-	0.24	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.07
H5421_041_0	2007	5																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1696.03	81.23	688.18	31.42	102.79	10.59	12.53	328.98	398.86		24.43		1.31	260.46	3813.53	5167.58	2.31	454.64	29.66	458.91	27.81	27.42			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															22.53	25.37	32.49	0.12	40.34	0.16	0.16	28.24	31.28		0.08		40.28	23.01	4.03	12.6	0.4	12.07	0.08	12.08	0.16	12.09			12.1		12.1															3.18	0.17	1.86	3.8	0.35	1.71	2.02	0.77	1.04	-	1.97	-	0	0.5	1.28	5.42	0.93	0.46	2.39	0.46	4.48	0.03	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.21		7.98	3.18	0.17	1.86	3.8	0.35	1.71	2.02	0.77	1.04	-	1.97	-	0	0.5	1.28	5.42	0.93	0.46	2.39	0.46	4.48	0.03	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.21																																																																																				-		0	3.18	0.17	1.86	3.8	0.35	1.71	2.02	0.77	1.04	-	1.97	-	0	0.5	1.28	5.42	0.93	0.46	2.39	0.46	4.48	0.03	-	-	0.13	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.21
H5421_042_0	2007	6																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1518.46	75.6	657.67	24.94	97.04	10.55	11.96	331.83	391.08		23.6		1.39	237.77	3761.85	4712.19	1.82	327.87	25.15	381.92	24.47	26.5			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															48.67	48.57	30.63	0.11	75.99	0.15	0.15	38.01	116.67		0.15		38	33.6	11.4	23.29	0.38	22.8	0.15	22.8	0.15	22.8			22.8		22.8															6.16	0.31	1.68	2.84	0.61	1.6	1.82	1.05	3.8	-	3.59	-	0	0.67	3.57	9.15	0.69	0.62	3.82	0.73	3.72	0.05	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.18		14.9	6.16	0.31	1.68	2.84	0.61	1.6	1.82	1.05	3.8	-	3.59	-	0	0.67	3.57	9.15	0.69	0.62	3.82	0.73	3.72	0.05	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.18																																																																																				-		0	6.16	0.31	1.68	2.84	0.61	1.6	1.82	1.05	3.8	-	3.59	-	0	0.67	3.57	9.15	0.69	0.62	3.82	0.73	3.72	0.05	-	-	0.25	-	0.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.18
H5421_043_0	2007	5																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1532.91	76.32	663.93	25.18	97.97	10.65	12.08	334.98	394.8		23.83		1.4	240.04	3797.66	4757.04	1.84	330.99	25.39	385.56	24.71	26.75			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															23.25	25.86	33.17	0.12	41.15	0.16	0.16	28.82	31.59		0.08		41.16	24.58	4.12	12.88	0.41	12.35	0.08	12.35	0.16	12.35			12.35		12.35															2.97	0.16	1.84	3.11	0.34	1.75	1.99	0.8	1.04	-	1.96	-	0	0.49	1.3	5.11	0.76	0.34	2.09	0.4	4.07	0.03	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.91		6.64	2.97	0.16	1.84	3.11	0.34	1.75	1.99	0.8	1.04	-	1.96	-	0	0.49	1.3	5.11	0.76	0.34	2.09	0.4	4.07	0.03	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.91																																																																																				-		0	2.97	0.16	1.84	3.11	0.34	1.75	1.99	0.8	1.04	-	1.96	-	0	0.49	1.3	5.11	0.76	0.34	2.09	0.4	4.07	0.03	-	-	0.13	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.91
H5421_044_0	2007	5																					3000											D	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1341.82	73.38	652.68	21.35	92.84	9.51	11.44	327.21	348.51		22.2		1.05	225.92	3841.18	4461.6	1.74	344.09	20.83	348.26	22.14	25.1			129.91		232.59															175 days 1-4	150 days 1-5	0 days 1-20 100 days 21-100	15	100	20	20	50	100 - ASC 200 OP Facility		20		50	30 OP Rehab; 50 OP MH/SA	15	30 - Spec. 35 - Chiro Podiatrist	50	30	20	30 - Opthalmology Services	20	30 - Medicare-covered eyewear			30 - 1 Routine Exam		30 - 1 Routine Exam															49.66	49.52	31.25	0.12	77.49	0.16	0.16	38.77	126.64		0.16		38.77	31.89	11.63	23.81	0.39	23.24	0.16	23.26	0.16	23.28			23.26		23.26															5.55	0.3	1.7	2.48	0.6	1.47	1.77	1.06	3.68	-	3.44	-	0	0.6	3.72	8.85	0.67	0.67	3.23	0.68	3.43	0.05	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.67		12.95	5.55	0.3	1.7	2.48	0.6	1.47	1.77	1.06	3.68	-	3.44	-	0	0.6	3.72	8.85	0.67	0.67	3.23	0.68	3.43	0.05	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.67																																																																																				-		0	5.55	0.3	1.7	2.48	0.6	1.47	1.77	1.06	3.68	-	3.44	-	0	0.6	3.72	8.85	0.67	0.67	3.23	0.68	3.43	0.05	-	-	0.25	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.67
H5421_045_0	2007	5																					2500											A	D	D	Coin	T	Coin	Coin	V	V	V	Coin	V	V	V	P	P	Coin	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1354.6	74.07	658.89	21.55	93.73	9.6	11.55	330.32	351.83		22.41		1.06	228.07	3877.74	4504.06	1.76	347.36	21.02	351.57	22.35	25.34			129.91		232.59															150	75 days 1-5	0 days 1-20 100 days 21-100	15	50	20	20	35	25 - ASC 50 OP Facility		10		50	15 OP Rehab; 50 OP MH/SA	5	15 - Spec. 20 - Chiro Podiatrist	50	15	10	15 - Opthalmology Services	20	15 - Medicare-covered eyewear			15 - 1 Routine Exam		15 - 1 Routine Exam															24.19	26.55	33.8	0.13	41.9	0.17	0.17	29.35	34.25		0.08		41.93	22.62	4.19	13.18	0.42	12.57	0.08	12.58	0.17	12.59			12.58		12.58															2.73	0.16	1.86	2.71	0.33	1.61	1.94	0.81	1	-	1.88	-	0	0.43	1.36	4.95	0.74	0.36	1.76	0.37	3.75	0.03	-	-	0.14	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.15		5.61	2.73	0.16	1.86	2.71	0.33	1.61	1.94	0.81	1	-	1.88	-	0	0.43	1.36	4.95	0.74	0.36	1.76	0.37	3.75	0.03	-	-	0.14	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.15																																																																																				-		0	2.73	0.16	1.86	2.71	0.33	1.61	1.94	0.81	1	-	1.88	-	0	0.43	1.36	4.95	0.74	0.36	1.76	0.37	3.75	0.03	-	-	0.14	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.15
H5421_801_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		251.39	5.09	22.56		4.35	10.29	12	12.03	39.75	21.59	23.5	2.99	0.26	20.82	20.38	35.67	1.96	3.26	26.06	96.11	25.04	0.15																				Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing																				0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56		0	18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56																																																																																				-		0	18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56
H5421_804_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		251.39	5.09	22.56		4.35	10.29	12	12.03	39.75	21.59	23.5	2.99	0.26	20.82	20.38	35.67	1.96	3.26	26.06	96.11	25.04	0.15																				Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing																				0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56		0	18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56																																																																																				-		0	18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56
H5421_805_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		251.39	5.09	22.56		4.35	10.29	12	12.03	39.75	21.59	23.5	2.99	0.26	20.82	20.38	35.67	1.96	3.26	26.06	96.11	25.04	0.15																				Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing	Medicare cost sharing																				0.08	0.08	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56		0	18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56																																																																																				-		0	18.9	0.38	4.21	-	1.03	2.43	2.83	2.84	9.38	5.1	5.55	0.7	0.06	4.91	4.81	8.42	0.46	0.77	6.15	22.68	5.91	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.56
H5422_001_0	2007	6																					none											A	A	D	V	T	coin	coin	V	V	P	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	272.46	2.76	837.95	0	306.37	25.65	1.16	243.81	251.18	1632.3	23.58	0	0.19	22.83	4438.34	5452.24	127.69	437.83	26.81	268.89	6.94	739.76	0	1785.6	378.56	0	180.11	0	0	0	0											400/Admit	400/Admit	1-20: 0/Day 21-100: 1500/Day		100 per	20 per	20 per	50 ER / 50 UC	200 ASC/ 200 OP	25 per	20 to 25 per		20 per	25 OP SA / 0 Cardiac	15 PCP	15 SCP / 15 Chiro / 15 Podiatrist	25 MH	15 Therapy	20 to 25 per	15 Hearing / 0 Preventive	20 per	15 Vision/0 Blood		25	15		15															400	400	41.71	0	100	0.2	0.2	50	200	25	0.11	0	0.2	0.07	15	14.98	25	15	0.01	5.41	0.2	14.79	0	25	15	0	15	0	0	0	0											9.08	0.09	2.91	-	2.55	5.13	0.23	1.02	4.19	3.4	2.51	-	0.04	1.63	5.55	6.81	0.27	0.55	0.28	0.12	1.42	0.91	-	3.72	0.47	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.1	0	0	9.08	0.09	2.91	-	2.55	5.13	0.23	1.02	4.19	3.4	2.51	-	0.04	1.63	5.55	6.81	0.27	0.55	0.28	0.12	1.42	0.91	-	3.72	0.47	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.1	none																																																																																			-	0	0	9.08	0.09	2.91	-	2.55	5.13	0.23	1.02	4.19	3.4	2.51	-	0.04	1.63	5.55	6.81	0.27	0.55	0.28	0.12	1.42	0.91	-	3.72	0.47	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.1
H5422_002_0	2007	6																					none											A	A	D	V	T	coin	coin	V	V	P	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	267	2.59	878.93	0	236.91	16.37	0.8	257.07	265.07	1720.56	22.74	0	0.26	22.07	4303.36	5526.56	149.25	511.53	30.96	263.27	6.7	718.3	0	1785.6	364.78	0	173.55	0	0	0	0											400/Admit	400/Admit	1-20: 0/Day 21-100: 1500/Day		100 per	20 per	20 per	50 ER / 50 UC	200 ASC/ 200 OP	25 per	20 to 25 per		20 per	25 OP SA / 0 Cardiac	15 PCP	15 SCP / 15 Chiro / 15 Podiatrist	25 MH	15 Therapy	20 to 25 per	15 Hearing / 0 Preventive	20 per	15 Vision/0 Blood		25	15		15															400	400	41.71	0	100	0.2	0.2	50	200	25	0.11	0	0.2	0.07	15	14.98	25	15	0.01	5.36	0.2	14.78	0	25	15	0	15	0	0	0	0											8.9	0.09	3.06	-	1.97	3.27	0.16	1.07	4.42	3.58	2.42	-	0.05	1.61	5.38	6.9	0.31	0.64	0.33	0.12	1.37	0.88	-	3.72	0.46	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.92	0	0	8.9	0.09	3.06	-	1.97	3.27	0.16	1.07	4.42	3.58	2.42	-	0.05	1.61	5.38	6.9	0.31	0.64	0.33	0.12	1.37	0.88	-	3.72	0.46	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.92	none																																																																																			-	0	0	8.9	0.09	3.06	-	1.97	3.27	0.16	1.07	4.42	3.58	2.42	-	0.05	1.61	5.38	6.9	0.31	0.64	0.33	0.12	1.37	0.88	-	3.72	0.46	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.92
H5422_003_0	2007	9																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		356.48	31.02	80.75	49.36	14.4	52.81	3.27	11.85	14.96	10.4	21.39	0	25.43	22.32	26.26	38.43	6.89	5.04	23.55	111.09	17.28	2.34	5	9.7	2.94	2.53	0.54	0	0	2.5	10											FFS Medicare: PBP 1a	FFS Medicare: PBP 1b	FFS Medicare: PBP 2	FFS Medicare: PBP 6	FFS Medicare: PBP 10a	FFS Medicare: PBP 11a	FFS Medicare: PBP 11b 11c	FFS Medicare: PBP 4a 4b	FFS Medicare: PBP 9a 9b	FFS Medicare: PBP 8a	FFS Medicare: PBP 8b	FFS Medicare:	FFS Medicare: PBP 12	FFS Medicare: PBP 3 5 9a 9c 9d 13a 13b	FFS Medicare: PBP 4b 7a 14b-i	FFS Medicare: PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	FFS Medicare: PBP 7e 7h	FFS Medicare: PBP 7c 7i	FFS Medicare: PBP 7d	FFS Medicare: PBP 7d 7g	FFS Medicare: PBP 15	FFS Medicare: PBP 7g																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				25.96	2.26	14.78	-	3.4	12.46	0.77	2.8	3.53	2.46	5.05	-	6	5.27	6.05	9.07	1.63	1.19	5.56	26.22	4.08	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	139.08	138	0	25.96	2.26	14.78	-	3.4	12.46	0.77	2.8	3.53	2.46	5.05	-	6	5.27	6.05	9.07	1.63	1.19	5.56	26.22	4.08	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	139.08																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	25.96	2.26	14.78	-	3.4	12.46	0.77	2.8	3.53	2.46	5.05	-	6	5.27	6.05	9.07	1.63	1.19	5.56	26.22	4.08	0.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	139.08
H5422_005_0	2007	6																					none											A	A	D	V	T	coin	coin	V	V	P	coin	O	coin	coin	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	255.12	2.5	683.19	0	261.95	18.12	0.88	222.14	228.97	1487.05	25.42	0	0.24	24.63	4542.92	5825	156.29	535.83	34.39	277.73	7.49	756.05	0	1785.6	386.68	0	183.97	0	0	0	0											400/Admit	400/Admit	1-20: 0/Day 21-100: 1500/Day		100 per	20 per	20 per	50 ER / 50 UC	200 ASC/ 200 OP	25 per	20 to 25 per		20 per	25 OP SA / 0 Cardiac	15 PCP	15 SCP / 15 Chiro / 15 Podiatrist	25 MH	15 Therapy	20 to 25 per	15 Hearing / 0 Preventive	20 per	15 Vision/0 Blood		25	15		15															400	400	41.71	0	100	0.2	0.2	50	200	25	0.11	0	0.2	0.07	15	14.98	25	15	0.01	5.36	0.2	14.82	0	25	15	0	15	0	0	0	0											8.5	0.08	2.37	-	2.18	3.62	0.18	0.93	3.82	3.1	2.69	-	0.05	1.71	5.68	7.27	0.33	0.67	0.36	0.12	1.53	0.93	-	3.72	0.48	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.57	0	0	8.5	0.08	2.37	-	2.18	3.62	0.18	0.93	3.82	3.1	2.69	-	0.05	1.71	5.68	7.27	0.33	0.67	0.36	0.12	1.53	0.93	-	3.72	0.48	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.57	none																																																																																			-	0	0	8.5	0.08	2.37	-	2.18	3.62	0.18	0.93	3.82	3.1	2.69	-	0.05	1.71	5.68	7.27	0.33	0.67	0.36	0.12	1.53	0.93	-	3.72	0.48	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.57
H5422_801_0	2007	2																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	248.58	1.82	24.96	0	7.33	17.04	0.83	4.14	22.49	8.75	23.93	0	0.23	23.2	45.08	127.75	1.22	4.12	30.68	22.87	7.05	5.49	0	0	0	0	0	0	0	0	0											Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare		Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare		Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.19	0.24	0.24	0.23	0	0	0	0	0	0	0	0	0											18.48	0.14	4.67	-	1.73	4.02	0.2	0.98	5.31	2.07	0.06	-	0.05	5.48	10.64	30.15	0.29	0.97	5.7	5.4	1.7	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.28	0	0	18.48	0.14	4.67	-	1.73	4.02	0.2	0.98	5.31	2.07	0.06	-	0.05	5.48	10.64	30.15	0.29	0.97	5.7	5.4	1.7	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.28	none																																																																																			-	0	0	18.48	0.14	4.67	-	1.73	4.02	0.2	0.98	5.31	2.07	0.06	-	0.05	5.48	10.64	30.15	0.29	0.97	5.7	5.4	1.7	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.28
H5422_802_0	2007	1																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	248.58	1.82	24.96	0	7.33	17.04	0.83	4.14	22.49	8.75	23.93	0	0.23	23.2	45.08	127.75	1.22	4.12	30.68	22.87	7.05	5.49	0	0	0	0	0	0	0	0	0											Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare		Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare		Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare	Consistent with 2007 FFS Medicare																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0.24	0.24	0.24	0.24	0.24	0.24	0.19	0.24	0.24	0.23	0	0	0	0	0	0	0	0	0											18.48	0.14	4.67	-	1.73	4.02	0.2	0.98	5.31	2.07	0.06	-	0.05	5.48	10.64	30.15	0.29	0.97	5.7	5.4	1.7	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.28	0	0	18.48	0.14	4.67	-	1.73	4.02	0.2	0.98	5.31	2.07	0.06	-	0.05	5.48	10.64	30.15	0.29	0.97	5.7	5.4	1.7	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.28	none																																																																																			-	0	0	18.48	0.14	4.67	-	1.73	4.02	0.2	0.98	5.31	2.07	0.06	-	0.05	5.48	10.64	30.15	0.29	0.97	5.7	5.4	1.7	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.28
H5424_001_0	2007	7																					2800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3600	1639.12	130.24	643.51	0	179.16	9.2	4.42	410.44	20.65	7026.25	36.3	0	0.13	17.68	3185.16	3350.02	495.78	1.29	0	0	14.83	734.78	0	0	113.35	0	167.11	0	0	0	0											275 (1a)	275 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											163.73	163.73	74.42	0	104.19	0.18	0.2	29.77	0.15	1.19	0.11	0	0.18	0.15	5	20	37.5	0.15	0	0	0.18	20	0	0	20	0	20	0	0	0	0											22.36	1.78	3.99	-	1.56	1.64	0.9	1.02	3.07	0.7	4.16	-	0.02	2.63	1.33	5.58	1.55	0.19	-	-	2.65	1.22	-	-	0.19	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.82		31.54	22.36	1.78	3.99	-	1.56	1.64	0.9	1.02	3.07	0.7	4.16	-	0.02	2.63	1.33	5.58	1.55	0.19	-	-	2.65	1.22	-	-	0.19	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.82		375 (1a)	375 (1b)	125 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.54	0.2	0.33	0.48	0.33	0.35	0.19	0.21	1.03	0.59	1.4	0	0	0.89	1.59	2.14	0.39	0.06	0	0	0.56	0.48	0	0	0.07	0	0.11	0	0	0	0											13.95		6.5	24.9	1.98	4.32	0.48	1.88	1.99	1.09	1.23	4.11	1.28	5.56	-	0.03	3.52	2.92	7.73	1.93	0.26	-	-	3.21	1.7	-	-	0.26	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.77
H5424_003_0	2007	4																					2400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3400	1639.12	130.24	643.51	0	179.16	9.2	4.42	410.44	20.65	7026.25	36.3	0	0.13	17.68	3185.16	3350.02	495.78	1.29	0	0	14.83	734.78	0	0	113.35	0	167.11	0	0	0	0											225 (1a)	225 (1b)	75 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	10 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 10 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	10 (17a)	0 n/c (17b1-17b5)	10 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											133.79	133.79	44.6	0	104.06	0.18	0.2	29.73	0.12	3.57	0.09	0	0.18	0.12	5	10	37.5	0.12	0	0	0.18	10	0	0	10	0	10	0	0	0	0											18.28	1.45	2.39	-	1.55	1.64	0.89	1.02	2.46	2.09	3.41	-	0.02	2.1	1.33	2.79	1.55	0.15	-	-	2.65	0.61	-	-	0.09	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.62		27.16	18.28	1.45	2.39	-	1.55	1.64	0.89	1.02	2.46	2.09	3.41	-	0.02	2.1	1.33	2.79	1.55	0.15	-	-	2.65	0.61	-	-	0.09	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.62		325 (1a)	325 (1b)	75 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	15 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 25 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.39	0.19	0.22	0.22	0.36	0.38	0.18	0.23	0.84	0.64	1.17	0	0.01	0.72	0.74	0.95	0.24	0.05	0	0	0.61	0.21	0	0	0.03	0	0.05	0	0	0	0											10.43		6.39	20.67	1.64	2.61	0.22	1.91	2.02	1.07	1.25	3.3	2.73	4.58	-	0.03	2.83	2.07	3.74	1.79	0.21	-	-	3.25	0.82	-	-	0.13	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.05
H5424_005_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2160.35	341.83			242.25	22.74	19.7	815.95	353.79	1856.19	870.84	60.27	2.73	1832.38		3342.86		500.04		778.09												261.2		148.63	221.11							(1a) 75 per Day	(1b) 75 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							38	38			38	10	10	18	13	5	5	13	10	13		5		5		5												5		5	5							6.92	1.1	-	-	0.78	2.33	2.02	1.26	0.38	0.79	0.37	0.06	0.28	1.96	-	1.43	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	20.49		19.47	6.92	1.1	-	-	0.78	2.33	2.02	1.26	0.38	0.79	0.37	0.06	0.28	1.96	-	1.43	-	0.21	-	0.33	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	20.49		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							1.86	0.13	0.24	0.31	0.06	0.14	0.12	0.04	0.16	0.11	0.11	0.01	0.01	0.18	0.32	0.18	0.04	0.03	0.12	0.58	0.12	0																				4.88		0	8.78	1.23	0.24	0.31	0.83	2.47	2.14	1.3	0.54	0.91	0.48	0.08	0.29	2.14	0.32	1.61	0.04	0.24	0.12	0.91	0.12	0	-	-	-	-	-	-	-	-	-	0.11	-	0.06	0.09	-	-	-	-	-	-	25.37
H5424_801_0	2007	3																					3500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1721.07	136.76	675.68	0	188.11	9.66	4.65	430.96	21.69	7377.57	38.12	0	0.14	18.56	3344.42	3517.52	520.57	1.36	0	0	15.57	771.52	0	0	119.02	0	175.46	0	0	0	0											275 (1a)	275 (1b)	130 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											170.89	170.89	80.78	0	108.75	0.19	0.21	31.07	0.19	3.73	0.15	0	0.19	0.19	10	20	37.5	0.19	0	0	0.19	20	0	0	20	0	20	0	0	0	0											24.51	1.95	4.55	-	1.7	1.8	0.97	1.12	4.04	2.29	5.56	-	0.03	3.46	2.79	5.86	1.63	0.25	-	-	2.9	1.29	-	-	0.2	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.19		33.42	24.51	1.95	4.55	-	1.7	1.8	0.97	1.12	4.04	2.29	5.56	-	0.03	3.46	2.79	5.86	1.63	0.25	-	-	2.9	1.29	-	-	0.2	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.19		375 (1a)	375 (1b)	130 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											4.68	0.37	0.64	0.51	0.6	0.64	0.31	0.39	1.9	1.08	2.62	0	0.01	1.63	1.67	2.25	0.4	0.12	0	0	1.03	0.5	0	0	0.08	0	0.11	0	0	0	0											21.54		0	29.19	2.32	5.19	0.51	2.31	2.44	1.27	1.51	5.95	3.37	8.18	-	0.03	5.09	4.46	8.11	2.03	0.37	-	-	3.93	1.79	-	-	0.27	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.73
H5425_001_0	2007	10																																D	D	D		T	Coin	Coin	V	V	Coin	Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V				V																																																				-		409.74	7.25	303.19	0	182.76	5.5	3.44	295.73	170.75	6.63	18.49	0	0	155.04	4808.63	4357.54	209.35	1795.9	39.8	12388.54	5.25	772.31	0	0	279.84	192.35	191.62	0	0	0	1571.33											copay/days 1-4	copay/days 1-4	copay/days 21-100		100/run	0-10 DME	0-10 Prosthetics 0 Diab Supplies	50 ER 25 urgent care	100/OP hospital and ASC visits	20 coinsurance	20 rad therapy 20 specialized			10/visit cardiac rehab	10/visit	10/visit	10/visit	10 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing podiatry & chiro 20 lab	20 coinsurance	10/visit			10/visit	25/service	0-10/visit				Copay for In-Home Assistance Benefit											100	100	20	0	100	0.05	0.05	40.43	100	0.2	0.09	0	0	10	10	10	10	11	0.09	4.07	0.2	10	0	0	10	25	5	0	0	0	10											3.41	0.06	0.51	-	1.52	0.27	0.16	1	1.42	1.33	1.63	-	-	0.13	4.01	3.63	0.17	1.65	3.5	4.2	1.05	0.64	-	-	0.23	0.4	0.08	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	32.32			3.41	0.06	0.51	-	1.52	0.27	0.16	1	1.42	1.33	1.63	-	-	0.13	4.01	3.63	0.17	1.65	3.5	4.2	1.05	0.64	-	-	0.23	0.4	0.08	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	32.32																																																																																				-			3.41	0.06	0.51	-	1.52	0.27	0.16	1	1.42	1.33	1.63	-	-	0.13	4.01	3.63	0.17	1.65	3.5	4.2	1.05	0.64	-	-	0.23	0.4	0.08	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	32.32
H5425_003_0	2007	9																																D	D	D		T	Coin	Coin	V	V	Coin	Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V				V																																																				-		478.43	8.52	385.76	0	175.36	12.31	7.68	269.36	169.86	6.5	18.58	0	0	154.25	3775.48	3415.21	172.37	1477.56	36.39	10051.11	5.52	606.65	0	0	254.93	189	150.77	0	0	0	1571.44											copay/days 1-4	copay/days 1-4	copay/days 21-100		100/run	0-10 DME	0-10 Prosthetics 0 Diab Supplies	50 ER 25 urgent care	100/OP hospital and ASC visits	20 coinsurance	20 rad therapy 20 specialized			10/visit cardiac rehab	10/visit	10/visit	10/visit	10 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing podiatry & chiro 20 lab	20 coinsurance	10/visit			10/visit	25/service	0-10/visit				Copay for In-Home Assistance Benefits											100	100	20	0	100	0.05	0.05	41.74	100	0.2	0.09	0	0	10	10	10	10	11	0.09	4.34	0.2	10	0	0	10	25	5	0	0	0	10											3.99	0.07	0.64	-	1.46	0.62	0.35	0.94	1.42	1.3	1.64	-	-	0.13	3.15	2.85	0.14	1.35	3.2	3.63	1.1	0.51	-	-	0.21	0.39	0.06	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	30.46			3.99	0.07	0.64	-	1.46	0.62	0.35	0.94	1.42	1.3	1.64	-	-	0.13	3.15	2.85	0.14	1.35	3.2	3.63	1.1	0.51	-	-	0.21	0.39	0.06	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	30.46																																																																																				-			3.99	0.07	0.64	-	1.46	0.62	0.35	0.94	1.42	1.3	1.64	-	-	0.13	3.15	2.85	0.14	1.35	3.2	3.63	1.1	0.51	-	-	0.21	0.39	0.06	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	30.46
H5425_004_0	2007	10																																				T	Coin	Coin	V	V		Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V				V																																																				-						174.99	12.46	7.82	345.81	227.99		24.99			206.99	4322.78	3912.08	188.26	1612.56	28.28	1434.84	7.26	694.51			294.12	214.17	172.54				1571.31															100/run	20 DME	20 Prosthetics 0 Diab. Supplies	50 ER 25 urgent care	200/OP hospital and ASC visits		20 rad therapy 20 specialized			25/visit cardiac rehab	10/visit	25/visit	25/visit	25 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing 25 podiatry & chiro	20 coinsurance	10/visit			10/visit	25/service	0-10/visit				Copay for In-Home Assistance Benefit															100	0.2	0.18	42.64	200		0.09			25	10	25	25	24.5	0.09	24.03	0.2	10			10	25	5				10											-	-	-	-	1.46	2.49	1.43	1.23	3.8	-	2.2	-	-	0.43	3.6	8.15	0.39	3.29	2.49	2.87	1.45	0.58	-	-	0.25	0.45	0.07	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	37.94			-	-	-	-	1.46	2.49	1.43	1.23	3.8	-	2.2	-	-	0.43	3.6	8.15	0.39	3.29	2.49	2.87	1.45	0.58	-	-	0.25	0.45	0.07	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	37.94																																																																																				-			-	-	-	-	1.46	2.49	1.43	1.23	3.8	-	2.2	-	-	0.43	3.6	8.15	0.39	3.29	2.49	2.87	1.45	0.58	-	-	0.25	0.45	0.07	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	37.94
H5425_005_0	2007	9																																				T	Coin	Coin	V	V		Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V				V																																																				-						175.6	12.51	7.84	347.01	228.78		25.08			207.71	4337.78	3925.65	188.92	1618.15	28.38	1439.82	7.29	696.92			294.07	214.13	173.14				1571.2															100/run	20 DME	20 Prosthetics 0 Diab. Supplies	50 ER 25 urgent care	100/OP hospital and ASC visits		20 rad therapy 20 specialized			25/visit cardiac rehab	10/visit	25/visit	25/visit	25 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing 25 podiatry & chiro	20 coinsurance	10/visit			10/visit	25/service	0-10/visit				Copay for In-Home Assistance Benefit															100	0.2	0.18	42.64	100		0.09			25	10	25	25	24.5	0.09	24.03	0.2	10			10	25	5				10											-	-	-	-	1.46	2.5	1.43	1.23	1.91	-	2.21	-	-	0.43	3.61	8.18	0.39	3.3	2.5	2.88	1.46	0.58	-	-	0.25	0.45	0.07	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	36.16			-	-	-	-	1.46	2.5	1.43	1.23	1.91	-	2.21	-	-	0.43	3.61	8.18	0.39	3.3	2.5	2.88	1.46	0.58	-	-	0.25	0.45	0.07	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	36.16																																																																																				-			-	-	-	-	1.46	2.5	1.43	1.23	1.91	-	2.21	-	-	0.43	3.61	8.18	0.39	3.3	2.5	2.88	1.46	0.58	-	-	0.25	0.45	0.07	-	-	-	1.31	-	-	-	-	-	-	-	-	-	-	36.16
H5425_801_0	2007	8																																D	D	D					V	V	V	V				V	V	V	V	V	V	Coin	V			V	P	V				V																																																				-		173.34	3.07	329.82					312.54	177.91	1068.06	565.3				4941.57	4476.12	216.56	1857.16	4693.43	12632.15	5.54	793.75			280.6	196.48	197.02				1550.31											copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab	20 coinsurance	15/visit			15/visit	20/service	0-15/visit				Copay for In-Home Assistance Benefits											100	100	100					36.28	15	15	15				15	30	15	10	15	14.2	0.2	15			15	20	7.5				8.5											1.44	0.03	2.75	-	-	-	-	0.94	0.22	1.34	0.71	-	-	-	6.18	11.19	0.27	1.55	5.87	14.95	1.11	0.99	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.43			1.44	0.03	2.75	-	-	-	-	0.94	0.22	1.34	0.71	-	-	-	6.18	11.19	0.27	1.55	5.87	14.95	1.11	0.99	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.43																																																																																				-			1.44	0.03	2.75	-	-	-	-	0.94	0.22	1.34	0.71	-	-	-	6.18	11.19	0.27	1.55	5.87	14.95	1.11	0.99	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.43
H5425_802_0	2007	8																																D	D	D					V	V	V	V				V	V	V	V	V	V	Coin	V			V	P	V				V																																																				-		173.34	3.07	329.82					312.54	177.91	1068.06	565.3				4941.57	4476.12	216.56	1857.16	4693.43	12632.15	5.54	793.75			280.6	196.48	197.02				1550.31											copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab	20 coinsurance	15/visit			15/visit	20/service	0-15/visit				Copay for In-Home Assistance Benefits											100	100	100					36.28	15	15	15				15	30	15	10	15	14.2	0.2	15			15	20	7.5				8.5											1.44	0.03	2.75	-	-	-	-	0.94	0.22	1.34	0.71	-	-	-	6.18	11.19	0.27	1.55	5.87	14.95	1.11	0.99	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.43			1.44	0.03	2.75	-	-	-	-	0.94	0.22	1.34	0.71	-	-	-	6.18	11.19	0.27	1.55	5.87	14.95	1.11	0.99	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.43																																																																																				-			1.44	0.03	2.75	-	-	-	-	0.94	0.22	1.34	0.71	-	-	-	6.18	11.19	0.27	1.55	5.87	14.95	1.11	0.99	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.43
H5425_803_0	2007	8																																D	D	D					V	V	V	V				V	V	V	V	V	V	Coin	V			V	P	V				V																																																				-		175.07	3.1	335.07					313	179.39	1076.63	569.92				4897.45	4435.81	214.88	1842.64	4663.73	12501.73	5.6	786.68			280.37	196.98	195.28				1550.31											copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab	20 coinsurance	15/visit			15/visit	20/service	0-15/visit				Copay for In-Home Assistance Benefits											100	100	100					36.42	15	15	15				15	30	15	10	15	14.21	0.2	15			15	20	7.5				8.5											1.46	0.03	2.79	-	-	-	-	0.95	0.22	1.35	0.71	-	-	-	6.12	11.09	0.27	1.54	5.83	14.8	1.12	0.98	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.16			1.46	0.03	2.79	-	-	-	-	0.95	0.22	1.35	0.71	-	-	-	6.12	11.09	0.27	1.54	5.83	14.8	1.12	0.98	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.16																																																																																				-			1.46	0.03	2.79	-	-	-	-	0.95	0.22	1.35	0.71	-	-	-	6.12	11.09	0.27	1.54	5.83	14.8	1.12	0.98	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	51.16
H5425_804_0	2007	8																																D	D	D					V	V	V	V				V	V	V	V	V	V	Coin	V			V	P	V				V																																																				-		176.42	3.12	339.19					313.36	180.53	1083.29	573.5				4862.89	4404.25	213.56	1831.25	4640.32	12399.84	5.64	781.14			279.88	197.14	193.92				1550.31											copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab	20 coinsurance	15/visit			15/visit	20/service	0-15/visit				Copay for In-Home Assistance Benefits											100	100	100					36.53	15	15	15				15	30	15	10	15	14.22	0.2	15			15	20	7.5				8.5											1.47	0.03	2.83	-	-	-	-	0.95	0.23	1.35	0.72	-	-	-	6.08	11.01	0.27	1.53	5.8	14.69	1.13	0.98	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	50.95			1.47	0.03	2.83	-	-	-	-	0.95	0.23	1.35	0.72	-	-	-	6.08	11.01	0.27	1.53	5.8	14.69	1.13	0.98	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	50.95																																																																																				-			1.47	0.03	2.83	-	-	-	-	0.95	0.23	1.35	0.72	-	-	-	6.08	11.01	0.27	1.53	5.8	14.69	1.13	0.98	-	-	0.35	0.33	0.12	-	-	-	1.1	-	-	-	-	-	-	-	-	-	-	50.95
H5426_001_0	2007	10																					3000											D	D	D		T	Coin	Coin	V	P	P	P	P	P	P		V	V	V	V	V	S				V	V	V	V																																																							-	3000	1207.01	55.62	553.55		66.94	8.87	11.08	230.18	419.49	920.59	536.51	37.14	1.04	650.43		7553.88	303.47	506.33	3948.41	1896.88	1324.01				129.91		232.59															150 (Days 1-7)	400/Admit	0(1-7)/50(8+)		75/Trip	20 Coin	20 Coin	50	200 Hosp/25 ASC	25	25	25	200	25		20	20 Psych/10 Therapy	10	10	10	10				10	85 Max	10	700 Max														66.06	40.33	30.18		62.88	0.17	0.17	41.92	62.3	20.96	33.28	20.96	167.69	12.58		13.4	12.89	8.38	8.38	9.09	8.38				8.38		8.38															6.64	0.19	1.39	-	0.35	1.49	1.86	0.8	2.18	1.61	1.49	0.06	0.01	0.68	-	8.44	0.33	0.35	2.76	1.44	0.93	-	-	-	0.09	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.25		6.41	6.64	0.19	1.39	-	0.35	1.49	1.86	0.8	2.18	1.61	1.49	0.06	0.01	0.68	-	8.44	0.33	0.35	2.76	1.44	0.93	-	-	-	0.09	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.25		300 (Days 1-7)		150 (Days 1-7)												50	100	100		100																							0.58		0.07												0.52	1.55	0.09		1.22	0																						4.04		3.24	7.23	0.19	1.46	-	0.35	1.49	1.86	0.8	2.18	1.61	1.49	0.06	0.01	0.68	0.52	9.98	0.42	0.35	3.98	1.44	0.93	-	-	-	0.09	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.29
H5426_002_0	2007	10																					3000											D	D	D		T	Coin	Coin	V	P	P	P	P	P	P		V	V	V	V	V	S				V	V	V	V																																																							-	3000	1148.98	52.95	526.96		63.72	8.04	10.04	219.11	399.33	876.34	510.72	35.36	0.99	619.16		7194.54	288.88	481.99	3758.58	1805.68	1260.36				129.91		232.59															150 (Days 1-7)	400/Admit	0(1-7)/50(8+)		75/Trip	20 Coin	20 Coin	50	200 Hosp/25 ASC	25	25	25	200	25		20	20 Psych/10 Therapy	10	10	10	10				10	85 Max	10	700 Max														66.96	40.88	30.59		63.74	0.17	0.17	42.49	63.14	21.25	33.73	21.25	169.97	12.75		13.58	13.07	8.5	8.5	9.21	8.5				8.5		8.5															6.41	0.18	1.34	-	0.34	1.37	1.71	0.78	2.1	1.55	1.44	0.06	0.01	0.66	-	8.14	0.31	0.34	2.66	1.39	0.89	-	-	-	0.09	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.94		5.64	6.41	0.18	1.34	-	0.34	1.37	1.71	0.78	2.1	1.55	1.44	0.06	0.01	0.66	-	8.14	0.31	0.34	2.66	1.39	0.89	-	-	-	0.09	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.94		300 (Days 1-7)		150 (Days 1-7)												50	100	100		100																							0.57		0.07												0.51	1.5	0.09		1.19	0																						3.93		3	6.98	0.18	1.41	-	0.34	1.37	1.71	0.78	2.1	1.55	1.44	0.06	0.01	0.66	0.51	9.65	0.41	0.34	3.85	1.39	0.89	-	-	-	0.09	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.87
H5426_003_0	2007	7																					3000											D	D	D		T	Coin	Coin	V	P	P	P	P	P	P		V	V	V	V	V	S				V	V	V	V																																																							-	3000	1132.27	52.18	519.31		62.79	7.81	9.75	215.92	393.52	863.59	503.29	34.84	0.98	610.16		7091.06	284.68	474.98	3703.92	1779.42	1242.03				129.91		232.59															150 (Days 1-7)	400/Admit	0(1-7)/50(8+)		75/Trip	20 Coin	20 Coin	50	200 Hosp/25 ASC	25	25	25	200	25		20	20 Psych/10 Therapy	10	10	10	10				10	85 Max	10	700 Max														67.16	41.01	30.68		63.93	0.17	0.17	42.62	63.33	21.31	33.83	21.31	170.48	12.78		13.62	13.11	8.52	8.52	9.24	8.52				8.52		8.52															6.34	0.18	1.33	-	0.33	1.33	1.66	0.77	2.08	1.53	1.42	0.06	0.01	0.65	-	8.05	0.31	0.34	2.63	1.37	0.88	-	-	-	0.09	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.53		5.46	6.34	0.18	1.33	-	0.33	1.33	1.66	0.77	2.08	1.53	1.42	0.06	0.01	0.65	-	8.05	0.31	0.34	2.63	1.37	0.88	-	-	-	0.09	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.53		300 (Days 1-7)		150 (Days 1-7)												50	100	100		100	100																						0.56		0.07												0.51	1.49	0.09		1.18	0																						3.9		2.93	6.9	0.18	1.4	-	0.33	1.33	1.66	0.77	2.08	1.53	1.42	0.06	0.01	0.65	0.51	9.54	0.4	0.34	3.81	1.37	0.88	-	-	-	0.09	-	0.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.43
H5426_007_0	2007	12																																D	D	D		T	Coin	Coin	V	P	P	P	P	P	P		V	V	V	V	V	S				V	V	V	V																																																							-		1207.01	55.62	553.55		66.94	8.87		230.18	419.49	920.59	536.51	37.14	1.04	650.43		7553.88	303.47	506.33	3948.41	1891.72	1324.01				129.91		232.59															350 (Days 1-7)	400/Admit	0(1-7)/75(8+)		75/Trip	20 Coin	20 Coin	50	300 Hosp/25 ASC	25	25	25	200	25		35	20 Psych/10 Therapy	10	10	10	10				10	85 Max	10	700 Max														183.85	48.11	53.98		75	0.2		50	102.47	25	39.69	25	200	15		27.31	15.38	10	10	12.1	10				10		10															18.49	0.22	2.49	-	0.42	1.77	-	0.96	3.58	1.92	1.77	0.08	0.02	0.81	-	17.19	0.39	0.42	3.29	1.91	1.1	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.14		0	18.49	0.22	2.49	-	0.42	1.77	-	0.96	3.58	1.92	1.77	0.08	0.02	0.81	-	17.19	0.39	0.42	3.29	1.91	1.1	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.14		500 (Days 1-7)		150 (Days 1-7)												50	100	100		100																							1.75		0.13												0.94	2.78	0.17		2.2	0.01																						7.98		0	20.25	0.22	2.62	-	0.42	1.77	-	0.96	3.58	1.92	1.77	0.08	0.02	0.81	0.94	19.97	0.56	0.42	5.49	1.91	1.1	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.13
H5426_008_0	2007	12																																D	D	D		T	Coin	Coin	V	P	P	P	P	P	P		V	V	V	V	V	S				V	V	V	V																																																							-		1149.8	52.99	527.34		63.76	8.05		219.27	399.61	876.96	511.08	35.38	0.99	619.6		7199.62	289.08	482.33	3761.26	1802.06	1261.26				129.91		232.59															350 (Days 1-7)	400/Admit	0(1-7)/75(8+)		75/Trip	20 Coin	20 Coin	50	300 Hosp/25 ASC	25	25	25	200	25		35	20 Psych/10 Therapy	10	10	10	10				10	85 Max	10	700 Max														183.85	48.11	53.98		75	0.2		50	102.47	25	39.69	25	200	15		27.3	15.38	10	10	12.1	10				10		10															17.62	0.21	2.37	-	0.4	1.61	-	0.91	3.41	1.83	1.69	0.07	0.02	0.77	-	16.38	0.37	0.4	3.13	1.82	1.05	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37		0	17.62	0.21	2.37	-	0.4	1.61	-	0.91	3.41	1.83	1.69	0.07	0.02	0.77	-	16.38	0.37	0.4	3.13	1.82	1.05	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37		500 (Days 1-7)		150 (Days 1-7)												50	100	100		100																							1.67		0.12												0.9	2.65	0.16		2.09	0.01																						7.6		0	19.29	0.21	2.5	-	0.4	1.61	-	0.91	3.41	1.83	1.69	0.07	0.02	0.77	0.9	19.03	0.53	0.4	5.23	1.82	1.05	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.98
H5426_009_0	2007	11																																D	D	D		T	Coin	Coin	V	P	P	P	P	P	P		V	V	V	V	V	S				V	V	V	V																																																							-		1132.27	52.18	519.31		62.79	7.81		215.92	393.52	863.59	503.29	34.84	0.98	610.16		7091.06	284.68	474.98	3703.92	1774.58	1242.03				129.91		232.59															350 (Days 1-7)	400/Admit	0(1-7)/75(8+)		75/Trip	20 Coin	20 Coin	50	300 Hosp/25 ASC	25	25	25	200	25		35	20 Psych/10 Therapy	10	10	10	10				10	85 Max	10	700 Max														183.85	48.11	53.98		75	0.2		50	102.47	25	39.69	25	200	15		27.3	15.38	10	10	12.1	10				10		10															17.35	0.21	2.34	-	0.39	1.56	-	0.9	3.36	1.8	1.66	0.07	0.02	0.76	-	16.13	0.36	0.4	3.09	1.79	1.04	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.52		0	17.35	0.21	2.34	-	0.39	1.56	-	0.9	3.36	1.8	1.66	0.07	0.02	0.76	-	16.13	0.36	0.4	3.09	1.79	1.04	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.52		500 (Days 1-7)		150 (Days 1-7)												50	100	100		100																							1.65		0.12												0.88	2.61	0.16		2.06	0																						7.49		0	18.99	0.21	2.46	-	0.39	1.56	-	0.9	3.36	1.8	1.66	0.07	0.02	0.76	0.88	18.74	0.52	0.4	5.15	1.79	1.04	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.01
H5426_013_0	2007	12																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5426_014_0	2007	12																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5426_015_0	2007	11																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5427_001_0	2007	6	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								2500	ASC	Chiropractor	Podiatrist								D	D	D	V	T	Coin	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	V	V	V	O	O	Coin	V	V	V																																																	-	none	1208	54	1112	1459	238	13	1	253	148	2881	624	66	-	6172	4454	3927	330	998	3897	25717	279	139	-	869	-	92	145	26	-	13003	10	79	354	235								100 for 1st 5 days	150 for 1st 7 days	50 for days 8-20 and 100 for over day 21	0 Copay	100 per Trip	20 Coinsurance	20 Coinsurance	50 ER/20 Urgent Care	100 Copay	0	0	0	0	0	0 Copay	5 Copay	20 Copay	20 Copay	Varies 0 to 150	0	0	0	0	0 Copay	10 Copay (Capitated Benefit)	10 Copay	10 Copay	0 Copay	0	0	Benefit reduced 2/3	25 Copay	20 Copay	20 Copay								68.65	117.6	35.51	0	100	0.2	0.2	44	100	0	0	0	0	0	0	5	20	20	8.52	0	0	0	0	0	10	10	10	0	0	0	0.67	25	20	20								6.91	0.53	3.29	-	1.98	2.52	0.21	0.93	1.23	-	-	-	-	-	-	1.64	0.55	1.66	2.77	-	-	-	-	-	-	0.08	0.12	-	-	-	6.67	0.17	0.59	0.39	-	-	-	-	-	-	-	32.23		0.48	6.91	0.53	3.29	-	1.98	2.52	0.21	0.93	1.23	-	-	-	-	-	-	1.64	0.55	1.66	2.77	-	-	-	-	-	-	0.08	0.12	-	-	-	6.67	0.17	0.59	0.39	-	-	-	-	-	-	-	32.23	none																																																																																			-		0	6.91	0.53	3.29	-	1.98	2.52	0.21	0.93	1.23	-	-	-	-	-	-	1.64	0.55	1.66	2.77	-	-	-	-	-	-	0.08	0.12	-	-	-	6.67	0.17	0.59	0.39	-	-	-	-	-	-	-	32.23
H5427_002_0	2007	3	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								2500	ASC	Chiropractor	Podiatrist								D	D	D	V	T	P	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	V	V	V	O	O	Coin	V																																																			-	none	2386	430	903	5160	491	140664	2	258	187	3622	885	48	-	15045	5953	6377	1552	4399	5481	33275	358	180		869	214	92	592	104	-	7474	10	100										0	0	0	0 Copay	50 per Trip	0 Copay	20 Coinsurance	25 ER/0 Urgent Care	50 Copay	0	0	0	0	0	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0	0	0		0	0 Copay	0 Copay	0 Copay	0 Copay	0	0	Reduce by 8/15	0 Copay	0 Copay	0 Copay								0	0	0	0	50	0	0.2	20	50	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0.53	0	0	0								-	-	-	-	2.05	-	0.41	0.43	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.33	-	-	-	-	-	-	-	-	-	-	9		0	-	-	-	-	2.05	-	0.41	0.43	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.33	-	-	-	-	-	-	-	-	-	-	9	none																																																																																			-		0	-	-	-	-	2.05	-	0.41	0.43	0.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.33	-	-	-	-	-	-	-	-	-	-	9
H5427_003_0	2007	3	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								2000	ASC	Chiropractor	Podiatrist								D	D	D	V	T	P	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	Ded		Ded	O	O	Coin	V																																																			-	none	1492	270	591	2790	451	14410	0	408	192	5904	1582	120	-	8384	5362	5322	953	1708	3424	30164	358	180	68	869	214	92		104	-	7474	10	103												25 for days 8-20 and 0 for over day 21	0 Copay	50 Copay	0 Copay	20 Coinsurance	25 ER/0 Urgent Care	50 Copay	0	0	0	0	0	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0	0	0	0	0	0 Copay	0 Copay		0 Copay	0	0	Reduce by 8/15	0 Copay	0 Copay	0 Copay										8.52	0	50	0	0.2	20	50	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0	0	0.53	0	0	0								-	-	0.42	-	1.88	-	0.05	0.68	0.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.33	-	-	-	-	-	-	-	-	-	-	9.16		0	-	-	0.42	-	1.88	-	0.05	0.68	0.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.33	-	-	-	-	-	-	-	-	-	-	9.16	none																																																																																			-		0	-	-	0.42	-	1.88	-	0.05	0.68	0.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.33	-	-	-	-	-	-	-	-	-	-	9.16
H5427_010_0	2007	5	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								2500	ASC	Chiropractor	Podiatrist								D	D	D	V	T	Coin	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	V	V		O	O	Coin	V	V	V																																																	-	none	1702	76	1404	2166	478	14	1	275	150	3291	713	75	-	7050	4649	4098	344	1042	4066	26839	279	139	-	869	-	92	145		-	13003	10	81	354	235								50 for 1st 5 days	50 for 1st 5 days	50 for days 8-100 and 0 for over day 100	0 Copay	100 per Trip	20 Coinsurance	20 Coinsurance	50 ER/15 Urgent Care	75 Copay	0	0	0	0	0	0 Copay	10 Copay	15 Copay	15 Copay	Varies 0 to 75	0	0	0	0	0	10 Copay (Capitated Benefit)	10 Copay	10 Copay		0	0	Reduce by 2/3	50 Copay	15 Copay	15 Copay								34.33	34.33	26.28	0	100	0.2	0.2	43	75	0	0	0	0	0	0	10	15	15	6.38	0	0	0	0	0	10	10	10		0	0	0.67	50	15	15								4.87	0.22	3.08	-	3.98	2.7	0.23	0.99	0.94	-	-	-	-	-	-	3.42	0.43	1.3	2.16	-	-	-	-	-	-	0.08	0.12	-	-	-	6.67	0.34	0.44	0.29	-	-	-	-	-	-	-	32.24		0.02	4.87	0.22	3.08	-	3.98	2.7	0.23	0.99	0.94	-	-	-	-	-	-	3.42	0.43	1.3	2.16	-	-	-	-	-	-	0.08	0.12	-	-	-	6.67	0.34	0.44	0.29	-	-	-	-	-	-	-	32.24	none																																																																																			-		0	4.87	0.22	3.08	-	3.98	2.7	0.23	0.99	0.94	-	-	-	-	-	-	3.42	0.43	1.3	2.16	-	-	-	-	-	-	0.08	0.12	-	-	-	6.67	0.34	0.44	0.29	-	-	-	-	-	-	-	32.24
H5427_015_0	2007	5	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								3100	ASC	Chiropractor	Podiatrist								D	D	D	V	T	Coin	Coin	V	Coin	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	V	V	V	O	O	O	V	V	V																																																	-	none	1208	54	1112	1459	238	12.61	1.05	253	5.18	2881	624	66	-	6172	4454	3927	330	998	3897	25717	279	139	-	869	214	92	145	26	-	13003	-	79	354	235								200 for 1st 7 days	200 for 1st 7 days	100 for days 8-20 and 150 for over day 21	35 Copay	100 per Trip	20 Coinsurance	20 Coinsurance	50 ER/20 Urgent Care	20 Coinsurance	0	0	0	0	0	10 Copay	20 Copay	25 Copay	25 Copay	Varies 0 to 150	0	0	0	0	0	10 Copay	20 Copay	0	0	0	0	0	50 Copay	25 Copay	25 Copay								150.52	144.49	59.32	35	100	0.2	0.2	44	0.2	0	0	0	0	0	10	20	25	25	12.24	0	0	0	0	0	10	20	0	0	0	0	0	50	25	25								15.15	0.65	5.5	4.26	1.98	2.52	0.21	0.93	1.04	-	-	-	-	-	3.71	6.54	0.69	2.08	3.97	-	-	-	-	-	0.18	0.15	-	-	-	-	-	0.33	0.74	0.49	-	-	-	-	-	-	-	51.11		4.04	15.15	0.65	5.5	4.26	1.98	2.52	0.21	0.93	1.04	-	-	-	-	-	3.71	6.54	0.69	2.08	3.97	-	-	-	-	-	0.18	0.15	-	-	-	-	-	0.33	0.74	0.49	-	-	-	-	-	-	-	51.11	none																																																																																			-		0	15.15	0.65	5.5	4.26	1.98	2.52	0.21	0.93	1.04	-	-	-	-	-	3.71	6.54	0.69	2.08	3.97	-	-	-	-	-	0.18	0.15	-	-	-	-	-	0.33	0.74	0.49	-	-	-	-	-	-	-	51.11
H5427_020_0	2007	5	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								3100	ASC	Chiropractor	Podiatrist								D	D	D	V	T	P	Coin	V	Coin	P	V	V	V	V	V	V	V	V	P	V	O	O		V	V	V	V	V	O	O	O	V																																																			-	none	2386	430	903	5160	491	140404	2	217	6	3622	885	48	-	15045	5953	6377	1552	4399	5481	33275	358	180		869	214	92	592	104	-	7474	128	100										75 for 1st 6 days	75 for 1st 6 days	50 for days 8-20 and 0 for over day 21	20 Copay	50 per Trip	0 Copay	20 Coinsurance	25 ER/0 Urgent Care	20 Coinsurance	0	0	0	0	0	0 Copay	0 Copay	0 Copay	10 Copay	Varies 0 to 40	0	0	0		0	0 Copay	0 Copay	0	0	0	0	0	0 Copay	0 Copay	0 Copay								51.36	51.36	15.76	20	50	0	0.2	20	0.2	0	0	0	0	0	0	0	0	10	4.1	0	0	0		0	0	0	0	0	0	0	0	0	0	0								10.21	1.84	1.19	8.6	2.05	-	0.41	0.36	1.29	-	-	-	-	-	-	-	-	3.67	1.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.48		4.04	10.21	1.84	1.19	8.6	2.05	-	0.41	0.36	1.29	-	-	-	-	-	-	-	-	3.67	1.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.48	none																																																																																			-		0	10.21	1.84	1.19	8.6	2.05	-	0.41	0.36	1.29	-	-	-	-	-	-	-	-	3.67	1.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.48
H5427_021_0	2007	5	s.										OP Facility - Surgery										3100	ASC										D	D	D	V	T	P	Coin	V	Coin	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	V	V	V	O	O	O	V																																																			-	none	1492	270	591	2790	451	14177	0	371	7	5904	1582	120	-	8384	5362	5322	953	1708	3424	30164	358	180	68	869	214	92	592	104	-	7474	128	103										125 for 1st 5 days	125 for 1st 5 days	50 for days 8-20 and 0 for over day 21	15 Copay	100 Copay	0 Copay	20 Coinsurance	50 ER/10 Urgent Care	20 Coinsurance	0	0	0	0	0	0 Copay	15 Copay	20 Copay	20 Copay	Varies 0 to 50	0	0	0	0	0	10 Copay	10 Copay	0	0	0	0	0	0 Copay										85.48	85.48	16.98	15	100	0	0.2	42	0.2	0	0	0	0	0	0	15	20	20	5.12	0	0	0	0	0	10	10	0	0	0	0	0	0										10.63	1.92	0.84	3.49	3.76	-	0.05	1.3	1.42	-	-	-	-	-	-	6.65	1.59	2.85	1.46	-	-	-	-	-	0.18	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.2		0.07	10.63	1.92	0.84	3.49	3.76	-	0.05	1.3	1.42	-	-	-	-	-	-	6.65	1.59	2.85	1.46	-	-	-	-	-	0.18	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.2	none																																																																																			-		0	10.63	1.92	0.84	3.49	3.76	-	0.05	1.3	1.42	-	-	-	-	-	-	6.65	1.59	2.85	1.46	-	-	-	-	-	0.18	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.2
H5427_022_0	2007	4	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								3000	ASC	Chiropractor	Podiatrist								D	D	D	V	T	Coin	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	V	V	V	O	O	O	V	V	V																																																	-	none	1702	76	1404	2166	478	14	1	275	150	3291	713	75	-	7050	4649	4098	344	1042	4066	26839	279	139	-	869	214	92	145	26	-	13003	704	81	354	235								195 for 1st 7 days	195 for 1st 7 days	100 for days 8-100 and 0 for over day 100	25 Copay	100 per Trip	20 Coinsurance	20 Coinsurance	50 ER/15 Urgent Care	75 Copay	0	0	0	0	0	0 Copay	15 Copay	20 Copay	20 Copay	Varies 0 to 100	0	0	0	0	0	0	10 Copay	0	0	0	0	0	50 Copay	20 Copay	20 Copay								152.87	152.87	52.56	25	100	0.2	0.2	43	75	0	0	0	0	0	0	15	20	20	11.04	0	0	0	0	0	0	10	0	0	0	0	0	50	20	20								21.68	0.97	6.15	4.51	3.98	2.7	0.23	0.99	0.94	-	-	-	-	-	-	5.12	0.57	1.74	3.74	-	-	-	-	-	-	0.08	-	-	-	-	-	0.34	0.59	0.39	-	-	-	-	-	-	-	54.71		1.27	21.68	0.97	6.15	4.51	3.98	2.7	0.23	0.99	0.94	-	-	-	-	-	-	5.12	0.57	1.74	3.74	-	-	-	-	-	-	0.08	-	-	-	-	-	0.34	0.59	0.39	-	-	-	-	-	-	-	54.71	none																																																																																			-		0	21.68	0.97	6.15	4.51	3.98	2.7	0.23	0.99	0.94	-	-	-	-	-	-	5.12	0.57	1.74	3.74	-	-	-	-	-	-	0.08	-	-	-	-	-	0.34	0.59	0.39	-	-	-	-	-	-	-	54.71
H5427_049_0	2007	5	s.	i7.	i8.								OP Facility - Surgery	Professional	Professional								none	ASC	Chiropractor	Podiatrist								D	D	D	V	T	Coin	Coin	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	Ded	V	Ded	O	O	O	V	V	V																																																	-	none	2648	118	1860	4932	702	47	4	364	204	4941	1070	113	-	10583	7122	6278	527	1596	6230	41118	279	139	-	869	214	92	145	26	-	13003	704	110	354	235								0	0	0	0	50 per Trip	0	0	25 ER/0 Urgent Care	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10 Copay	0	0	0	0	0	0	0	0								0	0	0	0	50	0	0	20	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0	0								-	-	-	-	2.92	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.61	0	0	-	-	-	-	2.92	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.61	none																																																																																			-	0	0	-	-	-	-	2.92	-	-	0.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	3.61
H5427_050_0	2007	5																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5428_001_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5429_001_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V			V	V	V	V	Coin					V	V	V	V						Coin	V	V	S																																															-		1323.37	121.5	373.91	619.18	203.12	5.57	0.46	336.32	33.23	3532.64	9.77	59.45		4528.79	1924.32	1282.88	219.51	674.03	10.49					462.31	372.98	183.71	135.15					8651.96	17.9	589.52	1094.81	3170.11						300 (Days 1-10)	300 (Days 1-10)	150 (Days 7-100)	30	150	20	20	50	25	0-75	0-20				10 Urgent Care else 5	25	25	25	20					0-75	10	10	10						5	25	25	0-75						259.81	259.81	86.4	29.92	149.59	0.2	0.2	49.76	0.25	14.93	0.07	0		0	5.47	24.88	24.88	24.88	0.07					4.98	9.95	9.95	9.95					0	0.05	24.88	24.88	14.93						28.65	2.63	2.69	1.54	2.53	1.11	0.09	1.39	8.27	4.39	0.73	-	-	-	0.88	2.66	0.46	1.4	0.78	-	-	-	-	0.19	0.31	0.15	0.11	-	-	-	-	-	0.89	1.22	2.27	3.94	-	-	-	-	-	69.31		0.33	28.65	2.63	2.69	1.54	2.53	1.11	0.09	1.39	8.27	4.39	0.73	-	-	-	0.88	2.66	0.46	1.4	0.78	-	-	-	-	0.19	0.31	0.15	0.11	-	-	-	-	-	0.89	1.22	2.27	3.94	-	-	-	-	-	69.31		20		20	20	20	20		20	25					20	20						20			20	20		20			20	20											4.04		0.27	0.14	0.07	0.21		0.09	1.42					0.79	2.67						0.06			0.06	0.05		0			0.08	0.03											9.98			32.69	2.63	2.96	1.68	2.6	1.31	0.09	1.48	9.69	4.39	0.73	-	-	0.79	3.55	2.66	0.46	1.4	0.78	-	0.06	-	-	0.25	0.36	0.15	0.12	-	-	0.08	0.03	-	0.89	1.22	2.27	3.94	-	-	-	-	-	79.28
H5429_005_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V			V	V	V	V	Coin					V	V	V	V						Coin	V	V	S																																															-		1220.15	112.03	344.75	570.89	187.28	5.31	0.44	310.09	31.67	3257.11	9.31	54.81		4175.57	1774.23	1182.82	202.39	621.46	10					426.25	343.89	169.38	124.61					7977.15	17.05	543.54	1009.42	2922.86						300 (Days 1-10)	300 (Days 1-10)	150 (Days 6-100)	30	150	20	20	50	25	0-75	0-20				10 Urgent Care else 5	25	25	25	20					0-75	10	10	10						5	25	25	0-75						259.81	259.81	95.33	29.86	149.29	0.2	0.2	49.76	0.25	14.93	0.07	0		0	5.47	24.88	24.88	24.88	0.07					4.98	9.95	9.95	9.95					0	0.05	24.88	24.88	14.93						26.42	2.43	2.74	1.42	2.33	1.06	0.09	1.29	7.88	4.05	0.7	-	-	-	0.81	2.45	0.42	1.29	0.75	-	-	-	-	0.18	0.29	0.14	0.1	-	-	-	-	-	0.85	1.13	2.09	3.64	-	-	-	-	-	64.52		0.3	26.42	2.43	2.74	1.42	2.33	1.06	0.09	1.29	7.88	4.05	0.7	-	-	-	0.81	2.45	0.42	1.29	0.75	-	-	-	-	0.18	0.29	0.14	0.1	-	-	-	-	-	0.85	1.13	2.09	3.64	-	-	-	-	-	64.52		20		20	20	20	20		20	25					20	20						20			20	20		20			20	20											3.84		0.25	0.13	0.06	0.2		0.08	1.35					0.76	2.55						0.06			0.05	0.05		0			0.08	0.03											9.51			30.26	2.43	2.99	1.55	2.39	1.25	0.09	1.37	9.23	4.05	0.7	-	-	0.76	3.36	2.45	0.42	1.29	0.75	-	0.06	-	-	0.23	0.33	0.14	0.11	-	-	0.08	0.03	-	0.85	1.13	2.09	3.64	-	-	-	-	-	74.02
H5429_007_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V			V	V	V	V	Coin					V	V	V	V						Coin	V	V	S																																															-		1752.19	160.87	495.07	819.82	268.94	7.62	0.63	445.31	45.48	4677.34	13.37	78.71		5996.28	2547.87	1698.58	290.64	892.44	14.36					612.12	493.84	243.24	178.94					11455.5	24.49	780.54	1449.57	4197.34						300 (Days 1-5)	300 (Days 1-5)	150 (Days 7-100)	20	100	20	20	50	25	0-75	0-20				10 Urgent Care else 5	25	25	25	20					0-75	10	10	10						5	25	25	0-75						205.95	205.95	86.63	19.95	99.73	0.2	0.2	49.9	0.25	14.97	0.07	0		0	5.49	24.95	24.95	24.95	0.07					4.99	9.98	9.98	9.98					0	0.05	24.95	24.95	14.97						30.07	2.76	3.57	1.36	2.23	1.52	0.13	1.85	11.35	5.83	1	-	-	-	1.17	3.53	0.6	1.86	1.07	-	-	-	-	0.25	0.41	0.2	0.15	-	-	-	-	-	1.22	1.62	3.01	5.24	-	-	-	-	-	82.03		0.39	30.07	2.76	3.57	1.36	2.23	1.52	0.13	1.85	11.35	5.83	1	-	-	-	1.17	3.53	0.6	1.86	1.07	-	-	-	-	0.25	0.41	0.2	0.15	-	-	-	-	-	1.22	1.62	3.01	5.24	-	-	-	-	-	82.03		20		20	20	20	20		20	25					20	20						20			20	20		20			20	20											5.52		0.37	0.19	0.09	0.28		0.12	1.94					1.09	3.66						0.09			0.08	0.07		0			0.11	0.05											13.65			35.59	2.76	3.94	1.55	2.32	1.8	0.13	1.97	13.29	5.83	1	-	-	1.09	4.82	3.53	0.6	1.86	1.07	-	0.09	-	-	0.33	0.48	0.2	0.15	-	-	0.11	0.05	-	1.22	1.62	3.01	5.24	-	-	-	-	-	95.68
H5429_011_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V			V	V	V	V	Coin														Coin	V	V	S																																															-		2664.93	244.68	752.97	1246.87	409.03	11.59	0.97	677.27	69.17	7113.84	20.34	119.72		9119.83	3875.09	2583.39	442.04	1357.33	21.84													17422.85	37.24	1187.13	2204.68	6383.8						250 (Days 1-7)	250 (Days 1-7)	150 (Days 7-100)	20	100	20	20	50	25	0-75	0-20				10 Urgent Care else 0	20	20	20	20														5	20	20	0-75						195.99	195.99	86.65	19.95	99.73	0.2	0.2	49.91	0.25	14.97	0.07	0		0	1	19.97	19.97	19.97	0.07													0	0.05	19.97	19.97	14.97						43.53	4	5.44	2.07	3.4	2.31	0.19	2.82	17.26	8.88	1.52	-	-	-	0.32	4.3	0.74	2.26	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	1.86	1.98	3.67	7.97	-	-	-	-	-	116.13		0.55	43.53	4	5.44	2.07	3.4	2.31	0.19	2.82	17.26	8.88	1.52	-	-	-	0.32	4.3	0.74	2.26	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	1.86	1.98	3.67	7.97	-	-	-	-	-	116.13		20		20	20	20	20		20	25					20	20						20			20	20		20			20	20											8.4		0.56	0.29	0.14	0.43		0.18	2.96					1.65	5.56						0.13			0.12	0.1		0			0.17	0.07											20.76			51.92	4	5.99	2.36	3.53	2.74	0.19	3	20.22	8.88	1.52	-	-	1.65	5.88	4.3	0.74	2.26	1.64	-	0.13	-	-	0.12	0.1	-	0	-	-	0.17	0.07	-	1.86	1.98	3.67	7.97	-	-	-	-	-	136.89
H5429_015_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V			V	V	V	V	Coin					V	V	V	V						Coin	V	V	S																																															-		1298.83	119.25	366.98	607.7	199.35	5.65	0.47	330.09	33.71	3467.13	9.91	58.35		4444.81	1888.64	1259.09	215.44	661.53	10.64					453.74	366.07	180.3	132.64					8491.52	18.15	578.58	1074.51	3111.32						300 (Days 1-9)	300 (Days 1-9)	150 (Days 7-100)	30	150	20	20	50	25	0-75	0-20				10 Urgent Care else 5	25	25	25	20					0-75	10	10	10						5	25	25	0-75						253.23	253.23	86.42	29.92	149.59	0.2	0.2	49.78	0.25	14.93	0.07	0		0	5.48	24.89	24.89	24.89	0.07					4.98	9.96	9.96	9.96					0	0.05	24.89	24.89	14.93						27.41	2.52	2.64	1.52	2.49	1.12	0.09	1.37	8.39	4.31	0.74	-	-	-	0.86	2.61	0.45	1.37	0.79	-	-	-	-	0.19	0.3	0.15	0.11	-	-	-	-	-	0.9	1.2	2.23	3.87	-	-	-	-	-	67.64		0.32	27.41	2.52	2.64	1.52	2.49	1.12	0.09	1.37	8.39	4.31	0.74	-	-	-	0.86	2.61	0.45	1.37	0.79	-	-	-	-	0.19	0.3	0.15	0.11	-	-	-	-	-	0.9	1.2	2.23	3.87	-	-	-	-	-	67.64		20		20	20	20	20		20	25					20	20						20			20	20		20			20	20											4.09		0.27	0.14	0.07	0.21		0.09	1.44					0.81	2.71						0.06			0.06	0.05		0			0.09	0.03											10.12			31.5	2.52	2.91	1.66	2.55	1.33	0.09	1.46	9.83	4.31	0.74	-	-	0.81	3.57	2.61	0.45	1.37	0.79	-	0.06	-	-	0.25	0.35	0.15	0.11	-	-	0.09	0.03	-	0.9	1.2	2.23	3.87	-	-	-	-	-	77.76
H5429_020_0	2007	6	s.	t.	u.	v.	w.						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						3800	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	V			V	V	V	V	Coin					V	V	V	V						Coin	V	V	S																																															-		1257.16	115.42	355.21	588.2	192.96	5.47	0.46	319.5	32.63	3355.9	9.6	56.48		4302.21	1828.04	1218.7	208.53	640.31	10.3					439.18	354.32	174.52	128.38					8219.09	17.57	560.02	1040.04	3011.5						275 (Days 1-12)	275 (Days 1-12)	150 (Days 11-100)	30	150	20	20	50	25	0-75	0-20				10 Urgent Care else 5	20	20	20	20					0-75	10	10	10						5	20	20	0-75						247.05	247.05	59.3	29.92	149.59	0.2	0.2	49.79	0.25	14.94	0.07	0		0	5.48	19.92	19.92	19.92	0.07					4.98	9.96	9.96	9.96					0	0.05	19.92	19.92	14.94						25.88	2.38	1.76	1.47	2.41	1.09	0.09	1.33	8.12	4.18	0.72	-	-	-	0.83	2.02	0.35	1.06	0.77	-	-	-	-	0.18	0.29	0.14	0.11	-	-	-	-	-	0.87	0.93	1.73	3.75	-	-	-	-	-	62.45		0.29	25.88	2.38	1.76	1.47	2.41	1.09	0.09	1.33	8.12	4.18	0.72	-	-	-	0.83	2.02	0.35	1.06	0.77	-	-	-	-	0.18	0.29	0.14	0.11	-	-	-	-	-	0.87	0.93	1.73	3.75	-	-	-	-	-	62.45		20		20	20	20	20		20	25					20	20						20			20	20		20			20	20											3.96		0.26	0.14	0.06	0.2		0.09	1.39					0.78	2.62						0.06			0.06	0.05		0			0.08	0.03											9.79			29.84	2.38	2.02	1.6	2.47	1.29	0.09	1.41	9.52	4.18	0.72	-	-	0.78	3.46	2.02	0.35	1.06	0.77	-	0.06	-	-	0.24	0.34	0.14	0.11	-	-	0.08	0.03	-	0.87	0.93	1.73	3.75	-	-	-	-	-	72.24
H5430_001_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5431_001_0	2007	5	s.										OP Facility - Surgery										none	ASC										D	D	D	V	T	P	P	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	Ded	V	Ded	O	O	O	V																																																			-	none	2157	389	837	4795	461	129473	10789	249	180	3492	853	46	-	14507	5708	6114	1488	4218	5255	31905	290	145	226	1197	573	245	598	106	-	6052	7773	97											200 Copay days 1-5						50 each visit																																		0	137.3	0	0	0	0	0	50	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	4.45	-	-	-	-	-	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.48		0	-	4.45	-	-	-	-	-	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.48	none																																																																																			-		0	-	4.45	-	-	-	-	-	1.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.48
H5431_002_0	2007	5	s.	t.									Professional	OP Facility - Surgery									none	Mental Health(SA)	ASC									D	D	D	V	T	P	P	V	V	P	V	V	V	V	V	V	V	V	P	V	O	O	T	V	V	P	V	P	DED	O	O	V	V																																																		-	none		268	556		337			249							5708		1488								573								97										75 copay days 1-5	25 Copay days 7 to 25		25 per trip			25 each visit							25 urgent care per visit		20 per visit								10 per Medicare covered exam								50 per visit to ASC										51.49	11.02		25			25							2.5		20								10								50									-	1.15	0.51	-	0.7	-	-	0.52	-	-	-	-	-	-	1.19	-	2.48	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	7.43		0	-	1.15	0.51	-	0.7	-	-	0.52	-	-	-	-	-	-	1.19	-	2.48	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	7.43	none																																																																																			-		0	-	1.15	0.51	-	0.7	-	-	0.52	-	-	-	-	-	-	1.19	-	2.48	-	-	-	-	-	-	-	0.48	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	7.43
H5431_003_0	2007	5	s.	s.	s.								Professional	Professional	Professional								none	Chiropractic	Podiatry	Diabetes Supplies								D	D	D		T		Coin	V	V		P				V	V	V	V							V							V	V	Coin																																																	-	none	1431	358	556		337		0.28	211	229		1469				4322	2881	155	1625							611							216	130	1.94								150 days 2-7	200 days 1-5	100 days 15-30		100 per trip		20 coinsurance	50 each visit	100 each visit		25 per procedure				10 urgent care	10 per visit	20 per visit	20 per visit							10 per exam							10 per visit	10 per visit	20 per diabetic supply								85.74	137.3	18.02		100		0.2	50	100		25				1	10	20	20							10							10	10	0.2								10.22	4.09	0.83	-	2.81	-	0.06	0.88	1.91	-	3.06	-	-	-	0.36	2.4	0.26	2.71	-	-	-	-	-	-	0.51	-	-	-	-	-	-	0.18	0.11	0.39	-	-	-	-	-	-	-	30.78		0	10.22	4.09	0.83	-	2.81	-	0.06	0.88	1.91	-	3.06	-	-	-	0.36	2.4	0.26	2.71	-	-	-	-	-	-	0.51	-	-	-	-	-	-	0.18	0.11	0.39	-	-	-	-	-	-	-	30.78	none																																																																																			-		0	10.22	4.09	0.83	-	2.81	-	0.06	0.88	1.91	-	3.06	-	-	-	0.36	2.4	0.26	2.71	-	-	-	-	-	-	0.51	-	-	-	-	-	-	0.18	0.11	0.39	-	-	-	-	-	-	-	30.78
H5433_001_0	2007	5																					0											A	A	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0.0 coins (PBP #1A)	0.0 coins (PBP #1B)	0.0 coins (PBP #2)	0.0 coins (PBP #6)	0.0 coins (PBP #10A)	0.0 coins (PBP #11A)	0.0 coins (PBP #11B/11C)	0.0 coins (PBP #4A/4B)	0.0 coins (PBP #9A/9B)	0.0 coins (PBP #8A/9A)	0.0 coins (PBP #8B/9A)	0.0 coins (PBP #5/9A)	0.0 coins (PBP #12/9A)	0.0 coins (PBP #3/5/9A/9C/9D)	0.0 coins (PBP #7A/14B-14I)	0.0 coins (PBP #7B/7D/7F/7G/14D-14I)	0.0 coins (PBP #7E/7H)	0.0 coins (PBP #7C/7I)	0.0 coins (PBP #7D)	0.0 coins (PBP #7B/7D/7F/7G/14D-14I)	0.0 coins (PBP #15)	0.0 coins (PBP #13A/14A)			2x per year ILO 1x per year (PBP# 17A)	75 every two years (PBP# 17B)			N/A	Health classes nutrition training smoking cessation congestive heart program alternative medicine disease management newsletter (PBP# 14A)												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5434_001_0	2007	3	e.3.	f.1.	f.2.	f.3.	g.1.	h.6.	i.7.				DME/Prosthetics/Supplies	OP Facility - Emergency	OP Facility - Emergency	OP Facility - Emergency	OP Facility - Surgery	OP Facility - Other	Professional				3000	Electric Wheelchairs	Urgent Care	Worldwide ER	Worldwide Urgent  Care	Ambulatory Surgical Center	Cardiac Rehab	Allergy Injections				A	A	D		T			V	V					V	V	V	V															O	V	V	V	V	V	P																																													-		312.2	3.33	215.61		231.21			344.42	166.27					528.45	4458.64	8339.05	449.5															0.86	0.04			143.31	572.93	748.25				150 for days 1-5	150 for days 1-5	135 for days 21-100	0 copay for Home Health Care 0 copay for Respite Care	100 per trip	0 copay for DME except electric wheelchairs and scooters	0 copay	50 copay	150 copay	100 copay	100 copay	100 copay	0 copay	100 copay on OP Facility 75 copay on IDTF	10 copay	25 copay	25 copay	with Cardiac Rehab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	500 copay	25 copay	50 copay	25 copay	75 copay	25 copay for Cardiac Rehab and PT/OT/ST	5 copay				463.2	463.2	135		100			50	144.55					51.76	9.64	24.09	24.09															220.56	24.09			75	24.09	5				12.05	0.13	2.43	-	1.93	-	-	1.44	2	-	-	-	-	2.28	3.58	16.74	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	0	-	-	0.9	1.15	0.31	-	-	-	45.85	0	1.46	12.05	0.13	2.43	-	1.93	-	-	1.44	2	-	-	-	-	2.28	3.58	16.74	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	0	-	-	0.9	1.15	0.31	-	-	-	45.85		CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	100 per trip	CYD + 30 coins	CYD + 30 coins	50 copay	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	0 copay	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 50 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	25 copay	50 copay	25 copay	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins				8.25	0.09	0.93	1.26	0.21	0.54	0.04	0.16	0.51	0.49	0.73	0	0	0.26	0.93	0.83	0.12	0.08	1.07	4.76	0	1.16	0	0	0	0	0	0	0	0	0	0	0	0.01	0	0.18	0.45	0.02				23.07	500		20.3	0.22	3.36	1.26	2.14	0.54	0.04	1.59	2.52	0.49	0.73	-	-	2.54	4.51	17.57	1.02	0.08	1.07	4.76	-	1.16	-	-	-	-	-	-	-	-	-	0.02	0	0.01	0	1.07	1.6	0.33	-	-	-	68.92
H5434_002_0	2007	3	e.3.	f.1.	f.2.	f.3.	g.1.	h.6.	i.7.				DME/Prosthetics/Supplies	OP Facility - Emergency	OP Facility - Emergency	OP Facility - Emergency	OP Facility - Surgery	OP Facility - Other	Professional				3000	Electric Wheelchairs	Urgent Care	Worldwide ER	Worldwide Urgent  Care	Ambulatory Surgical Center	Cardiac Rehab	Allergy Injections				A	A	D		T			V	V					V	V	V	V															O	V	V	V	V	V	P																																													-		318.82	3.4	323.01		225.68			308.3	148.83					473.03	3412.02	6036.78	324.32															0.84	0.03			128.28	570.24	572.6				150 for days 1-5	150 for days 1-5	135 for days 21-100	0 copay for Home Health Care 0 copay for Respite Care	100 per trip	0 copay for DME except electric wheelchairs and scooters	0 copay	50 copay	150 copay	100 copay	100 copay	100 copay	0 copay	100 copay on OP Facility 75 copay on IDTF	10 copay	25 copay	25 copay	with Cardiac Rehab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	500 copay	25 copay	50 copay	25 copay	75 copay	25 copay for Cardiac Rehab and PT/OT/ST	5 copay				463.2	463.2	135		100			50	144.55					51.76	9.64	24.09	24.09															220.56	24.09			75	24.09	5				12.31	0.13	3.63	-	1.88	-	-	1.28	1.79	-	-	-	-	2.04	2.74	12.12	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	0	-	-	0.8	1.14	0.24	-	-	-	40.78	0	1.24	12.31	0.13	3.63	-	1.88	-	-	1.28	1.79	-	-	-	-	2.04	2.74	12.12	0.65	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	0	-	-	0.8	1.14	0.24	-	-	-	40.78		CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	100 per trip	CYD + 30 coins	CYD + 30 coins	50 copay	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	0 copay	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 50 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins	25 copay	50 copay	25 copay	CYD + 30 coins	CYD + 30 coins	CYD + 30 coins				9.36	0.1	1.18	1.63	0.21	0.68	0.05	0.14	0.48	0.46	0.68	0	0	0.25	0.86	0.77	0.11	0.07	1.07	4.72	0	1.07	0	0	0	0	0	0	0	0	0	0	0	0.01	0	0.16	0.42	0.02				24.49	500		21.67	0.23	4.82	1.63	2.09	0.68	0.05	1.43	2.27	0.46	0.68	-	-	2.29	3.6	12.89	0.76	0.07	1.07	4.72	-	1.07	-	-	-	-	-	-	-	-	-	0.02	0	0.01	0	0.97	1.56	0.25	-	-	-	65.28
H5434_801_0	2007	5																																Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin						Coin	Coin	Coin																																																													-		219.98		26.19	35.94	6.73	19.39		4.16	19.89					55.74						227.65	2.01	33.42																				For all IP visits MH and Acute		FFS coin for all SNF visits	FFS coin for all HH	FFS coin for all Amb	FFS coin for all DME		FFS coin for all OP -ER	FFS coin for all OP -Surg					FFS coin for all OP -Oth						FFS coin for all Professional	FFS coin for all Part B Rx	FFS coin for all Other																				0.08		0.18	0	0.24	0.24		0.24	0.24					0.24						0.24	0.24	0.24																				17.3	-	4.6	-	1.59	4.58	-	0.98	4.69	-	-	-	-	13.16	-	-	-	-	-	53.73	0.48	7.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.98	0		17.3	-	4.6	-	1.59	4.58	-	0.98	4.69	-	-	-	-	13.16	-	-	-	-	-	53.73	0.48	7.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.98		For all IP visits MH and Acute	see a.1.	FFS coin for all SNF visits	FFS coin for all HH	FFS coin for all Amb	FFS coin for all DME	see e.1.	FFS coin for all OP -ER	FFS coin for all OP -Surg	see h.5.	see h.5.	see h.5.	see h.5.	FFS coin for all OP -Oth	see i.6.	see i.6.	see i.6.	see i.6.	see i.6.	FFS coin for all Professional	no OON benefit	FFS coin for all Other																				1.92	0	0.51	0	0.18	0.51	0	0.11	0.52	0	0	0	0	1.46	0	0	0	0	0	5.97	0	0.88	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	12.06	0		19.22	-	5.11	-	1.77	5.08	-	1.09	5.21	-	-	-	-	14.62	-	-	-	-	-	59.7	0.48	8.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.03
H5434_802_0	2007	5																																Coin		Coin	Coin	Coin	Coin		Coin	Coin					Coin						Coin	Coin	Coin																																																													-		219.98		26.19	35.94	6.73	19.39		4.16	19.89					55.74						227.65	2.01	33.42																				For all IP visits MH and Acute		FFS coin for all SNF visits	FFS coin for all HH	FFS coin for all Amb	FFS coin for all DME		FFS coin for all OP -ER	FFS coin for all OP -Surg					FFS coin for all OP -Oth						FFS coin for all Professional	FFS coin for all Part B Rx	FFS coin for all Other																				0.08		0.18	0	0.24	0.24		0.24	0.24					0.24						0.24	0.24	0.24																				17.3	-	4.6	-	1.59	4.58	-	0.98	4.69	-	-	-	-	13.16	-	-	-	-	-	53.73	0.48	7.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.98	0		17.3	-	4.6	-	1.59	4.58	-	0.98	4.69	-	-	-	-	13.16	-	-	-	-	-	53.73	0.48	7.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.98		For all IP visits MH and Acute	see a.1.	FFS coin for all SNF visits	FFS coin for all HH	FFS coin for all Amb	FFS coin for all DME	see e.1.	FFS coin for all OP -ER	FFS coin for all OP -Surg	see h.5.	see h.5.	see h.5.	see h.5.	FFS coin for all OP -Oth	see i.6.	see i.6.	see i.6.	see i.6.	see i.6.	FFS coin for all Professional	no OON benefit	FFS coin for all Other																				1.92	0	0.51	0	0.18	0.51	0	0.11	0.52	0	0	0	0	1.46	0	0	0	0	0	5.97	0	0.88	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	12.06	0		19.22	-	5.11	-	1.77	5.08	-	1.09	5.21	-	-	-	-	14.62	-	-	-	-	-	59.7	0.48	8.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.03
H5435_001_0	2007	2																					2800											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2800	2112.93	59.24	1051.27	1965.68	181.15	10	0.7	409.82	360.23	721.5	15.45	22.05	2.28	529.22	4622.2	3696.6	261.12	507.6	16.8	24519.68	18.4	0	0	0	109.13	240.63	190.7	34.14	0	0	706.14											125/day	125/day	0 [Day(s) 1-10]; 75 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 30	Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 20; Pulmonary Rehabilitation: 20; Ambulatory Surgical Center Copay: 100; Outpatient Hospital Copay: 100	10	20	25	Occupational Therapy: 20; PT and Speech/Language Therapy: 20	Routine Outpatient X-Ray: 25; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											91.55	91.55	35.89	0	109.86	0.21	0.21	35.8	73.24	0	0.15	0	0.2	52.38	9.57	15.71	18.31	14.65	0.45	0	0.2	0	0	0	0	0	0	0	0	0	0											16.12	0.45	3.14	-	1.66	2.1	0.15	1.22	2.2	-	2.38	-	0.46	2.31	3.69	4.84	0.4	0.62	7.49	0.01	3.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.91	0	19.33	16.12	0.45	3.14	-	1.66	2.1	0.15	1.22	2.2	-	2.38	-	0.46	2.31	3.69	4.84	0.4	0.62	7.49	0.01	3.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.91	2800																																																																																			-	0	0	16.12	0.45	3.14	-	1.66	2.1	0.15	1.22	2.2	-	2.38	-	0.46	2.31	3.69	4.84	0.4	0.62	7.49	0.01	3.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.91
H5435_002_0	2007	2																					2900											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	2900	2112.93	59.24	1051.27	1965.68	181.15	10.27	0.72	409.82	360.23	721.5	15.88	22.05	2.35	529.22	4622.2	3696.6	261.12	507.6	17.27	24519.68	17.58	0	0	0	109.13	240.63	190.7	34.14	0	0	706.14											150/day	150/day	40 [Day(s) 1-10]; 75 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 30	Ambulatory Surgical Center Copay: 125; Outpatient Hospital Copay: 125	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 25; Pulmonary Rehabilitation: 25; Ambulatory Surgical Center Copay: 125; Outpatient Hospital Copay: 125	15	30	25	Occupational Therapy: 25; PT and Speech/Language Therapy: 25	Routine Outpatient X-Ray: 25; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											104.99	104.99	44.1	0	104.99	0.21	0.21	34.22	87.49	0	0.15	0	0.2	62.57	10.32	21	17.5	21	0.42	0	0.2	0	0	0	0	0	0	0	0	0	0											18.49	0.52	3.86	-	1.58	2.16	0.15	1.17	2.63	-	2.44	-	0.47	2.76	3.98	6.47	0.38	0.89	7.26	0.01	3.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.73	0	25.18	18.49	0.52	3.86	-	1.58	2.16	0.15	1.17	2.63	-	2.44	-	0.47	2.76	3.98	6.47	0.38	0.89	7.26	0.01	3.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.73	2900																																																																																			-	0	0	18.49	0.52	3.86	-	1.58	2.16	0.15	1.17	2.63	-	2.44	-	0.47	2.76	3.98	6.47	0.38	0.89	7.26	0.01	3.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.73
H5435_003_0	2007	2																					3200											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3200	2112.93	59.24	1051.27	1965.68	181.15	10.31	0.72	409.82	360.23	721.5	15.94	22.05	2.36	529.22	4622.2	3696.6	261.12	507.6	17.34	24519.68	17.19	0	0	0	109.13	240.63	190.7	34.14	0	0	706.14											200/day	200/day	80 [Day(s) 1-10]; 115 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 25; Pulmonary Rehabilitation: 25; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	25	Occupational Therapy: 25; PT and Speech/Language Therapy: 25	Routine Outpatient X-Ray: 25; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											136.86	136.86	70.48	0	102.65	0.21	0.21	33.83	102.65	0	0.15	0	0.2	72.46	10.09	20.53	17.11	20.53	0.41	0	0.2	0	0	0	0	0	0	0	0	0	0											24.1	0.68	6.17	-	1.55	2.17	0.15	1.16	3.08	-	2.45	-	0.47	3.2	3.89	6.32	0.37	0.87	7.14	0.01	3.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.21	0	31.01	24.1	0.68	6.17	-	1.55	2.17	0.15	1.16	3.08	-	2.45	-	0.47	3.2	3.89	6.32	0.37	0.87	7.14	0.01	3.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.21	3200																																																																																			-	0	0	24.1	0.68	6.17	-	1.55	2.17	0.15	1.16	3.08	-	2.45	-	0.47	3.2	3.89	6.32	0.37	0.87	7.14	0.01	3.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.21
H5435_004_0	2007	2																					3900											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3900	2112.93	59.24	1051.27	1965.68	181.15	12.91	0.9	409.82	360.23	721.5	19.96	22.05	2.95	529.22	4622.2	3696.6	261.12	507.6	21.7	24519.68	18.01	0	0	0	109.13	240.63	190.7	34.14	0	0	706.14											225/day	225/day	80 [Day(s) 1-10]; 115 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 25; Pulmonary Rehabilitation: 25; Ambulatory Surgical Center Copay: 175; Outpatient Hospital Copay: 175	15	30	25	Occupational Therapy: 25; PT and Speech/Language Therapy: 25	Routine Outpatient X-Ray: 25; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											161.36	161.36	73.87	0	107.57	0.21	0.21	35.46	125.5	0	0.15	0	0.2	87.78	10.58	21.51	17.93	21.51	0.36	0	0.2	0	0	0	0	0	0	0	0	0	0											28.41	0.8	6.47	-	1.62	2.71	0.19	1.21	3.77	-	3.07	-	0.59	3.87	4.07	6.63	0.39	0.91	7.79	0.01	3.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.12	0	30.02	28.41	0.8	6.47	-	1.62	2.71	0.19	1.21	3.77	-	3.07	-	0.59	3.87	4.07	6.63	0.39	0.91	7.79	0.01	3.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.12	3900																																																																																			-	0	0	28.41	0.8	6.47	-	1.62	2.71	0.19	1.21	3.77	-	3.07	-	0.59	3.87	4.07	6.63	0.39	0.91	7.79	0.01	3.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.12
H5435_008_0	2007	3																					1500											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	1500	2405.22	67.44	1196.7	2237.6	206.21	10.96	0.76	466.51	410.06	821.31	16.94	25.1	2.5	602.42	5261.59	4207.96	297.24	577.82	18.42	27911.53	16.78	0	0	0	124.23	273.91	217.08	38.86	0	0	794.31											100 per day	100 per day	0 [Day(s) 1-10]; 115 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 0 [Day(s) 1-10]; 15 [Day(s) 11+; Pulmonary Rehabilitation: 0 [Day(s) 1-10]; 15 [Day(s) 11+; Ambulatory Surgical Center Copay: 50; Outpatient Hospital Copay: 50	5	5	15	Occupational Therapy: 0 [Day(s) 1-10]; 15 [Day(s) 11+; PT and Speech/Language Therapy: 0 [Day(s) 1-10]; 15 [Day(s) 11+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											58.69	58.69	44.02	0	88.03	0.21	0.21	29.02	29.34	0	0.15	0	0.2	20.66	3.83	3.79	8.8	2.93	0.27	0	0.2	0	0	0	0	0	0	0	0	0	0											11.76	0.33	4.39	-	1.51	2.3	0.16	1.13	1	-	2.61	-	0.5	1.04	1.68	1.33	0.22	0.14	4.9	0	3.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.35	0	27	11.76	0.33	4.39	-	1.51	2.3	0.16	1.13	1	-	2.61	-	0.5	1.04	1.68	1.33	0.22	0.14	4.9	0	3.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.35	1500																																																																																			-	0	0	11.76	0.33	4.39	-	1.51	2.3	0.16	1.13	1	-	2.61	-	0.5	1.04	1.68	1.33	0.22	0.14	4.9	0	3.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.35
H5435_009_0	2007	3																					500											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	500	2405.22	67.44	1196.7	2237.6	206.21	7.54	0.53	466.51	410.06	821.31	11.66	25.1	1.72	602.42	5261.59	4207.96	297.24	577.82	12.68	27911.53	12.95	0	0	0	124.23	273.91	217.08	38.86	0	0	794.31											0 per admit	0 per admit	0 [Day(s) 1-10]; 115 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 0 [Day(s) 1-10]; 15 [Day(s) 11+; Pulmonary Rehabilitation: 0 [Day(s) 1-10]; 15 [Day(s) 11+; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	15	Occupational Therapy: 0 [Day(s) 1-10]; 15 [Day(s) 11+; PT and Speech/Language Therapy: 0 [Day(s) 1-10]; 15 [Day(s) 11+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	0	33.97	0	67.94	0.21	0.21	22.4	0	0	0.15	0	0.2	1	1.1	0.99	6.79	0	0.29	0	0.2	0	0	0	0	0	0	0	0	0	0											-	-	3.39	-	1.17	1.58	0.11	0.87	-	-	1.79	-	0.34	0.05	0.48	0.35	0.17	-	3.65	-	2.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.54	0	19.98	-	-	3.39	-	1.17	1.58	0.11	0.87	-	-	1.79	-	0.34	0.05	0.48	0.35	0.17	-	3.65	-	2.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.54	500																																																																																			-	0	0	-	-	3.39	-	1.17	1.58	0.11	0.87	-	-	1.79	-	0.34	0.05	0.48	0.35	0.17	-	3.65	-	2.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	16.54
H5435_010_0	2007	3																					3900											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3900	2112.93	59.24	1051.27	1965.68	181.15	11.01	0.77	409.82	360.23	721.5	17.03	22.05	2.52	529.22	4622.2	3696.6	261.12	507.6	18.52	24519.68	17.34	0	0	0	109.13	240.63	190.7	34.14	0	0	706.14											275/day	275/day	100 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	35	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 25; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											189.83	189.83	69.03	0	103.54	0.21	0.21	34.13	138.06	0	0.15	0	0.2	96.83	10.18	24.16	20.71	24.16	0.39	0.01	0.2	0	0	0	0	0	0	0	0	0	0											33.42	0.94	6.05	-	1.56	2.31	0.16	1.17	4.14	-	2.62	-	0.5	4.27	3.92	7.44	0.45	1.02	7.29	0.01	3.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.75	0	36.23	33.42	0.94	6.05	-	1.56	2.31	0.16	1.17	4.14	-	2.62	-	0.5	4.27	3.92	7.44	0.45	1.02	7.29	0.01	3.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.75	3900																																																																																			-	0	0	33.42	0.94	6.05	-	1.56	2.31	0.16	1.17	4.14	-	2.62	-	0.5	4.27	3.92	7.44	0.45	1.02	7.29	0.01	3.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.75
H5435_013_0	2007	4																					3200											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3200	2112.93	59.24	1051.27	1965.68	181.15	9.99	0.7	409.82	360.23	721.5	15.44	22.05	2.28	529.22	4622.2	3696.6	261.12	507.6	16.79	24519.68	17.21	0	0	0	109.13	240.63	190.7	34.14	0	0	706.14											200/day	200/day	80 [Day(s) 1-10]; 115 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 25; Pulmonary Rehabilitation: 25; Ambulatory Surgical Center Copay: 150; Outpatient Hospital Copay: 150	15	30	25	Occupational Therapy: 25; PT and Speech/Language Therapy: 25	Routine Outpatient X-Ray: 25; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											137.03	137.03	70.57	0	102.77	0.21	0.21	33.88	102.77	0	0.15	0	0.2	72.55	10.11	20.55	17.13	20.55	0.42	0	0.2	0	0	0	0	0	0	0	0	0	0											24.13	0.68	6.18	-	1.55	2.1	0.15	1.16	3.09	-	2.38	-	0.46	3.2	3.89	6.33	0.37	0.87	7.1	0.01	3.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.07	0	30.82	24.13	0.68	6.18	-	1.55	2.1	0.15	1.16	3.09	-	2.38	-	0.46	3.2	3.89	6.33	0.37	0.87	7.1	0.01	3.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.07	3200																																																																																			-	0	0	24.13	0.68	6.18	-	1.55	2.1	0.15	1.16	3.09	-	2.38	-	0.46	3.2	3.89	6.33	0.37	0.87	7.1	0.01	3.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.07
H5435_014_0	2007	2																					3900											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3900	2112.93	59.24	1051.27	1965.68	181.15	9.68	0.68	409.82	360.23	721.5	14.97	22.05	2.21	529.22	4622.2	3696.6	261.12	507.6	16.28	24519.68	17.41	0	0	0	109.13	240.63	190.7	34.14	0	0	706.14											275/day	275/day	100 [Day(s) 1-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 30; Pulmonary Rehabilitation: 30; Ambulatory Surgical Center Copay: 200; Outpatient Hospital Copay: 200	15	35	30	Occupational Therapy: 30; PT and Speech/Language Therapy: 30	Routine Outpatient X-Ray: 25; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											190.64	190.64	69.32	0	103.98	0.21	0.21	34.27	138.65	0	0.15	0	0.2	97.24	10.23	24.26	20.8	24.26	0.44	0.01	0.2	0	0	0	0	0	0	0	0	0	0											33.57	0.94	6.07	-	1.57	2.03	0.14	1.17	4.16	-	2.3	-	0.44	4.29	3.94	7.47	0.45	1.03	7.12	0.01	3.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.2	0	35.49	33.57	0.94	6.07	-	1.57	2.03	0.14	1.17	4.16	-	2.3	-	0.44	4.29	3.94	7.47	0.45	1.03	7.12	0.01	3.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.2	3900																																																																																			-	0	0	33.57	0.94	6.07	-	1.57	2.03	0.14	1.17	4.16	-	2.3	-	0.44	4.29	3.94	7.47	0.45	1.03	7.12	0.01	3.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.2
H5435_016_0	2007	3																					1000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	1000	2405.22	67.44	1196.7	2237.6	206.21	10.8	0.75	466.51	410.06	821.31	16.7	25.1	2.47	602.42	5261.59	4207.96	297.24	577.82	18.16	27911.53	18.12	0	0	0	124.23	273.91	217.08	38.86	0	0	794.31											0 per admit	0 per admit	0 [Day(s) 1-10]; 115 [Day(s) 11-100];Day 101 - Mbr Responsibility	Covered in Full	150	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 20 Coinsurance	ER Copay (per visit): 50; Urgent Care: 40	Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	20 Coinsurance	Cardiac Rehabilitation: 0 [Day(s) 1-10]; 15 [Day(s) 11+; Pulmonary Rehabilitation: 0 [Day(s) 1-10]; 15 [Day(s) 11+; Ambulatory Surgical Center Copay: 0; Outpatient Hospital Copay: 0	0	0	15	Occupational Therapy: 0 [Day(s) 1-10]; 15 [Day(s) 11+; PT and Speech/Language Therapy: 0 [Day(s) 1-10]; 15 [Day(s) 11+	Routine Outpatient X-Ray: 15; Radiation Therapy: 20 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 20 Coinsurance	0	Inhalation Solutions: 20 Coinsurance; Oral Chemo: 20 Coinsurance; Anti-Emetics: 20 Coinsurance; Outpatient Injectables  -Self Administered: 20 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											0	0	47.52	0	95.05	0.21	0.21	31.33	0	0	0.15	0	0.2	1.4	1.54	1.38	9.5	0	0.28	0	0.2	0	0	0	0	0	0	0	0	0	0											-	-	4.74	-	1.63	2.27	0.16	1.22	-	-	2.57	-	0.49	0.07	0.67	0.48	0.24	-	5.14	-	3.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.31	0	13.47	-	-	4.74	-	1.63	2.27	0.16	1.22	-	-	2.57	-	0.49	0.07	0.67	0.48	0.24	-	5.14	-	3.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.31	1000																																																																																			-	0	0	-	-	4.74	-	1.63	2.27	0.16	1.22	-	-	2.57	-	0.49	0.07	0.67	0.48	0.24	-	5.14	-	3.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.31
H5435_849_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	2405.22	67.44	1196.7	2237.6	206.21	10.51	0.73	466.51	410.06	821.31	16.26	25.1	2.4	602.42	5261.59	4207.96	297.24	577.82	17.68	27911.53	18.9	0	0	0	124.23	273.91	217.08	38.86	0	0	794.31											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											231.37	231.33	105.75	0	115.66	0.3	0.3	9.64	229.47	0	0.23	0	0.3	52.48	7.65	13.22	26.44	13.22	0.34	4.32	0.3	0	0	0	0	0	0	0	0	0	0											46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	0	56.39	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	5000																																																																																			-	0	0	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93
H5435_850_0	2007	3																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	2405.22	67.44	1196.7	2237.6	206.21	10.51	0.73	466.51	410.06	821.31	16.26	25.1	2.4	602.42	5261.59	4207.96	297.24	577.82	17.68	27911.53	18.9	0	0	0	124.23	273.91	217.08	38.86	0	0	794.31											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											231.37	231.33	105.75	0	115.66	0.3	0.3	9.64	229.47	0	0.23	0	0.3	52.48	7.65	13.22	26.44	13.22	0.34	4.32	0.3	0	0	0	0	0	0	0	0	0	0											46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	0	56.39	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	5000																																																																																			-	0	0	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93
H5435_869_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	2405.22	67.44	1196.7	2237.6	206.21	10.51	0.73	466.51	410.06	821.31	16.26	25.1	2.4	602.42	5261.59	4207.96	297.24	577.82	17.68	27911.53	18.9	0	0	0	124.23	273.91	217.08	38.86	0	0	794.31											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											231.37	231.33	105.75	0	115.66	0.3	0.3	9.64	229.47	0	0.23	0	0.3	52.48	7.65	13.22	26.44	13.22	0.34	4.32	0.3	0	0	0	0	0	0	0	0	0	0											46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	0	56.39	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	5000																																																																																			-	0	0	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93
H5435_870_0	2007	4																					5000											D	D	D	V	T	Coin	Coin	V	P	P	Coin	P	Coin	P	V	V	V	V	Coin	V	Coin	O	T	P	P	P	P	P	O	O	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	5000	2405.22	67.44	1196.7	2237.6	206.21	10.51	0.73	466.51	410.06	821.31	16.26	25.1	2.4	602.42	5261.59	4207.96	297.24	577.82	17.68	27911.53	18.9	0	0	0	124.23	273.91	217.08	38.86	0	0	794.31											350 dayTransplant has additional copay/coinsurance and 1500 Deductible	350 day	160 day	0	175 per trip	30 Coinsurance	Prosthetic Devices: 30 Coinsurance; Diabetes Monitoring Supplies: 30 Coinsurance	ER Copay (per visit): 50; Urgent Care: 50	Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	0	Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	0	30 Coinsurance	Cardiac Rehabilitation: 30 Coinsurance; Pulmonary Rehabilitation: 30 Coinsurance; Ambulatory Surgical Center Copay: 30 Coinsurance; Outpatient Hospital Copay: 30 Coinsurance	15	35	40 Ind/30 Group	Occupational Therapy: 30 Coinsurance; PT and Speech/Language Therapy: 30 Coinsurance	Routine Outpatient X-Ray: 15; Radiation Therapy: 30 Coinsurance; Compex Radiology (MRIMRACTPETSpec): 30 Coinsurance	15	Inhalation Solutions: 30 Coinsurance; Oral Chemo: 30 Coinsurance; Anti-Emetics: 30 Coinsurance; Outpatient Injectables  -Self Administered: 30 Coinsurance	0	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	0	Acupuncture: Not Covered; Routine Chiropractic: Not Covered											231.37	231.33	105.75	0	115.66	0.3	0.3	9.64	229.47	0	0.23	0	0.3	52.48	7.65	13.22	26.44	13.22	0.34	4.32	0.3	0	0	0	0	0	0	0	0	0	0											46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	0	56.39	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93	5000																																																																																			-	0	0	46.38	1.3	10.55	-	1.99	3.15	0.22	0.37	7.84	-	3.75	-	0.72	2.63	3.36	4.64	0.65	0.64	6.01	10.05	5.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.93
H5436_001_0	2007	7	h.6.										OP Fac - Other											MH Substance Abuse										D	D	D	P	T	Coin	Coin	V	Coin	V	V	V	V	V	V	V	V	V	P	P	O	O	T	P	P	P	P	P	O	V	P	V										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		2170.1	1.39	1140.75	2488.18	273.02	0.47	0	285.6	60.81	141.98	1560.67	51.76	40.83	2210.6	8798.92	25171.07	516.51	199.51	4417.86	0	7.65	0	42.1	0	5.02	0	55.85	0	0	1512.69	0	0										100 per day for days 1-10 unlimited days thereafter	100 per day for days 1-10	110 for Days 21-100	No Cost Sharing	100 per Trip	10 per Device	10 for Diabetes Supplies	50 per ER Visit; 25 per Urgent Care Visit	10 per Episode for Hospital 25 per Episode for ASC	No Cost Sharing	25 Copayment	No Cost Sharing	No Cost Sharing	25 Copayment for Diagnostic Testing; 20 Copayment for OP Rehab	10 per Visit Copayment	20 per Visit Copayment	20 per Visit Individual Copayment; 10 per Visit Group Copays	20 per Visit Copayment	No Cost Sharing	No Cost Sharing	10 per Visit Diabetes Nutritional Therapy	No Cost Sharing	No Cost Sharing	20 per Visit Copayment	20 per Visit Copayment	10  per Pair (1 pair per year)	20 per Visit Copayment	No Cost Sharing	Not Applicable	10 per Visit for Diabetes Training	No Cost Sharing	20 per Visit Individual Copayment; 10 per Visit Group Copays										36.63	70	31.72	0	70	0.07	0.04	34.79	0.07	0	17.5	0	0	0.18	4.83	3.1	13.3	14	0	0	7	0	0	14	14	7	14	0	0	0.01	0	13.3										6.62	0.01	3.02	-	1.59	0.03	-	0.83	4.26	-	2.28	-	-	0.03	3.54	6.51	0.57	0.23	-	-	0	-	-	-	0.01	-	0.07	-	-	0	-	-	-	-	-	-	-	-	-	-	-	29.6	0	0	6.62	0.01	3.02	-	1.59	0.03	-	0.83	4.26	-	2.28	-	-	0.03	3.54	6.51	0.57	0.23	-	-	0	-	-	-	0.01	-	0.07	-	-	0	-	-	-	-	-	-	-	-	-	-	-	29.6		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	100/Trip	20 Coinsurance	20 Coinsurance	50 per ER Visit; 25 per Urgent Care Visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance; 25 Copayment for OP Rehab	20 Coinsurance	20 Coinsurance	10 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance; 40 frame allowance	20 Coinsurance	20 Coinsurance	Not Applicable	20 Coinsurance	20 Coinsurance	10 Coinsurance										32.34	0.01	2.18	1.91	0.68	0.04	0	0.35	4.56	0.47	6.01	0.82	0.07	3.15	3.21	17.19	0.17	0.19	1.87	0	0	0	0.02	0	0	0	0.02	0	0	0	0	0										75.28	0	0	38.96	0.02	5.2	1.91	2.28	0.07	-	1.18	8.82	0.47	8.28	0.82	0.07	3.18	6.75	23.7	0.75	0.43	1.87	-	0.01	-	0.02	-	0.01	-	0.08	-	-	0	-	-	-	-	-	-	-	-	-	-	-	104.88
H5436_002_0	2007	7	h.6.										OP Fac - Other											MH Substance Abuse										D	D	D	P	T	Coin	Coin	V	Coin	V	V	V	V	V	V	V	V	V	P	P	O	O	T	P	P	P	P	P	O	V	P	V										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-		1962.35	0.73	917.67	3025.64	356.93	0.28	0.01	362.85	62.73	147.95	1464.03	95.27	27.66	1689.47	9703.67	25495.24	523.23	469.27	4734.48	0	5.73	0	0.22	0	2.39	0.11	47.45	0	0	1.95	0	0										100 per day for days 1-10 unlimited days thereafter	100 per day for days 1-10	110 for Days 21-100	No Cost Sharing	100 per Trip	10 per Device	10 for Diabetes Supplies	50 per ER Visit; 25 per Urgent Care Visit	10 per Episode for Hospital 25 per Episode for ASC	No Cost Sharing	25 Copayment	No Cost Sharing	No Cost Sharing	25 Copayment for Diagnostic Testing; 20 Copayment for OP Rehab	10 per Visit Copayment	20 per Visit Copayment	20 per Visit Individual Copayment; 10 per Visit Group Copays	20 per Visit Copayment	No Cost Sharing	No Cost Sharing	10 per Visit Diabetes Nutritional Therapy	No Cost Sharing	No Cost Sharing	20 per Visit Copayment	20 per Visit Copayment	10  per Pair (1 pair per year)	20 per Visit Copayment	No Cost Sharing	Not Applicable	10 per Visit for Diabetes Training	No Cost Sharing	20 per Visit Individual Copayment; 10 per Visit Group Copays										36.63	70	31.72	0	70	0.07	0.04	34.2	0.07	0	17.5	0	0	0.25	5.17	3.23	13.3	14	0	0	7	0	0	14	14	7	14	0	0	7	0	7										5.99	0	2.43	-	2.08	0.02	0	1.03	4.39	-	2.14	-	-	0.03	4.18	6.86	0.58	0.55	-	-	0	-	-	-	0	0	0.06	-	-	0	-	-	-	-	-	-	-	-	-	-	-	30.34	0	0	5.99	0	2.43	-	2.08	0.02	0	1.03	4.39	-	2.14	-	-	0.03	4.18	6.86	0.58	0.55	-	-	0	-	-	-	0	0	0.06	-	-	0	-	-	-	-	-	-	-	-	-	-	-	30.34		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	100/Trip	20 Coinsurance	20 Coinsurance	50 per ER Visit; 25 per Urgent Care Visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance; 25 Copayment for OP Rehab	20 Coinsurance	20 Coinsurance	10 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance; 40 frame allowance	20 Coinsurance	20 Coinsurance	Not Applicable	20 Coinsurance	20 Coinsurance	10 Coinsurance										30.77	0.01	1.6	2.12	0.89	0.02	0	0.44	4.7	0.68	3.96	1.17	0.05	4.5	3.36	17.39	0.18	0.43	2.02	0	0	0	0	0	0	0	0.01	0	0	0	0	0										74.33	0	0	36.76	0.01	4.03	2.12	2.97	0.04	0	1.48	9.1	0.68	6.1	1.17	0.05	4.53	7.54	24.24	0.76	0.98	2.02	-	0.01	-	0	-	0	0	0.07	-	-	0	-	-	-	-	-	-	-	-	-	-	-	104.67
H5437_001_0	2007	6																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	1925.41	989.53	0	0	0	4776.46	5902.51	173.99	503.41	825.61	1247.87	0	0	0	0	0	279.21	0	19.5	0	0	0											225/day 1-10	225/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	20	100	20	20	50 ER 25 urgent care	150	35	35 routine 100 complex	35	30	35	25	35 Specialist; 30 Renal Dialysis	35	35	35	35	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	500 Every 3 Years	N/A	Fitness	0											183.69	183.69	65.39	20	100	0.2	0.2	46.75	150	35	57.23	35	30	35	25	34.4	35	35	35	35	45	0	0	0	0	0	0	0	0	0	0											20.97	0.41	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	9.95	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.61			20.97	0.41	6.1	3.06	1.69	2.77	0.18	1.43	3.79	5.62	4.72	-	-	-	9.95	16.92	0.51	1.47	2.41	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.61		30	30	30	30	100	30	30	50 ER 30 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45	0	Not Covered	Not Covered	30	0	30	0	N/A	Not Covered	0											4.96	0	0.8	0.72	0.16	0.41	0	0.14	0.51	0.18	0.5	0	0.16	0.55	0.64	0.81	0.03	0.09	0.6	2.17	0.08	0	0	0	0.08	0	0.02	0	0	0	0											13.61	500	12.53	25.93	0.41	6.9	3.78	1.85	3.18	0.18	1.57	4.29	5.79	5.21	-	0.16	0.55	10.6	17.73	0.54	1.55	3.01	5.81	0.08	-	-	-	0.08	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.22
H5437_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30	30	30	30	150	30	30	50	30	30	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0	0	0	0.13	0	0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H5437_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30	30	30	30	150	30	30	50	30	30	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0	0	0	0.13	0	0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H5439_001_0	2007	5																					1500											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											10.09	0.07	1.61	1.33	0.28	0.99	0.05	0.2	1.05	0.39	1.08	0	0.01	1.09	2.08	6.31	0.06	0.2	1.39	1.36	0.31	0.29	0	0	0.14	0.1	0.04	0	0	0	0											30.51	2750	179.79	1.66	792.69	0	146.98	16.98	0.89	184.17	186.83	0	605.41	0	0.23	366.4	3863.95	4573.57	133.52	426.62	0	208.78	346.31	595.88	0	0	284.6	0	121.62	0	0	850	0											Per Admit: 50	Per Admit: 50	Per Admit: 50 100 Days Limit		25 per Ambulance Service	10 DME	10 DME	50 ER/ 25 UC	50 ASC / 50 OP	No Charge	No Charge		10 RD	25 OP SA	10 PCP	10 SCP/ 15 Chiro	25 MH	25 per Visit	0 X-Ray/ 10 MRI	10 per Visit	10 Rx	10 Mdcr Cov Vision/Hearing			10 per Visit		10 per Visit															45.14	45.14	2.78	0	22.56	0.1	0.04	37.46	45.13	0	2.66	0	0.04	22.56	9	12.14	22.54	22.54	0	8.5	9.03	8.44	0	0	9.02	0	9.02	0	0	0	0											0.68	0.01	0.18	-	0.28	1.68	0.03	0.57	0.7	-	0.13	-	0.01	0.69	2.9	4.63	0.25	0.8	-	0.15	0.26	0.42	-	-	0.21	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	14.68	500	3.85	10.76	0.08	1.8	1.33	0.56	2.67	0.09	0.77	1.75	0.39	1.22	-	0.02	1.78	4.98	10.94	0.31	1	1.39	1.51	0.57	0.71	-	-	0.35	0.1	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.19	4250	10 Coin Contracted Rate	10 Coin Contracted Rate	10 Coin Contracted Rate		25 per Ambulance Service	10 Coin Contracted Rate	10 Coin Contracted Rate	50 ER	10 ASC / 10 OP	10 Coin Contracted Rate	10 Coin Contracted Rate		10 Coin Contracted Rate	50 OP SA	10 Coin Contracted Rate	10 SCP/ 50 Chiro	50 MH	35 per Visit	10 Coin Contracted Rate	10 Coin Contracted Rate	10 Coin Contracted Rate	10 Coin Contracted Rate		35 Ded with 20 Comp	10 Coin		10 Coin Contracted Rate															5.48	0.04	0.85	0.31	0.11	0.5	0.02	0.15	0.53	0.21	0.57		0.01	0.52	1.03	3.78	0.1	0.22	0.68	0.65	0.16	0.13																				16.06	750	2.26	16.24	0.12	2.65	1.64	0.67	3.18	0.11	0.92	2.28	0.6	1.78	-	0.03	2.3	6.01	14.71	0.41	1.22	2.07	2.15	0.73	0.84	-	-	0.35	0.1	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.25
H5440_001_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1100	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T	V						O	O																																																				-		2600.35	373.29	1750.88		333.85	30.95	25.82	978.13					3.48								19.77																					(1a) 25 per Day	(1b) 25 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 50 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 0 per Visit	(8a) 0 per Visit	(8b) 0 per Visit	(9a) 0 per Visit	(12) 20 Coinsurance	(9a) 0 per Visit	(7a) 0 per Visit	(7d) 0 per Visit	(7h) 0 per Visit	(7c) 0 per Visit	0 per Visit	(7g) 0 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit						(14a) 0	(13a1) 0											17	17	25		34	14	14	27					14								14																					3.69	0.53	3.58	-	0.95	4.22	3.52	2.19	-	-	-	-	0.47	-	-	-	-	-	-	-	2.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.83		10.23	3.69	0.53	3.58	-	0.95	4.22	3.52	2.19	-	-	-	-	0.47	-	-	-	-	-	-	-	2.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.83																																																																																				-		0	3.69	0.53	3.58	-	0.95	4.22	3.52	2.19	-	-	-	-	0.47	-	-	-	-	-	-	-	2.69	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	21.83
H5485_001_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	V	O	O	O																																																				-		1241.5	22.7	1614	0	231.6	15.46	9.42	604.8	496.7	3248.5	1646	0	0	920.6	5109.6	4593.6	205.6	603	1700	3353.4	8.62	758.8	0	0	428.9	0	156.3	0	0	0	0											140/day for days 1-5	140/day for days 1-5	25/day for days 16-30; 75/day for days 31-100		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay	20 Copay	20 Copay			30 Copay	15 PCP Copay	30 Copay	30 Copay	30 Copay	20 Copay	30 Copay Specialist; 20 Copay Lab		30 Copay			30 Copay		30 Copay															140	140	37.66	0	75	0.2	0.2	50	175	20	20	0	0	30	15	30	30	30	20	25.31	0	30	0	0	30	0	30	0	0	0	0											14.48	0.26	5.07	-	1.45	3.09	1.89	2.52	7.24	5.41	2.74	-	-	2.3	6.39	11.48	0.51	1.51	2.83	7.07	-	1.9	-	-	1.07	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.62			14.48	0.26	5.07	-	1.45	3.09	1.89	2.52	7.24	5.41	2.74	-	-	2.3	6.39	11.48	0.51	1.51	2.83	7.07	-	1.9	-	-	1.07	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.62																																																																																				-			14.48	0.26	5.07	-	1.45	3.09	1.89	2.52	7.24	5.41	2.74	-	-	2.3	6.39	11.48	0.51	1.51	2.83	7.07	-	1.9	-	-	1.07	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.62
H5485_002_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	V	O	O	O																																																				-		1309.4	23.8	493.7	0	244.2	16.31	9.94	637.9	523.9	0	0	0	0	971	5389.4	4845.1	216.9	637	0	1879	0	800.3	0	0	452.4	0	164.8	0	0	0	0											120/day for days 1-5	120/day for days 1-5	25/day for days 16-30		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay					30 Copay	15 PCP Copay	30 Copay	30 Copay	30 Copay		30 Copay Specialist		30 Copay			30 Copay		30 Copay															120	120	25	0	75	0.2	0.2	50	175	0	0	0	0	30	15	30	30	30	0	30	0	30	0	0	30	0	30	0	0	0	0											13.09	0.24	1.03	-	1.53	3.26	1.99	2.66	7.64	-	-	-	-	2.43	6.74	12.11	0.54	1.59	-	4.7	-	2	-	-	1.13	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.09			13.09	0.24	1.03	-	1.53	3.26	1.99	2.66	7.64	-	-	-	-	2.43	6.74	12.11	0.54	1.59	-	4.7	-	2	-	-	1.13	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.09																																																																																				-			13.09	0.24	1.03	-	1.53	3.26	1.99	2.66	7.64	-	-	-	-	2.43	6.74	12.11	0.54	1.59	-	4.7	-	2	-	-	1.13	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.09
H5485_801_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	V	O	O	O																																																				-		1282.5	23.3	1667.4	0	239.2	15.97	9.73	624.8	513.2	3355.8	1700.4	0	0	951	5278.5	4745.4	212.4	623	1756	3464.3	8.91	783.8	0	0	0	0	0	0	0	0	0											140/day for days 1-5	140/day for days 1-5	25/day for days 16-30; 75/day for days 31-100		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay	20 Copay	20 Copay			30 Copay	15 PCP Copay	30 Copay	30 Copay	30 Copay	20 Copay	30 Copay Specialist; 20 Copay Lab		30 Copay																				140	140	37.66	0	75	0.2	0.2	50	175	20	20	0	0	30	15	30	30	30	20	25.31	0	30	0	0	0	0	0	0	0	0	0											14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73																																																																																				-			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73
H5485_802_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	V	O	O	O																																																				-		1282.5	23.3	1667.4	0	239.2	15.97	9.73	624.8	513.2	3355.8	1700.4	0	0	951	5278.5	4745.4	212.4	623	1756	3464.3	8.91	783.8	0	0	0	0	0	0	0	0	0											140/day for days 1-5	140/day for days 1-5	25/day for days 16-30; 75/day for days 31-100		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay	20 Copay	20 Copay			30 Copay	15 PCP Copay	30 Copay	30 Copay	30 Copay	20 Copay	30 Copay Specialist; 20 Copay Lab		30 Copay																				140	140	37.66	0	75	0.2	0.2	50	175	20	20	0	0	30	15	30	30	30	20	25.31	0	30	0	0	0	0	0	0	0	0	0											14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73																																																																																				-			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73
H5485_803_0	2007	2																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	V	O	O	O																																																				-		1282.5	23.3	1667.4	0	239.2	15.97	9.73	624.8	513.2	3355.8	1700.4	0	0	951	5278.5	4745.4	212.4	623	1756	3464.3	8.91	783.8	0	0	0	0	0	0	0	0	0											140/day for days 1-5	140/day for days 1-5	25/day for days 16-30; 75/day for days 31-100		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay	20 Copay	20 Copay			30 Copay	15 PCP Copay	30 Copay	30 Copay	30 Copay	20 Copay	30 Copay Specialist; 20 Copay Lab		30 Copay																				140	140	37.66	0	75	0.2	0.2	50	175	20	20	0	0	30	15	30	30	30	20	25.31	0	30	0	0	0	0	0	0	0	0	0											14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73																																																																																				-			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73
H5485_804_0	2007	2																																D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	V	O	O	O																																																				-		1282.5	23.3	1667.4	0	239.2	15.97	9.73	624.8	513.2	3355.8	1700.4	0	0	951	5278.5	4745.4	212.4	623	1756	3464.3	8.91	783.8	0	0	0	0	0	0	0	0	0											140/day for days 1-5	140/day for days 1-5	25/day for days 16-30; 75/day for days 31-100		75 Copay	20 Coinsurance	20 Coinsurance	50 ER/Urgent Care Copay	175 Copay	20 Copay	20 Copay			30 Copay	15 PCP Copay	30 Copay	30 Copay	30 Copay	20 Copay	30 Copay Specialist; 20 Copay Lab		30 Copay																				140	140	37.66	0	75	0.2	0.2	50	175	20	20	0	0	30	15	30	30	30	20	25.31	0	30	0	0	0	0	0	0	0	0	0											14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73																																																																																				-			14.96	0.27	5.23	-	1.5	3.19	1.94	2.6	7.48	5.59	2.83	-	-	2.38	6.6	11.86	0.53	1.56	2.93	7.31	-	1.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.73
H5500_001_0	2007	5																					4400											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	7500	2223.33	105.21	748.17	0	258.77	16.57	12.43	542.24	30.12	9571.04	43.49	0	0.57	17.58	4432.08	4188.06	377.72	2.31	0	0	39.83	773.45	0	0	184.25	0	194.98	0	0	0	0											325 (1a)	325 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											190.51	190.51	87.93	0	102.58	0.15	0.15	29.31	0.18	3.52	0.14	0	0.18	0.18	15	25	37.5	0.18	0	0	0.18	25	0	0	25	0	25	0	0	0	0											35.3	1.67	5.48	-	2.21	2.43	1.92	1.32	5.3	2.81	5.91	-	0.1	3.09	5.54	8.73	1.18	0.41	-	-	7	1.61	-	-	0.38	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.79		52.75	35.3	1.67	5.48	-	2.21	2.43	1.92	1.32	5.3	2.81	5.91	-	0.1	3.09	5.54	8.73	1.18	0.41	-	-	7	1.61	-	-	0.38	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.79		425 (1a)	425 (1b)	185 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											4.66	0.22	0.68	0.42	0.39	0.51	0.39	0.34	1.35	0.95	1.35	0	0.03	0.79	1.54	1.82	0.2	0.1	0	0	1.78	0.34	0	0	0.08	0	0.08	0	0	0	0											18.02		8.49	39.95	1.89	6.16	0.42	2.6	2.94	2.3	1.66	6.65	3.76	7.26	-	0.13	3.88	7.08	10.55	1.38	0.51	-	-	8.79	1.95	-	-	0.46	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.81
H5501_001_0	2007	7																																D	D	Coin	Coin	Coin	Coin	Coin	D	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		1565.48	0	21.49	16.16	7.93	8.64	13.68	278.59	30.63	2.12	25.83	0	0.24	24.17	53.97	115.67	2.64	1.42	30.71	39.56	4.39	7.23	0	11.69	0	0	0	0	0	2.03	3.31																		50 Copay MC & WW 5000 annual max for WW.																																		0	0	0	0	0	0	0	50	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.16			-	-	-	-	-	-	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.16		Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	20 of MA services Additional Days	20 Coinsurance MC Visits	20 of MC services	20 of MC services	20 of MC services	50 Copay MC & WW 5000 annual max for WW.	20 of MA services	20 of MA services	20 of MA services			20 of MC services	20 of MC services	20 of MC services	20 of MC services	20 of MC services	20 of MC services	20 of MC services	20 of MC services	20 of MC services																				6.43	0	1.08	0.81	0.4	0.43	0.68	0.29	1.53	0.11	1.29	0	0	1.21	2.7	5.79	0.13	0.07	1.54	1.91	0.22	0.36	0	0	0	0	0	0	0	0	0											26.98			6.43	-	1.08	0.81	0.4	0.43	0.68	1.45	1.53	0.11	1.29	-	-	1.21	2.7	5.79	0.13	0.07	1.54	1.91	0.22	0.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.14
H5507_001_0	2007	5																					4600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2030.77	97.93	535.34	0	120.81	13.47	8.36	343.47	39.34	9605.12	53.97	0	0.23	37.38	3762.51	4937.72	384.25	2.83	0	0	27.69	2275.96	0	0	235.2	0	188.96	0	0	0	0											265 (1a)	265 (1b)	125 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											179.78	179.78	84.8	0	118.73	0.17	0.19	33.92	0.17	4.07	0.13	0	0.2	0.17	15	30	37.5	0.17	0	0	0.2	30	0	0	30	0	30	0	0	0	0											30.43	1.47	3.78	-	1.2	2.28	1.59	0.97	6.67	3.26	7.27	-	0.05	6.34	4.7	12.34	1.2	0.48	-	-	5.64	5.69	-	-	0.59	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.41		33.59	30.43	1.47	3.78	-	1.2	2.28	1.59	0.97	6.67	3.26	7.27	-	0.05	6.34	4.7	12.34	1.2	0.48	-	-	5.64	5.69	-	-	0.59	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.41		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c 14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											1.8	0.04	0.47	0.32	0.17	0.4	0.25	0.11	0.89	0.48	0.98	0	0.01	0.84	0.77	3.45	0.13	0.08	0	0	0.82	0.49	0	0	0.04	0	0.03	0	0	0	0											12.56		0	32.22	1.5	4.25	0.32	1.37	2.68	1.84	1.08	7.56	3.74	8.25	-	0.05	7.18	5.48	15.79	1.34	0.56	-	-	6.46	6.18	-	-	0.62	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.98
H5508_001_0	2007	5																					4000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	V	V	V	V	O	V																																																				-		1390.24	110.5			102.21	8.96	11.72	299.57	362.51		146.91	45.74		293.71	3295.88	3815.47	281.89	130.68			22.4																					100 Days 1-5 (1a)	100 Days 1-5 (1b)	0 (2)	0 (6)	50 (10a)	20 (11a)	20 (11b 11c)	50 (4a 4b)	100 (9b)	0 (8a 8b)	100 (8a 8b)	100 (9a)	0 (12)	25 (9c) 0 (3 5 9a 9d)	10 (7a); 0 (14b 14c 14d 14e 14f 14g 14h)	25 (7b 7d 7f 17a)	25 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (7g 14i)	20 (15)	0 (13a)	0 n/c (10b)	0 n/c (16a 16b)	0 n/c	0 n/c (17b)	0 n/c (18a)	0 n/c (18b)	n/a	0 (14a)	0 n/c (13b)											58.38	45.63			50	0.2	0.2	47.62	95.24		95.24	95.24		23.81	10	25	25	25			0.19																					6.76	0.42	-	-	0.43	1.79	2.34	1.19	2.88	-	1.17	0.36	-	0.58	2.75	7.95	0.59	0.27	-	-	4.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.74		0.91	6.76	0.42	-	-	0.43	1.79	2.34	1.19	2.88	-	1.17	0.36	-	0.58	2.75	7.95	0.59	0.27	-	-	4.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.74		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				3.83	0.11	8.11		0.28	0.61	0.8	0.51	1.54	0.73	0.72	0.12	0.08	0.8	0.81	1.35	0.11	0.07	0.99	3.95	1.25	0.01																				26.77		0	10.59	0.53	8.11	-	0.7	2.4	3.15	1.7	4.41	0.73	1.89	0.49	0.08	1.39	3.55	9.3	0.69	0.34	0.99	3.95	5.51	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.52
H5508_002_0	2007	2																					4000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	V	V	V	V	O	V																																																				-		1390.24	110.5			102.21	8.96	11.72	299.57	362.51		146.91	45.74		293.71	3295.88	3815.47	281.89	130.68			22.4																					100 Days 1-5 (1a)	100 Days 1-5 (1b)	0 (2)	0 (6)	50 (10a)	20 (11a)	20 (11b 11c)	50 (4a 4b)	100 (9b)	0 (8a 8b)	100 (8a 8b)	100 (9a)	0 (12)	25 (9c) 0 (3 5 9a 9d)	10 (7a); 0 (14b 14c 14d 14e 14f 14g 14h)	25 (7b 7d 7f 17a)	25 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (7g 14i)	20 (15)	0 (13a)	0 n/c (10b)	0 n/c (16a 16b)	0 n/c	0 n/c (17b)	0 n/c (18a)	0 n/c (18b)	n/a	0 (14a)	0 n/c (13b)											58.38	45.63			50	0.2	0.2	47.62	95.24		95.24	95.24		23.81	10	25	25	25			0.19																					6.76	0.42	-	-	0.43	1.79	2.34	1.19	2.88	-	1.17	0.36	-	0.58	2.75	7.95	0.59	0.27	-	-	4.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.74		0.91	6.76	0.42	-	-	0.43	1.79	2.34	1.19	2.88	-	1.17	0.36	-	0.58	2.75	7.95	0.59	0.27	-	-	4.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.74		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				3.83	0.11	8.11		0.28	0.61	0.8	0.51	1.54	0.73	0.72	0.12	0.08	0.8	0.81	1.35	0.11	0.07	0.99	3.95	1.25	0.01																				26.77		0	10.59	0.53	8.11	-	0.7	2.4	3.15	1.7	4.41	0.73	1.89	0.49	0.08	1.39	3.55	9.3	0.69	0.34	0.99	3.95	5.51	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.52
H5509_001_0	2007	5	H.6.	H.7.	H.8.	I.7.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							3000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V																																																-		1583.04	86.84	826.53		171.1	9.1	1.11	281.19	461.21		318.88			52.52	3361.87	3141.12	218.76	684.52	205.95		17.65				471.79						336.43			2.17								1a 180 days 1-7	1b 100 days 1-90	2 100 days 8-100		10a 100	11a 20	11b 20	4a 50	9a 1509b 150		8a 208b 100			9d 35	17a 107a 107f 10	17a 3518a 357b 357d 357f 35	7e 35	7c 357i 35	8a 208b 100		0.2				17a 35						14c 107f 35			4b 10								101.58	57.98	46.5		78.61	0.16	0.16	34.43	82.87		68.01			25.82	7.85	24.09	21.37	25.09	25.72		0.16				6.99						4.9			7.86								13.4	0.42	3.2	-	1.12	1.45	0.18	0.81	3.19	-	1.81	-	-	0.11	2.2	6.31	0.39	1.43	0.44	-	2.82	-	-	-	0.27	-	-	-	-	-	0.14	-	-	0	-	-	-	-	-	-	-	39.69		10.83	13.4	0.42	3.2	-	1.12	1.45	0.18	0.81	3.19	-	1.81	-	-	0.11	2.2	6.31	0.39	1.43	0.44	-	2.82	-	-	-	0.27	-	-	-	-	-	0.14	-	-	0	-	-	-	-	-	-	-	39.69		0.2	20	0.2	0	100	0	0	50	0	0	0.2	0.2	0.2	0	0	0.2	0	0	20	0.2	0.2	0.2			0.2	0.2	0				0.2			10	0.2							5.53	0.01	0.62	0.35	0.39	0.73	0.09	0.28	2.45	0.04	1.36	0.01	0.04	0.31	2.36	5.78	0	0.29	1.81	0.74	1.44	0			0.25	0.05	0				0.2			0	0.17							25.29		0	18.93	0.43	3.82	0.35	1.51	2.19	0.27	1.09	5.63	0.04	3.17	0.01	0.04	0.42	4.56	12.09	0.39	1.72	2.25	0.74	4.27	0	-	-	0.53	0.05	0	-	-	-	0.33	-	-	0	0.17	-	-	-	-	-	-	64.98
H5509_003_0	2007	6	H.6.	H.7.	H.8.	I.7.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional							4000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay							D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	Coin	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V																																																-		1580.39	76.39	766.82		189.81	10.47	1.31	315.66	516.41		361.59			60.84	4078.95	3804.26	218.11	771.36	251.05		20.59				561.48						403.43			1.82								1a 180 days 1-10	1b 180 days 1-10 max 3000	2 90 days 4-100		10a 150	11a 20	11b 20	4a 50	9a 2009b 200		8a 208b 100			9d 35	17a 157a 157f 15	17a 3518a 357b 357d 357f 35	7e 35	7c 357i 35	8a 208b 100		0.2				17a 35						14c 157f 35			4b 15								123.51	82.05	66.28		128.18	0.17	0.17	37.43	120.11		71.57			27.19	12.59	25.87	24.46	27.15	27.48		0.17				10.47						7.82			12.82								16.27	0.52	4.24	-	2.03	1.79	0.22	0.98	5.17	-	2.16	-	-	0.14	4.28	8.2	0.44	1.75	0.58	-	3.52	-	-	-	0.49	-	-	-	-	-	0.26	-	-	0	-	-	-	-	-	-	-	53.03		8.62	16.27	0.52	4.24	-	2.03	1.79	0.22	0.98	5.17	-	2.16	-	-	0.14	4.28	8.2	0.44	1.75	0.58	-	3.52	-	-	-	0.49	-	-	-	-	-	0.26	-	-	0	-	-	-	-	-	-	-	53.03		0.2	20	0.2	0	150	0	0	50	0	0	0.2	0.2	0.2	0	0	0.2	0	0	20	0.2	0.2	0.2			0.2	0.2	0				0.2			15	0.2							5.12	0.01	0.55	0.12	0.25	0.24	0.03	0.2	1.03	0.02	0.57	0	0.02	0.13	0.8	1.96	0	0.11	0.62	0.26	0.5	0			0.09	0.02	0				0.07			0	0.06							12.76		0	21.39	0.53	4.79	0.12	2.28	2.03	0.26	1.18	6.2	0.02	2.72	0	0.02	0.27	5.08	10.16	0.44	1.86	1.19	0.26	4.01	0	-	-	0.58	0.02	0	-	-	-	0.33	-	-	0	0.06	-	-	-	-	-	-	65.79
H5509_801_0	2007	3	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional								Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-		209.42	2.88	13.99		10.15	9.3	1.19	7.38	51.34	3.75	17.92	0.39	0.06	5.92	63.57	82.48	3.64	5.3	28.24	6.43	19.98	0.02												0.03	2.15							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		0	16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							2.06	0	0.31		0.66	0.81	0.1	0.48	3.26	0.06	1.17	0.03	0.01	0.39	2.58	6.75		0.38	2.26	0.56	1.66	0												0	0.19							23.67		0	18.84	0.23	2.81	-	3.06	3	0.38	2.22	15.37	0.94	5.39	0.12	0.02	1.78	17.58	26.22	0.86	1.63	8.92	2.07	6.37	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.69	-	-	-	-	-	-	118.53
H5509_802_0	2007	2	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional								Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-		209.42	2.88	13.99		10.15	9.3	1.19	7.38	51.34	3.75	17.92	0.39	0.06	5.92	63.57	82.48	3.64	5.3	28.24	6.43	19.98	0.02												0.03	2.15							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		0	16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							2.06	0	0.31		0.66	0.81	0.1	0.48	3.26	0.06	1.17	0.03	0.01	0.39	2.58	6.75		0.38	2.26	0.56	1.66	0												0	0.19							23.67		0	18.84	0.23	2.81	-	3.06	3	0.38	2.22	15.37	0.94	5.39	0.12	0.02	1.78	17.58	26.22	0.86	1.63	8.92	2.07	6.37	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.69	-	-	-	-	-	-	118.53
H5509_803_0	2007	3	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional								Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-		209.42	2.88	13.99		10.15	9.3	1.19	7.38	51.34	3.75	17.92	0.39	0.06	5.92	63.57	82.48	3.64	5.3	28.24	6.43	19.98	0.02												0.03	2.15							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		0	16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							2.06	0	0.31		0.66	0.81	0.1	0.48	3.26	0.06	1.17	0.03	0.01	0.39	2.58	6.75		0.38	2.26	0.56	1.66	0												0	0.19							23.67		0	18.84	0.23	2.81	-	3.06	3	0.38	2.22	15.37	0.94	5.39	0.12	0.02	1.78	17.58	26.22	0.86	1.63	8.92	2.07	6.37	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.69	-	-	-	-	-	-	118.53
H5509_804_0	2007	2	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional								Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-		209.42	2.88	13.99		10.15	9.3	1.19	7.38	51.34	3.75	17.92	0.39	0.06	5.92	63.57	82.48	3.64	5.3	28.24	6.43	19.98	0.02												0.03	2.15							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		0	16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							2.06	0	0.31		0.66	0.81	0.1	0.48	3.26	0.06	1.17	0.03	0.01	0.39	2.58	6.75		0.38	2.26	0.56	1.66	0												0	0.19							23.67		0	18.84	0.23	2.81	-	3.06	3	0.38	2.22	15.37	0.94	5.39	0.12	0.02	1.78	17.58	26.22	0.86	1.63	8.92	2.07	6.37	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.69	-	-	-	-	-	-	118.53
H5509_805_0	2007	3	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional								Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-		209.42	2.88	13.99		10.15	9.3	1.19	7.38	51.34	3.75	17.92	0.39	0.06	5.92	63.57	82.48	3.64	5.3	28.24	6.43	19.98	0.02												0.03	2.15							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		0	16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							2.06	0	0.31		0.66	0.81	0.1	0.48	3.26	0.06	1.17	0.03	0.01	0.39	2.58	6.75		0.38	2.26	0.56	1.66	0												0	0.19							23.67		0	18.84	0.23	2.81	-	3.06	3	0.38	2.22	15.37	0.94	5.39	0.12	0.02	1.78	17.58	26.22	0.86	1.63	8.92	2.07	6.37	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.69	-	-	-	-	-	-	118.53
H5509_806_0	2007	3	H.	H.	H.	I.							OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional								Radiology Copay	Lab Copay	Urgent Care	Lab Copay							Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																-		209.42	2.88	13.99		10.15	9.3	1.19	7.38	51.34	3.75	17.92	0.39	0.06	5.92	63.57	82.48	3.64	5.3	28.24	6.43	19.98	0.02												0.03	2.15							FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							0.08	0.08	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		0	16.78	0.23	2.5	-	2.39	2.19	0.28	1.74	12.12	0.89	4.23	0.09	0.01	1.4	15	19.47	0.86	1.25	6.66	1.52	4.72	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.51	-	-	-	-	-	-	94.86		FFS Medicare 8.0	FFS Medicare 8.0	FFS Medicare 17.9		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6		FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6	FFS Medicare 23.6												FFS Medicare 23.6	FFS Medicare 23.6							2.06	0	0.31		0.66	0.81	0.1	0.48	3.26	0.06	1.17	0.03	0.01	0.39	2.58	6.75		0.38	2.26	0.56	1.66	0												0	0.19							23.67		0	18.84	0.23	2.81	-	3.06	3	0.38	2.22	15.37	0.94	5.39	0.12	0.02	1.78	17.58	26.22	0.86	1.63	8.92	2.07	6.37	0.01	-	-	-	-	-	-	-	-	-	-	-	0.01	0.69	-	-	-	-	-	-	118.53
H5510_002_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	5000	1725.95		986.18	798.17	79.65	32.79		461.96	230.09	152.91	1551.89	0	6.98	144.87	1300.79	1277.63	0	369.09	0	0	270.37				626.36		40.93															350 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 100 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															57.09		67.84	20	100	0.2		48	200	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															8.21	-	5.58	1.33	0.66	6.56	-	1.85	3.83	0.32	6.55	-	0.01	0.3	1.08	2.66	-	0.77	-	-	1.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.74	0	0	8.21	-	5.58	1.33	0.66	6.56	-	1.85	3.83	0.32	6.55	-	0.01	0.3	1.08	2.66	-	0.77	-	-	1.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.74		20 150 ded 5000 OOP max		20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	100 per trip	20 150 ded 5000 OOP max		50 ER; 35 UC	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	45 per script				20 150 ded 5000 OOP max		20 150 ded 5000 OOP max															8.56		0.61	0.1	0.06	0.58		0.17	0.6	0.28	0.95	0	0	0.26	0.47	2.91	0	0.2	0	0	0.1				0.05		0															15.89	150	6.03	16.77	-	6.18	1.43	0.72	7.14	-	2.01	4.44	0.6	7.5	-	0.02	0.56	1.55	5.58	-	0.97	-	-	1.11	-	-	-	0.05	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.62
H5510_003_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	7500	1698.39		970.43	785.42	78.38	32.27		454.58	226.41	150.47	1527.1	0	6.87	142.56	1280.01	1257.22	0	363.2	0	0	266.05				616.35		40.28															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	31.4 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	31.4	35	35	35	35	45				0		0															19.62	-	5.49	1.31	0.65	6.45	-	1.82	3.77	0.44	8.37	-	0.02	0.42	2.13	3.29	-	1.06	-	-	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.84	0	0	19.62	-	5.49	1.31	0.65	6.45	-	1.82	3.77	0.44	8.37	-	0.02	0.42	2.13	3.29	-	1.06	-	-	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.84		30 500 ded 7500 OOP max		30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	100 per trip	30 500 ded 7500 OOP max		50 ER; 35 UC	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	45 per script				30 500 ded 7500 OOP max		30 500 ded 7500 OOP max															13.44		0.95	0.15	0.06	0.92		0.19	0.94	0.44	1.48	0	0	0.41	0.74	4.58	0	0.31	0	0	0.11				0.08		0															24.82	500	9.23	33.07	-	6.44	1.46	0.72	7.37	-	2.01	4.72	0.88	9.86	-	0.02	0.82	2.87	7.87	-	1.37	-	-	1.11	-	-	-	0.08	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.66
H5510_005_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	7500	1776.699214		816.8803889	569.0624374	89.0261615	32.57400077		497.7495324	253.8679608	182.1288586	1526.527253	0	142.7209572	159.8427902	1221.649194	1171.655222	0	288.7826419	0	0	250.9750297				556.9447485		51.48148812															50/day 1-8		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	20 per visit	20 X-ray; 100 CATPETMRI	20 per visit	20 per visit	20 per visit	0 per visit	20 per visit	20 per visit	20 per visit	20 per visit	20 per visit	45 per script				0 per visit		0 per visit															37.9		67.84	20	100	0.2		48	200	20	47.36	20	20	20	0	20	20	20	20	20	45				0		0															5.61	-	4.62	0.95	0.74	6.51	-	1.99	4.23	0.3	6.02	-	0.24	0.27	-	1.95	-	0.48	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.86	0	0	5.61	-	4.62	0.95	0.74	6.51	-	1.99	4.23	0.3	6.02	-	0.24	0.27	-	1.95	-	0.48	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.86		30 500 ded 7500 OOP max		30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	100 per trip	30 500 ded 7500 OOP max		50 ER; 35 UC	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	30 500 ded 7500 OOP max	45 per script				30 500 ded 7500 OOP max		30 500 ded 7500 OOP max															14.5		0.84	0.1	0.07	0.92		0.21	0.98	0.53	1.57	0	0.26	0.42	0.7	4.34	0	0.27	0	0	0.11				0.07		0															25.89	500	9.23	20.11	-	5.46	1.05	0.81	7.43	-	2.2	5.21	0.84	7.6	-	0.5	0.69	0.7	6.29	-	0.75	-	-	1.05	-	-	-	0.07	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.76
H5510_006_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-	5000	1786.98		821.61	572.36	89.54	32.76		500.63	255.34	183.18	1535.36	0	143.55	160.77	1228.72	1178.44	0	290.45	0	0	252.43				560.17		51.78															50/day 1-8		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	10 per visit	10 X-ray; 100 CATPETMRI	10 per visit	10 per visit	10 per visit	0 per visit	10 per visit	10 per visit	10 per visit	10 per visit	10 per visit	45 per script				0 per visit		0 per visit															37.9		67.84	20	100	0.2		48	200	10	40.78	10	10	10	0	10	10	10	10	10	45				0		0															5.64	-	4.64	0.95	0.75	6.55	-	2	4.26	0.15	5.22	-	0.12	0.13	-	0.98	-	0.24	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.59	0	0	5.64	-	4.64	0.95	0.75	6.55	-	2	4.26	0.15	5.22	-	0.12	0.13	-	0.98	-	0.24	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.59		20 150 ded 5000 OOP max		20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	100 per trip	20 150 ded 5000 OOP max		50 ER; 35 UC	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	20 150 ded 5000 OOP max	45 per script				20 150 ded 5000 OOP max		20 150 ded 5000 OOP max															9.16		0.53	0.06	0.07	0.58		0.18	0.62	0.34	0.99	0	0.17	0.27	0.44	2.74	0	0.17	0	0	0.09				0.04		0															16.45	150	6.03	14.81	-	5.17	1.02	0.81	7.13	-	2.18	4.88	0.49	6.21	-	0.29	0.4	0.44	3.72	-	0.41	-	-	1.04	-	-	-	0.04	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.05
H5510_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30	30	30	30	150	30	30	50	30	30	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0	0	0	0.13	0	0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H5510_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9				0		0															200/day 1-7	200/day 1-7	100/day 1-100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20				Not Covered		0															143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30	30	30	30	150	30	30	50	30	30	30	30	30	30	30	30	30	30	30	30	20				30		30															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0	0	0	0.13	0	0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
H5512_001_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1630.48		953.45	868.58	222.32	20.78		421.86	225.41	980.12	1518.04		44.01	425.78	2551.84	5683.33		1437.12			225.64				720.86		44.54															150 / day 1-8		0/day 1-5 75/day 6-14 100/day 15-100	35	100	20		50 ER  25 urgent care	100	35	35 routine 100 complex	35	30	35	25	35 Specialist 30 Renal Dialysis	35	35	35	35	45				0		0															113.69		73.07	35	100	0.2		46.75	100	35	57.23	35	30	35	25	34.42	35	35	35	35	45				0		0															15.45	-	5.81	2.53	1.85	4.16	-	1.64	1.88	2.86	7.24	-	0.11	1.24	5.32	16.3	-	4.19	-	-	0.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.42			15.45	-	5.81	2.53	1.85	4.16	-	1.64	1.88	2.86	7.24	-	0.11	1.24	5.32	16.3	-	4.19	-	-	0.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.42		30		30	30	100	20		50 ER 25 Urgent Care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45				30		30															10.15		0.98	0.17	0.2	0.47		0.17	0.98	0.46	2.08	0	0.44	0.42	0.82	6.12	0	0.36	0	0	0.12				0.11		0.01															24.06	1000	13.09	25.6	-	6.78	2.71	2.05	4.62	-	1.81	2.86	3.32	9.32	-	0.56	1.66	6.13	22.42	-	4.56	-	-	0.97	-	-	-	0.11	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.49
H5512_002_0	2007	6																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	3500	1640.84		959.51	874.09	223.73	20.91		424.54	226.85	986.34	1527.68		44.29	428.49	2568.05	5719.43		1446.25			227.08				725.44		44.83															150 / day 1-8		0/day 1-5 75/day 6-14 100/day 15-100	35	100	20		50 ER 25 urgent care	100	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45				0		0															113.69		73.07	35	100	0.2		46.75	100	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															15.55	-	5.84	2.55	1.86	4.18	-	1.65	1.89	2.05	6.45	-	0.09	0.89	2.14	11.92	-	3.01	-	-	0.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.94			15.55	-	5.84	2.55	1.86	4.18	-	1.65	1.89	2.05	6.45	-	0.09	0.89	2.14	11.92	-	3.01	-	-	0.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.94		30		30	30	100	20		50 ER 25 Urgent Care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45				30		30															7.86		0.76	0.13	0.18	0.35		0.13	0.76	0.36	1.61	0	0.34	0.32	0.63	4.73	0	0.28	0	0	0.08				0.09		0															18.63	500	15.27	23.4	-	6.6	2.68	2.04	4.53	-	1.79	2.65	2.41	8.06	-	0.44	1.22	2.77	16.65	-	3.29	-	-	0.94	-	-	-	0.09	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	79.56
H5512_005_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1605.82		841.7	576.79	132.81	20.73		396.47	189.17	919.13	1291.52		135.06	357.32	2840.94	5284.43		1215.2			219.03				698.29		51.41															225 / day 1-8		0/day 1-5 75/day 6-14 100/day 15-100	35	100	20		50 ER  25urgent care	100	35	35 routine 100 complex	35	30	35	25	35 Specialist 30 Renal Dialysis	35	35	35	35	45				0		0															170.54		73.07	35	100	0.2		46.75	100	35	57.23	35	30	35	25	34.43	35	35	35	35	45				0		0															22.82	-	5.13	1.68	1.11	4.15	-	1.54	1.58	2.68	6.16	-	0.34	1.04	5.92	15.16	-	3.54	-	-	0.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.67			22.82	-	5.13	1.68	1.11	4.15	-	1.54	1.58	2.68	6.16	-	0.34	1.04	5.92	15.16	-	3.54	-	-	0.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.67		30		30	30	100	20		50 ER 25 Urgent Care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45				30		30															10.69		0.79	0.14	0.12	0.47		0.17	0.82	0.53	1.95	0	0.15	0.35	0.81	6.18	0	0.31	0	0	0.12				0.12		0.01															23.73	1000	13.09	33.51	-	5.92	1.82	1.23	4.62	-	1.72	2.4	3.21	8.11	-	0.48	1.39	6.72	21.34	-	3.86	-	-	0.94	-	-	-	0.12	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.4
H5512_006_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1639.67		859.44	588.95	135.61	21.17		404.82	193.16	938.51	1318.75		137.91	364.85	2900.83	5395.85		1240.82			223.65				713.01		52.49															175/ day 1-8		0/day 1-5 75/day 6-14 100/day 15-100	35	100	20		50 ER 25 urgent care	100	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45				0		0															132.64		73.07	35	100	0.2		46.75	100	25	50.65	25	25	25	10	25	25	25	25	25	45				0		0															18.12	-	5.23	1.72	1.13	4.23	-	1.58	1.61	1.96	5.57	-	0.29	0.76	2.42	11.24	-	2.59	-	-	0.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.28			18.12	-	5.23	1.72	1.13	4.23	-	1.58	1.61	1.96	5.57	-	0.29	0.76	2.42	11.24	-	2.59	-	-	0.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.28		30		30	30	100	20		50 ER 25 Urgent Care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45				30		30															9.73		0.72	0.13	0.11	0.41		0.15	0.75	0.48	1.78	0	0.13	0.32	0.73	5.63	0	0.28	0	0	0.1				0.11		0.01															21.57	500	12.53	27.86	-	5.96	1.85	1.24	4.65	-	1.73	2.35	2.43	7.35	-	0.42	1.08	3.15	16.87	-	2.87	-	-	0.93	-	-	-	0.11	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.85
H5512_008_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	7500	1964.47		1657.7	1249.26	247.12	24.61		406.21	173.32	698.77	943.66	0	0	327.38	2666.67	4555.94	0	878.48	0	0	267.71																					850/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per visit	35 per visit	35 X-ray; 20 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 dialysis	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.21	35	35	35	35	45																					22.7	-	9.37	2.08	2.06	4.92	-	1.62	2.89	2.04	5.17	-	-	0.95	4.44	12.99	-	2.56	-	-	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.81			22.7	-	9.37	2.08	2.06	4.92	-	1.62	2.89	2.04	5.17	-	-	0.95	4.44	12.99	-	2.56	-	-	1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.81		30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP		50 ER; 35 UC	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	45 per script				30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP															12.71		1.75	0.27	0.19	0.7		0.17	1.24	0.38	1.79	0	0	0.64	1.07	4.23	0	0.29	0	0	0.11				0.08		0.01															25.64	500	9.23	35.41	-	11.12	2.35	2.25	5.62	-	1.8	4.13	2.42	6.97	-	-	1.6	5.52	17.21	-	2.86	-	-	1.12	-	-	-	0.08	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.46
H5512_009_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	5000	2267.49		1913.39	1441.95	285.24	28.13		468.87	200.05	806.56	1089.22	0	0	377.88	3078	5258.7	0	1013.98	0	0	309.01																					300/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per visit	25 per visit	25 X-ray; 20 CAT PET MRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script																					48.94		67.84	20	100	0.2		48	200	25	59.2	25	25	25	10	25	25	25	25	25	45																					9.25	-	10.82	2.4	2.38	5.63	-	1.88	3.33	1.68	5.37	-	-	0.79	2.56	10.96	-	2.11	-	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.31			9.25	-	10.82	2.4	2.38	5.63	-	1.88	3.33	1.68	5.37	-	-	0.79	2.56	10.96	-	2.11	-	-	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.31		20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP		50 ER; 35 UC	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	45 per script				20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP															8.53		1.17	0.18	0.13	0.47		0.16	0.83	0.25	1.2	0	0	0.43	0.72	2.83	0	0.2	0	0	0.1				0.05		0															17.27	250	6.12	17.77	-	11.99	2.58	2.51	6.09	-	2.04	4.17	1.93	6.58	-	-	1.22	3.29	13.79	-	2.31	-	-	1.26	-	-	-	0.05	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.59
H5512_801_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1568.59		1388.23	878.85	199.97	20.28		379.39	261.93	13.15	61.92	0	0	494.76	2457.85	9003.46	0	1259.38	0	0	8.09																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.78	-	11.57	2.56	2.5	6.08	-	1.58	3.27	2.63	12.38	-	-	1.44	7.17	26.26	-	3.67	-	-	1.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.53			18.78	-	11.57	2.56	2.5	6.08	-	1.58	3.27	2.63	12.38	-	-	1.44	7.17	26.26	-	3.67	-	-	1.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.53		500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	150 per trip	500 deductible; 30 coins; no max OOP		50 per visit	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP				500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP															6.45		0.89	0.13	0.16	0.41		0.11	0.7	0.26	1.24	0	0	0.3	0.63	3.75	0	0.25	0	0	0.17				0.08		0															15.53	500		25.23	-	12.46	2.69	2.66	6.49	-	1.69	3.98	2.89	13.62	-	-	1.74	7.8	30.01	-	3.92	-	-	1.79	-	-	-	0.08	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	117.06
H5512_802_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1568.59		1388.23	878.85	199.97	20.28		379.39	261.93	13.15	61.92	0	0	494.76	2457.85	9003.46	0	1259.38	0	0	8.09																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.78	-	11.57	2.56	2.5	6.08	-	1.58	3.27	2.63	12.38	-	-	1.44	7.17	26.26	-	3.67	-	-	1.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.53			18.78	-	11.57	2.56	2.5	6.08	-	1.58	3.27	2.63	12.38	-	-	1.44	7.17	26.26	-	3.67	-	-	1.62	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.53		500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	150 per trip	500 deductible; 30 coins; no max OOP		50 per visit	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP				500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP															6.45		0.89	0.13	0.16	0.41		0.11	0.7	0.26	1.24	0	0	0.3	0.63	3.75	0	0.25	0	0	0.17				0.08		0															15.53	500		25.23	-	12.46	2.69	2.66	6.49	-	1.69	3.98	2.89	13.62	-	-	1.74	7.8	30.01	-	3.92	-	-	1.79	-	-	-	0.08	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	117.06
H5516_001_0	2007	6																					3950											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	6500	1521.29	126.59	531.68	0	90.44	11.94	4.64	422.82	40.19	11145.32	51.03	0	0.14	30.69	4488.6	5287.37	489.5	4.05	0	0	40.53	1139.37	0	0	175.99	0	198.28	0	0	0	0											325 (1a)	325 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											199.64	199.64	98.28	0	107.5	0.18	0.21	30.71	0.18	3.69	0.14	0	0.18	0.18	15	25	37.5	0.18	0	0	0.18	25	0	0	25	0	25	0	0	0	0											25.31	2.11	4.35	-	0.81	2.2	0.97	1.08	7.41	3.42	7.18	-	0.02	5.65	5.61	11.02	1.53	0.75	-	-	7.47	2.37	-	-	0.37	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.05		42.97	25.31	2.11	4.35	-	0.81	2.2	0.97	1.08	7.41	3.42	7.18	-	0.02	5.65	5.61	11.02	1.53	0.75	-	-	7.47	2.37	-	-	0.37	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.05		375 (1a)	375 (1b)	185 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											0.68	0.06	0.37	0.25	0.09	0.25	0.11	0.09	0.64	0.39	0.64	0	0	0.49	1.1	1.53	0.17	0.08	0	0	0	0.33	0	0	0.05	0	0.06	0	0	0	0											7.36		1.65	25.99	2.16	4.72	0.25	0.9	2.45	1.08	1.18	8.04	3.81	7.83	-	0.03	6.14	6.71	12.54	1.7	0.83	-	-	7.47	2.7	-	-	0.42	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.41
H5517_001_0	2007	3	h.6.	h.7.	i.6.	i.7.	g.2.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						D	D	D	Coin	T	Coin	Coin	V	V	P	P	Coin	Coin	Coin	V	V	V	V	P	P	Coin	P	T	V	V	P	V	P	P	P	P	P	P	P	P	V																																															-		2322	139.47			395.33	10.12	11.7	369.06	544.68						1958.12	8736.13	225.49	778.66		5.95	10.09				5.75						36.91											1a 150/admit	1b 150/admit			10a 25	11a 20	11b 20	4a 50	9a 509b 50						7a 10	17a 2018a 207b 207d 207f 20	7e 35	7c 157i 15		7g 20	20 11c 20				17a 20						14c 10											29.33	42.23			25	0.19	0.19	45	50						10	20	35	15		20	0.11				20						10											5.67	0.49	-	-	0.82	1.92	2.22	1.38	2.27	-	-	-	-	-	1.63	14.56	0.66	0.97	-	0.01	1.08	-	-	-	0.01	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	33.74			5.67	0.49	-	-	0.82	1.92	2.22	1.38	2.27	-	-	-	-	-	1.63	14.56	0.66	0.97	-	0.01	1.08	-	-	-	0.01	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	33.74		0.2		0.2	0	0	0	0	50	0	0	0.2	0.2	0.2	0	0	0.2	1	0	20	0.2	0.2	0.2													0.2							0.9		0.18	0.02	0.5	0.17	0.17	0.01	0.1	0.09	0.06	0	0	0.07	1.05	0.33	0	0.04	0.08	0.08	0.03	0													0.03							3.92	300		6.57	0.49	0.18	0.02	1.33	2.09	2.39	1.4	2.37	0.09	0.06	0	0	0.07	2.68	14.89	0.66	1.02	0.08	0.09	1.11	0	-	-	0.01	-	-	-	-	-	0.03	-	-	-	0.03	-	-	-	-	-	-	37.66
H5517_802_0	2007	4	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		256.05	3.58	29.34		9.24	10.3	11.91	12.43	52.56	25.29	44.94	1.68	0.67	26.7	126.01	54.83	1.48	10.09	49.33	8.52	38.48	0.31												0.09	16.13							Medicare FFS 8.0	Medicare FFS 8.0	Medicare FFS 20.5		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6												Medicare FFS 23.6	Medicare FFS 23.6							0.08	0.08	0.21		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							20.41	0.29	6.03	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.95			20.41	0.29	6.03	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.95		Medicare FFS 8.0		Medicare FFS 20.5		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6													Medicare FFS 23.6							0.23		0.11		0.37	0.12	0.13	0.02	0.08	0.07	0.04	0	0	0.05	0.78	0.24	0	0.03	0.06	0.06	0.02	0													0.02							2.45			20.63	0.29	6.14	-	2.56	2.55	2.94	2.96	12.48	6.03	10.65	0.4	0.16	6.35	30.52	13.18	0.35	2.41	11.7	2.07	9.1	0.08	-	-	-	-	-	-	-	-	-	-	-	0.02	3.82	-	-	-	-	-	-	147.4
H5517_804_0	2007	3	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		256.05	3.58	29.34		9.24	10.3	11.91	12.43	52.56	25.29	44.94	1.68	0.67	26.7	126.01	54.83	1.48	10.09	49.33	8.52	38.48	0.31												0.09	16.13							Medicare FFS 7.9	Medicare FFS 7.9	Medicare FFS 20.3		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6												Medicare FFS 23.6	Medicare FFS 23.6							0.08	0.08	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							20.34	0.28	5.96	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.81			20.34	0.28	5.96	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.81		Medicare FFS 7.9		Medicare FFS 20.3		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6													Medicare FFS 23.6							0.22		0.11		0.37	0.12	0.13	0.02	0.08	0.07	0.04	0	0	0.05	0.78	0.24	0	0.03	0.06	0.06	0.02	0													0.02							2.44			20.56	0.28	6.07	-	2.56	2.55	2.94	2.96	12.48	6.03	10.65	0.4	0.16	6.35	30.52	13.18	0.35	2.41	11.7	2.07	9.1	0.08	-	-	-	-	-	-	-	-	-	-	-	0.02	3.82	-	-	-	-	-	-	147.26
H5517_805_0	2007	3	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		256.05	3.58	29.34		9.24	10.3	11.91	12.43	52.56	25.29	44.94	1.68	0.67	26.7	126.01	54.83	1.48	10.09	49.33	8.52	38.48	0.31												0.09	16.13							Medicare FFS 8.0	Medicare FFS 8.0	Medicare FFS 20.5		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6												Medicare FFS 23.6	Medicare FFS 23.6							0.08	0.08	0.21		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							20.41	0.29	6.03	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.95			20.41	0.29	6.03	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.95		Medicare FFS 8.0		Medicare FFS 20.5		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6													Medicare FFS 23.6							0.23		0.11		0.37	0.12	0.13	0.02	0.08	0.07	0.04	0	0	0.05	0.78	0.24	0	0.03	0.06	0.06	0.02	0													0.02							2.45			20.63	0.29	6.14	-	2.56	2.55	2.94	2.96	12.48	6.03	10.65	0.4	0.16	6.35	30.52	13.18	0.35	2.41	11.7	2.07	9.1	0.08	-	-	-	-	-	-	-	-	-	-	-	0.02	3.82	-	-	-	-	-	-	147.4
H5517_806_0	2007	4	H.	H.	I.	I.	G.						OP Facility - Other	OP Facility - Other	Professional	Professional	OP Facility - Surgery							Radiology Copay	Lab Copay	Radiology Copay	Lab Copay	Transplant						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		256.05	3.58	29.34		9.24	10.3	11.91	12.43	52.56	25.29	44.94	1.68	0.67	26.7	126.01	54.83	1.48	10.09	49.33	8.52	38.48	0.31												0.09	16.13							Medicare FFS 8.0	Medicare FFS 8.0	Medicare FFS 20.5		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6												Medicare FFS 23.6	Medicare FFS 23.6							0.08	0.08	0.21		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24												0.24	0.24							20.41	0.29	6.03	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.95			20.41	0.29	6.03	-	2.18	2.43	2.81	2.93	12.4	5.97	10.61	0.4	0.16	6.3	29.74	12.94	0.35	2.38	11.64	2.01	9.08	0.07	-	-	-	-	-	-	-	-	-	-	-	0.02	3.81	-	-	-	-	-	-	144.95		Medicare FFS 8.0		Medicare FFS 20.5		Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6	Medicare FFS 23.6													Medicare FFS 23.6							0.23		0.11		0.37	0.12	0.13	0.02	0.08	0.07	0.04	0	0	0.05	0.78	0.24	0	0.03	0.06	0.06	0.02	0													0.02							2.45			20.63	0.29	6.14	-	2.56	2.55	2.94	2.96	12.48	6.03	10.65	0.4	0.16	6.35	30.52	13.18	0.35	2.41	11.7	2.07	9.1	0.08	-	-	-	-	-	-	-	-	-	-	-	0.02	3.82	-	-	-	-	-	-	147.4
H5520_001_0	2007	7																					1500											A	A	D	V	T	coin	coin	V	V	P	V	O	P	P	V	V	V	V	V	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	198.4	0.94	539.89	0	139.48	11.33	0.86	287.09	226.78	1395.61	769.8	0	14	55.17	4438.05	3808.76	8.08	169.01	723.67	182.39	0	264	0	557.6	157.08	0	0	0	0	0	590.57											Per Day: 100 (1-4)	Per Day: 100 (1-4)	Per Day: 100 (1-4)		25 per Ambulance Service	20 - 600 Copay (estimated to equivalent coin.)	20 - 600 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	200 ASC / 200 OP	0-10 Diagnostic Lab	20 - 600 per Visit		20 Copay	25 OP SA / 25 Cardiac Rehab	10 PCP	10 SCP / 15 Chiro / 25 Podiatrist	25 MH	25 Therapy	0-10 Simple X-Ray	10 Hearing / 10 Preventive		10 Vision		35 Ded 0 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											246.25	246.25	19.57	0	25	0.07	0.05	37.44	168.95	4.22	41.2	0	0.01	21.12	8.33	8.79	21.12	21.12	3.73	8.45	0	8.45	0	35	8.39	0	0	0	0	0	17											4.07	0.02	0.88	-	0.29	0.78	0.04	0.9	3.19	0.49	2.64	-	0	0.1	3.08	2.79	0.01	0.3	0.22	0.13	-	0.19	-	1.63	0.11	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	22.7	0	4.38	4.07	0.02	0.88	-	0.29	0.78	0.04	0.9	3.19	0.49	2.64	-	0	0.1	3.08	2.79	0.01	0.3	0.22	0.13	-	0.19	-	1.63	0.11	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	22.7	4500	Per Day: 200 (1-4)	Per Day: 200 (1-4)	Per Day: 200 (1-4)		25 per Ambulance Service	30 - 900 Copay (estimated to equivalent coin.)	30 - 900 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	400 ASC / 400 OP	20 Diagnostic Lab	30 - 900 per Visit		30 Copay	50 OP SA / 35 Cardiac Rehab	20 PCP	20 SCP / 50 Chiro / 35 Podiatrist	50 MH	35 Therapy	20 Simple X-Ray	20 Hearing / 20 Preventive		20 Vision		35 Ded 20 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											1.56	0.01	0.32	0	0.05	0.01	0	0.18	1.18	0.36	0.56	0	0	0.06	1.07	0.93	0.01	0.05	0.04	0.04	0	0.06	0	0.29	0.02	0	0	0	0	0	0.15											6.94	0	0.86	5.64	0.03	1.2	-	0.34	0.79	0.04	1.08	4.37	0.85	3.2	-	0	0.16	4.15	3.72	0.02	0.35	0.26	0.17	-	0.25	-	1.91	0.13	-	-	-	-	-	0.98	-	-	-	-	-	-	-	-	-	-	29.64
H5520_002_0	2007	9																					1950											A	A	D	V	T	coin	coin	V	V	P	V	O	P	P	V	V	V	V	V	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3000	198.41	0.94	539.9	0	139.48	11.33	0.86	287.09	226.79	1395.65	769.82	0	14	55.17	4438.16	3808.86	8.08	169.01	723.69	182.39	0	264.01	0	557.6	157.09	0	0	0	0	0	590.57											Per Day: 100 (1-4)	Per Day: 100 (1-4)	Per Day: 100 (1-4)		25 per Ambulance Service	20 - 600 Copay (estimated to equivalent coin.)	20 - 600 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	200 ASC / 200 OP	0-10 Diagnostic Lab	20 - 600 per Visit		20 Copay	25 OP SA / 25 Cardiac Rehab	10 PCP	10 SCP / 15 Chiro / 25 Podiatrist	25 MH	25 Therapy	0-10 Simple X-Ray	10 Hearing / 10 Preventive		10 Vision		35 Ded 0 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											261.56	261.56	20.79	0	25	0.07	0.05	39.75	179.45	4.49	43.76	0	0.01	22.43	8.86	9.33	22.43	22.43	3.96	8.97	0	8.97	0	35	9	0	0	0	0	0	17											4.32	0.02	0.94	-	0.29	0.78	0.04	0.95	3.39	0.52	2.81	-	0	0.1	3.28	2.96	0.02	0.32	0.24	0.14	-	0.2	-	1.63	0.12	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	23.89	0	3.18	4.32	0.02	0.94	-	0.29	0.78	0.04	0.95	3.39	0.52	2.81	-	0	0.1	3.28	2.96	0.02	0.32	0.24	0.14	-	0.2	-	1.63	0.12	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	23.89	4950	Per Day: 200 (1-4)	Per Day: 200 (1-4)	Per Day: 200 (1-4)		25 per Ambulance Service	30 - 900 Copay (estimated to equivalent coin.)	30 - 900 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	400 ASC / 400 OP	20 Diagnostic Lab	30 - 900 per Visit		30 Copay	50 OP SA / 35 Cardiac Rehab	20 PCP	20 SCP / 50 Chiro / 35 Podiatrist	50 MH	35 Therapy	20 Simple X-Ray	20 Hearing / 20 Preventive		20 Vision		35 Ded 20 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											1.56	0.01	0.32	0	0.05	0.01	0	0.18	1.18	0.36	0.56	0	0	0.06	1.07	0.93	0.01	0.05	0.04	0.04	0	0.06	0	0.29	0.02	0	0	0	0	0	0.15											6.94	0	0.86	5.89	0.03	1.25	-	0.34	0.79	0.04	1.13	4.57	0.88	3.37	-	0	0.16	4.34	3.89	0.02	0.37	0.27	0.18	-	0.26	-	1.91	0.14	-	-	-	-	-	0.98	-	-	-	-	-	-	-	-	-	-	30.83
H5520_003_0	2007	7																					1750											A	A	D	V	T	coin	coin	V	V	P	V	O	P	P	V	V	V	V	V	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3250	224.95	1.07	605.88	0	158.14	12.84	0.97	325.5	257.13	1582.35	872.8	0	14	62.56	4742.42	4078.61	9.16	191.62	820.5	193.87	0	280.62	0	557.6	165.79	0	0	0	0	0	590.57											Per Day: 100 (1-7)	Per Day: 100 (1-7)	Per Day: 100 (1-7)		25 per Ambulance Service	20 - 600 Copay (estimated to equivalent coin.)	20 - 600 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	200 ASC / 200 OP	0-20 Diagnostic Lab	20 - 600 per Visit		20 Copay	25 OP SA / 25 Cardiac Rehab	20 PCP	20 SCP / 15 Chiro / 25 Podiatrist	25 MH	25 Therapy	0-20 Simple X-Ray	20 Hearing / 20 Preventive		20 Vision		35 Ded 0 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											294.71	294.71	30.02	0	25	0.09	0.05	34.87	157.34	7.87	37.77	0	0.01	19.67	14.99	15.9	19.67	19.67	3.47	15.73	0	15.73	0	35	7.79	0	0	0	0	0	17											5.52	0.03	1.52	-	0.33	1.15	0.05	0.95	3.37	1.04	2.75	-	0	0.1	5.92	5.41	0.02	0.31	0.24	0.25	-	0.37	-	1.63	0.11	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	31.89	0	9.48	5.52	0.03	1.52	-	0.33	1.15	0.05	0.95	3.37	1.04	2.75	-	0	0.1	5.92	5.41	0.02	0.31	0.24	0.25	-	0.37	-	1.63	0.11	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	31.89	5000	Per Day: 200 (1-7)	Per Day: 200 (1-7)	Per Day: 200 (1-7)		25 per Ambulance Service	30 - 900 Copay (estimated to equivalent coin.)	30 - 900 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	400 ASC / 400 OP	30 Diagnostic Lab	30 - 900 per Visit		30 Copay	50 OP SA / 35 Cardiac Rehab	35 PCP	35 SCP / 50 Chiro / 35 Podiatrist	50 MH	35 Therapy	30 Simple X-Ray	35 Hearing / 35 Preventive		35 Vision		35 Ded 20 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											2.14	0.01	0.55	0	0.06	0.01	0	0.19	1.25	0.58	0.58	0	0	0.06	1.91	1.66	0.01	0.06	0.04	0.08	0	0.12	0	0.29	0.02	0	0	0	0	0	0.15											9.75	0	1.91	7.67	0.04	2.06	-	0.39	1.16	0.05	1.14	4.63	1.62	3.32	-	0	0.17	7.83	7.06	0.02	0.37	0.27	0.34	-	0.49	-	1.91	0.13	-	-	-	-	-	0.98	-	-	-	-	-	-	-	-	-	-	41.64
H5520_004_0	2007	9																					2000											A	A	D	V	T	coin	coin	V	V	P	V	O	P	P	V	V	V	V	V	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	3500	224.96	1.07	605.91	0	158.15	12.84	0.97	325.51	257.14	1582.41	872.83	0	14	62.56	4742.61	4078.78	9.16	191.63	820.53	193.88	0	280.63	0	557.6	165.8	0	0	0	0	0	590.57											Per Day: 100 (1-7)	Per Day: 100 (1-7)	Per Day: 100 (1-7)		25 per Ambulance Service	20 - 600 Copay (estimated to equivalent coin.)	20 - 600 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	200 ASC / 200 OP	0-20 Diagnostic Lab	20 - 600 per Visit		20 Copay	25 OP SA / 25 Cardiac Rehab	20 PCP	20 SCP / 15 Chiro / 25 Podiatrist	25 MH	25 Therapy	0-20 Simple X-Ray	20 Hearing / 20 Preventive		20 Vision		35 Ded 0 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											306.29	306.29	31.2	0	25	0.09	0.05	36.24	163.52	8.18	39.25	0	0.01	20.44	15.59	16.53	20.44	20.44	3.61	16.35	0	16.35	0	35	8.13	0	0	0	0	0	17											5.74	0.03	1.58	-	0.33	1.15	0.05	0.98	3.5	1.08	2.85	-	0	0.11	6.16	5.62	0.02	0.33	0.25	0.26	-	0.38	-	1.63	0.11	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	32.99	0	8.2	5.74	0.03	1.58	-	0.33	1.15	0.05	0.98	3.5	1.08	2.85	-	0	0.11	6.16	5.62	0.02	0.33	0.25	0.26	-	0.38	-	1.63	0.11	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	32.99	5500	Per Day: 200 (1-7)	Per Day: 200 (1-7)	Per Day: 200 (1-7)		25 per Ambulance Service	30 - 900 Copay (estimated to equivalent coin.)	30 - 900 Copay (estimated to equivalent coin.)	50 ER/ 25 UC	400 ASC / 400 OP	30 Diagnostic Lab	30 - 900 per Visit		30 Copay	50 OP SA / 35 Cardiac Rehab	35 PCP	35 SCP / 50 Chiro / 35 Podiatrist	50 MH	35 Therapy	30 Simple X-Ray	35 Hearing / 40 Preventive		35 Vision		35 Ded 20 Coin	10 Routine Vision / Eyewear 100 Max in 2 yrs						15 Accup / 25 Message Thera											2.18	0.01	0.56	0	0.06	0.01	0	0.2	1.28	0.59	0.59	0	0	0.07	1.95	1.69	0.01	0.06	0.04	0.08	0	0.12	0	0.29	0.02	0	0	0	0	0	0.15											9.93	0	1.72	7.92	0.04	2.13	-	0.39	1.16	0.05	1.18	4.78	1.67	3.44	-	0	0.17	8.11	7.31	0.02	0.38	0.28	0.35	-	0.5	-	1.91	0.13	-	-	-	-	-	0.98	-	-	-	-	-	-	-	-	-	-	42.92
H5520_005_0	2007	9																					3100											A	A	D	V	T	coin	coin	V	coin	P	V	O	P	coin	V	V	V	coin	V	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	6200	198.43	0.94	528.95	0	139.5	11.33	0.86	277.69	18.56	1395.82	769.91	0	14	17.44	4322.21	4206.01	8.08	2.98	723.78	176.71	0	255.79	0	0	151.96	0	0	0	0	0	590.57											Per Day: 200 (1-10)	Per Day: 200 (1-10)	Per Day: 100 (1-10)		150 per Ambulance Service	30 of Contract Rate	30 of Contract Rate	50 ER/ 50 UC	30 Contracted Rate	0-15 Diagnostic Lab	20 - 600 per Visit		20 Copay	40 OP SA / 25 Cardiac Rehab	15 PCP	15 SCP / 15 Chiro / 25 Podiatrist	40 MH	30 of Contract Rate	0-15 Simple X-Ray	15 Hearing / 15 Preventive		15 Vision			15 Routine Vision / Eyewear Not Covered						15 Accup / 25 Message Thera											721.84	721.84	44.14	0	150	0.32	0.3	43.55	0.26	6.53	42.12	0	0.01	0.05	13.83	26.43	34.82	0.26	3.84	13.06	0	13.06	0	0	10.61	0	0	0	0	0	17											11.94	0.06	1.95	-	1.74	3.61	0.26	1.01	4.85	0.76	2.7	-	0	0.79	4.98	9.26	0.02	0.78	0.23	0.19	-	0.28	-	-	0.13	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	46.37	0	6.9	11.94	0.06	1.95	-	1.74	3.61	0.26	1.01	4.85	0.76	2.7	-	0	0.79	4.98	9.26	0.02	0.78	0.23	0.19	-	0.28	-	-	0.13	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	46.37	9300	Per Day: 400 (1-10)	Per Day: 400 (1-10)	Per Day: 200 (1-10)		150 per Ambulance Service	30 of Contract Rate	30 of Contract Rate	50 ER/ 50 UC	40 Contracted Rate	30 Diagnostic Lab	30 - 900 per Visit		30 Copay	40 OP SA / 35 Cardiac Rehab	30 PCP	30 SCP / 50 Chiro / 35 Podiatrist	40 MH	40 Contracted Rate	30 Simple X-Ray	30 Hearing / 30 Preventive		30 Vision			30 Routine Vision / Eyewear 40						15 Accup / 25 Message Thera											4.68	0.02	0.72	0	0.31	0.02	0	0.19	1.02	0.57	0.57	0	0	0.2	1.67	2.32	0	0.07	0.04	0.07	0	0.1	0	0	0.06	0	0	0	0	0	0.15											12.78	0	0.95	16.62	0.08	2.66	-	2.05	3.63	0.26	1.2	5.87	1.33	3.27	-	0	0.99	6.65	11.58	0.03	0.85	0.27	0.26	-	0.38	-	-	0.19	-	-	-	-	-	0.98	-	-	-	-	-	-	-	-	-	-	59.15
H5520_006_0	2007	8																					3100											A	A	D	V	T	coin	coin	V	coin	P	V	O	P	coin	V	V	V	coin	V	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	6200	225.01	1.07	599.79	0	158.19	12.85	0.97	314.89	21.05	1582.76	873.03	0	14	19.77	4901.09	4769.33	9.17	3.38	820.71	200.38	0	290.05	0	0	172.32	0	0	0	0	0	590.57											Per Day: 200 (1-10)	Per Day: 200 (1-10)	Per Day: 100 (1-10)		150 per Ambulance Service	30 of Contract Rate	30 of Contract Rate	50 ER/ 50 UC	30 Contracted Rate	0-15 Diagnostic Lab	20 - 600 per Visit		20 Copay	40 OP SA / 25 Cardiac Rehab	15 PCP	15 SCP / 15 Chiro / 25 Podiatrist	40 MH	30 of Contract Rate	0-15 Simple X-Ray	15 Hearing / 15 Preventive		15 Vision			15 Routine Vision / Eyewear Not Covered						15 Accup / 25 Message Thera											700.71	700.71	42.85	0	150	0.32	0.3	42.27	0.25	6.34	40.89	0	0.01	0.04	13.43	25.65	33.8	0.25	3.73	12.68	0	12.68	0	0	10.24	0	0	0	0	0	17											13.14	0.06	2.14	-	1.98	4.09	0.29	1.11	5.34	0.84	2.97	-	0	0.87	5.48	10.2	0.03	0.86	0.25	0.21	-	0.31	-	-	0.15	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	51.14	0	9.39	13.14	0.06	2.14	-	1.98	4.09	0.29	1.11	5.34	0.84	2.97	-	0	0.87	5.48	10.2	0.03	0.86	0.25	0.21	-	0.31	-	-	0.15	-	-	-	-	-	0.84	-	-	-	-	-	-	-	-	-	-	51.14	9300	Per Day: 400 (1-10)	Per Day: 400 (1-10)	Per Day: 200 (1-10)		150 per Ambulance Service	30 of Contract Rate	30 of Contract Rate	50 ER/ 50 UC	40 Contracted Rate	30 Diagnostic Lab	30 - 900 per Visit		30 Copay	40 OP SA / 35 Cardiac Rehab	30 PCP	30 SCP / 50 Chiro / 35 Podiatrist	40 MH	40 Contracted Rate	30 Simple X-Ray	30 Hearing / 30 Preventive		30 Vision			30 Routine Vision / Eyewear 40						15 Accup / 25 Message Thera											5.22	0.02	0.8	0	0.35	0.02	0	0.21	1.14	0.64	0.64	0	0	0.22	1.86	2.59	0	0.08	0.04	0.08	0	0.11	0	0	0.07	0	0	0	0	0	0.15											14.23	0	1.31	18.36	0.09	2.94	-	2.33	4.11	0.3	1.32	6.47	1.47	3.61	-	0	1.09	7.34	12.78	0.03	0.94	0.3	0.29	-	0.42	-	-	0.21	-	-	-	-	-	0.98	-	-	-	-	-	-	-	-	-	-	65.37
H5520_801_0	2007	1																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	151.22	0.39	12.64	0	6.26	11.67	0.88	4.64	19.13	9.36	22.34	0	0.11	17.96	32.67	97.51	0.14	3.14	19.48	11.89	15.31	1.62	0	0	0	0	0	0	0	0	0											Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				0.07	0.07	0.14	0	0.24	0.24	0.24	0.24	0.24	0.13	0.36	0	0.24	0.13	0.23	0.24	0.24	0.24	0.22	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.01	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.36	0	0	11.01	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.36	none	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				2.46	0.01	0.46	0	0.17	0.01	0	0.16	0.67	0.13	1.13	0	0	0.19	1.03	3	0	0.05	0.43	0.08	0.36	0.06	0	0	0	0	0	0	0	0	0											10.43	0	0	13.47	0.04	2.19	-	1.65	2.77	0.21	1.26	5.18	1.33	9.24	-	0.03	2.49	8.55	26.49	0.04	0.81	4.7	2.94	3.97	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.8
H5520_803_0	2007	2																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	151.98	0.39	12.64	0	6.26	11.67	0.88	4.64	19.13	9.36	22.34	0	0.11	17.96	32.67	97.51	0.14	3.14	19.48	11.89	15.31	1.62	0	0	0	0	0	0	0	0	0											Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				0.07	0.07	0.14	0	0.24	0.24	0.24	0.24	0.24	0.13	0.36	0	0.24	0.13	0.23	0.24	0.24	0.24	0.22	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.07	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.42	0	0	11.07	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.42	none	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				2.47	0.01	0.46	0	0.17	0.01	0	0.16	0.67	0.13	1.13	0	0	0.19	1.03	3	0	0.05	0.43	0.08	0.36	0.06	0	0	0	0	0	0	0	0	0											10.45	0	0	13.54	0.04	2.19	-	1.65	2.77	0.21	1.26	5.18	1.33	9.24	-	0.03	2.49	8.55	26.49	0.04	0.81	4.7	2.94	3.97	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.86
H5520_804_0	2007	1																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	151.22	0.39	12.64	0	6.26	11.67	0.88	4.64	19.13	9.36	22.34	0	0.11	17.96	32.67	97.51	0.14	3.14	19.48	11.89	15.31	1.62	0	0	0	0	0	0	0	0	0											Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				0.07	0.07	0.14	0	0.24	0.24	0.24	0.24	0.24	0.13	0.36	0	0.24	0.13	0.23	0.24	0.24	0.24	0.22	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.01	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.36	0	0	11.01	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.36	none	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				2.46	0.01	0.46	0	0.17	0.01	0	0.16	0.67	0.13	1.13	0	0	0.19	1.03	3	0	0.05	0.43	0.08	0.36	0.06	0	0	0	0	0	0	0	0	0											10.43	0	0	13.47	0.04	2.19	-	1.65	2.77	0.21	1.26	5.18	1.33	9.24	-	0.03	2.49	8.55	26.49	0.04	0.81	4.7	2.94	3.97	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.8
H5520_806_0	2007	2																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	151.98	0.39	12.64	0	6.26	11.67	0.88	4.64	19.13	9.36	22.34	0	0.11	17.96	32.67	97.51	0.14	3.14	19.48	11.89	15.31	1.62	0	0	0	0	0	0	0	0	0											Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				0.07	0.07	0.14	0	0.24	0.24	0.24	0.24	0.24	0.13	0.36	0	0.24	0.13	0.23	0.24	0.24	0.24	0.22	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											11.07	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.42	0	0	11.07	0.03	1.73	-	1.48	2.75	0.21	1.09	4.51	1.2	8.1	-	0.03	2.3	7.52	23.49	0.03	0.76	4.26	2.86	3.61	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.42	none	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit		Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit	Medicare FFS Benefit																				2.47	0.01	0.46	0	0.17	0.01	0	0.16	0.67	0.13	1.13	0	0	0.19	1.03	3	0	0.05	0.43	0.08	0.36	0.06	0	0	0	0	0	0	0	0	0											10.45	0	0	13.54	0.04	2.19	-	1.65	2.77	0.21	1.26	5.18	1.33	9.24	-	0.03	2.49	8.55	26.49	0.04	0.81	4.7	2.94	3.97	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.86
H5521_002_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	7500	1498.99		1103.39	701.13	157.95	15.95		365.98	300.03	683.58	1041.09	0	4.07	565.37	3037.98	3519.94	0	844.51	0	0	224.23																					800/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per proc	35 per visit	35 X-ray; 100 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 diailysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					130.5		67.84	20	100	0.2		48	200	35	57.23	35	30	35	20	33.98	35	35	35	35	45																					16.3	-	6.24	1.17	1.32	3.19	-	1.46	5	1.99	4.97	-	0.01	1.65	5.06	9.97	-	2.46	-	-	0.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.63			16.3	-	6.24	1.17	1.32	3.19	-	1.46	5	1.99	4.97	-	0.01	1.65	5.06	9.97	-	2.46	-	-	0.84	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.63		30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP		50 ER; 35 UC	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	45 per script				30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP															10.14		1.25	0.12	0.16	0.53		0.16	1.16	0.38	1.73	0	0	0.5	0.88	3.62	0	0.29	0	0	0.11				0.07		0															21.11	500	9.23	26.44	-	7.49	1.29	1.48	3.72	-	1.63	6.16	2.37	6.69	-	0.01	2.15	5.95	13.58	-	2.75	-	-	0.95	-	-	-	0.07	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.75
H5521_003_0	2007	6																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	5000	1543.08		1135.84	721.75	162.59	16.14		376.74	308.85	703.69	1071.71	0	4.18	582	3127.33	3623.46	0	869.35	0	0	230.83																					350/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	20 per visit	20 X-ray; 100 CAT PET MRI	20 per visit	20 per visit	20 per visit	10 per visit	20 per visit	20 per visit	20 per visit	20 per visit	20 per visit	45 per script																					57.09		67.84	20	100	0.2		48	200	20	47.36	20	20	20	10	20	20	20	20	20	45																					7.34	-	6.42	1.2	1.35	3.23	-	1.51	5.15	1.17	4.23	-	0.01	0.97	2.61	6.04	-	1.45	-	-	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.54			7.34	-	6.42	1.2	1.35	3.23	-	1.51	5.15	1.17	4.23	-	0.01	0.97	2.61	6.04	-	1.45	-	-	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.54		20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP		50 ER; 35 UC	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	45 per script				20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP															6.73		0.83	0.08	0.11	0.35		0.16	0.77	0.25	1.15	0	0	0.33	0.59	2.4	0	0.19	0	0	0.1				0.05		0															14.09	250	6.12	14.07	-	7.25	1.29	1.46	3.58	-	1.66	5.92	1.42	5.38	-	0.01	1.3	3.19	8.44	-	1.64	-	-	0.97	-	-	-	0.05	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.63
H5521_005_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	7500	1670.8		1031.4	1369.68	183.91	19.44		404.43	343.73	787.32	902.54	0	0	649.26	3296.78	4288.22	0	1326.34	0	0	236.59																					850/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per visit	35 per visit	35 X-ray; 125 CAT PET MRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script																					138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.16	35	35	35	35	45																					19.31	-	5.83	2.28	1.53	3.89	-	1.62	5.73	2.3	4.95	-	-	1.89	5.49	12.21	-	3.87	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.78			19.31	-	5.83	2.28	1.53	3.89	-	1.62	5.73	2.3	4.95	-	-	1.89	5.49	12.21	-	3.87	-	-	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.78		30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP		50 ER; 35 UC	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	45 per script				30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP															12.25		1.26	0.28	0.19	0.63		0.18	1.57	0.54	1.78	0	0	0.67	0.97	4.27	0	0.4	0	0	0.11				0.08		0.01															25.18	500	9.23	31.55	-	7.09	2.56	1.72	4.51	-	1.8	7.29	2.84	6.73	-	-	2.56	6.47	16.48	-	4.26	-	-	1	-	-	-	0.08	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	96.96
H5521_006_0	2007	6																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	5000	1662		1025.97	1362.47	182.94	19.51	0	402.3	341.92	783.18	897.79	0	0	645.84	3279.43	4265.65	0	1319.36	0	0	235.34																					350/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance	0	50 ER; 35 UC	0	25 per visit	25 X-ray; 100 CAT PET MRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script																					57.09		67.84	20	100	0.2		48	200	25	47.36	25	25	25	10	25	25	25	25	25	45																					7.91	-	5.8	2.27	1.52	3.9	-	1.61	5.7	1.63	3.54	-	-	1.35	2.73	8.89	-	2.75	-	-	0.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.48			7.91	-	5.8	2.27	1.52	3.9	-	1.61	5.7	1.63	3.54	-	-	1.35	2.73	8.89	-	2.75	-	-	0.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.48		20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP		50 ER; 35 UC	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	45 per script				20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP															8.08		0.83	0.18	0.12	0.41		0.17	1.03	0.36	1.18	0	0	0.44	0.64	2.82	0	0.26	0	0	0.1				0.05		0															16.7	250	6.12	15.99	-	6.63	2.46	1.65	4.31	-	1.78	6.73	1.99	4.72	-	-	1.79	3.38	11.7	-	3.01	-	-	0.98	-	-	-	0.05	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.18
H5521_008_0	2007	4																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	7500	2527.03		1625.49	1221.53	273.92	24.88		547.74	279.59	620.41	843.08	0	0	528.06	3858.29	4851.12	0	404.84	0	0	287.31																					800/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	0	30 per visit	30 X-ray; 100 CAT PET MRI	30 per visit	30 per visit	30 per visit	0 per visit	30 per visit	30 per visit	30 per visit	30 per visit	30 per visit	45 per script																					130.5		67.84	20	100	0.2		48	200	30	57.23	30	30	30	0	30	30	30	30	30	45																					27.48	-	9.19	2.04	2.28	4.98	-	2.19	4.66	1.55	4.02	-	-	1.32	-	12.13	-	1.01	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.92			27.48	-	9.19	2.04	2.28	4.98	-	2.19	4.66	1.55	4.02	-	-	1.32	-	12.13	-	1.01	-	-	1.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.92		30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP		50 ER; 35 UC	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	30 coins; 500ded; 7500 max OOP	45 per script				30 coins; 500ded; 7500 max OOP		30 coins; 500ded; 7500 max OOP															14.4		1.65	0.23	0.21	0.7		0.21	1.34	0.47	1.83	0	0	0.57	1.18	4.29	0	0.19	0	0	0.12				0.08		0.01															27.49	500	9.23	41.88	-	10.84	2.26	2.49	5.67	-	2.41	6	2.02	5.85	-	-	1.89	1.18	16.42	-	1.2	-	-	1.2	-	-	-	0.08	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.41
H5521_009_0	2007	8																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-	5000	2516.3		1618.58	1216.34	272.76	24.77		545.41	278.4	617.78	839.49	0	0	525.82	3841.89	4830.51	0	403.12	0	0	286.09																					350/admission		0 days 1-7 75 days 8-14; 100 15+	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	0	20 per visit	20 X-ray; 100 CAT PET MRI	20 per visit	20 per visit	20 per visit	10 per visit	20 per visit	20 per visit	20 per visit	20 per visit	20 per visit	45 per script																					57.09		67.84	20	100	0.2		48	200	20	47.36	20	20	20	10	20	20	20	20	20	45																					11.97	-	9.15	2.03	2.27	4.95	-	2.18	4.64	1.03	3.31	-	-	0.88	3.2	8.05	-	0.67	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.41			11.97	-	9.15	2.03	2.27	4.95	-	2.18	4.64	1.03	3.31	-	-	0.88	3.2	8.05	-	0.67	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.41		20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP		50 ER; 35 UC	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	20 coins; 250ded; 5000 max OOP	45 per script				20 coins; 250ded; 5000 max OOP		20 coins; 250ded; 5000 max OOP															9.45		1.09	0.15	0.14	0.46		0.2	0.88	0.31	1.2	0	0	0.38	0.77	2.81	0	0.13	0	0	0.11				0.05		0.01															18.13	250	6.12	21.42	-	10.24	2.18	2.41	5.41	-	2.38	5.52	1.34	4.51	-	-	1.25	3.97	10.86	-	0.8	-	-	1.18	-	-	-	0.05	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.54
H5521_801_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1861.3		1258.05	1223.97	236.91	19.66		419.52	333.44	12.68	64.07	0	0	629.84	3066.73	7081.51	0	639.63	0	0	8.03				609.55		69.84															200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance				0 per visit		0 per visit															143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															22.29	-	10.48	3.57	2.96	5.9	-	1.75	4.17	2.54	12.81	-	-	1.84	8.94	20.65	-	1.87	-	-	1.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.37			22.29	-	10.48	3.57	2.96	5.9	-	1.75	4.17	2.54	12.81	-	-	1.84	8.94	20.65	-	1.87	-	-	1.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.37		500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	150 per trip	500 deductible; 70 coins; no max OOP		50 per visit	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP				500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP															8.15		0.97	0.17	0.19	0.39		0.12	0.88	0.25	1.27	0	0	0.38	0.71	2.62	0	0.17	0	0	0.12				0.05		0.01															16.46	500		30.44	-	11.45	3.74	3.16	6.29	-	1.87	5.05	2.79	14.09	-	-	2.22	9.65	23.27	-	2.03	-	-	1.73	-	-	-	0.05	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	117.83
H5521_802_0	2007	1																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1861.3		1258.05	1223.97	236.91	19.66		419.52	333.44	12.68	64.07	0	0	629.84	3066.73	7081.51	0	639.63	0	0	8.03				609.55		69.84															200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance				0 per visit		0 per visit															143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2				0		0															22.29	-	10.48	3.57	2.96	5.9	-	1.75	4.17	2.54	12.81	-	-	1.84	8.94	20.65	-	1.87	-	-	1.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.37			22.29	-	10.48	3.57	2.96	5.9	-	1.75	4.17	2.54	12.81	-	-	1.84	8.94	20.65	-	1.87	-	-	1.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.37		500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	150 per trip	500 deductible; 70 coins; no max OOP		50 per visit	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP				500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP															8.15		0.97	0.17	0.19	0.39		0.12	0.88	0.25	1.27	0	0	0.38	0.71	2.62	0	0.17	0	0	0.12				0.05		0.01															16.46	500		30.44	-	11.45	3.74	3.16	6.29	-	1.87	5.05	2.79	14.09	-	-	2.22	9.65	23.27	-	2.03	-	-	1.73	-	-	-	0.05	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	117.83
H5522_001_0	2007	6	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-	3000			951.51		295.29			296							3741.44	4746.24	1295.01	638.91		6.01	1030.72				132.42						213.47													2 40 days 21-100		10a 25			4a 50							7a 10	16b 2517a 2518a 257b 257d 257f 257b 25	7e 257h 259c 25	7c 157i 15		7g 25	0.2				17a 25						14c 107f 25													12.81		23.39			42.11							9.36	23.39	23.39	14.04		23.39	7.11				25						23.18											-	-	1.02	-	0.58	-	-	1.04	-	-	-	-	-	-	2.92	9.25	2.52	0.75	-	0.01	0.61	-	-	-	0.28	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	19.38		1.31	-	-	1.02	-	0.58	-	-	1.04	-	-	-	-	-	-	2.92	9.25	2.52	0.75	-	0.01	0.61	-	-	-	0.28	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	19.38		0.2	20	0.2	0	0	0	0	50	0	0	0.2	0.2	0.2	0	0	0.2	1	0	20	0.2	0.2	0.2			0.2	0.2	0	0		0.5	0.2				0.2							2.26	0.07	0.25	0.18	0.07	0.09	0.05	0.04	0.23	0.02	0.24	0.01	0.01	0.14	0.16	0.99	0.1	0.04	0.33	0.12	0.29	0			0.01	0.03		0.02		0.18	0.01				0.05							5.99	300	3.92	2.26	0.07	1.27	0.18	0.65	0.09	0.05	1.08	0.23	0.02	0.24	0.01	0.01	0.14	3.08	10.24	2.62	0.79	0.33	0.14	0.9	0	-	-	0.28	0.03	-	0.02	-	0.18	0.42	-	-	-	0.05	-	-	-	-	-	-	25.37
H5522_002_0	2007	6	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-	2000			951.51		295.29			296							3741.44	4746.24	1295.01			6.01	1030.72				132.42						213.47													2 25 days 21-100		10a 25			4a 50							7a 10	16b 2017a 2018a 207b 207d 207f 207b 20	7e 257h 259c 25			7g 20	0.2				17a 20						14c 107f 20													6.98		23.05			41.48							9.22	18.44	23.05			18.44	3.95				20						18.3											-	-	0.55	-	0.57	-	-	1.02	-	-	-	-	-	-	2.87	7.29	2.49	-	-	0.01	0.34	-	-	-	0.22	-	-	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	15.69		1.31	-	-	0.55	-	0.57	-	-	1.02	-	-	-	-	-	-	2.87	7.29	2.49	-	-	0.01	0.34	-	-	-	0.22	-	-	-	-	-	0.33	-	-	-	-	-	-	-	-	-	-	15.69		0.2	20	0.2	0	0	0	0	50	0	0	0.2	0.2	0.2	0	0	0.2	1	0	20	0.2	0.2	0.2			0.2	0.2		0		0.5	0.2				0.2							1.74	0.05	0.19	0.19	0.06	0.07	0.04	0.03	0.18	0.02	0.18	0.01	0	0.11	0.13	0.76	0.08	0.03	0.25	0.1	0.23	0			0.01	0.04		0.02		0.2	0.01				0.04							4.75	300	4.72	1.74	0.05	0.75	0.19	0.62	0.07	0.04	1.06	0.18	0.02	0.18	0.01	0	0.11	3	8.05	2.57	0.03	0.25	0.1	0.56	0	-	-	0.23	0.04	-	0.02	-	0.2	0.34	-	-	-	0.04	-	-	-	-	-	-	20.44
H5522_003_0	2007	6	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional						1000	Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						D	D	D	V	T	Coin	Coin	V	V	Coin	V	Coin	Coin	O	V	V	V	V	V	V	S	Coin	T	V	V	P	V	P	P	P	P	V	V	V	V	V																																															-	3000			951.51		295.29			296							3741.44	4746.24	1295.01	638.91		6.01	1030.72				132.42						213.47													2 40 days 21-100		10a 25			4a 50							7a 10	16b 2517a 2518a 257b 257d 257f 257b 25	7e 257h 259c 25	7c 157i 15		7g 25	0.2				17a 25						14c 107f 25													12.69		23.39			42.11							9.36	23.39	23.39	14.04		23.39	7.11				25						23.18											-	-	1.01	-	0.58	-	-	1.04	-	-	-	-	-	-	2.92	9.25	2.52	0.75	-	0.01	0.61	-	-	-	0.28	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	19.37		1.31	-	-	1.01	-	0.58	-	-	1.04	-	-	-	-	-	-	2.92	9.25	2.52	0.75	-	0.01	0.61	-	-	-	0.28	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	19.37		0.2	20	0.2	0	0	0	0	50	0	0	0.2	0.2	0.2	0	0	0.2	1	0	20	0.2	0.2	0.2			0.2	0.2	0	0		0.5	0.2				0.2							2.13	0.07	0.24	0.18	0.07	0.08	0.05	0.04	0.21	0.02	0.23	0.01	0	0.14	0.15	0.94	0.09	0.04	0.31	0.12	0.28	0			0.01	0.03		0.02		0.19	0.01				0.04							5.69	300	3.92	2.13	0.07	1.24	0.18	0.65	0.08	0.05	1.08	0.21	0.02	0.23	0.01	0	0.14	3.07	10.19	2.62	0.78	0.31	0.13	0.89	0	-	-	0.28	0.03	-	0.02	-	0.19	0.42	-	-	-	0.04	-	-	-	-	-	-	25.06
H5522_802_0	2007	2	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		270.86	2.63	33.2		9.43	10.19	6.03	11.23	30.46	5.94	33.28	1.31	1.08	16.18	23.49	131.3	3.53	8.01	44.57	16.88	33.26														6.2							FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6			19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6		FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							1.14	0.01	0.36		0.13	0.14	0.08	0.15	0.42	0.08	0.45	0.02	0.01	0.22	0.3	1.79	0.04	0.11	0.61	0.23	0.47														0.08							6.86			20.8	0.2	6.5	-	2.35	2.55	1.5	2.8	7.6	1.48	8.31	0.33	0.27	4.04	5.85	32.78	0.88	2	11.13	4.21	8.32	-	-	-	-	-	-	-	-	-	-	-	-	-	1.55	-	-	-	-	-	-	125.46
H5522_803_0	2007	2	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		270.86	2.63	33.2		9.43	10.19	6.03	11.23	30.46	5.94	33.28	1.31	1.08	16.18	23.49	131.3	3.53	8.01	44.57	16.88	33.26														6.2							FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6			19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6		FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							1.14	0.01	0.36		0.13	0.14	0.08	0.15	0.42	0.08	0.45	0.02	0.01	0.22	0.3	1.79	0.04	0.11	0.61	0.23	0.47														0.08							6.86			20.8	0.2	6.5	-	2.35	2.55	1.5	2.8	7.6	1.48	8.31	0.33	0.27	4.04	5.85	32.78	0.88	2	11.13	4.21	8.32	-	-	-	-	-	-	-	-	-	-	-	-	-	1.55	-	-	-	-	-	-	125.46
H5522_805_0	2007	2	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		270.86	2.63	33.2		9.43	10.19	6.03	11.23	30.46	5.94	33.28	1.31	1.08	16.18	23.49	131.3	3.53	8.01	44.57	16.88	33.26														6.2							FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6			19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6		FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							1.14	0.01	0.36		0.13	0.14	0.08	0.15	0.42	0.08	0.45	0.02	0.01	0.22	0.3	1.79	0.04	0.11	0.61	0.23	0.47														0.08							6.86			20.8	0.2	6.5	-	2.35	2.55	1.5	2.8	7.6	1.48	8.31	0.33	0.27	4.04	5.85	32.78	0.88	2	11.13	4.21	8.32	-	-	-	-	-	-	-	-	-	-	-	-	-	1.55	-	-	-	-	-	-	125.46
H5522_806_0	2007	2	H.6.	H.7.	H.8.	I.7.	I.8.						OP Facility - Other	OP Facility - Other	OP Facility - Other	Professional	Professional							Radiology Copay	Lab Copay	Urgent Care	Lab Copay	Radiology Coins						Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																															-		270.86	2.63	33.2		9.43	10.19	6.03	11.23	30.46	5.94	33.28	1.31	1.08	16.18	23.49	131.3	3.53	8.01	44.57	16.88	33.26														6.2							FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24														0.24							19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6			19.66	0.19	6.14	-	2.22	2.41	1.42	2.65	7.19	1.4	7.85	0.31	0.26	3.82	5.54	30.99	0.83	1.89	10.52	3.98	7.85	-	-	-	-	-	-	-	-	-	-	-	-	-	1.46	-	-	-	-	-	-	118.6		FFS 7.3	FFS 7.3	FFS 18.5		FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6	FFS 23.6														FFS 23.6							1.14	0.01	0.36		0.13	0.14	0.08	0.15	0.42	0.08	0.45	0.02	0.01	0.22	0.3	1.79	0.04	0.11	0.61	0.23	0.47														0.08							6.86			20.8	0.2	6.5	-	2.35	2.55	1.5	2.8	7.6	1.48	8.31	0.33	0.27	4.04	5.85	32.78	0.88	2	11.13	4.21	8.32	-	-	-	-	-	-	-	-	-	-	-	-	-	1.55	-	-	-	-	-	-	125.46
H5523_001_0	2007	5																																A	A	A			coin	coin	V	P					V			V			V		V			V																																																										-		281.54	22.97	121.14			5.73	2.86	386.85	294.72					2685.19			314.21			33772.38		27.9			108.52																	250 per admission copayment	250 per admission copayment	100 per admission copayment			20 cost sharing	20 cost sharing	40 ER 15 Urgent Care	100 per case					15 PT/OT/ST			20 MH/SA			15 Office Visit Copay		15 Vision 10 Hearing			15 per exam																	250	250	100			0.2	0.2	37.14	100					0.89			20			4.45		14.98			15																	5.87	0.48	1.01	-	-	1.15	0.57	1.2	2.46	-	-	-	-	0.2	-	-	0.52	-	-	12.53	-	0.03	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.14			5.87	0.48	1.01	-	-	1.15	0.57	1.2	2.46	-	-	-	-	0.2	-	-	0.52	-	-	12.53	-	0.03	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	26.14		30 cost sharing	50 cost sharing	30 cost sharing	30 cost sharing	30 cost sharing	30 cost sharing	30 cost sharing	40 ER 15 Urgent Care	30 cost sharing				30 cost sharing	15 PT/OT/ST 30 cost sharing all other			30 cost sharing		30 cost sharing	30 cost sharing		15 Vision 10 Hearing			15 per exam																	10.38	0.54	2.31	0.82	0.44	0.33	0.16	0.17	0.85				0.15	1.5			0.15		1.25	10.91		0			0.02																	29.98			16.25	1.02	3.32	0.82	0.44	1.47	0.74	1.37	3.31	-	-	-	0.15	1.7	-	-	0.68	-	1.25	23.43	-	0.04	-	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.13
H5525_001_0	2007	3																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-	2400	299.27	5.42	0	0	189.84	15.87	5.17	439.79	0	0	0	52.36	0	13.52	4075.56	3325.98	395.87	0	0	0	33.35	835.31	7.28	0	21.44	0	10.68	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-15 copay 17a/18a. 15 copay	10b. 25 copay		17a1. 10 - 15 copay		18a1. 10 - 15 copay			14a. 10 nutrition 0 other												143.53	143.53	0	0	50	0.02	0.1	38.61	0	0	0	19.14	0	19.14	9.57	14.35	19.14	0	0	0	0.1	14.35	25	0	11.96	0	11.96	0	0	0	0											3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.82	0	0.74	3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.82		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.23	0	0.02	0	0	0.44	0.13	0	0.08	0.09	0.06	0	0	0.02	0	3.14	0	0.19	0.07	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.62	110	1.3	3.81	0.06	0.02	0	0.79	0.72	0.64	1.42	0.08	0.09	0.06	0.09	0	0.04	3.25	7.12	0.63	0.19	0.07	0	3.24	1.06	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.44
H5525_002_0	2007	4																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-	2400	299.27	5.42	0	0	189.84	15.87	5.17	439.79	0	0	0	52.36	0	13.52	4075.56	3325.98	395.87	0	0	0	33.35	835.31	7.28	0	21.44	0	10.68	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-15 copay 17a/18a. 15 copay	10b. 25 copay		17a1. 10 - 15 copay		18a1. 10 - 15 copay			14a. 10 nutrition 0 other												143.53	143.53	0	0	50	0.02	0.1	38.61	0	0	0	19.14	0	19.14	9.57	14.35	19.14	0	0	0	0.1	14.35	25	0	11.96	0	11.96	0	0	0	0											3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.82	0	0.74	3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.82		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.23	0	0.02	0	0	0.44	0.13	0	0.08	0.09	0.06	0	0	0.02	0	3.14	0	0.19	0.07	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.62	110	1.3	3.81	0.06	0.02	0	0.79	0.72	0.64	1.42	0.08	0.09	0.06	0.09	0	0.04	3.25	7.12	0.63	0.19	0.07	0	3.24	1.06	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.44
H5525_003_0	2007	5																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T	Coin	V		V																																																								-	2400	299.27	5.42	0	0	189.84	15.87	5.17	439.79	0	0	0	52.36	0	13.52	4075.56	3325.98	395.87	0	0	0	33.35	835.31	7.28	36.15	21.44	0	10.68	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-15 copay 17a/18a. 15 copay	10b. 25 copay	16. 90/75/50 dental plan 250 class II & III ded 850 annual max	17a1. 10 - 15 copay	17b. no copay 150 annual maximum	18a1. 10 - 15 copay			14a. 10 nutrition 0 other												143.53	143.53	0	0	50	0.02	0.1	38.61	0	0	0	19.14	0	19.14	9.57	14.35	19.14	0	0	0	0.1	14.35	25	0.57	11.96	0	11.96	0	0	0	0											3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	20.69	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.51	0	0.74	3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	20.69	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.51		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.23	0	0.02	0	0	0.44	0.13	0	0.08	0.09	0.06	0	0	0.02	0	3.14	0	0.19	0.07	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.62	110	1.3	3.81	0.06	0.02	0	0.79	0.72	0.64	1.42	0.08	0.09	0.06	0.09	0	0.04	3.25	7.12	0.63	0.19	0.07	0	3.24	1.06	0.02	20.69	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.13
H5525_004_0	2007	5																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-	2400	299.27	5.42	0	0	189.84	15.87	5.17	439.79	0	0	0	52.36	0	13.52	4075.56	3325.98	395.87	0	0	0	33.35	835.31	7.28	0	21.44	0	10.68	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-15 copay 17a/18a. 15 copay	10b. 25 copay		17a1. 10 - 15 copay		18a1. 10 - 15 copay			14a. 10 nutrition 0 other												143.53	143.53	0	0	50	0.02	0.1	38.61	0	0	0	19.14	0	19.14	9.57	14.35	19.14	0	0	0	0.1	14.35	25	0	11.96	0	11.96	0	0	0	0											3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.82	0	0.74	3.58	0.06	-	-	0.79	0.28	0.52	1.42	-	-	-	0.08	-	0.02	3.25	3.98	0.63	-	-	-	3.17	1	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.82		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.23	0	0.02	0	0	0.44	0.13	0	0.08	0.09	0.06	0	0	0.02	0	3.14	0	0.19	0.07	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.62	110	1.3	3.81	0.06	0.02	0	0.79	0.72	0.64	1.42	0.08	0.09	0.06	0.09	0	0.04	3.25	7.12	0.63	0.19	0.07	0	3.24	1.06	0.02	-	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.44
H5525_801_0	2007	4																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-	2400	298.58	5.4	0	0	189.84	15.87	5.17	438.94	0	0	0	52.35	0	13.51	4015.21	3276.73	390.01	0	0	0	33.35	809.39	7.28	0	20.35	0	10.2	0	0	0	0											1a. 300 copay / admit	1b. 300 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 20 coinsurance (no copay on rentals) 1000 OOP Max	11b. 20 coins 11c. no coins	4a. 50 copay 4b. 20 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 40 copay	12. no copay	3/9d. no copay 9c. 30 copay	7a/14b-i. 20 copay	7b/7d/7f/7g. 30 copay	7e/7h. 30 copay	7c/7i. no copay			15. 20 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-50 copay 17a/18a. 30 copay	10b. 25 copay		17a1. 20 - 30 copay		18a1. 20 - 30 copay			14a. 10 nutrition 0 other												273.69	273.69	0	0	50	0.02	0.2	41.46	0	0	0	36.49	0	27.37	18.25	27.37	27.37	0	0	0	0.19	27.37	25	0	22.81	0	22.81	0	0	0	0											6.81	0.12	-	-	0.79	0.28	1.03	1.52	-	-	-	0.16	-	0.03	6.11	7.47	0.89	-	-	-	6.34	1.85	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47	0	2.59	6.81	0.12	-	-	0.79	0.28	1.03	1.52	-	-	-	0.16	-	0.03	6.11	7.47	0.89	-	-	-	6.34	1.85	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.23	0	0.02	0	0	0.44	0.13	0	0.08	0.09	0.06	0	0	0.02	0	3.14	0	0.19	0.07	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.62	110	1.3	7.04	0.12	0.02	0	0.79	0.72	1.16	1.52	0.08	0.09	0.06	0.16	0	0.05	6.11	10.62	0.89	0.19	0.07	0	6.41	1.91	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.08
H5525_802_0	2007	4																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-	2400	298.58	5.4	0	0	189.84	15.87	5.17	438.94	0	0	0	52.35	0	13.51	4015.21	3276.73	390.01	0	0	0	33.35	809.39	7.28	0	20.35	0	10.2	0	0	0	0											1a. 300 copay / admit	1b. 300 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 20 coinsurance (no copay on rentals) 1000 OOP Max	11b. 20 coins 11c. no coins	4a. 50 copay 4b. 20 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 40 copay	12. no copay	3/9d. no copay 9c. 30 copay	7a/14b-i. 20 copay	7b/7d/7f/7g. 30 copay	7e/7h. 30 copay	7c/7i. no copay			15. 20 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-50 copay 17a/18a. 30 copay	10b. 25 copay		17a1. 20 - 30 copay		18a1. 20 - 30 copay			14a. 10 nutrition 0 other												273.69	273.69	0	0	50	0.02	0.2	41.46	0	0	0	36.49	0	27.37	18.25	27.37	27.37	0	0	0	0.19	27.37	25	0	22.81	0	22.81	0	0	0	0											6.81	0.12	-	-	0.79	0.28	1.03	1.52	-	-	-	0.16	-	0.03	6.11	7.47	0.89	-	-	-	6.34	1.85	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47	0	2.59	6.81	0.12	-	-	0.79	0.28	1.03	1.52	-	-	-	0.16	-	0.03	6.11	7.47	0.89	-	-	-	6.34	1.85	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.23	0	0.02	0	0	0.44	0.13	0	0.08	0.09	0.06	0	0	0.02	0	3.14	0	0.19	0.07	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.62	110	1.3	7.04	0.12	0.02	0	0.79	0.72	1.16	1.52	0.08	0.09	0.06	0.16	0	0.05	6.11	10.62	0.89	0.19	0.07	0	6.41	1.91	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.08
H5525_805_0	2007	4																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T		V		V																																																								-	2400	298.58	5.4	0	0	189.84	15.87	5.17	438.94	0	0	0	52.35	0	13.51	4015.21	3276.73	390.01	0	0	0	33.35	809.39	7.28	0	20.35	0	10.2	0	0	0	0											1a. 300 copay / admit	1b. 300 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 20 coinsurance (no copay on rentals) 1000 OOP Max	11b. 20 coins 11c. no coins	4a. 50 copay 4b. 20 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 40 copay	12. no copay	3/9d. no copay 9c. 30 copay	7a/14b-i. 20 copay	7b/7d/7f/7g. 30 copay	7e/7h. 30 copay	7c/7i. no copay			15. 20 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-50 copay 17a/18a. 30 copay	10b. 25 copay		17a1. 20 - 30 copay		18a1. 20 - 30 copay			14a. 10 nutrition 0 other												273.69	273.69	0	0	50	0.02	0.2	41.46	0	0	0	36.49	0	27.37	18.25	27.37	27.37	0	0	0	0.19	27.37	25	0	22.81	0	22.81	0	0	0	0											6.81	0.12	-	-	0.79	0.28	1.03	1.52	-	-	-	0.16	-	0.03	6.11	7.47	0.89	-	-	-	6.34	1.85	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47	0	2.59	6.81	0.12	-	-	0.79	0.28	1.03	1.52	-	-	-	0.16	-	0.03	6.11	7.47	0.89	-	-	-	6.34	1.85	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.23	0	0.02	0	0	0.44	0.13	0	0.08	0.09	0.06	0	0	0.02	0	3.14	0	0.19	0.07	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.62	110	1.3	7.04	0.12	0.02	0	0.79	0.72	1.16	1.52	0.08	0.09	0.06	0.16	0	0.05	6.11	10.62	0.89	0.19	0.07	0	6.41	1.91	0.02	-	0.04	-	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.08
H5525_806_0	2007	4																					1000											A	A			T	Coin	Coin	V				V		V	V	V	V				Coin	V	T	Coin	V		V																																																								-	2400	273.1	4.94	0	0	173.23	14.48	4.72	401.32	0	0	0	47.78	0	12.33	3719.09	3035.07	361.24	0	0	0	30.43	762.25	6.64	36.15	19.56	0	9.74	0	0	0	0											1a. 150 copay / admit	1b. 150 copay /admit	2. no copay	6. no copay	10a. 50 copay	11a. 10 coinsurance (no copay on rentals) 1000 OOP Max	11b. 10 coins 11c. no coins	4a. 50 copay 4b. 10 copay	9a/9b. no copay	8a. no copay	8b. no copay	5. 20 copay	12. no copay	3/9d. no copay 9c. 20 copay	7a/14b-i. 10 copay	7b/7d/7f/7g. 15 copay	7e/7h. 20 copay	7c/7i. no copay			15. 10 coinsurance 800 OOP Max	13a/17b. no copay 16b. 10-15 copay 17a/18a. 15 copay	10b. 25 copay	16. 90/75/50 dental plan 250 class II & III ded 850 annual max	17a1. 10 - 15 copay	17b. no copay 150 annual maximum	18a1. 10 - 15 copay			14a. 10 nutrition 0 other												143.53	143.53	0	0	50	0.02	0.1	38.61	0	0	0	19.14	0	19.14	9.57	14.35	19.14	0	0	0	0.1	14.35	25	0.57	11.96	0	11.96	0	0	0	0											3.27	0.06	-	-	0.72	0.25	0.47	1.29	-	-	-	0.08	-	0.02	2.97	3.63	0.58	-	-	-	2.89	0.91	0.01	20.69	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.87	0	0.67	3.27	0.06	-	-	0.72	0.25	0.47	1.29	-	-	-	0.08	-	0.02	2.97	3.63	0.58	-	-	-	2.89	0.91	0.01	20.69	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.87		800-1000 / admit	800-1000 / admit	100-120 / admit	100-120 / admit		20	20		20-30	20	20	20	20	20	20	20	20	20	20	20	20	20		0	20		20			0.5	0											0.21	0	0.02	0	0	0.4	0.11	0	0.08	0.08	0.05	0	0	0.02	0	2.87	0	0.17	0.06	0	0.07	0.06	0	0	0	0	0	0	0	0	0	0										4.21	110	1.19	3.48	0.06	0.02	0	0.72	0.66	0.59	1.29	0.08	0.08	0.05	0.08	0	0.04	2.97	6.5	0.58	0.17	0.06	0	2.96	0.97	0.01	20.69	0.02	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.08
H5526_001_0	2007	6																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	432.44	0.66	93.53		188.42	9.99	1.24	237.33	355.83		861.53	0.06	0.32	8.69	4223.32	6255.1	0.79	1059.46	1111.95	2078.39	0.74	42.89			763.66		26.35															250 Copay	250 Copay	250 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	100 Copay		15 Copay	50 Coinsurance	15 Copay	20 Coinsurance	15 Copay	15 Copay	50 Coinsurance	15 Copay	15 Copay	15 Copay	20 Coinsurance	15 Copay			15 Copay		15 Copay															250	250	250		50	0.25	0.25	50	100		15	0.5	15	0.2	15	15	0.5	15	15	15	0.2	15			15		15															9.01	0.01	1.95	-	0.79	2.5	0.31	0.99	2.97	-	1.08	0.03	0	1.74	5.28	7.82	0.4	1.32	1.39	2.6	0.15	0.05	-	-	0.95	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	0	4.15	9.01	0.01	1.95	-	0.79	2.5	0.31	0.99	2.97	-	1.08	0.03	0	1.74	5.28	7.82	0.4	1.32	1.39	2.6	0.15	0.05	-	-	0.95	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Copay	50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	20 Coinsurance	20 Copay	20 Copay	55 Coinsurance	20 Copay	55 Coinsurance	20 Copay	20 Copay	55 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															1.87	0	0.17	0.01	0.14	0.23	0.03	0.06	0.35	0.32	0.11	0.06	0	0.63	0.3	1.32	0.06	0.13	0.64	1.89	0.09	0			0.1		0.01															8.52	0	0.85	10.88	0.02	2.12	0.01	0.93	2.73	0.35	1.04	3.31	0.32	1.18	0.09	0	2.37	5.58	9.14	0.46	1.45	2.03	4.49	0.24	0.06	-	-	1.05	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.88
H5526_002_0	2007	4																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	345.09	0	100.37		166.65	9.38	0.94	187.86	385.28		602.25	0.01	0.41	8.21	3859.03	5153.71	0.65	998.71	1091.99	1993.49	0.69	12.44			719.36		28.64															250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	50 Copay		20 Copay	50 Coinsurance	20 Copay	20 Coinsurance	10 Copay	20 Copay	50 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															250	250	250		50	0.3	0.3	50	50		20	0.5	20	0.2	10	20	0.5	20	20	20	0.2	20			20		20															7.19	-	2.09	-	0.69	2.81	0.28	0.78	1.61	-	1	0.01	0	1.64	3.22	8.59	0.33	1.66	1.82	3.32	0.14	0.02	-	-	1.2	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.46	0	4.11	7.19	-	2.09	-	0.69	2.81	0.28	0.78	1.61	-	1	0.01	0	1.64	3.22	8.59	0.33	1.66	1.82	3.32	0.14	0.02	-	-	1.2	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.46	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay	50 Copay	35 Coinsurance	35 Coinsurance	50 Copay	75 Copay	25 Copay	25 Copay	55 Coinsurance	25 Copay	55 Coinsurance	15 Copay	25 Copay	55 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Copay		25 Copay															1.22	0	0.14	0.01	0.14	0.27	0.04	0.05	0.17	0.24	0.12	0.03	0	0.6	0.41	1.41	0.05	0.15	0.73	2.35	0.07	0			0.12		0.01															8.34	0	0.89	8.4	0	2.23	0.01	0.84	3.09	0.32	0.84	1.78	0.24	1.12	0.03	0	2.24	3.62	10	0.37	1.82	2.55	5.68	0.21	0.02	-	-	1.32	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.8
H5526_003_0	2007	7																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	432.44	0.66	93.53		188.42	9.99	1.24	237.33	355.83		861.53	0.06	0.32	8.69	4223.32	6255.1	0.79	1059.46	1111.95	2078.39	0.74	42.89			763.66		26.35															250 Copay	250 Copay	250 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	100 Copay		15 Copay	50 Coinsurance	15 Copay	20 Coinsurance	15 Copay	15 Copay	50 Coinsurance	15 Copay	15 Copay	15 Copay	20 Coinsurance	15 Copay			15 Copay		15 Copay															250	250	250		50	0.25	0.25	50	100		15	0.5	15	0.2	15	15	0.5	15	15	15	0.2	15			15		15															9.01	0.01	1.95	-	0.79	2.5	0.31	0.99	2.97	-	1.08	0.03	0	1.74	5.28	7.82	0.4	1.32	1.39	2.6	0.15	0.05	-	-	0.95	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36		4.15	9.01	0.01	1.95	-	0.79	2.5	0.31	0.99	2.97	-	1.08	0.03	0	1.74	5.28	7.82	0.4	1.32	1.39	2.6	0.15	0.05	-	-	0.95	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.36	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Copay	50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	20 Coinsurance	20 Copay	20 Copay	55 Coinsurance	20 Copay	55 Coinsurance	20 Copay	20 Copay	55 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															1.87	0	0.17	0.01	0.14	0.23	0.03	0.06	0.35	0.32	0.11	0.06	0	0.63	0.3	1.32	0.06	0.13	0.64	1.89	0.09	0			0.1		0.01															8.52		0.85	10.88	0.02	2.12	0.01	0.93	2.73	0.35	1.04	3.31	0.32	1.18	0.09	0	2.37	5.58	9.14	0.46	1.45	2.03	4.49	0.24	0.06	-	-	1.05	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.88
H5526_004_0	2007	6																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	340.29	0	98.98		164.33	9.25	0.93	185.25	379.93		597.64	0.01	0.4	7.68	3805.36	5171.6	0.64	984.82	1076.8	1965.77	0.68	10.8			729.82		28.5															250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	50 Copay		15 Copay	50 Coinsurance	15 Copay	20 Coinsurance	10 Copay	15 Copay	50 Coinsurance	15 Copay	15 Copay	15 Copay	20 Coinsurance	15 Copay			15 Copay		15 Copay															250	250	250		50	0.3	0.3	50	50		15	0.5	15	0.2	10	15	0.5	15	15	15	0.2	15			15		15															7.09	-	2.06	-	0.68	2.77	0.28	0.77	1.58	-	0.75	0.01	0	1.54	3.17	6.46	0.32	1.23	1.35	2.46	0.14	0.01	-	-	0.91	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.62		4.12	7.09	-	2.06	-	0.68	2.77	0.28	0.77	1.58	-	0.75	0.01	0	1.54	3.17	6.46	0.32	1.23	1.35	2.46	0.14	0.01	-	-	0.91	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.62	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Copay	50 Copay	35 Coinsurance	35 Coinsurance	50 Copay	75 Copay	20 Copay	20 Copay	55 Coinsurance	20 Copay	55 Coinsurance	15 Copay	20 Copay	55 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															1.2	0	0.14	0.01	0.14	0.27	0.04	0.05	0.17	0.19	0.09	0.02	0	0.59	0.4	1.11	0.05	0.12	0.58	1.86	0.07	0			0.1		0.01															7.21		0.88	8.29	0	2.2	0.01	0.82	3.05	0.32	0.82	1.75	0.19	0.84	0.03	0	2.13	3.57	7.57	0.37	1.35	1.92	4.31	0.21	0.02	-	-	1.01	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.83
H5526_007_0	2007	6																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	432.44	0.66	93.53		188.42	10	1.21	237.33	378.79		861.53	0.06	0.32	8.69	4477.9	6255.1	0.79	1059.46	1111.95	2078.39	0.74	36.93			763.66		26.35															150 Copay	150 Copay	150 Copay		50 Copay	25 Coinsurance	25 Coinsurance	50 Copay	75 Copay		15 Copay	50 Coinsurance	15 Copay	20 Coinsurance	5 Copay	15 Copay	50 Coinsurance	15 Copay	15 Copay	15 Copay	20 Coinsurance	15 Copay			15 Copay		15 Copay															150	150	150		50	0.25	0.25	50	75		15	0.5	15	0.2	5	15	0.5	15	15	15	0.2	15			15		15															5.41	0.01	1.17	-	0.79	2.5	0.3	0.99	2.37	-	1.08	0.03	0	1.74	1.87	7.82	0.4	1.32	1.39	2.6	0.15	0.05	-	-	0.95	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.95		3.97	5.41	0.01	1.17	-	0.79	2.5	0.3	0.99	2.37	-	1.08	0.03	0	1.74	1.87	7.82	0.4	1.32	1.39	2.6	0.15	0.05	-	-	0.95	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.95	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Copay	50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	20 Coinsurance	20 Copay	20 Copay	55 Coinsurance	20 Copay	55 Coinsurance	10 Copay	20 Copay	55 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															1.87	0	0.17	0.01	0.14	0.23	0.03	0.06	0.35	0.32	0.11	0.06	0	0.63	0.3	1.32	0.06	0.13	0.64	1.89	0.09	0			0.1		0.01															8.52		1.03	7.27	0.01	1.34	0.01	0.93	2.73	0.34	1.04	2.71	0.32	1.18	0.09	0	2.37	2.16	9.14	0.46	1.45	2.03	4.49	0.24	0.05	-	-	1.05	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.46
H5526_008_0	2007	6																					3000											A		A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	306.45	0	89.14		147.99	8.33	0.83	166.83	366.99		555.16	0.01	0.39	6.92	3542.08	4845.6	0.58	949.33	985.48	1786.56	0.61	31.38			700.25		78.65															100 Copay	100 Copay	100 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	35 Copay		5 Copay	50 Coinsurance	5 Copay	20 Coinsurance	5 Copay	5 Copay	50 Coinsurance	5 Copay	5 Copay	5 Copay	20 Coinsurance	5 Copay			5 Copay		5 Copay															100	100	100		50	0.3	0.3	50	35		5	0.5	5	0.2	5	5	0.5	5	5	5	0.2	5			5		5															2.55	-	0.74	-	0.62	2.5	0.25	0.7	1.07	-	0.23	0.01	0	1.38	1.48	2.02	0.29	0.4	0.41	0.74	0.12	0.01	-	-	0.29	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.84		3.9	2.55	-	0.74	-	0.62	2.5	0.25	0.7	1.07	-	0.23	0.01	0	1.38	1.48	2.02	0.29	0.4	0.41	0.74	0.12	0.01	-	-	0.29	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.84	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	10 Copay	50 Copay	35 Coinsurance	35 Coinsurance	50 Copay	50 Copay	10 Copay	10 Copay	55 Coinsurance	10 Copay	55 Coinsurance	10 Copay	10 Copay	55 Coinsurance	10 Copay	10 Copay	10 Copay	20 Coinsurance	10 Copay			10 Copay		10 Copay															1.08	0	0.12	0	0.13	0.24	0.04	0.05	0.1	0.09	0.04	0.02	0	0.53	0.24	0.5	0.04	0.05	0.26	0.84	0.07	0			0.04		0.01															4.49		1.1	3.63	0	0.86	0	0.74	2.74	0.29	0.74	1.17	0.09	0.27	0.03	0	1.92	1.72	2.52	0.33	0.45	0.67	1.58	0.19	0.01	-	-	0.34	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.33
H5526_801_0	2007	4																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	394.98	0.6	85.43		177.27	9.27	1.17	225.05	443.41		811.26	0.06	0.3	8.74	4076.03	5783.47	0.75	966.45	1039.51	1947.56	0.69	25.42			698.09		24.58															250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	50 Copay		20 Copay	50 Coinsurance	20 Copay	20 Coinsurance	10 Copay	20 Copay	50 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															250	250	250		50	0.3	0.3	50	50		20	0.5	20	0.2	10	20	0.5	20	20	20	0.2	20			20		20															8.23	0.01	1.78	-	0.74	2.78	0.35	0.94	1.85	-	1.35	0.03	0	1.75	3.4	9.64	0.38	1.61	1.73	3.25	0.14	0.04	-	-	1.16	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	0	4.04	8.23	0.01	1.78	-	0.74	2.78	0.35	0.94	1.85	-	1.35	0.03	0	1.75	3.4	9.64	0.38	1.61	1.73	3.25	0.14	0.04	-	-	1.16	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay	50 Copay	35 Coinsurance	35 Coinsurance	50 Copay	20 Coinsurance	25 Copay	25 Copay	55 Coinsurance	25 Copay	55 Coinsurance	15 Copay	25 Copay	55 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Coinsurance		25 Coinsurance															2.65	0	0.24	0.01	0.13	0.24	0.04	0.05	0.27	0.35	0.11	0.05	0	0.48	0.42	1.55	0.05	0.15	0.75	2.21	0.07	0			0		0.01															9.84	0	0.96	10.88	0.02	2.02	0.01	0.87	3.02	0.39	0.99	2.12	0.35	1.47	0.08	0	2.23	3.82	11.19	0.43	1.76	2.48	5.46	0.21	0.05	-	-	1.16	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.03
H5526_802_0	2007	4																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	406.95	0.62	88.02		182.97	9.85	1.32	231.69	456.5		835.2	0.07	0.3	9.56	4207.13	5969.48	0.8	997.54	1072.94	2010.2	0.74	26.17			720.55		25.37															250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	50 Copay		20 Copay	50 Coinsurance	20 Copay	20 Coinsurance	10 Copay	20 Copay	50 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															250	250	250		50	0.3	0.3	50	50		20	0.5	20	0.2	10	20	0.5	20	20	20	0.2	20			20		20															8.48	0.01	1.83	-	0.76	2.96	0.4	0.97	1.9	-	1.39	0.03	0	1.91	3.51	9.95	0.4	1.66	1.79	3.35	0.15	0.04	-	-	1.2	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.73	0	4.06	8.48	0.01	1.83	-	0.76	2.96	0.4	0.97	1.9	-	1.39	0.03	0	1.91	3.51	9.95	0.4	1.66	1.79	3.35	0.15	0.04	-	-	1.2	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.73	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay	50 Copay	35 Coinsurance	35 Coinsurance	50 Copay	20 Coinsurance	25 Copay	25 Copay	55 Coinsurance	25 Copay	55 Coinsurance	15 Copay	25 Copay	55 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Coinsurance		25 Coinsurance															2.66	0	0.24	0.01	0.13	0.24	0.04	0.05	0.27	0.35	0.11	0.05	0	0.49	0.42	1.55	0.05	0.15	0.75	2.22	0.07	0			0		0.01															9.86	0	0.94	11.14	0.02	2.07	0.01	0.9	3.2	0.43	1.01	2.17	0.35	1.51	0.08	0	2.4	3.93	11.5	0.45	1.81	2.54	5.57	0.22	0.05	-	-	1.2	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.6
H5526_803_0	2007	5																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	394.98	0.6	85.43		177.27	9.27	1.17	225.05	443.41		811.26	0.06	0.3	8.74	4076.03	5783.47	0.75	966.45	1039.51	1947.56	0.69	25.42			698.09		24.58															250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	50 Copay		20 Copay	50 Coinsurance	20 Copay	20 Coinsurance	10 Copay	20 Copay	50 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															250	250	250		50	0.3	0.3	50	50		20	0.5	20	0.2	10	20	0.5	20	20	20	0.2	20			20		20															8.23	0.01	1.78	-	0.74	2.78	0.35	0.94	1.85	-	1.35	0.03	0	1.75	3.4	9.64	0.38	1.61	1.73	3.25	0.14	0.04	-	-	1.16	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	0	4.04	8.23	0.01	1.78	-	0.74	2.78	0.35	0.94	1.85	-	1.35	0.03	0	1.75	3.4	9.64	0.38	1.61	1.73	3.25	0.14	0.04	-	-	1.16	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	41.2	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay	50 Copay	35 Coinsurance	35 Coinsurance	50 Copay	20 Coinsurance	25 Copay	25 Copay	55 Coinsurance	25 Copay	55 Coinsurance	15 Copay	25 Copay	55 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Coinsurance		25 Coinsurance															2.65	0	0.24	0.01	0.13	0.24	0.04	0.05	0.27	0.35	0.11	0.04	0	0.48	0.42	1.55	0.05	0.15	0.75	2.21	0.07	0			0		0.01															9.83	0	0.96	10.88	0.02	2.02	0.01	0.87	3.02	0.39	0.99	2.12	0.35	1.47	0.07	0	2.23	3.82	11.19	0.43	1.76	2.48	5.46	0.21	0.05	-	-	1.16	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.03
H5526_804_0	2007	5																					3000											A	A	A		T	Coin	Coin	V	V		V	Coin	V	Coin	V	V	Coin	V	V	V	Coin	V			V		V																																																								-	3000	406.95	0.62	88.02		182.97	9.85	1.32	231.69	456.5		835.2	0.07	0.3	9.56	4207.13	5969.48	0.8	997.54	1072.94	2010.2	0.74	26.17			720.55		25.37															250 Copay	250 Copay	250 Copay		50 Copay	30 Coinsurance	30 Coinsurance	50 Copay	50 Copay		20 Copay	50 Coinsurance	20 Copay	20 Coinsurance	10 Copay	20 Copay	50 Coinsurance	20 Copay	20 Copay	20 Copay	20 Coinsurance	20 Copay			20 Copay		20 Copay															250	250	250		50	0.3	0.3	50	50		20	0.5	20	0.2	10	20	0.5	20	20	20	0.2	20			20		20															8.48	0.01	1.83	-	0.76	2.96	0.4	0.97	1.9	-	1.39	0.03	0	1.91	3.51	9.95	0.4	1.66	1.79	3.35	0.15	0.04	-	-	1.2	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.73	0	4.06	8.48	0.01	1.83	-	0.76	2.96	0.4	0.97	1.9	-	1.39	0.03	0	1.91	3.51	9.95	0.4	1.66	1.79	3.35	0.15	0.04	-	-	1.2	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.73	3000	20 Coinsurance	20 Coinsurance	20 Coinsurance	25 Copay	50 Copay	35 Coinsurance	35 Coinsurance	50 Copay	20 Coinsurance	25 Copay	25 Copay	55 Coinsurance	25 Copay	55 Coinsurance	15 Copay	25 Copay	55 Coinsurance	25 Copay	25 Copay	25 Copay	20 Coinsurance	25 Copay			25 Coinsurance		25 Coinsurance															2.66	0	0.24	0.01	0.13	0.24	0.04	0.05	0.27	0.35	0.11	0.05	0	0.49	0.42	1.55	0.05	0.15	0.75	2.22	0.07	0			0		0.01															9.86	0	0.94	11.14	0.02	2.07	0.01	0.9	3.2	0.43	1.01	2.17	0.35	1.51	0.08	0	2.4	3.93	11.5	0.45	1.81	2.54	5.57	0.22	0.05	-	-	1.2	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.6
H5527_001_0	2007	8																					3800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1911.52	130.14	1261.89	0	320.32	13.53	5.67	754.7	27.24	12339.83	48.02	0	-2.23	41.74	4269.97	5347.01	493.54	3.22	0	0	15.15	1531.19	0	0	95.16	0	206.4	0	0	0	0											280 (1a)	280 (1b)	140 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											171.24	171.24	85.62	0	107.03	0.18	0.21	30.58	0.15	3.67	0.12	0	0.18	0.15	10	20	37.5	0.15	0	0	0.18	20	0	0	20	0	20	0	0	0	0											27.28	1.86	9	-	2.86	2.48	1.21	1.92	4.17	3.77	5.67	-	-0.41	6.38	3.56	8.91	1.54	0.49	-	-	2.78	2.55	-	-	0.16	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.54		43.84	27.28	1.86	9	-	2.86	2.48	1.21	1.92	4.17	3.77	5.67	-	-0.41	6.38	3.56	8.91	1.54	0.49	-	-	2.78	2.55	-	-	0.16	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.54		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c 14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											1.63	0.05	0.75	0.64	0.46	0.4	0.17	0.24	0.62	0.62	0.84	0	-0.05	0.94	0.74	3.09	0.17	0.1	0	0	0.45	0.19	0	0	0.01	0	0.03	0	0	0	0											12.09		0	28.91	1.91	9.75	0.64	3.32	2.88	1.38	2.16	4.78	4.39	6.52	-	-0.46	7.32	4.3	12	1.72	0.59	-	-	3.23	2.74	-	-	0.17	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	98.63
H5528_001_0	2007	2	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	284.45	9.88	826.62	1468.82	292.24	6.23		103.36	124.16	227.52	260.36			489.16	3597.91	3556.35	388.1	754.24	312.99	1068.55	3.96				437.31	218.71						224.22	640.24	7.85	204.67	541.54	0.92					0 per stay	0 per stay	0 copayment days 1-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	50 copayment	0 copayment	0 copayment	Outpatient Radiology Therapy @ 20 copayment; Others: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 10 copayment; Other: 0	0 copayment	10 copayment	10 copayment	10 copayment	10 copayment	10 copayment	20 coinsurance				0 copay	Eyewear every 2 years						10 copayment	10 copayment	10 copayment	0 copayment	20 copayment	10 copayment					0	0	0	0	50	0.2	0.2	50	0	0	1.84			0.58	0	10	10	10	10	10	0.2				0	10						10	10	10	0	20	10					-	-	-	-	1.22	1.25	-	0.43	-	-	0.04	-	-	0.02	-	2.96	0.32	0.63	0.26	0.89	0.79	-	-	-	-	0.18	-	-	-	-	-	0.19	0.53	0.01	-	0.9	0	-	-	-	-	10.63	0	0	-	-	-	-	1.22	1.25	-	0.43	-	-	0.04	-	-	0.02	-	2.96	0.32	0.63	0.26	0.89	0.79	-	-	-	-	0.18	-	-	-	-	-	0.19	0.53	0.01	-	0.9	0	-	-	-	-	10.63	Unlimited	25; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	50 copayment	25 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded			50 outpatient rehab & substance abuse CORF Partial Hospital; all other 25 after ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						2.37	0.11	0.88	0.63	0.22	0.51		0.12	0.97	0.53	0.89			1.27	1.31	3.59	0.24	0.52	1.26	1.99	0.25			0	0.04	0.02					0.02	0.07	0.17	0		0.07						18.03	150	6.58	2.37	0.11	0.88	0.63	1.44	1.75	-	0.55	0.97	0.53	0.93	-	-	1.29	1.31	6.55	0.56	1.15	1.52	2.88	1.05	-	-	0	0.04	0.2	-	-	-	-	0.02	0.26	0.7	0.01	-	0.97	0	-	-	-	-	28.66
H5528_002_0	2007	3	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	275.01	9.55	799.19	1420.08	282.54	6.02		99.93	120.04	219.97	251.72			472.93	3478.52	3438.35	375.22	729.22	302.61	1033.07	3.83				422.8	211.45						216.78	619	7.59	197.88	523.57	0.92					0 per stay	0 per stay	0 days 1-20; 75 per day for days 21-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	ER @ 50 copayment; Urgent Care @ 0 if administered by PCP 15 for specialist	0 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; 75 High-tech Radiology; Others: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 20 copayment; Other: 0	0 copayment	15 copayment	20 copayment	20 copayment	15 copayment	15 copayment	20 coinsurance			0 copay	0 copay	Eyewear every 2 years						15 copayment	15 copayment	15 copayment	75 copayment	20 copayment	10 copayment					0	0	35.33	0	50	0.2	0.2	50	0	0	6.64			1.16	0	15	20	20	15	15	0.2			0	0	10						15	15	15	75	20	10					-	-	2.35	-	1.18	1.2	-	0.42	-	-	0.14	-	-	0.05	-	4.3	0.63	1.22	0.38	1.29	0.77	-	-	-	-	0.18	-	-	-	-	-	0.27	0.77	0.01	1.24	0.87	0	-	-	-	-	17.25	0	0	-	-	2.35	-	1.18	1.2	-	0.42	-	-	0.14	-	-	0.05	-	4.3	0.63	1.22	0.38	1.29	0.77	-	-	-	-	0.18	-	-	-	-	-	0.27	0.77	0.01	1.24	0.87	0	-	-	-	-	17.25	Unlimited	25; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	ER @ 50 copayment Urgent Care @ 25 after Ded	25 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded			50 outpatient rehab & substance abuse CORF Partial Hospital; all other 25 after ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						2.29	0.1	0.85	0.61	0.22	0.49		0.12	0.93	0.51	0.86			1.23	1.26	3.47	0.23	0.5	1.21	1.93	0.25			0	0.04	0.02					0.02	0.07	0.16	0		0.07						17.44	150	6.36	2.29	0.1	3.2	0.61	1.39	1.7	-	0.54	0.93	0.51	1	-	-	1.27	1.26	7.77	0.86	1.72	1.59	3.22	1.01	-	-	0	0.04	0.2	-	-	-	-	0.02	0.34	0.93	0.01	1.24	0.94	0	-	-	-	-	34.69
H5528_003_0	2007	4	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	275.01	9.55	799.19	1420.08	282.54	6.02		99.93	120.04	219.97	251.72			472.93	3478.52	3438.35	375.22	729.22	302.61	1033.07	3.83				422.8	211.45						216.78	619	7.59	197.88	523.57	0.92					50 per day; days 1-5	50 per day; days 1-5	0 days 1-20; 75 per day for days 21-100	0 per day	50 copayment	20 coinsurance	20 coinsurance	ER @ 50 copayment; Urgent Care @ 5 if administered by PCP 15 for Specialist	50 copayment		Outpatient Radiology Therapy @20 copayment; 75 High-tech Radiology; Others: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 20 copayment; Others: 0	5 copayment	15 copayment	20 copayment	20 copayment	15 copayment	15 copayment	20 coinsurance			0 copay	0 copay	Eyewear every 2 years						15 copayment	15 copayment	15 copayment	75 copayment	20 copayment	10 copayment					195	225	35.33	0	50	0.2	0.2	50	50	0	6.64			1.16	5	15	20	20	15	15	0.2			0	0	10						15	15	15	75	20	10					4.47	0.18	2.35	-	1.18	1.2	-	0.42	0.5	-	0.14	-	-	0.05	1.45	4.3	0.63	1.22	0.38	1.29	0.77	-	-	-	-	0.18	-	-	-	-	-	0.27	0.77	0.01	1.24	0.87	0	-	-	-	-	23.85	0	0	4.47	0.18	2.35	-	1.18	1.2	-	0.42	0.5	-	0.14	-	-	0.05	1.45	4.3	0.63	1.22	0.38	1.29	0.77	-	-	-	-	0.18	-	-	-	-	-	0.27	0.77	0.01	1.24	0.87	0	-	-	-	-	23.85	Unlimited	25; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 25 after Ded	25 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded			50 outpatient rehab & substance abuse CORF Partial Hospital; all other 25 after ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						2.29	0.1	0.85	0.61	0.22	0.49		0.12	0.93	0.51	0.86			1.23	1.26	3.47	0.23	0.5	1.21	1.93	0.25			0	0.04	0.02					0.02	0.07	0.16	0		0.07						17.44	150	6.36	6.76	0.28	3.2	0.61	1.39	1.7	-	0.54	1.43	0.51	1	-	-	1.27	2.71	7.77	0.86	1.72	1.59	3.22	1.01	-	-	0	0.04	0.2	-	-	-	-	0.02	0.34	0.93	0.01	1.24	0.94	0	-	-	-	-	41.28
H5528_004_0	2007	3	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	233.68	6.16	713.59	1423.52	275.89	5.66		120.6	133.42	224.89	284.87			453.58	3315.84	3255.46	336.37	613.01	301.67	932.82	4.51				429.14	214.58						250.76	590.36	9	197.27	531.34	0.92					0 per stay	0 per stay	0 copayment days 1-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	50 copayment	0 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; Others: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 10 copayment; Others: 0	0 copayment	10 copayment	10 copayment	10 copayment	10 copayment	10 copayment	20 coinsurance			0 copay	0 copay	Eyewear every 2 years						10 copayment	10 copayment	10 copayment	0 copayment	20 copayment	10 copayment					0	0	0	0	50	0.2	0.2	50	0	0	1.84			0.58	0	10	10	10	10	10	0.2			0	0	10						10	10	10	0	20	10					-	-	-	-	1.15	1.13	-	0.5	-	-	0.04	-	-	0.02	-	2.71	0.28	0.51	0.25	0.78	0.9	-	-	-	-	0.18	-	-	-	-	-	0.21	0.49	0.01	-	0.89	0	-	-	-	-	10.06	0	0	-	-	-	-	1.15	1.13	-	0.5	-	-	0.04	-	-	0.02	-	2.71	0.28	0.51	0.25	0.78	0.9	-	-	-	-	0.18	-	-	-	-	-	0.21	0.49	0.01	-	0.89	0	-	-	-	-	10.06	Unlimited	25; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	50 copayment	25 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded			50 outpatient rehab & substance abuse CORF Partial Hospital; all other 25 after ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						4.11	0.13	1.67	1.36	0.46	1.02		0.14	1	0.41	0.77			1.25	2.78	7.83	0.53	0.89	2.66	4.25	0.65			0	0.04	0.02					0.06	0.19	0.34	0		0.07						32.63	150	11.38	4.11	0.13	1.67	1.36	1.61	2.15	-	0.65	1	0.41	0.82	-	-	1.27	2.78	10.55	0.81	1.4	2.92	5.03	1.55	-	-	0	0.04	0.2	-	-	-	-	0.06	0.39	0.83	0.01	-	0.95	0	-	-	-	-	42.69
H5528_005_0	2007	4	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	225.6	5.93	689.02	1374.45	266.38	5.46		116.45	128.79	217.15	275.06			437.95	3201.55	3143.26	324.81	591.87	291.27	900.64	4.36				414.32	207.17						242.1	570.02	8.69	190.47	513.04	0.92					50 per day; days 1-5	50 per day; days 1-5	0 days 1-20; 100 per day for days 21-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	ER @ 50 copayment; Urgent care @ 5 if administered by PCP 15 for specialist	50 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; 75 High-tech Radiology; Others: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 20 copayment; Others: 0	5 copayment	15 copayment	20 copayment	20 copayment	15 copayment	15 copayment	20 coinsurance			0 copay	0 copay	Eyewear every 2 years						15 copayment	15 copayment	15 copayment	75 copayment	20 copayment	10 copayment					195	225	47.1	0	50	0.2	0.2	50	50	0	6.64			1.16	5	15	20	20	15	15	0.2			0	0	10						15	15	15	75	20	10					3.67	0.11	2.7	-	1.11	1.09	-	0.49	0.54	-	0.15	-	-	0.04	1.33	3.93	0.54	0.99	0.36	1.13	0.87	-	-	-	-	0.17	-	-	-	-	-	0.3	0.71	0.01	1.19	0.86	0	-	-	-	-	22.3	0	0	3.67	0.11	2.7	-	1.11	1.09	-	0.49	0.54	-	0.15	-	-	0.04	1.33	3.93	0.54	0.99	0.36	1.13	0.87	-	-	-	-	0.17	-	-	-	-	-	0.3	0.71	0.01	1.19	0.86	0	-	-	-	-	22.3	Unlimited	25; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	ER @ 50 copayment; Urgent care @ 25 after Ded	25 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded			50 outpatient rehab & substance abuse CORF Partial Hospital; all other 25 after ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						3.97	0.12	1.61	1.32	0.44	0.98		0.14	0.97	0.39	0.75			1.2	2.69	7.56	0.51	0.85	2.57	4.1	0.63			0	0.04	0.02					0.06	0.18	0.33	0		0.07						31.51	150	10.99	7.64	0.24	4.32	1.32	1.55	2.07	-	0.63	1.5	0.39	0.9	-	-	1.24	4.02	11.49	1.05	1.84	2.94	5.23	1.5	-	-	0	0.04	0.19	-	-	-	-	0.06	0.48	1.04	0.01	1.19	0.92	0	-	-	-	-	53.81
H5528_008_0	2007	5	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	225.6	5.93	689.02	1374.45	266.38	5.46		116.45	128.79	217.15	275.06			437.95	3201.55	3143.26	324.81	591.87	291.27	900.64	4.36				414.32	207.17						242.1	570.02	8.69	190.47	513.04	0.92					50 per day; days 1-5	50 per day; days 1-5	0 days 1-20; 75 per day for days 21-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	ER @ 50 copayment; Urgent Care @ 5 copay if administered by PCP 15 for specialist	50 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; 75 High-tech Radiology; Other: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 20 copayment; Other: 0	5 copayment	15 copayment	20 copayment	20 copayment	15 copayment	15 copayment	20 coinsurance			0 copay	0 copay	Eyewear every 2 years						15 copayment	15 copayment	15 copayment	75 copayment	20 copayment	10 copayment					195	225	35.33	0	50	0.2	0.2	50	50	0	6.64			1.16	5	15	20	20	15	15	0.2			0	0	10						15	15	15	75	20	10					3.67	0.11	2.03	-	1.11	1.09	-	0.49	0.54	-	0.15	-	-	0.04	1.33	3.93	0.54	0.99	0.36	1.13	0.87	-	-	-	-	0.17	-	-	-	-	-	0.3	0.71	0.01	1.19	0.86	0	-	-	-	-	21.62	0	0	3.67	0.11	2.03	-	1.11	1.09	-	0.49	0.54	-	0.15	-	-	0.04	1.33	3.93	0.54	0.99	0.36	1.13	0.87	-	-	-	-	0.17	-	-	-	-	-	0.3	0.71	0.01	1.19	0.86	0	-	-	-	-	21.62	Unlimited	25; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded		ER @50 copayment; Urgent Care @ 25 after Ded	25 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded			50 outpatient rehab & substance abuse CORF Partial Hospital; all other 25 after ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded	25 coinsurance after Ded	25 coinsurance after Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						3.97	0.12	1.61	1.32	0.44	0.98		0.14	0.97	0.39	0.75			1.2	2.69	7.56	0.51	0.85	2.57	4.1	0.63			0	0.04	0.02					0.06	0.18	0.33	0		0.07						31.51	150	10.99	7.64	0.24	3.64	1.32	1.55	2.07	-	0.63	1.5	0.39	0.9	-	-	1.24	4.02	11.49	1.05	1.84	2.94	5.23	1.5	-	-	0	0.04	0.19	-	-	-	-	0.06	0.48	1.04	0.01	1.19	0.92	0	-	-	-	-	53.13
H5528_009_0	2007	2	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	27.94	8.73	730.62	1298.25	186.55	3.98		11.42	13.72	25.14	28.77			54.04	2296.73	2270.19	247.72	481.47	199.8	548.8	2.53				386.51	193.35						143.15	408.71	5.01	130.65	478.68	0.92					50 per day; days 1-5	50 per day; days 1-5	0 days 1-20; 25 per day for days 21-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	ER @ 50 copayment; Urgent Care @ 0 if administered by PCP; 10 for specialist	0 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; Other: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 10 copayment; Other 0	0 copayment	10 copayment	10 copayment	10 copayment	10 copayment	10 copayment	20 coinsurance			0 copay	0 copay	Eyewear every 2 years						10 copayment	10 copayment	10 copayment	0 copayment	20 copayment	10 copayment					195	225	11.78	0	50	0.2	0.2	50	0	0	1.84			0.58	0	10	10	10	10	10	0.2			0	0	10						10	10	10	0	20	10					0.45	0.16	0.72	-	0.78	0.8	-	0.05	-	-	0	-	-	0	-	1.89	0.21	0.4	0.17	0.46	0.51	-	-	-	-	0.16	-	-	-	-	-	0.12	0.34	0	-	0.8	0	-	-	-	-	8.01	0	0	0.45	0.16	0.72	-	0.78	0.8	-	0.05	-	-	0	-	-	0	-	1.89	0.21	0.4	0.17	0.46	0.51	-	-	-	-	0.16	-	-	-	-	-	0.12	0.34	0	-	0.8	0	-	-	-	-	8.01	Unlimited	50 per day; days 1-5; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 25 after Ded	0 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment			CORFOutpatient Rehab Partial Hospital @ 10 copayment; Substance Abuse @50; Other: 0	25 Coinsurance after Ded	25 Coinsurance after Ded	50 coinsurance after Ded	10 copayment	25 Coinsurance after Ded	25 Coinsurance after Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						4.7	0.07	0.19	0.55	0.7	1.52		0.5	0	0	0.05			0.07	4.09	11.21	0.75	0.97	3.93	6.22	0.78			0	0.04	0.02					0.05	0.22	0.51	0		0.08						37.21	150	0.55	5.15	0.23	0.91	0.55	1.48	2.31	-	0.54	-	-	0.05	-	-	0.07	4.09	13.11	0.95	1.37	4.09	6.68	1.29	-	-	0	0.04	0.18	-	-	-	-	0.05	0.34	0.85	0	-	0.88	0	-	-	-	-	45.22
H5528_010_0	2007	5	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	27.94	8.73	730.62	1298.25	186.55	3.98		11.42	13.72	25.14	28.77			54.04	2296.73	2270.19	247.72	481.47	199.8	548.8	2.53				386.51	193.35						143.15	408.71	5.01	130.65	478.68	0.92					50 per day; days 1-5	50 per day; days 1-5	0 days 1-20; 50 per day for days 21-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	ER @ 50 copayment; Urgent Care @ 10 if administered by PCP 20 for specialist	50 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; 50 High-tech Radiology; Others: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 20 copayment; Others: 0	10 copayment	20 copayment	20 copayment	20 copayment	20 copayment	20 copayment	20 coinsurance			0 copay	0 copay	Eyewear every 2 years						20 copayment	20 copayment	20 copayment	50 copayment	20 copayment	10 copayment					195	225	23.55	0	50	0.2	0.2	50	50	0	5.04			1.16	10	20	20	20	20	20	0.2			0	0	10						20	20	20	50	20	10					0.45	0.16	1.43	-	0.78	0.8	-	0.05	0.06	-	0.01	-	-	0.01	1.91	3.78	0.41	0.8	0.33	0.91	0.51	-	-	-	-	0.16	-	-	-	-	-	0.24	0.68	0.01	0.54	0.8	0	-	-	-	-	14.84	0	0	0.45	0.16	1.43	-	0.78	0.8	-	0.05	0.06	-	0.01	-	-	0.01	1.91	3.78	0.41	0.8	0.33	0.91	0.51	-	-	-	-	0.16	-	-	-	-	-	0.24	0.68	0.01	0.54	0.8	0	-	-	-	-	14.84	Unlimited	50 per day; days 1-5; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 25 coinsurance after Ded	50 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; 50 High-tech Radiology; Other: 0			CORFOutpatient Rehab Partial Hospital @ 20 copayment; Substance Abuse @50; Other 0	25 after 150 Ded	25 after 150 Ded	50 coinsurance after Ded	20 copayment	25 after 150 Ded	25 after 150 Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						4.7	0.07	0.19	0.55	0.7	1.52		0.5	0.59	0	0.13			0.1	4.09	11.21	0.75	1.94	3.93	6.22	0.78			0	0.04	0.02					0.05	0.22	0.51	0		0.06						38.86	150	0.55	5.15	0.23	1.63	0.55	1.48	2.31	-	0.54	0.65	-	0.14	-	-	0.1	6	15	1.16	2.74	4.26	7.14	1.29	-	-	0	0.04	0.18	-	-	-	-	0.05	0.46	1.19	0.01	0.54	0.86	0	-	-	-	-	53.71
H5528_011_0	2007	5	i.6.	i.6.	i.6.	i.6.	i.6.	i.6.					Professional	Professional	Professional	Professional	Professional	Professional					Unlimited	Chiropractic	Podiatry	Hearing Exams	High Tech Radiology	Vision Exams	Hepatitis B					A	A	D	V	T	Coin	Coin	V	V	V	V			V	V	V	V	V	V	V	Coin			V	V	V					Coin	V	V	V	V	V	V																																														-	Unlimited	27.94	8.73	730.62	1298.25	186.55	3.98		11.42	13.72	25.14	28.77			54.04	2296.73	2270.19	247.72	481.47	199.8	548.8	2.53				386.51	193.35						143.15	408.71	5.01	201	478.68	0.92					50 per day; days 1-5	50 per day; days 1-5	0 days 1-20; 75 per day for days 21-100	0 copayment	50 copayment	20 coinsurance	20 coinsurance	ER @ 50 copayment; Urgent Care @ 0 if administered by PCP 15 for specialist	50 copayment	0 copayment	Outpatient Radiology Therapy @20 copayment; 50 High-tech Radiology; Others: 0			CORF Outpatient Rehab Substance Abuse Partial Hospital @ 20 copayment; Other: 0	0 copayment	15 copayment	20 copayment	20 copayment	15 copayment	15 copayment	20 coinsurance			0 Copay	0 Copay	Eyewear every 2 years						15 copayment	15 copayment	15 copayment	50 copayment	20 copayment	10 copayment					195	225	35.33	0	50	0.2	0.2	50	50	0	5.04			1.16	0	15	20	20	15	15	0.2			0	0	10						15	15	15	50	20	10					0.45	0.16	2.15	-	0.78	0.8	-	0.05	0.06	-	0.01	-	-	0.01	-	2.84	0.41	0.8	0.25	0.69	0.51	-	-	-	-	0.16	-	-	-	-	-	0.18	0.51	0.01	0.84	0.8	0	-	-	-	-	12.45	0	0	0.45	0.16	2.15	-	0.78	0.8	-	0.05	0.06	-	0.01	-	-	0.01	-	2.84	0.41	0.8	0.25	0.69	0.51	-	-	-	-	0.16	-	-	-	-	-	0.18	0.51	0.01	0.84	0.8	0	-	-	-	-	12.45	Unlimited	50 per day; days 1-5; 1500 OOP Max	25; 7500 OOP Max	25 coinsurance after Ded	40 copayment	25 no deductible	50 coinsurance after Ded	50 coinsurance after Ded	ER @ 50 copayment; Urgent Care at 25 after Ded	50 copayment	0 copayment	CORFOutpatient Rehab Partial Hospital @ 20 copayment; 50 High-tech Radiology; Other: 0			Outpatient Rehab 20 copayment; Substance Abuse @50; Other 0	25 after 150 Ded	25 after 150 Ded	50 coinsurance after Ded	20 copayment	25 after 150 Ded	25 after 150 Ded	50 coinsurance after Ded			50 coinsurance after Ded	50 coinsurance after Ded	50 coinsurance after Ded					Routine Physicals @25 after Ded	40 copayment	40 copayment	40 copayment		50 coinsurance after Ded						4.7	0.07	0.19	0.55	0.7	1.52		0.5	0.59	0	0.13			0.1	4.09	11.21	0.75	1.94	3.93	6.22	0.78			0	0.07	0.03					0.05	0.22	0.51	0		0.12						38.97	150	0.55	5.15	0.23	2.34	0.55	1.48	2.31	-	0.54	0.65	-	0.14	-	-	0.1	4.09	14.05	1.16	2.74	4.18	6.91	1.29	-	-	0	0.07	0.2	-	-	-	-	0.05	0.4	1.02	0.01	0.84	0.92	0	-	-	-	-	51.42
H5528_012_0	2007	2																					0											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	431.86	0	0	0	0	0	223.46	0	12115.5	1921.19	879.48	0	1618.54	0	0	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute - 0 per day (unlimited days)	1B IP Psych - 0 per day (190 day lifetime limit)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 0	11B Pros./Med Supp. - 0; 11C Diabetes Mon Supplies - 0	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	3 CORF - 20; 5 Partial Hosp - 20; 7C Occupational Therapy - 20; 7I PT and ST Services - 20; 9D Cardiac Rehab Svcs - 20	7A Primary Care - 0; 14B Immunizations - 0; 14C Routine Physical Exams - 0; 14D Pap/Pelvic - 0; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 0	7D Physician Specialist - 10	7E Mental Health - 20; 7H Psychiatric Services - 20; 9C Outpatient Sub Abuse - 20	7C Occupational Therapy - 20; 7I PT and ST Services - 20	8B Outpatient X-Rays - 0	7B Chiropractic Services - 15; 7F Podiatry Services - 15; 7G Other Health Care - 0; 16B Comp Dental - 0; 18A Hearing Exams (Medicare Covered) - 0	15 Medicare Part B Rx Drugs - 0	13A Blood - 0; 17A Eye Exams (Medicare Covered) - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - 0	17B Eye Wear - 0	18A Hearing Exams (Routine) - 0	18B Hearing Aids - 0	19 POS - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											0	0	0	0	0	0	0	47.75	0	0	0	0	0	20	0	10	20	20	0	15	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.72	-	-	-	-	-	0.37	-	10.1	3.2	1.47	-	2.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.88	0	0	-	-	-	-	-	-	-	1.72	-	-	-	-	-	0.37	-	10.1	3.2	1.47	-	2.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.88	0	PBP: 1A IP Acute - 0 per day (unlimited days)	1B IP Psych - 0 per day (190 day lifetime limit)	2 SNF - 0 per day for days 1-100	6 Home Health - 0 per day	10A Ambulance - 0 per trip	11A DME - 0	11B Pros./Med Supp. - 0; 11C Diabetes Mon Supplies - 0	4A Emergency Care - 50; 4B Urgent Care - 10	9B ASC Services - 0	8A Outpatient C/D/T - 0	8B Outpatient X-Rays - 0	9A Outpatient Hospital - 0	12 Renal Dialysis - 0	3 CORF - 20; 5 Partial Hosp - 20; 7C Occupational Therapy - 20; 7I PT and ST Services - 20; 9D Cardiac Rehab Svcs - 20	7A Primary Care - 0; 14B Immunizations - 0; 14C Routine Physical Exams - 0; 14D Pap/Pelvic - 0; 14E Prostate Screening - 0; 14F Colorectal Screening - 0; 14G Bone Mass Meas. - 0; 14H Mammography - 0; 14I Diabetes Monitoring - 0	7D Physician Specialist - 10	7E Mental Health - 20; 7H Psychiatric Services - 20; 9C Outpatient Sub Abuse - 20	7C Occupational Therapy - 20; 7I PT and ST Services - 20	8B Outpatient X-Rays - 0	7B Chiropractic Services - 15; 7F Podiatry Services - 15; 7G Other Health Care - 0; 16B Comp Dental - 0; 18A Hearing Exams (Medicare Covered) - 0	15 Medicare Part B Rx Drugs - 0	13A Blood - 0; 17A Eye Exams (Medicare Covered) - 0	10B Transportation - not covered	16A Preventative Dental - not covered	17A Eye Exams (Routine) - 0	17B Eye Wear - 0	18A Hearing Exams (Routine) - 0	18B Hearing Aids - 0	19 POS - not covered	14A Health Ed/Wellness - 0	13B Acupuncture - not covered											0	0	0	0	0	0	0	0.45	0	0	0	0	0	0.09	0	2.99	1.02	0.47	0	0.68	0	0	0	0	0	0	0	0	0	0	0											5.7	0	0	-	-	-	-	-	-	-	2.17	-	-	-	-	-	0.46	-	13.08	4.22	1.94	-	2.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.58
H5528_802_0	2007	1																					Unlimited											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																														-	Unlimited	298.22	4.25	27.62	10.77	7.92	6.02		99.93	18.4	9.72	11.81			14.3	27.72	99.02	2.39	7.79	29.21	48.96	3.83																					Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day. Lifetime max of 190 days	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					0.05	0.05	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24			0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					15.03	0.21	4.68	-	1.87	1.42	-	0.42	4.34	2.29	2.79	-	-	3.38	6.54	23.37	0.56	1.84	6.89	11.55	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.09	0	0	15.03	0.21	4.68	-	1.87	1.42	-	0.42	4.34	2.29	2.79	-	-	3.38	6.54	23.37	0.56	1.84	6.89	11.55	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.09	Unlimited	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day. Lifetime max of 190 days	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					1.7	0.03	0.53	0	0.2	0.23		0.12	0.81	0.44	0.75			0.94	1.1	3.03	0.11	0.24	1.06	2.12	0.12																					13.52	0	0	16.73	0.24	5.21	-	2.07	1.65	-	0.54	5.16	2.74	3.53	-	-	4.32	7.65	26.39	0.67	2.08	7.95	13.67	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.62
H5528_804_0	2007	1																					Unlimited											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																														-	Unlimited	199.67	2.07	23.54	7.03	6.77	5.46		116.45	14.5	5.38	9.09			10.18	26.04	87.03	2.46	7.89	27.65	45.94	4.36																					Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days Lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					0.05	0.05	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24			0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					10.98	0.11	4.07	-	1.6	1.29	-	0.49	3.42	1.27	2.15	-	-	2.4	6.15	20.54	0.58	1.86	6.53	10.84	1.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.3	0	0	10.98	0.11	4.07	-	1.6	1.29	-	0.49	3.42	1.27	2.15	-	-	2.4	6.15	20.54	0.58	1.86	6.53	10.84	1.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.3	Unlimited	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days Lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					3.22	0.04	1.03	0	0.42	0.46		0.14	0.84	0.34	0.65			0.92	2.34	6.59	0.24	0.4	2.24	4.46	0.3																					24.63	0	0	14.19	0.15	5.1	-	2.02	1.75	-	0.63	4.26	1.61	2.8	-	-	3.33	8.49	27.13	0.82	2.27	8.77	15.3	1.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.93
H5528_806_0	2007	1																					Unlimited											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																														-	Unlimited	298.22	4.25	27.62	10.77	7.92	6.02		99.93	18.4	9.72	11.81			14.3	27.72	99.02	2.39	7.79	29.21	48.96	3.83																					Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day. Lifetime max of 190 days	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					0.05	0.05	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24			0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					15.03	0.21	4.68	-	1.87	1.42	-	0.42	4.34	2.29	2.79	-	-	3.38	6.54	23.37	0.56	1.84	6.89	11.55	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.09	0	0	15.03	0.21	4.68	-	1.87	1.42	-	0.42	4.34	2.29	2.79	-	-	3.38	6.54	23.37	0.56	1.84	6.89	11.55	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.09	Unlimited	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day. Lifetime max of 190 days	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					1.7	0.03	0.53	0	0.2	0.23		0.12	0.81	0.44	0.75			0.94	1.1	3.03	0.11	0.24	1.06	2.12	0.12																					13.52	0	0	16.73	0.24	5.21	-	2.07	1.65	-	0.54	5.16	2.74	3.53	-	-	4.32	7.65	26.39	0.67	2.08	7.95	13.67	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.62
H5528_807_0	2007	1																					Unlimited											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																														-	Unlimited	199.67	2.07	23.54	7.03	6.77	5.46		116.45	14.5	5.38	9.09			10.18	26.04	87.03	2.46	7.89	27.65	45.94	4.36																					Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days Lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					0.05	0.05	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24			0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					10.98	0.11	4.07	-	1.6	1.29	-	0.49	3.42	1.27	2.15	-	-	2.4	6.15	20.54	0.58	1.86	6.53	10.84	1.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.3	0	0	10.98	0.11	4.07	-	1.6	1.29	-	0.49	3.42	1.27	2.15	-	-	2.4	6.15	20.54	0.58	1.86	6.53	10.84	1.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.3	Unlimited	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days Lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	ER @ 50 copayment; Urgent Care @ 20 coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					3.22	0.04	1.03	0	0.42	0.46		0.14	0.84	0.34	0.65			0.92	2.34	6.59	0.24	0.4	2.24	4.46	0.3																					24.63	0	0	14.19	0.15	5.1	-	2.02	1.75	-	0.63	4.26	1.61	2.8	-	-	3.33	8.49	27.13	0.82	2.27	8.77	15.3	1.32	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.93
H5528_809_0	2007	1																					Unlimited											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																														-	Unlimited	20.58	2.64	25.25	9.83	5.23	3.98		11.42	1.53	0.81	0.98			1.19	18.1	65.18	1.57	5.14	19.29	32.32	2.53																					Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					0.06	0.06	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24			0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					1.26	0.16	4.24	-	1.23	0.94	-	0.05	0.36	0.19	0.23	-	-	0.28	4.27	15.38	0.37	1.21	4.55	7.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.96	0	0	1.26	0.16	4.24	-	1.23	0.94	-	0.05	0.36	0.19	0.23	-	-	0.28	4.27	15.38	0.37	1.21	4.55	7.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.96	Unlimited	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					12.5	0.02	0.48	0	0.66	0.71		0.5	3.35	1.83	3.07			3.87	3.56	9.77	0.35	0.76	3.42	6.83	0.37																					52.04	0	0	13.76	0.18	4.71	-	1.89	1.65	-	0.54	3.71	2.02	3.3	-	-	4.15	7.83	25.15	0.72	1.98	7.97	14.45	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.99
H5528_810_0	2007	1																					Unlimited											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin			Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																														-	Unlimited	20.58	2.64	25.25	9.83	5.23	3.98		11.42	1.53	0.81	0.98			1.19	18.1	65.18	1.57	5.14	19.29	32.32	2.53																					Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					0.06	0.06	0.17	0	0.24	0.24	0.24	50	0.24	0.24	0.24			0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					1.26	0.16	4.24	-	1.23	0.94	-	0.05	0.36	0.19	0.23	-	-	0.28	4.27	15.38	0.37	1.21	4.55	7.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.96	0	0	1.26	0.16	4.24	-	1.23	0.94	-	0.05	0.36	0.19	0.23	-	-	0.28	4.27	15.38	0.37	1.21	4.55	7.63	0.6	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.96	Unlimited	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day	Deductible for days 1-60: 1000; Days 61-90:250 per day; Days 91-150:500 per day (190 days lifetime max)	125 for Days 21-100	0 Copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 copayment	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded			20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	50 Coinsurance after Ded of Medicare approved amounts; 20 for certain approved charges	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded	20 Coinsurance after Ded																					12.5	0.02	0.48	0	0.66	0.71		0.5	3.35	1.83	3.07			3.87	3.56	9.77	0.35	0.76	3.42	6.83	0.37																					52.04	0	0	13.76	0.18	4.71	-	1.89	1.65	-	0.54	3.71	2.02	3.3	-	-	4.15	7.83	25.15	0.72	1.98	7.97	14.45	0.96	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	94.99
H5529_001_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	280.81	10.55	312.12		115.71	10.1	4.29	280.99	473.11	732.22	1020.28	39.21	5.95	0.17	4321.92	1561.55	7.82	386.72			253.24				18.11		33.53					1175.02	23.09	77.29	254.28	97.54	0.04	616.54	1.24			750/admit with 1500 yearly max	750/admit with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	15 copay	20 coinsurance	25 copay	25 copay			601.14	570.88	75		75	0.2	0.2	50	175	51.45	60.78	175	34.63	25	10	25	25	25			31.5				25		25					25	50	25	25	13.88	0.2	25	25			14.07	0.5	1.95	-	0.72	2.02	0.86	1.17	6.9	3.14	5.17	0.57	0.02	0	3.6	3.25	0.02	0.81	-	-	0.66	-	-	-	0.04	-	0.07	-	-	-	-	2.45	0.1	0.16	0.53	0.11	0.01	1.28	0	-	-	50.18		1.84	14.07	0.5	1.95	-	0.72	2.02	0.86	1.17	6.9	3.14	5.17	0.57	0.02	0	3.6	3.25	0.02	0.81	-	-	0.66	-	-	-	0.04	-	0.07	-	-	-	-	2.45	0.1	0.16	0.53	0.11	0.01	1.28	0	-	-	50.18	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			16.37	0.03	1.28		0.1	0.23	0.74	0.21	1.27	0.64	0.97	0.01	0	0	1.05	0.67	0	0.06			0.19				0		0					0.29	0.03	0	0.03	0.08	0.01	0.17	0			24.45		0.63	30.44	0.53	3.23	-	0.82	2.25	1.6	1.38	8.17	3.78	6.14	0.59	0.02	0	4.65	3.92	0.02	0.87	-	-	0.85	-	-	-	0.04	-	0.07	-	-	-	-	2.74	0.13	0.16	0.56	0.19	0.02	1.45	0	-	-	74.63
H5529_002_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	1594.78	57.75	312.12		115.71	10.1	4.29	280.99	473.11	732.22	1020.28	39.21	5.95	0.17	4321.92	1561.55	7.82	386.72			253.24				18.11		33.53					1175.02	23.09	77.29	254.28	97.54	0.04	616.54	1.24			175/day with 1750 yearly max	175/day with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	20 copay	10 copay	20 copay	20 copay	20 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 copay	50 copay	20 copay	20 copay	10 copay	20 coinsurance	20 copay	20 copay			116.54	137.36	75		75	0.2	0.2	50	150	51.45	60.78	150	34.63	20	10	20	20	20			31.5				20		20					20	50	20	20	10	0.2	20	20			15.49	0.66	1.95	-	0.72	2.02	0.86	1.17	5.91	3.14	5.17	0.49	0.02	0	3.6	2.6	0.01	0.64	-	-	0.66	-	-	-	0.03	-	0.06	-	-	-	-	1.96	0.1	0.13	0.42	0.08	0.01	1.03	0	-	-	48.94		1.83	15.49	0.66	1.95	-	0.72	2.02	0.86	1.17	5.91	3.14	5.17	0.49	0.02	0	3.6	2.6	0.01	0.64	-	-	0.66	-	-	-	0.03	-	0.06	-	-	-	-	1.96	0.1	0.13	0.42	0.08	0.01	1.03	0	-	-	48.94	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			16.42	0.03	1.29		0.1	0.23	0.74	0.21	1.27	0.64	0.97	0.01	0	0	1.05	0.67	0	0.06			0.19				0		0					0.29	0.03	0	0.03	0.08	0.01	0.17	0			24.51		0.64	31.91	0.69	3.24	-	0.82	2.25	1.6	1.38	7.19	3.78	6.14	0.5	0.02	0	4.65	3.27	0.01	0.71	-	-	0.85	-	-	-	0.03	-	0.06	-	-	-	-	2.25	0.13	0.13	0.46	0.16	0.02	1.19	0	-	-	73.45
H5529_801_0	2007	4	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	298.43	3.96	252.16		0.2	10.65	4.83	240.27	431.31	760.53	988.64	34.1	8.5	0	5256.08	1783.34	2.2	587.19			201.27				24.79		129.6					899.39	19.67	116.91	382.29	127.09	0.04	808.32	2.52			750/admit with 1500 yearly max	750/admit with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			535.47	558.19	72.02		72.02	0.19	0.19	48.02	168.06	49.25	58.11	168.06	33.61	24.01	9.6	24.01	24.01	24.01			36.2				24.01		24.01					24.01	48.02	24.01	24.01	9.6	0.19	24.01	24.01			13.32	0.18	1.51	-	0	2.05	0.93	0.96	6.04	3.12	4.79	0.48	0.02	0	4.21	3.57	0	1.17	-	-	0.61	-	-	-	0.05	-	0.26	-	-	-	-	1.8	0.08	0.23	0.76	0.1	0.01	1.62	0.01	-	-	47.88		1.98	13.32	0.18	1.51	-	0	2.05	0.93	0.96	6.04	3.12	4.79	0.48	0.02	0	4.21	3.57	0	1.17	-	-	0.61	-	-	-	0.05	-	0.26	-	-	-	-	1.8	0.08	0.23	0.76	0.1	0.01	1.62	0.01	-	-	47.88	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			12.02	0.07	1.59		0	0.86	0.39	0.27	1.84	0.41	1.1	0.04	0.01	0	4.58	2.82	0	0.33			0.17				0		0					0.36	0.03	0.02	0.15	0.06	0	0.74	0			27.88		0.49	25.33	0.26	3.1	-	0	2.91	1.32	1.23	7.88	3.53	5.89	0.52	0.03	0	8.79	6.39	0.01	1.51	-	-	0.78	-	-	-	0.05	-	0.26	-	-	-	-	2.16	0.11	0.26	0.91	0.16	0.01	2.36	0.01	-	-	75.76
H5530_001_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	281.19	10.56	312.55		115.87	10.13	4.3	281.38	473.77	733.23	1021.69	39.27	5.96	0.17	4327.9	1563.71	7.83	387.25			253.59				18.13		33.53					1176.64	23.12	77.4	254.63	97.67	0.04	617.39	1.24			750/admit with 1500 yearly max	750/admit with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	15 copay	20 coinsurance	25 copay	25 copay			601.14	570.88	75		75	0.2	0.2	50	175	51.45	60.78	175	34.63	25	10	25	25	25			31.5				25		25					25	50	25	25	13.88	0.2	25	25			14.09	0.5	1.95	-	0.72	2.03	0.86	1.17	6.91	3.14	5.17	0.57	0.02	0	3.61	3.26	0.02	0.81	-	-	0.67	-	-	-	0.04	-	0.07	-	-	-	-	2.45	0.1	0.16	0.53	0.11	0.01	1.29	0	-	-	50.25		1.84	14.09	0.5	1.95	-	0.72	2.03	0.86	1.17	6.91	3.14	5.17	0.57	0.02	0	3.61	3.26	0.02	0.81	-	-	0.67	-	-	-	0.04	-	0.07	-	-	-	-	2.45	0.1	0.16	0.53	0.11	0.01	1.29	0	-	-	50.25	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			16.41	0.03	1.29		0.1	0.23	0.74	0.21	1.27	0.64	0.97	0.01	0	0	1.05	0.67	0	0.06			0.19				0		0					0.29	0.03	0	0.03	0.08	0.01	0.17	0			24.51		0.63	30.5	0.53	3.24	-	0.82	2.25	1.6	1.38	8.18	3.79	6.14	0.59	0.02	0	4.66	3.93	0.02	0.87	-	-	0.85	-	-	-	0.04	-	0.07	-	-	-	-	2.74	0.13	0.17	0.56	0.19	0.02	1.45	0	-	-	74.76
H5530_002_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	1596.98	57.83	312.55		115.87	10.13	4.3	281.38	473.77	733.23	1021.69	39.27	5.96	0.17	4327.9	1563.71	7.83	387.25			253.59				18.13		33.53					1176.64	23.12	77.4	254.63	97.67	0.04	617.39	1.24			175/day with 1750 yearly max	175/day with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	20 copay	10 copay	20 copay	20 copay	20 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 copay	50 copay	20 copay	20 copay	10 copay	20 coinsurance	20 copay	20 copay			116.54	137.36	75		75	0.2	0.2	50	150	51.45	60.78	150	34.63	20	10	20	20	20			31.5				20		20					20	50	20	20	10	0.2	20	20			15.51	0.66	1.95	-	0.72	2.03	0.86	1.17	5.92	3.14	5.17	0.49	0.02	0	3.61	2.61	0.01	0.65	-	-	0.67	-	-	-	0.03	-	0.06	-	-	-	-	1.96	0.1	0.13	0.42	0.08	0.01	1.03	0	-	-	49.01		1.83	15.51	0.66	1.95	-	0.72	2.03	0.86	1.17	5.92	3.14	5.17	0.49	0.02	0	3.61	2.61	0.01	0.65	-	-	0.67	-	-	-	0.03	-	0.06	-	-	-	-	1.96	0.1	0.13	0.42	0.08	0.01	1.03	0	-	-	49.01	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			16.46	0.03	1.29		0.1	0.23	0.74	0.21	1.28	0.65	0.97	0.01	0	0	1.05	0.67	0	0.06			0.19				0		0					0.29	0.03	0	0.03	0.08	0.01	0.17	0			24.57		0.64	31.97	0.69	3.24	-	0.82	2.25	1.6	1.38	7.2	3.79	6.15	0.51	0.02	0	4.66	3.28	0.01	0.71	-	-	0.85	-	-	-	0.03	-	0.06	-	-	-	-	2.26	0.13	0.13	0.46	0.16	0.02	1.2	0	-	-	73.58
H5530_801_0	2007	4	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			A	A	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	298.43	3.96	252.16		0.2	10.65	4.83	240.27	431.31	760.53	988.64	34.1	8.5	0	5256.08	1783.34	2.2	587.19			201.27				24.79		129.6					899.39	19.67	116.91	382.29	127.09	0.04	808.32	2.52			750/admit with 1500 yearly max	750/admit with 1500 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			535.47	558.19	72.02		72.02	0.19	0.19	48.02	168.06	49.25	58.11	168.06	33.61	24.01	9.6	24.01	24.01	24.01			36.2				24.01		24.01					24.01	48.02	24.01	24.01	9.6	0.19	24.01	24.01			13.32	0.18	1.51	-	0	2.05	0.93	0.96	6.04	3.12	4.79	0.48	0.02	0	4.21	3.57	0	1.17	-	-	0.61	-	-	-	0.05	-	0.26	-	-	-	-	1.8	0.08	0.23	0.76	0.1	0.01	1.62	0.01	-	-	47.88		1.98	13.32	0.18	1.51	-	0	2.05	0.93	0.96	6.04	3.12	4.79	0.48	0.02	0	4.21	3.57	0	1.17	-	-	0.61	-	-	-	0.05	-	0.26	-	-	-	-	1.8	0.08	0.23	0.76	0.1	0.01	1.62	0.01	-	-	47.88	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			12.02	0.07	1.59		0	0.86	0.39	0.27	1.84	0.41	1.1	0.04	0.01	0	4.58	2.82	0	0.33			0.17				0		0					0.36	0.03	0.02	0.15	0.06	0	0.74	0			27.88		0.49	25.33	0.26	3.1	-	0	2.91	1.32	1.23	7.88	3.53	5.89	0.52	0.03	0	8.79	6.39	0.01	1.51	-	-	0.78	-	-	-	0.05	-	0.26	-	-	-	-	2.16	0.11	0.26	0.91	0.16	0.01	2.36	0.01	-	-	75.76
H5531_001_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	5000	1831.94		1122.64	616.33	161.6	16.04		317.9	218.72	1342.36	1550.52	0	112.98	375.47	3394	5576.25		620.81			251.52				903.44		85.3															175/day 1-10		0/day 1-10; 100/day 11-100	35	100	20		50 ER 25 urgent care	200	35	35 routine 100 complex	35	30	35	25	35 Specialist; 30 Renal Dialysis	35	35	35	35	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Not Covered	0											142.87		63.47	35	100	0.2		46.75	200	35	57.23	35	30	35	25	34.45	35	35	35	35	45	0	0	0	0	0	0	0	0	0	0											21.81	-	5.94	1.8	1.35	3.21	-	1.24	3.65	3.92	7.39	-	0.28	1.1	7.07	16.01	-	1.81	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.51			21.81	-	5.94	1.8	1.35	3.21	-	1.24	3.65	3.92	7.39	-	0.28	1.1	7.07	16.01	-	1.81	-	-	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.51		30	30	30	30	100	20	20	50 ER 25 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45	0	Not Covered	Not Covered	30	0	30	0	N/A	Not Covered	0											12.38	0	1.11	0.14	0.14	0.35	0	0.14	0.97	0.63	1.91	0	0.17	0.24	1.1	7.44	0	0.22	0	0	0.13	0	0	0	0.17	0	0.01	0	0	0	0											27.26	1000	13.09	34.19	-	7.05	1.94	1.49	3.56	-	1.37	4.61	4.55	9.31	-	0.45	1.34	8.17	23.45	-	2.03	-	-	1.07	-	-	-	0.17	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.77
H5531_002_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	3500	1842.6		1129.18	619.91	162.54	16.13		319.75	219.99	1350.17	1559.54	0	113.64	377.66	3413.75	5608.7		624.43			252.98				908.7		85.79															175/day 1-10		0/day 1-10; 100/day 11-100	35	100	20		50 ER 25 urgent care	200	25	25 routine 100 complex	25	25	25	10	25	25	25	25	25	45	0	Not Covered	Not Covered	0	100 Every 2 Years	0	750 Every 3 Years	N/A	Fitness	0											142.87		63.47	35	100	0.2		46.75	200	20	47.36	25	25	25	10	25	25	25	25	25	45	0	0	0	0	0	0	0	0	0	0											21.94	-	5.97	1.81	1.35	3.23	-	1.25	3.67	2.25	6.15	-	0.24	0.79	2.84	11.68	-	1.3	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.42			21.94	-	5.97	1.81	1.35	3.23	-	1.25	3.67	2.25	6.15	-	0.24	0.79	2.84	11.68	-	1.3	-	-	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.42		30	30	30	30	100	20	20	50 ER 25 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45	0	Not Covered	Not Covered	30	0	30	0	N/A	Not Covered	0											9.66	0	0.87	0.11	0.11	0.26	0	0.1	0.76	0.49	1.49	0	0.13	0.19	0.86	5.81	0	0.17	0	0	0.09	0	0	0	0.13	0	0.01	0	0	0	0											21.26	500	15.27	31.6	-	6.84	1.92	1.46	3.49	-	1.35	4.42	2.75	7.65	-	0.37	0.98	3.71	17.5	-	1.48	-	-	1.04	-	-	-	0.13	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.68
H5531_801_0	2007	2																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1450.61		645.65	679.24	109.33	20.73		208.76	192.32	18.9	58.68	0	0	363.27	3854.17	8588.66	0	960.09	0	0	7.93																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					17.37	-	5.38	1.98	1.37	6.22	-	0.87	2.4	3.78	11.74	-	-	1.06	11.24	25.05	-	2.8	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.84			17.37	-	5.38	1.98	1.37	6.22	-	0.87	2.4	3.78	11.74	-	-	1.06	11.24	25.05	-	2.8	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.84		500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	150 per trip	500 deductible; 70 coins; no max OOP		50 per visit	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP				500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP															9.39		0.6	0.12	0.12	0.3		0.08	0.84	0.5	1.56	0	0	0.36	1.05	5.97	0	0.22	0	0	0.23				0.16		0.01															21.51			26.76	-	5.98	2.1	1.49	6.52	-	0.95	3.24	4.28	13.29	-	-	1.42	12.29	31.02	-	3.02	-	-	1.82	-	-	-	0.16	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.35
H5531_802_0	2007	2																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1450.61		645.65	679.24	109.33	20.73		208.76	192.32	18.9	58.68	0	0	363.27	3854.17	8588.66	0	960.09	0	0	7.93																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					17.37	-	5.38	1.98	1.37	6.22	-	0.87	2.4	3.78	11.74	-	-	1.06	11.24	25.05	-	2.8	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.84			17.37	-	5.38	1.98	1.37	6.22	-	0.87	2.4	3.78	11.74	-	-	1.06	11.24	25.05	-	2.8	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	92.84		500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	150 per trip	500 deductible; 70 coins; no max OOP		50 per visit	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP	500 deductible; 70 coins; no max OOP				500 deductible; 70 coins; no max OOP		500 deductible; 70 coins; no max OOP															9.39		0.6	0.12	0.12	0.3		0.08	0.84	0.5	1.56	0	0	0.36	1.05	5.97	0	0.22	0	0	0.23				0.16		0.01															21.51			26.76	-	5.98	2.1	1.49	6.52	-	0.95	3.24	4.28	13.29	-	-	1.42	12.29	31.02	-	3.02	-	-	1.82	-	-	-	0.16	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.35
H5532_001_0	2007	5																					4000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1705.02	92.92	1017.57	0	127.14	19.45	13.02	394.71	55.68	13459.66	69.11	0	0.06	32.72	4868.37	7383.68	354.54	5.97	0	0	45.84	1829.11	0	0	32.24	0	199.71	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											172.39	172.39	87.66	0	102.27	0.15	0.16	29.22	0.15	3.51	0.11	0	0.18	0.15	15	25	37.5	0.15	0	0	0.18	25	0	0	25	0	25	0	0	0	0											24.49	1.33	7.43	-	1.08	2.84	2.03	0.96	8.14	3.93	7.67	-	0.01	4.78	6.09	15.38	1.11	0.87	-	-	8.04	3.81	-	-	0.07	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.49		52.14	24.49	1.33	7.43	-	1.08	2.84	2.03	0.96	8.14	3.93	7.67	-	0.01	4.78	6.09	15.38	1.11	0.87	-	-	8.04	3.81	-	-	0.07	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	100.49		350 (1a)	350 (1b)	175 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 30 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											1.01	0.06	0.95	0.35	0.18	0.58	0.39	0.12	1.26	0.68	1.19	0	0	0.74	0.97	1.83	0.12	0.18	0	0	1.36	0.45	0	0	0.01	0	0.05	0	0	0	0											12.46		0	25.51	1.39	8.38	0.35	1.27	3.42	2.42	1.08	9.39	4.61	8.86	-	0.01	5.52	7.05	17.21	1.23	1.05	-	-	9.4	4.26	-	-	0.08	-	0.47	-	-	-	-	-	-	-	-	-	-	-	-	-	-	112.95
H5533_002_0	2007	3																					3100											A	A	D		T	coin	coin	V	V		P			V	V	V	V	V			S	V	T	V	V		V																																																								-	N/A	307.6	7.11	187.93		155.36	13.21	2.03	507.31	535		2212.98			224.08	4104.93	5300.56	0.12	763.33			1453.54	244.31	21.89	1.13	0		0.04															1a:  100 Copay max 3	1b:  100 Copay max 3	2:  50 per day day 16 - 100		10a:  100 per Trip	11a:  15 Coinsurance	11b:  15 Coinsurance	4:  50 Copay	9ab:  60 Copay		8b:  0/20 Copay			7ci:  20 Copay	7a 14c:  10 Copay	7bdfg 16a17a 18a:  20 Copay	7eh 9c:  20 Copay	7ci:  20 Copay			15:  10/30 Copay per 30/90 day supply	11c:  10/30 Copay per 30/90 day supply	10a:  100 per Trip	16a:  20 Copay 16b:  20 coinsurance	17a:  20 Copay		18a:  20 Copay															95	95	47.5		95	0.14	0.14	47.5	57		9.05			19	9.5	19	19	19			9.5	9.5	95	19	19		19															2.44	0.06	0.74	-	1.23	1.85	0.28	2.01	2.54	-	1.67	-	-	0.35	3.25	8.39	0	1.21	-	-	1.15	0.19	0.17	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.54			2.44	0.06	0.74	-	1.23	1.85	0.28	2.01	2.54	-	1.67	-	-	0.35	3.25	8.39	0	1.21	-	-	1.15	0.19	0.17	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.54	3100	coin	coin	coin	coin	coin	coin	coin	copay	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin											2.08	0.03	0.03	0.12	0.35	0	0.01	0.14	0.36	0	0.39	0	0	0.05	0.16	0.34	0	0.26	0	0	0	0	0.01	0	0	0	0	0	0	0	0											4.33			4.52	0.09	0.77	0.12	1.58	1.85	0.29	2.15	2.9	-	2.06	-	-	0.4	3.41	8.73	0	1.47	-	-	1.15	0.19	0.18	0	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.87
H5533_801_0	2007	4																					3100															T	coin	coin	V	V		P			V	V	V	V	V			S	V	T	V	V		V																																																								-	N/A					241.86	14.68	2.23	755.78	697.53		3276.22			325.53	5972.78	7371.07	0.2	1162.27			1038.19	298.19	33.96	2.66	0		0.07																			10a:  50 per Trip	11a:  15 Coinsurance	11b:  15 Coinsurance	4:  50 Copay	9a-b:  25 Copay		8b:  0/25 Copay			7ci:  15 Copay	7a14c:  15 Copay	7bdfg:  15 Copay  16a17a18a:  25 Copay	7eh9c:  15 Copay	7ci:  15 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  50 per Trip	16a:  25 Copay 16b:  20 coinsurance	17a:  25 Copay		18a:  25 Copay																			47.5	0.14	0.14	47.5	23.75		11.33			14.25	14.25	14.25	14.25	14.25			19	19	47.5	23.75	23.75		23.75															-	-	-	-	0.96	2.06	0.31	2.99	1.38	-	3.09	-	-	0.39	7.09	8.75	0	1.38	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66			-	-	-	-	0.96	2.06	0.31	2.99	1.38	-	3.09	-	-	0.39	7.09	8.75	0	1.38	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66	3100	coin	coin	coin	coin	coin	coin	coin	copay	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin											2.8	0.05	0.05	0.19	0.14	0	0.06	0.15	0.33	0	0.45	0	0	0.01	0.23	0.35	0	0.21	0	0	0	0	0	0	0	0	0	0	0	0	0											5.02			2.8	0.05	0.05	0.19	1.1	2.06	0.37	3.14	1.71	-	3.54	-	-	0.4	7.32	9.1	0	1.59	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.68
H5533_802_0	2007	4																					3100															T	coin	coin	V	V		P			V	V	V	V	V			S	V	T	V	V		V																																																								-	N/A					241.86	14.68	2.23	755.78	697.53		3276.22			325.53	5972.78	7371.07	0.2	1162.27			1038.19	298.19	33.96	2.66	0		0.07																			10a:  50 per Trip	11a:  15 Coinsurance	11b:  15 Coinsurance	4:  50 Copay	9a-b:  25 Copay		8b:  0/25 Copay			7ci:  15 Copay	7a14c:  15 Copay	7bdfg:  15 Copay  16a17a18a:  25 Copay	7eh9c:  15 Copay	7ci:  15 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  50 per Trip	16a:  25 Copay 16b:  20 coinsurance	17a:  25 Copay		18a:  25 Copay																			47.5	0.14	0.14	47.5	23.75		11.33			14.25	14.25	14.25	14.25	14.25			19	19	47.5	23.75	23.75		23.75															-	-	-	-	0.96	2.06	0.31	2.99	1.38	-	3.09	-	-	0.39	7.09	8.75	0	1.38	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66			-	-	-	-	0.96	2.06	0.31	2.99	1.38	-	3.09	-	-	0.39	7.09	8.75	0	1.38	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66	3100	coin	coin	coin	coin	coin	coin	coin	copay	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin											2.8	0.05	0.05	0.19	0.14	0	0.06	0.15	0.33	0	0.45	0	0	0.01	0.23	0.35	0	0.21	0	0	0	0	0	0	0	0	0	0	0	0	0											5.02			2.8	0.05	0.05	0.19	1.1	2.06	0.37	3.14	1.71	-	3.54	-	-	0.4	7.32	9.1	0	1.59	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.68
H5533_803_0	2007	4																					3100															T	coin	coin	V	V		P			V	V	V	V	V			S	V	T	V	V		V																																																								-	N/A					241.86	14.68	2.23	755.78	697.53		3276.22			325.53	5972.78	7371.07	0.2	1162.27			1038.19	298.19	33.96	2.66	0		0.07																			10a:  50 per Trip	11a:  15 Coinsurance	11b:  15 Coinsurance	4:  50 Copay	9a-b:  25 Copay		8b:  0/25 Copay			7ci:  15 Copay	7a14c:  15 Copay	7bdfg:  15 Copay  16a17a18a:  25 Copay	7eh9c:  15 Copay	7ci:  15 Copay			15:  20/60 Copay per 30/90 day supply	11c:  20/60 Copay per 30/90 day supply	10a:  50 per Trip	16a:  25 Copay 16b:  20 coinsurance	17a:  25 Copay		18a:  25 Copay																			47.5	0.14	0.14	47.5	23.75		11.33			14.25	14.25	14.25	14.25	14.25			19	19	47.5	23.75	23.75		23.75															-	-	-	-	0.96	2.06	0.31	2.99	1.38	-	3.09	-	-	0.39	7.09	8.75	0	1.38	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66			-	-	-	-	0.96	2.06	0.31	2.99	1.38	-	3.09	-	-	0.39	7.09	8.75	0	1.38	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.66	3100	coin	coin	coin	coin	coin	coin	coin	copay	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin											2.8	0.05	0.05	0.19	0.14	0	0.06	0.15	0.33	0	0.45	0	0	0.01	0.23	0.35	0	0.21	0	0	0	0	0	0	0	0	0	0	0	0	0											5.02			2.8	0.05	0.05	0.19	1.1	2.06	0.37	3.14	1.71	-	3.54	-	-	0.4	7.32	9.1	0	1.59	-	-	1.64	0.47	0.13	0.01	-	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.68
H5539_001_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		349.43	35.75	86.13		14.09	22.56	22.2	23.77	28.31	23.45	19.5	2.56	2.57	45.84	25.18	31.57	11.28	5.15	22.74	115.79	25.95	0.09																				Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				23.2	2.37	15.81	-	3.32	5.32	5.24	5.61	6.68	5.53	4.6	0.61	0.61	10.82	5.94	7.45	2.66	1.22	5.37	27.33	6.12	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	145.84	138	0	23.2	2.37	15.81	-	3.32	5.32	5.24	5.61	6.68	5.53	4.6	0.61	0.61	10.82	5.94	7.45	2.66	1.22	5.37	27.33	6.12	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	145.84		Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin																																										-		0	23.2	2.37	15.81	-	3.32	5.32	5.24	5.61	6.68	5.53	4.6	0.61	0.61	10.82	5.94	7.45	2.66	1.22	5.37	27.33	6.12	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	145.84
H5549_001_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		764.18	108.44	191.19		18.68	23.01	18.83	22.66	32.48	41.31	31.52	4.81	3.49	77.45	44.26	65.53	19.76	17.99	39.5	165.97	33.59	0.06																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.05	0.05	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				38.51	5.47	32.39	-	4.41	5.43	4.44	5.35	7.66	9.75	7.44	1.14	0.82	18.28	10.44	15.47	4.66	4.25	9.32	39.17	7.93	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	232.34		0	38.51	5.47	32.39	-	4.41	5.43	4.44	5.35	7.66	9.75	7.44	1.14	0.82	18.28	10.44	15.47	4.66	4.25	9.32	39.17	7.93	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	232.34																																																																																				-		0	38.51	5.47	32.39	-	4.41	5.43	4.44	5.35	7.66	9.75	7.44	1.14	0.82	18.28	10.44	15.47	4.66	4.25	9.32	39.17	7.93	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	232.34
H5554_001_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	324.64	19.01	69.82	0	12.6	29.52	19.21	9.7	21.02	14.81	29.83	1	1.15	41.98	74.54	137.29	9.3	6.33	28.71	50.97	9.78	5.17	0	0	0	0	0	0	0	0	0											5.5 Medicare equivalent Coinsurance	5.5 Medicare equivalent Coinsurance	12.7 Medicare equivalent Coinsurance	0.0 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.4 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	22.9 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	23.6 Medicare equivalent Coinsurance	0	0	0	0	0	0	0	0	0											0.06	0.06	0.13	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.23	0.24	0.24	0	0	0	0	0	0	0	0	0											17.89	1.05	8.89	-	2.97	6.97	4.53	2.29	4.96	3.5	7.04	0.24	0.27	9.91	17.48	32.4	2.19	1.49	6.78	11.65	2.31	1.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.02	0	0	17.89	1.05	8.89	-	2.97	6.97	4.53	2.29	4.96	3.5	7.04	0.24	0.27	9.91	17.48	32.4	2.19	1.49	6.78	11.65	2.31	1.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.02	0																																																																																			-	0	0	17.89	1.05	8.89	-	2.97	6.97	4.53	2.29	4.96	3.5	7.04	0.24	0.27	9.91	17.48	32.4	2.19	1.49	6.78	11.65	2.31	1.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.02
H5575_001_0	2007	19																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		456.91	8.92	425.42	0	18.91	3.52	11.45	10.76	9.99	17.17	16.5	0.64	0.96	97.9	0	103.23	6.14	0.88	20.84	37.35	3.85	4.44	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9A OP Hospital:  138 Ded and 20 Coinsurance   9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	5 Partial Hosp:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 0 14B Immunizations: 0 14C Routine Physical Exam: 0  14D Pap Smears:  0 14D Pelvic Exams:  0 14E Prostate Screening:  0 14F Colorectal Screening:  0 14G Bone Mass Measurement:  0 14H Mammography:  0 14I Diabetes Monitoring:  0	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance   9C OP Substance Abuse:  138 Ded and 20 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance for Radiology Services	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 0 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: 12 Trips Per Year	16A Preventive Dental Services: Not Covered  16B Comprehensive Dental Services:  Not Covered	17A Routine Eye Exams: 0 Copay	17B Eye Wear: 1 Pair of Glasses or Contacts Per Year	18A Routine Hearing Exams: 20 Coinsurance	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.22	0.24	0.24	0.24	0.23	0.24	0.24	0	0	0	0	0	0	0	0	0											35.55	0.69	84.83	-	4.46	0.83	2.7	2.54	2.36	4.05	3.89	0.15	0.23	23.1	-	22.92	1.45	0.21	4.92	8.58	0.91	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	205.43	0	0	35.55	0.69	84.83	-	4.46	0.83	2.7	2.54	2.36	4.05	3.89	0.15	0.23	23.1	-	22.92	1.45	0.21	4.92	8.58	0.91	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	205.43																																																																																				-			35.55	0.69	84.83	-	4.46	0.83	2.7	2.54	2.36	4.05	3.89	0.15	0.23	23.1	-	22.92	1.45	0.21	4.92	8.58	0.91	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	205.43
H5575_002_0	2007	20																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 0 copay  4B Urgent Care: 0 copay	9A Outpatient Hospital: 0 copay   9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay	5  Partial Hosp:  0 copay	12 Renal Dialysis: 0 copay	3 CORF: 0 copay  9D Cardiac Rehab: 0 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 0 copay	7E Mental Health:   0 copay 7H Psychiatric:   0 copay   9C OP Substance Abuse: 0 copay	7C Occupational Therapy:  0 copay 7I Physical and Speech Therapy:  0 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  0 copay 7F Podiatry:  0 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  0 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay	10B Transportation: 12 Trips Per Year	16A Preventive Dental Services: Not covered  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 0 copay	17B Eye Wear: 1 Pair of Glasses or Contacts Per Year	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5576_001_0	2007	3																					3100											D	D	D	V	Coin	Coin	Coin	V	V	V	V	V	Coin	V	P	P	P	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	Coin	P	P																																																				-		1938.8	146.76			5.79	19.01	3.56	365.61	403.05		236.67		0.01	203.28	3138.65	4163.43	264.96	3.94		0.57	22.78								14.58													1a: 200/days 1-4	1b: 200/days 1-4			10a: 20	11a: 20	11b-c: 20	4a: 50	9a-b: 200		0.472222222		12:20		7a: 5	7b 7d 7f 7g 17a: 30	7e7h 9c: 30	3 7c 7i: 20		20 - Allergy	15:20								Addtl 20													56.42	56.42			0.15	0.15	0.15	38.54	154.15		154.15		0.15	69.47	3.85	23.12	23.12	0.15		0.15	0.15								0.58													9.12	0.69	-	-	0.89	2.93	0.55	1.17	5.18	-	3.04	-	0	1.18	1.01	8.02	0.51	0.61	-	0.09	3.51	-	-	-	-	-	-	-	8.4	-	-	-	-	-	-	-	-	-	-	-	-	46.9		13.95	9.12	0.69	-	-	0.89	2.93	0.55	1.17	5.18	-	3.04	-	0	1.18	1.01	8.02	0.51	0.61	-	0.09	3.51	-	-	-	-	-	-	-	8.4	-	-	-	-	-	-	-	-	-	-	-	-	46.9																																																																																				-		0	9.12	0.69	-	-	0.89	2.93	0.55	1.17	5.18	-	3.04	-	0	1.18	1.01	8.02	0.51	0.61	-	0.09	3.51	-	-	-	-	-	-	-	8.4	-	-	-	-	-	-	-	-	-	-	-	-	46.9
H5576_002_0	2007	3																					3100											D	D	D	V	Coin	Coin	Coin	V	V	V	V	V	Coin	V	P	P	P	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	Coin	P	P																																																				-		2014.39	152.48			5.79	19.01	3.56	379.08	417.92		245.39		0.01	210.78	3254.4	4316.97	274.73	4.09		0.59	23.62								15.16													1a: 100/Admit	1b: 100/Admit			10a: 20	11a: 20	11b-c: 20	4a: 50	9a-b: 100		8:50		12:20		7a: 5	7b 7d 7f 7g 17a: 25	7e7h 9c: 25	3 7c 7i: 20		20 - Allergy	15:20								Addtl 20													13.61	8.91			0.17	0.17	0.17	41.77	83.54		41.77		0.17	74.57	4.18	21.08	20.88	0.17		0.17	0.17								0.63													2.28	0.11	-	-	0.97	3.18	0.59	1.32	2.91	-	0.85	-	0	1.31	1.13	7.59	0.48	0.68	-	0.1	3.95	-	-	-	-	-	-	-	9.54	-	-	-	-	-	-	-	-	-	-	-	-	37		7.2	2.28	0.11	-	-	0.97	3.18	0.59	1.32	2.91	-	0.85	-	0	1.31	1.13	7.59	0.48	0.68	-	0.1	3.95	-	-	-	-	-	-	-	9.54	-	-	-	-	-	-	-	-	-	-	-	-	37																																																																																				-		0	2.28	0.11	-	-	0.97	3.18	0.59	1.32	2.91	-	0.85	-	0	1.31	1.13	7.59	0.48	0.68	-	0.1	3.95	-	-	-	-	-	-	-	9.54	-	-	-	-	-	-	-	-	-	-	-	-	37
H5576_003_0	2007	3																					3100											D	D	D	V	Coin	Coin	Coin	V	V	V	V	V	Coin	V	P	P	P	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	Coin	P	P																																																				-		2137.85	161.83			5.46	17.93	3.36	400.52	441.56		259.28		0.01	222.71	3438.53	4561.22	290.27	4.2		0.6	24.24								15.29													1a: 200/days 1-4	1b: 200/days 1-4			10a: 20	11a: 20	11b-c: 20	4a: 50	9a-b: 200		0.472222222		12:20		7a: 5	7b 7d 7f 7g 17a: 30	7e7h 9c: 30	3 7c 7i: 20		20 - Allergy	15:20								Addtl 20													55.51	55.51			0.15	0.15	0.15	37.92	151.66		151.66		0.15	66.49	3.79	23.1	22.75	0.15		0.15	0.15								0.57													9.89	0.75	-	-	0.83	2.72	0.51	1.27	5.58	-	3.28	-	0	1.23	1.09	8.78	0.55	0.64	-	0.09	3.68	-	-	-	-	-	-	-	8.75	-	-	-	-	-	-	-	-	-	-	-	-	49.63		15.64	9.89	0.75	-	-	0.83	2.72	0.51	1.27	5.58	-	3.28	-	0	1.23	1.09	8.78	0.55	0.64	-	0.09	3.68	-	-	-	-	-	-	-	8.75	-	-	-	-	-	-	-	-	-	-	-	-	49.63																																																																																				-		0	9.89	0.75	-	-	0.83	2.72	0.51	1.27	5.58	-	3.28	-	0	1.23	1.09	8.78	0.55	0.64	-	0.09	3.68	-	-	-	-	-	-	-	8.75	-	-	-	-	-	-	-	-	-	-	-	-	49.63
H5576_004_0	2007	3																					3100											D	D	D	V	Coin	Coin	Coin	V	V	V	V	V	Coin	V	P	P	P	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	Coin	P	P																																																				-		2213.43	167.55			5.46	17.93	3.36	413.99	456.42		268		0.01	230.2	3554.25	4714.72	300.04	4.34		0.62	25.06								15.84													1a: 100/Admit	1b: 100/Admit			10a: 20	11a: 20	11b-c: 20	4a: 50	9a-b: 100		8:50		12:20		7a: 5	7b 7d 7f 7g 17a: 25	7e7h 9c: 25	3 7c 7i: 20		20 - Allergy	15:20								Addtl 20													13.43	8.79			0.16	0.16	0.16	41.21	82.42		41.21		0.16	71.56	4.12	20.82	20.6	0.16		0.16	0.16								0.63													2.48	0.12	-	-	0.9	2.96	0.55	1.42	3.13	-	0.92	-	0	1.37	1.22	8.18	0.52	0.72	-	0.1	4.13	-	-	-	-	-	-	-	9.92	-	-	-	-	-	-	-	-	-	-	-	-	38.65		8.14	2.48	0.12	-	-	0.9	2.96	0.55	1.42	3.13	-	0.92	-	0	1.37	1.22	8.18	0.52	0.72	-	0.1	4.13	-	-	-	-	-	-	-	9.92	-	-	-	-	-	-	-	-	-	-	-	-	38.65																																																																																				-		0	2.48	0.12	-	-	0.9	2.96	0.55	1.42	3.13	-	0.92	-	0	1.37	1.22	8.18	0.52	0.72	-	0.1	4.13	-	-	-	-	-	-	-	9.92	-	-	-	-	-	-	-	-	-	-	-	-	38.65
H5576_005_0	2007	3																					3100											D	D	D	V	Coin	Coin	Coin	V	V	V	V	V	Coin	V	P	P	P	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	Coin	P	P																																																				-		2060.61	155.98			6.11	20.06	3.76	387.85	427.61		251.08		0.01	215.67	3329.84	4417.05	281.1	4.38		0.63	25.27								15.93													1a: 200/days 1-4	1b: 200/days 1-4			10a: 20	11a: 20	11b-c: 20	4a: 50	9a-b: 200		0.472222222		12:20		7a: 5	7b 7d 7f 7g 17a: 30	7e7h 9c: 30	3 7c 7i: 20		20 - Allergy	15:20								Addtl 20													55.34	55.34			0.15	0.15	0.15	37.8	151.21		151.21		0.15	69.91	3.78	22.68	22.68	0.15		0.15	0.15								0.58													9.5	0.72	-	-	0.92	3.03	0.57	1.22	5.39	-	3.16	-	0	1.26	1.05	8.35	0.53	0.66	-	0.1	3.82	-	-	-	-	-	-	-	9.17	-	-	-	-	-	-	-	-	-	-	-	-	49.46		15.96	9.5	0.72	-	-	0.92	3.03	0.57	1.22	5.39	-	3.16	-	0	1.26	1.05	8.35	0.53	0.66	-	0.1	3.82	-	-	-	-	-	-	-	9.17	-	-	-	-	-	-	-	-	-	-	-	-	49.46																																																																																				-		0	9.5	0.72	-	-	0.92	3.03	0.57	1.22	5.39	-	3.16	-	0	1.26	1.05	8.35	0.53	0.66	-	0.1	3.82	-	-	-	-	-	-	-	9.17	-	-	-	-	-	-	-	-	-	-	-	-	49.46
H5576_006_0	2007	3																					3100											D	D	D	V	Coin	Coin	Coin	V	V	V	V	V	Coin	V	P	P	P	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	Coin	P	P																																																				-		2136	161.69			6.11	20.06	3.76	401.29	442.43		259.79		0.02	223.14	3445.27	4570.16	290.84	4.53		0.65	26.15								16.47													1a: 100/Admit	1b: 100/Admit			10a: 20	11a: 20	11b-c: 20	4a: 50	9a-b: 100		8:50		12:20		7a: 5	7b 7d 7f 7g 17a: 25	7e7h 9c: 25	3 7c 7i: 20		20 - Allergy	15:20								Addtl 20													13.37	8.75			0.16	0.16	0.16	41.04	82.07		41.04		0.16	75.18	4.1	20.74	20.52	0.16		0.16	0.16								0.63													2.38	0.12	-	-	1	3.29	0.62	1.37	3.03	-	0.89	-	0	1.4	1.18	7.9	0.5	0.74	-	0.11	4.29	-	-	-	-	-	-	-	10.35	-	-	-	-	-	-	-	-	-	-	-	-	39.16		8.45	2.38	0.12	-	-	1	3.29	0.62	1.37	3.03	-	0.89	-	0	1.4	1.18	7.9	0.5	0.74	-	0.11	4.29	-	-	-	-	-	-	-	10.35	-	-	-	-	-	-	-	-	-	-	-	-	39.16																																																																																				-		0	2.38	0.12	-	-	1	3.29	0.62	1.37	3.03	-	0.89	-	0	1.4	1.18	7.9	0.5	0.74	-	0.11	4.29	-	-	-	-	-	-	-	10.35	-	-	-	-	-	-	-	-	-	-	-	-	39.16
H5576_801_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	Coin	P	P																																																				-		305.84	12.35	12.9		5.97	19.6	12.25	13.07	45.09	23.12	24.61	5.09	0.01	23.74	17.56	37.78	1.86	4.4	28.08	110.58	25.41	0.12																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.22		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55		0	22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55																																																																																				-		0	22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55
H5576_802_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	Coin	P	P																																																				-		305.84	12.35	12.9		5.97	19.6	12.25	13.07	45.09	23.12	24.61	5.09	0.01	23.74	17.56	37.78	1.86	4.4	28.08	110.58	25.41	0.12																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.22		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55		0	22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55																																																																																				-		0	22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55
H5576_803_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	Coin	P	P																																																				-		305.84	12.35	12.9		5.97	19.6	12.25	13.07	45.09	23.12	24.61	5.09	0.01	23.74	17.56	37.78	1.86	4.4	28.08	110.58	25.41	0.12																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.22		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55		0	22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55																																																																																				-		0	22.8	0.92	2.81	-	1.41	4.63	2.89	3.08	10.64	5.46	5.81	1.2	0	5.6	4.14	8.92	0.44	1.04	6.63	26.1	6	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	120.55
H5577_001_0	2007	7																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5577_002_0	2007	4																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5578_002_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1504.5	86.15	605.13	1569.93	93.91	8.23	8.1	294.5	37.72		17.03	1.93	0.21	12.8	3713.85	5172.78	248.01	460.58	15.49	6	24.94				126.91		113.6															#1A: 110 days 1-5	#1B: 200 days 1-5	#2: 25 days 11-100	#6: 15	#10A: 125	#11A: 20	#11B/11C: 20	#4: 50	#9A OP Hosp: 15 NTE 400; #9B ASC: 15 NTE 250	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 20; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 20	#7A: 15; #14C: 15	#7B : 20; #7D/7F/7G #16B #17A #18A: 30	#7E/#7H: 40	#7C/#7I: 20	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	67.42	122.59	13.45	15	125	0.2	0.2	50	0.12		0.16	0.15	0.2	0.16	15	29.5	40	20	0.15	0.15	0.2				25		30															8.45	0.88	0.68	1.96	0.98	1.65	1.62	1.23	4.39	-	2.68	0.29	0.04	1.99	4.64	12.72	0.83	0.77	2.32	0.9	4.99	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.55		0	8.45	0.88	0.68	1.96	0.98	1.65	1.62	1.23	4.39	-	2.68	0.29	0.04	1.99	4.64	12.72	0.83	0.77	2.32	0.9	4.99	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.55																																																																																				-		0	8.45	0.88	0.68	1.96	0.98	1.65	1.62	1.23	4.39	-	2.68	0.29	0.04	1.99	4.64	12.72	0.83	0.77	2.32	0.9	4.99	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.55
H5578_003_0	2007	7																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1492.2	75.65	591.4		89.77	7.94	7.9	290.98	39.31		17.57	1.98	0.18	12.79	3989.22	5725.89	253.43	505.51	16.96	6.55	27.05				129.91		116.29															#1A: 50 days 1-5	#1B: 150 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 250; #9B ASC: 15 NTE 125	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 15; #5: 35; #9A OP Hosp 15 / Chemo 20; #9C: 35; #9D: 15	#7A: 10; #14C: 0	#7B : 15; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 35	#7C/#7I: 15	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 125 Allowance every two years	#18A: 20	#18B: 500 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	28.01	84.03	9.83		91.4	0.18	0.15	45.7	0.09		0.11	0.14	0.18	0.14	9.14	22.38	31.99	13.71	0.09	0.09	0.18				25		20															3.48	0.53	0.48	-	0.68	1.45	1.17	1.11	3.69	-	1.85	0.27	0.03	1.82	3.04	10.68	0.68	0.58	1.55	0.6	4.94	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.1		3.64	3.48	0.53	0.48	-	0.68	1.45	1.17	1.11	3.69	-	1.85	0.27	0.03	1.82	3.04	10.68	0.68	0.58	1.55	0.6	4.94	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.1																																																																																				-		0	3.48	0.53	0.48	-	0.68	1.45	1.17	1.11	3.69	-	1.85	0.27	0.03	1.82	3.04	10.68	0.68	0.58	1.55	0.6	4.94	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.1
H5580_001_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		353	36.12	89.76		14.68	23.51	23.13	24.77	29.51	24.39	20.32	2.67	2.68	47.77	25.45	32.88	11.75	5.31	23.65	119.58	26.87	0.09																				Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	0.07	0.07	0.15		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				24.93	2.55	13.74	-	3.46	5.55	5.46	5.85	6.96	5.76	4.79	0.63	0.63	11.27	6.01	7.76	2.77	1.25	5.58	28.22	6.34	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.56	138	0	24.93	2.55	13.74	-	3.46	5.55	5.46	5.85	6.96	5.76	4.79	0.63	0.63	11.27	6.01	7.76	2.77	1.25	5.58	28.22	6.34	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.56																																																																																				-		0	24.93	2.55	13.74	-	3.46	5.55	5.46	5.85	6.96	5.76	4.79	0.63	0.63	11.27	6.01	7.76	2.77	1.25	5.58	28.22	6.34	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.56
H5586_001_0	2007	4																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5586_002_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		273.9	20.27	59.57	32.11	10.25	23.07	15.23	10.14	19.76	13.37	26.82	0	2.86	40.01	38.62	82.68	5.99	3.35	15.91	27.23	8.65	2.82	3.16	0	1.08	3.79	0	0	0	0	8.29											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.09	0.09	0.13	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											23.5	1.74	7.96	-	2.42	5.44	3.59	2.39	4.66	3.16	6.33	-	0.67	9.44	9.11	19.51	1.41	0.79	3.75	6.43	2.04	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.04			23.5	1.74	7.96	-	2.42	5.44	3.59	2.39	4.66	3.16	6.33	-	0.67	9.44	9.11	19.51	1.41	0.79	3.75	6.43	2.04	0.66	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	115.04		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				1.24	0.09	0.42		0.13	0.29	0.19	0.13	0.25	0.17	0.33		0.04	0.5	0.48	1.03	0.07	0.04	0.2	0.34	0.11	0.03																				6.05			24.74	1.83	8.38	-	2.55	5.73	3.78	2.52	4.91	3.32	6.66	-	0.71	9.94	9.59	20.54	1.49	0.83	3.95	6.76	2.15	0.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.09
H5587_001_0	2007	6																					0											Ded	Ded	D		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	0	1962.79	53.16	977.61	0	15.85	15.03	2.59	17.73	52.42	11.36	37.86	1.85	0.78	36.01	57.57	124.89	2.1	1.75	1.25	26.46	2.92	0.51																				Medicare Deductible	Medicare Deductible	Medicare Copay		Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance	Medicare Deductible & Coinsurance																				157.4	51.67	71.04	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				25.74	0.23	5.79	-	3.74	3.55	0.61	4.18	12.37	2.68	8.94	0.44	0.18	8.5	13.59	29.47	0.5	0.41	0.29	6.25	0.69	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.27	0	0	25.74	0.23	5.79	-	3.74	3.55	0.61	4.18	12.37	2.68	8.94	0.44	0.18	8.5	13.59	29.47	0.5	0.41	0.29	6.25	0.69	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.27	0																																																																																			-		0	25.74	0.23	5.79	-	3.74	3.55	0.61	4.18	12.37	2.68	8.94	0.44	0.18	8.5	13.59	29.47	0.5	0.41	0.29	6.25	0.69	0.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.27
H5588_001_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		307.27	22.25	42.8	56.85	15.86	35.55	23.52	10.47	20.14	13.31	27.16	0	2.99	41.27	61.5	120.33	9.19	5.2	34.51	39.84	8.82	3.97	0	6.2	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											20.44	1.48	6.99	-	3.74	8.39	5.55	2.47	4.75	3.14	6.41	-	0.71	9.74	14.51	28.4	2.17	1.23	8.14	9.4	2.08	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	140.69			20.44	1.48	6.99	-	3.74	8.39	5.55	2.47	4.75	3.14	6.41	-	0.71	9.74	14.51	28.4	2.17	1.23	8.14	9.4	2.08	0.94	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	140.69		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				1.08	0.08	0.37		0.2	0.44	0.29	0.13	0.25	0.17	0.34		0.04	0.51	0.76	1.49	0.11	0.06	0.43	0.49	0.11	0.05																				7.4			21.51	1.56	7.36	-	3.94	8.83	5.84	2.6	5	3.31	6.75	-	0.74	10.25	15.28	29.89	2.28	1.29	8.57	9.9	2.19	0.99	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.09
H5591_001_0	2007	6																					2500											D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	Coin	V	V	V	V	V	V	V	Coin	P	T	P	P	P	P	P	P	P	P																																																				-		2242.35	67	873.53		300	11.13	12.42	375.68	438.79	4	19.5		0.81	993.22	4473.66	4008	548.51	450			17.37																					200/day for 1-7	200/day for 1-7	0 copay for days 0-20 125 copay for days 21-100		100/trip	20 Coins	20 Coins	50/visit ER 35/visit UC	175/procedure	20 Coins	10 Coins TR 20 all else		20 Coins	20/visit	15/visit	20/visit	20/visit-ind 10 grp	20/visit			20 Coins										20 Coins Plan pays up to 1000											74.93	106.72	34.44		71.58	0.14	0.14	33.64	125.27	0.14	0.12		0.14	18.76	10.74	14.32	13.96	14.32			0.14																					14	0.6	2.51	-	1.79	1.59	1.78	1.05	4.58	0.57	2.36	-	0.12	1.55	4	4.78	0.64	0.54	-	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.95		17.86	14	0.6	2.51	-	1.79	1.59	1.78	1.05	4.58	0.57	2.36	-	0.12	1.55	4	4.78	0.64	0.54	-	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.95		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	14	0.6	2.51	-	1.79	1.59	1.78	1.05	4.58	0.57	2.36	-	0.12	1.55	4	4.78	0.64	0.54	-	-	2.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.95
H5594_001_0	2007	4	e.3.	h.6.	i.6.								DME/Prosthetics/Supplies	OP Facility - Surgery	Professional								5000	Diabetic Supplies	ASC	Lab								D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	O	V	V	V	V	P		Coin						V					Coin	P	P																																																	-		1290.57	74.38	1329.94	2344.41	472.44	17.06	1.42	317.99	146.88	4384.03	978.58	99.77	0	6356.23	5656.05	5342.07	320.73	994.53	4097.02		3.25				234.9	548.1	175					9.95	79.09	7528.89								175 for 1st 7 days	175 for 1st 7 days	150 for days 6-100	30 per visiit	100 per trip	20 Coinsurance	20 Coinsurance	20 15 Urg Care/80 50 ER	350 per procedure						5 per visit	15 per visit	20 per visit	20 per visit	Varies 15 to 250 copay		20 Coinsurance				15 per exam	15 per glasses or contacts	15 per exam					20 Coinsurance	150 per procedure									130.62	130.62	87.62	30	100	0.2	0.2	43	350	0	0	0	0	0	5	15	20	20	33.14	0	0.2	0	0	0	15	15	15	0	0	0	0	0.2	150	0								14.05	0.81	9.71	5.86	3.94	3.41	0.28	1.14	4.28	-	-	-	-	-	2.36	6.68	0.53	1.66	11.31	-	0.65	-	-	-	0.29	0.69	0.22	-	-	-	-	1.99	0.99	-	-	-	-	-	-	-	-	70.85	0	1.83	14.05	0.81	9.71	5.86	3.94	3.41	0.28	1.14	4.28	-	-	-	-	-	2.36	6.68	0.53	1.66	11.31	-	0.65	-	-	-	0.29	0.69	0.22	-	-	-	-	1.99	0.99	-	-	-	-	-	-	-	-	70.85																																																																																				-	0	0	14.05	0.81	9.71	5.86	3.94	3.41	0.28	1.14	4.28	-	-	-	-	-	2.36	6.68	0.53	1.66	11.31	-	0.65	-	-	-	0.29	0.69	0.22	-	-	-	-	1.99	0.99	-	-	-	-	-	-	-	-	70.85
H5594_002_0	2007	4	e.3.	h.6.	i.6.								DME/Prosthetics/Supplies	OP Facility - Surgery	Professional								1850	Diabetic Supplies	ASC	Lab								D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	O	V	V	V	V	P		Coin											Coin	P	P																																																	-		1331.35	76.63	1392.96	2455.51	494.82	17.87	1.49	333.06	153.84	4591.79	1024.96	104.5	0	6657.46	5924.1	5595.23	335.93	1041.66	4291.18		3.25				234.9	548.1	175					10.43	82.84	7885.69								50 for 1st 7 days	50 for 1st 7 days	150 for days 8-100		100 per trip	20 Coinsurance	20 Coinsurance	20 10 Urg Care/80 50 ER	300 per procedure							10 per visit	10 per visit	10 per visit	Varies 0 to 150 copay		20 Coinsurance				15 per exam	15 per glasses or contacts	10 per exam					20 Coinsurance	50 per procedure									32.55	32.55	71.74	0	100	0.2	0.2	42	300	0	0	0	0	0	0	10	10	10	10.26	0	0.2	0	0	0	15	15	10	0	0	0	0	0.2	50	0								3.61	0.21	8.33	-	4.12	3.57	0.3	1.17	3.85	-	-	-	-	-	-	4.66	0.28	0.87	3.67	-	0.65	-	-	-	0.29	0.69	0.15	-	-	-	-	2.09	0.35	-	-	-	-	-	-	-	-	38.84	0	1.66	3.61	0.21	8.33	-	4.12	3.57	0.3	1.17	3.85	-	-	-	-	-	-	4.66	0.28	0.87	3.67	-	0.65	-	-	-	0.29	0.69	0.15	-	-	-	-	2.09	0.35	-	-	-	-	-	-	-	-	38.84																																																																																				-	0	0	3.61	0.21	8.33	-	4.12	3.57	0.3	1.17	3.85	-	-	-	-	-	-	4.66	0.28	0.87	3.67	-	0.65	-	-	-	0.29	0.69	0.15	-	-	-	-	2.09	0.35	-	-	-	-	-	-	-	-	38.84
H5604_003_0	2007	3																					3100											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	O	T	P	V	P	V	P	O	O	O																																																				-		3146.93	114.88			247.73	16.93	3.01	386.55	375.8		766.13			1704.8	6113.37	6950.22	382.77	399.69																								135 days 1-5 (1a)	135 days 1-5 (1b)	0 (2a)	0 (6a)	100 (10a)	20 (11a)	20 prosth (11b1) 0 Supplies (11b211c)	50 ER 10 UC (4a 4b)	20 (9b)	0 (8a 8b)	20 (Diagnostic/PET/CT/MRI) (8a 8b)	0 (incl in h.5)	0 (12)	10 (9c 9d) 0 (3 5 9a)	10 (7a) 0 (14)	10 (7b 7d 7f 17a 18a) 0 (7g)	10 (7e 7h)	10 (7c 7i)	0 (incl in h.2)	0 (14i)	0 (15)	0 (13a 16a 17b)	0 (10b)	0 n/c (16b)	0 n/c (17a)	0 n/c (17b)	0 n/c (18a)	0 n/c (18b)	optional supplemental	0 (14a)	0 n/c (13b)											66.56	66.56			100	0.2	0.2	42.31	16.94		16.94			8.47	9.76	8.98	10	10																								17.46	0.64	-	-	2.06	3.39	0.6	1.36	0.53	-	1.08	-	-	1.2	4.97	5.2	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.14		4.03	17.46	0.64	-	-	2.06	3.39	0.6	1.36	0.53	-	1.08	-	-	1.2	4.97	5.2	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.14																																																																																				-		0	17.46	0.64	-	-	2.06	3.39	0.6	1.36	0.53	-	1.08	-	-	1.2	4.97	5.2	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.14
H5608_001_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		347.22	36.77	50.3		11.17	20.04	44.65	36.27	37.17	25.27	27.28	5	1.12	63.68	22.23	25.66	12.16	2.83	17.53	93.22	20.13	0.11																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	FFS Medicare Deductible	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible																				0.07	0.07	0.16		0.24	0.24	0.24	0.24	0.24	0.04	0.24	0.24	0.24	0.24	0.04	0.23	0.23	0.23	0.23	0.19	0.22	0.24																				23.72	2.51	8.07	-	2.64	4.73	10.54	8.56	8.77	0.91	6.44	1.18	0.26	15.03	0.8	5.96	2.84	0.64	4.04	17.58	4.51	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.76		0	23.72	2.51	8.07	-	2.64	4.73	10.54	8.56	8.77	0.91	6.44	1.18	0.26	15.03	0.8	5.96	2.84	0.64	4.04	17.58	4.51	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.76																																																																																				-		0	23.72	2.51	8.07	-	2.64	4.73	10.54	8.56	8.77	0.91	6.44	1.18	0.26	15.03	0.8	5.96	2.84	0.64	4.04	17.58	4.51	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.76
H5608_002_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		276.43	22.62	31.61		7.83	13.91	31.01	25.77	39.37	25.38	28.29	5.35	0.64	45.91	23.83	32.08	7.36	4.62	21.91	93.33	25.43	0.08																				FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare Deductible	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare	FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible	Non-PCP Medicare FFS PCP FFS Medicare Deductible																				0.07	0.07	0.16		0.24	0.24	0.24	0.24	0.24	0.04	0.24	0.24	0.24	0.24	0.04	0.23	0.23	0.23	0.23	0.2	0.21	0.24																				18.88	1.55	5.07	-	1.85	3.28	7.32	6.08	9.29	0.91	6.68	1.26	0.15	10.83	0.86	7.42	1.72	1.05	5.03	18.55	5.4	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.19		0	18.88	1.55	5.07	-	1.85	3.28	7.32	6.08	9.29	0.91	6.68	1.26	0.15	10.83	0.86	7.42	1.72	1.05	5.03	18.55	5.4	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.19																																																																																				-		0	18.88	1.55	5.07	-	1.85	3.28	7.32	6.08	9.29	0.91	6.68	1.26	0.15	10.83	0.86	7.42	1.72	1.05	5.03	18.55	5.4	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.19
H5608_801_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		293.44	6.27	33.36		5.11	8.89	24.1	15.38	49.03	26.87	34.01	6.17	0	34.18	25.11	38.28	2.37	6.04	26.7	100.95	32.64	0.09																				Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07	0.07	0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.04	0.43	5.35	-	1.2	2.1	5.69	3.63	11.57	6.34	8.03	1.46	0	8.07	5.93	9.03	0.56	1.42	6.3	23.82	7.7	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.7		0	20.04	0.43	5.35	-	1.2	2.1	5.69	3.63	11.57	6.34	8.03	1.46	0	8.07	5.93	9.03	0.56	1.42	6.3	23.82	7.7	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.7																																																																																				-		0	20.04	0.43	5.35	-	1.2	2.1	5.69	3.63	11.57	6.34	8.03	1.46	0	8.07	5.93	9.03	0.56	1.42	6.3	23.82	7.7	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.7
H5609_001_0	2007	4	e.3.	i.7.	i.8.	i.9.	i.10.	i.11.					DME/Prosthetics/Supplies	Professional	Professional	Professional	Professional	OP Facility - Other					0	Diabetic Supplies	Other-Coins	Podiatry	Chiropractic	Lab	Radiation Therapy					A	A	D	V	T	Coin	Coin	V	P	P	P	V	P	O	V	V	V	V	P	V	O	O	T	V	V	V	V	V	O	O	O	O	Coin	V	V	P	Coin					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0					-		273.7	3.6	1052.5	602.2	377.1	16.13	10.71	325.1	233.6	1112.9	591.1	0	6.1	1202.4	4808.9	5210	226.6	192	4027.3	17422.4	0	0	0	0	363.9	268	0	0	0	0	0	0	11.27	849.1	465.1	9967.4	1.88					150 per admisson	948.48 per admission			175 per Trip	20 Coinsurance	20 Coinsurance	50 per Visit ER and 10 per visit Urgent Care (Assume 80 ER /20 UC usage)	100 per surgery						5 per visit	10 per visit	30 per visit								20 Copay	75 per Glasses or Contacts							Coinsurance on Chemo Drugs	15 per visit	15 per visit		20 Coinsurance					150	948.48			175	0.2	0.2	42	100						5	10	30								20	75							0.2	15	15		0.2					3.42	0.28	-	-	5.5	3.23	2.14	1.14	1.95	-	-	-	-	-	2	4.34	0.57	-	-	-	-	-	-	-	0.61	1.68	-	-	-	-	-	-	2.25	1.06	0.58	-	0.38	-	-	-	-	31.12	0	0	3.42	0.28	-	-	5.5	3.23	2.14	1.14	1.95	-	-	-	-	-	2	4.34	0.57	-	-	-	-	-	-	-	0.61	1.68	-	-	-	-	-	-	2.25	1.06	0.58	-	0.38	-	-	-	-	31.12																																																																																				-	0	0	3.42	0.28	-	-	5.5	3.23	2.14	1.14	1.95	-	-	-	-	-	2	4.34	0.57	-	-	-	-	-	-	-	0.61	1.68	-	-	-	-	-	-	2.25	1.06	0.58	-	0.38	-	-	-	-	31.12
H5609_002_0	2007	7	e.3.	i.7.	i.8.	i.9.	i.10.						DME/Prosthetics/Supplies	Professional	Professional	Professional	Professional							Diabetic Supplies	Other-Coins	Podiatry	Chiropractic	Lab						A	A	D	V	T	Coin	Coin	V	P	P	P	V	P	O	V	V	V	V	P	V	O	O	T	V	V	V	V	V	O	O	O	O	Coin	V	V	P						0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0						-		346.13	4.55	1331.02	761.56	476.89	20.4	13.54	411.13	295.42	1407.4	747.52	0	7.71	1520.59	6081.47	6588.71	286.56	242.81	5093.04	22032.85	0	0	0	0	460.2	338.92	0	0	0	0	0	0	14.25	1073.8	588.18	12605.05							948.48 per admission			100 per Trip	20 Coinsurance	20 Coinsurance	50 per Visit ER and 0 per visit Urgent Care (Assume 80 ER /20 UC usage)	100 per surgery																20 Copay	50 per Glasses or Contacts																	948.48			100	0.2	0.2	40	100																20	50																-	0.36	-	-	3.97	4.08	2.71	1.37	2.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.13	0	0	-	0.36	-	-	3.97	4.08	2.71	1.37	2.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.13																																																																																				-	0	0	-	0.36	-	-	3.97	4.08	2.71	1.37	2.46	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77	1.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.13
H5609_801_0	2007	4	e.3.	i.7.	i.8.	i.9.	i.10.						DME/Prosthetics/Supplies	Professional	Professional	Professional	Professional							Diabetic Supplies	Other-Coins	Podiatry	Chiropractic	Lab						Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin																																																																				-		287.67		31.41		13.71	26.84		11.82	26.63	42.74					160.59																											FFS Medicare Actl. Equiv. cost sharing		FFS Medicare Actl. Equiv. cost sharing		FFS Medicare Actl. Equiv. cost sharing	FFS Medicare Actl. Equiv. cost sharing		FFS Medicare Actl. Equiv. cost sharing	FFS Medicare Actl. Equiv. cost sharing	FFS Medicare Actl. Equiv. cost sharing					FFS Medicare Actl. Equiv. cost sharing																											0.07		0.15		0.24	0.24		0.24	0.24	0.24					0.24																											18.81	-	4.72	-	3.24	6.33	-	2.79	6.28	10.09	-	-	-	-	37.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.16	0	0	18.81	-	4.72	-	3.24	6.33	-	2.79	6.28	10.09	-	-	-	-	37.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.16																																																																																				-	0	0	18.81	-	4.72	-	3.24	6.33	-	2.79	6.28	10.09	-	-	-	-	37.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.16
H5611_001_0	2007	6																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1600.26	108.76	464.78		83.08		0.82	241.45	349.07		221.31		1.97	327.07		7819.62	750.79	999.29		1.13	47.18										0.89											1a: 50 days 1-5	1a: 100 days 1-5	2a: 75 days 8-100		10a: 100		11b: 10 - Prosthetics	4a-b: 50 Emergency - 25 Urgent	9a-b: 50 ASC - 150 OP Facility		8: 50 PET 50 CT 50 MRI 25 Radiation Therapy		12:35	20 Rehab		7bdfg: 10 Spec. 15 Podiatry 15 Chiro	7e 7h 9c: 15 Group 25 Individual	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											21.3	42.6	53.55		100		0.1	44.99	93.24		46.83		35	19.92		10.74	17.5	20		0.2	0.2										0.16											2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67																																																																																				-		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67
H5611_003_0	2007	4																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1600.26	108.76	464.78		83.08		0.82	241.45	349.07		221.31		1.97	327.07		7819.62	750.79	999.29		1.13	47.18										0.89											1a: 50 days 1-5	1a: 100 days 1-5	2a: 75 days 8-100		10a: 100		11b: 10 - Prosthetics	4a-b: 50 Emergency - 25 Urgent	9a-b: 50 ASC - 150 OP Facility		8: 50 PET 50 CT 50 MRI 25 Radiation Therapy		12:35	20 Rehab		7bdfg: 10 Spec. 15 Podiatry 15 Chiro	7e 7h 9c: 15 Group 25 Individual	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											21.3	42.6	53.55		100		0.1	44.99	93.24		46.83		35	19.92		10.74	17.5	20		0.2	0.2										0.16											2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67																																																																																				-		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67
H5611_004_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1351.49	33.13	590.79		46.01		1.05	273.06	410.83		168.24			220.37		5988.53	300.45	421.49		1.36	25.5										0.67											1a: 200 Days 1-7	1b: 200 Days 1-7	2a: 75 Days 21-100		10a: 100		11b: 15 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 200 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	20 - OP Rehab MH - 35 Ind./20 Group		7bdfg 17a: 25	7e 7h 9c: 35 Ind./20 Group	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											104.6	104.6	30.23		100		0.15	44.99	137.33		47.68			20.1		20.52	23.75	20		0.2	0.2										0.17											11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88																																																																																				-		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88
H5611_005_0	2007	4																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-																										393						0.87																																			17a: 10						Travel: 1000 per IP admit 20 all other services																																			10						0.17											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	0.47		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	0.47																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	0.47
H5611_006_0	2007	4																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1351.49	33.13	590.79		46.01		1.05	273.06	410.83		168.24			220.37		5988.53	300.45	421.49		1.36	25.5										0.67											1a: 200 Days 1-7	1b: 200 Days 1-7	2a: 75 Days 21-100		10a: 100		11b: 15 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 200 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	20 - OP Rehab MH - 35 Ind./20 Group		7bdfg 17a: 25	7e 7h 9c: 35 Ind./20 Group	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											104.6	104.6	30.23		100		0.15	44.99	137.33		47.68			20.1		20.52	23.75	20		0.2	0.2										0.17											11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88																																																																																				-		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88
H5611_007_0	2007	6																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1370.73	68.71	573.82		62.91	5.64	0.94	258.64	316.95		602.8		1.22	270.3		4482.83	254.89	236.8		1.58	28.54										0.63											1a: 100 Days 1-8	1b: 100 Days 1-8	2a: 75 Days 8-100		10a: 100	11a: 20	11b: 20 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 150 OP Facility		8: 10 X-Ray 100 MRI 100 PET 100 CT 50 Radiation Therapy		12:35	25 - OP Rehab MH - 30 Ind./20 Group		7bdfg: 25 Spec. 30 - Chiro	7eh 9c: 30 Ind./20 Group	3 7c 7i: 25		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											56.3	56.3	53.55		100	0.1	0.2	44.98	121.11		32.47		35	24.89		25.16	22.5	25		0.2	0.2										0.16											6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45																																																																																				-		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45
H5611_008_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-																										393						0.85																																			17a: 10						Travel: 1000 per IP admit 20 all other services																																			10						0.16											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	0.46		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	0.46																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	0.46
H5611_009_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1370.73	68.71	573.82		62.91	5.64	0.94	258.64	316.95		602.8		1.22	270.3		4482.83	254.89	236.8		1.58	28.54										0.63											1a: 100 Days 1-8	1b: 100 Days 1-8	2a: 75 Days 8-100		10a: 100	11a: 20	11b: 20 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 150 OP Facility		8: 10 X-Ray 100 MRI 100 PET 100 CT 50 Radiation Therapy		12:35	25 - OP Rehab MH - 30 Ind./20 Group		7bdfg: 25 Spec. 30 - Chiro	7eh 9c: 30 Ind./20 Group	3 7c 7i: 25		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											56.3	56.3	53.55		100	0.1	0.2	44.98	121.11		32.47		35	24.89		25.16	22.5	25		0.2	0.2										0.16											6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45																																																																																				-		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45
H5611_010_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	Coin																																																				-		386.6	43.26	32		6.32	33.41	99.32	31.35	55.4	34.91	39.2	5.9	3.48	249.5	46.12	51.6	11.28	17.76	36.23	176.32	203.01	0.09			393						1.61											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing			10 - 1 routine exam per year						Travel: 1000 per IP admit 20 all other services											0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24			10						0.17											27.03	3.03	6.01	-	1.49	7.88	23.44	7.4	13.07	8.24	9.25	1.39	0.82	58.88	10.88	12.18	2.66	4.19	8.55	41.61	47.91	0.02	-	-	0.33	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	296.55		0	27.03	3.03	6.01	-	1.49	7.88	23.44	7.4	13.07	8.24	9.25	1.39	0.82	58.88	10.88	12.18	2.66	4.19	8.55	41.61	47.91	0.02	-	-	0.33	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	296.55																																																																																				-		0	27.03	3.03	6.01	-	1.49	7.88	23.44	7.4	13.07	8.24	9.25	1.39	0.82	58.88	10.88	12.18	2.66	4.19	8.55	41.61	47.91	0.02	-	-	0.33	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	296.55
H5611_011_0	2007	3																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		4208.61	661.32	14575.17		672.28	7.17	22.07	555.83	160.57	26329.13	357.2	53.29	18.05	3283.38	1400.54	5907.06	7394.29	675.31	31.84	310.02	57.22	12.1			393																	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing			10 - 1 routine exam per year																	114.46	58.88	77.94		119.67	0.24	0.24	314.45	722.81	10.51	212.23	421.3	547.51	507.87	26.45	19.17	14.47	22.51	0.24	0.24	0.24	16.26			10																	40.14	3.24	94.66	-	6.7	1.69	5.21	14.57	9.67	23.06	6.32	1.87	0.82	138.96	3.09	9.44	8.92	1.27	7.51	73.17	13.5	0.02	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	464.16		0	40.14	3.24	94.66	-	6.7	1.69	5.21	14.57	9.67	23.06	6.32	1.87	0.82	138.96	3.09	9.44	8.92	1.27	7.51	73.17	13.5	0.02	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	464.16																																																																																				-		0	40.14	3.24	94.66	-	6.7	1.69	5.21	14.57	9.67	23.06	6.32	1.87	0.82	138.96	3.09	9.44	8.92	1.27	7.51	73.17	13.5	0.02	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	464.16
H5611_012_0	2007	7																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-			156.84	361.51		63.72			177.38	267.28		215.91		1.41	418.82		6093.17	943.41	1047.66		1.3	47.77				393						0.92												1b: 50 Days 1-7	2a: 50 Days 8-100		10a: 75			4a-b: 50 - Emergency 25 - Urgent	9a-b: 25 - ASC 100 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	10 - OP Rehab MH - 35 Ind./20 Group		7bdfg: 5 spec. 15 Podiatry 15 Chiro	7e h 9c: 35 Ind./20 Group	3 7c 7i: 10		20 Chemo	15:20				17a: 10						Travel: 1000 per IP admit 20 all other services												26.15	35.7		75			44.99	67		44.88		35	12.18		6.08	23.75	10		0.2	0.2				10						0.16											-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32																																																																																				-		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32
H5611_013_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-			156.84	361.51		63.72			177.38	267.28		215.91		1.41	418.82		6093.17	943.41	1047.66		1.3	47.77				393						0.92												1b: 50 Days 1-7	2a: 50 Days 8-100		10a: 75			4a-b: 50 - Emergency 25 - Urgent	9a-b: 25 - ASC 100 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	10 - OP Rehab MH - 35 Ind./20 Group		7bdfg: 5 spec. 15 Podiatry 15 Chiro	7e h 9c: 35 Ind./20 Group	3 7c 7i: 10		20 Chemo	15:20				17a: 10						Travel: 1000 per IP admit 20 all other services												26.15	35.7		75			44.99	67		44.88		35	12.18		6.08	23.75	10		0.2	0.2				10						0.16											-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32																																																																																				-		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32
H5611_807_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		241.47	5.79	17.62		2.82	4.79	10.26	14.42	53.3	31.64	33.41	4.35	0.27	35.12	25.32	50.23	3.81	5.43	35.99	123.5	39.48	0.09																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.73	0.43	3.23	-	0.67	1.13	2.42	3.4	12.58	7.47	7.89	1.03	0.06	8.29	5.98	11.86	0.9	1.28	8.49	29.15	9.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.31		0	17.73	0.43	3.23	-	0.67	1.13	2.42	3.4	12.58	7.47	7.89	1.03	0.06	8.29	5.98	11.86	0.9	1.28	8.49	29.15	9.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.31																																																																																				-		0	17.73	0.43	3.23	-	0.67	1.13	2.42	3.4	12.58	7.47	7.89	1.03	0.06	8.29	5.98	11.86	0.9	1.28	8.49	29.15	9.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.31
H5611_808_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		241.68	5.8	17.63		2.82	4.79	10.27	14.44	53.35	31.67	33.44	4.35	0.27	35.15	25.35	50.28	3.81	5.43	36.03	123.61	39.52	0.09																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42																																																																																				-		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42
H5611_809_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		241.68	5.8	17.63		2.82	4.79	10.27	14.44	53.35	31.67	33.44	4.35	0.27	35.15	25.35	50.28	3.81	5.43	36.03	123.61	39.52	0.09																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42																																																																																				-		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42
H5619_001_0	2007	8																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1233.3	94.48	796.34		180.72	3.77	5.79	388.39	34.98		23.06	6.48	0.67	26.65	3350.21	4466.2	399.23	562.95	2161.63	1217.7	16.11				129.91		116.29															#1A: 75 days 1-5	#1B: 100 days 1-5	#2: 20 days 10-100	#6: 0	#10A: 100	#11A: 15	#11B/11C: 15	#4: 50; Worldwide: 40	#9A OP Hosp: 15 NTE 200; #9B ASC: 15 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 10; #5: 25; #9A OP Hosp 15 / Chemo 20; #9C: 25; #9D: 10	#7A: 5; #14C: 0	#7B : 8; #7D/7F/7G #16B #17A #18A: 15	#7E/#7H: 25	#7C/#7I: 10	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 100 Allowance every two years	#18A: 20	#18B: 600 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	45.97	61.29	10.76		100	0.15	0.15	49.99	0.09		0.16	0.15	0.2	0.16	5	14.17	25	10	15	15	0.2				10		20															4.72	0.48	0.71	-	1.51	0.57	0.87	1.62	3.31	-	3.74	0.97	0.13	4.23	1.4	5.27	0.83	0.47	2.7	1.52	3.22	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.59		0	4.72	0.48	0.71	-	1.51	0.57	0.87	1.62	3.31	-	3.74	0.97	0.13	4.23	1.4	5.27	0.83	0.47	2.7	1.52	3.22	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.59																																																																																				-		0	4.72	0.48	0.71	-	1.51	0.57	0.87	1.62	3.31	-	3.74	0.97	0.13	4.23	1.4	5.27	0.83	0.47	2.7	1.52	3.22	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.59
H5619_002_0	2007	8																					4000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1266.55	97.03	817.8		185.59	3.88	5.94	398.85	35.92		23.69	6.66	0.69	27.37	3440.53	4693.14	409.99	578.13	2219.91	1250.53	16.55				129.91		116.29															#1A: 40 days 1-5	#1B: 15 days 1-5	#2: 15 days 10-100	#6: 0	#10A: 75	#11A: 10	#11B/11C: 10	#4: 50; Worldwide: 35	#9A OP Hosp: 10 NTE 200; #9B ASC: 10 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 10	#12: 20	#3: 8; #5: 20; #9A OP Hosp 10 / Chemo 20; #9C: 20; #9D: 8	#7A: 3; #14C: 0	#7B : 5; #7D/7F/7G #16B #17A #18A: 12	#7E/#7H: 20	#7C/#7I: 8	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 150 Allowance every two years	#18A: 15	#18B: 700 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	22.69	8.51	7.47		69.41	0.09	0.09	46.27	0.07		0.12	0.09	0.19	0.11	2.78	10.29	18.51	7.4	13.88	13.88	0.19				10		15															2.39	0.07	0.51	-	1.07	0.36	0.55	1.54	2.46	-	2.73	0.62	0.13	3.06	0.8	4.02	0.63	0.36	2.57	1.45	3.06	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.62		2.28	2.39	0.07	0.51	-	1.07	0.36	0.55	1.54	2.46	-	2.73	0.62	0.13	3.06	0.8	4.02	0.63	0.36	2.57	1.45	3.06	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.62																																																																																				-		0	2.39	0.07	0.51	-	1.07	0.36	0.55	1.54	2.46	-	2.73	0.62	0.13	3.06	0.8	4.02	0.63	0.36	2.57	1.45	3.06	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.62
H5619_003_0	2007	5																					1000											D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-							10.65	2.57				4.77		0.26	4.77							9.16				126.9		113.59															#1A: 0 days 1-5	#1B: 0 days 1-5	#2: 0 days 10-100	#6: 0	#10A: 0	#11A: 15	#11B Pros: 10; #11B Supplies: 0; #11C: 0	#4: 0	#9B ASC: 0; #9A OP Hosp: 0	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 0	#9A: 0	#12: 20	#9A Chemo 20	#7A: 0; #14C: 0	#7B: 0; #7D/7F/7G #16B #17A #18A: 0	#7E/#7H: 0	#7C/#7I: 0	#8B: 0	#7A/#7D Cardio. Testing: 0; #14I Nutrition Therapy: 0	Part B Rx: 15	0 Copay	0 Copay	0 Copay	#17A: 5	#17B: 100 Allowance every two years	#18A: 15	#18B: 750 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay						0.14	0.1				0.19		0.19	0.19							0.14				5		15															-	-	-	-	-	1.53	0.25	-	-	-	0.92	-	0.05	0.92	-	-	-	-	-	-	1.32	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.17		0.21	-	-	-	-	-	1.53	0.25	-	-	-	0.92	-	0.05	0.92	-	-	-	-	-	-	1.32	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.17																																																																																				-		0	-	-	-	-	-	1.53	0.25	-	-	-	0.92	-	0.05	0.92	-	-	-	-	-	-	1.32	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.17
H5628_001_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		268	21.17	56.67	88.91	15.7	35.78	23.16	9.7	18.54	12.83	25.68	0	2.66	37.27	42.98	95.9	6.58	3.67	17.25	27.81	8.11	3.28	0	11.87	1.61	4.35	0	0	0	0	0.8											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											19.99	1.58	10.27	-	3.71	8.44	5.47	2.29	4.37	3.03	6.06	-	0.63	8.8	10.14	22.63	1.55	0.87	4.07	6.56	1.91	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.15			19.99	1.58	10.27	-	3.71	8.44	5.47	2.29	4.37	3.03	6.06	-	0.63	8.8	10.14	22.63	1.55	0.87	4.07	6.56	1.91	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	123.15		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				1.05	0.08	0.54		0.2	0.44	0.29	0.12	0.23	0.16	0.32		0.03	0.46	0.53	1.19	0.08	0.05	0.21	0.35	0.1	0.04																				6.48			21.04	1.66	10.81	-	3.9	8.89	5.75	2.41	4.61	3.19	6.38	-	0.66	9.26	10.68	23.82	1.63	0.91	4.29	6.91	2.01	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.63
H5640_001_0	2007	4																					None											coin	Coin	Coin	V	T	O	O	V	V	V	V	V	V	V	V	V	Coin	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	269.27	14.66	55.71	0	0	0	0	0	0	0	0	0	0	0	0	0	7.45	0	0	0	0	0	0	0	0	0	0	0	0	0	0											6 Medicare Equivalent Coin (PBP #1A)	6 Medicare Equivalent Coin (PBP #1B)	15 Medicare Equivalent Coin (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9A/9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	50 Medicare Equivalent Coin (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #13A/14A)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13B)											0.06	0.06	0.15	0	0	0	0	0	0	0	0	0	0	0	0	0	0.5	0	0	0	0	0	0	0	0	0	0	0	0	0	0											17.42	0.95	8.39	-	-	-	-	-	-	-	-	-	-	-	-	-	3.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.49	0	0	17.42	0.95	8.39	-	-	-	-	-	-	-	-	-	-	-	-	-	3.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.49	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	17.42	0.95	8.39	-	-	-	-	-	-	-	-	-	-	-	-	-	3.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.49
H5649_001_0	2007	4																					Unlimited											D	D	D	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	O	P	P	P	P	P	P	P	P	P	P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	169.29	1415.82	6096.39	232.81	0	0	30.08	0	2.17	278.28	45.26	0	199.37	569.12	0	0	496.47	0	0	837	0	285.42	0	0	0	0	1206.55											1A - no cost sharing	1B - no cost sharing	2 - no cost sharing	6 - no cost sharing	10A - 50 copay	11A - 20 coins	11B - 20 coins	4A - 50 copay	9 - no cost sharing	8B - no cost sharing	8A - 20 coins	no cost sharing	11C - 20 coins	9D - 10 copay	4B - 20 copay	7D - no cost sharing	7E & 7H - 10 copay	7C&7I - 10 copay	no cost sharing	no cost sharing	30 coins	no cost sharing	10B - no cost sharing	16A - 20 copay	17A - no cost sharing	17B - 20 copay	18A - no cost sharing	18B - no cost sharing	no cost sharing	14A - no cost sharing	13B - 20 copay											0	0	0	0	50	30.88	0.91	50	0	0	409.76	0	186.15	10	20	0	10	10	0	0	49.07	0	0	20	0	20	0	0	0	0	20											-	-	-	-	0.71	3.64	0.46	0.97	-	-	1.03	-	0.03	0.23	0.08	-	0.17	0.47	-	-	2.03	-	-	1.4	-	0.48	-	-	-	-	2.01	-	-	-	-	-	-	-	-	-	-	13.7			-	-	-	-	0.71	3.64	0.46	0.97	-	-	1.03	-	0.03	0.23	0.08	-	0.17	0.47	-	-	2.03	-	-	1.4	-	0.48	-	-	-	-	2.01	-	-	-	-	-	-	-	-	-	-	13.7	0	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			-	-	-	-	0.71	3.64	0.46	0.97	-	-	1.03	-	0.03	0.23	0.08	-	0.17	0.47	-	-	2.03	-	-	1.4	-	0.48	-	-	-	-	2.01	-	-	-	-	-	-	-	-	-	-	13.7
H5649_002_0	2007	5																					Unlimited											D	D	D	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	P	O	P	P	P	P	P	P	P	P	P	P											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	346.96	0	0	47.28	0	0	0	0	0	0	0	0	0	728.84	0	0	0	0	0	0	0	0	0	5											1A - no cost sharing	1B - no cost sharing	2 - no cost sharing	6 - no cost sharing	10A  - no cost sharing	11A  - no cost sharing	11B  - no cost sharing	4A - 50 copay	9 - no cost sharing	8B - no cost sharing	8A - 20 coins radiation therapy	no cost sharing	11C  - no cost sharing	9D  - no cost sharing	4B  - no cost sharing	7D - no cost sharing	7E & 7H  - no cost sharing	7C&7I  - no cost sharing	no cost sharing	no cost sharing	20 coins	no cost sharing	10B - no cost sharing	16A - - no cost sharing	17A - no cost sharing	17B  - no cost sharing	18A - no cost sharing	18B - no cost sharing	no cost sharing	14A - no cost sharing	5 coins - foreign travel											0	0	0	0	0	0	0	50	0	0	403.91	0	0	0	0	0	0	0	0	0	32.3	0	0	0	0	0	0	0	0	0	250											-	-	-	-	-	-	-	1.45	-	-	1.59	-	-	-	-	-	-	-	-	-	1.96	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	5.1			-	-	-	-	-	-	-	1.45	-	-	1.59	-	-	-	-	-	-	-	-	-	1.96	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	5.1	0	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits	HMO - no OON benefits											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			-	-	-	-	-	-	-	1.45	-	-	1.59	-	-	-	-	-	-	-	-	-	1.96	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	5.1
H5652_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							14.13	14.13	439.35	404.41		269.81	58.28		1059.09	8002.28	6134.04	134.21	530.64		961.92					137.43		289.34					255.34	11.79	352.76		100.46	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0/20 per Visit	(7d) 0/20 per Visit	(7h) 20 per Visit	(7c)(7i) (0/20)(0/20) per Visit	0 per Visit	(7g) 0/20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0/20 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 0/20 per Visit	(13b) 20 per Visit										18	18	37	45		18	45		45	2	9	18	9		9					20		20					9	18	18		9	20					-	-	-	-	-	2.56	2.56	1.36	1.53	-	0.41	0.22	-	4	1.21	4.63	0.2	0.4	-	0.73	-	-	-	-	0.23	-	0.48	-	-	-	-	0.19	0.02	0.53	-	0.08	0.23	-	-	-	-	21.57		2.14	-	-	-	-	-	2.56	2.56	1.36	1.53	-	0.41	0.22	-	4	1.21	4.63	0.2	0.4	-	0.73	-	-	-	-	0.23	-	0.48	-	-	-	-	0.19	0.02	0.53	-	0.08	0.23	-	-	-	-	21.57		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.28	0.03	0.41	0.37	0.06	0.09	0.09	0.03	0.24	0.15	0.14	0.02	0	0.15		0.29	0.01	0.03	0.17	0.67	0.15	0			0.01		0.01															5.41		0	2.28	0.03	0.41	0.37	0.06	2.65	2.65	1.39	1.77	0.15	0.55	0.24	0	4.15	1.21	4.92	0.21	0.43	0.17	1.4	0.15	0	-	-	0.24	-	0.49	-	-	-	-	0.19	0.02	0.53	-	0.08	0.23	-	-	-	-	26.97
H5652_002_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							14.19	14.18	440.21	405.2		270.34	58.39		1061.16	8001.11	6146.04	134.47	531.67		963.8					137.43		289.34					255.84	11.81	353.45		100.66	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0/20 per Visit	(7d) 0/20 per Visit	(7h) 20 per Visit	(7c)(7i) (0/20)(0/20) per Visit	0 per Visit	(7g) 0/20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0/20 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 0/20 per Visit	(13b) 20 per Visit										18	18	37	45		18	45		45	2	9	18	9		9					20		20					9	18	18		9	20					-	-	-	-	-	2.57	2.57	1.36	1.53	-	0.41	0.22	-	4.01	1.21	4.64	0.2	0.4	-	0.74	-	-	-	-	0.23	-	0.48	-	-	-	-	0.19	0.02	0.53	-	0.08	0.23	-	-	-	-	21.61		2.15	-	-	-	-	-	2.57	2.57	1.36	1.53	-	0.41	0.22	-	4.01	1.21	4.64	0.2	0.4	-	0.74	-	-	-	-	0.23	-	0.48	-	-	-	-	0.19	0.02	0.53	-	0.08	0.23	-	-	-	-	21.61		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.29	0.03	0.41	0.37	0.06	0.09	0.09	0.03	0.25	0.15	0.14	0.02	0	0.15		0.29	0.01	0.03	0.17	0.67	0.15	0			0.01		0.01															5.43		0	2.29	0.03	0.41	0.37	0.06	2.66	2.66	1.39	1.77	0.15	0.55	0.24	0	4.16	1.21	4.93	0.21	0.43	0.17	1.4	0.15	0	-	-	0.24	-	0.49	-	-	-	-	0.19	0.02	0.53	-	0.08	0.23	-	-	-	-	27.04
H5652_003_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1828.12	117.76	7907.92	120.08	543.54	1498.26	1883.79	146.85	162.84	5851.38	152.43	1.49	4.46	235.43	28741.94	1530.53	2662.68	22.88		76.53	119.84	652.37	2250		140.2	166		54.6				84.76		0.37	300	295.2						(1a) 25/day	(1b) 25/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 20/visit (waived if admitted)		(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						24	24			48			48																								19										3.65	0.24	-	-	2.17	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	6.79		0.29	3.65	0.24	-	-	2.17	-	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	6.79		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							20		30	30	30						2.89	0.07	0.94	0.08	0.24	0.33	0.04	0.03	0.37	0.55	0.74	0	0.01	0.13																		0.01		0								6.44		0	6.54	0.31	0.94	0.08	2.42	0.33	0.04	0.62	0.37	0.55	0.74	0	0.01	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.14	-	0	-	-	-	-	-	-	-	13.23
H5652_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								30.93	731.49	568.64		431.78	91.08		1716.78	8657.59	6875.49	441.01	650.04		1466.83							289.34					333.36	67.54	354.78		286.03	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0/20 per Visit	(7d) 0/20 per Visit	(7h) 20 per Visit	(7c)(7i) (0/20)(0/20) per Visit	0 per Visit	(7g) 0/20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0/20 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 0/20 per Visit	(13b) 20 per Visit											17	36	43		17	43		43	2	9	17	9		10							20					9	17	17		9	20					-	-	-	-	-	-	5.37	2.17	2.06	-	0.63	0.33	-	6.21	1.25	4.98	0.64	0.47	-	1.25	-	-	-	-	-	-	0.48	-	-	-	-	0.24	0.1	0.51	-	0.21	0.23	-	-	-	-	27.13		3.94	-	-	-	-	-	-	5.37	2.17	2.06	-	0.63	0.33	-	6.21	1.25	4.98	0.64	0.47	-	1.25	-	-	-	-	-	-	0.48	-	-	-	-	0.24	0.1	0.51	-	0.21	0.23	-	-	-	-	27.13		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						3.01	0.11	0.3	0.37	0.07	0.16	0.19	0.04	0.33	0.19	0.2	0.03	0.01	0.23		0.34	0.03	0.03	0.22	0.83	0.19	0			0.01		0.01															6.91		0	3.01	0.11	0.3	0.37	0.07	0.16	5.56	2.22	2.39	0.19	0.83	0.36	0.01	6.44	1.25	5.32	0.67	0.5	0.22	2.07	0.19	0	-	-	0.01	-	0.49	-	-	-	-	0.24	0.1	0.51	-	0.21	0.23	-	-	-	-	34.04
H5656_001_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1634.94	51.27	611.06		83.57	7.05	1.17	292.1	350.68		430.42			203.31		4057.3	208.67	262.77		3.85	36.79				202.29																	1a: 150 per admit	1b: 300 per admit	2a: 125 days 21-100		10a: 100	11a: 15	11b-c: 15	4: 50 Emergency 20 Urgent	9a-b: 75 ASC 150 OP Facility		8: 15 Radiation Therapy 20 X-Rays			20 OP Rehab 20/35 MH/SA		7bdfg: 20	7eh 9c: 20 - group 35 - individual	3 7c 7i: 20		20 Chemo	15:20				17a: 20 - 1 routine eye exam																	26.25	40.14	50.38		100	0.15	0.15	43.98	105.76		51.6			20.54		20	31.25	20		0.24	0.2				20																	3.58	0.17	2.57	-	0.7	1.06	0.18	1.07	3.09	-	1.85	-	-	0.35	-	6.76	0.54	0.44	-	0.93	7.36	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.97		0	3.58	0.17	2.57	-	0.7	1.06	0.18	1.07	3.09	-	1.85	-	-	0.35	-	6.76	0.54	0.44	-	0.93	7.36	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.97																																																																																				-		0	3.58	0.17	2.57	-	0.7	1.06	0.18	1.07	3.09	-	1.85	-	-	0.35	-	6.76	0.54	0.44	-	0.93	7.36	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.97
H5656_002_0	2007	3																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5656_003_0	2007	2																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1634.94	51.27	611.06		83.57	7.05	1.17	292.1	350.68		430.42			203.31		4057.3	208.67	262.77		3.85	36.79				202.29																	1a: 150 per admit	1b: 300 per admit	2a: 125 days 21-100		10a: 100	11a: 15	11b-c: 15	4: 50 Emergency 20 Urgent	9a-b: 75 ASC 150 OP Facility		8: 15 Radiation Therapy 20 X-Rays			20 OP Rehab 20/35 MH/SA		7bdfg: 20	7eh 9c: 20 - group 35 - individual	3 7c 7i: 20		20 Chemo	15:20				17a: 15 - 1 routine eye exam																	26.25	40.14	50.38		100	0.15	0.15	43.98	105.76		51.6			20.54		20	31.25	20		0.24	0.2				20																	3.58	0.17	2.57	-	0.7	1.06	0.18	1.07	3.09	-	1.85	-	-	0.35	-	6.76	0.54	0.44	-	0.93	7.36	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.97		0	3.58	0.17	2.57	-	0.7	1.06	0.18	1.07	3.09	-	1.85	-	-	0.35	-	6.76	0.54	0.44	-	0.93	7.36	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.97																																																																																				-		0	3.58	0.17	2.57	-	0.7	1.06	0.18	1.07	3.09	-	1.85	-	-	0.35	-	6.76	0.54	0.44	-	0.93	7.36	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.97
H5656_004_0	2007	4																																D	D	D	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	V	Coin	P	P	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1634.94	51.27	611.06	25.5	3.14	7.05	8.69	292.1	40.13	20.51	11.36	2.34		17.94	3354.91	5382.09	1.46	2.4	31.02	81.24	36.79	11.65			202.29																	1a: 175 days 1-5	1b: 175 days 1-5	2a: 100 days 21-100	6:20	10a: 20	11a: 20	11b-c: 20	4: 50 Emergency 50 Urgent	9a-b: 20 ASC 20 OP Facility	0	8: 20 Radiation Therapy 20 X-Rays	0.2		20 OP Rehab 20 MH/SA	7a: 15	7bdfg: 40	7eh 9c: 20	3 7c 7i: 20	8:20	20 Chemo	15:20				17a: 40 - 1 routine eye exam																	74.55	74.55	40.3	0.2	0.2	0.2	0.2	50	0.2	0.2	0.2	0.2		0.2	15	35.37	0.2	0.2	0.2	0.21	0.2	13.35			40																	10.16	0.32	2.05	5.1	0.63	1.41	1.74	1.22	8.03	4.1	2.27	0.47	-	3.59	4.19	15.86	0.29	0.48	6.2	16.95	7.36	0.01	-	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.11		0	10.16	0.32	2.05	5.1	0.63	1.41	1.74	1.22	8.03	4.1	2.27	0.47	-	3.59	4.19	15.86	0.29	0.48	6.2	16.95	7.36	0.01	-	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.11																																																																																				-		0	10.16	0.32	2.05	5.1	0.63	1.41	1.74	1.22	8.03	4.1	2.27	0.47	-	3.59	4.19	15.86	0.29	0.48	6.2	16.95	7.36	0.01	-	-	0.67	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.11
H5656_801_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		256.22	4.72	21.57		3.14	7.05	8.69	10.52	40.13	20.51	11.36	2.34		17.94	22.74	37.15	1.46	2.4	31.02	106.84	36.79	0.06																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.55		0	17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.55																																																																																				-		0	17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.55
H5656_802_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		256.2	4.72	21.57		3.13	7.05	8.69	10.52	40.13	20.51	11.36	2.34		17.94	22.74	37.14	1.46	2.4	31.02	106.83	36.79	0.06																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54		0	17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54																																																																																				-		0	17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54
H5656_803_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		256.2	4.72	21.57		3.13	7.05	8.69	10.52	40.13	20.51	11.36	2.34		17.94	22.74	37.14	1.46	2.4	31.02	106.83	36.79	0.06																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.2		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54		0	17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54																																																																																				-		0	17.86	0.33	4.37	-	0.74	1.66	2.05	2.48	9.47	4.84	2.68	0.55	-	4.23	5.37	8.77	0.34	0.57	7.32	25.21	8.68	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.54
H5657_004_0	2007	4	s.	t.	u.								Inpatient Facility	Professional	OP Facility - Other								5000	Mental Health Level 2	Physician Administered Injectibles	Radiology								A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	Coin	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		187.91	9.41	890.19	2274.06	7.43	0.57	0.04	14.9	35.62	38.01	40.37	1.73	4.95	14.69	10378.08	6751.49			2.2		6.05											0.5	13.17	24.19								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	20 Coins	0 - 20 Coins								423.73	423.73	26.71	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.56	23.11			0.15		0.15											423.73	0.15	0.14								6.64	0.33	1.98	-	1.15	0.09	0.01	2.3	5.49	5.86	-	0.27	0.76	2.26	9.99	13	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.03	3.46	-	-	-	-	-	-	-	56.9	0	21.01	6.64	0.33	1.98	-	1.15	0.09	0.01	2.3	5.49	5.86	-	0.27	0.76	2.26	9.99	13	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.03	3.46	-	-	-	-	-	-	-	56.9	5000																																																																																			-		0	6.64	0.33	1.98	-	1.15	0.09	0.01	2.3	5.49	5.86	-	0.27	0.76	2.26	9.99	13	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.02	2.03	3.46	-	-	-	-	-	-	-	56.9
H5657_005_0	2007	7	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		189.78	9.5	899.05	2296.69	7.58	0.58	0.04	15.2	36.33	38.77	40.77	1.76	5.05	14.98	10481.34	6818.68			2.25		6.17											9.99	0.5	13.44	24.67							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							421.36	421.36	26.56	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.49	22.98			0.15		0.15											421.36	421.36	0.15	0.14							6.66	0.33	1.99	-	1.16	0.09	0.01	2.33	5.57	5.94	-	0.27	0.77	2.3	10.04	13.06	-	-	0.34	-	0.95	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.06	3.51	-	-	-	-	-	-	57.75	0	21.84	6.66	0.33	1.99	-	1.16	0.09	0.01	2.33	5.57	5.94	-	0.27	0.77	2.3	10.04	13.06	-	-	0.34	-	0.95	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.06	3.51	-	-	-	-	-	-	57.75	5000																																																																																			-		0	6.66	0.33	1.99	-	1.16	0.09	0.01	2.33	5.57	5.94	-	0.27	0.77	2.3	10.04	13.06	-	-	0.34	-	0.95	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.06	3.51	-	-	-	-	-	-	57.75
H5657_006_0	2007	6	s.	t.	u.	v.							Inpatient Facility	Inpatient Facility	Professional	OP Facility - Other							5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles	Radiology							A	A	D	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	V	V			Coin		Coin											A	A	Coin	Coin							0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0	0							-		187.91	9.41	890.19	2274.06	7.43	0.57	0.04	14.9	35.62	38.01	40.37	1.73	4.95	14.69	10378.08	6751.5			2.2		6.05											9.89	0.5	13.17	24.19							550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	20 Coins	0/ Visit	20 Coins	20 Coins	20 Coins	15/ Visit	30/ Visit			20 Coins		20 Coins											550/admit	550/admit	20 Coins	0 - 20 Coins							423.02	423.02	26.66	0	0.15	0.15	0.15	0.15	0.15	0.15	0	0.15	0.15	0.15	11.54	23.07			0.15		0.15											423.02	423.02	0.15	0.14							6.62	0.33	1.98	-	1.14	0.09	0.01	2.29	5.48	5.85	-	0.27	0.76	2.26	9.98	12.98	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.03	3.46	-	-	-	-	-	-	57.15	0	21.23	6.62	0.33	1.98	-	1.14	0.09	0.01	2.29	5.48	5.85	-	0.27	0.76	2.26	9.98	12.98	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.03	3.46	-	-	-	-	-	-	57.15	5000																																																																																			-		0	6.62	0.33	1.98	-	1.14	0.09	0.01	2.29	5.48	5.85	-	0.27	0.76	2.26	9.98	12.98	-	-	0.34	-	0.93	-	-	-	-	-	-	-	-	-	-	0.35	0.02	2.03	3.46	-	-	-	-	-	-	57.15
H5657_805_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1177.37	91.37	480.47	2454.8	149.82	0.66	0.05	219.42	396.42	217.88	653.64	43.58	1145.62	370.4	11202.89	7288.08			369.97		7.06											61.97	4.81	15.39								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								20.02	1.55	0.71	-	1.25	0.17	0.01	0.91	3.29	0.91	3.18	0.36	-	1.38	18.67	18.22	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.08	-	-	-	-	-	-	-	77.79	0	0	20.02	1.55	0.71	-	1.25	0.17	0.01	0.91	3.29	0.91	3.18	0.36	-	1.38	18.67	18.22	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.08	-	-	-	-	-	-	-	77.79																																																																																				-		0	20.02	1.55	0.71	-	1.25	0.17	0.01	0.91	3.29	0.91	3.18	0.36	-	1.38	18.67	18.22	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.08	-	-	-	-	-	-	-	77.79
H5657_806_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1175.11	91.2	479.54	2450.07	149.53	0.66	0.05	219	395.66	217.46	652.39	43.49	1143.41	369.69	11181.32	7274.05			369.26		7.04											61.85	4.8	15.34								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63	0	0	19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63																																																																																				-		0	19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63
H5657_807_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1175.11	91.2	479.54	2450.07	149.53	0.66	0.05	219	395.66	217.46	652.39	43.49	1143.41	369.69	11181.32	7274.05			369.26		7.04											61.85	4.8	15.34								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63	0	0	19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63																																																																																				-		0	19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63
H5657_808_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1175.11	91.2	479.54	2450.07	149.53	0.66	0.05	219	395.66	217.46	652.39	43.49	1143.41	369.69	11181.32	7274.05			369.26		7.04											61.85	4.8	15.34								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63	0	0	19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63																																																																																				-		0	19.98	1.55	0.7	-	1.25	0.17	0.01	0.9	3.28	0.91	3.17	0.36	-	1.38	18.64	18.19	-	-	1.54	-	1.41	-	-	-	-	-	-	-	-	-	-	1.05	0.08	3.07	-	-	-	-	-	-	-	77.63
H5665_001_0	2007	10																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	272.69	29.07	3219.49	0	22.01	49.6	29.91	16.44	32.53	3136.36	42.04	0	0	175.88	97.14	194.87	16.43	4.18	9808.34	64.28	32.3	6.08	0	0	45.32	0	0	0	0	0	924.16											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.21	0.01	0.55	0.18	0.25	32.99	0.25	0	0	0.25	0.22	0.21	0.51	0.22	15.49	0.21	0.26	0.18	0	0	9.73	0	0	0	0	0	0											22.72	2.42	33.54	-	4.72	0.48	16.58	2.92	8.21	8.62	10.62	-	-	44.42	21.63	41	8.31	0.9	12.66	13.79	8.39	1.12	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	263.09	138	0	22.72	2.42	33.54	-	4.72	0.48	16.58	2.92	8.21	8.62	10.62	-	-	44.42	21.63	41	8.31	0.9	12.66	13.79	8.39	1.12	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	263.09	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	22.72	2.42	33.54	-	4.72	0.48	16.58	2.92	8.21	8.62	10.62	-	-	44.42	21.63	41	8.31	0.9	12.66	13.79	8.39	1.12	-	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	263.09
H5665_002_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1637.15	2.55	1343.81	0	250.49	27.82	17.16	346.01	450.68	0	239.07	0	0	294.05	7488.44	8584.87	382.34	996.12	0	335.96	0	969.78	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											70	1000	100	0	50	0	0.23	49.37	100	0	32.65	0	0	28.75	10	25	29.25	25	0	28.46	0	23.89	0	0	0	0	0	0	0	0	0											9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39	0	0	9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39
H5665_003_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	2.55	0	0	250.49	27.82	17.16	346.01	0	0	239.07	0	0	35.31	6228.12	4810.73	0	0	0	232.71	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.23	48.75	0	0	32.65	0	0	19.63	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51	0	0	-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51
H5665_004_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1637.15	2.55	1343.81	0	250.49	27.82	17.16	346.01	450.68	0	239.07	0	0	294.05	7488.44	8584.87	382.34	996.12	0	335.96	0	969.78	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											70	1000	100	0	50	0	0.23	49.37	100	0	32.65	0	0	28.75	10	25	29.25	25	0	28.46	0	23.89	0	0	0	0	0	0	0	0	0											9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39	0	0	9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39
H5665_005_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1637.15	2.55	1343.81	0	250.49	27.82	17.16	346.01	450.68	0	239.07	0	0	294.05	7488.44	8584.87	382.34	996.12	0	335.96	0	969.78	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											70	1000	100	0	50	0	0.23	49.37	100	0	32.65	0	0	28.75	10	25	29.25	25	0	28.46	0	23.89	0	0	0	0	0	0	0	0	0											9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39	0	0	9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.55	0.21	11.2	-	1.04	0.11	3.88	1.42	3.76	-	0.65	-	-	0.7	6.24	17.89	0.93	2.08	-	0.8	-	1.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.39
H5665_006_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	2.55	0	0	250.49	27.82	17.16	346.01	0	0	239.07	0	0	35.31	6228.12	4810.73	0	0	0	232.71	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.23	48.75	0	0	32.65	0	0	19.63	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51	0	0	-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51
H5665_007_0	2007	8																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	2.55	0	0	250.49	27.82	17.16	346.01	0	0	239.07	0	0	35.31	6228.12	4810.73	0	0	0	232.71	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.23	48.75	0	0	32.65	0	0	19.63	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51	0	0	-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.21	-	-	-	0.11	3.88	1.41	-	-	0.65	-	-	0.06	5.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.51
H5665_803_0	2007	4																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	137.81	2.8	1249.74	0	6.76	25.59	15.79	6.63	32.78	1656.42	25.97	0	0	56.84	76.09	174.98	4.34	7.28	6452.72	72.19	22.28	8.68	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.21	0.01	0.55	0.19	0.25	24.03	0.25	0	0	0.25	0.23	0.21	0.51	0.22	20.84	0.21	0.26	0.2	0	0	0	0	0	0	0	0	0											11.48	0.23	13.02	-	1.45	0.25	8.63	1.26	8.27	3.32	6.55	-	-	14.34	17.67	36.18	2.2	1.57	11.21	15.49	5.79	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	160.63	138	0	11.48	0.23	13.02	-	1.45	0.25	8.63	1.26	8.27	3.32	6.55	-	-	14.34	17.67	36.18	2.2	1.57	11.21	15.49	5.79	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	160.63	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	11.48	0.23	13.02	-	1.45	0.25	8.63	1.26	8.27	3.32	6.55	-	-	14.34	17.67	36.18	2.2	1.57	11.21	15.49	5.79	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	160.63
H5665_804_0	2007	4																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	137.81	2.8	1249.74	0	6.76	25.59	15.79	6.63	32.78	1656.42	25.97	0	0	56.84	76.09	174.98	4.34	7.28	6452.72	72.19	22.28	8.68	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.21	0.01	0.55	0.19	0.25	24.03	0.25	0	0	0.25	0.23	0.21	0.51	0.22	20.84	0.21	0.26	0.2	0	0	0	0	0	0	0	0	0											11.48	0.23	13.02	-	1.45	0.25	8.63	1.26	8.27	3.32	6.55	-	-	14.34	17.67	36.18	2.2	1.57	11.21	15.49	5.79	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	160.63	138	0	11.48	0.23	13.02	-	1.45	0.25	8.63	1.26	8.27	3.32	6.55	-	-	14.34	17.67	36.18	2.2	1.57	11.21	15.49	5.79	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	160.63	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	11.48	0.23	13.02	-	1.45	0.25	8.63	1.26	8.27	3.32	6.55	-	-	14.34	17.67	36.18	2.2	1.57	11.21	15.49	5.79	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	160.63
H5678_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							11.83	11.95	399.53	376.5		251.26	53.59		970.6		5663.54	122.2			890.13					137.43		289.34						10.75	328.47		90.86	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	37	45		18	45		45		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.13	2.15	1.23	1.41	-	0.38	0.2	-	3.63	-	8.48	0.18	-	-	1.33	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.49	-	0.14	0.23	-	-	-	-	22.69		2.46	-	-	-	-	-	2.13	2.15	1.23	1.41	-	0.38	0.2	-	3.63	-	8.48	0.18	-	-	1.33	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.49	-	0.14	0.23	-	-	-	-	22.69		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						1.91	0.03	0.34	0.31	0.05	0.07	0.07	0.03	0.21	0.13	0.12	0.01	0	0.13		0.25	0.01	0.02	0.14	0.56	0.13	0			0.01		0.01															4.55		0	1.91	0.03	0.34	0.31	0.05	2.2	2.22	1.25	1.62	0.13	0.5	0.22	0	3.76	-	8.73	0.19	0.02	0.14	1.9	0.13	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.49	-	0.14	0.23	-	-	-	-	27.24
H5678_002_0	2007	2	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							11.83	11.95	399.53	376.5		251.26	53.59		970.6		5663.54	122.2			890.13					137.43		289.34						10.75	328.47		90.86	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	37	45		18	45		45		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.13	2.15	1.23	1.41	-	0.38	0.2	-	3.63	-	8.48	0.18	-	-	1.33	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.49	-	0.14	0.23	-	-	-	-	22.69		2.46	-	-	-	-	-	2.13	2.15	1.23	1.41	-	0.38	0.2	-	3.63	-	8.48	0.18	-	-	1.33	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.49	-	0.14	0.23	-	-	-	-	22.69		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						1.91	0.03	0.34	0.31	0.05	0.07	0.07	0.03	0.21	0.13	0.12	0.01	0	0.13		0.25	0.01	0.02	0.14	0.56	0.13	0			0.01		0.01															4.55		0	1.91	0.03	0.34	0.31	0.05	2.2	2.22	1.25	1.62	0.13	0.5	0.22	0	3.76	-	8.73	0.19	0.02	0.14	1.9	0.13	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.49	-	0.14	0.23	-	-	-	-	27.24
H5678_003_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1896.59	122.17	7240.09	109.94	497.63	1371.73	1724.7	134.45	149.09	5357.23	139.56	1.36	4.08	215.55	26314.67	1401.28	2437.81	20.95		70.06	109.72	597.28	2250		140.2	166		54.6				77.61		0.34	300	295.2						(1a) 25/day	(1b) 25/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 20/visit (waived if admitted)		(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						24	24			48			48																								19										3.8	0.24	-	-	1.99	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.12	-	-	-	-	-	-	-	-	-	6.69		0.27	3.8	0.24	-	-	1.99	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.12	-	-	-	-	-	-	-	-	-	6.69		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							20		30	30	30						2.75	0.07	0.79	0.06	0.2	0.28	0.04	0.03	0.31	0.46	0.62	0	0.01	0.11																		0.01		0								5.74		0	6.54	0.31	0.79	0.06	2.2	0.28	0.04	0.57	0.31	0.46	0.62	0	0.01	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.13	-	0	-	-	-	-	-	-	-	12.43
H5678_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								26.32	674.79	524.56		398.31	84.02		1583.69		6342.5	406.82			1353.12							289.34						62.3	327.28		263.86	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit											17	35	43		17	43		43		17	17			18							20						17	17		17	20					-	-	-	-	-	-	4.51	1.98	1.87	-	0.57	0.3	-	5.66	-	9.06	0.58	-	-	1.98	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.47	-	0.38	0.23	-	-	-	-	28.14		4.53	-	-	-	-	-	-	4.51	1.98	1.87	-	0.57	0.3	-	5.66	-	9.06	0.58	-	-	1.98	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.47	-	0.38	0.23	-	-	-	-	28.14		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.56	0.1	0.26	0.32	0.06	0.14	0.16	0.04	0.28	0.17	0.17	0.02	0.01	0.19		0.29	0.03	0.03	0.19	0.7	0.16	0			0.01		0.01															5.89		0	2.56	0.1	0.26	0.32	0.06	0.14	4.67	2.02	2.15	0.17	0.74	0.32	0.01	5.85	-	9.35	0.61	0.03	0.19	2.68	0.16	0	-	-	0.01	-	0.49	-	-	-	-	-	0.09	0.47	-	0.38	0.23	-	-	-	-	34.03
H5679_001_0	2007	8																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	P	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	264.48	2.59	1156.8	0	276.03	18.27	0.87	299.35	307.41	0	1018.43	0	15.36	583.14	3759.25	4983.44	155.59	504.67	0	214.19	8.04	609.56	0	0	344.27	0	147.42	0	0	0	0											350/Admit	700/Admit	1-20: 0/Day 21-100: 100/Day		100 per	30 per	30 per	50 ER / 50 UC	150 ASC/ 150 OP		0 - 50 per		30 per	30 OP SA / 50 Cardiac	10 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	30 Therapy		30 Hearing / 0 Preventive	20 per	30 Vision/0 Blood			20		20															350	700	23.83	0	100	0.3	0.3	50	150	0	14.04	0	30	39.53	10	29.94	30	29.05	0	11.12	0.2	29.39	0	0	20	0	20	0	0	0	0											7.71	0.15	2.3	-	2.3	5.48	0.26	1.25	3.84	-	1.19	-	0.04	1.92	3.13	12.44	0.39	1.22	-	0.2	1.64	1.49	-	-	0.57	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.77	0	0	7.71	0.15	2.3	-	2.3	5.48	0.26	1.25	3.84	-	1.19	-	0.04	1.92	3.13	12.44	0.39	1.22	-	0.2	1.64	1.49	-	-	0.57	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.77	none																																																																																			-	0	0	7.71	0.15	2.3	-	2.3	5.48	0.26	1.25	3.84	-	1.19	-	0.04	1.92	3.13	12.44	0.39	1.22	-	0.2	1.64	1.49	-	-	0.57	-	0.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.77
H5683_801_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1152.61	89.45	470.36	2403.16	146.67	0.64	0.05	214.81	388.09	213.3	639.9	42.66	1121.52	362.61	10967.25	7134.78			362.19		6.78											60.66	4.71	14.77								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06	0	0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06																																																																																				-		0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06
H5683_802_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1152.61	89.45	470.36	2403.16	146.67	0.64	0.05	214.81	388.09	213.3	639.9	42.66	1121.52	362.61	10967.25	7134.78			362.19		6.78											60.66	4.71	14.77								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06	0	0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06																																																																																				-		0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06
H5683_803_0	2007	3	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1152.61	89.45	470.36	2403.16	146.67	0.64	0.05	214.81	388.09	213.3	639.9	42.66	1121.52	362.61	10967.25	7134.78			362.19		6.78											60.66	4.71	14.77								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06	0	0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06																																																																																				-		0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06
H5683_804_0	2007	4	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional									Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								D	D	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											D	D	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0	0								-		1152.61	89.45	470.36	2403.16	146.67	0.64	0.05	214.81	388.09	213.3	639.9	42.66	1121.52	362.61	10967.25	7134.78			362.19		6.78											60.66	4.71	14.77								300/day (1-5)	300/day (1-5)	100/day (21-100)	0/Visit	100/ Trip	25 Coins	25 Coins	30-50/ Visit	50-200/ Visit	50/ Visit	50-100/ Visit	100/ Visit	0/ Procedure	30-100/ Visit	20/ Visit	30/ Visit			50/ Visit		20 Coins											300/day (1-5)	300/day (1-5)	20 Coins								204.06	204.06	17.61	0	100	0.25	0.25	49.51	99.5	50	58.33	100	0	44.71	20	30			50		0.2											204.06	204.06	0.2								19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06	0	0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06																																																																																				-		0	19.6	1.52	0.69	-	1.22	0.16	0.01	0.89	3.22	0.89	3.11	0.36	-	1.35	18.28	17.84	-	-	1.51	-	1.36	-	-	-	-	-	-	-	-	-	-	1.03	0.08	2.95	-	-	-	-	-	-	-	76.06
H5685_001_0	2007	6																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	429.78	32.82	75.31	0	16.31	37.92	24.92	897.38	25.41	17.17	34.09	1.17	1.36	49.16	73.02	132.19	11.17	5.83	27.88	41.06	11.4	4.47	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	9C OP Hospital:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 5 Partial Hosp:  138 Ded and 20 Coinsurance 9C OP Substance Abuse:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 138 Ded and 20 Coinsurance 14B Immunizations: 138 Ded and 20 Coinsurance 14D Pap Smears:  138 Ded and 20 Coinsurance 14D Pelvic Exams:  138 Ded and 20 Coinsurance 14E Prostate Screening:  138 Ded and 20 Coinsurance 14F Colorectal Sc	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 138 Ded and 20 Coinsurance 16B Comprehensive Dental Services:  138 Ded and 20 Coinsurance 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0.06	0.06	0.19	0	0.24	0.24	0.24	24.25	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											27.46	2.1	14.14	-	3.85	8.95	5.88	1.81	6	4.05	8.05	0.28	0.32	11.6	17.23	31.2	2.64	1.38	6.58	9.69	2.69	1.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	166.94	0	0	27.46	2.1	14.14	-	3.85	8.95	5.88	1.81	6	4.05	8.05	0.28	0.32	11.6	17.23	31.2	2.64	1.38	6.58	9.69	2.69	1.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	166.94	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	27.46	2.1	14.14	-	3.85	8.95	5.88	1.81	6	4.05	8.05	0.28	0.32	11.6	17.23	31.2	2.64	1.38	6.58	9.69	2.69	1.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	166.94
H5696_001_0	2007	4	e.3.	h.6.	i.7.								DME/Prosthetics/Supplies	OP Facility - Surgery									2400	Diabetic Supplies	ASC									D	D	D	V	T	Coin	Coin	V	P		V	P		V		V	V	V														Coin	V																																																		-		1501.47	86.39	1916.14	2080.88	457.02	22.12	1.84	310.88	183.94		713.68	72.16		4293.38		4597.7	242.58	1420.31														12.9	99.04									195 for 1st 5 days	195 for 1st 5 days	100 for days 6-30	30 per visit	100 per trip	Coin	Coin	50 for ER waived if admitted;  30 for Urgent	190 per procedure including lab work		One copay per visit (highest copay applies)	190 per observation		30 Per Visit		30 per visit (10 Visits chiro podiatry)	30 per visit (15 visits max)	30 per visit (15 visits)														20 Coinsurance	190 per procedure including lab work									130.17	130.17	48.62	30	100	0.2	0.2	46	190		22.78	190		30		30	30	30														0.2	190									16.29	0.94	7.76	5.2	3.81	4.42	0.37	1.19	2.91	-	1.35	1.14	-	10.73	-	11.49	0.61	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	2.58	1.57	-	-	-	-	-	-	-	-	75.92	0	1.53	16.29	0.94	7.76	5.2	3.81	4.42	0.37	1.19	2.91	-	1.35	1.14	-	10.73	-	11.49	0.61	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	2.58	1.57	-	-	-	-	-	-	-	-	75.92																																																																																				-	0	0	16.29	0.94	7.76	5.2	3.81	4.42	0.37	1.19	2.91	-	1.35	1.14	-	10.73	-	11.49	0.61	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	2.58	1.57	-	-	-	-	-	-	-	-	75.92
H5696_002_0	2007	5	e.3.	h.6.	i.7.								DME/Prosthetics/Supplies	OP Facility - Surgery	Professional								5000	Diabetic Supplies	ASC	Lab								D	D	D	V	T	Coin	Coin	V	P		V	P		V	V	V	V	V														Coin	V																																																		-		1501.47	86.39	1916.14	2080.88	457.02	22.12	1.84	310.88	183.94		713.68	72.16		4293.38	5101.65	4597.7	242.58	1420.31														12.9	99.04									255 for 1st 7 days	255 for 1st 7 days	Day 1-30 115 Days 22-100 0	35 per visit	115 Per trip	20 Coins	20 Coins	50 for er waived if admitted;  35 for urgent	255 Per procedure including lab work		One copay per visit (highest copay applies)	255 per observation		35 per visit	10 per visit	35 per visit (10 visit max chiro podiatry)	35 per visit (15 visit max)	35 per visit (15 visit max)														20 Coinsurance	255 Per procedure including lab work									200.12	200.12	99.77	35	115	0.2	0.2	47	255		51.79	255		35	10	35	35	35														0.2	255									25.04	1.44	15.93	6.07	4.38	4.42	0.37	1.22	3.91	-	3.08	1.53	-	12.52	4.25	13.41	0.71	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	2.58	2.1	-	-	-	-	-	-	-	-	107.11	0	0.61	25.04	1.44	15.93	6.07	4.38	4.42	0.37	1.22	3.91	-	3.08	1.53	-	12.52	4.25	13.41	0.71	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	2.58	2.1	-	-	-	-	-	-	-	-	107.11																																																																																				-	0	0	25.04	1.44	15.93	6.07	4.38	4.42	0.37	1.22	3.91	-	3.08	1.53	-	12.52	4.25	13.41	0.71	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	2.58	2.1	-	-	-	-	-	-	-	-	107.11
H5696_003_0	2007	6	e.3.	h.6.	i.7.								DME/Prosthetics/Supplies	OP Facility - Surgery	Professional								2400	Diabetic Supplies	ASC	Lab								D	D	D	V	T	Coin	Coin	V	P		V	P		V		V	V	V	V	V	O	O	T	V	V	V	V	V	V	V	V	Coin	V	V																																																	-		1190.49	68.5	1439.14	1743.46	277.66	16.54	1.38	332.39	167.67		818.33	71.38		5641.99		4522.02	253.42	842.96	4028.64	0	0	0	0	0	0	0	0	0	0	0	0	9.65	90.28	7029.48								Day 1-5 115 0 to 90 per benefit period 0 for lifetime day (maximum of 60 life time days)	Day 1-5 115 0 to 90 (maximum benefit of 190 life time days)(life threating only)	Day 1-3:  0 day 4-50: 50 day 51-100: 0	25 Per Visit	100 Per trip	Coinsurance	Coinsurance	50 for er waived if admitted;  25 for urgent	115 Per procedure including lab work		One copay per visit (highest copay applies)	115 Per observation		25 Per Visit		25 Per visit (10 visits max chiro podiatry)	25 Per visit (15 visits max)	25 Per visit (15 visits max)														Coinsurance	115 Per procedure including lab work									73.44	73.44	30.35	25	100	0.2	0.2	45	115		26.19	115		25		25	25	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0.2	115	0								7.29	0.42	3.64	3.63	2.31	3.31	0.28	1.25	1.61	-	1.79	0.68	-	11.75	-	9.42	0.53	1.76	-	-	-	-	-	-	-	-	-	-	-	-	-	1.93	0.87	-	-	-	-	-	-	-	-	52.45	0	1.44	7.29	0.42	3.64	3.63	2.31	3.31	0.28	1.25	1.61	-	1.79	0.68	-	11.75	-	9.42	0.53	1.76	-	-	-	-	-	-	-	-	-	-	-	-	-	1.93	0.87	-	-	-	-	-	-	-	-	52.45																																																																																				-	0	0	7.29	0.42	3.64	3.63	2.31	3.31	0.28	1.25	1.61	-	1.79	0.68	-	11.75	-	9.42	0.53	1.76	-	-	-	-	-	-	-	-	-	-	-	-	-	1.93	0.87	-	-	-	-	-	-	-	-	52.45
H5696_004_0	2007	7	e.3.	h.6.	i.7.								DME/Prosthetics/Supplies	OP Facility - Surgery									5000	Diabetic Supplies	ASC									D	D	D	V	T	Coin	Coin	V	P		V	P		V	V	V	V	V														Coin	V																																																		-		1190.49	68.5	1439.14	1743.46	277.66	16.54	1.38	332.39	167.67		818.33	71.38		5641.99	5196.95	4522.02	253.42	842.96														9.65	90.28									325 for 1st 7 days	325 for 1st 7 days	175 for days 1-28	30 Per visit	150 Per trip	Coinsurance	Coinsurance	50 for er waived if admitted;  30 for urgent	275 Per procedure including lab work		One copay per visit (highest copay applies)	275 Per observation		30 per visit	10 Per Visit	30 Per visit (10 visits chiro podiatry)	30 Per visit (15 visits max)	30 Per visit (15 visits)														Coinsurance	275 Per procedure including lab work									255.16	255.16	152.44	30	150	0.2	0.2	46	265		56.1	265		30	10	30	30	30														0.2	265									25.31	1.46	18.28	4.36	3.47	3.31	0.28	1.27	3.7	-	3.83	1.58	-	14.1	4.33	11.31	0.63	2.11	-	-	-	-	-	-	-	-	-	-	-	-	-	1.93	1.99	-	-	-	-	-	-	-	-	103.25	0	0.58	25.31	1.46	18.28	4.36	3.47	3.31	0.28	1.27	3.7	-	3.83	1.58	-	14.1	4.33	11.31	0.63	2.11	-	-	-	-	-	-	-	-	-	-	-	-	-	1.93	1.99	-	-	-	-	-	-	-	-	103.25																																																																																				-	0	0	25.31	1.46	18.28	4.36	3.47	3.31	0.28	1.27	3.7	-	3.83	1.58	-	14.1	4.33	11.31	0.63	2.11	-	-	-	-	-	-	-	-	-	-	-	-	-	1.93	1.99	-	-	-	-	-	-	-	-	103.25
H5696_005_0	2007	5	e.3.	h.6.	i.7.								DME/Prosthetics/Supplies	OP Facility - Surgery	Professional								2400	Diabetic Supplies	ASC									D	D	D	V	T	Coin	Coin	V	P		V	P		V		V	V	V														Coin	V																																																		-		1668.7	96.02	1983.34	2418.38	599.12	18.7	1.56	317.04	126.49		1218.16	128.24		4528.17		5228.02	422.59	615.22														10.91	68.11									Day 1-8 100 0 to 90 per benefit period 0 for lifetime day (maximum of 60 life time days)	Day 1-8 100 0 to 90 (maximum benefit of 190 life time days)(life threating only)	Day 1-3:  0 day 4-50: 50 day 51-100: 0	25 Per visit	100 Per trip	Coinsurance	Coinsurance	50 for er waived if admitted;  25 for urgent	100 Per procedure including lab work		One copay per visit (highest copay applies)	100 Per observation		25 Per visit		25 Per visit (10 visits max at 25 chiro podiatry)	25 Per visit (15 visits max)	25 Per visit (15 visits max)														Coinsurance	100 Per procedure including lab work									77.57	77.57	31.66	25	100	0.2	0.2	45	100		22.78	100		25		25	25	25														0.2	100									10.79	0.62	5.23	5.04	4.99	3.74	0.31	1.19	1.05	-	2.31	1.07	-	9.43	-	10.89	0.88	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	2.18	0.57	-	-	-	-	-	-	-	-	61.58	0	1.6	10.79	0.62	5.23	5.04	4.99	3.74	0.31	1.19	1.05	-	2.31	1.07	-	9.43	-	10.89	0.88	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	2.18	0.57	-	-	-	-	-	-	-	-	61.58																																																																																				-	0	0	10.79	0.62	5.23	5.04	4.99	3.74	0.31	1.19	1.05	-	2.31	1.07	-	9.43	-	10.89	0.88	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	2.18	0.57	-	-	-	-	-	-	-	-	61.58
H5696_006_0	2007	8	e.3.	h.6.	i.7.								DME/Prosthetics/Supplies	OP Facility - Surgery									5000	Diabetic Supplies	ASC									D	D	D	V	T	Coin	Coin	V	P	V	V	P		V	V	V	V	V														Coin	V																																																		-		1668.7	96.02	1983.34	2418.38	599.12	18.7	1.56	317.04	126.49	4639.52	1218.16	128.24		4528.17	5438.33	5228.02	422.59	615.22														10.91	68.11									270 for 1st 6 days	270 for 1st 6 days	135 for days 1-27	30 Per Visit	30 Per Trip	Coinsurance	Coinsurance	50 for er waived if admitted;  30 for urgent	Per procedure including lab work		One copay per visit (highest copay applies)	135 Per observation		30 Per visit	10 Per Visit	30 Per visit (10 visits chiro podiatry)	30 Per visit (15 visits max)	30 Per visit (15 visits)														Coinsurance	135 Per procedure including lab work									200.28	200.28	116.5	30	100	0.2	0.2	46	135		52.69	135		30	10	30	30	30														0.2	135									27.85	1.6	19.25	6.05	4.99	3.74	0.31	1.22	1.42	-	5.35	1.44	-	11.32	4.53	13.07	1.06	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	2.18	0.77	-	-	-	-	-	-	-	-	107.69	0	0.64	27.85	1.6	19.25	6.05	4.99	3.74	0.31	1.22	1.42	-	5.35	1.44	-	11.32	4.53	13.07	1.06	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	2.18	0.77	-	-	-	-	-	-	-	-	107.69																																																																																				-	0	0	27.85	1.6	19.25	6.05	4.99	3.74	0.31	1.22	1.42	-	5.35	1.44	-	11.32	4.53	13.07	1.06	1.54	-	-	-	-	-	-	-	-	-	-	-	-	-	2.18	0.77	-	-	-	-	-	-	-	-	107.69
H5697_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							12.35	13.25	385	424.16		287.51	55.6		994.71		5939.89	143.23			958.81					137.43		289.34						13.18	390.38		106.88	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	37	45		18	45		45		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.2	2.36	1.17	1.58	-	0.43	0.21	-	3.69	-	8.82	0.21	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.58	-	0.16	0.23	-	-	-	-	23.8		2.79	-	-	-	-	-	2.2	2.36	1.17	1.58	-	0.43	0.21	-	3.69	-	8.82	0.21	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.58	-	0.16	0.23	-	-	-	-	23.8		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						1.98	0.03	0.27	0.26	0.04	0.08	0.08	0.03	0.25	0.15	0.16	0.02	0	0.14		0.28	0.01	0.03	0.17	0.63	0.15	0			0.01		0.01															4.78		0	1.98	0.03	0.27	0.26	0.04	2.28	2.44	1.2	1.83	0.15	0.58	0.22	0	3.84	-	9.1	0.22	0.03	0.17	2.05	0.15	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.58	-	0.16	0.23	-	-	-	-	28.57
H5697_002_0	2007	2	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							12.35	13.25	385	424.16		287.51	55.6		994.7		5939.88	143.23			958.81					137.43		289.34						13.18	390.38		106.88	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	37	45		18	45		45		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.2	2.36	1.17	1.58	-	0.43	0.21	-	3.69	-	8.82	0.21	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.58	-	0.16	0.23	-	-	-	-	23.8		2.79	-	-	-	-	-	2.2	2.36	1.17	1.58	-	0.43	0.21	-	3.69	-	8.82	0.21	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.58	-	0.16	0.23	-	-	-	-	23.8		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						1.98	0.03	0.27	0.26	0.04	0.08	0.08	0.03	0.25	0.15	0.16	0.02	0	0.14		0.28	0.01	0.03	0.17	0.63	0.15	0			0.01		0.01															4.78		0	1.98	0.03	0.27	0.26	0.04	2.28	2.44	1.2	1.83	0.15	0.58	0.22	0	3.84	-	9.1	0.22	0.03	0.17	2.05	0.15	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.58	-	0.16	0.23	-	-	-	-	28.57
H5697_003_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								29.66	716.34	556.86		422.84	89.19		1681.22		6733.1	431.87			1436.46							289.34						66.14	347.43		280.11	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit											17	35	42		17	42		42		17	17			17							20						17	17		17	20					-	-	-	-	-	-	5	2.06	1.95	-	0.59	0.31	-	5.9	-	9.45	0.61	-	-	2.07	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.39	0.23	-	-	-	-	29.64		5.35	-	-	-	-	-	-	5	2.06	1.95	-	0.59	0.31	-	5.9	-	9.45	0.61	-	-	2.07	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.39	0.23	-	-	-	-	29.64		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.89	0.11	0.29	0.36	0.06	0.16	0.18	0.04	0.31	0.19	0.2	0.03	0.01	0.22		0.33	0.03	0.03	0.21	0.79	0.18	0			0.01		0.01															6.63		0	2.89	0.11	0.29	0.36	0.06	0.16	5.18	2.11	2.27	0.19	0.79	0.34	0.01	6.12	-	9.78	0.64	0.03	0.21	2.86	0.18	0	-	-	0.01	-	0.49	-	-	-	-	-	0.09	0.49	-	0.39	0.23	-	-	-	-	36.27
H5698_002_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1562.99	42.4	805.58		308.6	10.05	17.56	407.26	31.44		474.77	25.28		198.57	5040.14	4379.84	251.56	196.59		39.08	9		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.74	74.22	28.87		45	0.2	0.16	44.99	0.18		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.18	0.26	1.94	-	1.16	2.01	2.89	1.53	5.55	-	2.97	0.11	-	0.48	8.4	7.99	0.41	0.48	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.06		0.38	5.18	0.26	1.94	-	1.16	2.01	2.89	1.53	5.55	-	2.97	0.11	-	0.48	8.4	7.99	0.41	0.48	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.06		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.18	0.26	1.94	-	1.16	2.01	2.89	1.53	5.55	-	2.97	0.11	-	0.48	8.4	7.99	0.41	0.48	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.06
H5698_003_0	2007	4																																D	D	D	V	P	P	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	P	T	P	P	P	P	P	P	P	P																																																				-				2611.02		364.6			936.25				51.28									18.62		30		151.52		262.69															No Cost Share	No Cost Share	75/day days 21-100	No Cost Share	50 waived if adm.	No Cost Share	No Cost Share	35 waived if adm.	No Cost Share	No Cost Share	No Cost Share	35 Copay	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	10	No Cost Share	3 Copay	No Cost Share	30 Copay	Not Covered	30 Copay	Not Covered	Not Covered	No Cost Share	No Cost Share													28.87		45			31.5				35									0.1		0		10		10															-	-	6.28	-	1.37	-	-	2.46	-	-	-	0.15	-	-	-	-	-	-	-	-	1.86	-	0	-	0.13	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.46		0	-	-	6.28	-	1.37	-	-	2.46	-	-	-	0.15	-	-	-	-	-	-	-	-	1.86	-	0	-	0.13	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.46		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	-	-	6.28	-	1.37	-	-	2.46	-	-	-	0.15	-	-	-	-	-	-	-	-	1.86	-	0	-	0.13	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.46
H5698_005_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1734.58	47.05	805.58		303.43	10.05	17.6	389.34	30.14		481.5	25.64		201.39	4955.67	4306.44	247.34	193.3		38.43	8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.3	74.22	28.87		45	0.2	0.16	44.99	0.17		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.68	0.29	1.94	-	1.14	2.01	2.89	1.46	5.27	-	3.01	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.97		0.48	5.68	0.29	1.94	-	1.14	2.01	2.89	1.46	5.27	-	3.01	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.97		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.68	0.29	1.94	-	1.14	2.01	2.89	1.46	5.27	-	3.01	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.97
H5698_006_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1562.99	42.4	805.58		308.6	10.05	17.56	407.26	31.44		474.77	25.28		198.57	5040.14	4379.84	251.56	196.59		39.08	9		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.74	74.22	28.87		45	0.2	0.16	44.99	0.18		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.18	0.26	1.94	-	1.16	2.01	2.89	1.53	5.55	-	2.97	0.11	-	0.48	8.4	7.99	0.41	0.48	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.06		0.38	5.18	0.26	1.94	-	1.16	2.01	2.89	1.53	5.55	-	2.97	0.11	-	0.48	8.4	7.99	0.41	0.48	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.06		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.18	0.26	1.94	-	1.16	2.01	2.89	1.53	5.55	-	2.97	0.11	-	0.48	8.4	7.99	0.41	0.48	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.06
H5698_007_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1734.58	47.05	805.58		303.43	10.05	17.6	389.34	30.14		481.5	25.64		201.39	4955.67	4306.44	247.34	193.3		38.43	8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.3	74.22	28.87		45	0.2	0.16	44.99	0.17		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.68	0.29	1.94	-	1.14	2.01	2.89	1.46	5.27	-	3.01	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.97		0.48	5.68	0.29	1.94	-	1.14	2.01	2.89	1.46	5.27	-	3.01	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.97		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.68	0.29	1.94	-	1.14	2.01	2.89	1.46	5.27	-	3.01	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.97
H5698_009_0	2007	4																																D	D	D	V	P	P	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	P	T	P	P	P	P	P	P	P	P																																																				-				2382.87		229.63			527.42				6.86									23		30		144.49		250.5															No Cost Share	No Cost Share	75/day days 21-100	No Cost Share	50 waived if adm.	No Cost Share	No Cost Share	35 waived if adm.	No Cost Share	No Cost Share	No Cost Share	35 Copay	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	10	No Cost Share	3 Copay	No Cost Share	30 Copay	Not Covered	30 Copay	Not Covered	Not Covered	No Cost Share	No Cost Share													28.87		45			31.5				35									0.1		0		10		10															-	-	5.73	-	0.86	-	-	1.38	-	-	-	0.02	-	-	-	-	-	-	-	-	2.3	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.63		0	-	-	5.73	-	0.86	-	-	1.38	-	-	-	0.02	-	-	-	-	-	-	-	-	2.3	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.63		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	-	-	5.73	-	0.86	-	-	1.38	-	-	-	0.02	-	-	-	-	-	-	-	-	2.3	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.63
H5698_010_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1707.87	46.33	805.58		303.43	10.05	16.11	407.38	33.65		474.77	25.28		198.57	4955.67	4306.44	247.34	193.3		38.43	8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.37	74.22	28.87		45	0.2	0.16	44.99	0.18		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.6	0.29	1.94	-	1.14	2.01	2.66	1.53	5.89	-	2.97	0.11	-	0.48	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.29		0.47	5.6	0.29	1.94	-	1.14	2.01	2.66	1.53	5.89	-	2.97	0.11	-	0.48	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.29		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.6	0.29	1.94	-	1.14	2.01	2.66	1.53	5.89	-	2.97	0.11	-	0.48	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.29
H5698_012_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	P	P																																																				-		1707.87	46.33	805.58		303.43	10.05	16.11	407.38	33.65		474.77	25.28		184.11		818.89		179.19			8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	No Cost Sharing	No Cost Sharing	50 copay (waived if admitted)	No Cost Sharing	No Cost Sharing	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	25 Copay	50 copay	No Cost Sharing	10 Outpatient Rehab	No Cost Sharing	10 Opthalmology and Podiatrist Copay	No Cost Sharing	10 Copay	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	10 copay	75 allowance annually	10 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.37	74.22	28.87		45	0.2	0.13	44.99	0.18		25	50		10		4.33		10			0.2		3		10		10															5.6	0.29	1.94	-	1.14	2.01	2.09	1.53	5.89	-	0.99	0.11	-	0.15	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.26		0.47	5.6	0.29	1.94	-	1.14	2.01	2.09	1.53	5.89	-	0.99	0.11	-	0.15	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.26		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.6	0.29	1.94	-	1.14	2.01	2.09	1.53	5.89	-	0.99	0.11	-	0.15	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.26
H5698_013_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1707.87	46.33	805.58		303.43	10.05	16.11	407.38	33.65		474.77	25.28		198.57	4955.67	4306.44	247.34	193.3		38.43	8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.37	74.22	28.87		45	0.2	0.16	44.99	0.18		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.6	0.29	1.94	-	1.14	2.01	2.66	1.53	5.89	-	2.97	0.11	-	0.48	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.29		0.47	5.6	0.29	1.94	-	1.14	2.01	2.66	1.53	5.89	-	2.97	0.11	-	0.48	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.29		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.6	0.29	1.94	-	1.14	2.01	2.66	1.53	5.89	-	2.97	0.11	-	0.48	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.29
H5698_014_0	2007	4																																D	D	D	V	P	P	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	P	T	P	P	P	P	P	P	P	P																																																				-				1663.08		48.7			1255.29				18.72									26.61		30		146.21		253.48															No Cost Share	No Cost Share	75/day days 21-100	No Cost Share	50 waived if adm.	No Cost Share	No Cost Share	35 waived if adm.	No Cost Share	No Cost Share	No Cost Share	35 Copay	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	20	No Cost Share	3 Copay	No Cost Share	30 Copay	Not Covered	30 Copay	Not Covered	Not Covered	No Cost Share	No Cost Share													28.87		45			31.5				35									0.2		0		10		10															-	-	4	-	0.18	-	-	3.29	-	-	-	0.05	-	-	-	-	-	-	-	-	5.32	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.19		0	-	-	4	-	0.18	-	-	3.29	-	-	-	0.05	-	-	-	-	-	-	-	-	5.32	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.19		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	-	-	4	-	0.18	-	-	3.29	-	-	-	0.05	-	-	-	-	-	-	-	-	5.32	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.19
H5698_017_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	P	P																																																				-		1562.99	42.4	805.58		308.6	10.05	17.56	407.26	31.44		474.77	25.28		184.11		832.85		182.24			9		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	No Cost Sharing	No Cost Sharing	50 copay (waived if admitted)	No Cost Sharing	No Cost Sharing	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	25 Copay	50 copay	No Cost Sharing	10 Outpatient Rehab	No Cost Sharing	10 Opthalmology and Podiatrist Copay	No Cost Sharing	10 Copay	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	10 copay	75 allowance annually	10 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.74	74.22	28.87		45	0.2	0.13	44.99	0.18		25	50		10		4.33		10			0.2		3		10		10															5.18	0.26	1.94	-	1.16	2.01	2.26	1.53	5.55	-	0.99	0.11	-	0.15	-	0.3	-	0.15	-	-	1.8	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.69		0.38	5.18	0.26	1.94	-	1.16	2.01	2.26	1.53	5.55	-	0.99	0.11	-	0.15	-	0.3	-	0.15	-	-	1.8	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.69		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.18	0.26	1.94	-	1.16	2.01	2.26	1.53	5.55	-	0.99	0.11	-	0.15	-	0.3	-	0.15	-	-	1.8	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.69
H5698_018_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	P	P																																																				-		1734.58	47.05	805.58		303.43	10.05	17.6	389.34	30.14		481.5	25.64		186.72		818.89		179.19			8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	No Cost Sharing	No Cost Sharing	50 copay (waived if admitted)	No Cost Sharing	No Cost Sharing	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	25 Copay	50 copay	No Cost Sharing	10 Outpatient Rehab	No Cost Sharing	10 Opthalmology and Podiatrist Copay	No Cost Sharing	10 Copay	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	10 copay	75 allowance annually	10 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.3	74.22	28.87		45	0.2	0.13	44.99	0.17		25	50		10		4.33		10			0.2		3		10		10															5.68	0.29	1.94	-	1.14	2.01	2.27	1.46	5.27	-	1	0.11	-	0.16	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.84		0.48	5.68	0.29	1.94	-	1.14	2.01	2.27	1.46	5.27	-	1	0.11	-	0.16	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.84		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.68	0.29	1.94	-	1.14	2.01	2.27	1.46	5.27	-	1	0.11	-	0.16	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.84
H5698_019_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1820.25	49.38	805.58		290.58	10.05	14.94	377.46	29.4		471.1	24.63		96.65	4745.33	4125.98	240.81	184.57		36.8	8.47		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.06	74.22	28.87		45	0.2	0.17	44.98	0.17		75	50		29.82	20	21.91	19.5	29.19		0	0.2		3		30		30															5.93	0.31	1.94	-	1.09	2.01	2.47	1.41	5.14	-	2.94	0.1	-	0.24	7.91	7.54	0.39	0.45	-	0	1.69	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.48		0.54	5.93	0.31	1.94	-	1.09	2.01	2.47	1.41	5.14	-	2.94	0.1	-	0.24	7.91	7.54	0.39	0.45	-	0	1.69	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.48		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.93	0.31	1.94	-	1.09	2.01	2.47	1.41	5.14	-	2.94	0.1	-	0.24	7.91	7.54	0.39	0.45	-	0	1.69	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.48
H5698_020_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1820.25	49.38	805.58		290.58	10.05	14.94	377.46	29.4		471.1	24.63		96.65	4745.33	4125.98	240.81	184.57		36.8	8.47		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.06	74.22	28.87		45	0.2	0.17	44.98	0.17		75	50		29.82	20	21.91	19.5	29.19		0	0.2		3		30		30															5.93	0.31	1.94	-	1.09	2.01	2.47	1.41	5.14	-	2.94	0.1	-	0.24	7.91	7.54	0.39	0.45	-	0	1.69	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.48		0.54	5.93	0.31	1.94	-	1.09	2.01	2.47	1.41	5.14	-	2.94	0.1	-	0.24	7.91	7.54	0.39	0.45	-	0	1.69	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.48		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.93	0.31	1.94	-	1.09	2.01	2.47	1.41	5.14	-	2.94	0.1	-	0.24	7.91	7.54	0.39	0.45	-	0	1.69	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.48
H5698_021_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	P	P																																																				-		1820.25	49.38	805.58		290.58	10.05	14.94	377.46	29.4		471.1	24.63		95.03		790.11		169.65			8.47		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	No Cost Sharing	No Cost Sharing	50 copay (waived if admitted)	No Cost Sharing	No Cost Sharing	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	25 Copay	50 copay	No Cost Sharing	10 Outpatient Rehab	No Cost Sharing	10 Opthalmology and Podiatrist Copay	No Cost Sharing	10 Copay	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	10 copay	75 allowance annually	10 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.06	74.22	28.87		45	0.2	0.13	44.98	0.17		25	50		10		4.37		10			0.2		3		10		10															5.93	0.31	1.94	-	1.09	2.01	1.95	1.41	5.14	-	0.98	0.1	-	0.08	-	0.29	-	0.14	-	-	1.69	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.37		0.54	5.93	0.31	1.94	-	1.09	2.01	1.95	1.41	5.14	-	0.98	0.1	-	0.08	-	0.29	-	0.14	-	-	1.69	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.37		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.93	0.31	1.94	-	1.09	2.01	1.95	1.41	5.14	-	0.98	0.1	-	0.08	-	0.29	-	0.14	-	-	1.69	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.37
H5698_022_0	2007	5																																D	D	D	V	P	P	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	P	T	P	P	P	P	P	P	P	P																																																				-				1422.25		337.62			610.63				20.08									23.58		30		133.56		231.56															No Cost Share	No Cost Share	75/day days 21-100	No Cost Share	50 waived if adm.	No Cost Share	No Cost Share	35 waived if adm.	No Cost Share	No Cost Share	No Cost Share	35 Copay	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	10	No Cost Share	3 Copay	No Cost Share	10 Copay	Not Covered	10 Copay	Not Covered	Not Covered	No Cost Share	No Cost Share													28.87		45			31.5				35									0.1		0		10		10															-	-	3.42	-	1.27	-	-	1.6	-	-	-	0.06	-	-	-	-	-	-	-	-	2.36	-	0	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.01		0	-	-	3.42	-	1.27	-	-	1.6	-	-	-	0.06	-	-	-	-	-	-	-	-	2.36	-	0	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.01		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	-	-	3.42	-	1.27	-	-	1.6	-	-	-	0.06	-	-	-	-	-	-	-	-	2.36	-	0	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.01
H5698_027_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		2034.01	55.19	805.58		308.6	9.58	13.81	407.45	26.86		457.96	25.64		102.72	5039.71	4231.3	253.51	626.63		39.08	9		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											38.52	74.22	28.87		45	0.2	0.17	44.98	0.18		75	50		29.39	20	21.61	19.5	25.28		0	0.2		3		30		30															6.53	0.34	1.94	-	1.16	1.92	2.3	1.53	4.77	-	2.86	0.11	-	0.25	8.4	7.62	0.41	1.32	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.18		0.7	6.53	0.34	1.94	-	1.16	1.92	2.3	1.53	4.77	-	2.86	0.11	-	0.25	8.4	7.62	0.41	1.32	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.18		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	6.53	0.34	1.94	-	1.16	1.92	2.3	1.53	4.77	-	2.86	0.11	-	0.25	8.4	7.62	0.41	1.32	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.18
H5698_028_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		2034.01	55.19	805.58		308.6	9.58	13.81	407.45	26.86		457.96	25.64		102.72	5039.71	4231.3	253.51	626.63		39.08	9		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											38.52	74.22	28.87		45	0.2	0.17	44.98	0.18		75	50		29.39	20	21.61	19.5	25.28		0	0.2		3		30		30															6.53	0.34	1.94	-	1.16	1.92	2.3	1.53	4.77	-	2.86	0.11	-	0.25	8.4	7.62	0.41	1.32	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.18		0.7	6.53	0.34	1.94	-	1.16	1.92	2.3	1.53	4.77	-	2.86	0.11	-	0.25	8.4	7.62	0.41	1.32	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.18		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	6.53	0.34	1.94	-	1.16	1.92	2.3	1.53	4.77	-	2.86	0.11	-	0.25	8.4	7.62	0.41	1.32	-	0	1.8	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.18
H5698_029_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	P	P																																																				-		2034.01	55.19	805.58		308.6	9.58	13.81	407.45	26.86		457.96	25.64		96.78		682		330.78			9		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	No Cost Sharing	No Cost Sharing	50 copay (waived if admitted)	No Cost Sharing	No Cost Sharing	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	25 Copay	50 copay	No Cost Sharing	10 Outpatient Rehab	No Cost Sharing	10 Opthalmology and Podiatrist Copay	No Cost Sharing	10 Copay	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	10 copay	75 allowance annually	10 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											38.52	74.22	28.87		45	0.2	0.13	44.98	0.18		25	50		10		3.07		10			0.2		3		10		10															6.53	0.34	1.94	-	1.16	1.92	1.85	1.53	4.77	-	0.95	0.11	-	0.08	-	0.17	-	0.28	-	-	1.8	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.73		0.7	6.53	0.34	1.94	-	1.16	1.92	1.85	1.53	4.77	-	0.95	0.11	-	0.08	-	0.17	-	0.28	-	-	1.8	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.73		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	6.53	0.34	1.94	-	1.16	1.92	1.85	1.53	4.77	-	0.95	0.11	-	0.08	-	0.17	-	0.28	-	-	1.8	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.73
H5698_030_0	2007	5																																D	D	D	V	P	P	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	P	T	P	P	P	P	P	P	P	P																																																				-				2763.37		272.24			932.17				52.08									17.72		30		148.71		257.81															No Cost Share	No Cost Share	75/day days 21-100	No Cost Share	50 waived if adm.	No Cost Share	No Cost Share	35 waived if adm.	No Cost Share	No Cost Share	No Cost Share	35 Copay	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	10	No Cost Share	3 Copay	No Cost Share	10 Copay	Not Covered	10 Copay	Not Covered	Not Covered	No Cost Share	No Cost Share													28.87		45			31.5				35									0.1		0		10		10															-	-	6.65	-	1.02	-	-	2.45	-	-	-	0.15	-	-	-	-	-	-	-	-	1.77	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.38		0	-	-	6.65	-	1.02	-	-	2.45	-	-	-	0.15	-	-	-	-	-	-	-	-	1.77	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.38		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	-	-	6.65	-	1.02	-	-	2.45	-	-	-	0.15	-	-	-	-	-	-	-	-	1.77	-	0	-	0.12	-	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.38
H5698_035_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1617.4	43.88	805.58		303.43	10.05	16.78	407.35	31.79		478.27	25.47		200.03	4955.67	4306.44	247.34	193.3		38.43	8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.59	74.22	28.87		45	0.2	0.16	44.99	0.18		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.34	0.27	1.94	-	1.14	2.01	2.76	1.53	5.6	-	2.99	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.85		0.41	5.34	0.27	1.94	-	1.14	2.01	2.76	1.53	5.6	-	2.99	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.85		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.34	0.27	1.94	-	1.14	2.01	2.76	1.53	5.6	-	2.99	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.85
H5698_036_0	2007	5																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	Coin	V	Coin	P	P	P																																																				-		1617.4	43.88	805.58		303.43	10.05	16.78	407.35	31.79		478.27	25.47		200.03	4955.67	4306.44	247.34	193.3		38.43	8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	0/day days 1-2075/day days 21-100100 days per benefit period 3 day prior hospital stay required	No Cost Sharing	50 copay (waived if admitted)	10 member coinsurance	20 Member Coinsurance	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	75 Copay	50 copay	No Cost Sharing	30 Outpatient Rehab OP MH/SA - 20 (Ind) / 15 (Group)	20 copay	20 Specialist Copay 30 Opthalmology and Podiatrist Copay	20 copay - ind./15 copay - group	30 Copay	No Cost Sharing	No Cost Sharing	20 Member Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	30 copay	75 allowance annually plus 20 discount above 75	30 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.59	74.22	28.87		45	0.2	0.16	44.99	0.18		75	50		29.24	20	21.9	19.5	29.27		0	0.2		3		30		30															5.34	0.27	1.94	-	1.14	2.01	2.76	1.53	5.6	-	2.99	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.85		0.41	5.34	0.27	1.94	-	1.14	2.01	2.76	1.53	5.6	-	2.99	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.85		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.34	0.27	1.94	-	1.14	2.01	2.76	1.53	5.6	-	2.99	0.11	-	0.49	8.26	7.86	0.4	0.47	-	0	1.77	-	0.01	-	0.33	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.85
H5698_037_0	2007	4																					2000											D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	P	V	V	V	V	V	V	Coin	P	T	V	V	P	V	Coin	P	P	P																																																				-		1617.4	43.88	805.58		303.43	10.05	16.78	407.35	31.79		478.27	25.47		185.47		818.89		179.19			8.85		30		133.56		231.56															100/day days 1-10 0/day additional days	100/day days 1-10 0/day additional days	No Cost Sharing	No Cost Sharing	50 copay (waived if admitted)	No Cost Sharing	No Cost Sharing	50 copay for emergency care/30 for urgent care (waived if admitted) worldwide	20 coins not to exceed 250	No Cost Sharing	25 Copay	50 copay	No Cost Sharing	10 Outpatient Rehab	No Cost Sharing	10 Opthalmology and Podiatrist Copay	No Cost Sharing	10 Copay	No Cost Sharing	No Cost Sharing	20 Coinsurance	No Cost Sharing	3/one-way trip 40 one-way trips per year	Not Covered	10 copay	75 allowance annually	10 copay	Not Covered	Not Covered	No Cost Sharing	No Cost Sharing											39.59	74.22	28.87		45	0.2	0.13	44.99	0.18		25	50		10		4.33		10			0.2		3		10		10															5.34	0.27	1.94	-	1.14	2.01	2.17	1.53	5.6	-	1	0.11	-	0.15	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.77		0.41	5.34	0.27	1.94	-	1.14	2.01	2.17	1.53	5.6	-	1	0.11	-	0.15	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.77		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	5.34	0.27	1.94	-	1.14	2.01	2.17	1.53	5.6	-	1	0.11	-	0.15	-	0.3	-	0.15	-	-	1.77	-	0.01	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.77
H5698_038_0	2007	4																																D	D	D	V	P	P	Coin	V	P	P	P	P	P	P	V	V	V	V	V	V	Coin	P	T	P	P	P	P	P	P	P	P																																																				-				2288.71		443.16			999.51				18.55									19.01		30		153.42		265.98															No Cost Share	No Cost Share	75/day days 21-100	No Cost Share	50 waived if adm.	No Cost Share	No Cost Share	35 waived if adm.	No Cost Share	No Cost Share	No Cost Share	35 Copay	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	No Cost Share	10	No Cost Share	3 Copay	No Cost Share	30 Copay	Not Covered	30 Copay	Not Covered	Not Covered	No Cost Share	No Cost Share													28.87		45			31.5				35									0.1		0		10		10															-	-	5.51	-	1.66	-	-	2.62	-	-	-	0.05	-	-	-	-	-	-	-	-	1.9	-	0	-	0.13	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.1		0	-	-	5.51	-	1.66	-	-	2.62	-	-	-	0.05	-	-	-	-	-	-	-	-	1.9	-	0	-	0.13	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.1		N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A																																																				-		0	-	-	5.51	-	1.66	-	-	2.62	-	-	-	0.05	-	-	-	-	-	-	-	-	1.9	-	0	-	0.13	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.1
H5700_001_0	2007	9																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1728.36	90.64	603.85		117.32	8.34	7.88	310.81	37.5		16	1.8	0	13.77	3940.43	4964.43	235.69	504.85	14.13	6.17	29.24				129.91		116.29															#1A: 50 days 1-5	#1B: 50 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 75	#11A: 10	#11B/11C: 10	#4: 50	#9A OP Hosp: 10 NTE 200; #9B ASC: 10 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 10; #5: 20; #9A OP Hosp 15 / Chemo 20; #9C: 20; #9D: 10	#7A: 5; #14C: 0	#7B : 5; #7D/7F/7G #16B #17A #18A: 15	#7E/#7H: 20	#7C/#7I: 10	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 150 Allowance every two years	#18A: 15	#18B: 700 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	28.91	28.91	10.15		70.75	0.09	0.09	47.17	0.07		0.1	0.14	0.19	0.14	4.72	13.06	18.87	9.43	0.09	0.09	0.19				10		15															4.16	0.22	0.51	-	0.69	0.79	0.74	1.22	2.64	-	1.64	0.25	0	1.98	1.55	5.4	0.37	0.4	1.33	0.58	5.52	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.26		1.8	4.16	0.22	0.51	-	0.69	0.79	0.74	1.22	2.64	-	1.64	0.25	0	1.98	1.55	5.4	0.37	0.4	1.33	0.58	5.52	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.26																																																																																				-		0	4.16	0.22	0.51	-	0.69	0.79	0.74	1.22	2.64	-	1.64	0.25	0	1.98	1.55	5.4	0.37	0.4	1.33	0.58	5.52	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.26
H5700_002_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1651.05	86.59	576.85		112.07	7.96	7.52	296.92	35.82		15.28	1.71	0	13.15	3764.17	4637.77	225.14	482.26	13.5	5.9	27.93				129.91		116.29															#1A: 100 days 1-5	#1B: 100 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 15	#11B/11C: 15	#4: 50	#9A OP Hosp: 15 NTE 200; #9B ASC: 15 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 10; #5: 25; #9A OP Hosp 15 / Chemo 20; #9C: 25; #9D: 10	#7A: 10; #14C: 0	#7B : 8; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 25	#7C/#7I: 10	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 125 Allowance every two years	#18A: 20	#18B: 500 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	61.29	61.29	13.45		100	0.15	0.15	50	0.09		0.15	0.15	0.2	0.15	10	18.85	25	10	0.15	0.15	0.2				25		20															8.43	0.44	0.65	-	0.93	1.19	1.13	1.24	3.36	-	2.36	0.26	0	2.01	3.14	7.28	0.47	0.4	2.02	0.88	5.59	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.25		0	8.43	0.44	0.65	-	0.93	1.19	1.13	1.24	3.36	-	2.36	0.26	0	2.01	3.14	7.28	0.47	0.4	2.02	0.88	5.59	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.25																																																																																				-		0	8.43	0.44	0.65	-	0.93	1.19	1.13	1.24	3.36	-	2.36	0.26	0	2.01	3.14	7.28	0.47	0.4	2.02	0.88	5.59	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.25
H5700_004_0	2007	7																					7500											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1813.96	95.13	633.72	1584.53	123.13	9.18	8.68	326.18	41.31		17.62	1.98	0	15.17	4212.06	5095.39	247.36	529.85	15.56	6.8	32.21				129.91		116.29															#1A: 100 days 1-5	#1B: 200 days 1-5	#2: 25 days 11-100	#6: 5	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 275; #9B ASC: 15 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 20; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 20	#7A: 10; #14C: 15	#7B : 20; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 40	#7C/#7I: 20	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 20	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	57.52	115.03	12.62	4.69	93.84	0.19	0.15	46.92	0.1		0.1	0.14	0.19	0.14	9.49	23.01	37.54	18.77	0.09	0.09	0.19				25		20															8.69	0.91	0.67	0.62	0.96	1.72	1.3	1.28	4.06	-	1.8	0.28	0	2.19	3.33	9.77	0.77	0.83	1.46	0.64	6.05	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.79		3.1	8.69	0.91	0.67	0.62	0.96	1.72	1.3	1.28	4.06	-	1.8	0.28	0	2.19	3.33	9.77	0.77	0.83	1.46	0.64	6.05	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.79																																																																																				-		0	8.69	0.91	0.67	0.62	0.96	1.72	1.3	1.28	4.06	-	1.8	0.28	0	2.19	3.33	9.77	0.77	0.83	1.46	0.64	6.05	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.79
H5700_005_0	2007	4																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1798.5	109.83	632.09	1602.31	126.49	9.46	8.76	322.07	38.97		16.7	1.89	0	14.72	3792.78	4496.34	264.39	470.39	14.01	6.11	28.39				126.92		113.61															#1A: 125 days 1-5	#1B: 200 days 1-5	#2: 30 days 11-100	#6: 12	#10A: 125	#11A: 20	#11B Pros: 30; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 375; #9B ASC: 15 NTE 200	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 25; #5: 50; #9A OP Hosp 15 / Chemo 20; #9C: 50; #9D: 25	#7A: 15; #14C: 20	#7B : 25; #7D/7F/7G #16B #17A #18A: 30	#7E/#7H: 50	#7C/#7I: 25	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	76.62	122.59	16.14	12	125	0.2	0.18	50	0.11		0.15	0.15	0.2	0.15	15.1	29.53	50	25	0.15	0.15	0.2				25		30															11.48	1.12	0.85	1.6	1.32	1.89	1.58	1.34	4.31	-	2.58	0.28	0	2.27	4.77	11.06	1.1	0.98	2.1	0.92	5.68	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.8		0	11.48	1.12	0.85	1.6	1.32	1.89	1.58	1.34	4.31	-	2.58	0.28	0	2.27	4.77	11.06	1.1	0.98	2.1	0.92	5.68	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.8																																																																																				-		0	11.48	1.12	0.85	1.6	1.32	1.89	1.58	1.34	4.31	-	2.58	0.28	0	2.27	4.77	11.06	1.1	0.98	2.1	0.92	5.68	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.8
H5700_009_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1652.29	91.63	571.52		87.3	7.61	7.58	278.29	35.32		15.25	2.54	0	13.93	3828.33	4525.3	252.36	437.84	13.92	6.21	28.48				129.91		116.29															#1A: 100 days 1-5	#1B: 150 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B/11C: 15	#4: 50	#9A OP Hosp: 15 NTE 300; #9B ASC: 15 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 20; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 20	#7A: 10; #14C: 5	#7B : 20; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 40	#7C/#7I: 20	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 copay	0 copay	0 copay	#17A: 25	#17B: 100 Allowance every two years	#18A: 30	#18B: 500 Allowance every three years	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	61.29	91.94	13.45		100	0.2	0.15	50	0.11		0.16	0.15	0.2	0.15	9.9	24.57	40	20	0.15	0.15	0.2				25		30															8.44	0.7	0.64	-	0.73	1.52	1.14	1.16	4.01	-	2.38	0.38	0	2.15	3.16	9.27	0.84	0.73	2.09	0.93	5.7	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.52		0	8.44	0.7	0.64	-	0.73	1.52	1.14	1.16	4.01	-	2.38	0.38	0	2.15	3.16	9.27	0.84	0.73	2.09	0.93	5.7	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.52																																																																																				-		0	8.44	0.7	0.64	-	0.73	1.52	1.14	1.16	4.01	-	2.38	0.38	0	2.15	3.16	9.27	0.84	0.73	2.09	0.93	5.7	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.52
H5700_010_0	2007	7																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin				V	P	V	P																																																							-		1696.83	94.1	586.92		89.66	7.82	7.78	285.79	36.27		15.67	2.61	0	14.31	3853	4647.3	259.16	449.64	14.3	6.38	29.25				129.91		116.29															#1A: 50 days 1-5	#1B: 120 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 100	#11A: 15	#11B/11C: 10	#4: 50	#9A OP Hosp: 15 NTE 200; #9B ASC: 15 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 15; #5: 35; #9A OP Hosp 15 / Chemo 20; #9C: 35; #9D: 15	#7A: 5; #14C: 0	#7B : 15; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 35	#7C/#7I: 15	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 0	Part B Rx: 20				#17A: 10	#17B: 150 Allowance every two years	#18A: 20	#18B: 600 Allowance every three years														28.58	68.6	10.03		93.26	0.14	0.09	46.64	0.09		0.1	0.14	0.19	0.14	4.66	18.25	32.64	13.99	0.09	0.09	0.19				10		20															4.04	0.54	0.49	-	0.7	1.09	0.73	1.11	3.24	-	1.64	0.36	0	2.05	1.5	7.07	0.7	0.52	1.33	0.59	5.46	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47		2.4	4.04	0.54	0.49	-	0.7	1.09	0.73	1.11	3.24	-	1.64	0.36	0	2.05	1.5	7.07	0.7	0.52	1.33	0.59	5.46	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47																																																																																				-		0	4.04	0.54	0.49	-	0.7	1.09	0.73	1.11	3.24	-	1.64	0.36	0	2.05	1.5	7.07	0.7	0.52	1.33	0.59	5.46	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	33.47
H5700_013_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1698.55	99.6	597.06	1701.37	118.32	8.76	8.16	300.96	36.82		15.76	1.78	0	13.8	3608.41	4296.4	239.86	450.31	13.22	5.77	26.96				126.9		113.59															#1A: 125 days 1-5	#1B: 200 days 1-5	#2: 30 days 11-100	#6: 10	#10A: 125	#11A: 20	#11B Pros: 30; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 350; #9B ASC: 15 NTE 175	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 25; #5: 50; #9A OP Hosp 15 / Chemo 20; #9C: 50; #9D: 25	#7A: 15; #14C: 15	#7B : 25; #7D/7F/7G #16B #17A #18A: 30	#7E/#7H: 50	#7C/#7I: 25	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	76.62	122.59	16.14	10	125	0.2	0.18	50	0.11		0.15	0.15	0.2	0.15	15	29.53	50	25	0.15	0.15	0.2				25		30															10.84	1.02	0.8	1.42	1.23	1.75	1.47	1.25	4.04	-	2.43	0.27	0	2.13	4.51	10.57	1	0.94	1.98	0.87	5.39	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.47		0	10.84	1.02	0.8	1.42	1.23	1.75	1.47	1.25	4.04	-	2.43	0.27	0	2.13	4.51	10.57	1	0.94	1.98	0.87	5.39	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.47																																																																																				-		0	10.84	1.02	0.8	1.42	1.23	1.75	1.47	1.25	4.04	-	2.43	0.27	0	2.13	4.51	10.57	1	0.94	1.98	0.87	5.39	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.47
H5700_014_0	2007	7																					7500											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1696.54	88.97	592.72		115.16	8.51	8.04	305.09	38.27		16.33	1.83	0	14.06	3944.37	4765.57	231.35	495.55	14.42	6.3	29.85				129.91		116.29															#1A: 100 days 1-5	#1B: 200 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 250; #9B ASC: 15 NTE 125	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 20; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 20	#7A: 10; #14C: 10	#7B : 20; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 40	#7C/#7I: 20	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 20	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	57.99	115.98	12.72		94.61	0.19	0.15	47.31	0.1		0.1	0.14	0.19	0.15	9.47	23.2	37.84	18.92	0.09	0.09	0.19				25		20															8.2	0.86	0.63	-	0.91	1.61	1.22	1.2	3.64	-	1.68	0.26	0	2.05	3.11	9.21	0.73	0.78	1.36	0.6	5.65	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.16		2.49	8.2	0.86	0.63	-	0.91	1.61	1.22	1.2	3.64	-	1.68	0.26	0	2.05	3.11	9.21	0.73	0.78	1.36	0.6	5.65	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.16																																																																																				-		0	8.2	0.86	0.63	-	0.91	1.61	1.22	1.2	3.64	-	1.68	0.26	0	2.05	3.11	9.21	0.73	0.78	1.36	0.6	5.65	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.16
H5700_018_0	2007	4																					1000											D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	V	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-			492.41				16.73	2.87	660			1.41		0	1.41							20.74				127.73		114.34															#1A: 0 days 1-5	#1B: 30 days 1-5	#2: 0 days 11-100	#6: 0	#10A: 0	#11A: 20	#11B Pros: 10; #11B Supplies: 0; #11C: 0	#4: 25 / WorldWide: 0	#9B ASC: 0; #9A OP Hosp: 0	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 0	#9A: 0	#12: 20	#3: 0; #5: 0; #9A OP Hosp 0 / Chemo 20; #9C: 0; #9D: 0	#7A: 0; #14C: 0	#7B : 0; #7D/7F/7G #16B #17A #18A: 0	#7E/#7H: 0	#7C/#7I: 0	#8B: 0	#7A/#7D Cardio. Testing: 0; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 5	#17B: 100 Allowance	#18A: 15	#18B: 750 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay		16.3				0.18	0.09	22.16			0.18		0.18	0.18							0.18				5		15															-	0.67	-	-	-	2.97	0.25	1.22	-	-	0.25	-	0	0.25	-	-	-	-	-	-	3.68	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.48		1.19	-	0.67	-	-	-	2.97	0.25	1.22	-	-	0.25	-	0	0.25	-	-	-	-	-	-	3.68	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.48																																																																																				-		0	-	0.67	-	-	-	2.97	0.25	1.22	-	-	0.25	-	0	0.25	-	-	-	-	-	-	3.68	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	9.48
H5700_020_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1715.94	86.5	635.73		125.03	8.8	8.15	269.2	35.38		15.2	2.69	0.18	14.1	3416.2	4654.63	272.23	532.87	16.27	6.19	27.5				126.9		113.6															#1A: 100 days 1-5	#1B: 150 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B/11C: 15	#4: 50	#9A OP Hosp: 15 NTE 300; #9B ASC: 15 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 15; #5: 50; #9A OP Hosp 15 / Chemo 20; #9C: 50; #9D: 15	#7A: 10; #14C: 0	#7B : 10; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 50	#7C/#7I: 15	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 100 Allowance	#18A: 30	#18B: 550 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	61.29	91.94	13.45		100	0.2	0.15	50	0.1		0.16	0.15	0.2	0.15	10	24.03	50	15	0.15	0.15	0.2				10		30															8.76	0.66	0.71	-	1.04	1.76	1.22	1.12	3.5	-	2.38	0.4	0.04	2.11	2.85	9.32	1.13	0.67	2.44	0.93	5.5	-	-	-	0.11	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.94		0	8.76	0.66	0.71	-	1.04	1.76	1.22	1.12	3.5	-	2.38	0.4	0.04	2.11	2.85	9.32	1.13	0.67	2.44	0.93	5.5	-	-	-	0.11	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.94																																																																																				-		0	8.76	0.66	0.71	-	1.04	1.76	1.22	1.12	3.5	-	2.38	0.4	0.04	2.11	2.85	9.32	1.13	0.67	2.44	0.93	5.5	-	-	-	0.11	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.94
H5700_021_0	2007	11																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1726.39	79.45	636.36		123.12	8.65	8.11	276.95	36.81		15.74	2.79	0.11	14.36	3733.29	5248.68	281.66	462.34	17.77	6.76	30.1				129.91		116.29															#1A: 50 days 1-5	#1B: 100 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 75	#11A: 15	#11B/11C: 15	#4: 50	#9A OP Hosp: 10 NTE 200; #9B ASC: 10 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 12; #5: 35; #9A OP Hosp 15 / Chemo 20; #9C: 20; #9D: 12	#7A: 5; #14C: 0	#7B : 10; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 35	#7C/#7I: 12	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 150 Allowance	#18A: 20	#18B: 650 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	28.53	57.05	10.01		69.81	0.14	0.14	46.54	0.06		0.11	0.14	0.19	0.14	4.65	17.84	32.58	11.17	0.09	0.09	0.19				10		20															4.1	0.38	0.53	-	0.72	1.21	1.13	1.07	2.32	-	1.66	0.39	0.02	1.99	1.45	7.8	0.76	0.43	1.65	0.63	5.6	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.16		2.51	4.1	0.38	0.53	-	0.72	1.21	1.13	1.07	2.32	-	1.66	0.39	0.02	1.99	1.45	7.8	0.76	0.43	1.65	0.63	5.6	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.16																																																																																				-		0	4.1	0.38	0.53	-	0.72	1.21	1.13	1.07	2.32	-	1.66	0.39	0.02	1.99	1.45	7.8	0.76	0.43	1.65	0.63	5.6	-	-	-	0.11	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.16
H5700_022_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		3225.61	518.45	2694.61		411.22	18.55	15.25	694.9	393.5		16.49	2.31	0	20.59	4072.42	3784.6	1102.24		3021.07	1528.94	22.99				127.73		114.34															#1A: 50 days 1-5	#1B: 100 days 1-5	#2: 20 days 10-100	#6: 0	#10A: 100	#11A: 20	#11B/11C: 15	#4: 50	#9B ASC: 50; #9A OP Hosp: 75	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 10	#12: 20	#3: 0; #5: 25; #9A OP Hosp 10 / Chemo 20; #9C: 25; #9D: 0	#7A: 2; #14C: 0	#7B : 5; #7D/7F/7G #16B #17A #18A: 8	#7E/#7H: 25	#7C/#7I: 0	#8B: 8	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 100 Allowance	#18A: 30	#18B: 600 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	30.65	61.29	10.76		100	0.2	0.15	50	65.61		0.05	0.1	0.2	0.11	2	7.83	25		8	15	0.2				10		30															8.24	2.65	2.42	-	3.43	3.71	2.29	2.9	2.15	-	0.87	0.23	0	2.21	0.68	2.47	2.3	-	2.01	1.91	4.6	-	-	-	0.11	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.44		0	8.24	2.65	2.42	-	3.43	3.71	2.29	2.9	2.15	-	0.87	0.23	0	2.21	0.68	2.47	2.3	-	2.01	1.91	4.6	-	-	-	0.11	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.44																																																																																				-		0	8.24	2.65	2.42	-	3.43	3.71	2.29	2.9	2.15	-	0.87	0.23	0	2.21	0.68	2.47	2.3	-	2.01	1.91	4.6	-	-	-	0.11	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.44
H5700_023_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	V	V	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		3229.95	732.64	2268.92	8079.09	238.3	21.41	17.58	742.42	33.22	6686.38	16.1	2.43	1.84	27.61	75.22	3671.9	1322.36	384.33	3154.67	5.96	17.85				127.77		114.38															#1A: 50 days 1-5	#1B: 250 days 1-5	#2: 35 days 10-100	#6: 4	#10A: 100	#11A: 20	#11B/11C: 20	#4: 50	#9A OP Hosp: 10; #9B ASC: 10	#8A (Clin/Diag): 5	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 10	#12: 20	#3: 15; #5: 50; #9A OP Hosp 10 / Chemo 20; #9C: 50; #9D: 15	#7A: 0; #14C: 15	#7B : 5; #7D/7F/7G #16B #17A #18A: 10	#7E/#7H: 50	#7C/#7I: 15	#8B: 15	#7A/#7D Cardio. Testing: ; #14I Nutrition Therapy: 20	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance	#18A: 30	#18B: 400 Allowance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	30.65	153.23	18.83	4	100	0.2	0.2	50	0.1	5	0.08	0.1	0.2	0.11	15	9.82	50	15	15	0.27	0.2				25		30															8.25	9.36	3.56	2.69	1.99	4.28	3.52	3.09	3.32	2.79	1.31	0.24	0.37	2.92	0.09	3	5.51	0.48	3.94	1.63	3.57	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.47		0	8.25	9.36	3.56	2.69	1.99	4.28	3.52	3.09	3.32	2.79	1.31	0.24	0.37	2.92	0.09	3	5.51	0.48	3.94	1.63	3.57	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.47																																																																																				-		0	8.25	9.36	3.56	2.69	1.99	4.28	3.52	3.09	3.32	2.79	1.31	0.24	0.37	2.92	0.09	3	5.51	0.48	3.94	1.63	3.57	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.47
H5702_002_0	2007	4																					3100											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	O	T	P	V	P	V	P	O	O	O																																																				-		2270.81	27.2			205.22	21.87	2.38	403.74	553.5		558.17			200.79	5645.1	7594.77	223.28	892.08																								50 (1a)	50 (1b)	0 (2a)	0 (6a)	75 (10a)	20 (11a)	20 prosth (11b1) 0 Supplies (11b211c)	50 ER 5 UC (4a 4b)	5 (9b)	0 (8a 8b)	5 (Diagnostic/PET/CT/MRI) (8a 8b)	0 (incl in h.5)	0 (12)	5 (9c 9d) 0 (3 5 9a)	5 (7a) 0 (14)	5 (7b 7d 7f 17a 18a) 0 (7g)	5 (7e 7h)	5 (7c 7i)	0 (incl in h.2)	0 (14i)	0 (15)	0 (13a 16a 17b)	0 (10b)	0 n/c (16b)	0 n/c (17a)	0 n/c (17b)	0 n/c (18a)	0 n/c (18b)	optional supplemental	0 (14a)	0 n/c (13b)											9.01	9.71			75	0.2	0.2	49.61	4.96		4.96			4.96	4.9	4.66	5	5																								1.7	0.02	-	-	1.28	4.37	0.48	1.67	0.23	-	0.23	-	-	0.08	2.3	2.95	0.09	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.79		0.03	1.7	0.02	-	-	1.28	4.37	0.48	1.67	0.23	-	0.23	-	-	0.08	2.3	2.95	0.09	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.79																																																																																				-		0	1.7	0.02	-	-	1.28	4.37	0.48	1.67	0.23	-	0.23	-	-	0.08	2.3	2.95	0.09	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.79
H5703_001_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		191.45	49.37	19.14		11.86	22.94	21.08	27.71	25.31	19.71	16.9	2.5	1.28	42.18	16.95	23.97	16.08	3.03	15.99	76.74	26.76	0.05																				Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co	Med FFS Ded/Co																				0.08	0.08	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.16	3.91	3.3	-	2.8	5.41	4.98	6.54	5.97	4.65	3.99	0.59	0.3	9.96	4	5.66	3.8	0.72	3.77	18.11	6.32	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.95	138	0	15.16	3.91	3.3	0	2.8	5.41	4.98	6.54	5.97	4.65	3.99	0.59	0.3	9.96	4	5.66	3.8	0.72	3.77	18.11	6.32	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.95																																																																																				-		0	15.16	3.91	3.3	0	2.8	5.41	4.98	6.54	5.97	4.65	3.99	0.59	0.3	9.96	4	5.66	3.8	0.72	3.77	18.11	6.32	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	109.95
H5711_001_0	2007	5																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5721_001_0	2007	3																					3100											A	A	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	261.89	2.65	1518.82	0	210.47	21.35	0.98	451.89	450.33	0	24.81	0	0.22	846.49	4023.04	5342.47	155.42	532.81	27.52	231.36	6.71	732.15	0	0	0	0	0	0	0	0	0											300 per admit	300 per admit	1-8: 0/Day 9-100: 75/Day		100	30	30	50 ER / 30 UC	75		15 for x-rays/30 for CT/MRI/PET/Nuclear		0	25 OP SA/15 OP Therapy	5 PCP	15 SCP / 15 Chiro / 15 Podiatrist	25 MH	15 Therapy		15 Hearing / 0 Preventive	30	15 Vision/0 Blood																				267.6	267.6	38.38	0	89.2	0.27	0.27	38.55	66.9	0	0.25	0	0	13.55	4.46	13.36	22.3	13.38	0	4.93	0.27	11.72	0	0	0	0	0	0	0	0	0											5.84	0.06	4.86	-	1.56	5.71	0.26	1.45	2.51	-	6.15	-	-	0.96	1.49	5.95	0.29	0.59	-	0.1	1.8	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.3	0	4.88	5.84	0.06	4.86	-	1.56	5.71	0.26	1.45	2.51	-	6.15	-	-	0.96	1.49	5.95	0.29	0.59	-	0.1	1.8	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.3	3100																																																																																			-	0	0	5.84	0.06	4.86	-	1.56	5.71	0.26	1.45	2.51	-	6.15	-	-	0.96	1.49	5.95	0.29	0.59	-	0.1	1.8	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.3
H5721_002_0	2007	3																					3100											D	D	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	965.18	12.25	1459.41	0	232.8	23.06	1.06	563.43	561.39	0	27.33	0	0.2	1049.89	3828.25	4963.27	141.7	470.09	22.48	220.54	7.39	727.87	0	0	0	0	0	0	0	0	0											200 per day; days 1-5	200 per day; days 1-	1-8: 0/Day 9-100: 100/Day		150	30	30	50 ER / 30 UC	100		15 for x-rays/30 for CT/MRI/PET/Nuclear		0	30 OP SA/20 OP Therapy	10 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	20 Therapy		30 Hearing / 0 Preventive	30	30 Vision/0 Blood																				163.44	163.44	46.88	0	122.58	0.25	0.25	35.32	81.72	0	0.23	0	0	16.46	8.17	24.47	24.52	16.34	0	9.09	0.25	20.71	0	0	0	0	0	0	0	0	0											13.15	0.17	5.7	-	2.38	5.65	0.26	1.66	3.82	-	6.37	-	-	1.44	2.61	10.12	0.29	0.64	-	0.17	1.81	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.49	0	12.86	13.15	0.17	5.7	-	2.38	5.65	0.26	1.66	3.82	-	6.37	-	-	1.44	2.61	10.12	0.29	0.64	-	0.17	1.81	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.49	3100																																																																																			-	0	0	13.15	0.17	5.7	-	2.38	5.65	0.26	1.66	3.82	-	6.37	-	-	1.44	2.61	10.12	0.29	0.64	-	0.17	1.81	1.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.49
H5721_003_0	2007	3																					1000											A	A	D	V	T	coin	coin	V	coin	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	317.15	3.19	1746.22	0	244.44	24.73	1.14	558.98	27.09	0	28.83	0	0.25	20.35	0	0	193.9	0	33.24	0	7.8	106.31	0	0	0	0	0	0	0	0	0													1-8: 0/Day 9-100: 75/Day		100	30	30	50 ER / 0 UC			15 for x-rays/30 for CT/MRI/PET/Nuclear		0	10 OP SA/0 OP Therapy	0 PCP	0 SCP / 0 Chiro / 0 Podiatrist	10 MH	0 Therapy		0 Hearing / 0 Preventive	30	0 Vision/0 Blood																				0	0	31.19	0	72.5	0.22	0.22	23.97	0	0	0.2	0	0	7.25	0	0	7.25	0	0	0	0.22	0	0	0	0	0	0	0	0	0	0											-	-	4.54	-	1.48	5.38	0.25	1.12	-	-	5.82	-	-	0.01	-	-	0.12	-	-	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.41	0	7.74	-	-	4.54	-	1.48	5.38	0.25	1.12	-	-	5.82	-	-	0.01	-	-	0.12	-	-	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.41	1000																																																																																			-	0	0	-	-	4.54	-	1.48	5.38	0.25	1.12	-	-	5.82	-	-	0.01	-	-	0.12	-	-	-	1.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.41
H5721_801_0	2007	7																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5721_802_0	2007	7																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5721_803_0	2007	7																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5721_804_0	2007	7																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5729_001_0	2007	11																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		3496	65.67	9661.08	1745.02	123.52	43127.73	43774.9	558.35	267.98	2911.07	1207.7	0	68.03	1162.23	8133.11	12424.16	198.76	559.54	4679.6	14125.32	515.47	1054.84	1920	2416.57	874.61	545.46	374.72	0	0	0	60.72											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5729_004_0	2007	10																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1805.65	33.99	836.8	2931.25	227.44	25272.55	25697.84	252.97	218.52	1999.78	784.65	0	45.77	508.01	8914.72	13480.09	245.72	694.34	5158.7	17353.03	344.26	1004.75	960	2549.81	471.03	290.69	201.81	20.3	0	0	32.24											0 copay	0 copay	25 per day day 10 - 100	0 copay	0 copay	0 copay	0 copay	50 per visit	Effective copay 0 to 35	Effective copay 0 to 25	Effective copay 0 to 50	0 copay	25 copay	Effective copay 0 to 35	0 copay	0 copay	0 copay	0 copay	Effective copay 0 to 25	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Effective copay 0 to 50											0	0	17.61	0	0	0	0	50	23.33	5.15	31.13	0	25	1.67	0	0	0	0	11.3	0	0	0	0	0	0	0	0	0	0	0	1.44											-	-	1.23	-	-	-	-	1.05	0.42	0.86	2.04	-	0.1	0.07	-	-	-	-	4.86	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	10.63			-	-	1.23	-	-	-	-	1.05	0.42	0.86	2.04	-	0.1	0.07	-	-	-	-	4.86	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	10.63																																																																																				-			-	-	1.23	-	-	-	-	1.05	0.42	0.86	2.04	-	0.1	0.07	-	-	-	-	4.86	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	10.63
H5729_005_0	2007	8																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	coin	V	T	V	P	P	P	P	O	O	O																																																				-		1301.01	23.74	990.38	1782.15	174.2	20523.79	20899.41	218.23	197.5	1600.46	647.74	0	40.41	446.31	7129.32	11223.54	167.3	477.54	4168.79	12825.86	4.23	835.85	0	2416.65	386.45	265.45	165.55	18.53	0	0	29.26											100 per day days 1 - 5	100 per day days 1 - 5	75 per day days 8 - 100	10-25 copay	100 copay	0	Effective copay: 0-50	50 copay	Effective copay 0 to 100	Effective copay 0 to 75	Effective copay 0 to 75	0 copay	0-75 copay	Effective copay 0 to 100	Effective copay 0 to 20	Effective copay 0 to 20	20 copay	20 copay	Effective copay 0 to 75	Effective copay 0 to 20	20 coinsurance	Effective copay 0 or 10	0 copay	0 copay	10 copay	0 copay	10 copay	0 copay	0 copay	0 copay	Effective copay 0 or 50											52.61	52.61	46.23	14.22	81.25	0	0.69	40.63	54.17	29.08	38.05	0	30.47	11.28	0.15	9.18	16.25	16.25	14.04	7.42	0.2	6.65	0	0	8.13	0	8.13	0	0	0	1.2											5.7	0.1	3.82	2.11	1.18	-	1.21	0.74	0.89	3.88	2.05	-	0.1	0.42	0.09	8.59	0.23	0.65	4.88	7.93	0.85	0.46	-	-	0.26	-	0.11	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.25		10.64	5.7	0.1	3.82	2.11	1.18	-	1.21	0.74	0.89	3.88	2.05	-	0.1	0.42	0.09	8.59	0.23	0.65	4.88	7.93	0.85	0.46	-	-	0.26	-	0.11	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.25																																																																																				-			5.7	0.1	3.82	2.11	1.18	-	1.21	0.74	0.89	3.88	2.05	-	0.1	0.42	0.09	8.59	0.23	0.65	4.88	7.93	0.85	0.46	-	-	0.26	-	0.11	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.25
H5729_006_0	2007	7																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	Coin	V	T	V	P	P	P	P	O	O	O																																																				-		1357.68	25.02	892.55	1627.62	185.35	9.77	12.58	332.73	310.11	2481.54	1020.02	0	61.45	684.67	6696.85	10143.42	133.45	376.15	3842.09	8885.9	4.43	849.39	0	2416.65	348.74	283.96	149.48	19.84	0	0	28.15											200 per day days 1-5	150 per day days 1-5	100 per day days 10-30	10-30 copay	100 copay	0	Effective copay: 0 or 20 coinsurance	50 per visit	Effective copay 75 to 150	Effective copay 0 to 75	Effective copay 0 to 75	0 copay	0-75 copay	Effective copay 0 to 150	Effective copay 0 to 25	Effective copay 0 to 25	25 copay	25 copay	Effective copay 0 to 75	Effective copay 0 to 25	0.2	Effective copay 0 or 20	0 copay	0 copay	20 copay	0 copay	20 copay	0 copay	0 copay	0 copay	Effective copay 0 or 50											98.06	49.03	28.03	15.15	75.73	0.2	1252.9	37.86	94.66	26.29	35.46	0	28.4	14.29	0.12	10.5	18.93	18.93	13.36	7.56	0.2	10.96	0	0	15.15	0	15.15	0	0	0	1.25											11.09	0.1	2.08	2.05	1.17	1.95	1.31	1.05	2.45	5.44	3.01	-	0.15	0.82	0.06	8.88	0.21	0.59	4.28	5.6	0.89	0.78	-	-	0.44	-	0.19	-	-	-	0	-	-	-	-	-	-	-	-	-	-	54.6		17.28	11.09	0.1	2.08	2.05	1.17	1.95	1.31	1.05	2.45	5.44	3.01	-	0.15	0.82	0.06	8.88	0.21	0.59	4.28	5.6	0.89	0.78	-	-	0.44	-	0.19	-	-	-	0	-	-	-	-	-	-	-	-	-	-	54.6																																																																																				-			11.09	0.1	2.08	2.05	1.17	1.95	1.31	1.05	2.45	5.44	3.01	-	0.15	0.82	0.06	8.88	0.21	0.59	4.28	5.6	0.89	0.78	-	-	0.44	-	0.19	-	-	-	0	-	-	-	-	-	-	-	-	-	-	54.6
H5729_007_0	2007	7																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	Coin	V	T	V	P	P	P	P	O	O	O																																																				-		1621.71	29.96	1183.77	3326.39	226.87	24098.96	24547.85	279.4	232.47	1980.33	783.14	0	49.36	549.09	9579.88	14525.13	228.92	646.83	5328.96	16909.92	5.77	1089.88	960	2549.81	511.61	307.51	219.51	21.5	0	0	37.32											100 per day days 1-5	100 per day days 1-5	25 per day days 8-100	0 copay	50 copay	0 copay	0 copay	50 per visit	Effective copay: 0 or 100	Effective copay 0 to 75	Effective copay 0 to 75	0 copay	0-75 copay	Effective copay 0  to 100	Effective copay 0 to 20	Effective copay 0 to 20	20 copay	20 copay	Effective copay 0 to 75	Effective copay 0 - 100	0.2	Effective copay 0 or 10	0 copay	0 copay	10 copay	0 copay	10 copay	0 copay	0 copay	0 copay	Effective copay 0 or 50											64.75	64.75	18.97	0	50	0	0	50	66.67	34.7	46.83	0	37.5	13.54	0.17	11.32	20	20	16.54	8.93	0.2	8.33	0	0	10	0	10	0	0	0	1.31											8.75	0.16	1.87	-	0.95	-	-	1.16	1.29	5.73	3.06	-	0.15	0.62	0.14	13.71	0.38	1.08	7.35	12.58	1.15	0.76	-	-	0.43	-	0.18	-	-	-	0	-	-	-	-	-	-	-	-	-	-	61.5		0	8.75	0.16	1.87	-	0.95	-	-	1.16	1.29	5.73	3.06	-	0.15	0.62	0.14	13.71	0.38	1.08	7.35	12.58	1.15	0.76	-	-	0.43	-	0.18	-	-	-	0	-	-	-	-	-	-	-	-	-	-	61.5																																																																																				-			8.75	0.16	1.87	-	0.95	-	-	1.16	1.29	5.73	3.06	-	0.15	0.62	0.14	13.71	0.38	1.08	7.35	12.58	1.15	0.76	-	-	0.43	-	0.18	-	-	-	0	-	-	-	-	-	-	-	-	-	-	61.5
H5729_008_0	2007	5																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	O	V	T	V	P	P	P	P	O	O	O																																																				-		1993.9	36.67	1454.77	2979.93	259.57	30201.55	30756.86	393.84	291.64	2613.42	1083.15	0	59.88	662.29	11138.59	17328.47	284.92	813.6	6709.31	20767.06	6.39	1312.41	0	2416.65	613.75	372.72	262.96	24.29	0	0	793.47											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5729_009_0	2007	8																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		3554.56	66.77	9822.89	1774.25	125.59	43850.07	44508.08	567.7	272.47	2959.83	1227.92	0	69.17	1181.7	8269.33	12632.25	202.09	568.92	4757.98	14361.9	524.1	1072.51	1920	4049.5	889.26	554.6	381	38.72	0	0	24812.98											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5729_010_0	2007	6																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	O	V	T	V	P	P	P	P	O	O	O																																																				-		1390.84	25.58	1018.05	2092.03	180.87	21011.8	21393.31	223.36	199.93	1791.34	741.97	0	41.11	454.52	7775.26	12081.88	200.24	571.93	4695.67	14648.25	4.43	915.07	0	3911.45	429.31	259.47	183.93	16.91	0	0	24884.37											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	25 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0	50	0	0	0	0	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.93	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	1.02		0	-	-	-	-	-	-	-	0.93	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	1.02																																																																																				-			-	-	-	-	-	-	-	0.93	-	-	-	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	1.02
H5732_001_0	2007	5																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1124.73	19.94	544.98	1721.85	61	22040.84	22374.37	197.46	169.35	1454.85	615.58	0	35.25	383.62	7825.01	10957.95	186.81	528.92	3590.46	14266.42	266.75	958.49	0	3038	466.81	301.14	200.31	19.62	0	100	31.96											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	25 per visit	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.41			-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.41																																																																																				-			-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.41
H5732_002_0	2007	3																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1121.46	19.83	547.14	1721.95	182.62	21986.63	22320.87	197.87	169.78	1457.44	616.72	0	35.37	384.75	7812.35	10945.23	186.42	527.61	3589.62	14217.33	267.55	957.22	0	4602	466.01	301.12	199.96	19.63	0	100	73.02											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	25 per visit	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Effective copay - 25 for foreign ER 0											0	0	0	0	0	0	0	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0.37											-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	0.41			-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	0.41																																																																																				-			-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	0.41
H5732_003_0	2007	3																																D	D	D	V	T	O	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1508.66	27.99	645.61	2193.33	241.73	29340.22	29749.14	262.14	206.04	1795.8	758.76	0	42.25	463.19	10282.69	14312.72	247.03	704.36	4597.08	19310.75	322.02	1251.22	0	1519	613.48	384.44	263.24	24.84	0	100	40.95											0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	5 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											0	0	0	0	0	0	0	5	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.11			-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.11																																																																																				-			-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.11
H5736_002_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	P	P	V	P	V	V	V	V	V	V	V	Coin				V		V																																																								-		1853.43	39.12	1469.71	2220.11	255.9	13.05	0.98	467.18	382.38	2500.53	1267	0	0	0	5568.33	7231.33	216.68	635.62	1028.16	1597.78	16.93	0	0	0	0	321.3	0	22.44														200/day 1-7	200/day 1-7	100/day 1-100	0 per visit	50 per trip	20	20	50 per visit	125 per procedure	35 per visit	35 X-ray; 100 CAT PET MRI	35 per visit	30 per visit	35 per visit	35 per visit	35 per visit; 30 dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0	Not Covered	Not Covered	0	N/A	0	N/A														143.69	143.69	100	0	50	0.2	0.2	50	125	35	57.23	35	30	35	35	34.5	35	35	35	35	0.2	0	0	0	0	0	0	0														22.19	0.47	12.25	-	1.07	2.61	0.2	1.95	3.98	7.29	6.04	-	-	-	16.24	20.79	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.61			22.19	0.47	12.25	-	1.07	2.61	0.2	1.95	3.98	7.29	6.04	-	-	-	16.24	20.79	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.61																																																																																				-			22.19	0.47	12.25	-	1.07	2.61	0.2	1.95	3.98	7.29	6.04	-	-	-	16.24	20.79	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	108.61
H5736_003_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-10100/Day 11-100	0	50	0.2	0.2	50   (Waived if Admitted; Worldwide)  35	200	0	0  100	30	30	30	30	30	30	30	30	30	20 coinsurance	0	Not Covered	Not Covered	0	N/A	0	N/A														121.34	121.34	63.47	0	50	0.2	0.2	48.05	200	0	34.2	30	30	30	30	30	30	30	30	30	0.2	0	0	0	0	0	0	0														15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84																																																																																				-			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84
H5736_004_0	2007	2																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-10100/Day 11-100	0	50	0.2	0.2	50   (Waived if Admitted; Worldwide)  35	200	0	0  100	30	30	30	30	30	30	30	30	30	20 coinsurance	0	Not Covered	Not Covered	0	N/A	0	N/A														121.34	121.34	63.47	0	50	0.2	0.2	48.05	200	0	34.2	30	30	30	30	30	30	30	30	30	0.2	0	0	0	0	0	0	0														15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84																																																																																				-			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84
H5736_005_0	2007	2																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-10100/Day 11-100	0	50	0.2	0.2	50   (Waived if Admitted; Worldwide)  35	200	0	0  100	30	30	30	30	30	30	30	30	30	20 coinsurance	0	Not Covered	Not Covered	0	N/A	0	N/A														121.34	121.34	63.47	0	50	0.2	0.2	48.05	200	0	34.2	30	30	30	30	30	30	30	30	30	0.2	0	0	0	0	0	0	0														15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84																																																																																				-			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84
H5736_006_0	2007	2																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	O				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-10100/Day 11-100	0	50	0.2	0.2	50   (Waived if Admitted; Worldwide)  35	200	0	0  100	30	30	30	30	30	30	30	30	30	20 coinsurance	0	Not Covered	Not Covered	0	N/A	0	N/A														121.34	121.34	63.47	0	50	0.2	0.2	48.05	200	0	34.2	30	30	30	30	30	30	30	30	30	0.2	0	0	0	0	0	0	0														15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84																																																																																				-			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	3.2	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	75.84
H5736_007_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	19.45	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0																					200/day 1-7	200/day 1-7	0/day 1-10; 100/day 11-100	0	100	20	20	50 ER25 urgent care	20	30	30 routine 100 complex	30	30	30	30	30	30	30	30	30	45																					143.69	143.69	63.47	0	100	0.2	0.2	46.75	0.2	30	53.94	30	30	30	30	30	30	30	30	30	45																					18.64	0.36	6.72	-	1.92	3.14	0.2	1.63	3.89	5.47	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.18			18.64	0.36	6.72	-	1.92	3.14	0.2	1.63	3.89	5.47	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.18																																																																																				-			18.64	0.36	6.72	-	1.92	3.14	0.2	1.63	3.89	5.47	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.18
H5736_008_0	2007	5																																D	D	D	V	T	Coin	Coin	V	Coin	P	P	V	P	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	19.45	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0																					150/day 1-7	150/day 1-7	0/day 1-10; 100/day 11-100	0	100	20	20	50 ER 25 urgent care	20	20	20 routine 100 complex	20	20	20	20	20	20	20	20	20	45																					107.77	107.77	63.47	0	100	0.2	0.2	46.75	0.2	20	47.36	20	20	20	20	20	20	20	20	20	45																					13.98	0.27	6.72	-	1.92	3.14	0.2	1.63	3.89	3.65	4.44	-	-	-	9.05	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.28			13.98	0.27	6.72	-	1.92	3.14	0.2	1.63	3.89	3.65	4.44	-	-	-	9.05	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.28																																																																																				-			13.98	0.27	6.72	-	1.92	3.14	0.2	1.63	3.89	3.65	4.44	-	-	-	9.05	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.28
H5736_009_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	P	P	V	P	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	18.07	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-10100/Day 11-100	0	50	20	20	50  ER 35 UC	200	0	0 100 Complex	30	30	30	30	30	30	30	30	30	20	0	Not Covered	Not Covered	30	N/A	30	N/A														121.34	121.34	63.47	0	50	0.2	0.2	48.05	200	0	53.94	30	30	30	30	30	30	30	30	30	0.2	0	0	0	30	0	30	0	0	0	0											15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.3			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.3																																																																																				-			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.3
H5736_010_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	P	P	V	P	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	18.07	0	0	0	0	317.28	0	22.16														200/Day 1-5	200/Day 1-5	0/Day 1-10100/Day 11-100	0	50	20	20	50  ER 35 UC	200	0	0 100 Complex	30	30	30	30	30	30	30	30	30	20	0	Not Covered	Not Covered	30	N/A	30	N/A														121.34	121.34	63.47	0	50	0.2	0.2	48.05	200	0	53.94	30	30	30	30	30	30	30	30	30	0.2	0	0	0	30	0	30	0	0	0	0											15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.3			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.3																																																																																				-			15.74	0.31	6.72	-	0.96	3.14	0.2	1.67	5.74	-	5.05	-	-	-	13.57	16.77	0.49	1.43	2.35	3.55	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.3
H5736_801_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	P	P	V	P	V	V	V	V	V	V	V	Coin				V		V																																																								-		1853.43	39.12	1469.71	2220.11	255.9	13.05	0.98	467.18	382.38	2500.53	1267	0	0	0	5568.33	7231.33	216.68	635.62	1028.16	1597.78	16.93	0	0	0	0	321.3	0	22.44														200/day 1-7	200/day 1-7	100/day 1-100	0 per visit	50 per trip	30 coinsurance	30 coinsurance	50 per visit	150 per procedure	35 per visit	35 X-ray; 100 CAT PET MRI	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0	Not Covered	Not Covered	0	N/A	0	N/A														143.69	143.69	100	0	50	0.3	0.3	50	150	35	57.23	35	35	35	35	35	35	35	35	35	0.2	0	0	0	0	0	0	0														22.19	0.47	12.25	-	1.07	3.91	0.29	1.95	4.78	7.29	6.04	-	-	-	16.24	21.09	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.11			22.19	0.47	12.25	-	1.07	3.91	0.29	1.95	4.78	7.29	6.04	-	-	-	16.24	21.09	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.11																																																																																				-			22.19	0.47	12.25	-	1.07	3.91	0.29	1.95	4.78	7.29	6.04	-	-	-	16.24	21.09	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.11
H5736_802_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	P	P	V	P	V	V	V	V	V	V	V	Coin				V		V																																																								-		1853.43	39.12	1469.71	2220.11	255.9	13.05	0.98	467.18	382.38	2500.53	1267	0	0	0	5568.33	7231.33	216.68	635.62	1028.16	1597.78	16.93	0	0	0	0	321.3	0	22.44														200/day 1-7	200/day 1-7	100/day 1-100	0 per visit	50 per trip	30 coinsurance	30 coinsurance	50 per visit	150 per procedure	35 per visit	35 X-ray; 100 CAT PET MRI	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0	Not Covered	Not Covered	0	N/A	0	N/A														143.69	143.69	100	0	50	0.3	0.3	50	150	35	57.23	35	35	35	35	35	35	35	35	35	0.2	0	0	0	0	0	0	0	0	0	0											22.19	0.47	12.25	-	1.07	3.91	0.29	1.95	4.78	7.29	6.04	-	-	-	16.24	21.09	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.11			22.19	0.47	12.25	-	1.07	3.91	0.29	1.95	4.78	7.29	6.04	-	-	-	16.24	21.09	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.11																																																																																				-			22.19	0.47	12.25	-	1.07	3.91	0.29	1.95	4.78	7.29	6.04	-	-	-	16.24	21.09	0.63	1.85	3	4.66	3.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.11
H5750_001_0	2007	5																																A	A	A	P	T	Coin	O	V	V	V	P	P	P	O	V	V	V	P	P	P	O	O	T	P	V	Coin	V	P	O	O	O																																																				-		218.7	11.68	39.41	0	537.5	20.82	0	248.95	171.61	281.55	494.16	0	0	175.02	5485.85	545.36	443.02	181.45	0	0	0	0	0	0	521.98	0	260.99	0	0	0	0											500 per admit	500 per admit	500 per admit		50 per trip	20 of cost		50 per ER visit	250 per OP surgical visit	50 per lab visit	50 per radiology visit			50 per visit	30/15 per office visit(spec/pc)	30/15 per office visit(spec/pc)	30 per specialist office visit	30 per specialist office visit							15 per visit		15 per visit															500	500	500	0	50	0.19	0	50	250	50	50	0	0	50	21.38	26.32	30	30	0	0	0	0	0	0	15	0	15	0	0	0	0											9.11	0.49	1.64	-	2.24	3.96	-	1.04	3.58	1.17	2.06	-	-	0.73	9.77	1.2	1.11	0.45	-	-	-	-	-	-	0.65	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.52			9.11	0.49	1.64	-	2.24	3.96	-	1.04	3.58	1.17	2.06	-	-	0.73	9.77	1.2	1.11	0.45	-	-	-	-	-	-	0.65	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.52																																																																																				-			9.11	0.49	1.64	-	2.24	3.96	-	1.04	3.58	1.17	2.06	-	-	0.73	9.77	1.2	1.11	0.45	-	-	-	-	-	-	0.65	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	39.52
H5750_002_0	2007	4																																A	A	A	P	T	Coin	O	V	V	V	P	P	P	O	V	V	V	P	P	P	O	O	T	P	V	Coin	V	P	O	O	O																																																				-		218.7	11.68	39.41	0	537.5	20.82	0	248.95	171.61	281.55	494.16	0	0	55.89	5485.85	545.36	443.02	181.45	0	0	0	0	0	0	521.98	0	260.99	0	0	0	0											100 per admit	100 per admit	100 per admit		50 per trip	20 of cost		50 per ER visit	50 per OP surgical visit	15 per lab visit	15 per radiology visit			15 per visit	10 per visit	10 per visit	10 per visit	10 per visit							10 per visit		10 per visit															100	100	100	0	50	0.19	0	50	50	15	15	0	0	15	10	10	10	10	0	0	0	0	0	0	10	0	10	0	0	0	0											1.82	0.1	0.33	-	2.24	3.96	-	1.04	0.72	0.35	0.62	-	-	0.07	4.57	0.45	0.37	0.15	-	-	-	-	-	-	0.43	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.43		0.01	1.82	0.1	0.33	-	2.24	3.96	-	1.04	0.72	0.35	0.62	-	-	0.07	4.57	0.45	0.37	0.15	-	-	-	-	-	-	0.43	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.43																																																																																				-			1.82	0.1	0.33	-	2.24	3.96	-	1.04	0.72	0.35	0.62	-	-	0.07	4.57	0.45	0.37	0.15	-	-	-	-	-	-	0.43	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.43
H5750_003_0	2007	6																																A	A	A	P	T	Coin	O	V	V	V	P	P	P	O	V	V	V	P	P	P	O	O	T	P	V	Coin	V	P	O	O	O																																																				-		218.7	11.68	39.41	0	537.5	20.82	0	248.95	171.61	281.55	494.16	0	0	175.02	5485.85	545.36	443.02	181.45	0	0	0	0	0	0	521.98	0	260.99	0	0	0	0											500 per admit	500 per admit	500 per admit		50 per trip	20 of cost		50 per ER visit	100 per OP surgical visit	50 per lab visit	50 per radiology visit			50 per visit	30/15 per office visit(spec/pc)	30/15 per office visit(spec/pc)	30 per specialist office visit	30 per specialist office visit							15 per visit		15 per visit															250	250	250	0	50	0.19	0	50	100	50	50	0	0	50	21.38	26.32	30	30	0	0	0	0	0	0	15	0	15	0	0	0	0											4.56	0.24	0.82	-	2.24	3.96	-	1.04	1.43	1.17	2.06	-	-	0.73	9.77	1.2	1.11	0.45	-	-	-	-	-	-	0.65	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.75		0.01	4.56	0.24	0.82	-	2.24	3.96	-	1.04	1.43	1.17	2.06	-	-	0.73	9.77	1.2	1.11	0.45	-	-	-	-	-	-	0.65	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.75	5000																																																																																			-			4.56	0.24	0.82	-	2.24	3.96	-	1.04	1.43	1.17	2.06	-	-	0.73	9.77	1.2	1.11	0.45	-	-	-	-	-	-	0.65	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.75
H5754_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							13.29	13.87	412.7	421.33		282.86	57.26		1032.82		6100.44	140.9			971.06					137.43		289.34						12.76	378.07		104.82	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.36	2.46	1.25	1.56	-	0.42	0.21	-	3.82	-	9.02	0.21	-	-	1.44	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.56	-	0.16	0.23	-	-	-	-	24.42		2.98	-	-	-	-	-	2.36	2.46	1.25	1.56	-	0.42	0.21	-	3.82	-	9.02	0.21	-	-	1.44	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.56	-	0.16	0.23	-	-	-	-	24.42		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.14	0.03	0.34	0.32	0.05	0.08	0.08	0.03	0.25	0.15	0.15	0.02	0	0.15		0.29	0.01	0.03	0.17	0.66	0.15	0			0.01		0.01															5.13		0	2.14	0.03	0.34	0.32	0.05	2.44	2.55	1.28	1.81	0.15	0.57	0.23	0	3.97	-	9.31	0.22	0.03	0.17	2.09	0.15	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.56	-	0.16	0.23	-	-	-	-	29.55
H5754_002_0	2007	2	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							13.29	13.87	412.7	421.33		282.85	57.26		1032.81		6100.42	140.9			971.05													12.76	378.07		104.82	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18													18	18		18	20					-	-	-	-	-	2.36	2.46	1.25	1.56	-	0.42	0.21	-	3.82	-	9.02	0.21	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	0.02	0.56	-	0.16	0.23	-	-	-	-	23.71		2.98	-	-	-	-	-	2.36	2.46	1.25	1.56	-	0.42	0.21	-	3.82	-	9.02	0.21	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	0.02	0.56	-	0.16	0.23	-	-	-	-	23.71		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.14	0.03	0.34	0.32	0.05	0.08	0.08	0.03	0.25	0.15	0.15	0.02	0	0.15		0.29	0.01	0.03	0.17	0.66	0.15	0			0.01		0.01															5.13		0	2.14	0.03	0.34	0.32	0.05	2.44	2.55	1.28	1.81	0.15	0.57	0.23	0	3.97	-	9.31	0.22	0.03	0.17	2.09	0.15	0	-	-	0.01	-	0.01	-	-	-	-	-	0.02	0.56	-	0.16	0.23	-	-	-	-	28.83
H5754_003_0	2007	5	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1642.34	199.47	10149.46	346.27	644.36	2207.09	12264.6	228.21	117.32	3916.93	221.96	48	4.97	355.44	24112.4	1278.63	1805.17	1.85		421.2	564.66	2240.21	2250		140.2	166		54.6				190.51	0.55		300	295.2						(1a) 25/day	(1b) 25/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 20/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay		(7f1) 0/visit	(18a1) 0/visit						24	24			48			48																								19										3.25	0.39	-	-	2.55	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	7.4		0.39	3.25	0.39	-	-	2.55	-	-	0.9	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.3	-	-	-	-	-	-	-	-	-	7.4		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							20	30		30	30						2.01	0.08	1.08	0.2	0.56	0.47	0.19	0.05	0.15	0.89	0.83	0.07	0.01	0.19																		0.02	0									6.79		0	5.26	0.47	1.08	0.2	3.12	0.47	0.19	0.95	0.15	0.89	0.83	0.07	0.01	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.32	0	-	-	-	-	-	-	-	-	14.2
H5754_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								30.76	729.41	567.02		430.55	90.82		1711.89		6855.92	439.75			1462.66							289.34						67.35	353.77		285.22	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit											17	34	42		17	42		42		17	17			17							20						17	17		17	20					-	-	-	-	-	-	5.16	2.09	1.98	-	0.6	0.32	-	5.98	-	9.58	0.61	-	-	2.1	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	30.11		5.61	-	-	-	-	-	-	5.16	2.09	1.98	-	0.6	0.32	-	5.98	-	9.58	0.61	-	-	2.1	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	30.11		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.99	0.11	0.3	0.37	0.07	0.16	0.19	0.04	0.33	0.19	0.2	0.03	0.01	0.22		0.34	0.03	0.03	0.22	0.82	0.19	0			0.01		0.01															6.87		0	2.99	0.11	0.3	0.37	0.07	0.16	5.35	2.13	2.31	0.19	0.8	0.34	0.01	6.2	-	9.92	0.65	0.03	0.22	2.92	0.19	0	-	-	0.01	-	0.49	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	36.98
H5756_001_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin					0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		358.39	36.67	96.19		15.25	24.42	24.03	25.73	30.65	25.39	21.11	2.78	2.79	49.63	27.28	34.18	12.22	5.58	24.62	125.38	28.1	0.1																				Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	Medicare Ded/Coin	0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				24.23	2.48	16.09	-	3.6	5.76	5.67	6.07	7.23	5.99	4.98	0.66	0.66	11.71	6.44	8.07	2.88	1.32	5.81	29.59	6.63	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.9	138	0	24.23	2.48	16.09	-	3.6	5.76	5.67	6.07	7.23	5.99	4.98	0.66	0.66	11.71	6.44	8.07	2.88	1.32	5.81	29.59	6.63	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.9																																																																																				-		0	24.23	2.48	16.09	-	3.6	5.76	5.67	6.07	7.23	5.99	4.98	0.66	0.66	11.71	6.44	8.07	2.88	1.32	5.81	29.59	6.63	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.9
H5760_001_0	2007	2																																A	A	A	V	T	P	P	V	V	P	P	P	P	P	V	V	V	V	P	P	S	P	T	V	P	P	P	P	Coin	P																																																					-									455.63							7002.64	5067.54													12.2																				25 ER/'25 Urgent Care							2 PCP	5 Specialist													OON Benefit																				25							2	5																										-	-	-	-	-	-	-	0.95	-	-	-	-	-	-	1.17	2.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.23		0	-	-	-	-	-	-	-	0.95	-	-	-	-	-	-	1.17	2.11	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.23																														20 Coinsurance																																									10.25													10.25		0	-	-	-	-	-	-	-	0.95	-	-	-	-	-	-	1.17	2.11	-	-	-	-	-	-	-	-	-	-	-	-	10.25	-	-	-	-	-	-	-	-	-	-	-	-	14.47
H5760_002_0	2007	5																																A	A	A	V	T	P	P	V	V	P	P	P	P	P	V	V	V	V	P	P	S	P	T	V	P	P	P	P	Coin	P																																																					-									449.98							6915.35	5004.37													11.95																				25 ER/'25 Urgent Care							2 PCP	5 Specialist													OON Benefit																				25							2	5																										-	-	-	-	-	-	-	0.94	-	-	-	-	-	-	1.15	2.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18		0	-	-	-	-	-	-	-	0.94	-	-	-	-	-	-	1.15	2.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18																														20 Coinsurance																																									10.03													10.03		0	-	-	-	-	-	-	-	0.94	-	-	-	-	-	-	1.15	2.09	-	-	-	-	-	-	-	-	-	-	-	-	10.03	-	-	-	-	-	-	-	-	-	-	-	-	14.21
H5760_003_0	2007	5																																A	A	A	V	T	P	P	V	V	P	P	P	P	P	V	V	V	V	P	P	S	P	T	V	P	P	P	P	Coin	P																																																					-									450.48							6923.04	5009.93													11.97																				25 ER/'25 Urgent Care							2 PCP	5 Specialist													OON Benefit																				25							2	5																										-	-	-	-	-	-	-	0.94	-	-	-	-	-	-	1.15	2.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18		0	-	-	-	-	-	-	-	0.94	-	-	-	-	-	-	1.15	2.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.18																														20 Coinsurance																																									10.05													10.05		0	-	-	-	-	-	-	-	0.94	-	-	-	-	-	-	1.15	2.09	-	-	-	-	-	-	-	-	-	-	-	-	10.05	-	-	-	-	-	-	-	-	-	-	-	-	14.23
H5760_004_0	2007	4																																A	A	A	V	T	P	P	V	P	P	P	P	P	V	V	V	V	V	P	P	S	P	T	P	V	P	V	P	P		P																																																				-		1738.88	455.47			146.5	3047.16	2438.92	505.65	272.36	9781.58	457.77			1237.61	3643.56	3727.32	1183.24	873.14	4206.16			15.63		1500	300		232.59		724.52													25	2500			25	3	3	25/visit ER;  15/visit Urgent Care	15	3	3			5/visit MH/SA; /visit cardiac rehab	2	5	5	2	300	0/ Diabetes Self Mon./0 Nutri. Therapy		3/Medicare covered eyewear		3	3/annual routine vision exam		3//annual routine hearing exam		In-network copay		0/maternity services											4.08	2.7			25	3	3	25	15	3	3			1.22	2	5	5	2	3			3		3	3		3															0.59	0.1	-	-	0.31	0.76	0.61	1.05	0.34	2.45	0.11	-	-	0.13	0.61	1.55	0.49	0.15	1.05	-	-	0	-	0.38	0.08	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.81		0	0.59	0.1	-	-	0.31	0.76	0.61	1.05	0.34	2.45	0.11	-	-	0.13	0.61	1.55	0.49	0.15	1.05	-	-	0	-	0.38	0.08	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.81																														In-network copay																																									0.26													0.26		0	0.59	0.1	-	-	0.31	0.76	0.61	1.05	0.34	2.45	0.11	-	-	0.13	0.61	1.55	0.49	0.15	1.05	-	-	0	-	0.38	0.08	-	0.06	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	11.08
H5760_005_0	2007	6																																A	A	A	V	T	P	P	V	P	P	P	P	P	V	V	V	V	V	P	P	S	P	T	P	V	P	V	P	P		P																																																				-		1738.88	455.47			146.5	3047.16	2438.92	505.65	272.36	9781.58	457.77			1237.61	3643.56	3727.32	1183.24	873.14	4206.16			15.63		1500	300		232.59		724.52													25	2500			25	3	3	25/visit ER;  15/visit Urgent Care	15	3	3			5/visit MH/SA; /visit cardiac rehab	2	5	5	2	300	0/ Diabetes Self Mon./0 Nutri. Therapy		3/Medicare covered eyewear		3	3/annual routine vision exam		3//annual routine hearing exam		In-network copay		0/maternity services											4.08	2.7			25	3	3	25	15	3	3			1.22	2	5	5	2	3			3		3	3		3															0.59	0.1	-	-	0.31	0.76	0.61	1.05	0.34	2.45	0.11	-	-	0.13	0.61	1.55	0.49	0.15	1.05	-	-	0	-	0.38	0.08	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.81		0	0.59	0.1	-	-	0.31	0.76	0.61	1.05	0.34	2.45	0.11	-	-	0.13	0.61	1.55	0.49	0.15	1.05	-	-	0	-	0.38	0.08	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.81																														In-network copay																																									0.26													0.26		0	0.59	0.1	-	-	0.31	0.76	0.61	1.05	0.34	2.45	0.11	-	-	0.13	0.61	1.55	0.49	0.15	1.05	-	-	0	-	0.38	0.08	-	0.06	-	0.26	-	-	-	-	-	-	-	-	-	-	-	-	11.08
H5760_801_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																								0	0	0								0	0	0	0	0	0	0	0																				0		101.58	2.49	2.01		2.96	32.29	17.52	6.73	13.88	15.47	5.68	0.65	0.43	4.71	32.17	30.71	4.15	4.32	17.68	67.15	15.27	0.02																				FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance																				0.16	0.16	0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				16.73	0.41	0.32	-	0.7	7.62	4.13	1.59	3.28	3.65	1.34	0.15	0.1	1.11	7.59	7.25	0.98	1.02	4.17	15.85	3.6	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.6	138	0	16.73	0.41	0.32	-	0.7	7.62	4.14	1.59	3.28	3.65	1.34	0.15	0.1	1.11	7.59	7.25	0.98	1.02	4.17	15.85	3.6	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.6																																																																																				-		0	16.73	0.41	0.32	-	0.7	7.62	4.14	1.59	3.28	3.65	1.34	0.15	0.1	1.11	7.59	7.25	0.98	1.02	4.17	15.85	3.6	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	81.6
H5774_003_0	2007	4																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1418.68	20.56	99.07	1729.84	577.18	4830.37	147.43	743.83	131.06	857.09	434.28			924.13	5709.47	31527.78	188.04	1654.85	3243.87		515.17	366.9	0	1541.9	542.8	293.27	232.63	21.56			1792.58																		25 per visit copament																							5 Copay on Urgent Care and Travel Benefit											0	0	0	0	0	0	0	25	0	0	0			0	0	0	0	0	0		0	0	0	0	0	0	0	0			0.13											-	-	-	-	-	-	-	1.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	1.57			-	-	-	-	-	-	-	1.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	1.57																																																																																				-			-	-	-	-	-	-	-	1.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.02	-	-	-	-	-	-	-	-	-	-	1.57
H5774_004_0	2007	6																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1773.35	25.7	123.84	2162.3	721.48	6037.96	184.29	929.79	163.83	1071.36	542.85			1155.16	7136.83	39409.73	235.05	2068.56	4054.84		643.96	458.62	0	1927.37	678.5	366.58	290.78	26.95			4672																																																				0	0	0	0	0	0	0	0	0	0	0			0	0	0	0	0	0		0	0	0	0	0	0	0	0			0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5774_005_0	2007	8																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1631.48	23.64	113.93	1989.32	663.76	5554.92	169.54	855.41	150.72	985.65	499.42			1062.75	6565.89	36256.95	216.25	1903.08	3730.45		592.44	421.93	0	1773.18	624.22	337.25	267.52	24.79			1077.41																20 copayment per service	20 copayment per service	25 per visit copament	10 copay per visit							5 Vision and Hearing	10 copay per visit					10 copay Chiropratic		10 Copay Dental	5 Copay on Routine Exams		5 Copay on Routine Visits				5 Copay on Routnie Podiatry											0	0	0	0	0	13.11	43.24	25	10	0	0			0	0	0.16	10	0	0		0	9.99	0	10	5	0	5	0			1.94											-	-	-	-	-	6.07	0.61	1.78	0.13	-	-	-	-	-	-	0.48	0.18	-	-	-	-	0.35	-	1.48	0.26	-	0.11	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	11.63			-	-	-	-	-	6.07	0.61	1.78	0.13	-	-	-	-	-	-	0.48	0.18	-	-	-	-	0.35	-	1.48	0.26	-	0.11	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	11.63																																																																																				-			-	-	-	-	-	6.07	0.61	1.78	0.13	-	-	-	-	-	-	0.48	0.18	-	-	-	-	0.35	-	1.48	0.26	-	0.11	-	-	-	0.17	-	-	-	-	-	-	-	-	-	-	11.63
H5774_006_0	2007	6																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1489.61	21.58	104.02	1816.33	606.04	5071.89	154.8	781.02	137.62	899.95	456			970.34	5994.94	33104.17	197.44	1737.59	3406.07		540.93	577.76	0	1618.99	569.94	307.93	244.26	22.64			8683.72																																																				0	0	0	0	0	0	0	0	0	0	0			0	0	0	0	0	0		0	0	0	0	0	0	0	0			0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5774_007_0	2007	6																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1517.98	22	106	1850.93	617.59	5168.49	157.75	795.9	140.24	917.09	464.68			988.82	6109.13	33734.72	201.2	1770.69	3470.94		551.23	392.58	0	1649.83	580.79	313.79	248.91	23.07			8702.46											100 peradmit copay	100 peradmit copay	100 peradmit copay			20 copayment per service	20 copayment per service	25 per visit copament	10 copay per visit						5 PCP Copay	10 Copay Offic eVisits and Test	10 copay per visit		10 Copay			10 copay Chiropratic		10 per Visit DentalCopay	5 Copay on Routine Exams		5 Copay on Routine Visits				5 Copay on Urgent Care and Travel Benefit											20	20	20	0	0	13.11	43.24	25	10	0	0			0	5	1.75	10	0	10		0	9.99	0	10	5	0	5	0			1.06											2.53	0.04	0.18	-	-	5.65	0.57	1.66	0.12	-	-	-	-	-	2.55	4.92	0.17	-	2.89	-	-	0.33	-	1.37	0.24	-	0.1	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	24.08			2.53	0.04	0.18	-	-	5.65	0.57	1.66	0.12	-	-	-	-	-	2.55	4.92	0.17	-	2.89	-	-	0.33	-	1.37	0.24	-	0.1	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	24.08																																																																																				-			2.53	0.04	0.18	-	-	5.65	0.57	1.66	0.12	-	-	-	-	-	2.55	4.92	0.17	-	2.89	-	-	0.33	-	1.37	0.24	-	0.1	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	24.08
H5774_008_0	2007	7																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1773.35	25.7	123.84	2162.3	721.48	6037.96	184.29	929.79	163.83	1071.36	542.85			1155.16	7136.83	39409.73	235.05	2068.56	4054.84		643.96	458.62	0	1927.37	678.5	366.58	290.78	26.95			2095.5																		25 per visit copament								10 per specialist visit copayment								5 dental copay							5 Copay on Urgent Care and Travel Benefit											0	0	0	0	0	0	0	25	0	0	0			0	0	1.59	0	0	0		0	0	0	5	0	0	0	0			1.68											-	-	-	-	-	-	-	1.94	-	-	-	-	-	-	-	5.23	-	-	-	-	-	-	-	0.8	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	8.26			-	-	-	-	-	-	-	1.94	-	-	-	-	-	-	-	5.23	-	-	-	-	-	-	-	0.8	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	8.26																																																																																				-			-	-	-	-	-	-	-	1.94	-	-	-	-	-	-	-	5.23	-	-	-	-	-	-	-	0.8	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	8.26
H5774_009_0	2007	8																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1773.35	25.7	123.84	2162.3	721.48	6037.96	184.29	929.79	163.83	1071.36	542.85			1155.16	7136.83	39409.73	235.05	2068.56	4054.84		643.96	458.62	0	1927.37	678.5	366.58	290.78	26.95			2095.5																		25 per visit copament								10 per specialist visit copayment								5 dental copay							5 Copay on Urgent Care and Travel Benefit											0	0	0	0	0	0	0	25	0	0	0			0	0	1.59	0	0	0		0	0	0	5	0	0	0	0			1.68											-	-	-	-	-	-	-	1.94	-	-	-	-	-	-	-	5.23	-	-	-	-	-	-	-	0.8	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	8.26			-	-	-	-	-	-	-	1.94	-	-	-	-	-	-	-	5.23	-	-	-	-	-	-	-	0.8	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	8.26																																																																																				-			-	-	-	-	-	-	-	1.94	-	-	-	-	-	-	-	5.23	-	-	-	-	-	-	-	0.8	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	-	8.26
H5774_010_0	2007	6																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1517.98	22	106	1850.93	617.59	5168.49	157.75	795.9	140.24	917.09	464.68			988.82	6109.13	33734.72	201.2	1770.69	3470.94		551.23	392.58	0	1649.83	580.79	313.79	248.91	23.07			8702.46											100 peradmit copay	100 peradmit copay	100 peradmit copay			20 copayment per service	20 copayment per service	25 per visit copament	10 copay per visit						5 PCP Copay	10 Copay Offic eVisits and Test	10 copay per visit		10 Copay			10 copay Chiropratic		10 per Visit DentalCopay	5 Copay on Routine Exams		5 Copay on Routine Visits				5 Copay on Urgent Care and Travel Benefit											20	20	20	0	0	13.11	43.24	25	10	0	0			0	5	1.75	10	0	10		0	9.99	0	10	5	0	5	0			1.06											2.53	0.04	0.18	-	-	5.65	0.57	1.66	0.12	-	-	-	-	-	2.55	4.92	0.17	-	2.89	-	-	0.33	-	1.37	0.24	-	0.1	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	24.08			2.53	0.04	0.18	-	-	5.65	0.57	1.66	0.12	-	-	-	-	-	2.55	4.92	0.17	-	2.89	-	-	0.33	-	1.37	0.24	-	0.1	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	24.08																																																																																				-			2.53	0.04	0.18	-	-	5.65	0.57	1.66	0.12	-	-	-	-	-	2.55	4.92	0.17	-	2.89	-	-	0.33	-	1.37	0.24	-	0.1	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	24.08
H5774_802_0	2007	4																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1418.68	20.56	99.07	1729.84	577.18	4830.37	147.43	743.83	131.06	857.09	434.28			924.13	5709.47	31527.78	188.04	1654.85	3243.87		515.17	366.9	0	0	0	0	0	0			936.88											200 per admit Copay	200 per admit Copay	200 per admit Copay			20 copayment per service	20 copayment per service	25 per visit copament	20 copay per visit						20PCP Copay	20 Copay OfficeVisits and Test	20 copay per visit		10 Copay			20 copay Chiropratic									10 Copay on Urgent Care Benefit and Routine Physicals											40	40	40	0	0	13.11	43.24	25	20	0	0			0	20	3.5	20	0	10		0	19.99	0	0	0	0	0	0			8.25											4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7																																																																																				-			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7
H5774_804_0	2007	4																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1418.68	20.56	99.07	1729.84	577.18	4830.37	147.43	743.83	131.06	857.09	434.28			924.13	5709.47	31527.78	188.04	1654.85	3243.87		515.17	366.9	0	0	0	0	0	0			936.88											200 per admit Copay	200 per admit Copay	200 per admit Copay			20 copayment per service	20 copayment per service	25 per visit copament	20 copay per visit						20PCP Copay	20 Copay OfficeVisits and Test	20 copay per visit		10 Copay			20 copay Chiropratic									10 Copay on Urgent Care Benefit and Routine Physicals											40	40	40	0	0	13.11	43.24	25	20	0	0			0	20	3.5	20	0	10		0	19.99	0	0	0	0	0	0			8.25											4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7																																																																																				-			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7
H5774_806_0	2007	5																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1418.68	20.56	99.07	1729.84	577.18	4830.37	147.43	743.83	131.06	857.09	434.28			924.13	5709.47	31527.78	188.04	1654.85	3243.87		515.17	366.9	0	0	0	0	0	0			936.88											200 per admit Copay	200 per admit Copay	200 per admit Copay			20 copayment per service	20 copayment per service	25 per visit copament	20 copay per visit						20PCP Copay	20 Copay OfficeVisits and Test	20 copay per visit		10 Copay			20 copay Chiropratic									10 Copay on Urgent Care Benefit and Routine Physicals											40	40	40	0	0	13.11	43.24	25	20	0	0			0	20	3.5	20	0	10		0	19.99	0	0	0	0	0	0			8.25											4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7																																																																																				-			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7
H5774_807_0	2007	5																																D	D	D	V	T	P	P	P	P	P	P			P	V	P	P	P	P		S	P	T	P	P	P	P	P			P																																																				-		1418.68	20.56	99.07	1729.84	577.18	4830.37	147.43	743.83	131.06	857.09	434.28			924.13	5709.47	31527.78	188.04	1654.85	3243.87		515.17	366.9	0	0	0	0	0	0			936.88											200 per admit Copay	200 per admit Copay	200 per admit Copay			20 copayment per service	20 copayment per service	25 per visit copament	20 copay per visit						20PCP Copay	20 Copay OfficeVisits and Test	20 copay per visit		10 Copay			20 copay Chiropratic									10 Copay on Urgent Care Benefit and Routine Physicals											40	40	40	0	0	13.11	43.24	25	20	0	0			0	20	3.5	20	0	10		0	19.99	0	0	0	0	0	0			8.25											4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7																																																																																				-			4.73	0.07	0.33	-	-	5.28	0.53	1.55	0.22	-	-	-	-	-	9.52	9.2	0.31	-	2.7	-	-	0.61	-	-	-	-	-	-	-	-	0.64	-	-	-	-	-	-	-	-	-	-	35.7
H5782_001_0	2007	5																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5783_002_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1662.49	84.37	646.74	1451.6	117.81	8.98	8.48	279.31	38.82		17.81	1.57	0.26	13.84	3835.63	5139.84	256.8	477.43	15.19	6.15	27.05				126.9		113.6															#1A: 115 days 1-5	#1B: 175 days 1-5	#2: 25 days 11-100	#6: 10	#10A: 125	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 15 NTE 400; #9B ASC: 15 NTE 250	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 20; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 20	#7A: 15; #14C: 20	#7B : 12; #7D/7F/7G #16B #17A #18A: 30	#7E/#7H: 40	#7C/#7I: 20	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 15	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 400 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	70.49	107.26	13.45	10	125	0.2	0.16	50	0.12		0.16	0.15	0.2	0.16	15.1	29.08	40	20	0.15	0.15	0.2				25		30															9.77	0.75	0.72	1.21	1.23	1.8	1.38	1.16	4.73	-	2.81	0.23	0.05	2.19	4.83	12.45	0.86	0.8	2.28	0.92	5.41	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.12		0	9.77	0.75	0.72	1.21	1.23	1.8	1.38	1.16	4.73	-	2.81	0.23	0.05	2.19	4.83	12.45	0.86	0.8	2.28	0.92	5.41	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.12																																																																																				-		0	9.77	0.75	0.72	1.21	1.23	1.8	1.38	1.16	4.73	-	2.81	0.23	0.05	2.19	4.83	12.45	0.86	0.8	2.28	0.92	5.41	-	-	-	0.26	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.12
H5783_003_0	2007	7																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1641.96	72.61	628.82		110.82	8.68	8.22	274.3	40.52		18.47	1.63	0.23	13.92	4222.14	5696.51	262.42	525.53	16.64	6.71	29.41				129.91		116.29															#1A: 60 days 1-5	#1B: 150 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 15	#11B Pros: 15; #11B Supplies: 10; #11C: 10	#4: 50	#9A OP Hosp: 15 NTE 250; #9B ASC: 15 NTE 125	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 15; #5: 35; #9A OP Hosp 15 / Chemo 20; #9C: 35; #9D: 15	#7A: 10; #14C: 10	#7B : 10; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 35	#7C/#7I: 15	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 10	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 70 Allowance every two years	#18A: 30	#18B: 500 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	33.21	83.03	12.14		90.3	0.14	0.1	45.16	0.1		0.14	0.14	0.18	0.14	9.05	21.87	31.61	13.55	0.14	0.14	0.18				25		30															4.54	0.5	0.64	-	0.83	1.18	0.83	1.03	3.89	-	2.63	0.22	0.04	1.98	3.18	10.38	0.69	0.59	2.25	0.91	5.31	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.22		4.47	4.54	0.5	0.64	-	0.83	1.18	0.83	1.03	3.89	-	2.63	0.22	0.04	1.98	3.18	10.38	0.69	0.59	2.25	0.91	5.31	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.22																																																																																				-		0	4.54	0.5	0.64	-	0.83	1.18	0.83	1.03	3.89	-	2.63	0.22	0.04	1.98	3.18	10.38	0.69	0.59	2.25	0.91	5.31	-	-	-	0.27	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.22
H5783_006_0	2007	6																																D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1522.78	67.34	583.21		102.78	7.67	7.26	254.42	35.79		16.32	1.44	0.21	12.3	3921.23	5283.04	243.38	487.39	14.7	5.92	25.98				129.91		116.29															#1A: 100 days 1-5	#1B: 100 days 1-5	#2: 25 days 11-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 15; #11C: 15	#4: 50	#9A OP Hosp: 10 NTE 300; #9B ASC: 10 NTE 150	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 15	#9A: 15	#12: 20	#3: 15; #5: 40; #9A OP Hosp 15 / Chemo 20; #9C: 40; #9D: 15	#7A: 10; #14C: 5	#7B : 8; #7D/7F/7G #16B #17A #18A: 25	#7E/#7H: 40	#7C/#7I: 15	#8B: 15	#7A/#7D Cardio. Testing: 15; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 25	#17B: 125 Allowance every two years	#18A: 20	#18B: 500 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	61.29	61.29	13.45		100	0.2	0.16	50	0.09		0.16	0.15	0.2	0.16	9.9	24.12	40	15	0.15	0.15	0.2				25		20															7.78	0.34	0.65	-	0.86	1.53	1.18	1.06	3.17	-	2.58	0.22	0.04	1.94	3.24	10.62	0.81	0.61	2.2	0.89	5.2	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.38		0	7.78	0.34	0.65	-	0.86	1.53	1.18	1.06	3.17	-	2.58	0.22	0.04	1.94	3.24	10.62	0.81	0.61	2.2	0.89	5.2	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.38																																																																																				-		0	7.78	0.34	0.65	-	0.86	1.53	1.18	1.06	3.17	-	2.58	0.22	0.04	1.94	3.24	10.62	0.81	0.61	2.2	0.89	5.2	-	-	-	0.27	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.38
H5783_007_0	2007	8																					5000											D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		1563.84	69.15	598.93		105.55	7.87	7.45	261.27	36.75		16.76	1.48	0.21	12.63	3948.4	5644.44	249.94	500.53	15.09	6.08	26.68				129.91		116.29															#1A: 50 days 1-5	#1B: 50 days 1-5	#2: 20 days 11-100	#6: 0	#10A: 75	#11A: 15	#11B Pros: 15; #11B Supplies: 10; #11C: 10	#4: 50	#9A OP Hosp: 10 NTE 150; #9B ASC: 10 NTE 100	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 10	#9A: 15	#12: 20	#3: 10; #5: 30; #9A OP Hosp 15 / Chemo 20; #9C: 30; #9D: 10	#7A: 5; #14C: 0	#7B : 5; #7D/7F/7G #16B #17A #18A: 20	#7E/#7H: 30	#7C/#7I: 10	#8B: 10	#7A/#7D Cardio. Testing: 10; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 10	#17B: 150 Allowance every two years	#18A: 15	#18B: 700 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	28.7	28.7	10.08		70.24	0.14	0.11	46.83	0.07		0.11	0.14	0.19	0.15	4.68	17.5	28.1	9.37	0.09	0.09	0.19				10		15															3.74	0.17	0.5	-	0.62	1.11	0.78	1.02	2.51	-	1.82	0.21	0.04	1.86	1.54	8.23	0.59	0.39	1.41	0.57	5	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.35		2.17	3.74	0.17	0.5	-	0.62	1.11	0.78	1.02	2.51	-	1.82	0.21	0.04	1.86	1.54	8.23	0.59	0.39	1.41	0.57	5	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.35																																																																																				-		0	3.74	0.17	0.5	-	0.62	1.11	0.78	1.02	2.51	-	1.82	0.21	0.04	1.86	1.54	8.23	0.59	0.39	1.41	0.57	5	-	-	-	0.11	-	0.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.35
H5783_008_0	2007	3																																D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	V	Coin	Coin	V	V	V	V	V	Coin	Coin	V	V	V	V	P	V	P	V	V	V	V	V	V	V	V	V	V	V	V	V																																										-		3384.37	423.63	3242.56		488.16	19.21	5.11	848.99	357.79		2.32	25.27	0.99	23.05		4480.36	769.07		3151.23	5.7	32.32				127.78		114.38															#1A: 25 days 1-5	#1B: 50 days 1-5	#2: 20 days 10-100	#6: 0	#10A: 100	#11A: 20	#11B Pros: 20; #11B Supplies: 0; #11C: 0	#4: 50	#9B ASC: 25; #9A OP Hosp: 25	#8A (Clin/Diag): 0	#8A (Ther) Radiation Therapy: 20; #8B X-Ray: 0	#9A: 20	#12: 20	#3: 0; #5: 10; #9A OP Hosp 20 / Chemo 20; #9C: 10; #9D: 0	#7A: 0; #14C: 0	#7B : 2; #7D/7F/7G #16B #17A #18A: 4	#7E/#7H: 15	#7C/#7I: 0	#8B: 4	#7A/#7D Cardio. Testing: 4; #14I Nutrition Therapy: 0	Part B Rx: 20	0 Copay	0 Copay	0 Copay	#17A: 5	#17B: 100 Allowance every two years	#18A: 15	#18B: 750 Allowance every three years	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	15.32	30.65	10.76		100	0.2	0.2	50	25		0.2	20	0.2	0.17		3.95	15		4	0.09	0.2				5		15															4.32	1.08	2.91	-	4.07	3.84	1.02	3.54	0.75	-	0.46	0.04	0.2	4	-	1.47	0.96	-	1.05	0.54	6.46	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.91		0	4.32	1.08	2.91	-	4.07	3.84	1.02	3.54	0.75	-	0.46	0.04	0.2	4	-	1.47	0.96	-	1.05	0.54	6.46	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.91																																																																																				-		0	4.32	1.08	2.91	-	4.07	3.84	1.02	3.54	0.75	-	0.46	0.04	0.2	4	-	1.47	0.96	-	1.05	0.54	6.46	-	-	-	0.05	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.91
H5793_001_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				200/day 1-10	200/day 1-10	0/day 1-10; 100/day 11-100	0	100	20	20	50 ER 50 urgent care	100	35	35 routine 100 complex	35	30	35	20	35 Specialist 30 Renal Dialysis	35	35	35	35	45	0																				163.28	163.28	63.47	0	100	0.2	0.2	50	100	35	57.23	35	30	35	20	34.46	35	35	35	35	45	0																				21.18	0.41	6.72	-	1.92	3.14	0.2	1.74	2.87	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.36			21.18	0.41	6.72	-	1.92	3.14	0.2	1.74	2.87	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.36																																																																																				-			21.18	0.41	6.72	-	1.92	3.14	0.2	1.74	2.87	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	87.36
H5793_002_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-10; 100/day 11-100	0	100	20	20	50 ER 50 urgent care	100	25	25 routine 100 complex	25	25	25	15	25	25	25	25	25	45	0																				122.46	122.46	63.47	0	100	0.2	0.2	50	100	25	50.65	25	25	25	15	25	25	25	25	25	45	0																				15.88	0.31	6.72	-	1.92	3.14	0.2	1.74	2.87	4.56	4.75	-	-	-	6.78	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.36			15.88	0.31	6.72	-	1.92	3.14	0.2	1.74	2.87	4.56	4.75	-	-	-	6.78	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.36																																																																																				-			15.88	0.31	6.72	-	1.92	3.14	0.2	1.74	2.87	4.56	4.75	-	-	-	6.78	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.36
H5793_003_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				100/day 1-10	100/day 1-10	0/day 1-10; 100/day 11-100	0	100	20	20	50 ER 50 urgent care	100	15	15 routine 100 complex	15	15	15	5	15	15	15	15	15	45	0																				81.64	81.64	63.47	0	100	0.2	0.2	50	100	15	44.07	15	15	15	5	15	15	15	15	15	45	0																				10.59	0.21	6.72	-	1.92	3.14	0.2	1.74	2.87	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.81			10.59	0.21	6.72	-	1.92	3.14	0.2	1.74	2.87	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.81																																																																																				-			10.59	0.21	6.72	-	1.92	3.14	0.2	1.74	2.87	2.73	4.13	-	-	-	2.26	8.38	0.25	0.72	1.17	1.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.81
H5793_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5793_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5794_001_0	2007	4																																D	D	D		T	Coin	Coin	V	V		V			V	V	V	V	V	V	V				V																																																											-		1232.16	22.7	1235.87		249.07	8.57	6.1	280.62	271.56		613.8			379.2	7497	10366.33	531.97	1792.88	4028.39	799.05				927.24																		95/day - 1st 10 days	95/day - 1st 10 days	50/day after 5 days		135/Service	20	20 except for Diabetic Supplies	50/visit	250/visit		30/visit			30/visit (RT/PT/OT/ST/)	10/office visit	30/ office visit	30/office visit	30/visit	30/ visit	30/chiro or 20/pod visit				50/visit except for Preventive Care																		95	95	50		135	0.2	0.12	50	250		30			30	10	30	30	30	30	23.9				50																		9.75	0.18	5.15	-	2.8	1.71	0.72	1.17	5.66	-	1.53	-	-	0.95	6.25	25.92	1.33	4.48	10.07	1.59	-	-	-	3.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.13		0	9.75	0.18	5.15	-	2.8	1.71	0.72	1.17	5.66	-	1.53	-	-	0.95	6.25	25.92	1.33	4.48	10.07	1.59	-	-	-	3.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.13																																																																																				-			9.75	0.18	5.15	-	2.8	1.71	0.72	1.17	5.66	-	1.53	-	-	0.95	6.25	25.92	1.33	4.48	10.07	1.59	-	-	-	3.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	83.13
H5794_002_0	2007	6																																D	D	D		T	Coin	Coin	V	V		V			V	V	V	V	V	V	V				V																																																											-		1311.71	24.16	1315.66		265.15	9.12	6.49	298.74	289.09		653.42			403.68	7980.98	11035.55	566.31	1908.62	4288.45	850.63				931.31																		95/day - 1st 10 days	95/day - 1st 10 days	50/day after 5 days		135/Service	20	20 except for Diabetic Supplies	50/visit	250/visit		30/visit			30/visit (RT/PT/OT/ST/)	10/office visit	30/ office visit	30/office visit	30/visit	30/ visit	30/chiro or 20/pod visit				50/visit except for Preventive Care																		95	95	50		135	0.2	0.12	50	250		30			30	10	30	30	30	30	23.9				50																		10.38	0.19	5.48	-	2.98	1.82	0.77	1.24	6.02	-	1.63	-	-	1.01	6.65	27.59	1.42	4.77	10.72	1.69	-	-	-	3.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.27		0	10.38	0.19	5.48	-	2.98	1.82	0.77	1.24	6.02	-	1.63	-	-	1.01	6.65	27.59	1.42	4.77	10.72	1.69	-	-	-	3.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.27																																																																																				-			10.38	0.19	5.48	-	2.98	1.82	0.77	1.24	6.02	-	1.63	-	-	1.01	6.65	27.59	1.42	4.77	10.72	1.69	-	-	-	3.88	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.27
H5810_001_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		385.6	28.87	62.35	66.26	14.86	33.44	22.01	10.22	18.92	12.74	25.72	0	2.83	38.61	75.91	144.77	11.77	6.72	30.82	50.94	8.34	4.91	2.02	0	0	0	0	0.57	0	0	11.65											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.06	0.06	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											23.91	1.79	10.05	-	3.51	7.89	5.19	2.41	4.47	3.01	6.07	-	0.67	9.11	17.91	34.16	2.78	1.59	7.27	12.02	1.97	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	156.94			23.91	1.79	10.05	-	3.51	7.89	5.19	2.41	4.47	3.01	6.07	-	0.67	9.11	17.91	34.16	2.78	1.59	7.27	12.02	1.97	1.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	156.94		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				1.26	0.09	0.53		0.18	0.42	0.27	0.13	0.24	0.16	0.32		0.04	0.48	0.94	1.8	0.15	0.08	0.38	0.63	0.1	0.06																				8.26			25.17	1.88	10.58	-	3.69	8.31	5.47	2.54	4.7	3.16	6.39	-	0.7	9.59	18.86	35.96	2.92	1.67	7.66	12.65	2.07	1.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	165.2
H5811_001_0	2007	2																					3000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1112.74	23.41	962.39	0	197.13	15.09	9.2	394.9	388	0	0	0	0	979.82	5057.25	7098.51	175.98	472.46	0	1431.37	0	651.8	0	0	331.42	0	0	0	0	0	47											PBP: 1A IP Acute: 200 per admit	1B IP Psych: 200 per admit	2 SNF: 0/day days 1-10 50/day days 11-20 100/day days 21-100	6 Home Health: 0	10A Ambulance: 100	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 100	8A OP C/D/T: 0	8B OP X-Ray: 0	9C OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7D Physician Specialist: 20	7E Mental Health: 20 7H Psychiatric: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 0	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 5 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: 50 Allowance Every 2 Years	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: 20	0										117.61	117.61	53.91	0	95.41	0.19	0.19	46.68	95.41	0	0	0	0	19.08	19.08	19.08	18.13	19.08	0	19.08	0	19.08	0	0	19.08	0	0	0	0	0	19.08											10.91	0.23	4.32	-	1.57	2.88	1.74	1.54	3.08	-	-	-	-	1.56	8.04	11.29	0.27	0.75	-	2.28	-	1.04	-	-	0.53	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	52.09	0	2.84	10.91	0.23	4.32	-	1.57	2.88	1.74	1.54	3.08	-	-	-	-	1.56	8.04	11.29	0.27	0.75	-	2.28	-	1.04	-	-	0.53	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	52.09	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.91	0.23	4.32	-	1.57	2.88	1.74	1.54	3.08	-	-	-	-	1.56	8.04	11.29	0.27	0.75	-	2.28	-	1.04	-	-	0.53	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	52.09
H5811_002_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	370.73	30.63	72.16	0	17.6	41.56	26.74	8.76	17.81	12.47	24.96	0.82	0.94	34.42	60.89	116.46	9.09	4.71	29.32	38.81	8.06	4.01	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	9C OP Hospital:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 5 Partial Hosp:  138 Ded and 20 Coinsurance 9C OP Substance Abuse:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 5 14B Immunizations: 0 14D Pap Smears:  138 Ded and 20 Coinsurance 14D Pelvic Exams:  138 Ded and 20 Coinsurance 14E Prostate Screening:  138 Ded and 20 Coinsurance 14F Colorectal Screening:  138 Ded and 20 Coinsurance 14G Bone Mass Measurement:  138 Ded and 20 Coinsurance 14H Mammography:  138 Ded and 20 Coinsurance 14I Diabetes Monitoring:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7F Routine Podiatry:  0 Copay7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 0 16B Comprehensive Dental Services:  138 Ded and 20 Coinsurance 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: 24 one trips per year in taxi or van	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Covered for 10 visits per year	13C Home Adaptation: Covered up 300 per year										0.07	0.07	0.18	0	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.23	0.24	0.24	0.24	0.22	0.24	0.24	0	0	0	0	0	0	0	0	0											25.73	2.13	12.85	-	4.15	9.81	6.26	2.07	4.2	2.94	5.89	0.19	0.22	8.12	13.91	26.58	2.15	1.11	6.92	8.45	1.9	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.54	0	0	25.73	2.13	12.85	-	4.15	9.81	6.26	2.07	4.2	2.94	5.89	0.19	0.22	8.12	13.91	26.58	2.15	1.11	6.92	8.45	1.9	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.54	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	25.73	2.13	12.85	-	4.15	9.81	6.26	2.07	4.2	2.94	5.89	0.19	0.22	8.12	13.91	26.58	2.15	1.11	6.92	8.45	1.9	0.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.54
H5811_003_0	2007	2																					3000											D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1112.74	23.41	962.39	0	197.13	15.09	9.2	394.9	388	0	0	0	0	979.82	5057.25	7098.51	175.98	472.46	0	1431.37	0	651.8	0	0	331.42	0	0	0	0	0	47											PBP: 1A IP Acute: 200 per admit	1B IP Psych: 200 per admit	2 SNF: 0/day days 1-10 50/day days 11-20 100/day days 21-100	6 Home Health: 0	10A Ambulance: 100	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 20	9B ASC Services: 100	8A OP C/D/T: 0	8B OP X-Ray: 0	9C OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 20 5 Partial Hosp: 20 9C OP Substance Abuse: 20 9D Cardiac Rehab: 20	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0	7D Physician Specialist: 20	7E Mental Health: 20 7H Psychiatric: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	8B OP X-Ray: 0	7B Chiropractic: 20 7F Podiatry: 20 7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0	13A Blood: 0 16B Comprehensive Dental Services: 5 17A Medicare Covered Eye Exams: 20	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: 20	0										117.61	117.61	53.91	0	95.41	0.19	0.19	46.68	95.41	0	0	0	0	19.08	19.08	19.08	18.13	19.08	0	19.08	0	19.08	0	0	19.08	0	0	0	0	0	19.08											10.91	0.23	4.32	-	1.57	2.88	1.74	1.54	3.08	-	-	-	-	1.56	8.04	11.29	0.27	0.75	-	2.28	-	1.04	-	-	0.53	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	52.09	0	2.84	10.91	0.23	4.32	-	1.57	2.88	1.74	1.54	3.08	-	-	-	-	1.56	8.04	11.29	0.27	0.75	-	2.28	-	1.04	-	-	0.53	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	52.09	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	10.91	0.23	4.32	-	1.57	2.88	1.74	1.54	3.08	-	-	-	-	1.56	8.04	11.29	0.27	0.75	-	2.28	-	1.04	-	-	0.53	-	-	-	-	-	0.07	-	-	-	-	-	-	-	-	-	-	52.09
H5812_002_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.32	3.09	1507.78	1499.11	202.74	18.5	0.85	469.85	22.79	8.91	24.21	0	6.75	23.74	4742.14	5935.38	1.39	611.52	22.29	112.01	22.06	2.91	0	0	387.12	0	165.91	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											317.04	317.04	25	10	100	0.16	0.16	47.5	0.08	0.08	0.08	0	0.08	0.06	19.91	19.79	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	None	7.3	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04
H5812_003_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	222.18	3.22	937.78	1013.75	230.69	22.25	1.02	487.33	23.8	9.31	25.29	0	7.05	24.79	3777.95	4676.22	1.01	462.59	19.88	85.64	16.03	2.13	0	0	308.41	0	132.18	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											329.82	329.82	25	10	100	0.16	0.16	48.08	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	None	5.76	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95
H5812_004_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	232.61	3.37	1141.07	1575.2	229.92	21.09	0.96	495.81	22.8	8.91	24.23	0	6.76	23.75	4653.89	6019.72	1.29	690.8	22.86	94.39	20.44	2.64	0	0	379.92	0	162.82	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											318.84	318.84	25	10	100	0.16	0.16	47.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.7	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	None	6.99	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22
H5812_005_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.48	3.09	1375.6	1170.42	191.22	17.98	0.82	410.03	20.62	8.06	21.91	0	6.11	21.48	4588.55	5843.53	1.4	638.6	30.28	119.64	22.18	2.89	0	0	374.59	0	160.54	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											317.94	317.94	25	10	100	0.16	0.16	47.23	0.08	0.08	0.08	0	0.08	0.06	19.91	19.77	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	None	7.37	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37
H5812_006_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	203.73	2.95	1009.74	1249.92	238.37	22.99	1.05	732	36.52	14.28	38.8	0	10.82	38.04	3903.76	4831.94	1.04	478	20.54	88.49	16.57	2.21	0	0	318.68	0	136.58	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											318.87	318.87	25	10	100	0.16	0.16	48.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	None	7.54	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5
H5812_009_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	210.21	3.05	1148.51	1138.79	197.81	18.24	0.83	535.1	22.89	8.95	24.32	0	6.78	23.84	4911.24	6112.16	1.27	616.72	25.97	100.36	20.13	2.67	0	0	400.93	0	171.83	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											319.28	319.28	25	10	100	0.16	0.16	47.73	0.08	0.08	0.08	0	0.08	0.06	19.91	19.74	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	None	6.88	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11
H5812_010_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.83	3.03	1605.16	1500.31	240.51	22.11	1.01	715.7	34.56	13.51	36.72	0	10.24	35.69	4176.52	5087.95	1.02	458.38	21.84	86.44	15.82	2.14	0	0	340.95	0	146.12	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Line 8a 15/day (MRI/CAT/PET 15) 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Lines 9a 9d: 15 Line 9c: 50 Line 5: 25/day Line 3: 15/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 15/day	PBP Line 7d: 15	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											297.6	297.6	25	10	100	0.15	0.15	48.55	0.11	0.11	0.11	0	0.11	0.08	19.91	19.75	0.37	15	0.11	0.11	0.11	0.11	0	0	20	0	20	0	0	0	0											5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	None	12.38	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4
H5812_011_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.32	3.09	1507.78	1499.11	202.74	18.5	0.85	469.85	22.79	8.91	24.21	0	6.75	23.74	4742.14	5935.38	1.39	611.52	22.29	112.01	22.06	2.91	0	0	387.12	0	165.91	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											317.04	317.04	25	10	100	0.16	0.16	47.5	0.08	0.08	0.08	0	0.08	0.06	19.91	19.79	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	None	7.3	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04
H5812_012_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.32	3.09	1507.78	1499.11	202.74	18.5	0.85	469.85	22.79	8.91	24.21	0	6.75	23.74	4742.14	5935.38	1.39	611.52	22.29	112.01	22.06	2.91	0	0	387.12	0	165.91	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											317.04	317.04	25	10	100	0.16	0.16	47.5	0.08	0.08	0.08	0	0.08	0.06	19.91	19.79	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	None	7.3	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04
H5812_013_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.32	3.09	1507.78	1499.11	202.74	18.5	0.85	469.85	22.79	8.91	24.21	0	6.75	23.74	4742.14	5935.38	1.39	611.52	22.29	112.01	22.06	2.91	0	0	387.12	0	165.91	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											317.04	317.04	25	10	100	0.16	0.16	47.5	0.08	0.08	0.08	0	0.08	0.06	19.91	19.79	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	None	7.3	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.64	0.08	3.14	1.25	1.69	2.93	0.13	1.86	1.81	0.71	1.92	-	0.54	1.37	7.87	9.79	0.55	0.51	1.77	8.59	1.75	0.23	-	-	0.65	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	55.04
H5812_014_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	222.18	3.22	937.78	1013.75	230.69	22.25	1.02	487.33	23.8	9.31	25.29	0	7.05	24.79	3777.95	4676.22	1.01	462.59	19.88	85.64	16.03	2.13	0	0	308.41	0	132.18	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											329.82	329.82	25	10	100	0.16	0.16	48.08	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	None	5.76	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95
H5812_015_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	222.18	3.22	937.78	1013.75	230.69	22.25	1.02	487.33	23.8	9.31	25.29	0	7.05	24.79	3777.95	4676.22	1.01	462.59	19.88	85.64	16.03	2.13	0	0	308.41	0	132.18	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											329.82	329.82	25	10	100	0.16	0.16	48.08	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	None	5.76	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95
H5812_016_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	222.18	3.22	937.78	1013.75	230.69	22.25	1.02	487.33	23.8	9.31	25.29	0	7.05	24.79	3777.95	4676.22	1.01	462.59	19.88	85.64	16.03	2.13	0	0	308.41	0	132.18	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											329.82	329.82	25	10	100	0.16	0.16	48.08	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	None	5.76	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.11	0.09	1.95	0.84	1.92	3.67	0.17	1.95	1.96	0.77	2.09	-	0.58	1.49	6.27	7.7	0.42	0.39	1.64	6.71	1.32	0.18	-	-	0.51	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.95
H5812_017_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	232.61	3.37	1141.07	1575.2	229.92	21.09	0.96	495.81	22.8	8.91	24.23	0	6.76	23.75	4653.89	6019.72	1.29	690.8	22.86	94.39	20.44	2.64	0	0	379.92	0	162.82	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											318.84	318.84	25	10	100	0.16	0.16	47.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.7	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	None	6.99	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22
H5812_018_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	232.61	3.37	1141.07	1575.2	229.92	21.09	0.96	495.81	22.8	8.91	24.23	0	6.76	23.75	4653.89	6019.72	1.29	690.8	22.86	94.39	20.44	2.64	0	0	379.92	0	162.82	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											318.84	318.84	25	10	100	0.16	0.16	47.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.7	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	None	6.99	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22
H5812_019_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	232.61	3.37	1141.07	1575.2	229.92	21.09	0.96	495.81	22.8	8.91	24.23	0	6.76	23.75	4653.89	6019.72	1.29	690.8	22.86	94.39	20.44	2.64	0	0	379.92	0	162.82	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											318.84	318.84	25	10	100	0.16	0.16	47.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.7	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	None	6.99	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	6.18	0.09	2.38	1.31	1.92	3.36	0.15	1.97	1.82	0.71	1.93	-	0.54	1.39	7.72	9.88	0.51	0.58	1.82	7.21	1.63	0.21	-	-	0.63	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.22
H5812_020_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.48	3.09	1375.6	1170.42	191.22	17.98	0.82	410.03	20.62	8.06	21.91	0	6.11	21.48	4588.55	5843.53	1.4	638.6	30.28	119.64	22.18	2.89	0	0	374.59	0	160.54	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											317.94	317.94	25	10	100	0.16	0.16	47.23	0.08	0.08	0.08	0	0.08	0.06	19.91	19.77	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	None	7.37	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37
H5812_021_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.48	3.09	1375.6	1170.42	191.22	17.98	0.82	410.03	20.62	8.06	21.91	0	6.11	21.48	4588.55	5843.53	1.4	638.6	30.28	119.64	22.18	2.89	0	0	374.59	0	160.54	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											317.94	317.94	25	10	100	0.16	0.16	47.23	0.08	0.08	0.08	0	0.08	0.06	19.91	19.77	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	None	7.37	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37
H5812_022_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	213.48	3.09	1375.6	1170.42	191.22	17.98	0.82	410.03	20.62	8.06	21.91	0	6.11	21.48	4588.55	5843.53	1.4	638.6	30.28	119.64	22.18	2.89	0	0	374.59	0	160.54	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											317.94	317.94	25	10	100	0.16	0.16	47.23	0.08	0.08	0.08	0	0.08	0.06	19.91	19.77	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	None	7.37	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.66	0.08	2.87	0.98	1.59	2.86	0.13	1.61	1.64	0.64	1.74	-	0.49	1.24	7.61	9.63	0.56	0.53	2.41	9.23	1.76	0.23	-	-	0.62	-	0.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.37
H5812_023_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	203.73	2.95	1009.74	1249.92	238.37	22.99	1.05	732	36.52	14.28	38.8	0	10.82	38.04	3903.76	4831.94	1.04	478	20.54	88.49	16.57	2.21	0	0	318.68	0	136.58	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											318.87	318.87	25	10	100	0.16	0.16	48.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	None	7.54	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5
H5812_024_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	203.73	2.95	1009.74	1249.92	238.37	22.99	1.05	732	36.52	14.28	38.8	0	10.82	38.04	3903.76	4831.94	1.04	478	20.54	88.49	16.57	2.21	0	0	318.68	0	136.58	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											318.87	318.87	25	10	100	0.16	0.16	48.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	None	7.54	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5
H5812_025_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	203.73	2.95	1009.74	1249.92	238.37	22.99	1.05	732	36.52	14.28	38.8	0	10.82	38.04	3903.76	4831.94	1.04	478	20.54	88.49	16.57	2.21	0	0	318.68	0	136.58	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											318.87	318.87	25	10	100	0.16	0.16	48.68	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	None	7.54	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.41	0.08	2.1	1.04	1.99	3.67	0.17	2.97	2.91	1.14	3.09	-	0.86	2.22	6.48	7.96	0.42	0.4	1.64	6.71	1.32	0.18	-	-	0.53	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.5
H5812_026_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	210.21	3.05	1148.51	1138.79	197.81	18.24	0.83	535.1	22.89	8.95	24.32	0	6.78	23.84	4911.24	6112.16	1.27	616.72	25.97	100.36	20.13	2.67	0	0	400.93	0	171.83	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											319.28	319.28	25	10	100	0.16	0.16	47.73	0.08	0.08	0.08	0	0.08	0.06	19.91	19.74	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	None	6.88	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11
H5812_027_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	210.21	3.05	1148.51	1138.79	197.81	18.24	0.83	535.1	22.89	8.95	24.32	0	6.78	23.84	4911.24	6112.16	1.27	616.72	25.97	100.36	20.13	2.67	0	0	400.93	0	171.83	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											319.28	319.28	25	10	100	0.16	0.16	47.73	0.08	0.08	0.08	0	0.08	0.06	19.91	19.74	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	None	6.88	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11
H5812_028_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	210.21	3.05	1148.51	1138.79	197.81	18.24	0.83	535.1	22.89	8.95	24.32	0	6.78	23.84	4911.24	6112.16	1.27	616.72	25.97	100.36	20.13	2.67	0	0	400.93	0	171.83	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											319.28	319.28	25	10	100	0.16	0.16	47.73	0.08	0.08	0.08	0	0.08	0.06	19.91	19.74	0.4	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	None	6.88	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.59	0.08	2.39	0.95	1.65	2.91	0.13	2.13	1.83	0.71	1.94	-	0.54	1.4	8.15	10.05	0.51	0.51	2.07	7.78	1.61	0.21	-	-	0.67	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	54.11
H5812_029_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.83	3.03	1605.16	1500.31	240.51	22.11	1.01	715.7	34.56	13.51	36.72	0	10.24	35.69	4176.52	5087.95	1.02	458.38	21.84	86.44	15.82	2.14	0	0	340.95	0	146.12	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Line 8a 15/day (MRI/CAT/PET 15) 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Lines 9a 9d: 15 Line 9c: 50 Line 5: 25/day Line 3: 15/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 15/day	PBP Line 7d: 15	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											297.6	297.6	25	10	100	0.15	0.15	48.55	0.11	0.11	0.11	0	0.11	0.08	19.91	19.75	0.37	15	0.11	0.11	0.11	0.11	0	0	20	0	20	0	0	0	0											5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	None	12.38	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4
H5812_030_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.83	3.03	1605.16	1500.31	240.51	22.11	1.01	715.7	34.56	13.51	36.72	0	10.24	35.69	4176.52	5087.95	1.02	458.38	21.84	86.44	15.82	2.14	0	0	340.95	0	146.12	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Line 8a 15/day (MRI/CAT/PET 15) 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Lines 9a 9d: 15 Line 9c: 50 Line 5: 25/day Line 3: 15/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 15/day	PBP Line 7d: 15	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											297.6	297.6	25	10	100	0.15	0.15	48.55	0.11	0.11	0.11	0	0.11	0.08	19.91	19.75	0.37	15	0.11	0.11	0.11	0.11	0	0	20	0	20	0	0	0	0											5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	None	12.38	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4
H5812_031_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	208.83	3.03	1605.16	1500.31	240.51	22.11	1.01	715.7	34.56	13.51	36.72	0	10.24	35.69	4176.52	5087.95	1.02	458.38	21.84	86.44	15.82	2.14	0	0	340.95	0	146.12	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 15	PBP Line 8a 15/day (MRI/CAT/PET 15) 9a: 15	PBP Line 8b: 15/day Line 9a: 15	PBP Line 5: 25/day Line 9a: 15	PBP Lines 9a 12: 15	PBP Lines 9a 9d: 15 Line 9c: 50 Line 5: 25/day Line 3: 15/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 15/day	PBP Line 7d: 15	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 15 (1000 OOP)	PBP Lines 13a 16b: 15 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											297.6	297.6	25	10	100	0.15	0.15	48.55	0.11	0.11	0.11	0	0.11	0.08	19.91	19.75	0.37	15	0.11	0.11	0.11	0.11	0	0	20	0	20	0	0	0	0											5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	None	12.38	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	5.18	0.08	3.34	1.25	2	3.29	0.15	2.9	3.86	1.51	4.1	-	1.14	2.95	6.93	8.37	0.38	0.57	2.44	9.15	1.77	0.24	-	-	0.57	-	0.24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.4
H5812_032_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	110.78	1.61	894.17	763.38	135.76	13.1	0.6	1325.45	68.21	26.67	72.47	0	20.21	71.05	2223.4	2752.05	0.6	272.24	11.7	50.4	9.44	1.26	0	0	181.51	0	77.79	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: Not covered											327.83	327.83	25	10	100	0.16	0.16	49.58	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	None	6.74	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93
H5812_033_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	110.78	1.61	894.17	763.38	135.76	13.1	0.6	1325.45	68.21	26.67	72.47	0	20.21	71.05	2223.4	2752.05	0.6	272.24	11.7	50.4	9.44	1.26	0	0	181.51	0	77.79	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											327.83	327.83	25	10	100	0.16	0.16	49.58	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	None	6.74	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93
H5812_034_0	2007	6																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	110.78	1.61	894.17	763.38	135.76	13.1	0.6	1325.45	68.21	26.67	72.47	0	20.21	71.05	2223.4	2752.05	0.6	272.24	11.7	50.4	9.44	1.26	0	0	181.51	0	77.79	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											327.83	327.83	25	10	100	0.16	0.16	49.58	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	None	6.74	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93
H5812_035_0	2007	5																					3000											A	A	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin			V	V	V	V														0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	110.78	1.61	894.17	763.38	135.76	13.1	0.6	1325.45	68.21	26.67	72.47	0	20.21	71.05	2223.4	2752.05	0.6	272.24	11.7	50.4	9.44	1.26	0	0	181.51	0	77.79	0	0	0	0											PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 1a: 400/benefit period (2 Per Year)	PBP Line 2: 25/day	PBP Line 6: 10/day	PBP Line 10a: 100	PBP Line 11a: 20	PBP Line 11b 11c: 20	PBP Line 4a 4b: 50/day	PBP Line 9a 9b: 10	PBP Line 8a 10/day (MRI/CAT/PET 10) 9a: 10	PBP Line 8b: 15/day Line 9a: 10	PBP Line 5: 25/day Line 9a: 10	PBP Lines 9a 12: 10	PBP Lines 9a 9d: 10 Line 9c: 50 Line 5: 25/day Line 3: 10/day	PBP Line 7a: 20 Line 14b: 0; Lines 14c 14d 14e 14f 14g 14h 14i: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 7e 7h: 50	PBP Line 7c 7i: 10/day	PBP Line 7d: 10	PBP Lines 7b 7d 7f 7g: 20 Lines 14d 14e 14f 14g 14h 14i: 10	PBP Line 15: 10 (1000 OOP)	PBP Lines 13a 16b: 10 Line 14a: 0 Line 17a: 20 Line 17b: 1 per 24 mos. (150 max)	PBP Line 10b: Not covered	PBP Lines 16a 16b: Not covered	PBP Line 17a: 20	PBP Line 17b: 1 per 24 mos. (150 max)	PBP Line 18a: 20	PBP Line 18b: 1 per 36 mos. (400 max)			PBP Line 13b: No Cost Sharing											327.83	327.83	25	10	100	0.16	0.16	49.58	0.08	0.08	0.08	0	0.08	0.06	19.91	19.76	0.41	10	0.08	0.08	0.08	0.08	0	0	20	0	20	0	0	0	0											3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	None	6.74	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93	3000																																										0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	N/A	0	3.03	0.04	1.86	0.64	1.13	2.15	0.1	5.48	5.59	2.19	5.94	-	1.66	4.25	3.69	4.53	0.24	0.23	0.96	3.93	0.77	0.1	-	-	0.3	-	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.93
H5813_001_0	2007	2																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.46 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.46	35	35	35	35	45				0		0															17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09																																																																																				-			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09
H5813_002_0	2007	5																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S	P	T	V	V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0		0	0	0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0		0	3822.53	0		0															992/admission		0 days 1-20 100 21-100	0 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	400 per procedure	47.86 per visit	47.86 X-ray; 20 CAT PET MRI	47.86 per visit	30 per visit	30 per visit	0 per visit	50 per visit; 30 per dialysis visit	50 per visit	50 per visit	50 per visit	50 per visit	45 per script		40 one way trips per year	5 per visit	0 per visit		0 per visit															161.82		40.15	0	100	0.2		48	400	47.86	67.1	47.86	30	50	0	47.86	50	50	50	50	45		0	5	0		0															20.99	-	4.25	-	1.92	3.14	-	1.67	11.47	8.73	6.29	-	-	-	-	26.75	0.82	2.38	3.91	5.91	-	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.83			20.99	-	4.25	-	1.92	3.14	-	1.67	11.47	8.73	6.29	-	-	-	-	26.75	0.82	2.38	3.91	5.91	-	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.83																																																																																				-			20.99	-	4.25	-	1.92	3.14	-	1.67	11.47	8.73	6.29	-	-	-	-	26.75	0.82	2.38	3.91	5.91	-	-	-	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.83
H5813_003_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.46 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.46	35	35	35	35	45				0		0															17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09																																																																																				-			17.98	-	7.19	3.48	1.92	3.14	-	1.67	5.74	6.38	6.16	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	91.09
H5813_004_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1556.38		1271.3	2086.91	230.31	15.72		417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0				0		0															350 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 125 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															57.09		67.84	20	100	0.2		48	200	25	59.2	25	25	25	10	25	25	25	25	25	45				0		0															7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65			7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65																																																																																				-			7.4	-	7.19	3.48	1.92	3.14	-	1.67	5.74	4.56	5.55	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.65
H5813_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5813_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5817_001_0	2007	6																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	421.87	30.68	88.74	0	36.01	62.2	46.77	10.27	22.64	18.23	31.42	1.04	1.23	58.68	76.47	131.37	7.48	4.91	28.18	45.56	9.95	4.32	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing (PBP #1A)	Medicare Cost Sharing (PBP #1B)	Medicare Cost Sharing (PBP #2)	0 (PBP #6)	20 coinsurance (PBP #10A)	20 coinsurance (PBP #11A)	20 coinsurance (PBP #11B/11C)	20 coinsurance up to 50 for each Medicare-covered emergency room visit; cost sharing waived if admitted. (PBP #4A/4B)	20 coinsurance (PBP #9B)	20 coinsurance (PBP #8A/9A)	20 coinsurance (PBP #8B/9A)	20 coinsurance (PBP #5/9A)	20 coinsurance (PBP #12/9A)	20 coinsurance (PBP #3/5/9A/9C/9D)	20 coinsurance (PBP #7A/14B-14I)	20 coinsurance (PBP #7B/7D/7F/7G/14D-14I)	50 Medicare Equivalent Coin (PBP #7E/7H)	20 coinsurance (PBP #7C/7I)	20 coinsurance (PBP #7D)	20 coinsurance (PBP #7B/7D/7F/7G/14D-14I)	20 coinsurance (PBP #15)	20 coinsurance (PBP #13A/14A)	0 (PBP #10B) 12 round trips per year to plan-approved location;	0 (PBP #16A/16B) 2 oral exams 2 cleanings 1 fouride treatment 1 X-ray per year	0 (PBP# 17A) 1 exam per year	0 (PBP# 17B) 1 hardware piece per year up to 100	0 (PBP# 18A) 1 exam per year	0 (PBP# 18B) 1 hardware piece per year; up to 1000	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0.07	0.07	0.19	0	0.2	0.2	0.2	0.18	0.2	0.2	0.2	0.2	0.2	0.2	0.19	0.19	0.5	0.2	0.2	0.19	0.2	0.2	0	0	0	0	0	0	0	0	0											27.97	2.03	16.74	-	7.2	12.44	9.31	1.86	4.53	3.65	6.28	0.21	0.25	11.73	14.82	25.34	3.74	0.98	5.64	8.77	1.99	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	166.34	0	0	27.97	2.03	16.74	-	7.2	12.44	9.31	1.86	4.53	3.65	6.28	0.21	0.25	11.73	14.82	25.34	3.74	0.98	5.64	8.77	1.99	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	166.34	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	27.97	2.03	16.74	-	7.2	12.44	9.31	1.86	4.53	3.65	6.28	0.21	0.25	11.73	14.82	25.34	3.74	0.98	5.64	8.77	1.99	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	166.34
H5820_002_0	2007	8	s	t	u	v	w						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						4000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D		T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin					V	V	V	V						Coin			Coin																																															-		2320.19	95.65	1624.36		846.23	27.13	2.26	451.03	10.02	6.34	16.43	0.72	0	33.76	5582.34	5264.39	509.95	1447.92	26.55					600	179.2	119.47	2.4						5.4			58.36						300/day days 1-7 then 0	300/day days 1-7 then 0	100/day days 6-100		100	20	20	50 waived if admitted	20	0-10	0-20	20	20	20	25 urgent care; else 5	25	25	25	0-20					0-75	15	15	20						10			0-10						234.56	234.56	63.68		99.73	0.2	0.2	39.89	0.2	0.03	0.12	0.2	0.2	0.2	6.98	24.93	24.93	24.93	0.03					6.48	14.96	14.96	19.95						0.1			0.03						45.35	1.87	8.62	-	7.03	5.41	0.45	1.5	2	0.17	1.95	0.14	-	6.73	3.25	10.94	1.06	3.01	0.83	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.54	-	-	1.58	-	-	-	-	-	103.13		0.28	45.35	1.87	8.62	-	7.03	5.41	0.45	1.5	2	0.17	1.95	0.14	-	6.73	3.25	10.94	1.06	3.01	0.83	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.54	-	-	1.58	-	-	-	-	-	103.13																																																																																				-			45.35	1.87	8.62	-	7.03	5.41	0.45	1.5	2	0.17	1.95	0.14	-	6.73	3.25	10.94	1.06	3.01	0.83	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.54	-	-	1.58	-	-	-	-	-	103.13
H5820_003_0	2007	8	s	t	u	v	w						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						4000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin					V	V	V	V						Coin			Coin																																															-		2408.88	99.79	1686.78	3255.74	878.75	28.17	2.35	468.27	10.41	6.58	17.06	0.75	0	35.06	5795.74	5465.64	529.44	1503.27	27.57					600	179.2	119.47	2.4						5.6			60.6						300/day days 1-7 then 0	300/day days 1-7 then 0	100/day days 4-100	20	100	20	20	50 waived if admitted	20	0-10	0-20	20	20	20	25 urgent care; else 5	25	25	25	0-20					0-75	15	15	20						10			0-10						234.56	234.56	76.93	19.95	99.73	0.2	0.2	39.89	0.2	0.03	0.12	0.2	0.2	0.2	6.98	24.93	24.93	24.93	0.03					6.48	14.96	14.96	19.95						0.1			0.03						47.09	1.95	10.81	5.41	7.3	5.62	0.47	1.56	2.08	0.18	2.02	0.15	-	6.99	3.37	11.36	1.1	3.12	0.87	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.56	-	-	1.64	-	-	-	-	-	114.34		0.31	47.09	1.95	10.81	5.41	7.3	5.62	0.47	1.56	2.08	0.18	2.02	0.15	-	6.99	3.37	11.36	1.1	3.12	0.87	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.56	-	-	1.64	-	-	-	-	-	114.34																																																																																				-			47.09	1.95	10.81	5.41	7.3	5.62	0.47	1.56	2.08	0.18	2.02	0.15	-	6.99	3.37	11.36	1.1	3.12	0.87	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.56	-	-	1.64	-	-	-	-	-	114.34
H5820_004_0	2007	7	s	t	u	v	w						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional						4000	Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						D	D	D	V	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin					V	V	V	V						Coin			Coin																																															-		2227.15	91.31	1558.88	3010.11	812.12	26.03	2.17	432.94	9.62	6.08	15.77	0.69	0	32.4	5358.5	5053.29	489.5	1389.86	25.48					600	179.2	119.47	2.4						5.18			56.01						300/day days 1-7 then 0	300/day days 1-7 then 0	100/day days 6-100	20	100	20	20	50 waived if admitted	20	0-10	0-20	20	20	20	25 urgent care; else 5	30	30	25	20					0-75	15	15	20						10			0-10						234.56	234.56	63.68	19.95	99.73	0.2	0.2	39.89	0.2	0.03	0.12	0.2	0.2	0.2	6.98	29.92	29.92	24.93	0.03					6.48	14.96	14.96	19.95						0.1			0.03						43.53	1.78	8.27	5	6.75	5.19	0.43	1.44	1.92	0.16	1.87	0.14	-	6.46	3.12	12.6	1.22	2.89	0.8	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.52	-	-	1.51	-	-	-	-	-	106.31		0.29	43.53	1.78	8.27	5	6.75	5.19	0.43	1.44	1.92	0.16	1.87	0.14	-	6.46	3.12	12.6	1.22	2.89	0.8	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.52	-	-	1.51	-	-	-	-	-	106.31																																																																																				-			43.53	1.78	8.27	5	6.75	5.19	0.43	1.44	1.92	0.16	1.87	0.14	-	6.46	3.12	12.6	1.22	2.89	0.8	-	-	-	-	0.32	0.22	0.15	0	-	-	-	-	-	0.52	-	-	1.51	-	-	-	-	-	106.31
H5820_801_0	2007	6	s	t	u	v	w						DME/Prosthetics/Supplies	OP Facility-Surgery	Professional (Non-Covered)	Professional (Non-Covered)	Professional							Diabetic Supplies	ASC	Podiatry	Chiropractic	Lab						Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin																																																																				-		327.24		54.23		9.9	42.72		5.42	14.57					54.09	268.09																											Medicare FFS Cost Sharing		Medicare FFS Cost Sharing		Medicare FFS Cost Sharing	Medicare FFS Cost Sharing		Medicare FFS Cost Sharing	Medicare FFS Cost Sharing					Medicare FFS Cost Sharing	Medicare FFS Cost Sharing																											0.07		0.21		0.24	0.24	0.24	0.24	0.24					0.24	0.24																											24.11	-	11.21	-	2.34	10.08	-	1.28	3.44	-	-	-	-	12.76	63.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.49			24.11	-	11.21	-	2.34	10.08	-	1.28	3.44	-	-	-	-	12.76	63.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.49																																																																																				-			24.11	-	11.21	-	2.34	10.08	-	1.28	3.44	-	-	-	-	12.76	63.27	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.49
H5821_001_0	2007	6																																D	D	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																										-		1705.15	73.35	2.08		2.94	25.42	13.69	6.39	13.3	17.59	5.34	0.57	0.4	4.47	34.86	35.84	4.78	5.09	20.7	76.56	17.79	0.01																				No IP Ded Medicare CS Days 61+	No IP Ded Medicare CS Days 61+	Medicare CS	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded); 4A NTE 50	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	Medicare CS (No Ded)	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	OON Benefit	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	2.45	2.45	0.16		0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21	0.21																				0.35	0.01	0.32	-	0.62	5.38	2.9	1.35	2.81	3.72	1.13	0.12	0.08	0.94	7.37	7.58	1.01	1.08	4.38	16.19	3.76	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.13		0	0.35	0.01	0.32	-	0.62	5.38	2.9	1.35	2.81	3.72	1.13	0.12	0.08	0.94	7.37	7.58	1.01	1.08	4.38	16.19	3.76	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.13																														20 (excl #4A/B #10A #12)																																									4.8													4.8		0	0.35	0.01	0.32	-	0.62	5.38	2.9	1.35	2.81	3.72	1.13	0.12	0.08	0.94	7.37	7.58	1.01	1.08	4.38	16.19	3.76	0	-	-	-	-	-	-	4.8	-	-	-	-	-	-	-	-	-	-	-	-	65.93
H5821_004_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																										-									438.15																																		0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	#4A/B: 25	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	OON Benefit	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins								25																																		-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.91		0	-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.91																														20 (excl #4A/B #10A #12)																																									11.05													11.05		0	-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.05	-	-	-	-	-	-	-	-	-	-	-	-	11.96
H5821_007_0	2007	8																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																										-									438.15																																		0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	#4A/B: 25	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	OON Benefit	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins								25																																		-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.91		0	-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.91																														20 (excl #4A/B #10A #12)																																									11.09													11.09		0	-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.09	-	-	-	-	-	-	-	-	-	-	-	-	12
H5821_008_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																										-																																											0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	OON Benefit	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins																																										-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																														20 (excl #4A/B #10A #12)																																									11.09													11.09		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.09	-	-	-	-	-	-	-	-	-	-	-	-	11.09
H5821_009_0	2007	4																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	P	V	P	Coin	V	V	V	V	V	V	V	V	V	V	V	V																																										-		2260.05	96.82			132.35	4303.98	226.19	561.47	188.39	14525.24	551.93			38.55	8814.77	7048.45	704.53	1462.54	3376.1					3552	127.79		228.78															1A: 25 Copay	1B: 25 Copay	0 Copay	0 Copay	10A: 25 Copay	11A: 3 Copay	11B Pros.: 3 Copay	4A: 25; 4B: 15	9B: 15	8A: 3	8B: 3	0 Copay	0 Copay	5/9C: 5; 3/9D 2	7A/14C: 2	7B/7D/7F/14D/14E/14G: 5; 16B/17A/18A; 3; 14F 2	7E/H: 5	7C/I: 2	8B: 3; 14H 2	0 Copay	0 Coins	0 Copay	0 Copay	16A/16B: 3	17A: 3	17B: 100 Allowance	18A: 3	18B: 250 Allowance	OON Benefit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	25	25			25	3	3	24.7	15	3	3			2.06	2	4.75	5	2	2.92					3	3		3															4.71	0.2	-	-	0.28	1.08	0.06	1.16	0.24	3.63	0.14	-	-	0.01	1.47	2.79	0.29	0.24	0.82	-	-	-	-	0.89	0.03	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.08		0	4.71	0.2	-	-	0.28	1.08	0.06	1.16	0.24	3.63	0.14	-	-	0.01	1.47	2.79	0.29	0.24	0.82	-	-	-	-	0.89	0.03	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.08																														20 (excl #4A/B #10A #12)																																									12.44													12.44		0	4.71	0.2	-	-	0.28	1.08	0.06	1.16	0.24	3.63	0.14	-	-	0.01	1.47	2.79	0.29	0.24	0.82	-	-	-	-	0.89	0.03	-	0.06	-	12.44	-	-	-	-	-	-	-	-	-	-	-	-	30.52
H5821_013_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																										-									438.15																																		0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	#4A/B: 25	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	OON Benefit	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins	0 Coins								25																																		-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.91		0	-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.91																														20 (excl #4A/B #10A #12)																																									10.78													10.78		0	-	-	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.78	-	-	-	-	-	-	-	-	-	-	-	-	11.69
H5821_014_0	2007	4																																D	D	D	V	T	P	P	V	V	V	V	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	P	V	P	Coin	V	V	V	V	V	V	V	V	V	V	V	V																																										-		2260.05	96.82			132.35	4303.98	226.19	561.47	188.39	14525.24	551.93			38.55	8814.77	7048.45	704.53	1462.54	3376.1					3552	127.79		228.78															1A: 25 Copay	1B: 25 Copay	0 Copay	0 Copay	10A: 25 Copay	11A: 3 Copay	11B Pros.: 3 Copay	4A: 25; 4B: 15	9B: 15	8A: 3	8B: 3	0 Copay	0 Copay	5/9C: 5; 3/9D 2	7A/14C: 2	7B/7D/7F/14D/14E/14G: 5; 16B/17A/18A; 3; 14F 2	7E/H: 5	7C/I: 2	8B: 3; 14H 2	0 Copay	0 Coins	0 Copay	0 Copay	16A/16B: 3	17A: 3	17B: 100 Allowance	18A: 3	18B: 250 Allowance	OON Benefit	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	25	25			25	3	3	24.7	15	3	3			2.06	2	4.75	5	2	2.92					3	3		3															4.71	0.2	-	-	0.28	1.08	0.06	1.16	0.24	3.63	0.14	-	-	0.01	1.47	2.79	0.29	0.24	0.82	-	-	-	-	0.89	0.03	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.08		0	4.71	0.2	-	-	0.28	1.08	0.06	1.16	0.24	3.63	0.14	-	-	0.01	1.47	2.79	0.29	0.24	0.82	-	-	-	-	0.89	0.03	-	0.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.08																														20 (excl #4A/B #10A #12)																																									12.44													12.44		0	4.71	0.2	-	-	0.28	1.08	0.06	1.16	0.24	3.63	0.14	-	-	0.01	1.47	2.79	0.29	0.24	0.82	-	-	-	-	0.89	0.03	-	0.06	-	12.44	-	-	-	-	-	-	-	-	-	-	-	-	30.52
H5823_001_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		293.5	23.87	59.22	39.41	11.21	25.63	16.52	10.34	19.68	13.71	27.46	0	2.83	39.49	49.65	102.28	8.07	4.5	23.79	33.45	8.61	3.65	0	0	0	0	0	0.57	0	0	14											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											19.73	1.6	9.35	-	2.64	6.05	3.9	2.44	4.64	3.24	6.48	-	0.67	9.32	11.72	24.14	1.9	1.06	5.61	7.89	2.03	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.29			19.73	1.6	9.35	-	2.64	6.05	3.9	2.44	4.64	3.24	6.48	-	0.67	9.32	11.72	24.14	1.9	1.06	5.61	7.89	2.03	0.86	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.29		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				1.04	0.08	0.49		0.14	0.32	0.21	0.13	0.24	0.17	0.34		0.04	0.49	0.62	1.27	0.1	0.06	0.3	0.42	0.11	0.05																				6.59			20.77	1.69	9.84	-	2.78	6.37	4.1	2.57	4.89	3.41	6.82	-	0.7	9.81	12.33	25.41	2	1.12	5.91	8.31	2.14	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.88
H5826_005_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	Coin	P	P	P	P	P																																																				-		290.74	40.26	46.3		17.78	23.79	18.05	37.1	29.05	21.63	16.2	5.38	1.53	25.26	27.75	37.81	12.56	16.12	26.83	90.48	21.21																					MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing	MCR FFS Cost Sharing				0.2																0.07	0.07	0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					19.91	2.76	7.23	-	4.2	5.61	4.26	8.76	6.86	5.1	3.82	1.27	0.36	5.96	6.55	8.92	2.96	3.8	6.33	21.35	5.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.02		0	19.91	2.76	7.23	-	4.2	5.61	4.26	8.76	6.86	5.1	3.82	1.27	0.36	5.96	6.55	8.92	2.96	3.8	6.33	21.35	5.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.02																																																																																				-		0	19.91	2.76	7.23	-	4.2	5.61	4.26	8.76	6.86	5.1	3.82	1.27	0.36	5.96	6.55	8.92	2.96	3.8	6.33	21.35	5.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	131.02
H5826_006_0	2007	1																					3000											A	A	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	V	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		979.03	73.18	593.71		108.1	7.44	8.04	273.65	387.86	20.31	19.22	8.4	0.01	10.2	4380.62	6024.03	300.95	817.48	31.7	55.82	25.07																					400	40000	100/Day after 10 days		100	0	0	50	200	0	0.2	0.2	0.2	0	15	25	25	25	20	40	0.2																					81.19	37.93	36.75		100	0.18	0.18	45.94	183.75	0.18	0.18	0.18	0.18	0.18	15	25	24.92	24.42	0.18	40	0.18																					6.62	0.23	1.82	-	0.9	1.37	1.48	1.05	5.94	3.73	3.53	1.54	0	1.87	5.48	12.55	0.63	1.66	5.82	0.19	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.02		3.53	6.62	0.23	1.82	-	0.9	1.37	1.48	1.05	5.94	3.73	3.53	1.54	0	1.87	5.48	12.55	0.63	1.66	5.82	0.19	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.02																																																																																				-		0	6.62	0.23	1.82	-	0.9	1.37	1.48	1.05	5.94	3.73	3.53	1.54	0	1.87	5.48	12.55	0.63	1.66	5.82	0.19	4.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.02
H5826_007_0	2007	1																					5000											A	A	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	V	Coin	P	P	P	P	P	V	P	P	P	P																																																				-		983.88	43.77	517.3		107.63	8.84	9.17	336.98	394.4	21.48	22.29	4.34	0.37	22.87	3458.27	5452.75	130.94	777.31	26.37	123.5	23.37																					600	60000	100 Days 11-100		150	0	0	50	350	0	0.25	0.25	0.25	0	20	30	30	30	25	40	0.25																					135.47	51.49	37.66		150	0.24	0.24	47.08	311.62	0.24	0.24	0.24	0.24	0.24	20	30	29.89	29.53	0.24	40	0.24																					11.11	0.19	1.62	-	1.35	2.08	2.16	1.32	10.24	5.06	5.25	1.02	0.09	5.38	5.76	13.63	0.33	1.91	6.21	0.41	5.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.61		3.58	11.11	0.19	1.62	-	1.35	2.08	2.16	1.32	10.24	5.06	5.25	1.02	0.09	5.38	5.76	13.63	0.33	1.91	6.21	0.41	5.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.61																																																																																				-		0	11.11	0.19	1.62	-	1.35	2.08	2.16	1.32	10.24	5.06	5.25	1.02	0.09	5.38	5.76	13.63	0.33	1.91	6.21	0.41	5.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.61
H5826_008_0	2007	3																					3000											A	A	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	V	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		979.03	73.18	593.71		108.1	7.44	8.04	273.65	387.86	20.31	19.22	8.4	0.01	10.2	4380.62	6024.03	300.95	817.48	31.7	55.82	25.07				130.81																	400	40000	100/Day after 10 days		100	0	0	50	200	0	0.2	0.2	0.2	0	15	25	25	25	20	40	0.2				15																	81.19	37.93	36.75		100	0.18	0.18	45.94	183.75	0.18	0.18	0.18	0.18	0.18	15	25	24.92	24.42	0.18	40	0.18				15																	6.62	0.23	1.82	-	0.9	1.37	1.48	1.05	5.94	3.73	3.53	1.54	0	1.87	5.48	12.55	0.63	1.66	5.82	0.19	4.61	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.18		3.53	6.62	0.23	1.82	-	0.9	1.37	1.48	1.05	5.94	3.73	3.53	1.54	0	1.87	5.48	12.55	0.63	1.66	5.82	0.19	4.61	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.18																																																																																				-		0	6.62	0.23	1.82	-	0.9	1.37	1.48	1.05	5.94	3.73	3.53	1.54	0	1.87	5.48	12.55	0.63	1.66	5.82	0.19	4.61	-	-	-	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.18
H5826_009_0	2007	3																					5000											A	A	D	V	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	V	V	V	Coin	V	Coin	P	P	P	P	P	V	P	P	P	P																																																				-		983.88	43.77	517.3		107.63	8.84	9.17	336.98	394.4	21.48	22.29	4.34	0.37	22.87	3458.27	5452.75	130.94	777.31	26.37	123.5	23.37				130.81																	600	60000	100 Days 11-100		150	0	0	50	300	0	0.25	0.25	0.25	0	20	30	30	30	25	40	0.25				20																	135.47	51.49	37.66		150	0.24	0.24	47.08	311.62	0.24	0.24	0.24	0.24	0.24	20	30	29.89	29.53	0.24	40	0.24				20																	11.11	0.19	1.62	-	1.35	2.08	2.16	1.32	10.24	5.06	5.25	1.02	0.09	5.38	5.76	13.63	0.33	1.91	6.21	0.41	5.5	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.83		3.58	11.11	0.19	1.62	-	1.35	2.08	2.16	1.32	10.24	5.06	5.25	1.02	0.09	5.38	5.76	13.63	0.33	1.91	6.21	0.41	5.5	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.83																																																																																				-		0	11.11	0.19	1.62	-	1.35	2.08	2.16	1.32	10.24	5.06	5.25	1.02	0.09	5.38	5.76	13.63	0.33	1.91	6.21	0.41	5.5	-	-	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.83
H5832_001_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														150/day 1-8 (1200 max/stay)	150/day 1-8 (1200 max/stay)	0 copay day 1-20 / 100 21-100	0	75	0.2	0.2	50   (Waived if Admitted; Worldwide) 30	100	0	0  100	25	25	25	10	25	25	25	25	25	45	0	Not covered	100 copay	0	100 copay	0	500 Every 3 Yrs														113.69	113.69	40.15	0	75	0.2	0.2	47.4	100	0	34.2	25	25	25	10	25	25	25	25	25	45	0	0	0	0	0	0	0														14.75	0.29	4.25	-	1.44	3.14	0.2	1.65	2.87	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.8			14.75	0.29	4.25	-	1.44	3.14	0.2	1.65	2.87	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.8																																																																																				-			14.75	0.29	4.25	-	1.44	3.14	0.2	1.65	2.87	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.8
H5832_002_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														50/day 1-5 (250 max/stay)	50/day 1-5 (250 max/stay)	0 copay day 1-20 / 100 21-100	0	75	0.2	0.2	50   (Waived if Admitted; Worldwide)  30	50	0	0  100	25	25	25	10	25	25	25	25	25	45	0	Not covered	100 copay	0	100 copay	0	500 Every 3 Yrs														30.34	30.34	40.15	0	75	0.2	0.2	47.4	50	0	34.2	25	25	25	10	25	25	25	25	25	45	0	0	0	0	0	0	0														3.93	0.08	4.25	-	1.44	3.14	0.2	1.65	1.43	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.35			3.93	0.08	4.25	-	1.44	3.14	0.2	1.65	1.43	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.35																																																																																				-			3.93	0.08	4.25	-	1.44	3.14	0.2	1.65	1.43	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.35
H5832_003_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														150/day 1-8 (1200 max/stay)	150/day 1-8 (1200 max/stay)	0 copay day 1-20 / 100 21-100	0	75	0.2	0.2	50   (Waived if Admitted; Worldwide)  35	200	0	0  100	30	30	30	15	30	30	30	30	30	45	0	Not covered	100 copay	0	100 copay	0	500 Every 3 Yrs														113.69	113.69	40.15	0	75	0.2	0.2	48.05	200	0	34.2	30	30	30	15	30	30	30	30	30	45	0	0	0	0	0	0	0														14.75	0.29	4.25	-	1.44	3.14	0.2	1.67	5.74	-	3.2	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.05			14.75	0.29	4.25	-	1.44	3.14	0.2	1.67	5.74	-	3.2	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.05																																																																																				-			14.75	0.29	4.25	-	1.44	3.14	0.2	1.67	5.74	-	3.2	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	66.05
H5832_004_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0	0	0	0	317.28	0	22.16														100/day 1-5 (500 max/stay)	100/day 1-5 (500 max/stay)	0 copay day 1-20 / 100 21-100	0	75	0.2	0.2	50   (Waived if Admitted; Worldwide)  30	200	0	0  100	25	25	25	10	25	25	25	25	25	45	0	Not covered	100 copay	0	100 copay	0	500 Every 3 Yrs														60.67	60.67	40.15	0	75	0.2	0.2	47.4	200	0	34.2	25	25	25	10	25	25	25	25	25	45	0	0	0	0	0	0	0														7.87	0.15	4.25	-	1.44	3.14	0.2	1.65	5.74	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.66			7.87	0.15	4.25	-	1.44	3.14	0.2	1.65	5.74	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.66																																																																																				-			7.87	0.15	4.25	-	1.44	3.14	0.2	1.65	5.74	-	3.2	-	-	-	4.52	13.97	0.41	1.19	1.95	2.95	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.66
H5832_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0	0	0			200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	0.3	0.3	50 50	150	0.2	0.2 0.2	35	35	35	35	35	35	35	35	35	0.2	0	N/A	Not Covered	0	Not Covered	0	Not Covered	N/A	Not Covered	0	0	0	0	0	0	0	0	0			143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5832_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0	0	0			200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	0.3	0.3	50 50	150	0.2	0.2 0.2	35	35	35	35	35	35	35	35	35	0.2	0	N/A	Not Covered	0	Not Covered	0	Not Covered	N/A	Not Covered	0	0	0	0	0	0	0	0	0			143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5838_001_0	2007	4																																Coin		Coin		Coin	Coin		Coin	Coin	Coin					Coin						Coin																																																														-		487.14		41.95		27.53	28.61		20.38	23.73	154.27					230.87						2.87																					Medicare FFS		Medicare FFS		Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS					Medicare FFS						Medicare FFS																					0.07		0.18		0.24	0.24		0.24	0.24	0.24					0.24						0.24																					32	-	7.48	-	6.5	6.75	-	4.81	5.6	36.41	-	-	-	-	54.48	-	-	-	-	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	154.71			32	-	7.48	-	6.5	6.75	-	4.81	5.6	36.41	-	-	-	-	54.48	-	-	-	-	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	154.71																																																																																				-			32	-	7.48	-	6.5	6.75	-	4.81	5.6	36.41	-	-	-	-	54.48	-	-	-	-	-	0.68	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	154.71
H5839_001_0	2007	8																																D	D	D	Coin	T	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	Coin	Coin	V	Coin	Coin																																																													-		569.05	5.96	193.71	6.05	51.69	5.68	4.61	237.75	58.9	23.23	1.76	0.2	0.26	0.09	2711.76	2078.26	1.3	3.13	0	0	17.69	0.36																				150 day for 1st 5 days	150 day for 1st 5 days	35 day for days 11+	15 Coinsurance	150 Copay	20 Coinsurance	20 Coinsurance	50 per visit	15 Coinsurance	15 Coinsurance	15 Coinsurance	50 Coinsurance	15 Coinsurance	50 Coinsurance	10 Per Visit	35 Per Visit	50 Coinsurance	15 Coinsurance	15 Coinsurance	35 Per Visit	20 Coinsurance	15 Coinsurance																				150	150	35	0.15	150	0.2	0.2	50	0.15	0.15	0.15	0.5	0.15	0.5	10	35	0.5	0.15	0.15	35	0.2	0.15																				7.11	0.07	0.56	0.91	0.65	1.14	0.92	0.99	8.84	3.48	0.26	0.1	0.04	0.05	2.26	6.06	0.65	0.47	-	-	3.54	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.16			7.11	0.07	0.56	0.91	0.65	1.14	0.92	0.99	8.84	3.48	0.26	0.1	0.04	0.05	2.26	6.06	0.65	0.47	-	-	3.54	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.16		500 per day								20 Coinsurance																																	0.54								0.04																																	0.58			7.65	0.07	0.56	0.91	0.65	1.14	0.92	0.99	8.88	3.48	0.26	0.1	0.04	0.05	2.26	6.06	0.65	0.47	-	-	3.54	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.74
H5849_001_1	2007	7	i.5.	i.6.	i.2.								Professional	Professional	Professional								3750	Radiology	Other	Specialist excl. MH								D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	V	V	V	V	V	Coin		P					V					Coin	V	V								0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0		0					0					0	0	0								-	N.A.	1054.46	22.26	680.02	0	7.57	25.9	1.18	4.2	19.17	7.49	20.37		5.68	20.17	4310.5	4479.6	167.11	490.22	962.56	20.28		14.2					142.78					5.07	574.8	894.31								160 for first 5 days per admit	160 for first 5 days per admit	90 for days 4-100	no cost share	20 coinsurance	20 coinsurance	20 coinsurance	20 to max of 50	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	15 copay	25 copay	25 copay	25 copay	15 PCP/25 SCP copay	20 coinsurance		25 copay					25 copay					20 coinsurance	15 PCP/25 SCP copay	15 PCP/25 SCP copay								131.96	131.96	74.23	0	0.16	0.16	0.16	0.16	0.16	0.16	0.16		0.16	0.16	12.37	20.62	20.62	20.62	18.14	0.16		20.62					20.62					0.16	17.32	14.43								11.6	0.24	4.21	-	1.25	4.27	0.2	0.69	3.16	1.24	3.36	-	0.94	3.33	4.44	7.7	0.29	0.84	1.46	3.35	-	0.02	-	-	-	-	0.25	-	-	-	-	0.84	0.83	1.08	-	-	-	-	-	-	-	55.56	0	11.8	11.6	0.24	4.21	-	1.25	4.27	0.2	0.69	3.16	1.24	3.36	-	0.94	3.33	4.44	7.7	0.29	0.84	1.46	3.35	-	0.02	-	-	-	-	0.25	-	-	-	-	0.84	0.83	1.08	-	-	-	-	-	-	-	55.56	3750																																																																																			-	N.A.	0	11.6	0.24	4.21	-	1.25	4.27	0.2	0.69	3.16	1.24	3.36	-	0.94	3.33	4.44	7.7	0.29	0.84	1.46	3.35	-	0.02	-	-	-	-	0.25	-	-	-	-	0.84	0.83	1.08	-	-	-	-	-	-	-	55.56
H5849_001_2	2007	7	i.5.	i.6.	i.2.								Professional	Professional	Professional								3750	Radiology	Other	Specialist excl. MH								D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	V	V	V	V	V	Coin		P					V					Coin	V	V								0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0		0					0					0	0	0								-	n/a	1206.07	25.46	576.11	0	8.13	27.83	1.27	4.94	22.62	8.84	24.04		6.7	23.81	4632.24	4813.95	179.58	526.81	1034.4	21.8		15.26					153.44					5.45	617.71	961.06								160 for first 5 days per admit	160 for first 5 days per admit	90 for days 4-100	no cost share	20 coinsurance	20 coinsurance	20 coinsurance	20 to max of 50	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	15 copay	25 copay	25 copay	25 copay	15 PCP/25 SCP copay	20 coinsurance		25 copay					25 copay					20 coinsurance	15 PCP/25 SCP copay	15 PCP/25 SCP copay								128.33	128.33	72.18	0	0.16	0.16	0.16	0.16	0.16	0.16	0.16		0.16	0.16	12.03	20.05	20.05	20.05	17.65	0.16		20.05					20.05					0.16	16.84	14.04								12.9	0.27	3.47	-	1.3	4.46	0.2	0.79	3.63	1.42	3.86	-	1.08	3.82	4.64	8.04	0.3	0.88	1.52	3.5	-	0.03	-	-	-	-	0.26	-	-	-	-	0.87	0.87	1.12	-	-	-	-	-	-	-	59.23	0	14.62	12.9	0.27	3.47	-	1.3	4.46	0.2	0.79	3.63	1.42	3.86	-	1.08	3.82	4.64	8.04	0.3	0.88	1.52	3.5	-	0.03	-	-	-	-	0.26	-	-	-	-	0.87	0.87	1.12	-	-	-	-	-	-	-	59.23	3750																																																																																			-			12.9	0.27	3.47	-	1.3	4.46	0.2	0.79	3.63	1.42	3.86	-	1.08	3.82	4.64	8.04	0.3	0.88	1.52	3.5	-	0.03	-	-	-	-	0.26	-	-	-	-	0.87	0.87	1.12	-	-	-	-	-	-	-	59.23
H5849_001_3	2007	7	i.5.	i.6.	i.2.								Professional	Professional	Professional								3750	Radiology	Other	Specialist excl. MH								D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	V	V	V	V	V	Coin		P					V					Coin	V	V								0	0	0	0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0		0					0					0	0	0								-	n/a	1303.34	27.51	661.55	0	8.4	28.74	1.31	5.19	23.81	9.31	25.29		7.05	25.05	4783.26	4970.9	185.44	543.98	1068.12	22.51		15.75					158.44					5.63	637.85	992.39								160 for first 5 days per admit	160 for first 5 days per admit	90 for days 4-100	no cost share	20 coinsurance	20 coinsurance	20 coinsurance	20 to max of 50	20 coinsurance	20 coinsurance	20 coinsurance		20 coinsurance	20 coinsurance	15 copay	25 copay	25 copay	25 copay	15 PCP/25 SCP copay	20 coinsurance		25 copay					25 copay					20 coinsurance	15 PCP/25 SCP copay	15 PCP/25 SCP copay								126.23	126.23	71	0	0.16	0.16	0.16	0.16	0.16	0.16	0.16		0.16	0.16	11.83	19.72	19.72	19.72	17.36	0.16		19.72					19.72					0.16	16.57	13.81								13.71	0.29	3.91	-	1.32	4.53	0.21	0.82	3.76	1.47	3.99	-	1.11	3.95	4.72	8.17	0.3	0.89	1.54	3.55	-	0.03	-	-	-	-	0.26	-	-	-	-	0.89	0.88	1.14	-	-	-	-	-	-	-	61.46	0	16.44	13.71	0.29	3.91	-	1.32	4.53	0.21	0.82	3.76	1.47	3.99	-	1.11	3.95	4.72	8.17	0.3	0.89	1.54	3.55	-	0.03	-	-	-	-	0.26	-	-	-	-	0.89	0.88	1.14	-	-	-	-	-	-	-	61.46	3750																																																																																			-			13.71	0.29	3.91	-	1.32	4.53	0.21	0.82	3.76	1.47	3.99	-	1.11	3.95	4.72	8.17	0.3	0.89	1.54	3.55	-	0.03	-	-	-	-	0.26	-	-	-	-	0.89	0.88	1.14	-	-	-	-	-	-	-	61.46
H5850_001_0	2007	4																																																																																																																		-				794.33					188.92	87.93		19.19		0	27.04							863			701.55																		0 copay	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	50 copay @ Hospital PBP L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	20 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay													15.55					50	100		50		25	25							9.5			85.27																		-	-	1.03	-	-	-	-	0.79	0.73	-	0.08	-	-	0.06	-	-	-	-	-	-	0.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.35			-	-	1.03	-	-	-	-	0.79	0.73	-	0.08	-	-	0.06	-	-	-	-	-	-	0.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.35																	20 Travel Benefit Copay																																									0.02																										0.02			-	-	1.03	-	-	-	-	0.79	0.73	-	0.08	-	-	0.06	-	0.02	-	-	-	-	0.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.37
H5850_002_0	2007	3																																																							P																																																											-																									3043.09																		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay																																		17.51																		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44
H5850_003_0	2007	3																																																																																																																		-				1049.17					314.52	51.07		51.69		0.14	83.26							1133			701.32																		0 copay	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	50 copay @ Hospital PBP L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	30 copay PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay													15.55					50	100		50		25	25							16.34			85.3																		-	-	1.36	-	-	-	-	1.31	0.43	-	0.22	-	0	0.17	-	-	-	-	-	-	1.54	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.01			-	-	1.36	-	-	-	-	1.31	0.43	-	0.22	-	0	0.17	-	-	-	-	-	-	1.54	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.01																	20 Travel Benefit Copay																																									0.02																										0.02			-	-	1.36	-	-	-	-	1.31	0.43	-	0.22	-	0	0.17	-	0.02	-	-	-	-	1.54	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.03
H5850_004_0	2007	4																																																																																																																		-		1711.74		1393.12		349.54			331.36	74.42		1496.84		0	216.55		11858.27					827			701.32																		50/day (days 1-5)	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	100 copay PBP L.10	0 copay	0 copay	50 copay PBP L.4a	250 copay @ Hospital PBP L.9a	Included in OP-Facility Other	150 copay @ Hospital PBP; 50 copay @ Diagnostic Center L.8a/8b	0 copay	50 copay @ Hospital PBP L.12	50 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	20 copay per visit	0 copay	0 copay	0 copay	0 copay	40 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		15.55		100			50	250		52.19		50	50		20					21.23			85.3																		4.86	-	1.81	-	2.91	-	-	1.38	1.55	-	6.51	-	-	0.9	-	19.76	-	-	-	-	1.46	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.13			4.86	-	1.81	-	2.91	-	-	1.38	1.55	-	6.51	-	-	0.9	-	19.76	-	-	-	-	1.46	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.13																	20 Travel Benefit Copay																																									0.02																										0.02			4.86	-	1.81	-	2.91	-	-	1.38	1.55	-	6.51	-	-	0.9	-	19.78	-	-	-	-	1.46	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.15
H5850_005_0	2007	4																																																																																																																		-		1471.52		609.82		230.32			227.96	90.81		32.31		0.01	61.56		9587.75					558.98			701.32																		50/day (days 1-5)	0 copay	55 per day (days 8 through 34)  PBP L.2	0 copay	100 copay PBP L.10	0 copay	0 copay	50 copay PBP L.4a	250 copay @ Hospital PBP L.9a	Included in OP-Facility Other	100 copay @ Hospital PBP L.8a/8b	0 copay	50 copay @ Hospital PBP L.12	50 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	20 copay per visit	0 copay	0 copay	0 copay	0 copay	40 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		28.51		100			50	250		100		50	50		20					21.23			85.3																		4.18	-	1.45	-	1.92	-	-	0.95	1.89	-	0.27	-	0	0.26	-	15.98	-	-	-	-	0.99	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.87			4.18	-	1.45	-	1.92	-	-	0.95	1.89	-	0.27	-	0	0.26	-	15.98	-	-	-	-	0.99	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.87																	20 Travel Benefit Copay																																									0.02																										0.02			4.18	-	1.45	-	1.92	-	-	0.95	1.89	-	0.27	-	0	0.26	-	16	-	-	-	-	0.99	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	32.88
H5850_006_0	2007	5																																																																																																																		-				759.93					175.7	79.04		17.36		0	25.4							785.05			701.32																		0 copay	0 copay	25 per day (days 8 through 25)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	50 copay @ Hospital PBP L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	50 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay													11.13					50	100		50		25	25							25.66			85.3																		-	-	0.7	-	-	-	-	0.73	0.66	-	0.07	-	-	0.05	-	-	-	-	-	-	1.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.88			-	-	0.7	-	-	-	-	0.73	0.66	-	0.07	-	-	0.05	-	-	-	-	-	-	1.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.88																	20 Travel Benefit Copay																																									0.02																										0.02			-	-	0.7	-	-	-	-	0.73	0.66	-	0.07	-	-	0.05	-	0.02	-	-	-	-	1.68	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	8.9
H5850_007_0	2007	4																																																																																																																		-		1615.9		711.84					236.24	91.13		1755.83		0.02	71.86		9887.54					514.14			701.32																		50/day (days 1-5)	0 copay	30 per day (days 8 through 34)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	100 copay @ Hospital PBP L.9a	Included in OP-Facility Other	100 copay @ Hospital PBP; 25 copay @ Diagnostic Center L.8a/8b	0 copay	25 copay @ Hospital PBP L.12	40 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	15 copay per visit	0 copay	0 copay	0 copay	0 copay	40 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											34.07		15.55					50	100		26.61		25	40		15					21.23			85.3																		4.59	-	0.92	-	-	-	-	0.98	0.76	-	3.89	-	0	0.24	-	12.36	-	-	-	-	0.91	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.64			4.59	-	0.92	-	-	-	-	0.98	0.76	-	3.89	-	0	0.24	-	12.36	-	-	-	-	0.91	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.64																	15 Travel Benefit Copay																																									0.01																										0.01			4.59	-	0.92	-	-	-	-	0.98	0.76	-	3.89	-	0	0.24	-	12.37	-	-	-	-	0.91	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.65
H5850_008_0	2007	3																																																							P																																																											-																									3043.09																		0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay																																		17.51																		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.44
H5850_009_0	2007	3																																																																																																																		-		1492.56		653.93					219.4	84.9		34.64		0.02	66.01		9310.72					483.36			701.32																		200/day (days 1-5)	0 copay	50 per day (days 8 through 25)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	150 copay @ Hospital PBP L.9a	Included in OP-Facility Other	150 copay @ Hospital PBP L.8a	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	25 copay per visit	0 copay	0 copay	0 copay	0 copay	50 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											136.28		22.25					50	150		150		25	25		25					25.66			85.3																		16.95	-	1.21	-	-	-	-	0.91	1.06	-	0.43	-	0	0.14	-	19.4	-	-	-	-	1.03	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.12			16.95	-	1.21	-	-	-	-	0.91	1.06	-	0.43	-	0	0.14	-	19.4	-	-	-	-	1.03	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.12																	25 Travel Benefit Copay																																									0.02																										0.02			16.95	-	1.21	-	-	-	-	0.91	1.06	-	0.43	-	0	0.14	-	19.42	-	-	-	-	1.03	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.14
H5850_010_0	2007	3																																																																																																																		-		1710.42		1041.94					296.27	51.95		44.65		0.11	102.44		9611.67					998.92			701.32																		200/day (days 1-5)	0 copay	50 per day (days 8 through 25)  PBP L.2	0 copay	0 copay	0 copay	0 copay	50 copay PBP L.4a	150 copay @ Hospital PBP L.9a	Included in OP-Facility Other	150 copay @ Hospital PBP L.8a	0 copay	25 copay @ Hospital PBP L.12	25 copay @ Hospital PBP L.9a 8a 7c 7j	0 copay	25 copay per visit	0 copay	0 copay	0 copay	0 copay	50 copay per script PBP L.15	0 copay	0 copay	Various copays PBP L.16ab	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay											136.28		22.25					50	150		150		25	25		25					25.66			85.3																		19.42	-	1.93	-	-	-	-	1.23	0.65	-	0.56	-	0	0.21	-	20.02	-	-	-	-	2.14	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.16			19.42	-	1.93	-	-	-	-	1.23	0.65	-	0.56	-	0	0.21	-	20.02	-	-	-	-	2.14	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.16																	25 Travel Benefit Copay																																									0.02																										0.02			19.42	-	1.93	-	-	-	-	1.23	0.65	-	0.56	-	0	0.21	-	20.04	-	-	-	-	2.14	-	-	4.98	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.18
H5852_001_0	2007	6																																																																																																																		-																									1395.48																																									5 oral exam 5 cleaning 10 X Ray																																									6.65																		-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.77
H5854_002_0	2007	4																					1800											D	D	D	V	T	Coin	Coin	V	P	V	P	V	V	V	V	V	V	V	V	V	S	P	P	P	V	P	P	P	P	P	P																																																				-		1136.23	79.91	1215.94		138.71	5.52	7.64	264.37	265.84		267.44	30.76		673.81	3627.01	5472.77	487.7	725.9							166.41																	#1A 150/day days 1-6 0/day days 7-90.	#1B 150/day days 1-6 0/day days 7-90.	#2 25/day days 1-100	#6 0	#10A 75	#11A 20	#11B 20 #11C 20	#4A 50 #4B 25	#9A 25-100 #9B 100	#8A 0 lab svcs	#8A 100/vst Chemo/High cost diags. #8B 20	#9A 25-100	#12 0	#3 0 #5 25 #9C 25 #9D 0	#7A 15 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25	#7E 25 #7H 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 10-25	#17B 0	#18A 0	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											105.97	84.47	25		75	0.2	0.2	49.83	100		56.16	25		25	14.64	23.39	25	25							10																	10.03	0.56	2.53	-	0.87	1.1	1.53	1.1	2.22	-	1.25	0.06	-	1.4	4.43	10.67	1.02	1.51	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.42		0.53	10.03	0.56	2.53	-	0.87	1.1	1.53	1.1	2.22	-	1.25	0.06	-	1.4	4.43	10.67	1.02	1.51	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.42		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																																				-		0	10.03	0.56	2.53	-	0.87	1.1	1.53	1.1	2.22	-	1.25	0.06	-	1.4	4.43	10.67	1.02	1.51	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.42
H5854_003_0	2007	4																					490											D	D	D	V	T	Coin	Coin	V	P	V	P	V	V	V	V	V	V	V	V	V	S	P	P	P	V	P	P	P	P	P	P																																																				-		1298.54	91.33	1389.61		158.52	6.31	8.73	302.05	303.82		305.65	35.16		770.07	4145.16	6228.88	557.37	829.6							166.41																	#1A 35/day days 1-14 0/day days 15-90.	#1B 35/day day 1-14 0/day 15-90.	#2 25/day days 1-100	#6 0	#10A 50	#11A 20	#11B 20 #11C 0	#4A 50 #4B 25	#9A 15-50 #9B 50	#8A 0 lab svcs	#8A 50/vst Chemo/High cost diags. #8B 20	#9A 15-50	#12 0	#3 0 #5 25 #9C 25 #9D 0	#7A 10 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 15 #7D 15 #7F 15 #7G 15	#7E 25 #7H 25	#7C 15 #7I 15		#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 10-15	#17B 0	#18A 0	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											29.65	28.46	25		50	0.2	0.2	49.83	50		32.17	15		15.75	9.76	14.03	25	15							10																	3.21	0.22	2.9	-	0.66	1.26	1.75	1.25	1.27	-	0.82	0.04	-	1.01	3.37	7.28	1.16	1.04	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.37		0.23	3.21	0.22	2.9	-	0.66	1.26	1.75	1.25	1.27	-	0.82	0.04	-	1.01	3.37	7.28	1.16	1.04	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.37		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																																				-		0	3.21	0.22	2.9	-	0.66	1.26	1.75	1.25	1.27	-	0.82	0.04	-	1.01	3.37	7.28	1.16	1.04	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	27.37
H5854_004_0	2007	3																					1800											D	D	D	V	T	Coin	Coin	V	P	V	P	V	V	V	V	V	V	V	V	V	S	P	P	P	V	P	P	P	P	P	P																																																				-		1136.23	79.91	1215.94		138.71	5.52	7.64	264.37	265.84		267.44	30.76		673.81	3627.01	5472.77	487.7	725.9							166.41																	#1A 150/day days 1-6 0/day days 7-90.	#1B 150/day days 1-6 0/day days 7-90.	#2 25/day days 1-100	#6 0	#10A 75	#11A 20	#11B 20 #11C 20	#4A 50 #4B 25	#9A 25-100 #9B 100	#8A 0 lab svcs	#8A 100/vst Chemo/High cost diags. #8B 20	#9A 25-100	#12 0	#3 0 #5 25 #9C 25 #9D 0	#7A 15 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 25 #7D 25 #7F 25 #7G 25	#7E 25 #7H 25	#7C 25 #7I 25		#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 10-25	#17B 0	#18A 0	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											106.05	84.47	25		75	0.2	0.2	49.83	100		56.16	25		25	14.64	23.39	25	25							10																	10.04	0.56	2.53	-	0.87	1.1	1.53	1.1	2.22	-	1.25	0.06	-	1.4	4.43	10.67	1.02	1.51	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.43		0.52	10.04	0.56	2.53	-	0.87	1.1	1.53	1.1	2.22	-	1.25	0.06	-	1.4	4.43	10.67	1.02	1.51	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.43		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																																				-		0	10.04	0.56	2.53	-	0.87	1.1	1.53	1.1	2.22	-	1.25	0.06	-	1.4	4.43	10.67	1.02	1.51	-	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	40.43
H5854_801_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	V	P	P	P	P	P	P																																																				-		240.87	7.17	52.35		8.72	6.31	8.73	301.45	33.18	24.8	26.71	2.11	0.17	18.92	26.32	45.43	4.25	7.06	33.53	103.4	24	0.14																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.18		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95	138	0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																																				-		0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95
H5854_802_0	2007	6																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	V	P	P	P	P	P	P																																																				-		240.87	7.17	52.35		8.72	6.31	8.73	301.45	33.18	24.8	26.71	2.11	0.17	18.92	26.32	45.43	4.25	7.06	33.53	103.4	24	0.14																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.18		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95	138	0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																																				-		0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95
H5854_803_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	V	P	P	P	P	P	P																																																				-		240.87	7.17	52.35		8.72	6.31	8.73	301.45	33.18	24.8	26.71	2.11	0.17	18.92	26.32	45.43	4.25	7.06	33.53	103.4	24	0.14																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.18		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95	138	0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																																				-		0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95
H5854_804_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	V	P	P	P	P	P	P																																																				-		240.87	7.17	52.35		8.72	6.31	8.73	301.45	33.18	24.8	26.71	2.11	0.17	18.92	26.32	45.43	4.25	7.06	33.53	103.4	24	0.14																				Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	50	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	Medicare FFS Ded/Coins	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered	not covered											0.06	0.06	0.18		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95	138	0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95		n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a																																																				-		0	14.7	0.44	9.35	-	2.06	1.49	2.06	1.26	7.83	5.85	6.3	0.5	0.04	4.47	6.21	10.72	1	1.67	7.91	24.4	5.66	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.95
H5859_001_0	2007	4																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		267.73	39.38	40.81		21.42	32.28	28.46	38.68	44.22	30.74	31.23	2.59	0.1	49.9	29.33	30.34	5.07	3.7	20.74	94.71	18.2	0.05																				Medicare FFS	Medicare FFS	Medicare FFS		Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																				0.07	0.07	0.14		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				18.9	2.78	5.66	-	5.06	7.62	6.72	9.13	10.44	7.25	7.37	0.61	0.02	11.78	6.92	7.16	1.2	0.87	4.9	22.35	4.29	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.03		0	18.9	2.78	5.66	-	5.06	7.62	6.72	9.13	10.44	7.25	7.37	0.61	0.02	11.78	6.92	7.16	1.2	0.87	4.9	22.35	4.29	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.03																																																																																				-		0	18.9	2.78	5.66	-	5.06	7.62	6.72	9.13	10.44	7.25	7.37	0.61	0.02	11.78	6.92	7.16	1.2	0.87	4.9	22.35	4.29	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.03
H5862_001_0	2007	4																					5000											D	D	D	V	coin	coin	coin	coin	coin	coin	coin	V	coin	V	V	V	V	V	coin	coin	coin	V	T	P	V	V	V	V	O	O	coin																																																				-		631.9	9.3	1054.7	0	5.4	11.55	7.27	5.35	25.76	9.34	25.67	0	0.34	584.7	3885.9	3573.9	150.6	1283.5	22.09	31.85	7.22	650.5	0	0	0	0	155	0	0	0	2.38											200/days days 1-5	200/days days 1-5	110/day days4-100		20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance to 50 Copay	20 Coinsurance	20 Coinsurance	20 Coinsurance		20 Coinsurance	20 Coinsurance	30 PCP Copay	30 Specialist Copay	30 MH Copay	20 CORF; 30 PT/ST; 15 OT	20 Coinsurance	30 Chiro/Podiatry; 20 Other	20 Coinsurance	30 Vision Copay; 20 Blood					30 Copay				20 Coinsurance on Foreign Travel											200	200	110	0	0.2	0.2	0.2	0.23	0.2	0.2	0.2	0	0.21	44.58	30	30	30	27	0.2	0.15	0.2	31.52	0	0	0	0	30	0	0	0	0.2											10.53	0.16	9.67	-	1.08	2.31	1.46	1.22	5.15	1.87	5.13	-	0.07	2.17	9.71	8.93	0.38	2.89	4.42	4.66	1.44	1.71	-	-	-	-	0.39	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	75.83		0	10.53	0.16	9.67	-	1.08	2.31	1.46	1.22	5.15	1.87	5.13	-	0.07	2.17	9.71	8.93	0.38	2.89	4.42	4.66	1.44	1.71	-	-	-	-	0.39	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	75.83																																																																																				-			10.53	0.16	9.67	-	1.08	2.31	1.46	1.22	5.15	1.87	5.13	-	0.07	2.17	9.71	8.93	0.38	2.89	4.42	4.66	1.44	1.71	-	-	-	-	0.39	-	-	-	0.48	-	-	-	-	-	-	-	-	-	-	75.83
H5880_001_0	2007	4																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		340.63	9.05	99.88		15.12	26.26	29.74	815.53	32.16	21.6	20.19	1.4	2.43	29.56	25.07	30.75	6.86	1.47	21.69	112.28	24.77	0.11																				#1A 1000 ded 0/day days 1-60 250/day days 61-90	#1B 1000 ded 0/day days 1-60 250/day days 61-90	#2 0/day days 1-20 125/day days 21-100	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8A 20 #8B 20	0 (incl in h5)	#12 20	#3 20 #5 50 #9C 20 #9D 20	#7A 20 #14B 0/20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 20 #7D 20 #7F 20 #7G 20	#7E 50 #7H 50	#7C 20 #7I 20	0 (incl in h2)	#14I 20	#15 20	#13A 0 n/a	#10B 0	#16A 0 #16B 0	#17A 0	#17B 0	#18A 0	#18B 0	0 n/c	#14A 0 n/a	#13B 0 n/a											0.08	0.08	0.2		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				27.93	0.74	19.62	-	3.57	6.2	7.02	3.4	7.59	5.1	4.77	0.33	0.57	6.98	5.92	7.26	1.62	0.35	5.12	26.5	5.85	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.43	138	0	27.93	0.74	19.62	-	3.57	6.2	7.02	3.4	7.59	5.1	4.77	0.33	0.57	6.98	5.92	7.26	1.62	0.35	5.12	26.5	5.85	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.44																																																																																				-		0	27.93	0.74	19.62	-	3.57	6.2	7.02	3.4	7.59	5.1	4.77	0.33	0.57	6.98	5.92	7.26	1.62	0.35	5.12	26.5	5.85	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	146.44
H5883_001_1	2007	5																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	227.11	3.28	957.58	0	222.4	14.33	0.66	475.16	442.69	0	0	0	0	0	3951.8	4073.15	167.76	492.13	2541	3197.47	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 100 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	42.82	0	50	0.2	0.2	49.05	100	0	0	0	0	0	15	30	30	30	8	37.68	0	0	0	0	0	0	25	0	0	0	0											4.73	0.07	3.42	-	0.93	2.87	0.13	1.94	3.69	-	-	-	-	-	4.94	10.18	0.42	1.23	1.69	10.04	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.3	0	0	4.73	0.07	3.42	-	0.93	2.87	0.13	1.94	3.69	-	-	-	-	-	4.94	10.18	0.42	1.23	1.69	10.04	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.3	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.73	0.07	3.42	-	0.93	2.87	0.13	1.94	3.69	-	-	-	-	-	4.94	10.18	0.42	1.23	1.69	10.04	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.3
H5883_001_2	2007	6																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	266.38	3.85	1017.08	0	235.62	15.37	0.7	576.72	540.64	0	0	0	0	0	4351.9	4294.42	156.21	458.23	2840.39	3058.58	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 100 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	42.82	0	50	0.2	0.2	49.14	100	0	0	0	0	0	15	30	30	30	8	38.01	0	0	0	0	0	0	25	0	0	0	0											5.55	0.08	3.63	-	0.98	3.07	0.14	2.36	4.51	-	-	-	-	-	5.44	10.74	0.39	1.15	1.89	9.69	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.64	0	0	5.55	0.08	3.63	-	0.98	3.07	0.14	2.36	4.51	-	-	-	-	-	5.44	10.74	0.39	1.15	1.89	9.69	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.64	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.55	0.08	3.63	-	0.98	3.07	0.14	2.36	4.51	-	-	-	-	-	5.44	10.74	0.39	1.15	1.89	9.69	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.64
H5883_001_3	2007	6																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	291.14	4.21	1375.18	0	231.4	14.95	0.68	527.63	491.26	0	0	0	0	0	4423.05	4470.15	174.57	512.1	2786.55	3243.69	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 100 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	42.82	0	50	0.2	0.2	49.04	100	0	0	0	0	0	15	30	30	30	8	37.36	0	0	0	0	0	0	25	0	0	0	0											6.07	0.09	4.91	-	0.96	2.99	0.14	2.16	4.09	-	-	-	-	-	5.53	11.18	0.44	1.28	1.86	10.1	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.8	0	0	6.07	0.09	4.91	-	0.96	2.99	0.14	2.16	4.09	-	-	-	-	-	5.53	11.18	0.44	1.28	1.86	10.1	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.8	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.07	0.09	4.91	-	0.96	2.99	0.14	2.16	4.09	-	-	-	-	-	5.53	11.18	0.44	1.28	1.86	10.1	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.8
H5883_001_4	2007	6																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	302.28	4.37	932.86	0	286.77	17.48	0.8	455.86	418.29	0	0	0	0	0	4629.92	4762.2	195.17	572.53	3329.4	3560.52	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 100 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	42.82	0	50	0.2	0.2	48.84	100	0	0	0	0	0	15	30	30	30	8	37.13	0	0	0	0	0	0	25	0	0	0	0											6.3	0.09	3.33	-	1.19	3.5	0.16	1.86	3.49	-	-	-	-	-	5.79	11.91	0.49	1.43	2.22	11.02	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.78	0	0	6.3	0.09	3.33	-	1.19	3.5	0.16	1.86	3.49	-	-	-	-	-	5.79	11.91	0.49	1.43	2.22	11.02	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.78	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.3	0.09	3.33	-	1.19	3.5	0.16	1.86	3.49	-	-	-	-	-	5.79	11.91	0.49	1.43	2.22	11.02	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.78
H5883_001_5	2007	6																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	332.78	4.81	1359.01	0	284.71	18.09	0.83	491.66	448.77	0	0	0	0	0	5305.04	5614.14	247.24	725.27	3586.69	4360.45	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 100 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	42.82	0	50	0.2	0.2	48.76	100	0	0	0	0	0	15	30	30	30	8	36.69	0	0	0	0	0	0	25	0	0	0	0											6.93	0.1	4.85	-	1.19	3.62	0.17	2	3.74	-	-	-	-	-	6.63	14.04	0.62	1.81	2.39	13.33	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.43	0	0	6.93	0.1	4.85	-	1.19	3.62	0.17	2	3.74	-	-	-	-	-	6.63	14.04	0.62	1.81	2.39	13.33	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.43	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.93	0.1	4.85	-	1.19	3.62	0.17	2	3.74	-	-	-	-	-	6.63	14.04	0.62	1.81	2.39	13.33	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	61.43
H5883_002_1	2007	10																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	225.93	3.27	931.93	0	221.24	14.26	0.65	472.68	440.38	0	0	0	0	0	3931.18	4051.9	166.89	489.56	2527.74	3180.78	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 119 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	50.95	0	50	0.2	0.2	49.05	100	0	0	0	0	0	15	30	30	30	8	37.68	0	0	0	0	0	0	25	0	0	0	0											4.71	0.07	3.96	-	0.92	2.85	0.13	1.93	3.67	-	-	-	-	-	4.91	10.13	0.42	1.22	1.69	9.99	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.62	0	0	4.71	0.07	3.96	-	0.92	2.85	0.13	1.93	3.67	-	-	-	-	-	4.91	10.13	0.42	1.22	1.69	9.99	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.62	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.71	0.07	3.96	-	0.92	2.85	0.13	1.93	3.67	-	-	-	-	-	4.91	10.13	0.42	1.22	1.69	9.99	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.62
H5883_002_2	2007	9																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	267.32	3.86	998.53	0	236.45	15.42	0.71	578.75	542.54	0	0	0	0	0	4367.2	4309.52	156.76	459.84	2850.38	3069.33	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 119 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	50.95	0	50	0.2	0.2	49.14	100	0	0	0	0	0	15	30	30	30	8	38.01	0	0	0	0	0	0	25	0	0	0	0											5.57	0.08	4.24	-	0.99	3.08	0.14	2.37	4.52	-	-	-	-	-	5.46	10.77	0.39	1.15	1.9	9.72	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.41	0	0	5.57	0.08	4.24	-	0.99	3.08	0.14	2.37	4.52	-	-	-	-	-	5.46	10.77	0.39	1.15	1.9	9.72	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.41	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.57	0.08	4.24	-	0.99	3.08	0.14	2.37	4.52	-	-	-	-	-	5.46	10.77	0.39	1.15	1.9	9.72	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	50.41
H5883_002_3	2007	9																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	294.46	4.26	1360.71	0	234.03	15.12	0.69	533.64	496.86	0	0	0	0	0	4473.48	4521.12	176.56	517.94	2818.32	3280.67	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 119 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	50.95	0	50	0.2	0.2	49.04	100	0	0	0	0	0	15	30	30	30	8	37.36	0	0	0	0	0	0	25	0	0	0	0											6.13	0.09	5.78	-	0.98	3.02	0.14	2.18	4.14	-	-	-	-	-	5.59	11.3	0.44	1.29	1.88	10.21	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.21	0	0	6.13	0.09	5.78	-	0.98	3.02	0.14	2.18	4.14	-	-	-	-	-	5.59	11.3	0.44	1.29	1.88	10.21	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.21	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.13	0.09	5.78	-	0.98	3.02	0.14	2.18	4.14	-	-	-	-	-	5.59	11.3	0.44	1.29	1.88	10.21	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.21
H5883_002_4	2007	9																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	302.45	4.37	913.16	0	286.93	17.49	0.8	456.12	418.53	0	0	0	0	0	4632.57	4764.92	195.28	572.85	3331.3	3562.55	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 119 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	50.95	0	50	0.2	0.2	48.84	100	0	0	0	0	0	15	30	30	30	8	37.13	0	0	0	0	0	0	25	0	0	0	0											6.3	0.09	3.88	-	1.2	3.5	0.16	1.86	3.49	-	-	-	-	-	5.79	11.91	0.49	1.43	2.22	11.02	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.36	0	0	6.3	0.09	3.88	-	1.2	3.5	0.16	1.86	3.49	-	-	-	-	-	5.79	11.91	0.49	1.43	2.22	11.02	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.36	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.3	0.09	3.88	-	1.2	3.5	0.16	1.86	3.49	-	-	-	-	-	5.79	11.91	0.49	1.43	2.22	11.02	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.36
H5883_002_7	2007	9																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	334.63	4.84	1336.9	0	286.29	18.19	0.83	494.37	451.25	0	0	0	0	0	5334.35	5645.16	248.6	729.27	3606.51	4384.54	0	0	0	0	0	0	12	0	0	0	0											250 copay per admit	250 copay per admit	0 copay days 1-20 119 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	100 OP surgery						15 copay	30 copay	30 copay	30 copay	40 copay on MRI CT PET; 0 copay all other	50 office surgery 30 allergy 30 cardiovascular							25 copay on exam															250	250	50.95	0	50	0.2	0.2	48.76	100	0	0	0	0	0	15	30	30	30	8	36.69	0	0	0	0	0	0	25	0	0	0	0											6.97	0.1	5.68	-	1.19	3.64	0.17	2.01	3.76	-	-	-	-	-	6.67	14.11	0.62	1.82	2.4	13.4	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.57	0	0	6.97	0.1	5.68	-	1.19	3.64	0.17	2.01	3.76	-	-	-	-	-	6.67	14.11	0.62	1.82	2.4	13.4	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.57	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	6.97	0.1	5.68	-	1.19	3.64	0.17	2.01	3.76	-	-	-	-	-	6.67	14.11	0.62	1.82	2.4	13.4	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.57
H5883_003_1	2007	8																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	962.49	0	221.57	14.28	0.65	473.4	445.55	0	0	0	0	0	4165.76	4233.43	174.91	513.11	2543.35	3240.76	0	0	0	0	0	0	12	0	0	0	0													0 copay days 1-20 75 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	50 OP surgery						7 copay	20 copay	20 copay	20 copay	20 copay on MRI CT PET; 0 copay all other	30 office surgery 20 allergy 20 cardiovascular							25 copay on exam															0	0	32.11	0	50	0.2	0.2	49.05	50	0	0	0	0	0	7	20	20	20	4	23.81	0	0	0	0	0	0	25	0	0	0	0											-	-	2.58	-	0.92	2.86	0.13	1.93	1.86	-	-	-	-	-	2.43	7.06	0.29	0.86	0.85	6.43	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.21	0	0	-	-	2.58	-	0.92	2.86	0.13	1.93	1.86	-	-	-	-	-	2.43	7.06	0.29	0.86	0.85	6.43	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.21	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	2.58	-	0.92	2.86	0.13	1.93	1.86	-	-	-	-	-	2.43	7.06	0.29	0.86	0.85	6.43	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.21
H5883_003_2	2007	8																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	1053.27	0	241.86	15.78	0.72	591.99	560.61	0	0	0	0	0	4726.51	4597.82	167.8	492.24	2929.16	3193.32	0	0	0	0	0	0	12	0	0	0	0													0 copay days 1-20 75 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	50 OP surgery						7 copay	20 copay	20 copay	20 copay	20 copay on MRI CT PET; 0 copay all other	30 office surgery 20 allergy 20 cardiovascular							25 copay on exam															0	0	32.11	0	50	0.2	0.2	49.14	50	0	0	0	0	0	7	20	20	20	4	23.98	0	0	0	0	0	0	25	0	0	0	0											-	-	2.82	-	1.01	3.16	0.14	2.42	2.34	-	-	-	-	-	2.76	7.66	0.28	0.82	0.98	6.38	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.79	0	0	-	-	2.82	-	1.01	3.16	0.14	2.42	2.34	-	-	-	-	-	2.76	7.66	0.28	0.82	0.98	6.38	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.79	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	2.82	-	1.01	3.16	0.14	2.42	2.34	-	-	-	-	-	2.76	7.66	0.28	0.82	0.98	6.38	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.79
H5883_003_3	2007	9																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	1407.76	0	234.8	15.16	0.69	535.38	503.56	0	0	0	0	0	4748.63	4731.48	185.37	543.79	2840.64	3348.92	0	0	0	0	0	0	12	0	0	0	0													0 copay days 1-20 75 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	50 OP surgery						7 copay	20 copay	20 copay	20 copay	20 copay on MRI CT PET; 0 copay all other	30 office surgery 20 allergy 20 cardiovascular							25 copay on exam															0	0	32.11	0	50	0.2	0.2	49.04	50	0	0	0	0	0	7	20	20	20	4	23.65	0	0	0	0	0	0	25	0	0	0	0											-	-	3.77	-	0.98	3.03	0.14	2.19	2.1	-	-	-	-	-	2.77	7.89	0.31	0.91	0.95	6.6	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.65	0	0	-	-	3.77	-	0.98	3.03	0.14	2.19	2.1	-	-	-	-	-	2.77	7.89	0.31	0.91	0.95	6.6	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.65	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	3.77	-	0.98	3.03	0.14	2.19	2.1	-	-	-	-	-	2.77	7.89	0.31	0.91	0.95	6.6	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.65
H5883_003_4	2007	8																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	933.87	0	284.55	17.35	0.79	452.34	419.3	0	0	0	0	0	4860.96	4929.64	202.67	594.53	3319.08	3595.33	0	0	0	0	0	0	12	0	0	0	0													0 copay days 1-20 75 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	50 OP surgery						7 copay	20 copay	20 copay	20 copay	20 copay on MRI CT PET; 0 copay all other	30 office surgery 20 allergy 20 cardiovascular							25 copay on exam															0	0	32.11	0	50	0.2	0.2	48.84	50	0	0	0	0	0	7	20	20	20	4	23.54	0	0	0	0	0	0	25	0	0	0	0											-	-	2.5	-	1.19	3.47	0.16	1.84	1.75	-	-	-	-	-	2.84	8.22	0.34	0.99	1.11	7.05	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.46	0	0	-	-	2.5	-	1.19	3.47	0.16	1.84	1.75	-	-	-	-	-	2.84	8.22	0.34	0.99	1.11	7.05	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.46	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	2.5	-	1.19	3.47	0.16	1.84	1.75	-	-	-	-	-	2.84	8.22	0.34	0.99	1.11	7.05	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.46
H5883_003_5	2007	8																					n/a											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	P	P	P	O	P	T	P	P	P	P	P	P	P	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	0	0	1318.2	0	273.73	17.39	0.8	472.7	435.87	0	0	0	0	0	5396.62	5631.52	248.76	729.73	3464.41	4267.27	0	0	0	0	0	0	12	0	0	0	0													0 copay days 1-20 75 copay days 21 - 100		50 copay	20 coinsurance	20 coinsurance	50 ER copay 35 urgent care copay	50 OP surgery						7 copay	20 copay	20 copay	20 copay	20 copay on MRI CT PET; 0 copay all other	30 office surgery 20 allergy 20 cardiovascular							25 copay on exam															0	0	32.11	0	50	0.2	0.2	48.76	50	0	0	0	0	0	7	20	20	20	4	23.32	0	0	0	0	0	0	25	0	0	0	0											-	-	3.53	-	1.14	3.48	0.16	1.92	1.82	-	-	-	-	-	3.15	9.39	0.41	1.22	1.15	8.29	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.68	0	0	-	-	3.53	-	1.14	3.48	0.16	1.92	1.82	-	-	-	-	-	3.15	9.39	0.41	1.22	1.15	8.29	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.68	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	3.53	-	1.14	3.48	0.16	1.92	1.82	-	-	-	-	-	3.15	9.39	0.41	1.22	1.15	8.29	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.68
H5883_801_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5883_802_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5883_803_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5883_804_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5883_805_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5883_806_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5883_807_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5883_808_0	2007	4																					n/a											Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	n/a	245.62	2.64	38.63	34.96	7.55	17.06	0.78	6.8	31.48	9.84	33.44	0	9.33	33.12	28.58	43.77	1.82	5.05	33.72	121.99	24.77	3.21	0	0	0	0	0	0	0	0	0											Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing	Medicare FFS cost sharing																				0.07	0.07	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	0	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	200	0	16.52	0.18	7.29	-	1.78	4.03	0.18	1.61	7.43	2.32	7.89	-	2.2	7.82	6.74	10.33	0.43	1.19	7.96	28.79	5.85	0.76	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	121.29
H5884_001_1	2007	1																					4000											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	4000	314.86	8.74	961.6		149.1	10.95	12.99	353.47	454.6				1.69	846.32	4320.54	5532.82	240.44	236.97							129.09		231.11															#1A 250	#1B 250	#2 0/day days 1-20 75/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 100 #9B 100	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 20 #5 20 #9C 20 #9D 20	#7A 20 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 20 #7D 20 #7F 20 #7G 0	#7E 20 #7H 20	#7C 20 #7I 20	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 20	#17B 0	#18A 20	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											223.43	223.43	25.9		89.37	0.18	0.18	42.01	89.37				17.87	17.87	17.87	17.87	17.87	17.87							17.87		17.87															5.86	0.16	2.08	-	1.11	1.96	2.32	1.24	3.39	-	-	-	0	1.26	6.44	8.24	0.36	0.35	-	-	-	-	-	-	0.19	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.3		4.2	5.86	0.16	2.08	-	1.11	1.96	2.32	1.24	3.39	-	-	-	0	1.26	6.44	8.24	0.36	0.35	-	-	-	-	-	-	0.19	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.3																																																																																				-		0	5.86	0.16	2.08	-	1.11	1.96	2.32	1.24	3.39	-	-	-	0	1.26	6.44	8.24	0.36	0.35	-	-	-	-	-	-	0.19	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.3
H5884_001_2	2007	1																					4000											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	4000	304.41	8.45	929.68		144.15	10.24	12.14	341.73	439.51				1.64	818.22	4177.1	5349.14	232.46	229.1							129.09		231.11															#1A 250	#1B 250	#2 0/day days 1-20 75/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 100 #9B 100	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 20 #5 20 #9C 20 #9D 20	#7A 20 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 20 #7D 20 #7F 20 #7G 0	#7E 20 #7H 20	#7C 20 #7I 20	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 20	#17B 0	#18A 20	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											224.66	224.66	26.04		89.86	0.18	0.18	42.24	89.86				17.97	17.97	17.97	17.97	17.97	17.97							17.97		17.97															5.7	0.16	2.02	-	1.08	1.84	2.18	1.2	3.29	-	-	-	0	1.23	6.26	8.01	0.35	0.34	-	-	-	-	-	-	0.19	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.2		3.86	5.7	0.16	2.02	-	1.08	1.84	2.18	1.2	3.29	-	-	-	0	1.23	6.26	8.01	0.35	0.34	-	-	-	-	-	-	0.19	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.2																																																																																				-		0	5.7	0.16	2.02	-	1.08	1.84	2.18	1.2	3.29	-	-	-	0	1.23	6.26	8.01	0.35	0.34	-	-	-	-	-	-	0.19	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.2
H5884_002_1	2007	3																					5000											A	A	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	5000	294.66	8.18	961.6		139.53	10.25	12.15	330.79	425.43				1.58	792.02	4043.34	5177.84	225.01	221.77							129.09		231.11															#1A 595	#1B 595	#2 0/day days 1-20 90/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 30	#9A 200 #9B 200	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 30 #5 30 #9C 30 #9D 30	#7A 30 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 30 #7D 30 #7F 30 #7G 0	#7E 30 #7H 30	#7C 30 #7I 30	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 30	#17B 0	#18A 30	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											515.77	515.77	30.14		86.68	0.17	0.17	41.61	173.37				26.01	26.01	26.01	26.01	26.01	26.01							26.01		26.01															12.66	0.35	2.42	-	1.01	1.78	2.11	1.15	6.15	-	-	-	0	1.72	8.76	11.22	0.49	0.48	-	-	-	-	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.07		7.84	12.66	0.35	2.42	-	1.01	1.78	2.11	1.15	6.15	-	-	-	0	1.72	8.76	11.22	0.49	0.48	-	-	-	-	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.07																																																																																				-		0	12.66	0.35	2.42	-	1.01	1.78	2.11	1.15	6.15	-	-	-	0	1.72	8.76	11.22	0.49	0.48	-	-	-	-	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.07
H5884_002_2	2007	3																					5000											A	A	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	5000	284.88	7.91	929.68		134.9	9.58	11.36	319.81	411.31				1.53	765.73	3909.11	5005.95	217.54	214.4							129.09		231.11															#1A 595	#1B 595	#2 0/day days 1-20 90/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 30	#9A 200 #9B 200	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 30 #5 30 #9C 30 #9D 30	#7A 30 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 30 #7D 30 #7F 30 #7G 0	#7E 30 #7H 30	#7C 30 #7I 30	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 30	#17B 0	#18A 30	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											519.18	519.18	30.34		87.26	0.17	0.17	41.88	174.52				26.18	26.18	26.18	26.18	26.18	26.18							26.18		26.18															12.33	0.34	2.35	-	0.98	1.67	1.98	1.12	5.98	-	-	-	0	1.67	8.53	10.92	0.47	0.47	-	-	-	-	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.6		7.24	12.33	0.34	2.35	-	0.98	1.67	1.98	1.12	5.98	-	-	-	0	1.67	8.53	10.92	0.47	0.47	-	-	-	-	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.6																																																																																				-		0	12.33	0.34	2.35	-	0.98	1.67	1.98	1.12	5.98	-	-	-	0	1.67	8.53	10.92	0.47	0.47	-	-	-	-	-	-	0.28	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	49.6
H5884_003_1	2007	3																					4000											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	4000	314.86	8.74	961.6		149.1	10.95	12.99	353.47	454.6				1.69	846.32	4320.54	5532.82	240.44	236.97							129.09		231.11															#1A 250	#1B 250	#2 0/day days 1-20 75/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 100 #9B 100	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 20 #5 20 #9C 20 #9D 20	#7A 20 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 20 #7D 20 #7F 20 #7G 0	#7E 20 #7H 20	#7C 20 #7I 20	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 20	#17B 0	#18A 20	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											223.43	223.43	25.9		89.37	0.18	0.18	42.01	89.37				17.87	17.87	17.87	17.87	17.87	17.87							17.87		17.87															5.86	0.16	2.08	-	1.11	1.96	2.32	1.24	3.39	-	-	-	0	1.26	6.44	8.24	0.36	0.35	-	-	-	-	-	-	0.19	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.3		4.2	5.86	0.16	2.08	-	1.11	1.96	2.32	1.24	3.39	-	-	-	0	1.26	6.44	8.24	0.36	0.35	-	-	-	-	-	-	0.19	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.3																																																																																				-		0	5.86	0.16	2.08	-	1.11	1.96	2.32	1.24	3.39	-	-	-	0	1.26	6.44	8.24	0.36	0.35	-	-	-	-	-	-	0.19	-	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.3
H5884_003_2	2007	3																					4000											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	4000	304.41	8.45	929.68		144.15	10.24	12.14	341.73	439.51				1.64	818.22	4177.1	5349.14	232.46	229.1							129.09		231.11															#1A 250	#1B 250	#2 0/day days 1-20 75/day days 21-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 100 #9B 100	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 20 #5 20 #9C 20 #9D 20	#7A 20 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 20 #7D 20 #7F 20 #7G 0	#7E 20 #7H 20	#7C 20 #7I 20	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 20	#17B 0	#18A 20	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c											224.66	224.66	26.04		89.86	0.18	0.18	42.24	89.86				17.97	17.97	17.97	17.97	17.97	17.97							17.97		17.97															5.7	0.16	2.02	-	1.08	1.84	2.18	1.2	3.29	-	-	-	0	1.23	6.26	8.01	0.35	0.34	-	-	-	-	-	-	0.19	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.2		3.86	5.7	0.16	2.02	-	1.08	1.84	2.18	1.2	3.29	-	-	-	0	1.23	6.26	8.01	0.35	0.34	-	-	-	-	-	-	0.19	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.2																																																																																				-		0	5.7	0.16	2.02	-	1.08	1.84	2.18	1.2	3.29	-	-	-	0	1.23	6.26	8.01	0.35	0.34	-	-	-	-	-	-	0.19	-	0.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.2
H5884_004_1	2007	4																					2500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	2500					149.1	10.95	12.99	353.47					1.69	846.32	4320.54	5532.82	240.44	236.97							129.09		231.11															#1A 0	#1B 0	#2 0/day days 1-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 10	#9A 0 #9B 0	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 10 #5 10 #9C 10 #9D 10	#7A 10 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 10 #7D 10 #7F 10 #7G 0	#7E 10 #7H 10	#7C 10 #7I 10	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 10	#17B 0	#18A 10	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c															93.7	0.19	0.19	43.1					9.37	9.37	9.37	9.37	9.37	9.37							9.37		9.37															-	-	-	-	1.16	2.05	2.43	1.27	-	-	-	-	0	0.66	3.37	4.32	0.19	0.19	-	-	-	-	-	-	0.1	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.93		1.07	-	-	-	-	1.16	2.05	2.43	1.27	-	-	-	-	0	0.66	3.37	4.32	0.19	0.19	-	-	-	-	-	-	0.1	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.93																																																																																				-		0	-	-	-	-	1.16	2.05	2.43	1.27	-	-	-	-	0	0.66	3.37	4.32	0.19	0.19	-	-	-	-	-	-	0.1	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.93
H5884_004_2	2007	4																					2500											A	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	P	P	S	P	P	Coin	P	Coin	P	Coin	P	P	P																																																				-	2500					144.15	10.24	12.14	341.73					1.64	818.22	4177.1	5349.14	232.46	229.1							129.09		231.11															#1A 0	#1B 0	#2 0/day days 1-100	#6 0	#10A 100	#11A 20	#11B 20 #11C 20	#4A 50 #4B 10	#9A 0 #9B 0	#8A 0	#8A 0 #8B 0	0 (incl in h5)	#12 0	#3 10 #5 10 #9C 10 #9D 10	#7A 10 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 10 #7D 10 #7F 10 #7G 0	#7E 10 #7H 10	#7C 10 #7I 10	0 (incl in h2)	#14I 0	#15 0	#13A 0	#10B 0	#16A 0 #16B 0	#17A 10	#17B 0	#18A 10	#18B 0	#19 0 n/c	#14A 0	#13B 0 n/c															94.12	0.19	0.19	43.3					9.41	9.41	9.41	9.41	9.41	9.41							9.41		9.41															-	-	-	-	1.13	1.93	2.28	1.23	-	-	-	-	0	0.64	3.28	4.2	0.18	0.18	-	-	-	-	-	-	0.1	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.34		0.96	-	-	-	-	1.13	1.93	2.28	1.23	-	-	-	-	0	0.64	3.28	4.2	0.18	0.18	-	-	-	-	-	-	0.1	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.34																																																																																				-		0	-	-	-	-	1.13	1.93	2.28	1.23	-	-	-	-	0	0.64	3.28	4.2	0.18	0.18	-	-	-	-	-	-	0.1	-	0.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.34
H5884_801_0	2007	3																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		262.35	5.19	29.08		5.23	10.61	12.58	347.9	39.41	21.12	24.65	1.72	0.3	17.97	22.29	34.86	1.53	2.12	24.17	97.97	29.82	0.16																				#1A 1000 ded 0/day days 1-60 250/day days 61-90	#1B 1000 ded 0/day days 1-60 250/day days 61-90	#2 0/day days 1-20 119/day days 21-100	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8A 20 #8B 20	0 (incl in h5)	#12 20	#3 20 #5 50 #9C 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 20 #7D 20 #7F 20 #7G 20 #16B 20 #17A 20	#7E 50 #7H 50	#7C 20 #7I 20	0 (incl in h2)	#14I 20	#15 20	#13A 0 #17A 20	#10B 0 n/c	#16A 0 n/c #16B 0 n/c	#17A 0 n/c	#17B 0 n/c	#18A 0 n/c	#18B 0 n/c	0 n/c	#14A 0 n/c	#13B 0 n/c											0.08	0.08	0.21		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34	138	0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34																																																																																				-		0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34
H5884_802_0	2007	3																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		262.35	5.19	29.08		5.23	10.61	12.58	347.9	39.41	21.12	24.65	1.72	0.3	17.97	22.29	34.86	1.53	2.12	24.17	97.97	29.82	0.16																				#1A 1000 ded 0/day days 1-60 250/day days 61-90	#1B 1000 ded 0/day days 1-60 250/day days 61-90	#2 0/day days 1-20 119/day days 21-100	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8A 20 #8B 20	0 (incl in h5)	#12 20	#3 20 #5 50 #9C 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 20 #7D 20 #7F 20 #7G 20 #16B 20 #17A 20	#7E 50 #7H 50	#7C 20 #7I 20	0 (incl in h2)	#14I 20	#15 20	#13A 0 #17A 20	#10B 0 n/c	#16A 0 n/c #16B 0 n/c	#17A 0 n/c	#17B 0 n/c	#18A 0 n/c	#18B 0 n/c	0 n/c	#14A 0 n/c	#13B 0 n/c											0.08	0.08	0.21		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34	138	0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34																																																																																				-		0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34
H5884_803_0	2007	3																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		262.35	5.19	29.08		5.23	10.61	12.58	347.9	39.41	21.12	24.65	1.72	0.3	17.97	22.29	34.86	1.53	2.12	24.17	97.97	29.82	0.16																				#1A 1000 ded 0/day days 1-60 250/day days 61-90	#1B 1000 ded 0/day days 1-60 250/day days 61-90	#2 0/day days 1-20 119/day days 21-100	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8A 20 #8B 20	0 (incl in h5)	#12 20	#3 20 #5 50 #9C 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 20 #7D 20 #7F 20 #7G 20 #16B 20 #17A 20	#7E 50 #7H 50	#7C 20 #7I 20	0 (incl in h2)	#14I 20	#15 20	#13A 0 #17A 20	#10B 0 n/c	#16A 0 n/c #16B 0 n/c	#17A 0 n/c	#17B 0 n/c	#18A 0 n/c	#18B 0 n/c	0 n/c	#14A 0 n/c	#13B 0 n/c											0.08	0.08	0.21		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34	138	0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34																																																																																				-		0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34
H5884_804_0	2007	3																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		262.35	5.19	29.08		5.23	10.61	12.58	347.9	39.41	21.12	24.65	1.72	0.3	17.97	22.29	34.86	1.53	2.12	24.17	97.97	29.82	0.16																				#1A 1000 ded 0/day days 1-60 250/day days 61-90	#1B 1000 ded 0/day days 1-60 250/day days 61-90	#2 0/day days 1-20 119/day days 21-100	#6 0	#10A 20	#11A 20	#11B 20 #11C 20	#4A 50 #4B 20	#9A 20 #9B 20	#8A 20	#8A 20 #8B 20	0 (incl in h5)	#12 20	#3 20 #5 50 #9C 20 #9D 20	#7A 20 #14B 20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	#7B 20 #7D 20 #7F 20 #7G 20 #16B 20 #17A 20	#7E 50 #7H 50	#7C 20 #7I 20	0 (incl in h2)	#14I 20	#15 20	#13A 0 #17A 20	#10B 0 n/c	#16A 0 n/c #16B 0 n/c	#17A 0 n/c	#17B 0 n/c	#18A 0 n/c	#18B 0 n/c	0 n/c	#14A 0 n/c	#13B 0 n/c											0.08	0.08	0.21		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34	138	0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34																																																																																				-		0	20.54	0.41	6.17	-	1.23	2.5	2.97	1.45	9.3	4.98	5.82	0.41	0.07	4.24	5.26	8.23	0.36	0.5	5.7	23.12	7.04	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.34
H5887_001_0	2007	5																																							V									V																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	362.54	0	0	0	0	0	0	0	0	186.19	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	25	0	0	0	0	0	0	0	0	5	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	0.76	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.83	0	0	-	-	-	-	-	-	-	0.76	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.83		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	0.76	-	-	-	-	-	-	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.83
H5887_004_0	2007	5																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	431.56	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	40	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.44	0	0	-	-	-	-	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.44		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.44
H5887_005_0	2007	1																																																																									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	431.56	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	40	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.44	0	0	-	-	-	-	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.44		PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g	PBP 10b	PBP 16a 16b	PBP 17a	PBP 17b	PBP 18a	PBP 18b	PBP 19	PBP 14a												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	-	-	-	-	-	-	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.44
H5893_001_0	2007	1																					2000																																																																																													-	2000																																																																																																																												-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5893_002_0	2007	2																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5895_001_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5896_001_0	2007	6																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	450.14	30.27	131.89	0	19.85	34.35	25.83	13.99	26.95	23.85	41.09	1.36	1.61	76.74	87.77	161.32	11.58	6.59	45.05	58.19	13.01	5.95	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing (PBP #1A)	Medicare Cost Sharing (PBP #1B)	Medicare Cost Sharing (PBP #2)	0 (PBP #6)	20 coinsurance (PBP #10A)	20 coinsurance (PBP #11A)	20 coinsurance (PBP #11B/11C)	0 (PBP #4A/4B) Member pays 20 of the cost up to 50 for each Medicare-covered emergency room visit; cost sharing waived if admitted.	20 coinsurance (PBP #9B)	20 coinsurance (PBP #8A/9A)	20 coinsurance (PBP #8B/9A)	20 coinsurance (PBP #5/9A)	20 coinsurance (PBP #12/9A)	20 coinsurance (PBP #3/5/9A/9C/9D)	20 coinsurance (PBP #7A/14B-14I)	20 coinsurance (PBP #7B/7D/7F/7G/14D-14I)	50 Medicare Equivalent Coin (PBP #7E/7H)	20 coinsurance (PBP #7C/7I)	20 coinsurance (PBP #7D)	20 coinsurance (PBP #7B/7D/7F/7G/14D-14I)	20 coinsurance (PBP #15)	20 coinsurance (PBP #13A/14A)	0 (PBP #10B) 8 round trips per year to plan-approved location;	0 (PBP #16A/16B) 2 oral exams 2 cleanings 1 fouride treatment 1 X-ray per year	0 (PBP# 17A) 1 exam per year	0 (PBP# 17B) 1 hardware piece per year up to 100	0 (PBP# 18A) 1 exam per year	0 (PBP# 18B) 1 hardware piece per year; up to 1000	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0.06	0.06	0.16	0	0.2	0.2	0.2	0.17	0.2	0.2	0.2	0.2	0.2	0.2	0.19	0.19	0.5	0.2	0.2	0.15	0.2	0.2	0	0	0	0	0	0	0	0	0											27.44	1.84	21.18	-	3.97	6.87	5.2	2.41	5.39	4.77	8.22	0.27	0.32	15.35	16.91	31	5.79	1.32	9.01	8.79	2.6	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	179.84	0	0	27.44	1.84	21.18	-	3.97	6.87	5.2	2.41	5.39	4.77	8.22	0.27	0.32	15.35	16.91	31	5.79	1.32	9.01	8.79	2.6	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	179.84	0																																																																																			-	0	0	27.44	1.84	21.18	-	3.97	6.87	5.2	2.41	5.39	4.77	8.22	0.27	0.32	15.35	16.91	31	5.79	1.32	9.01	8.79	2.6	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	179.84
H5908_001_0	2007	7																																D	D	D	V	T	Coin	Coin	V	V	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	Coin	T	Coin	V	Coin	V	V	V	V	V																																																				-		1242.24	63.94	482.01	67.32	148.29	8.66	11.91	321.77	487.69	6.19	14.7		0.7	613.07	4233.08	7005.61	273.22	987.95		818.96	29.04	0.15																				1a: 150/225 days 1-4	1b: 150/225 days 1-8 175/250 days 31-90	2: 0/50 days 1-20 50/100 days 21-100	6: 0/20	10a: 150/15	11a: 0-20; 30	11b: 0-20; 30	4a: 50 4b: 25/35	9b: 150/250	8a: 0/20	8b: 100/250 CT/MRI; 150/350 PET; 0/20 Diag Rad 8b: 10/10	9a: 0	12: 20; 30	3: 10 9d: 10/30;  5: 20 9c9a: 20/40;	7a: 10/20; 14c: 20/30; 14f: 0-150/0-200; 14g: 10/20; 14b 14d 14e 14i: 0; 14h:  0/20	7d17a: 20/40; 16b: 20; 18a: 0/20	7e 7h: 20/40	7b: 30/40 7c 7i: 10/30		7g: 15-75	15:20	13a: 0 17b: 20	10b: 0	16a: 0	17a: 0	17b: 0	18a: 0	18b: 0		14a:  0	13e: 0											95.5	130.43	24.98	4	149.63	0.11	0.09	48	170	0.04	0.11		22	11.16	12.18	23.08	24	14		6.78	0.2	0.31																				9.89	0.7	1	0.02	1.85	0.95	1.06	1.29	6.91	0.25	1.63	-	0	0.57	4.3	13.47	0.55	1.15	-	0.46	5.81	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.9		0	9.89	0.7	1	0.02	1.85	0.95	1.06	1.29	6.91	0.25	1.63	-	0	0.57	4.3	13.47	0.55	1.15	-	0.46	5.81	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.9																																																																																				-		0	9.89	0.7	1	0.02	1.85	0.95	1.06	1.29	6.91	0.25	1.63	-	0	0.57	4.3	13.47	0.55	1.15	-	0.46	5.81	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	51.9
H5918_001_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							13.51	13.74	424.76	407.51		272.12	57.45		1038.06		6088.86	130.77			958.9					137.43		289.34						11.54	355.89		96.81	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.4	2.44	1.29	1.51	-	0.4	0.21	-	3.84	-	9.01	0.19	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.53	-	0.14	0.23	-	-	-	-	24.34		2.95	-	-	-	-	-	2.4	2.44	1.29	1.51	-	0.4	0.21	-	3.84	-	9.01	0.19	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.53	-	0.14	0.23	-	-	-	-	24.34		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.19	0.03	0.38	0.35	0.05	0.08	0.08	0.03	0.24	0.15	0.14	0.02	0	0.15		0.29	0.01	0.03	0.17	0.65	0.15	0			0.01		0.01															5.2		0	2.19	0.03	0.38	0.35	0.05	2.48	2.53	1.32	1.75	0.15	0.55	0.23	0	3.99	-	9.3	0.2	0.03	0.17	2.07	0.15	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.53	-	0.14	0.23	-	-	-	-	29.55
H5918_002_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-							13.51	13.74	424.76	407.51		272.12	57.45		1038.06		6088.85	130.77			958.89					137.43		289.34						11.54	355.89		96.81	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/20 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 20 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit										18	18	36	44		18	44		44		18	18			18					20		20						18	18		18	20					-	-	-	-	-	2.4	2.44	1.29	1.51	-	0.4	0.21	-	3.84	-	9.01	0.19	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.53	-	0.14	0.23	-	-	-	-	24.34		2.95	-	-	-	-	-	2.4	2.44	1.29	1.51	-	0.4	0.21	-	3.84	-	9.01	0.19	-	-	1.42	-	-	-	-	0.23	-	0.48	-	-	-	-	-	0.02	0.53	-	0.14	0.23	-	-	-	-	24.34		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.19	0.03	0.38	0.35	0.05	0.08	0.08	0.03	0.24	0.15	0.14	0.02	0	0.15		0.29	0.01	0.03	0.17	0.65	0.15	0			0.01		0.01															5.2		0	2.19	0.03	0.38	0.35	0.05	2.48	2.53	1.32	1.75	0.15	0.55	0.23	0	3.99	-	9.3	0.2	0.03	0.17	2.07	0.15	0	-	-	0.24	-	0.49	-	-	-	-	-	0.02	0.53	-	0.14	0.23	-	-	-	-	29.55
H5918_003_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						500	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1783.32	166.05	9149.84	171.48	643.6	1447.62	7035.54	185.09	122.89	3823.31	169.97	33.61	4.4	285.78	131.88	1349.96	1753.66	20.72		281.87	271.32	1378.39	2250		140.2	166		54.6				109.15	0.27	0.07	300	295.2						(1a) 25/day	(1b) 25/day	(2a) 0/day	(6a) 0/proc	(10a) 50/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 0/visit	(8a) 0/visit	(8b) 0/visit	(9a) 0/visit	(12) 0/proc	(9a) 0/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 20/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						23	23			46			46																								19										3.45	0.32	-	-	2.49	-	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	7.14		0.55	3.45	0.32	-	-	2.49	-	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.17	-	-	-	-	-	-	-	-	-	7.14		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							20	30	30	30	30						2.49	0.07	0.94	0.1	0.42	0.36	0.11	0.04	0.24	0.71	0.8	0.05	0.01	0.13																		0.01	0	0								6.47		0	5.94	0.39	0.94	0.1	2.91	0.36	0.11	0.76	0.24	0.71	0.8	0.05	0.01	0.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.18	0	0	-	-	-	-	-	-	-	13.61
H5918_004_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1500	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V	V	V	V	V	V																																														-								30.24	723.24	562.22		426.91	90.05		1697.4		6797.9	436.03			1450.28							289.34						66.78	350.78		282.8	135.78					(1a) 0 per Day	(1b) 0 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 0 per Trip	(11a) 0 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 50 per Visit	(8a) 0/20 per Visit	(8b) 0/20 per Visit	(9a) 50 per Visit	(12) 0 per Visit	(9a) 50 per Visit	(7a) 0 per Visit	(7d) 20 per Visit	(7h) 20 per Visit	(7c/7i) 0/0 per Visit	0 per Visit	(7g) 20 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 20 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 0 per Visit	(9c) 20 per Visit	(7b) 20 per Visit	(7f) 0 per Visit	(7e) 20 per Visit	(13b) 20 per Visit											17	34	42		17	42		42		17	17			17							20						17	17		17	20					-	-	-	-	-	-	5.08	2.08	1.97	-	0.6	0.32	-	5.94	-	9.52	0.61	-	-	2.08	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	29.89		5.48	-	-	-	-	-	-	5.08	2.08	1.97	-	0.6	0.32	-	5.94	-	9.52	0.61	-	-	2.08	-	-	-	-	-	-	0.48	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	29.89		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 20 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance			30 Coinsurance	(17b) 0 per Procedure	30 Coinsurance	(18b) 0 per Procedure			(13a1) 0	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance						2.94	0.11	0.29	0.37	0.06	0.16	0.19	0.04	0.32	0.19	0.2	0.03	0.01	0.22		0.34	0.03	0.03	0.22	0.81	0.19	0			0.01		0.01															6.76		0	2.94	0.11	0.29	0.37	0.06	0.16	5.27	2.12	2.29	0.19	0.8	0.34	0.01	6.16	-	9.86	0.64	0.03	0.22	2.89	0.19	0	-	-	0.01	-	0.49	-	-	-	-	-	0.09	0.49	-	0.4	0.23	-	-	-	-	36.64
H5926_001_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		390.03	29.07	67.16	78.71	14.38	32.35	21.35	11.29	21.44	14.47	28.95	0	3.14	43.33	64.84	119.29	9.72	5.52	25.24	39.13	9.36	4.12	2.06	0	0	0	0	0	0	0	7.77											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.06	0.06	0.19	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											24.91	1.86	12.55	-	3.39	7.64	5.04	2.67	5.06	3.41	6.83	-	0.74	10.23	15.3	28.15	2.29	1.3	5.96	9.23	2.21	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.74			24.91	1.86	12.55	-	3.39	7.64	5.04	2.67	5.06	3.41	6.83	-	0.74	10.23	15.3	28.15	2.29	1.3	5.96	9.23	2.21	0.97	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	149.74		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				1.31	0.1	0.66		0.18	0.4	0.27	0.14	0.27	0.18	0.36		0.04	0.54	0.81	1.48	0.12	0.07	0.31	0.49	0.12	0.05																				7.88			26.22	1.95	13.21	-	3.57	8.04	5.3	2.81	5.33	3.59	7.19	-	0.78	10.76	16.11	29.63	2.42	1.37	6.27	9.72	2.32	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	157.62
H5928_001_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5928_002_0	2007	5																																																																																																																		-		0	22.4	0	0	680.46	1787.88	172.62	251.47	162.82	0	0	0	49.5	8609.8	9234.62	7218.37	461.34	374.03	0	33345.98	1349.61	0	0	1184.07	0	725.12	192.8																																																									50			50	4	13	48.61	10				10	10	3	5	10	10		6.07	12.5			48.03		15	10															-	0.09	-	-	2.84	0.6	0.19	1.02	0.14	-	-	-	0.04	7.17	2.31	3.01	0.38	0.31	-	16.87	1.41	-	-	4.74	-	0.91	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.18			-	0.09	-	-	2.84	0.6	0.19	1.02	0.14	-	-	-	0.04	7.17	2.31	3.01	0.38	0.31	-	16.87	1.41	-	-	4.74	-	0.91	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.18																																																																																				-			-	0.09	-	-	2.84	0.6	0.19	1.02	0.14	-	-	-	0.04	7.17	2.31	3.01	0.38	0.31	-	16.87	1.41	-	-	4.74	-	0.91	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	42.18
H5932_001_0	2007	6																																D	D	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		2407.35	862.04	52.07	41.66	16.76	32.59	3.54	950.65	19.1	15.81	28.22	0	25.74	25.46	21.97	34.08	10.02	1.87	20.23	101.91	13.07	1.58	0	0	2.49	1.12	1	1.03	0	2	4.5											100/day: PBP 1a	FFS Medicare: PBP 1b	FFS Medicare: PBP 2	FFS Medicare: PBP 6	FFS Medicare: PBP 10a	FFS Medicare: PBP 11a	FFS Medicare: PBP 11b 11c	50 copay: PBP 4a 4b	FFS Medicare: PBP 9a 9b	FFS Medicare: PBP 8a	FFS Medicare: PBP 8b	FFS Medicare:	FFS Medicare: PBP 12	FFS Medicare: PBP 3 5 9a 9c 9d 13a 13b	FFS Medicare: PBP 4b 7a 14b-i	FFS Medicare: PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	FFS Medicare: PBP 7e 7h	FFS Medicare: PBP 7c 7i	FFS Medicare: PBP 7d	FFS Medicare: PBP 7d 7g	FFS Medicare: PBP 15	FFS Medicare: PBP 7g																				100.55	55.04	0.19	0	0.24	0.24	0.24	48.72	0.24	0.24	0.24	0	0.24	0.24	0.23	0.22	0.24	0.24	0.24	0.21	0.24	0.22	0	0	0	0	0	0	0	0	0											20.17	3.95	9.91	-	3.96	7.69	0.84	3.86	4.51	3.73	6.66	-	6.08	6.01	5.06	7.5	2.36	0.44	4.78	21.72	3.09	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.65	131	0	20.17	3.95	9.91	-	3.96	7.69	0.84	3.86	4.51	3.73	6.66	-	6.08	6.01	5.06	7.5	2.36	0.44	4.78	21.72	3.09	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.65																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	20.17	3.95	9.91	-	3.96	7.69	0.84	3.86	4.51	3.73	6.66	-	6.08	6.01	5.06	7.5	2.36	0.44	4.78	21.72	3.09	0.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.65
H5936_001_0	2007	6																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1600.26	108.76	464.78		83.08		0.82	241.45	349.07		221.31		1.97	327.07		7819.62	750.79	999.29		1.13	47.18										0.89											1a: 50 days 1-5	1a: 100 days 1-5	2a: 75 days 8-100		10a: 100		11b: 10 - Prosthetics	4a-b: 50 Emergency - 25 Urgent	9a-b: 50 ASC - 150 OP Facility		8: 50 PET 50 CT 50 MRI 25 Radiation Therapy		12:35	20 Rehab		7bdfg: 10 Spec. 15 Podiatry 15 Chiro	7e 7h 9c: 15 Group 25 Individual	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											21.3	42.6	53.55		100		0.1	44.99	93.24		46.83		35	19.92		10.74	17.5	20		0.2	0.2										0.16											2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67																																																																																				-		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67
H5936_003_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	Coin																																																				-		386.6	43.26	32		6.32	33.41	99.32	31.35	55.4	34.91	39.2	5.9	3.48	249.5	46.12	51.6	11.28	17.76	36.23	176.32	203.01	0.09			393						1.61											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing			10 - 1 routine exam per year						Travel: 1000 per IP admit 20 all other services											0.07	0.07	0.19		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24			10						0.17											27.03	3.03	6.01	-	1.49	7.88	23.44	7.4	13.07	8.24	9.25	1.39	0.82	58.88	10.88	12.18	2.66	4.19	8.55	41.61	47.91	0.02	-	-	0.33	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	296.55		0	27.03	3.03	6.01	-	1.49	7.88	23.44	7.4	13.07	8.24	9.25	1.39	0.82	58.88	10.88	12.18	2.66	4.19	8.55	41.61	47.91	0.02	-	-	0.33	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	296.55																																																																																				-		0	27.03	3.03	6.01	-	1.49	7.88	23.44	7.4	13.07	8.24	9.25	1.39	0.82	58.88	10.88	12.18	2.66	4.19	8.55	41.61	47.91	0.02	-	-	0.33	-	-	-	-	-	0.27	-	-	-	-	-	-	-	-	-	-	296.55
H5936_004_0	2007	4																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1600.26	108.76	464.78		83.08		0.82	241.45	349.07		221.31		1.97	327.07		7819.62	750.79	999.29		1.13	47.18										0.89											1a: 50 days 1-5	1a: 100 days 1-5	2a: 75 days 8-100		10a: 100		11b: 10 - Prosthetics	4a-b: 50 Emergency - 25 Urgent	9a-b: 50 ASC - 150 OP Facility		8: 50 PET 50 CT 50 MRI 25 Radiation Therapy		12:35	20 Rehab		7bdfg: 10 Spec. 15 Podiatry 15 Chiro	7e 7h 9c: 15 Group 25 Individual	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											21.3	42.6	53.55		100		0.1	44.99	93.24		46.83		35	19.92		10.74	17.5	20		0.2	0.2										0.16											2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67																																																																																				-		0	2.84	0.39	2.07	-	0.69	-	0.08	0.91	2.71	-	0.86	-	0.01	0.54	-	7	1.09	1.67	-	0.23	9.44	-	-	-	-	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	30.67
H5936_005_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1351.49	33.13	590.79		46.01		1.05	273.06	410.83		168.24			220.37		5988.53	300.45	421.49		1.36	25.5										0.67											1a: 200 Days 1-7	1b: 200 Days 1-7	2a: 75 Days 21-100		10a: 100		11b: 15 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 200 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	20 - OP Rehab MH - 35 Ind./20 Group		7bdfg 17a: 25	7e 7h 9c: 35 Ind./20 Group	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											104.6	104.6	30.23		100		0.15	44.99	137.33		47.68			20.1		20.52	23.75	20		0.2	0.2										0.17											11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88																																																																																				-		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88
H5936_006_0	2007	4																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-																										393						0.87																																			17a: 10						Travel: 1000 per IP admit 20 all other services																																			10						0.17											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	0.47		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	0.47																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.15	-	-	-	-	-	-	-	-	-	-	0.47
H5936_007_0	2007	4																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1351.49	33.13	590.79		46.01		1.05	273.06	410.83		168.24			220.37		5988.53	300.45	421.49		1.36	25.5										0.67											1a: 200 Days 1-7	1b: 200 Days 1-7	2a: 75 Days 21-100		10a: 100		11b: 15 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 200 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	20 - OP Rehab MH - 35 Ind./20 Group		7bdfg 17a: 25	7e 7h 9c: 35 Ind./20 Group	3 7c 7i: 20		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											104.6	104.6	30.23		100		0.15	44.99	137.33		47.68			20.1		20.52	23.75	20		0.2	0.2										0.17											11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88																																																																																				-		0	11.78	0.29	1.49	-	0.38	-	0.16	1.02	4.7	-	0.67	-	-	0.37	-	10.24	0.59	0.7	-	0.27	5.1	-	-	-	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	37.88
H5936_008_0	2007	6																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1370.73	68.71	573.82		62.91	5.64	0.94	258.64	316.95		602.8		1.22	270.3		4482.83	254.89	236.8		1.58	28.54										0.63											1a: 100 Days 1-8	1b: 100 Days 1-8	2a: 75 Days 8-100		10a: 100	11a: 20	11b: 20 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 150 OP Facility		8: 10 X-Ray 100 MRI 100 PET 100 CT 50 Radiation Therapy		12:35	25 - OP Rehab MH - 30 Ind./20 Group		7bdfg: 25 Spec. 30 - Chiro	7eh 9c: 30 Ind./20 Group	3 7c 7i: 25		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											56.3	56.3	53.55		100	0.1	0.2	44.98	121.11		32.47		35	24.89		25.16	22.5	25		0.2	0.2										0.16											6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45																																																																																				-		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45
H5936_009_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-																										393						0.85																																			17a: 10						Travel: 1000 per IP admit 20 all other services																																			10						0.16											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	0.46		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	0.46																																																																																				-		0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	0.46
H5936_010_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-		1370.73	68.71	573.82		62.91	5.64	0.94	258.64	316.95		602.8		1.22	270.3		4482.83	254.89	236.8		1.58	28.54										0.63											1a: 100 Days 1-8	1b: 100 Days 1-8	2a: 75 Days 8-100		10a: 100	11a: 20	11b: 20 Prosthetics	4a-b: 50 - Emergency 25 - Urgent	9a-b: 100 - ASC 150 OP Facility		8: 10 X-Ray 100 MRI 100 PET 100 CT 50 Radiation Therapy		12:35	25 - OP Rehab MH - 30 Ind./20 Group		7bdfg: 25 Spec. 30 - Chiro	7eh 9c: 30 Ind./20 Group	3 7c 7i: 25		20 Chemo	15:20										Travel: 1000 per IP admit 20 all other services											56.3	56.3	53.55		100	0.1	0.2	44.98	121.11		32.47		35	24.89		25.16	22.5	25		0.2	0.2										0.16											6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45																																																																																				-		0	6.43	0.32	2.56	-	0.52	0.56	0.19	0.97	3.2	-	1.63	-	0	0.56	-	9.4	0.48	0.49	-	0.32	5.71	-	-	-	-	-	-	-	-	-	0.1	-	-	-	-	-	-	-	-	-	-	33.45
H5936_011_0	2007	3																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		4208.61	661.32	14575.17		672.28	7.17	22.07	555.83	160.57	26329.13	357.2	53.29	18.05	3283.38	1400.54	5907.06	7394.29	675.31	31.84	310.02	57.22	12.1			393																	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing			10 - 1 routine exam per year																	114.46	58.88	77.94		119.67	0.24	0.24	314.45	722.81	10.51	212.23	421.3	547.51	507.87	26.45	19.17	14.47	22.51	0.24	0.24	0.24	16.26			10																	40.14	3.24	94.66	-	6.7	1.69	5.21	14.57	9.67	23.06	6.32	1.87	0.82	138.96	3.09	9.44	8.92	1.27	7.51	73.17	13.5	0.02	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	464.16		0	40.14	3.24	94.66	-	6.7	1.69	5.21	14.57	9.67	23.06	6.32	1.87	0.82	138.96	3.09	9.44	8.92	1.27	7.51	73.17	13.5	0.02	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	464.16																																																																																				-		0	40.14	3.24	94.66	-	6.7	1.69	5.21	14.57	9.67	23.06	6.32	1.87	0.82	138.96	3.09	9.44	8.92	1.27	7.51	73.17	13.5	0.02	-	-	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	464.16
H5936_013_0	2007	7																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-			156.84	361.51		63.72			177.38	267.28		215.91		1.41	418.82		6093.17	943.41	1047.66		1.3	47.77				393						0.92												1b: 50 Days 1-7	2a: 50 Days 8-100		10a: 75			4a-b: 50 - Emergency 25 - Urgent	9a-b: 25 - ASC 100 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	10 - OP Rehab MH - 35 Ind./20 Group		7bdfg: 5 spec. 15 Podiatry 15 Chiro	7e h 9c: 35 Ind./20 Group	3 7c 7i: 10		20 Chemo	15:20				17a: 10						Travel: 1000 per IP admit 20 all other services												26.15	35.7		75			44.99	67		44.88		35	12.18		6.08	23.75	10		0.2	0.2				10						0.16											-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32																																																																																				-		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32
H5936_014_0	2007	5																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	Coin																																																				-			156.84	361.51		63.72			177.38	267.28		215.91		1.41	418.82		6093.17	943.41	1047.66		1.3	47.77				393						0.92												1b: 50 Days 1-7	2a: 50 Days 8-100		10a: 75			4a-b: 50 - Emergency 25 - Urgent	9a-b: 25 - ASC 100 OP Facility		8: 50 MRI 50 PET 50 CT 25 Radiation Therapy		12:35	10 - OP Rehab MH - 35 Ind./20 Group		7bdfg: 5 spec. 15 Podiatry 15 Chiro	7e h 9c: 35 Ind./20 Group	3 7c 7i: 10		20 Chemo	15:20				17a: 10						Travel: 1000 per IP admit 20 all other services												26.15	35.7		75			44.99	67		44.88		35	12.18		6.08	23.75	10		0.2	0.2				10						0.16											-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32																																																																																				-		0	-	0.34	1.08	-	0.4	-	-	0.67	1.49	-	0.81	-	0	0.43	-	3.08	1.87	0.87	-	0.26	9.55	-	-	-	0.33	-	-	-	-	-	0.14	-	-	-	-	-	-	-	-	-	-	21.32
H5936_807_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		241.47	5.79	17.62		2.82	4.79	10.26	14.42	53.3	31.64	33.41	4.35	0.27	35.12	25.32	50.23	3.81	5.43	35.99	123.5	39.48	0.09																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.73	0.43	3.23	-	0.67	1.13	2.42	3.4	12.58	7.47	7.89	1.03	0.06	8.29	5.98	11.86	0.9	1.28	8.49	29.15	9.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.31		0	17.73	0.43	3.23	-	0.67	1.13	2.42	3.4	12.58	7.47	7.89	1.03	0.06	8.29	5.98	11.86	0.9	1.28	8.49	29.15	9.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.31																																																																																				-		0	17.73	0.43	3.23	-	0.67	1.13	2.42	3.4	12.58	7.47	7.89	1.03	0.06	8.29	5.98	11.86	0.9	1.28	8.49	29.15	9.32	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.31
H5936_808_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		241.68	5.8	17.63		2.82	4.79	10.27	14.44	53.35	31.67	33.44	4.35	0.27	35.15	25.35	50.28	3.81	5.43	36.03	123.61	39.52	0.09																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42																																																																																				-		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42
H5936_809_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		241.68	5.8	17.63		2.82	4.79	10.27	14.44	53.35	31.67	33.44	4.35	0.27	35.15	25.35	50.28	3.81	5.43	36.03	123.61	39.52	0.09																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42																																																																																				-		0	17.74	0.43	3.24	-	0.67	1.13	2.42	3.41	12.59	7.47	7.89	1.03	0.06	8.3	5.98	11.87	0.9	1.28	8.5	29.17	9.33	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	133.42
H5938_001_0	2007	4																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1321.85	25.86	1158.75	2147.11	211.48	11.08	24804.28	250.55	223.97	1861.43	760.63	0	46.94	514.9	7123.92	10735.91	148.85	414.66	4183.63	11933.52	353.56	864.45	0	0	393.53	3.9	163.42	0	0	0	31.17											250 day 1;  100 days 6 - 10	250 day 1;  100 days 6 - 10	75 days 7 - 100	0 copay	100 per trip	20 coinsurance	0 copay	50 per visit	100 per visit	Effective copay - 0 or 20	Effective copay - 0 or 100	0 copay	0 copay	Effective copay - 0 or 25	Effective copay - Range 0 - 25	Effective copay - Range 0 - 25	25 per visit	25 per visit	0 copay	Effective copay: Range 0 - 25	copay	Effecitve copay:  0 blood 15 vision			15 copay	0 copay	25 copay	0 copay			Effective copay- 0 and 50 (foreign ER)											67.02	67.02	59.07	0	100	0.2	0	50	100	7.52	24.09	0	0	11.03	9.86	14.13	25	25	0	1.5	0	11.98	0	0	15	0	25	0	0	0	1.67											7.38	0.14	5.7	-	1.76	2.22	-	1.04	1.87	1.17	1.53	-	-	0.47	5.85	12.64	0.31	0.86	-	1.49	-	0.86	-	-	0.49	-	0.34	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.15			7.38	0.14	5.7	-	1.76	2.22	-	1.04	1.87	1.17	1.53	-	-	0.47	5.85	12.64	0.31	0.86	-	1.49	-	0.86	-	-	0.49	-	0.34	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.15																																																																																				-			7.38	0.14	5.7	-	1.76	2.22	-	1.04	1.87	1.17	1.53	-	-	0.47	5.85	12.64	0.31	0.86	-	1.49	-	0.86	-	-	0.49	-	0.34	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.15
H5938_006_0	2007	4																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1321.85	25.86	1158.75	2147.11	211.48	11.08	24804.28	250.55	223.97	1861.43	760.63	0	46.94	514.9	7123.92	10735.91	148.85	414.66	4183.63	11933.52	353.56	864.45	0	0	393.53	3.9	163.42	0	0	0	31.17											250 day 1;  100 days 6 - 10	250 day 1;  100 days 6 - 10	75 days 7 - 100	0 copay	100 per trip	20 coinsurance	0 copay	50 per visit	100 per visit	Effective copay - 0 or 20	Effective copay - 0 or 100	0 copay	0 copay	Effective copay - 0 or 25	Effective copay - Range 0 - 25	Effective copay - Range 0 - 25	25 per visit	25 per visit	0 copay	Effective copay: Range 0 - 25	copay	Effecitve copay:  0 blood 15 vision			15 copay	0 copay	25 copay	0 copay			Effective copay- 0 and 50 (foreign ER)											67.02	67.02	59.07	0	100	0.2	0	50	100	7.52	24.09	0	0	11.03	9.86	14.13	25	25	0	1.5	0	11.98	0	0	15	0	25	0	0	0	1.67											7.38	0.14	5.7	-	1.76	2.22	-	1.04	1.87	1.17	1.53	-	-	0.47	5.85	12.64	0.31	0.86	-	1.49	-	0.86	-	-	0.49	-	0.34	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.15			7.38	0.14	5.7	-	1.76	2.22	-	1.04	1.87	1.17	1.53	-	-	0.47	5.85	12.64	0.31	0.86	-	1.49	-	0.86	-	-	0.49	-	0.34	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.15																																																																																				-			7.38	0.14	5.7	-	1.76	2.22	-	1.04	1.87	1.17	1.53	-	-	0.47	5.85	12.64	0.31	0.86	-	1.49	-	0.86	-	-	0.49	-	0.34	-	-	-	0	-	-	-	-	-	-	-	-	-	-	46.15
H5938_801_0	2007	2																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.81	0.16	0	0	0.24	0.38	0.48	0.14	0.64	0.44	0.66	0	0.02	0.55	1.38	3.5	0.04	0.11	1.01	1.21	0.16	0.24																				27.17		1367.02	27.12	1325.36	2253.13	6.59	10.54	13.38	3.9	17.88	12.33	18.28	0	0.62	15.23	38.28	97.17	1.04	2.99	28.18	33.55	4.33	6.69	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	0 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	0	0	0	0	0	0	0											10.31	5.19	78.73	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.17	0.01	8.7	-	1.32	2.11	2.68	0.78	3.58	2.47	3.66	-	0.12	3.05	7.66	19.43	0.21	0.6	5.64	6.71	0.87	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.08	Medicare deductible		16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24																																																																																				-			16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24
H5938_802_0	2007	4																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.81	0.16	0	0	0.24	0.38	0.48	0.14	0.64	0.44	0.66	0	0.02	0.55	1.38	3.5	0.04	0.11	1.01	1.21	0.16	0.24																				27.17		1367.02	27.12	1325.36	2253.13	6.59	10.54	13.38	3.9	17.88	12.33	18.28	0	0.62	15.23	38.28	97.17	1.04	2.99	28.18	33.55	4.33	6.69	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	0 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	0	0	0	0	0	0	0											10.31	5.19	78.73	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.17	0.01	8.7	-	1.32	2.11	2.68	0.78	3.58	2.47	3.66	-	0.12	3.05	7.66	19.43	0.21	0.6	5.64	6.71	0.87	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.08	Medicare deductible		16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24																																																																																				-			16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24
H5938_803_0	2007	3																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.81	0.16	0	0	0.24	0.38	0.48	0.14	0.64	0.44	0.66	0	0.02	0.55	1.38	3.5	0.04	0.11	1.01	1.21	0.16	0.24																				27.17		1367.02	27.12	1325.36	2253.13	6.59	10.54	13.38	3.9	17.88	12.33	18.28	0	0.62	15.23	38.28	97.17	1.04	2.99	28.18	33.55	4.33	6.69	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	0 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	0	0	0	0	0	0	0											10.31	5.19	78.73	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.17	0.01	8.7	-	1.32	2.11	2.68	0.78	3.58	2.47	3.66	-	0.12	3.05	7.66	19.43	0.21	0.6	5.64	6.71	0.87	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.08	Medicare deductible		16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24																																																																																				-			16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24
H5938_804_0	2007	4																																D	D	D	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				15.81	0.16	0	0	0.24	0.38	0.48	0.14	0.64	0.44	0.66	0	0.02	0.55	1.38	3.5	0.04	0.11	1.01	1.21	0.16	0.24																				27.17		1367.02	27.12	1325.36	2253.13	6.59	10.54	13.38	3.9	17.88	12.33	18.28	0	0.62	15.23	38.28	97.17	1.04	2.99	28.18	33.55	4.33	6.69	0	0	0	0	0	0	0	0	0											Standard Medicare benefits	Standard Medicare benefits	Standard Medicare benefits	0 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	0	0	0	0	0	0	0	0	0											10.31	5.19	78.73	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0	0	0	0	0	0	0	0											1.17	0.01	8.7	-	1.32	2.11	2.68	0.78	3.58	2.47	3.66	-	0.12	3.05	7.66	19.43	0.21	0.6	5.64	6.71	0.87	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.08	Medicare deductible		16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24																																																																																				-			16.99	0.17	8.7	-	1.56	2.49	3.16	0.92	4.22	2.91	4.31	-	0.15	3.59	9.03	22.93	0.25	0.71	6.65	7.92	1.02	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24
H5942_007_0	2007	5	s.	t.	u.	v							OP Facility - Surgery	Professional	Professional	Professional							none	ASC	Chiropractic	Podiatry	Mental Health (SA)							D	D	D	V	T	P	Coin	V	V	P	V	V	V	V	V	V	V	V	P													V	V	V	V																																																-	none	2247	406	929	4039	477	32219	0.73	468	212	4912	1316	100	-	480	6019	5974	749	1917	3843	33858	360	240		1710	442	110	379	67	-	14334	589	114	354	235	321							50 Copay days 1-5	50 Copay days 1-5	35 Copay days 21-100	10 Copay	50 per Trip			50 each visit	100 each visit	5 Copay					20 copay for urgent care	15 copay per visit	20 copay per visit	25 copay per visit														50 per visit	10 per covered service	15 per covered visit								34.33	34.33	6.46	10	50	0	0	50	100	5	0	0	0	0	2	15	20	25	0	0	0	0		0	0	0	0	0	0	0	0	50	10	15	0							6.43	1.16	0.5	3.37	1.99	-	-	1.95	1.77	2.05	-	-	-	-	1	7.47	1.25	3.99	-	-	-	-	-	-	-	-	-	-	-	-	-	0.48	0.3	0.29	-	-	-	-	-	-	-	33.98		0	6.43	1.16	0.5	3.37	1.99	-	-	1.95	1.77	2.05	-	-	-	-	1	7.47	1.25	3.99	-	-	-	-	-	-	-	-	-	-	-	-	-	0.48	0.3	0.29	-	-	-	-	-	-	-	33.98	none																																																																																			-			6.43	1.16	0.5	3.37	1.99	-	-	1.95	1.77	2.05	-	-	-	-	1	7.47	1.25	3.99	-	-	-	-	-	-	-	-	-	-	-	-	-	0.48	0.3	0.29	-	-	-	-	-	-	-	33.98
H5942_008_0	2007	5	s.										OP Facility - Surgery										none	ASC										D	D	D	V	T	P	P	V	V	P	V	V	V	V	V	V	V	V	P	P	O	O	T	V	V	V	V	V		O	O	V																																																			-	none	2490	449	1203	6797	518	159550	13296	259	182	4317	1055	57	-	17935	6226	6669	1623	4601	5732	34800	313	156	1440	1000	442	200	981	173	-	14334	589	98												25 Copay days 7-25	10 Copay	50 per Trip			25 each visit	50 each visit						25 urgent care copay																											0	0	11.02	10	50	0	0	25	50	0	0	0	0	0	2.5	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0										-	-	1.11	5.66	2.16	-	-	0.54	0.76	-	-	-	-	-	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.52		0	-	-	1.11	5.66	2.16	-	-	0.54	0.76	-	-	-	-	-	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.52	none																																																																																			-		0	-	-	1.11	5.66	2.16	-	-	0.54	0.76	-	-	-	-	-	1.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.52
H5942_009_0	2007	5	s.										DME/Prosthetics/Supplies										none	Diabetic Supplies										D	D	D	V	T	P	Coin	V	V	P	V	V	V	V					P																																																																-	none	1828	116	772	1802	322	14337	0.35	391	365	5222	2806	122	-	604	6576	5695	655	3913	3746	37393	360	240	1440	1710	442	110	379	67	-	14334	589	8363										50 Copay days 1-5	50 Copay days 1-5	50 Copay days 7-100	20 per visit	100 per trip		20 per item	50 each visit	50 each visit	12 Copay	0 to 50 per visit				10 copay for urgent care	20 copay per visit	20 to 30 copay per visit	30 copay per visit																								34.33	34.33	28.93	20	100	0	0.2	50	50	12	25	0	0	0	1	20	26	30	0	0	0	0	0	0	0	0	0	0	0	0	0	0										5.23	0.33	1.86	3	2.69	-	0.07	1.63	1.52	5.22	5.85	-	-	-	0.55	9.49	1.42	9.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.65		0	5.23	0.33	1.86	3	2.69	-	0.07	1.63	1.52	5.22	5.85	-	-	-	0.55	9.49	1.42	9.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.65	none																																																																																			-		0	5.23	0.33	1.86	3	2.69	-	0.07	1.63	1.52	5.22	5.85	-	-	-	0.55	9.49	1.42	9.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	48.65
H5948_001_0	2007	8																					None											D	D			T	Coin	Coin	V	V		V		Coin	V		V	V	V	Coin	V	Coin	Coin		V	V																																																										-	N/A	597.52	8.43			165.16	10.07	6.46	312.81	222.98		159.69		0.37	464.19		3802.4	162.39	1414.95	3.8	1460.91	7.11	0.79		2053.37	646.93																	150/Day Days 1-5	150/Day Days 1-5			100/Trip	20 Coinsurance	20 Coinsurance on Prosthetics	50/Visit ER; 25/Visit Urgent Care	100/Visit for Surgery		100/Visit for CAT Scans and MRIs		20 Coinsurance	10/Visit for PT/OT/ST Cardiac Rehab		10/Visit for PT/OT/ST Cardiac Rehab	25/Visit	10/Visit for PT/OT/ST Cardiac Rehab	20 for Radiation Oncology	10/Visit for Podiatry Hearing 15/Visit for Chiro	20 Cost-sharing	20 Cost-sharing		Various copayments; see schedule	25/Refraction																	150	150			100	0.2	0.18	36.65	100		100		0.2	10		10	25	10	0.2	11.15	0.2	0.2		9.93	25																	7.47	0.11	-	-	1.38	2.01	1.18	0.96	1.86	-	1.33	-	0.07	0.39	-	3.17	0.34	1.18	0.76	1.36	1.42	0.16	-	1.7	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.18	0	0	7.47	0.11	-	-	1.38	2.01	1.18	0.96	1.86	-	1.33	-	0.07	0.39	-	3.17	0.34	1.18	0.76	1.36	1.42	0.16	-	1.7	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.18	N/A																																																																																			-			7.47	0.11	-	-	1.38	2.01	1.18	0.96	1.86	-	1.33	-	0.07	0.39	-	3.17	0.34	1.18	0.76	1.36	1.42	0.16	-	1.7	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	28.18
H5948_002_0	2007	7																					None											Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																								0.48	1.12	0.73	0.4	0.73	0.5	1	0	0.11	1.47	3.18	6.31	0.57	0.33	1.37	2.44	0.32	0.21																				21.25	N/A	353.77	27.5	60.83		13.33	31.12	20.29	11.07	20.22	13.8	27.8	0	3.01	40.75	88.24	175.16	15.89	9.07	38.04	67.87	8.89	5.72																				Medicare Inpatient Deductibles	Medicare Inpatient Deductibles	Medicare SNF Deductibles		20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.	20 Cost-Sharing no OOP Max after Part B Deductible.																				0.07	0.07	0.16		0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2																				23.56	1.83	9.88	-	2.67	6.22	4.06	2.21	4.04	2.76	5.56	-	0.6	8.15	17.65	35.03	3.18	1.81	7.61	13.57	1.78	1.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	153.33	138		23.56	1.83	9.88	-	3.15	7.34	4.79	2.61	4.77	3.26	6.56	-	0.71	9.62	20.83	41.34	3.75	2.14	8.98	16.02	2.1	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	174.58	N/A																																																																																			-			23.56	1.83	9.88	-	3.15	7.34	4.79	2.61	4.77	3.26	6.56	-	0.71	9.62	20.83	41.34	3.75	2.14	8.98	16.02	2.1	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	174.58
H5949_001_0	2007	3																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	352.99	24.87	114.03	0	17.84	42.11	27.1	9.82	20.23	16.08	32.17	1.05	1.21	44.37	69.03	129.43	9.51	6.09	33.21	50.7	10.39	4.65	0	0	0	0	0	0	0	0	0											6.16 Medicare equivalent coinsurance	6.16 Medicare equivalent coinsurance	18.14 Medicare equivalent coinsurance	0	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.52 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	22.60 Medicare equivalent coinsurance	22.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.62 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	PBP 10B 0 coinsurance	0	PBP 17A 0 coinsurance	PBP 17B 0 coinsurance	0	0	0	0	PBP 13C Adult Day Care 0 coinsurance											0.06	0.06	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											21.75	1.53	20.68	-	4.21	9.94	6.4	2.32	4.77	3.79	7.59	0.25	0.29	10.47	16.29	30.55	2.24	1.44	7.84	11.96	2.45	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	167.86	0	0	21.75	1.53	20.68	-	4.21	9.94	6.4	2.32	4.77	3.79	7.59	0.25	0.29	10.47	16.29	30.55	2.24	1.44	7.84	11.96	2.45	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	167.86	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	21.75	1.53	20.68	-	4.21	9.94	6.4	2.32	4.77	3.79	7.59	0.25	0.29	10.47	16.29	30.55	2.24	1.44	7.84	11.96	2.45	1.1	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	167.86
H5950_001_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				200/day 1-10	200/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 Urgent Care	150	35	100 Complex Rad 35 Routine Rad	35	30	35	20	35 Spec; 30 Renal Dialysis	35	35	35	35	45	0																				163.28	163.28	65.39	0	100	0.2	0.2	46.75	150	35	57.23	35	30	35	20	34.46	35	35	35	35	45	0																				21.18	0.41	6.93	-	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.88			21.18	0.41	6.93	-	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.88																																																																																				-			21.18	0.41	6.93	-	1.92	3.14	0.2	1.63	4.3	6.38	5.36	-	-	-	9.05	19.26	0.58	1.67	2.74	4.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.88
H5950_002_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				150/day 1-10	150/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 Urgent Care	150	30	100 Complex Rad 30 Routine	30	30	30	15	30	30	30	30	30	45	0																				122.46	122.46	65.39	0	100	0.2	0.2	46.75	150	30	53.94	30	30	30	15	30	30	30	30	30	45	0																				15.88	0.31	6.93	-	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.2			15.88	0.31	6.93	-	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.2																																																																																				-			15.88	0.31	6.93	-	1.92	3.14	0.2	1.63	4.3	5.47	5.05	-	-	-	6.78	16.77	0.49	1.43	2.35	3.55	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	76.2
H5950_003_0	2007	4																																D	D	D	V	T	Coin	Coin	V	P	V	V	V	V	V	V	V	V	V	V	V	S																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	2187.96	1124.46	0	0	0	5427.79	6707.4	197.72	572.05	938.2	1418.03	0	0																				50/day 1-10	50/day 1-10	0/day 1-8; 75/day 9-14; 100/day 15-100	0	100	20	20	50 ER 25 Urgent Care	150	20	100 Complex 20 Routine	20	20	20	0	20	20	20	20	20	45	0																				40.82	40.82	65.39	0	100	0.2	0.2	46.75	150	20	47.36	20	20	20	0	20	20	20	20	20	45	0																				5.29	0.1	6.93	-	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.99			5.29	0.1	6.93	-	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.99																																																																																				-			5.29	0.1	6.93	-	1.92	3.14	0.2	1.63	4.3	3.65	4.44	-	-	-	-	11.18	0.33	0.95	1.56	2.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	47.99
H5950_801_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5950_802_0	2007	1																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin																																																														-		1556.38	30.32	1271.3	2086.91	230.31	15.72	1	417.71	344.14	6.75	18.95	0	0	0	5427.79	6885.59	197.72	1144.11	1563.66	2836.06	18.07																					200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35	150	30	30	50 50	150	20	0.2 0.2	35	35	35	35	35	35	35	35	35	20																					143.69	143.69	100	35	150	0.3	0.3	50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03																																																																																				-			18.64	0.36	10.59	6.09	2.88	4.72	0.3	1.74	4.3	1.35	3.79	-	-	-	15.83	20.08	0.58	3.34	4.56	8.27	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.03
H5952_001_0	2007	3																					3000											D	D	D	V	Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	V	V	V	Coin	Coin	P	Coin	P	P	Coin	V	Coin	V	Coin	P	P	P																																																				-		1764.66	119.33	792.71		4.73	7.34	10.94	278.7	31.11	10.53	18.97		0.49	4.61	3832.45	5971.56	584.06	11.26	34.33		25.02			4.79	131.15		234.81															180 Copay days 1-5	180 Copay days 1-5	92 Copay days 4-100		20 Coins	20 Coins	20 Coins	50 Copay waived if admitted	20 Coins	20 Coins	20 Coins		20 Coins	20 Coins	15 Copay	30 Copay 35 Chiro	35 Copay	20 Coins	20 Coins		20 Coins			50 Coins	30 Copay		30 Copay															79.42	79.42	57.68		0.14	0.14	0.14	35.99	0.14	0.14	0.12		0.14	0.13	10.8	21.87	25.14	0.14	0.02		0.14			0.36	21.59		21.59															11.68	0.79	3.81	-	0.68	1.06	1.57	0.84	4.48	1.52	2.28	-	0.07	0.61	3.45	10.88	1.22	1.62	0.84	-	3.6	-	-	1.72	0.24	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.38		20.78	11.68	0.79	3.81	-	0.68	1.06	1.57	0.84	4.48	1.52	2.28	-	0.07	0.61	3.45	10.88	1.22	1.62	0.84	-	3.6	-	-	1.72	0.24	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.38																																																																																				-			11.68	0.79	3.81	-	0.68	1.06	1.57	0.84	4.48	1.52	2.28	-	0.07	0.61	3.45	10.88	1.22	1.62	0.84	-	3.6	-	-	1.72	0.24	-	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.38
H5952_801_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H5952_802_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H5952_803_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H5952_804_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		277.84	5.87	26.13		5.54	10.35	12.83	12.64	41.93	25.14	26.17	3.36	0.33	22.9	24.08	44.13	2.79	5.65	31.84	111.52	28.84																					Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS	Medicare FFS																					0.07	0.07	0.18		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																					20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23																																																																																				-			20.32	0.43	4.72	-	1.31	2.44	3.03	2.98	9.89	5.93	6.18	0.79	0.08	5.4	5.68	10.41	0.66	1.33	7.51	26.32	6.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	122.23
H5969_001_0	2007	7																					3100											D	D	D	V	T	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	V	V	V	V	Coin	V	Coin	V			V	0					V																																																				-		758.7	15.2	320.7	0	129	7.93	4.92	363	24.46	0	25.34	0	0.31	25.26	9690.2	14620.9	131.8	1137.5	17.84	5264.1	6.86	727	0	0	416.1	0	0	0	0	0	0											275/day for 1st 10 days	275/day for 1st 10 days	150/day for 1st 20 days	0 Copay	90/trip	25 coinsurance	25 coinsurance	50/ER Visit 25 Urgent Care Center visit	25 coinsurance	0 Copay	25 coinsurance	0 Copay	25 coinsurance	25 coinsurance PBP line9d	10/visit 25 coinsurance surgery	15/visit 25 coinsurance surgery	25/visit	25/visit	25 coinsurance	15/visit 20 coinsurance misc.	25 coinsurance	15/visit	0 Copay	0 Copay	15 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay											275	275	150	0	90	0.25	0.25	42.66	0.25	0	0.25	0	0.26	0.17	7.75	15.3	25	25	0.25	12.76	0.25	15	0	0	15	0	0	0	0	0	0											17.39	0.35	4.01	-	0.97	1.98	1.23	1.29	6.12	-	6.33	-	0.08	4.17	6.26	18.64	0.27	2.37	4.46	5.6	1.72	0.91	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.66	0	0	17.39	0.35	4.01	-	0.97	1.98	1.23	1.29	6.12	-	6.33	-	0.08	4.17	6.26	18.64	0.27	2.37	4.46	5.6	1.72	0.91	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.66																																																																																				-			17.39	0.35	4.01	-	0.97	1.98	1.23	1.29	6.12	-	6.33	-	0.08	4.17	6.26	18.64	0.27	2.37	4.46	5.6	1.72	0.91	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	84.66
H5969_002_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin								V																																																					-		309.6	25.59	35.22	25.46	8.87	20.93	13.45	10.37	21.57	15.1	30.22	0	3.07	43.2	64.89	109.97	7.19	4.01	18.39	36.13	9.13	4.87	0	0	0	0	0	0	0	0	0											Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare coinsurance	0 Copay	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	Medicare deductible/coinsurance	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay	0 Copay											0.07	0.07	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.13	1.83	5.61	-	2.09	4.94	3.17	2.45	5.09	3.56	7.13	-	0.72	10.2	15.31	25.95	1.7	0.95	4.34	8.53	2.15	1.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.01	138	0	22.13	1.83	5.61	-	2.09	4.94	3.17	2.45	5.09	3.56	7.13	-	0.72	10.2	15.31	25.95	1.7	0.95	4.34	8.53	2.15	1.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.01																																																																																				-			22.13	1.83	5.61	-	2.09	4.94	3.17	2.45	5.09	3.56	7.13	-	0.72	10.2	15.31	25.95	1.7	0.95	4.34	8.53	2.15	1.15	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	129.01
H5980_001_0	2007	19																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		670.06	11.58	502.53	0	28.52	5.3	17.26	11.05	10.25	20.83	16.94	0.66	0.99	115.94	0	162.12	7.28	1.19	29.57	49.36	3.95	4.74	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9A OP Hospital:  138 Ded and 20 Coinsurance   9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	5 Partial Hosp:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 0 14B Immunizations: 0 14C Routine Physical Exam: 0  14D Pap Smears:  0 14D Pelvic Exams:  0 14E Prostate Screening:  0 14F Colorectal Screening:  0 14G Bone Mass Measurement:  0 14H Mammography:  0 14I Diabetes Monitoring:  0	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance   9C OP Substance Abuse:  138 Ded and 20 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance for Radiology Services	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 0 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: 12 Trips Per Year	16A Preventive Dental Services: Not Covered  16B Comprehensive Dental Services:  Not Covered	17A Routine Eye Exams: 0 Copay	17B Eye Wear: 1 Pair of Glasses or Contacts Per Year	18A Routine Hearing Exams: 20 Coinsurance	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0.07	0.07	0.2	0	0.24	0.24	0.24	0.2	0.24	0.24	0.24	0.24	0.24	0.24	0	0.22	0.24	0.24	0.24	0.23	0.24	0.24	0	0	0	0	0	0	0	0	0											46.08	0.8	98.17	-	6.73	1.25	4.07	2.23	2.42	4.92	4	0.16	0.23	27.36	-	36.15	1.72	0.28	6.98	11.33	0.93	1.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	256.92	0	0	46.08	0.8	98.17	-	6.73	1.25	4.07	2.23	2.42	4.92	4	0.16	0.23	27.36	-	36.15	1.72	0.28	6.98	11.33	0.93	1.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	256.92																																																																																				-			46.08	0.8	98.17	-	6.73	1.25	4.07	2.23	2.42	4.92	4	0.16	0.23	27.36	-	36.15	1.72	0.28	6.98	11.33	0.93	1.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	256.92
H5980_002_0	2007	20																																D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 0 copay	1B IP Psych: 0 copay	2 SNF: 0 copay	6 Home Health: 0 copay	10A Ambulance: 0 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 0 copay  4B Urgent Care: 0 copay	9A Outpatient Hospital: 0 copay   9B ASC Services: 0 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay	5  Partial Hosp:  0 copay	12 Renal Dialysis: 0 copay	3 CORF: 0 copay  9D Cardiac Rehab: 0 copay	7A PCP: 0 copay 14B Immunizations: 0 copay 14C Routine Physical:  0 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 0 copay	7E Mental Health:   0 copay 7H Psychiatric:   0 copay   9C OP Substance Abuse: 0 copay	7C Occupational Therapy:  0 copay 7I Physical and Speech Therapy:  0 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  0 copay 7F Podiatry:  0 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  0 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay	10B Transportation: 12 Trips Per Year	16A Preventive Dental Services: Not covered  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 0 copay	17B Eye Wear: 1 Pair of Glasses or Contacts Per Year	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: Not Covered	13B Acupuncture: Not Covered											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H5985_001_0	2007	4																																D	D	D	V	T	Coin	Coin	V	V	Coin	P	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	P	V	V	V	V	P	V	V	V	V	V	V	V	V	V	V																																										-		1045.25	64.45	493.22		147.29	5.27	6.4	216.62	434.29	5.55	541.91	80.24	0.8	315.06		6051.67	255.12	1158.08	4354.18		22.82				127.95						1200											#1A: 100 copay days 1-3; #13A 20 coin	#1B: 956 deductible; 239 copay days 61 - 90	#2: 75 copay days 61-90	#6: 0 copay	#10A: 100 copay	#11A: 20 coin	#11B/11C: 20 coin	#4A: 50; #4B: 0 PCP Office; #4B: 35 Urgent Care Center	#9A: 250; #9B: 150; #14F: 20 coin	#8A: 20 coin	#8A: 20; #8B: 150 copay	#9A: 20 coin	#12: 30 copay	#3: 20; #5: 35#9A: 20; #9C: 35; #9D: 20	#7A: 0 copay	#7B/F/G #17A  #18A: 30; #7D: 35; #14F: 25	#7E/7H: 35 copay	#7C/7I: 30; #14I Nutrition Therapy: 5	#7D Radiology: 35	#14I: 20 coin; #17A: 30 copay	Part B Rx: 20	0 copay	0 copay	0 copay	#17A: 10	#17B: 50 annual allowance	0 copay	0 copay	0 copay	0 copay	#13A: 20 coin; #13C: 15 copay											41.97	50.14	22.51		100	0.2	0.2	49.7	177.8	0.2	63.04	75.67	30	53.64		30.7	35	29.86	35		0.2				10						15.33											3.66	0.27	0.93	-	1.23	1.05	1.28	0.9	6.43	1.11	2.85	0.51	0	1.41	-	15.48	0.74	2.88	12.7	-	4.56	-	-	-	0.11	-	-	-	-	-	1.53	-	-	-	-	-	-	-	-	-	-	59.63	0	0	3.66	0.27	0.93	-	1.23	1.05	1.28	0.9	6.43	1.11	2.85	0.51	0	1.41	-	15.48	0.74	2.88	12.7	-	4.56	-	-	-	0.11	-	-	-	-	-	1.53	-	-	-	-	-	-	-	-	-	-	59.63																																																																																				-	0	0	3.66	0.27	0.93	-	1.23	1.05	1.28	0.9	6.43	1.11	2.85	0.51	0	1.41	-	15.48	0.74	2.88	12.7	-	4.56	-	-	-	0.11	-	-	-	-	-	1.53	-	-	-	-	-	-	-	-	-	-	59.63
H5985_002_0	2007	5																																Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	V	V	V	V	V	V	V	V	V	V																																										-		336.71	40.63	33.94		12.51	26.27	27.51	26.06	32.36	23.05	22.32	2.97	2.66	29.63	25.86	33.67	10.41	16.16	24.6	105.31	27.22										0.16											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing									#14A: 0 copay	#13A: 20 coin											0.07	0.07	0.15		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24										0.2											23.87	2.88	5.12	-	2.95	6.2	6.49	6.15	7.64	5.44	5.27	0.7	0.63	6.99	6.1	7.95	2.46	3.81	5.81	24.85	6.42	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	137.77			23.87	2.88	5.12	-	2.95	6.2	6.49	6.15	7.64	5.44	5.27	0.7	0.63	6.99	6.1	7.95	2.46	3.81	5.81	24.85	6.42	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	137.77																																																																																				-			23.87	2.88	5.12	-	2.95	6.2	6.49	6.15	7.64	5.44	5.27	0.7	0.63	6.99	6.1	7.95	2.46	3.81	5.81	24.85	6.42	-	-	-	-	-	-	-	-	-	0.03	-	-	-	-	-	-	-	-	-	-	137.77
H5989_002_0	2007	8																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	667.15	55.14	119.04	0	15.43	36.41	23.43	10.54	21.37	14.97	29.95	0.98	1.13	41.31	99.59	178.93	18.48	9.59	43.85	77.89	9.67	5.47	0	0	0	0	0	0	0	0	0											5.04 Medicare equivalent coinsurance	5.04 Medicare equivalent coinsurance	16.94 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	22.89 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.59 Medicare equivalent coinsurance	23.03 Medicare equivalent coinsurance	22.94 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	23.60 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance	0.00 Medicare equivalent coinsurance											0.05	0.05	0.17	0	0.24	0.24	0.24	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.23	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											33.62	2.78	20.17	-	3.64	8.59	5.53	2.41	5.04	3.53	7.07	0.23	0.27	9.75	22.93	41.04	4.36	2.26	10.35	18.38	2.28	1.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	205.54	0	0	33.62	2.78	20.17	-	3.64	8.59	5.53	2.41	5.04	3.53	7.07	0.23	0.27	9.75	22.93	41.04	4.36	2.26	10.35	18.38	2.28	1.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	205.54	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	33.62	2.78	20.17	-	3.64	8.59	5.53	2.41	5.04	3.53	7.07	0.23	0.27	9.75	22.93	41.04	4.36	2.26	10.35	18.38	2.28	1.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	205.54
H5989_003_0	2007	5																					0											A	A	D	V	T	O	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	456.88	55.47	2945.62	0	473.76	0	20.71	531.28	191.23	0	0	0	0	549.04	8990.2	11854.85	2475.06	1146.12	0	2312.82	668.21	561.54	0	0	317.44	0	188.43	0	0	0	148.61											PBP: 1A IP Acute: 300 per admit	1B IP Psych: 300 per admit	2 SNF: 50 for days 21-100	6 Home Health: 0	10A Ambulance: 50	11A DME: 0	11B Prosthetic Medical Supplies: 20 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 50	9B ASC Services: 100	8A OP C/D/T: 0	8B OP X-Ray: 0	9A OP Hospital: 0	12 Renal Dialysis: 0	3 CORF: 25 9C OP Substance Abuse: 25 9D Cardiac Rehab: 25	7A PCP: 10 14B Immunizations: 0 14C Routine Physical Exams: 10 14D Pap Smears: 10 14D Pelvic Exams: 10 14E Prostate Screening: 10 14F Colorectal Screening: 10 14G Bone Mass Measurement: 10 14H Mammography: 10 14I Diabetes Monitoring: 10	7D Physician Specialist: 25	7E Mental Health: 25 7H Psychiatric: 25	7C Occupational Therapy: 25 7I Physical and Speech Therapy: 25	Included in i.2.	7B Chiropractic: 25 7F Podiatry: 25 7G Other Health Care: 25 18A Medicare Covered Hearing Exams: 25	15 Part B Drugs: 10-70	13A Blood: 0 16B Comprehensive Dental Services: not covered 17A Medicare Covered Eye Exams: 25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 25	17B Eye Wear: Medicare Covered: 0 Routine: Not Covered	18A Routine Hearing Exams: 25	18B Hearing Aids: 0	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: 25											300	300	24	0	50	0	0.2	50	100	0	0	0	0	25	10.13	25	25	25	0	25	40	25	0	0	25	0	25	0	0	0	25											11.42	1.39	5.89	-	1.97	-	4.11	2.21	1.59	-	-	-	-	1.14	7.59	24.7	5.16	2.39	-	4.82	2.23	1.17	-	-	0.66	-	0.39	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	79.14	0	0	11.42	1.39	5.89	-	1.97	-	4.11	2.21	1.59	-	-	-	-	1.14	7.59	24.7	5.16	2.39	-	4.82	2.23	1.17	-	-	0.66	-	0.39	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	79.14	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.42	1.39	5.89	-	1.97	-	4.11	2.21	1.59	-	-	-	-	1.14	7.59	24.7	5.16	2.39	-	4.82	2.23	1.17	-	-	0.66	-	0.39	-	-	-	0.31	-	-	-	-	-	-	-	-	-	-	79.14
H5991_001_0	2007	2																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	V	V	V	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-									557.56						489.33		5270	2058.94	2051.4																															#4A: 50 #4B: 10						#5 #9C: 20		#7D/F/G: 10	#7E/#7H: 20	#7C/#7I: 10																															49.2						20		10	20	10																								-	-	-	-	-	-	-	2.29	-	-	-	-	-	0.82	-	4.39	3.43	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.63		0	-	-	-	-	-	-	-	2.29	-	-	-	-	-	0.82	-	4.39	3.43	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.63																																																																																				-		0	-	-	-	-	-	-	-	2.29	-	-	-	-	-	0.82	-	4.39	3.43	1.71	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.63
H5991_002_0	2007	3																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-									538.71																																									#4a: 25																																									25																																		-	-	-	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.12		0	-	-	-	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.12																																																																																				-		0	-	-	-	-	-	-	-	1.12	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	1.12
H5992_001_0	2007	4																					0											A	A	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	397.48	46.37	0	3420	515.08	0	0	771.83	287.1	0	0	0	0	71.88	7577.53	6578.29	1577.85	795.65	0	1533.7	0	0	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 300 copay per stay	1B IP Psych: 300 copay per stay	2 SNF: 0 copay	6 Home Health: 10 copay	10A Ambulance: 50 copay	11A DME:  0 coins	11B Prosthetic Medical Supplies: 0 copay 11C Diabetes Monitoring Supplies: 0 copay	4A ER: 50 copay  4B Urgent Care: 20 copay	9A Outpatient Hospital: 35 copay   9B ASC Services: 35 copay	8A OP C/D/T: 0 copay	8B OP X-Ray: 0 copay	0	12 Renal Dialysis: 0 copay	3 CORF: 20 copay  5  Partial Hosp:  0 copay 9D Cardiac Rehab: 20 copay	7A PCP: 10 copay 14B Immunizations: 0 copay 14C Routine Physical:  10 copay  14D Pap Smears:  0 copay 14D Pelvic Exams:  0 copay 14E Prostate Screening:  0 copay 14F Colorectal Screening:  0 copay 14G Bone Mass Measurement:  0 copay 14H Mammography:  0 copay 14I Diabetes Monitoring:  0 copay	7D Physician Specialist: 20 copay	7E Mental Health:   20 copay 7H Psychiatric:   20 copay    9C OP Substance Abuse: 20 copay	7C Occupational Therapy:  20 copay 7I Physical and Speech Therapy:  20 copay	7D Physician Specialist: 0 copay for radiology services	7B Chiropractic:  20 copay 7F Podiatry:  20 copay for medically necessary services 0 copay for 4 routine exams 7G Other Health Care:  20 copay 18A Medicare Covered Hearing Exams:  0 copay	15 Part B Drugs: 0 copay	13A Blood: 0 copay 17A Medicare Covered Eye Exams: 0 copay	10B Transportation: Not Covered	16A Preventive Dental Services: Not covered  16B Comprehensive Dental Service: Not covered	17A Routine Eye Exams: 0 copay	17B Eye Wear:  0 copay	18A Routine Hearing Exams: 0 copay	18B Hearing Aids: 0 copay	19 POS: N/A	14A Health Education/Wellness Programs: 0 copay	13B Acupuncture: Not Covered											300	300	0	10	50	0	0	48.97	35	0	0	0	0	20	10	20	20	20	0	20	0	0	0	0	0	0	0	0	0	0	0											9.94	1.16	-	2.85	2.15	-	-	3.15	0.84	-	-	-	-	0.12	6.31	10.96	2.63	1.33	-	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.99	0	0	9.94	1.16	-	2.85	2.15	-	-	3.15	0.84	-	-	-	-	0.12	6.31	10.96	2.63	1.33	-	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.99	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	9.94	1.16	-	2.85	2.15	-	-	3.15	0.84	-	-	-	-	0.12	6.31	10.96	2.63	1.33	-	2.56	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	43.99
H5995_001_0	2007	6																					None											Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0		0.55	1.3	0.83	0.44	0.84	0.59	1.17	0	0.12	1.68	2.11	4.41	0.34	0.19	0.8	1.44	0.37	0.16																				17.32	N/A	336.3	27.85	28.79		15.27	36.07	23.17	12.27	23.25	16.28	32.57	0	3.32	46.56	58.68	122.41	9.36	5.22	22.25	39.91	10.16	4.45																				Medicare Cost-Sharing	Medicare Cost-Sharing	Medicare Cost-Sharing		20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max	20 Cost-Sharing no OOP Max																				0.07	0.07	0.14		0.2	0.2	0.2	0.2	0.2	0.2	0.2	0	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2	0.2																				25.05	2.07	3.91	-	3.05	7.21	4.63	2.45	4.65	3.26	6.51	-	0.66	9.31	11.74	24.48	1.87	1.04	4.45	7.98	2.03	0.89	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	127.27	138		25.05	2.07	3.91	-	3.6	8.51	5.47	2.9	5.49	3.84	7.69	-	0.78	10.99	13.85	28.89	2.21	1.23	5.25	9.42	2.4	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.59	N/A																																																																																			-			25.05	2.07	3.91	-	3.6	8.51	5.47	2.9	5.49	3.84	7.69	-	0.78	10.99	13.85	28.89	2.21	1.23	5.25	9.42	2.4	1.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	144.59
H5996_001_0	2007	1																					3100											A	A	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	263.3	2.65	1183.9	0	226.98	23.21	1.07	266.93	265.99	0	24.87	0	0.26	507.61	4003.84	5410.76	164.47	563.77	32.49	230.24	6.73	691.94	0	0	0	0	0	0	0	0	0											300 per admit	300 per admit	1-8: 0/Day 9-100: 75/Day		100	30	30	50 ER / 30 UC	75		15 for x-rays/30 for CT/MRI/PET/Nuclear		0	25 OP SA/15 OP Therapy	5 PCP	15 SCP / 15 Chiro / 15 Podiatrist	25 MH	15 Therapy		15 Hearing / 0 Preventive	30	15 Vision/0 Blood																				269.86	269.86	38.7	0	89.95	0.27	0.27	38.88	67.47	0	0.23	0	0	13.8	4.5	13.47	22.49	13.49	0	4.98	0.27	12.45	0	0	0	0	0	0	0	0	0											5.92	0.06	3.82	-	1.7	6.26	0.29	0.86	1.5	-	5.73	-	-	0.58	1.5	6.08	0.31	0.63	-	0.1	1.82	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	0	4.23	5.92	0.06	3.82	-	1.7	6.26	0.29	0.86	1.5	-	5.73	-	-	0.58	1.5	6.08	0.31	0.63	-	0.1	1.82	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88	3100																																																																																			-	0	0	5.92	0.06	3.82	-	1.7	6.26	0.29	0.86	1.5	-	5.73	-	-	0.58	1.5	6.08	0.31	0.63	-	0.1	1.82	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	37.88
H5996_002_0	2007	1																					3100											D	D	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	911.71	11.29	1012.89	0	251.75	27.29	1.26	293.93	292.84	0	27.08	0	0.24	555.86	3610.41	4833.62	150.59	499.48	28.92	207.99	7.32	638.74	0	0	0	0	0	0	0	0	0											200 per day; days 1-5	200 per day; days 1-	1-8: 0/Day 9-100: 100/Day		150	30	30	50 ER / 30 UC	100		15 for x-rays/30 for CT/MRI/PET/Nuclear		0	30 OP SA/20 OP Therapy	10 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	20 Therapy		30 Hearing / 0 Preventive	30	30 Vision/0 Blood																				165.48	165.48	47.46	0	124.11	0.25	0.25	35.76	82.74	0	0.21	0	0	16.78	8.27	24.78	24.82	16.55	0	9.2	0.25	22.53	0	0	0	0	0	0	0	0	0											12.57	0.16	4.01	-	2.6	6.77	0.31	0.88	2.02	-	5.75	-	-	0.78	2.49	9.98	0.31	0.69	-	0.16	1.82	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.49	0	10.95	12.57	0.16	4.01	-	2.6	6.77	0.31	0.88	2.02	-	5.75	-	-	0.78	2.49	9.98	0.31	0.69	-	0.16	1.82	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.49	3100																																																																																			-	0	0	12.57	0.16	4.01	-	2.6	6.77	0.31	0.88	2.02	-	5.75	-	-	0.78	2.49	9.98	0.31	0.69	-	0.16	1.82	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	52.49
H5996_003_0	2007	1																					3100											D	D	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1015.42	12.81	1183.03	0	279.63	29.89	1.38	346.78	345.52	0	30.67	0	0.27	654.35	3986.37	5315.85	163.9	543.73	32.66	229.65	8.29	709.7	0	0	0	0	0	0	0	0	0											200 per day; days 1-5	200 per day; days 1-	1-8: 0/Day 9-100: 100/Day		150	30	30	50 ER / 30 UC	100		15 for x-rays/30 for CT/MRI/PET/Nuclear		0	30 OP SA/20 OP Therapy	10 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	20 Therapy		30 Hearing / 0 Preventive	30	30 Vision/0 Blood																				160.32	160.32	45.98	0	120.24	0.24	0.24	34.65	80.16	0	0.21	0	0	16.24	8.01	24	24.05	16.03	0	8.92	0.24	21.69	0	0	0	0	0	0	0	0	0											13.57	0.17	4.53	-	2.8	7.19	0.33	1	2.31	-	6.34	-	-	0.89	2.66	10.63	0.33	0.73	-	0.17	1.99	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.93	0	14.09	13.57	0.17	4.53	-	2.8	7.19	0.33	1	2.31	-	6.34	-	-	0.89	2.66	10.63	0.33	0.73	-	0.17	1.99	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.93	3100																																																																																			-	0	0	13.57	0.17	4.53	-	2.8	7.19	0.33	1	2.31	-	6.34	-	-	0.89	2.66	10.63	0.33	0.73	-	0.17	1.99	1.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	56.93
H5996_004_0	2007	1																					3100											D	D	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1272.39	15.07	1279.16	0	319.56	34.71	1.6	304.23	303.14	0	28.49	0	0.26	575.92	3774.53	5091.35	161.56	536.11	31.92	217.44	7.7	667.22	0	0	0	0	0	0	0	0	0											200 per day; days 1-5	200 per day; days 1-	1-8: 0/Day 9-100: 100/Day		150	30	30	50 ER / 30 UC	100		15 for x-rays/30 for CT/MRI/PET/Nuclear		0	30 OP SA/20 OP Therapy	10 PCP	30 SCP / 30 Chiro / 30 Podiatrist	30 MH	20 Therapy		30 Hearing / 0 Preventive	30	30 Vision/0 Blood																				157.79	157.79	45.26	0	118.34	0.24	0.24	34.1	78.89	0	0.2	0	0	16.01	7.89	23.62	23.67	15.78	0	8.78	0.24	21.5	0	0	0	0	0	0	0	0	0											16.73	0.2	4.82	-	3.15	8.22	0.38	0.86	1.99	-	5.76	-	-	0.77	2.48	10.02	0.32	0.7	-	0.16	1.82	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.59	0	15.94	16.73	0.2	4.82	-	3.15	8.22	0.38	0.86	1.99	-	5.76	-	-	0.77	2.48	10.02	0.32	0.7	-	0.16	1.82	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.59	3100																																																																																			-	0	0	16.73	0.2	4.82	-	3.15	8.22	0.38	0.86	1.99	-	5.76	-	-	0.77	2.48	10.02	0.32	0.7	-	0.16	1.82	1.2	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	59.59
H5996_005_0	2007	1																					3100											D	D	D	V	T	coin	coin	V	V	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	634.17	8	618.5	0	164.84	16.06	0.74	363.58	343.47	0	25.26	0	0.16	644.99	3952.61	4920.86	112.07	403.99	18.06	231	6.83	726.77	0	0	0	0	0	0	0	0	0											100 per day; days 1-5	100 per day; days 1-	1-8: 0/Day 9-100: 120/Day		150	30	30	50 ER / 0 UC	50		15 for x-rays/30 for CT/MRI/PET/Nuclear		0	20 OP SA/5 OP Therapy	5 PCP	5 SCP / 5 Chiro / 5 Podiatrist	20 MH	5 Therapy		5 Hearing / 0 Preventive	30	5 Vision/0 Blood																				93.9	93.9	64.64	0	140.85	0.28	0.28	31.04	46.95	0	0.25	0	0	4.95	4.7	4.7	18.78	4.7	0	1.78	0.28	4.25	0	0	0	0	0	0	0	0	0											4.96	0.06	3.33	-	1.93	4.52	0.21	0.94	1.34	-	6.28	-	-	0.27	1.55	1.93	0.18	0.16	-	0.03	1.92	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88	0	1.94	4.96	0.06	3.33	-	1.93	4.52	0.21	0.94	1.34	-	6.28	-	-	0.27	1.55	1.93	0.18	0.16	-	0.03	1.92	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88	3100																																																																																			-	0	0	4.96	0.06	3.33	-	1.93	4.52	0.21	0.94	1.34	-	6.28	-	-	0.27	1.55	1.93	0.18	0.16	-	0.03	1.92	0.26	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.88
H5996_006_0	2007	2																					1000											A	A	D	V	T	coin	coin	V	coin	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	295.78	2.99	1162.11	0	239.72	25.63	1.18	363.98	28.23	0	30.04	0	0.29	19.99	0	0	190.44	0	35.06	0	8.12	69.22	0	0	0	0	0	0	0	0	0													1-8: 0/Day 9-100: 75/Day		100	30	30	50 ER / 0 UC			15 for x-rays/30 for CT/MRI/PET/Nuclear		0	10 OP SA/0 OP Therapy	0 PCP	0 SCP / 0 Chiro / 0 Podiatrist	10 MH	0 Therapy		0 Hearing / 0 Preventive	30	0 Vision/0 Blood																				0	0	32.09	0	74.6	0.22	0.22	24.66	0	0	0.19	0	0	7.46	0	0	7.46	0	0	0	0.22	0	0	0	0	0	0	0	0	0	0											-	-	3.11	-	1.49	5.74	0.26	0.75	-	-	5.79	-	-	0.01	-	-	0.12	-	-	-	1.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.09	0	6.5	-	-	3.11	-	1.49	5.74	0.26	0.75	-	-	5.79	-	-	0.01	-	-	0.12	-	-	-	1.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.09	1000																																																																																			-	0	0	-	-	3.11	-	1.49	5.74	0.26	0.75	-	-	5.79	-	-	0.01	-	-	0.12	-	-	-	1.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.09
H5996_007_0	2007	1																					1000											A	A	D	V	T	coin	coin	V	coin	P	coin	O	coin	P	V	V	V	V	coin	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	345.83	3.49	1395.76	0	302.51	31.77	1.47	329.17	27.9	0	29.69	0	0.29	20.9	0	0	199.05	0	41.64	0	8.03	62.59	0	0	0	0	0	0	0	0	0													1-8: 0/Day 9-100: 75/Day		100	30	30	50 ER / 0 UC			15 for x-rays/30 for CT/MRI/PET/Nuclear		0	10 OP SA/0 OP Therapy	0 PCP	0 SCP / 0 Chiro / 0 Podiatrist	10 MH	0 Therapy		0 Hearing / 0 Preventive	30	0 Vision/0 Blood																				0	0	30.83	0	71.66	0.21	0.21	23.69	0	0	0.18	0	0	7.17	0	0	7.17	0	0	0	0.21	0	0	0	0	0	0	0	0	0	0											-	-	3.59	-	1.81	6.83	0.32	0.65	-	-	5.44	-	-	0.01	-	-	0.12	-	-	-	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.48	0	8.1	-	-	3.59	-	1.81	6.83	0.32	0.65	-	-	5.44	-	-	0.01	-	-	0.12	-	-	-	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.48	1000																																																																																			-	0	0	-	-	3.59	-	1.81	6.83	0.32	0.65	-	-	5.44	-	-	0.01	-	-	0.12	-	-	-	1.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	20.48
H5996_008_0	2007	1																					500											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	323.38	3.29	2989.13	0	234	25.95	1.19	436.09	30.84	0	0	0	0.32	409	5220.78	7122.83	209.18	754.13	0	305.09	8.87	951.49	0	0	0	0	0	0	0	0	0													1-20: 0/Day 21-100: 50/Day		100	20	20	50 ER / 0 UC			for x-rays/0 for CT/MRI/PET/Nuclear		0	20 OP SA/5 OP Therapy	5 PCP	5 SCP / 5 Chiro / 5 Podiatrist	20 MH	5 Therapy		5 Hearing / 0 Preventive	20	5 Vision/0 Blood																				0	0	7.57	0	63.53	0.1	0.13	21	0	0	0	0	0	3.69	3.18	3.18	12.71	3.18	0	1.2	0.13	2.9	0	0	0	0	0	0	0	0	0											-	-	1.89	-	1.24	2.69	0.15	0.76	-	-	-	-	-	0.13	1.38	1.89	0.22	0.2	-	0.03	1.13	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.93	0	6.85	-	-	1.89	-	1.24	2.69	0.15	0.76	-	-	-	-	-	0.13	1.38	1.89	0.22	0.2	-	0.03	1.13	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.93	500																																																																																			-	0	0	-	-	1.89	-	1.24	2.69	0.15	0.76	-	-	-	-	-	0.13	1.38	1.89	0.22	0.2	-	0.03	1.13	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.93
H5996_009_0	2007	3																					500											A	A	D	V	T	coin	coin	V	coin	P	P	O	coin	P	V	V	V	V	P	V	coin	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	323.38	3.29	2989.13	0	234	25.95	1.19	436.09	30.84	0	0	0	0.32	408.51	5220.78	7018.29	204.54	754.13	0	300.47	8.87	916.75	0	0	0	0	0	0	0	0	0													1-20: 0/Day 21-100: 50/Day		100	20	20	50 ER / 0 UC			for x-rays/0 for CT/MRI/PET/Nuclear		0	25 OP SA/5 OP Therapy	5 PCP	5 SCP / 10 Chiro / 10 Podiatrist	25 MH	5 Therapy		10 Hearing / 0 Preventive	20	10 Vision/0 Blood																				0	0	7.37	0	61.83	0.1	0.12	20.44	0	0	0	0	0	3.74	3.09	3.98	15.46	3.09	0	2.28	0.12	5.62	0	0	0	0	0	0	0	0	0											-	-	1.84	-	1.21	2.62	0.15	0.74	-	-	-	-	-	0.13	1.35	2.33	0.26	0.19	-	0.06	1.1	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.39	0	7.65	-	-	1.84	-	1.21	2.62	0.15	0.74	-	-	-	-	-	0.13	1.35	2.33	0.26	0.19	-	0.06	1.1	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.39	500																																																																																			-	0	0	-	-	1.84	-	1.21	2.62	0.15	0.74	-	-	-	-	-	0.13	1.35	2.33	0.26	0.19	-	0.06	1.1	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.39
H5996_801_0	2007	5																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5996_802_0	2007	5																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5996_803_0	2007	5																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5996_804_0	2007	5																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	310.33	2.38	44.43	0	7.69	26.36	1.21	5.84	30.35	11.81	32.3	0	0.26	31.28	47.39	138.98	1.42	4.84	31.31	26.36	8.73	6.31	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.18	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02	none																																																																																			-	0	0	22.49	0.17	8.02	-	1.82	6.22	0.29	1.38	7.16	2.79	7.62	-	0.06	7.38	11.18	32.8	0.33	1.14	7.39	6.22	2.06	1.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	128.02
H5998_001_0	2007	4																																D	D	D		T	Coin	Coin	V	V					V	V	V	V	V	V	V				V																																																											-		1205.93	22.21	1100.53		221.8	6.91	4.92	249.89	241.82					337.67	6675.97	9231.08	473.71	1596.53	1076.17	711.54				1831.26																		150/day - 1st 15 days	150/day - 1st 15 days	85/day - after 5 days		150/Service	20	20 except 10 diabetic supplies	50/visit	250/visit					30/visit (RT/PT/OT/ST/)	15/office visit	30/ office visit	30/office visit	30/visit	30/therapy visit	30/chiro or pod visit				30/visit																		150	150	85		150	0.2	0.16	50	250					30	15	30	30	30	30	30				30																		15.07	0.28	7.8	-	2.77	1.38	0.78	1.04	5.04	-	-	-	-	0.84	8.34	23.08	1.18	3.99	2.69	1.78	-	-	-	4.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.65	0		15.07	0.28	7.8	-	2.77	1.38	0.78	1.04	5.04	-	-	-	-	0.84	8.34	23.08	1.18	3.99	2.69	1.78	-	-	-	4.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.65																																																																																				-			15.07	0.28	7.8	-	2.77	1.38	0.78	1.04	5.04	-	-	-	-	0.84	8.34	23.08	1.18	3.99	2.69	1.78	-	-	-	4.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.65
H5998_002_0	2007	4																					2000											D	D	D		T	Coin	Coin	V	V					V	V	V	V	V	V	V				V																																																											-		1163.44	21.42	1166.44		235.08	7.33	5.22	264.86	256.3					357.9	7075.82	9783.97	502.08	1692.15	1140.62	754.16				2125.93																		95/day - 1st 10 days	95/day - 1st 10 days	75/day - after 5 days		150/Service	20	20 except 10 diabetic supplies	50/visit	250/visit					30/visit (RT/PT/OT/ST/)	15/office visit	30/ office visit	30/office visit	30/visit	30/therapy visit	30/chiro or pod visit				30/visit																		90.25	90.25	71.25		142.5	0.19	0.15	47.5	237.5					28.5	14.25	28.5	28.5	28.5	28.5	28.5				30																		8.75	0.16	6.93	-	2.79	1.39	0.79	1.05	5.07	-	-	-	-	0.85	8.4	23.24	1.19	4.02	2.71	1.79	-	-	-	5.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.45		3.92	8.75	0.16	6.93	-	2.79	1.39	0.79	1.05	5.07	-	-	-	-	0.85	8.4	23.24	1.19	4.02	2.71	1.79	-	-	-	5.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.45																																																																																				-			8.75	0.16	6.93	-	2.79	1.39	0.79	1.05	5.07	-	-	-	-	0.85	8.4	23.24	1.19	4.02	2.71	1.79	-	-	-	5.31	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	74.45
H5998_003_0	2007	2																																A	A	D		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																									0.14	0.36	0.23	0.74	2.52	0.27	0.76	0	0	2.55	0.97	4.3	0.07	0.16	0.75	0.74	0																					14.54		256.1	7.69	792.56		3.81	10.08	6.28	20.51	70.06	7.45	21			70.73	26.98	119.56	1.84	4.41	20.79	20.43	0																					Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare	Std Medicare																					1014	1014	127		20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20	20																					21.64	0.65	8.37	-	0.76	2.02	1.26	4.1	14.01	1.49	4.2	-	-	14.15	5.4	23.91	0.37	0.88	4.16	4.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.44			21.64	0.65	8.37	-	0.9	2.38	1.48	4.84	16.53	1.76	4.95	-	-	16.69	6.37	28.22	0.43	1.04	4.91	4.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.98																																																																																				-			21.64	0.65	8.37	-	0.9	2.38	1.48	4.84	16.53	1.76	4.95	-	-	16.69	6.37	28.22	0.43	1.04	4.91	4.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	125.98
H6421_001_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	V	P	Coin	P	Coin	Coin	V	V	V	V	P	V	Coin	Coin	T	V	V	P	V	P	O	O	V	P	P	P	P	P	P	P	P	P	P																																										-		1620.07	65.43	786.06		69.6	7.17	9.64	298.74	499.58		30.72		0.46	19.3	3849.08	6264.73	379.06	693.05		7.7	24.69	0.11																				#1A 150/day days 1-4 0/day days 5-90	#1B 150/day days 1-4 0/day days 5-90	#2 0/day days 1-10 115/day days 11-100	#6 0	#10A 150	#11A 30	#11B 30 #11C 20	#4A 50 #4B 40	#9A 150 #9B 100	#8A 0 diag lab	#8A 20 #8B 25		#12 20	#3 20 #5 20 #9C 25 #9D 25	#7A 5 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0	#7B 10 #7D 10 #7F 10 #7G 10	#7E 25 #7H 25	#7C 25 #7I 25		#14I 0	#15 20	#13A 20	#10B 0 n/c	#16A 0 n/c #16B 0	#17A 0	#17B 0	#18A 0	#18B 0 n/c	#19 0 n/c	#14A 0 n/c	#13B 0 n/c											78.32	78.32	51.33		145.57	0.29	0.29	47.55	119.4		0.08		0.19	0.05	4.85	12.22	24.05	24.26		4.85	0.19	0.4																				10.57	0.43	3.36	-	0.84	2.09	2.78	1.18	4.97	-	2.54	-	0.09	0.87	1.56	6.38	0.76	1.4	-	0	4.79	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.66		1.36	10.57	0.43	3.36	-	0.84	2.09	2.78	1.18	4.97	-	2.54	-	0.09	0.87	1.56	6.38	0.76	1.4	-	0	4.79	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.66		.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.	.																																										-		0	10.57	0.43	3.36	-	0.84	2.09	2.78	1.18	4.97	-	2.54	-	0.09	0.87	1.56	6.38	0.76	1.4	-	0	4.79	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.66
H6499_005_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2586.37	54.59	1916.89	2133.23	8.68	23.37	4.07	5.24	28.52	3553.27	28.64	0	8.45	18.47	25.65	67.86	2.27	1620.54	35.42	36215.46	9.1	7819.11	0	0	338.4	260.8	48.3	6.1	0	311.41	1812											952  0 (1-60) 238(61-90) 476 (91+)	952  0 (1-60) 238(61-90) 476 (91+)	119  Days 21 - 100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2 to 0.2		0.2 to 0.2	0.2	0.2	0 to 0.2	0.5 to 0.5	0.2	0 - 0.2	0 to 0.2	0 to 0.2	0	0		0	1pr glasses/cont per yr 260 max bft	0 copay for exams; 1000 max comb. bft	2 aids per 3yrs with 10 copay; 1000 max comb. Bft		0	0 to 0											85.34	31.11	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0	0.17	3.53	0.2	0	0	0	0	10	0	10	0	0	0											18.39	0.14	4.32	-	1.74	4.67	0.81	1.05	5.7	-	5.73	-	1.69	3.69	4.97	13.57	1.13	-	6.02	10.67	1.82	-	-	-	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	86.34		0	18.39	0.14	4.32	-	1.74	4.67	0.81	1.05	5.7	-	5.73	-	1.69	3.69	4.97	13.57	1.13	-	6.02	10.67	1.82	-	-	-	-	0.22	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	86.34	0																								0	50 coinsurance; 100 max bft	50 coinsurance; 100 max bft	50 coinsurance	50 coinsurance																																					0	0.18	0.26	0.03	0.06														0.53		0	18.39	0.14	4.32	-	1.74	4.67	0.81	1.05	5.7	-	5.73	-	1.69	3.69	4.97	13.57	1.13	-	6.02	10.67	1.82	-	-	-	0.18	0.48	0.03	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	86.87
H6499_006_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1796.85	37.93	1432.45	1028.96	6.56	17.68	3.79	746.88	578.04	4006.89	31.53	0	8.87	1071.25	4680.91	9859.42	1.09	964.52	21.67	98.9	9.55	14.98	0	0	0	0	0	0	0	223.19	549.36											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.31	3.54	0.76	-	-	-	1.58	-	1.77	-	-	-	0.01	-	0.69	1	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.65		0	-	-	-	-	1.31	3.54	0.76	-	-	-	1.58	-	1.77	-	-	-	0.01	-	0.69	1	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.65	0																																																																																			-		0	-	-	-	-	1.31	3.54	0.76	-	-	-	1.58	-	1.77	-	-	-	0.01	-	0.69	1	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	10.65
H6499_007_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1968.24	41.55	1473.89	1540.56	7.52	20.26	3.57	647	500.74	3471.05	27	0	7.48	928	5206.62	11215.27	1.21	1131.35	24.94	109.84	8.05	20.18	0	0	0	0	0	0	0	248.25	549.45											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.5	4.05	0.71	-	-	-	1.35	-	1.5	-	-	-	0.01	-	0.79	1.32	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.23		0	-	-	-	-	1.5	4.05	0.71	-	-	-	1.35	-	1.5	-	-	-	0.01	-	0.79	1.32	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.23	0																																																																																			-		0	-	-	-	-	1.5	4.05	0.71	-	-	-	1.35	-	1.5	-	-	-	0.01	-	0.79	1.32	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.23
H6499_008_0	2007	5																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2122.51	44.8	1526.31	1518.95	7.68	20.69	3.69	672.12	520.18	3605.82	28.17	0	7.81	964.03	5398.47	11809.02	1.31	1215.53	26.08	117.18	8.4	22.73	0	0	0	0	0	0	0	257.4	549.49											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.54	4.14	0.74	-	-	-	1.41	-	1.56	-	-	-	0.01	-	0.83	1.51	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.73		0	-	-	-	-	1.54	4.14	0.74	-	-	-	1.41	-	1.56	-	-	-	0.01	-	0.83	1.51	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.73	0																																																																																			-		0	-	-	-	-	1.54	4.14	0.74	-	-	-	1.41	-	1.56	-	-	-	0.01	-	0.83	1.51	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.73
H6499_009_0	2007	5																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2032.05	42.89	1762.35	1939.88	7.34	19.76	3.53	603.27	466.89	3236.42	26.77	0	7.46	865.27	5091.66	11172.89	1.29	1154.68	30.57	113.16	8.04	21.06	0	0	0	0	0	0	0	242.77	549.42											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.47	3.95	0.71	-	-	-	1.34	-	1.49	-	-	-	0.01	-	0.97	1.4	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.33		0	-	-	-	-	1.47	3.95	0.71	-	-	-	1.34	-	1.49	-	-	-	0.01	-	0.97	1.4	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.33	0																																																																																			-		0	-	-	-	-	1.47	3.95	0.71	-	-	-	1.34	-	1.49	-	-	-	0.01	-	0.97	1.4	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.33
H6499_010_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1949.64	41.15	1727.93	1559.41	7.48	20.15	3.27	481.48	372.64	2583.05	23.26	0	6.48	690.58	5108.93	11189.33	1.26	1153.55	31.03	113.17	6.98	22.21	0	0	0	0	0	0	0	243.59	549.32											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.01	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.5	4.03	0.65	-	-	-	1.16	-	1.3	-	-	-	0.01	-	0.99	1.47	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.11		0	-	-	-	-	1.5	4.03	0.65	-	-	-	1.16	-	1.3	-	-	-	0.01	-	0.99	1.47	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.11	0																																																																																			-		0	-	-	-	-	1.5	4.03	0.65	-	-	-	1.16	-	1.3	-	-	-	0.01	-	0.99	1.47	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.11
H6499_011_0	2007	3																					0											D	D	D	V	Coin	Coin	Coin	V	V	V	Coin	V	Coin	V	V	V	Coin	V	Coin	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2474.03	52.22	1848.72	2417.61	8.08	21.75	3.97	534.5	413.68	2867.53	30.59	0	8.5	766.64	5979.36	13996.52	1.79	1562.12	38.29	148.18	9.15	36.78	0	0	0	0	0	0	0	285.09	549.64											0  unlimited	0  unlimited	0  Days 1 - 100	0	0.2	0.2	0.2	0	0-ASC/ 0-OP/ 0-Non Surg	0	0 to 0.2		0.2	0	0	0	50 after 50 visits	0	0 to 0.2	0 to 0.2	0 to 0.2	0	0	Not Covered	Not Covered	Not Covered	Not Covered	0		0	0											0	0	0	0	0.2	0.2	0.2	0	0	0	0.05	0	0.2	0	0	0	0	0	0.03	0.02	0	0	0	0	0	0	0	0	0	0	0											-	-	-	-	1.62	4.35	0.79	-	-	-	1.53	-	1.7	-	-	-	0.01	-	1.22	2.3	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.51		0	-	-	-	-	1.62	4.35	0.79	-	-	-	1.53	-	1.7	-	-	-	0.01	-	1.22	2.3	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.51	0																																																																																			-		0	-	-	-	-	1.62	4.35	0.79	-	-	-	1.53	-	1.7	-	-	-	0.01	-	1.22	2.3	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.51
H6499_012_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1906.14	40.28	1551.75	1746.36	6.99	18.83	3.26	419.99	428.48	9.08	22.95	0	6.75	794.07	4434.96	9347.94	216.74	908.54	5074.86	108.71	7.27	20.17	0	0	442.99	0	189.85	0	0	236.26	2.18											250  Days 1 - 5	250  Days 1 - 5	119  days 21 - 100	0	0.2	0.3	0.3	50	75-ASC/ 150-OP/ 150-Non Surg	0.2	0.2		0.2	40 to 150	15	40	30 to 40	40	Phy. Off. 10-40 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	50											144.66	144.66	24.5	0	0.18	0.27	0.27	45.35	129.26	0.18	0.18	0	0.18	85.18	11.44	36.28	29.48	36.28	14.79	0.1	0.18	0	0	0	18.14	0	18.14	0	0	0	45.35											22.98	0.49	3.17	-	1.27	5.12	0.89	1.59	4.62	1.65	4.16	-	1.22	5.64	4.23	28.26	0.53	2.75	6.25	11.03	1.32	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	108.13		11.07	22.98	0.49	3.17	-	1.27	5.12	0.89	1.59	4.62	1.65	4.16	-	1.22	5.64	4.23	28.26	0.53	2.75	6.25	11.03	1.32	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	108.13	3650																																																																																			-		0	22.98	0.49	3.17	-	1.27	5.12	0.89	1.59	4.62	1.65	4.16	-	1.22	5.64	4.23	28.26	0.53	2.75	6.25	11.03	1.32	-	-	-	0.67	-	0.29	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	108.13
H6499_013_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	1959.4	41.36	1508.09	1568.06	7.3	19.66	3.59	487.87	497.72	10.36	26.16	0	7.69	922.4	4595.62	9636.06	221.85	929.96	5014.89	111.56	8.29	20.34	0	0	459.04	0	196.73	0	0	244.82	549.46											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											130.9	130.9	26.27	0	0.18	0.23	0.23	45.6	105.34	0.18	0.18	0	0.18	69.91	7.67	31.92	25.08	31.92	13.64	0.09	0.18	0	0	0	18.24	0	18.24	0	0	0	0.3											21.37	0.45	3.3	-	1.33	4.48	0.82	1.85	4.37	1.89	4.77	-	1.4	5.37	2.94	25.63	0.46	2.47	5.7	9.8	1.51	-	-	-	0.7	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.95		9.76	21.37	0.45	3.3	-	1.33	4.48	0.82	1.85	4.37	1.89	4.77	-	1.4	5.37	2.94	25.63	0.46	2.47	5.7	9.8	1.51	-	-	-	0.7	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.95	3650																																																																																			-		0	21.37	0.45	3.3	-	1.33	4.48	0.82	1.85	4.37	1.89	4.77	-	1.4	5.37	2.94	25.63	0.46	2.47	5.7	9.8	1.51	-	-	-	0.7	-	0.3	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.95
H6499_014_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2080.5	43.92	1582.77	1928.75	7.52	20.26	3.49	390.15	398.03	9.63	24.31	0	7.21	737.64	4825.9	10542.17	255.94	1072.88	5255.03	125.81	7.76	27.77	0	0	482.04	0	206.59	0	0	257.09	549.46											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.38	131.38	26.38	0	0.18	0.23	0.23	45.77	105.72	0.18	0.18	0	0.18	70.16	7.7	32.04	25.17	32.04	15.09	0.1	0.18	0	0	0	18.31	0	18.31	0	0	0	0.31											22.78	0.48	3.48	-	1.38	4.64	0.8	1.49	3.51	1.76	4.45	-	1.32	4.31	3.1	28.14	0.54	2.86	6.61	12.29	1.42	-	-	-	0.74	-	0.32	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	106.41		9.94	22.78	0.48	3.48	-	1.38	4.64	0.8	1.49	3.51	1.76	4.45	-	1.32	4.31	3.1	28.14	0.54	2.86	6.61	12.29	1.42	-	-	-	0.74	-	0.32	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	106.41	3650																																																																																			-		0	22.78	0.48	3.48	-	1.38	4.64	0.8	1.49	3.51	1.76	4.45	-	1.32	4.31	3.1	28.14	0.54	2.86	6.61	12.29	1.42	-	-	-	0.74	-	0.32	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	106.41
H6499_015_0	2007	5																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2446.34	51.64	1683.78	2389.9	8.01	21.57	3.86	346.53	353.53	10.76	27.23	0	8.16	655.17	5383.94	12418.53	321.22	1346.52	5257.57	156.51	8.79	41.29	0	0	537.78	0	230.48	0	0	286.82	549.59											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											130.07	130.07	26.11	0	0.18	0.23	0.23	45.31	104.67	0.18	0.18	0	0.18	69.46	7.62	31.72	24.92	31.72	16.44	0.1	0.18	0	0	0	18.12	0	18.12	0	0	0	0.3											26.52	0.56	3.66	-	1.45	4.89	0.87	1.31	3.08	1.95	4.94	-	1.48	3.79	3.42	32.82	0.67	3.56	7.2	16.16	1.59	-	-	-	0.81	-	0.35	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	121.1		12.63	26.52	0.56	3.66	-	1.45	4.89	0.87	1.31	3.08	1.95	4.94	-	1.48	3.79	3.42	32.82	0.67	3.56	7.2	16.16	1.59	-	-	-	0.81	-	0.35	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	121.1	3650																																																																																			-		0	26.52	0.56	3.66	-	1.45	4.89	0.87	1.31	3.08	1.95	4.94	-	1.48	3.79	3.42	32.82	0.67	3.56	7.2	16.16	1.59	-	-	-	0.81	-	0.35	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	121.1
H6499_016_0	2007	3																					3650											D	D	D	V	Coin	Coin	Coin	V	V	Coin	Coin	V	Coin	V	V	V	V	V	V	Coin	Coin	V	T	V	V	V	V	V	V	V	V																																																				-	0	2206.19	46.57	1400.38	1270.7	6.42	17.3	2.94	238.21	243.02	7.84	20.11	0	6	450.37	4730.12	10280.52	248.02	1039.65	4937.16	127.58	6.46	25.71	0	0	472.47	0	202.49	0	0	251.99	549.4											225  days 1 - 5	225  days 1 - 5	90  days 16 - 60	0	0.2	0.25	0.25	50	75-ASC/ 120-OP/ 120-Non Surg	0.2	0.2		0.2	35 to 120	10	35	25 to 35	35	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0	0	Not Covered	20	Not Covered	20	0		0	0 to 50											131.06	131.06	26.29	0	0.18	0.23	0.23	45.66	105.47	0.18	0.18	0	0.18	69.99	7.68	31.96	25.11	31.96	15.44	0.1	0.18	0	0	0	18.26	0	18.26	0	0	0	0.3											24.1	0.51	3.07	-	1.17	3.95	0.67	0.91	2.14	1.43	3.67	-	1.1	2.63	3.03	27.38	0.52	2.77	6.35	12.91	1.18	-	-	-	0.72	-	0.31	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.52		9.55	24.1	0.51	3.07	-	1.17	3.95	0.67	0.91	2.14	1.43	3.67	-	1.1	2.63	3.03	27.38	0.52	2.77	6.35	12.91	1.18	-	-	-	0.72	-	0.31	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.52	3650																																																																																			-		0	24.1	0.51	3.07	-	1.17	3.95	0.67	0.91	2.14	1.43	3.67	-	1.1	2.63	3.03	27.38	0.52	2.77	6.35	12.91	1.18	-	-	-	0.72	-	0.31	-	-	-	0.01	-	-	-	-	-	-	-	-	-	-	100.52
H6499_801_0	2007	4																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1783.43	37.65	1202.12	1894.63	7.79	20.97	3.67	4.76	25.87	2673.35	25.83	0	7.67	16.76	19.25	47.49	1.66	2.11	4871.92	118.92	8.26	17.89	0	0	0	0	0	0	0	237.14	0											952  0 (1-60) 238 (61 - 90) 476 (91+)	952  0 (1-60) 238 (61 - 90) 476 (91+)	119  Days 21-100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2		0.2	0.2	0.2	0.2	0.5 to 0.5	0.2	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0.2	0	Not covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.8	52.03	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0.2	10.45	0.1	0.2	0.2	0	0	0	0	0	0	0	0	0											21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9	0																																																																																			-		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9
H6499_802_0	2007	4																					0											D	D	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	V	V	V																																																				-	0	1783.43	37.65	1202.12	1894.63	7.79	20.97	3.67	4.76	25.87	2673.35	25.83	0	7.67	16.76	19.25	47.49	1.66	2.11	4871.92	118.92	8.26	17.89	0	0	0	0	0	0	0	237.14	0											952  0 (1-60) 238 (61 - 90) 476 (91+)	952  0 (1-60) 238 (61 - 90) 476 (91+)	119  Days 21-100	0	0.2	0.2	0.2	0.2	0.2-ASC/ 0.2-OP/ 0.2-Non Surg	0	0.2		0.2	0.2	0.2	0.2	0.5 to 0.5	0.2	Phy. Off. 10-35 / OP: 20	0 to 0.2	0.2	0.2	0	Not covered	Not Covered	Not Covered	Not Covered	0		0	0 to 0											142.8	52.03	27.01	0	0.2	0.2	0.2	0.2	0.2	0	0.2	0	0.2	0.2	0.19	0.2	0.5	0.2	10.45	0.1	0.2	0.2	0	0	0	0	0	0	0	0	0											21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9	0																																																																																			-		0	21.22	0.16	2.71	-	1.56	4.19	0.73	0.95	5.17	-	5.17	-	1.53	3.35	3.71	9.5	0.83	0.42	4.24	12.21	1.65	3.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	82.9
H6717_001_0	2007	3	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1000	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		2425.26	225.83	8492.71	159.17	597.38	1343.65	6530.25	171.8	114.07	3548.73	157.77	31.2	4.08	265.25	118.86	1190.36	1546.33	18.27		248.55	251.84	1215.42	2137.5		133.19							101.31	0.26	0.06	285	280.44						(1a) 125/day	(1b) 125/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit							(4b) 10/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						103	103			62			41	21			21		21		8				8		8										8		21								20.76	1.93	-	-	3.07	-	-	0.59	0.2	-	-	0.05	-	0.45	-	0.81	-	-	-	0.17	-	0.83	-	-	-	-	-	-	-	-	-	0.07	-	0	-	-	-	-	-	-	-	28.93		6.28	20.76	1.93	-	-	3.07	-	-	0.59	0.2	-	-	0.05	-	0.45	-	0.81	-	-	-	0.17	-	0.83	-	-	-	-	-	-	-	-	-	0.07	-	0	-	-	-	-	-	-	-	28.93		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10	30	30	30	30						3.15	0.09	0.81	0.08	0.36	0.31	0.1	0.04	0.19	0.59	0.66	0.04	0.01	0.11	0.01	1.7	0.15	0		0.17		0.12	0.11		0.02							0	0	0	0.02	0.02						8.84		0	23.9	2.02	0.81	0.08	3.43	0.31	0.1	0.63	0.39	0.59	0.66	0.09	0.01	0.56	0.01	2.51	0.15	0	-	0.34	-	0.95	0.11	-	0.02	-	-	-	-	-	-	0.07	0	0	0.02	0.02	-	-	-	-	-	37.77
H6934_001_0	2007	2																																D	D	D	V	P	P	P	V	V	V	V	V	V	V	P	P	P	P	Coin	P	Coin	P	P	P	P	P	P	P	P	P	P																																																				-									1026.06																																									25 per visit																																									25																																		-	-	-	-	-	-	-	2.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.14		0	-	-	-	-	-	-	-	2.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.14																																																																																				-		0	-	-	-	-	-	-	-	2.14	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	2.14
H7065_001_0	2007	3																																Coin	Coin	Coin	V	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P															0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0																				0		300.07	8.73	83.54		10.73	15.4	16.05	681.19	29.56	23.98	28.15	4.54	0.35	33.69	20.63	28.31	6.63	1.71	17.91	87.9	23.96	0.1																				Medicare FFS cost sharing: #1A 1000 ded 0/day days 1-60 250/day days 61-90 500/day lifetime reserve days	Medicare FFS cost sharing: #1B 1000 ded 0/day days 1-60 250/day days 61-90 500/day lifetime reserve days	Medicare FFS cost sharing: #2 0/day days 1-20 125/day days 21-100	Medicare FFS cost sharing: #6 0	Medicare FFS cost sharing: #10A 20	Medicare FFS cost sharing: #11A 20	Medicare FFS cost sharing: #11B 20 #11C 20 #11D 20	Medicare FFS cost sharing: #4A 50 #4B 20	Medicare FFS cost sharing: #9A 20 #9B 20	Medicare FFS cost sharing: #8A 20	Medicare FFS cost sharing: #8A 20 #8B 20	Medicare FFS cost sharing: #9A 20	Medicare FFS cost sharing: #12 20	Medicare FFS cost sharing: #3 20 #5 50 #9C 20 #9D 20	Medicare FFS cost sharing: #7A 20 #14B 0/20 #14C 20 #14D 20 #14E 20 #14F 20 #14G 20 #14H 20	Medicare FFS cost sharing: #7B 20 #7D 20 #7F 20 #7G 20 #16B 20 #17A 20 #18A 20	Medicare FFS cost sharing: #7E 50 #7H 50	Medicare FFS cost sharing: #7C 20 #7I 20	Medicare FFS cost sharing: #7D 20	Medicare FFS cost sharing: #14I 20	Medicare FFS cost sharing: #15 20	Medicare FFS cost sharing: #13A 20	#10B not covered	#16A not covered #16B1-16B5 not covered	#17A1 not covered	#17B1-17B5 not covered	#18A1-18A5 not covered	#18B not covered	Not covered	#14A 0	#13B not covered											0.08	0.08	0.17		0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				24.43	0.71	14.12	-	2.53	3.63	3.79	2.84	6.98	5.66	6.64	1.07	0.08	7.95	4.87	6.68	1.56	0.4	4.23	20.74	5.65	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.6	138	0	24.43	0.71	14.12	-	2.53	3.63	3.79	2.84	6.98	5.66	6.64	1.07	0.08	7.95	4.87	6.68	1.56	0.4	4.23	20.74	5.65	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.6																																																																																				-		0	24.43	0.71	14.12	-	2.53	3.63	3.79	2.84	6.98	5.66	6.64	1.07	0.08	7.95	4.87	6.68	1.56	0.4	4.23	20.74	5.65	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.6
H7187_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						700	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	P	P	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1886.13	121.49	7417.13	112.63	509.8	1405.27	1766.87	137.74	152.73	5488.22	142.97	1.39	4.18	220.82	26955.33	1363.77	2372.55	20.39		68.19	112.4	581.29	2137.5		133.19	315.4		51.87				79.5		0.35	285	280.44						(1a) 75/day	(1b) 75/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 0/proc	(11a/11c) 0/proc	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 0/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 0/visit	(15) 0/proc	(16b/17a) 0/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 10/visit (waived if admitted)		(9d) 0/visit	(7f1) 0/visit	(18a1) 0/visit						64	64			64			43	21			21		21																		9										10.05	0.65	-	-	2.72	-	-	0.49	0.27	-	-	0	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	14.63		2.52	10.05	0.65	-	-	2.72	-	-	0.49	0.27	-	-	0	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.06	-	-	-	-	-	-	-	-	-	14.63		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							10		30	30	30						2.8	0.07	0.82	0.07	0.21	0.29	0.04	0.03	0.33	0.48	0.65	0	0.01	0.12	0.01	1.97	0.22	0		0.27		0.08	0.11		0.02							0		0	0.02	0.02						8.64		0	12.85	0.72	0.82	0.07	2.93	0.29	0.04	0.52	0.6	0.48	0.65	0	0.01	0.51	0.01	1.97	0.22	0	-	0.27	-	0.08	0.11	-	0.02	-	-	-	-	-	-	0.06	-	0	0.02	0.02	-	-	-	-	-	23.27
H7187_002_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2458.17	352.88	1661.01		304.84	26.33	21.97	877.86	356.34	2102.02	875.09	62.57	2.91	1941.45		3499.59		501.27		806.54												308.38		143.5	243.67							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							35	35	17		35	9	9	17	12	5	5	12	9	12		5		5		5												5		5	5							7.12	1.02	2.31	-	0.88	2.44	2.04	1.22	0.34	0.81	0.34	0.06	0.27	1.87	-	1.35	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.86		26.46	7.12	1.02	2.31	-	0.88	2.44	2.04	1.22	0.34	0.81	0.34	0.06	0.27	1.87	-	1.35	-	0.19	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	22.86		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.23	0.15	0.4	0.41	0.07	0.16	0.13	0.05	0.17	0.13	0.12	0.01	0.02	0.22	0.34	0.2	0.04	0.03	0.13	0.68	0.13	0																				5.83		0	9.35	1.17	2.71	0.41	0.96	2.6	2.17	1.27	0.52	0.94	0.45	0.08	0.28	2.09	0.34	1.55	0.04	0.22	0.13	0.99	0.13	0	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	28.68
H7187_003_0	2007	7																					2575											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3650	1766.62	153.9	840.83	0	237.79	12.45	5.38	439.85	27.61	6340.81	38.42	0	0.19	21.01	2907.88	3407.44	584.88	1.61	0	0	19.27	592.54	0	0	133.44	0	184.91	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	5 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											152.31	152.31	77.45	0	90.35	0.15	0.18	25.82	0.15	1.03	0.12	0	0.15	0.16	10	25	37.5	0.15	0	0	0.15	25	0	0	25	0	25	0	0	0	0											22.42	1.95	5.43	-	1.79	1.93	0.98	0.95	4.28	0.55	4.53	-	0.03	3.26	2.42	7.1	1.83	0.25	-	-	2.99	1.23	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.57		47.79	22.42	1.95	5.43	-	1.79	1.93	0.98	0.95	4.28	0.55	4.53	-	0.03	3.26	2.42	7.1	1.83	0.25	-	-	2.99	1.23	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	64.57		395 (1a)	395 (1b)	175 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	40 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.82	0.25	0.6	0.52	0.42	0.46	0.23	0.22	1.02	0.52	1.08	0	0.01	0.77	1.35	2.18	0.45	0.06	0	0	0.71	0.38	0	0	0.09	0	0.12	0	0	0	0											14.24		7.19	25.25	2.2	6.02	0.52	2.22	2.39	1.2	1.17	5.29	1.06	5.61	-	0.04	4.03	3.78	9.28	2.28	0.31	-	-	3.69	1.61	-	-	0.36	-	0.5	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.81
H7187_004_0	2007	3																					2100											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	Coin	O	O																																																				-	3100	1766.62	153.9	840.83	0	237.79	12.45	5.38	439.85	27.61	6340.81	38.42	0	0.19	21.01	2907.88	3407.44	584.88	1.61	0	0	19.27	592.54	0	0	133.44	0	184.91	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	see OON	0 (14a)	0 n/c (13b 13c 13d 13e)											136.34	136.34	69.33	0	80.88	0.14	0.17	23.11	0.14	2.77	0.11	0	0.14	0.14	10	25	37.5	0.14	0	0	0.14	25	0	0	25	0	25	0	0	0	0											20.07	1.75	4.86	-	1.6	1.73	0.91	0.85	3.83	1.47	4.06	-	0.03	2.92	2.42	7.1	1.83	0.22	-	-	2.67	1.23	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.19		54.28	20.07	1.75	4.86	-	1.6	1.73	0.91	0.85	3.83	1.47	4.06	-	0.03	2.92	2.42	7.1	1.83	0.22	-	-	2.67	1.23	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	60.19		395 (1a)	395 (1b)	175 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	40 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	see specific bid cats	0 n/c (14a)	0 n/c (13b 13c 13d 13e)											2.72	0.24	0.57	0.28	0.41	0.44	0.19	0.22	0.98	0.5	1.04	0	0.01	0.74	0.73	1.17	0.24	0.06	0	0	0.68	0.2	0	0	0.05	0	0.06	0	0	0	0											11.53		9.9	22.79	1.99	5.43	0.28	2.01	2.17	1.1	1.06	4.81	1.96	5.09	-	0.03	3.66	3.15	8.27	2.07	0.28	-	-	3.35	1.44	-	-	0.32	-	0.45	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.73
H7187_801_0	2007	4																					4300											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		2016.25	175.64	959.64	0	304.49	15.95	6.88	563.22	35.36	8119.33	49.19	0	0.24	26.9	3723.51	4363.19	748.93	2.06	0	0	24.68	758.74	0	0	170.87	0	236.77	0	0	0	0											325 (1a)	325 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	25 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	30 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 30 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	30 (17a)	0 n/c (17b1-17b5)	30 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											199.48	199.48	92.07	0	107.41	0.18	0.21	30.69	0.18	3.68	0.14	0	0.18	0.18	25	30	37.5	0.18	0	0	0.18	30	0	0	30	0	30	0	0	0	0											33.52	2.92	7.36	-	2.73	2.94	1.42	1.44	6.51	2.49	6.9	-	0.04	4.96	7.76	10.91	2.34	0.38	-	-	4.54	1.9	-	-	0.43	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.06		48.92	33.52	2.92	7.36	-	2.73	2.94	1.42	1.44	6.51	2.49	6.9	-	0.04	4.96	7.76	10.91	2.34	0.38	-	-	4.54	1.9	-	-	0.43	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.06																																																																																				-			33.52	2.92	7.36	-	2.73	2.94	1.42	1.44	6.51	2.49	6.9	-	0.04	4.96	7.76	10.91	2.34	0.38	-	-	4.54	1.9	-	-	0.43	-	0.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.06
H7226_001_0	2007	5																					3000											D	D	D	V	T	P	P	V	P	P	P	P	P	V	V	V	V	V	P	V	S	P	P	P	P	P	P	P	P	P	P																																																				-									457.61						1520.31	3519.06	4631.32	679.34	391.2		607.32					300		232.59																						50 ER/15 Urgent Care						15 OP SA/15 Cardiac Rehab	15 PCP/15 Routine Physical	15	15	15		15 Diab Mon Training/5 Allergy Tests & Treatment					15 Routine Eye Exam		15 Routine Hearing																						48.2						0.36	14.47	14.47	14.47	14.47		0.63					14.47		14.47															-	-	-	-	-	-	-	1.84	-	-	-	-	-	0.05	4.24	5.58	0.82	0.47	-	0.03	-	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.67		0.5	-	-	-	-	-	-	-	1.84	-	-	-	-	-	0.05	4.24	5.58	0.82	0.47	-	0.03	-	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.67																																																																																				-		0	-	-	-	-	-	-	-	1.84	-	-	-	-	-	0.05	4.24	5.58	0.82	0.47	-	0.03	-	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.67
H7226_002_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	V	V	V	V	V	P	V	S	P	P	P	P	P	P	P	P	P	P																																																				-		1399.22	133.64	867.17		179.84	7.06	9.62	457.61	394.19		289.18			1520.31	3519.06	4631.32	679.34	391.2		607.32					300		232.59															150 per day; days 1-5	150 per day; days 1-5	115 per day; days 11-100		150	0	30 Prosth/20 Non Diab. Mon. Supplies	50 ER/15 Urgent Care	100		20 Therapeutic PET Scan CT Scan MRI			25 OP SA/25 Cardiac Rehab	15 PCP/15 Routine Physical	15 Spec./25 Chiro/25 Podiatrist	25	25		25 Diab Mon Training/5 Allergy Tests & Treatment					25 Routine Eye Exam		25 Routine Hearing															74.83	74.83	58.87		122.07	0.24	0.16	40.67	81.38		161.62			0.5	12.21	13.23	20.35	20.35		0.53					20.35		20.35															8.73	0.83	4.25	-	1.83	1.72	1.56	1.55	2.67	-	3.89	-	-	0.06	3.58	5.11	1.15	0.66	-	0.03	-	-	-	-	0.51	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.54		8.82	8.73	0.83	4.25	-	1.83	1.72	1.56	1.55	2.67	-	3.89	-	-	0.06	3.58	5.11	1.15	0.66	-	0.03	-	-	-	-	0.51	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.54																																																																																				-		0	8.73	0.83	4.25	-	1.83	1.72	1.56	1.55	2.67	-	3.89	-	-	0.06	3.58	5.11	1.15	0.66	-	0.03	-	-	-	-	0.51	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.54
H7226_006_0	2007	3																					3000											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	V	V	V	V	V	P	V	S	P	P	P	P	P	P	P	P	P	P																																																				-		1399.22	133.64	867.17		179.84	7.06	9.62	457.61	394.19		289.18			1520.31	3519.06	4631.32	679.34	391.2		607.32					300		232.59															150 per day; days 1-5	150 per day; days 1-5	115 per day; days 11-100	0	150	0	30 Prosth/20 Non Diab. Mon. Supplies	50 ER/15 Urgent Care	100	0	20 Therapeutic PET Scan CT Scan MRI	0	0	25 OP SA/25 Cardiac Rehab	15 PCP/15 Routine Physical	15 Spec./25 Chiro/25 Podiatrist	25	25	0	25 Diab Mon Training/5 Allergy Tests & Treatment	0	0			25 Routine Eye Exam		25 Routine Hearing															74.83	74.83	58.87		122.07	0.24	0.16	40.67	81.38		161.62			0.5	12.21	13.23	20.35	20.35		0.53					20.35		20.35															8.73	0.83	4.25	-	1.83	1.72	1.56	1.55	2.67	-	3.89	-	-	0.06	3.58	5.11	1.15	0.66	-	0.03	-	-	-	-	0.51	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.54		8.82	8.73	0.83	4.25	-	1.83	1.72	1.56	1.55	2.67	-	3.89	-	-	0.06	3.58	5.11	1.15	0.66	-	0.03	-	-	-	-	0.51	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.54																																																																																				-		0	8.73	0.83	4.25	-	1.83	1.72	1.56	1.55	2.67	-	3.89	-	-	0.06	3.58	5.11	1.15	0.66	-	0.03	-	-	-	-	0.51	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.54
H7226_007_0	2007	6																					3000											D	D	D	V	T	P	P	V	P	P	P	P	P	V	V	V	V	V	P	V	S	P	P	P	P	P	P	P	P	P	P																																																				-									393.89						1635.7	3663.82	5473.52	743.78	675.73		738.9					300		232.59																						50 ER/15 Urgent Care						15 OP SA/15 Cardiac Rehab	15 PCP/15 Routine Physical	15	15	15		15 Diab Mon Training/5 Allergy Tests & Treatment					15 Routine Eye Exam		15 Routine Hearing																						47.91						1.07	14.38	14.38	14.38	14.38		0.56					14.38		14.38															-	-	-	-	-	-	-	1.57	-	-	-	-	-	0.15	4.39	6.56	0.89	0.81	-	0.03	-	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.04		0.65	-	-	-	-	-	-	-	1.57	-	-	-	-	-	0.15	4.39	6.56	0.89	0.81	-	0.03	-	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.04																																																																																				-		0	-	-	-	-	-	-	-	1.57	-	-	-	-	-	0.15	4.39	6.56	0.89	0.81	-	0.03	-	-	-	-	0.36	-	0.28	-	-	-	-	-	-	-	-	-	-	-	-	-	-	15.04
H7226_008_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	V	V	V	V	V	P	V	S	P	P	P	P	P	P	P	P	P	P																																																				-		2138.18	129.63	1257.59		272.27	4.91	8.27	394.59	445.73		332.29			1638.63	3670.26	5483.34	745.12	676.94		740.22					300		232.59															150 per day; days 1-5	150 per day; days 1-5	115 per day; days 11-100		150	0	30 Prosth/20 Non Diab. Mon. Supplies	50 ER/15 Urgent Care	100		20 Therapeutic PET Scan CT Scan MRI			25 OP SA/25 Cardiac Rehab	15 PCP/15 Routine Physical	15 Spec./25 Chiro/25 Podiatrist	25	25		25 Diab Mon Training/5 Allergy Tests & Treatment					25 Routine Eye Exam		25 Routine Hearing															70.76	70.76	55.67		115.44	0.23	0.16	38.46	76.96		168.22			1.44	11.54	12.35	19.24	19.24		0.45					19.24		19.24															12.61	0.76	5.83	-	2.62	1.13	1.3	1.26	2.86	-	4.66	-	-	0.2	3.53	5.64	1.19	1.09	-	0.03	-	-	-	-	0.48	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.57		13.64	12.61	0.76	5.83	-	2.62	1.13	1.3	1.26	2.86	-	4.66	-	-	0.2	3.53	5.64	1.19	1.09	-	0.03	-	-	-	-	0.48	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.57																																																																																				-		0	12.61	0.76	5.83	-	2.62	1.13	1.3	1.26	2.86	-	4.66	-	-	0.2	3.53	5.64	1.19	1.09	-	0.03	-	-	-	-	0.48	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.57
H7226_009_0	2007	3																					3000											D	D	D	V	T	Coin	Coin	V	P	P	P	P	P	V	V	V	V	V	P	V	S	P	P	P	P	P	P	P	P	P	P																																																				-		2136.15	129.51	1256.4		272.01	4.9	8.26	394.22	445.31		331.97			1637.08	3666.85	5478.14	744.41	676.3		739.52					300		232.59															150 per day; days 1-5	150 per day; days 1-5	115 per day; days 11-100	0	150	30	30 Prosth/20 Non Diab. Mon. Supplies	50 ER/15 Urgent Care	100	0	20 Therapeutic PET Scan CT Scan MRI	0	0	25 OP SA/25 Cardiac Rehab	15 PCP/15 Routine Physical	15 Spec./25 Chiro/25 Podiatrist	25	25	0	25 Diab Mon Training/5 Allergy Tests & Treatment	0	0			25 Routine Eye Exam		25 Routine Hearing															70.78	70.78	55.68		115.47	0.23	0.16	38.47	76.98		168.1			1.44	11.55	12.35	19.25	19.25		0.45					19.25		19.25															12.6	0.76	5.83	-	2.62	1.13	1.29	1.26	2.86	-	4.65	-	-	0.2	3.53	5.64	1.19	1.08	-	0.03	-	-	-	-	0.48	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.53		13.62	12.6	0.76	5.83	-	2.62	1.13	1.29	1.26	2.86	-	4.65	-	-	0.2	3.53	5.64	1.19	1.08	-	0.03	-	-	-	-	0.48	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.53																																																																																				-		0	12.6	0.76	5.83	-	2.62	1.13	1.29	1.26	2.86	-	4.65	-	-	0.2	3.53	5.64	1.19	1.08	-	0.03	-	-	-	-	0.48	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.53
H7226_801_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																								0	0	0								0	0	0	0	0	0	0	0																				0		230.38	9.07	32.74		6.89	7.06	9.62	16.17	39.38	23.66	35.42	2.18	0.95	31.72	20.37	35.42	4.71	3.24	17.31	87.23	12.78	0.11																				FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.02	0.59	5.6	-	1.63	1.67	2.27	3.82	9.29	5.58	8.36	0.51	0.22	7.49	4.81	8.36	1.11	0.76	4.08	20.59	3.02	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.8	138		15.02	0.59	5.6	-	1.63	1.67	2.27	3.82	9.29	5.58	8.36	0.51	0.22	7.49	4.81	8.36	1.11	0.76	4.08	20.59	3.02	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.8																																																																																				-		0	15.02	0.59	5.6	-	1.63	1.67	2.27	3.82	9.29	5.58	8.36	0.51	0.22	7.49	4.81	8.36	1.11	0.76	4.08	20.59	3.02	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.8
H7226_806_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																													-		230.38	9.07	32.74		6.89	7.06	9.62	16.17	39.38	23.66	35.42	2.18	0.95	31.72	20.37	35.42	4.71	3.24	17.31	87.23	12.78	0.11																				FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				15.02	0.59	5.6	-	1.63	1.67	2.27	3.82	9.29	5.58	8.36	0.51	0.22	7.49	4.81	8.36	1.11	0.76	4.08	20.59	3.02	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.8		0	15.02	0.59	5.6	-	1.63	1.67	2.27	3.82	9.29	5.58	8.36	0.51	0.22	7.49	4.81	8.36	1.11	0.76	4.08	20.59	3.02	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.8																																																																																				-		0	15.02	0.59	5.6	-	1.63	1.67	2.27	3.82	9.29	5.58	8.36	0.51	0.22	7.49	4.81	8.36	1.11	0.76	4.08	20.59	3.02	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	104.8
H7226_807_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																								0	0	0								0	0	0	0	0	0	0	0																				0		303.51	8.02	34.12		9.91	4.32	7.7	12.38	40.73	31.81	45.77	4.44	0.35	29.23	23.26	48.61	5.13	5.07	29.74	105.97	10.9	0.07																				FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				19.79	0.52	5.83	-	2.34	1.02	1.82	2.92	9.61	7.51	10.8	1.05	0.08	6.9	5.49	11.47	1.21	1.2	7.02	25.01	2.57	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.18	138	0	19.79	0.52	5.83	-	2.34	1.02	1.82	2.92	9.61	7.51	10.8	1.05	0.08	6.9	5.49	11.47	1.21	1.2	7.02	25.01	2.57	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.18																																																																																				-		0	19.79	0.52	5.83	-	2.34	1.02	1.82	2.92	9.61	7.51	10.8	1.05	0.08	6.9	5.49	11.47	1.21	1.2	7.02	25.01	2.57	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.18
H7226_808_0	2007	5																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																								0	0	0								0	0	0	0	0	0	0	0																				0		303.51	8.02	34.12		9.91	4.32	7.7	12.38	40.72	31.81	45.77	4.44	0.35	29.23	23.26	48.61	5.13	5.07	29.74	105.97	10.9	0.07																				FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance	FFS Medicare Deductible/Coinsurance																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				19.79	0.52	5.83	-	2.34	1.02	1.82	2.92	9.61	7.51	10.8	1.05	0.08	6.9	5.49	11.47	1.21	1.2	7.02	25.01	2.57	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.18	138	0	19.79	0.52	5.83	-	2.34	1.02	1.82	2.92	9.61	7.51	10.8	1.05	0.08	6.9	5.49	11.47	1.21	1.2	7.02	25.01	2.57	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.18																																																																																				-		0	19.79	0.52	5.83	-	2.34	1.02	1.82	2.92	9.61	7.51	10.8	1.05	0.08	6.9	5.49	11.47	1.21	1.2	7.02	25.01	2.57	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.18
H7254_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						2400	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V	P				V	V	V	V	V																																															-		1668.77	130.31	8662.65	25.1	1179.68	29.8	2.33	165.2	139.65	2365.3	164.74	31.03	4.56	125.95	32133	1111.08	491.14	29.69		24.88	84.55	663.09	2137.5		133.19	157.7		51.87				107.7			285	280.44						(1a) 175/day	(1b) 175/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 35/visit	(8a) 0/visit	(8b) 0/visit	(9a) 35/visit	(12) 0/proc	(9a) 35/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 15/visit	(7e/7h) 32.5/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 15/visit	(15) 0/proc	(16b/17a) 15/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc		(18b) 0/proc				(4b) 35/visit (waived if admitted)			(7f1) 0/visit	(18a1) 0/visit						162	162			70	19	19	46	32			32		32		14	30			14		14										32										22.59	1.76	-	-	6.84	5.53	0.43	0.64	0.38	-	-	0.08	-	0.34	-	1.29	1.23	-	-	0.03	-	0.77	-	-	-	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	42.23		3.26	22.59	1.76	-	-	6.84	5.53	0.43	0.64	0.38	-	-	0.08	-	0.34	-	1.29	1.23	-	-	0.03	-	0.77	-	-	-	-	-	-	-	-	-	0.29	-	-	-	-	-	-	-	-	-	42.23		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35			30	30						2.2	0.04	0.76	0.01	0.56	0.47	0.04	0.04	0.13	0.46	0.66	0.04	0.01	0.05	0.01	1.76	0.08	0		0.07		0.09	0.11		0.02							0.02			0.02	0.02						7.65		0	24.79	1.81	0.76	0.01	7.41	6	0.47	0.68	0.51	0.46	0.66	0.12	0.01	0.39	0.01	3.05	1.31	0	-	0.1	-	0.86	0.11	-	0.02	-	-	-	-	-	-	0.31	-	-	0.02	0.02	-	-	-	-	-	49.88
H7254_002_0	2007	4	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2509.17	360.2	1695.47		311.16	27.43	22.89	896.07	363.73	2145.63	893.24	63.87	3.03	1981.73		3572.2		511.67		823.27												314.78		146.47	248.73							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							34	34	16		34	9	9	16	11	5	5	11	9	11		5		5		5												5		5	5							7.18	1.03	2.33	-	0.89	2.51	2.1	1.23	0.35	0.82	0.34	0.06	0.28	1.89	-	1.36	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.14		27.41	7.18	1.03	2.33	-	0.89	2.51	2.1	1.23	0.35	0.82	0.34	0.06	0.28	1.89	-	1.36	-	0.2	-	0.31	-	-	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	23.14		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.32	0.15	0.42	0.43	0.08	0.17	0.14	0.05	0.18	0.14	0.12	0.02	0.02	0.22	0.34	0.21	0.04	0.03	0.14	0.71	0.14	0																				6.06		0	9.5	1.18	2.75	0.43	0.97	2.68	2.24	1.28	0.53	0.95	0.46	0.08	0.29	2.11	0.34	1.57	0.04	0.23	0.14	1.02	0.14	0	-	-	-	-	-	-	-	-	-	0.12	-	0.06	0.09	-	-	-	-	-	-	29.21
H7981_001_0	2007	6																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	Coin	P	P	P	P	P	P	P																																																				-									424.28						0.53			540.37							12.66																									25 - Emergency 5 Urgent						10 - MH/SA			10							0.25																									21						10			10							0.25																		-	-	-	-	-	-	-	0.74	-	-	-	-	-	0	-	-	0.45	-	-	-	-	-	-	3.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.36		0	-	-	-	-	-	-	-	0.74	-	-	-	-	-	0	-	-	0.45	-	-	-	-	-	-	3.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.36																																																																																				-		0	-	-	-	-	-	-	-	0.74	-	-	-	-	-	0	-	-	0.45	-	-	-	-	-	-	3.17	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	4.36
H7981_004_0	2007	7																					3100											D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		2396.42	93.15			137.99			487.06	153.61					33.64	7649.29	5650.62	608.48	1064.74		1.62																						100 per admit	100 per admit			25			25 Emergency and Urgent	100					15 OP Rehab	6	15	15	15		15 Specialist																						13.9	11.68			23.66			23.66	94.63					14.2	5.68	14.2	14.05	13.95		0.23																						2.78	0.09	-	-	0.27	-	-	0.96	1.21	-	-	-	-	0.04	3.62	6.68	0.71	1.24	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.98		1.02	2.78	0.09	-	-	0.27	-	-	0.96	1.21	-	-	-	-	0.04	3.62	6.68	0.71	1.24	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.98																																																																																				-		0	2.78	0.09	-	-	0.27	-	-	0.96	1.21	-	-	-	-	0.04	3.62	6.68	0.71	1.24	-	0.38	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.98
H7981_801_0	2007	13																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		164.96	3.64	2.39		4.63	32.38	27.82	10.87	22.85	22.7	9.52	1.17	0.68	7.69	45.98	44.65	5.04	5.82	26.03	95.48	21.85	0.03																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.09	0.09	0.16		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				14.37	0.32	0.39	-	1.09	7.64	6.56	2.57	5.39	5.36	2.25	0.28	0.16	1.81	10.85	10.54	1.19	1.37	6.14	22.53	5.16	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.98		0	14.37	0.32	0.39	-	1.09	7.64	6.56	2.57	5.39	5.36	2.25	0.28	0.16	1.81	10.85	10.54	1.19	1.37	6.14	22.53	5.16	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.98																																																																																				-		0	14.37	0.32	0.39	-	1.09	7.64	6.56	2.57	5.39	5.36	2.25	0.28	0.16	1.81	10.85	10.54	1.19	1.37	6.14	22.53	5.16	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.98
H7981_802_0	2007	12																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	Coin	P	P	P	P	P	P	P																																																				-		121.01	2.76	1.66		3.4	24.78	21.07	7.87	16.5	17.01	6.59	0.77	0.52	5.44	34.9	33.49	3.86	4.36	19.36	71.54	16.17	0.02																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.16	0.16	0.15		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				19.88	0.45	0.26	-	0.8	5.85	4.97	1.86	3.89	4.02	1.56	0.18	0.12	1.28	8.24	7.9	0.91	1.03	4.57	16.88	3.82	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.48		0	19.88	0.45	0.26	-	0.8	5.85	4.97	1.86	3.89	4.02	1.56	0.18	0.12	1.28	8.24	7.9	0.91	1.03	4.57	16.88	3.82	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.48																																																																																				-		0	19.88	0.45	0.26	-	0.8	5.85	4.97	1.86	3.89	4.02	1.56	0.18	0.12	1.28	8.24	7.9	0.91	1.03	4.57	16.88	3.82	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.48
H7981_803_0	2007	12																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	Coin	P	P	P	P	P	P	P																																																				-		121.01	2.76	1.66		3.4	24.78	21.07	7.87	16.5	17.01	6.59	0.77	0.52	5.44	34.9	33.49	3.86	4.36	19.36	71.54	16.17	0.02																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.16	0.16	0.15		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				19.88	0.45	0.26	-	0.8	5.85	4.97	1.86	3.89	4.02	1.56	0.18	0.12	1.28	8.24	7.9	0.91	1.03	4.57	16.88	3.82	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.48		0	19.88	0.45	0.26	-	0.8	5.85	4.97	1.86	3.89	4.02	1.56	0.18	0.12	1.28	8.24	7.9	0.91	1.03	4.57	16.88	3.82	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.48																																																																																				-		0	19.88	0.45	0.26	-	0.8	5.85	4.97	1.86	3.89	4.02	1.56	0.18	0.12	1.28	8.24	7.9	0.91	1.03	4.57	16.88	3.82	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.48
H8031_001_0	2007	6																																D	D	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		2321.93	457.57	115.72	39.83	13.83	44.74	2.77	828.35	16.93	11.78	24.21	0	28.79	25.27	25.09	34.45	6.43	4.7	18.56	111.16	16.12	2.16	5	0	2.47	1.12	0.99	1.03	0	2	10											100/day: PBP 1a	FFS Medicare: PBP 1b	FFS Medicare: PBP 2	FFS Medicare: PBP 6	FFS Medicare: PBP 10a	FFS Medicare: PBP 11a	FFS Medicare: PBP 11b 11c	50 copay: PBP 4a 4b	FFS Medicare: PBP 9a 9b	FFS Medicare: PBP 8a	FFS Medicare: PBP 8b	FFS Medicare:	FFS Medicare: PBP 12	FFS Medicare: PBP 3 5 9a 9c 9d 13a 13b	FFS Medicare: PBP 4b 7a 14b-i	FFS Medicare: PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	FFS Medicare: PBP 7e 7h	FFS Medicare: PBP 7c 7i	FFS Medicare: PBP 7d	FFS Medicare: PBP 7d 7g	FFS Medicare: PBP 15	FFS Medicare: PBP 7g																				100.46	50.95	0.19	0	0.24	0.24	0.24	48.41	0.24	0.24	0.24	0	0.24	0.24	0.23	0.21	0.24	0.24	0.24	0.22	0.24	0.2	0	0	0	0	0	0	0	0	0											19.44	1.94	22.03	-	3.26	10.56	0.65	3.34	4	2.78	5.71	-	6.79	5.96	5.8	7.37	1.52	1.11	4.38	24.14	3.8	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	135.02	131	0	19.44	1.94	22.03	-	3.26	10.56	0.65	3.34	4	2.78	5.71	-	6.79	5.96	5.8	7.37	1.52	1.11	4.38	24.14	3.8	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	135.02																																											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	19.44	1.94	22.03	-	3.26	10.56	0.65	3.34	4	2.78	5.71	-	6.79	5.96	5.8	7.37	1.52	1.11	4.38	24.14	3.8	0.42	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	135.02
H8201_001_0	2007	3																																A	A	A	P	T	Coin	O	V	V	V	V	P	P	O	V	V	V	P	P	P	O	O	T	P	V	Coin	V	P	O	O	O																																																				-		221.13	11.81	39.85	0	543.48	20.24	0	251.71	173.52	284.68	499.66	0	0	176.97	0	6098.29	447.95	183.47	0	0	0	0	0	0	527.79	0	263.89	0	0	0	0											100 per admit	100 per admit	100 per admit		50 per trip	20 of cost		50 per ER visit	50 per OP surgical visit	15 per lab visit	15 per radiology visit			15 per visit		10 per visit	10 per visit	10 per visit							10 per vist		10 per visit															100	100	100	0	50	0.19	0	50	50	15	15	0	0	15	0	10	10	10	0	0	0	0	0	0	10	0	10	0	0	0	0											1.84	0.1	0.33	-	2.26	3.85	-	1.05	0.72	0.36	0.62	-	-	0.22	-	5.08	0.37	0.15	-	-	-	-	-	-	0.44	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.62		0.01	1.84	0.1	0.33	-	2.26	3.85	-	1.05	0.72	0.36	0.62	-	-	0.22	-	5.08	0.37	0.15	-	-	-	-	-	-	0.44	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.62	2700																																																																																			-			1.84	0.1	0.33	-	2.26	3.85	-	1.05	0.72	0.36	0.62	-	-	0.22	-	5.08	0.37	0.15	-	-	-	-	-	-	0.44	-	0.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	17.62
H8742_001_0	2007	4																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1357.7	61.79	722.3		101.83	3.46	5.8	256.35	332.79		475.93		2.58	247.01	3374.22	3748.89	355.18	331.15		1.26	23.26				393																	1a: 450 per stay	1b: 450 per stay	2a: 125 per days - days 21-100		10a: 100	11a: 20	11b-c: 20 prosthetics 20 Diabetes supply	4a-b: 50 Emergency 25 Urgent	9a-b: 75 ASC 150 Facility		8: 125 MRI 300 PET 125 CT 50 Radiation Therapy		12:50	30 ind. 30 group MH/SA 25 PT/OT/ST	7a: 5	7bdfg: 25	7eh 9c: 30 ind. 30 group	3 7c 7i: 25		20 Chemo	15:20				17a: 15 - 1 routine eye exam																	85.6	59.81	39.13		100	0.2	0.2	44.98	124.29		59.84		50	25.43	5	25	30	25		0.2	0.2				15																	9.69	0.31	2.36	-	0.85	0.69	1.16	0.96	3.45	-	2.37	-	0.01	0.52	1.41	7.81	0.89	0.69	-	0.25	4.65	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.55		0	9.69	0.31	2.36	-	0.85	0.69	1.16	0.96	3.45	-	2.37	-	0.01	0.52	1.41	7.81	0.89	0.69	-	0.25	4.65	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.55																																																																																				-		0	9.69	0.31	2.36	-	0.85	0.69	1.16	0.96	3.45	-	2.37	-	0.01	0.52	1.41	7.81	0.89	0.69	-	0.25	4.65	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.55
H8742_003_0	2007	2																																D	D	D	V	P	Coin	Coin	V	V	V	V	V	V	V	P	P	P	P	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P	P																																																				-		1357.7	61.79	722.3		101.83	3.46	5.8	256.35	332.79		475.93		2.58	247.01	3374.22	3748.89	355.18	331.15		1.26	23.26				393																	1a: 450 per stay	1b: 450 per stay	2a: 125 per days - days 21-100		10a: 100	11a: 20	11b-c: 20 prosthetics 20 Diabetes supply	4a-b: 50 Emergency 25 Urgent	9a-b: 75 ASC 150 Facility		8: 125 MRI 300 PET 125 CT 50 Radiation Therapy		12:50	30 ind. 30 group MH/SA 25 PT/OT/ST	7a: 5	7bdfg: 25	7eh 9c: 30 ind. 30 group	3 7c 7i: 25		20 Chemo	15:20				17a: 15 - 1 routine eye exam																	85.6	59.81	39.13		100	0.2	0.2	44.98	124.29		59.84		50	25.43	5	25	30	25		0.2	0.2				15																	9.69	0.31	2.36	-	0.85	0.69	1.16	0.96	3.45	-	2.37	-	0.01	0.52	1.41	7.81	0.89	0.69	-	0.25	4.65	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.55		0	9.69	0.31	2.36	-	0.85	0.69	1.16	0.96	3.45	-	2.37	-	0.01	0.52	1.41	7.81	0.89	0.69	-	0.25	4.65	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.55																																																																																				-		0	9.69	0.31	2.36	-	0.85	0.69	1.16	0.96	3.45	-	2.37	-	0.01	0.52	1.41	7.81	0.89	0.69	-	0.25	4.65	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.55
H8742_801_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		236.07	5.99	24.98		3.02	3.46	5.8	8.75	35.61	21.24	29.28	7.48	0.13	19.45	22.1	30.12	2.48	2.81	20.94	83.17	23.26	0.1																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17.01	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.77	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.13		0	17.01	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.77	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.13																																																																																				-		0	17.01	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.77	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.13
H8742_802_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		236.06	5.99	24.98		3.01	3.46	5.8	8.75	35.61	21.24	29.27	7.48	0.13	19.45	22.1	30.12	2.48	2.81	20.94	83.17	23.26	0.1																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.76	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.12		0	17	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.76	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.12																																																																																				-		0	17	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.76	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.12
H8742_803_0	2007	2																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	P	P	P	P	P	P	P	P	P																																																				-		236.06	5.99	24.98		3.01	3.46	5.8	8.75	35.61	21.24	29.27	7.48	0.13	19.45	22.1	30.12	2.48	2.81	20.94	83.17	23.26	0.1																				Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.17		0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				17	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.76	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.12		0	17	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.76	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.12																																																																																				-		0	17	0.43	4.36	-	0.71	0.82	1.37	2.07	8.4	5.01	6.91	1.76	0.03	4.59	5.22	7.11	0.59	0.66	4.94	19.63	5.49	0.02	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.12
H9001_001_0	2007	3																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	238.8	3.26	65	0	259.47	0	0	999.8	0	0	943.11	0	0	0	8622.46	2352.33	258.95	490.06	0	38.23	181.5	71.47	0	509.47	1085.54	0	0	0	0	361.84	0											PBP: 1A IP Acute: 250 per admit 750 annual OOP Max	1B IP Psych: 250 per admit 750 annual OOP Max	2 SNF: 250 per admit 750 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 15	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 15	7B Chiropractic: 15 7D Physician Specialist: 15 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 15 9C OP Substance Abuse: 15	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-15 17A Medicare Covered Eye Exams: 15	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 15	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 15	13B Acupuncture: Not Covered											248.75	248.75	248.75	0	49.75	0	0	47.27	0	0	49.75	0	0	0	14.77	14.93	14.93	14.93	0	14.93	13.66	13.37	0	16.08	14.93	0	0	0	0	14.93	0											4.95	0.07	1.35	-	1.08	-	-	3.94	-	-	3.91	-	-	-	10.61	2.93	0.32	0.61	-	0.05	0.21	0.08	-	0.68	1.35	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	32.57	0	0.16	4.95	0.07	1.35	-	1.08	-	-	3.94	-	-	3.91	-	-	-	10.61	2.93	0.32	0.61	-	0.05	0.21	0.08	-	0.68	1.35	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	32.57	0																																																																																			-	0	0	4.95	0.07	1.35	-	1.08	-	-	3.94	-	-	3.91	-	-	-	10.61	2.93	0.32	0.61	-	0.05	0.21	0.08	-	0.68	1.35	-	-	-	-	0.45	-	-	-	-	-	-	-	-	-	-	-	32.57
H9001_006_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	290.85	3.56	82.65	0	355.33	0	0	1309.61	0	0	1025.53	0	0	0	10435.94	2787.93	321.7	664.19	0	51.03	794.39	27.95	0	612.25	1307.31	0	0	0	0	438.37	0											PBP: 1A IP Acute: 100 per admit 300 annual OOP Max	1B IP Psych: 100 per admit 300 annual OOP Max	2 SNF: 100 per admit 300 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 10	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 10 14B Immunizations: 0 14C Routine Physical Exams: 10 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 10	7B Chiropractic: 10 7D Physician Specialist: 10 7F Podiatry: 10	7E Mental Health: 10 7H Psychiatric: 10 9C OP Substance Abuse: 10	7C Occupational Therapy: 10 7I Physical and Speech Therapy: 10	Included in i.2.	7G Other Health Care: 10 18A Medicare Covered Hearing Exams: 10	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10 17A Medicare Covered Eye Exams: 10	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 10	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 10	13B Acupuncture: Not Covered											99.5	99.5	99.5	0	49.75	0	0	47.33	0	0	49.75	0	0	0	9.84	9.95	9.95	9.95	0	9.95	11.47	5.74	0	15.87	9.95	0	0	0	0	9.95	0											2.41	0.03	0.69	-	1.47	-	-	5.17	-	-	4.25	-	-	-	8.56	2.31	0.27	0.55	-	0.04	0.76	0.01	-	0.81	1.08	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	28.78	0	0.14	2.41	0.03	0.69	-	1.47	-	-	5.17	-	-	4.25	-	-	-	8.56	2.31	0.27	0.55	-	0.04	0.76	0.01	-	0.81	1.08	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	28.78	0																																																																																			-	0	0	2.41	0.03	0.69	-	1.47	-	-	5.17	-	-	4.25	-	-	-	8.56	2.31	0.27	0.55	-	0.04	0.76	0.01	-	0.81	1.08	-	-	-	-	0.36	-	-	-	-	-	-	-	-	-	-	-	28.78
H9001_010_0	2007	3																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	148.29	4.49	29.95	0	170.31	0	0	814.35	0	0	687.68	0	0	0	7239.35	1589.35	215.24	422.6	0	43.31	164.45	71.07	0	386.18	1143.32	0	0	0	0	393.73	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit 1350 annual OOP Max	2 SNF: 450 per admit 1350 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 15	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 15	7B Chiropractic: 15 7D Physician Specialist: 20 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 20 9C OP Substance Abuse: 15	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 15-20	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 15	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 15	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.52	0	0	49.75	0	0	0	14.7	18.91	14.93	14.93	0	14.93	10.81	13.95	0	16.07	14.93	0	0	0	0	14.93	0											5.53	0.17	1.12	-	0.71	-	-	3.22	-	-	2.85	-	-	-	8.87	2.51	0.27	0.53	-	0.05	0.15	0.08	-	0.52	1.42	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	28.48	0	0.14	5.53	0.17	1.12	-	0.71	-	-	3.22	-	-	2.85	-	-	-	8.87	2.51	0.27	0.53	-	0.05	0.15	0.08	-	0.52	1.42	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	28.48	0																																																																																			-	0	0	5.53	0.17	1.12	-	0.71	-	-	3.22	-	-	2.85	-	-	-	8.87	2.51	0.27	0.53	-	0.05	0.15	0.08	-	0.52	1.42	-	-	-	-	0.49	-	-	-	-	-	-	-	-	-	-	-	28.48
H9001_011_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	169.01	5.12	34.13	0	194.12	0	0	928.17	0	0	1212.12	0	0	0	8251.2	1811.49	245.32	481.67	0	49.36	187.43	81.01	0	440.16	1303.12	0	0	0	0	448.76	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit 1350 annual OOP Max	2 SNF: 450 per admit 1350 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 15	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 15	7B Chiropractic: 15 7D Physician Specialist: 20 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 20 9C OP Substance Abuse: 15	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 15-20	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 15	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 15	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.52	0	0	49.75	0	0	0	14.7	18.91	14.93	14.93	0	14.93	10.81	13.95	0	16.07	14.93	0	0	0	0	14.93	0											6.31	0.19	1.27	-	0.8	-	-	3.68	-	-	5.03	-	-	-	10.1	2.86	0.31	0.6	-	0.06	0.17	0.09	-	0.59	1.62	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	34.23	0	0.17	6.31	0.19	1.27	-	0.8	-	-	3.68	-	-	5.03	-	-	-	10.1	2.86	0.31	0.6	-	0.06	0.17	0.09	-	0.59	1.62	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	34.23	0																																																																																			-	0	0	6.31	0.19	1.27	-	0.8	-	-	3.68	-	-	5.03	-	-	-	10.1	2.86	0.31	0.6	-	0.06	0.17	0.09	-	0.59	1.62	-	-	-	-	0.56	-	-	-	-	-	-	-	-	-	-	-	34.23
H9001_012_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	346.32	9.4	100.69	0	630.35	0	0	1934.83	0	0	1385.63	0	0	0	9018.71	2049.84	1270.32	346.04	0	37.82	660.31	53.99	0	3.5	1452.11	0	0	0	0	426.96	0											PBP: 1A IP Acute: 100 per admit 300 annual OOP Max	1B IP Psych: 100 per admit 300 annual OOP Max	2 SNF: 100 per admit 300 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 5	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 5 14B Immunizations: 0 14C Routine Physical Exams: 5 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 5	7B Chiropractic: 5 7D Physician Specialist: 10 7F Podiatry: 5	7E Mental Health: 5 7H Psychiatric: 5 9C OP Substance Abuse: 5	7C Occupational Therapy: 5 7I Physical and Speech Therapy: 5	Included in i.2.	7G Other Health Care: 5 18A Medicare Covered Hearing Exams: 5	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 5-10 17A Medicare Covered Eye Exams: 5-10	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 5-49	17A Routine Eye Exams: 5	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 5	13B Acupuncture: Not Covered											99.5	99.5	99.5	0	49.75	0	0	48.3	0	0	49.75	0	0	0	4.94	8.34	4.98	4.98	0	4.98	14	7.06	0	27.58	4.98	0	0	0	0	4.98	0											2.87	0.08	0.83	-	2.61	-	-	7.79	-	-	5.74	-	-	-	3.71	1.42	0.53	0.14	-	0.02	0.77	0.03	-	0.01	0.6	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	27.34	0	0.14	2.87	0.08	0.83	-	2.61	-	-	7.79	-	-	5.74	-	-	-	3.71	1.42	0.53	0.14	-	0.02	0.77	0.03	-	0.01	0.6	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	27.34	0																																																																																			-	0	0	2.87	0.08	0.83	-	2.61	-	-	7.79	-	-	5.74	-	-	-	3.71	1.42	0.53	0.14	-	0.02	0.77	0.03	-	0.01	0.6	-	-	-	-	0.18	-	-	-	-	-	-	-	-	-	-	-	27.34
H9001_013_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	157.14	4.76	31.74	0	180.48	0	0	862.98	0	0	728.75	0	0	0	7671.68	1684.27	228.09	447.84	0	45.9	174.27	75.32	0	409.24	1211.6	0	0	0	0	417.24	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit 1350 annual OOP Max	2 SNF: 450 per admit 1350 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 15	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 15	7B Chiropractic: 15 7D Physician Specialist: 20 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 20 9C OP Substance Abuse: 15	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 15-20	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 15	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 15	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.52	0	0	49.75	0	0	0	14.7	18.91	14.93	14.93	0	14.93	10.81	13.95	0	16.07	14.93	0	0	0	0	14.93	0											5.86	0.18	1.18	-	0.75	-	-	3.42	-	-	3.02	-	-	-	9.39	2.65	0.28	0.56	-	0.06	0.16	0.09	-	0.55	1.51	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	30.18	0	0.15	5.86	0.18	1.18	-	0.75	-	-	3.42	-	-	3.02	-	-	-	9.39	2.65	0.28	0.56	-	0.06	0.16	0.09	-	0.55	1.51	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	30.18	0																																																																																			-	0	0	5.86	0.18	1.18	-	0.75	-	-	3.42	-	-	3.02	-	-	-	9.39	2.65	0.28	0.56	-	0.06	0.16	0.09	-	0.55	1.51	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	30.18
H9001_014_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	274.9	3.75	74.83	0	298.69	0	0	1150.93	0	0	1085.66	0	0	0	9925.75	2707.89	298.09	564.13	0	44	208.94	82.27	0	586.48	1249.62	0	0	0	0	416.53	0											PBP: 1A IP Acute: 250 per admit 750 annual OOP Max	1B IP Psych: 250 per admit 750 annual OOP Max	2 SNF: 250 per admit 750 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 15	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 15	7B Chiropractic: 15 7D Physician Specialist: 15 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 15 9C OP Substance Abuse: 15	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-15 17A Medicare Covered Eye Exams: 15	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 15	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 15	13B Acupuncture: Not Covered											248.75	248.75	248.75	0	49.75	0	0	47.27	0	0	49.75	0	0	0	14.77	14.93	14.93	14.93	0	14.93	13.66	13.37	0	16.08	14.93	0	0	0	0	14.93	0											5.7	0.08	1.55	-	1.24	-	-	4.53	-	-	4.5	-	-	-	12.21	3.37	0.37	0.7	-	0.05	0.24	0.09	-	0.79	1.55	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	37.5	0	0.19	5.7	0.08	1.55	-	1.24	-	-	4.53	-	-	4.5	-	-	-	12.21	3.37	0.37	0.7	-	0.05	0.24	0.09	-	0.79	1.55	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	37.5	0																																																																																			-	0	0	5.7	0.08	1.55	-	1.24	-	-	4.53	-	-	4.5	-	-	-	12.21	3.37	0.37	0.7	-	0.05	0.24	0.09	-	0.79	1.55	-	-	-	-	0.52	-	-	-	-	-	-	-	-	-	-	-	37.5
H9001_015_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	221.11	3.01	60.19	0	240.25	0	0	925.74	0	0	873.25	0	0	0	7983.76	2178.08	239.77	453.76	0	35.39	168.06	66.17	0	471.73	1005.13	0	0	0	0	335.04	0											PBP: 1A IP Acute: 250 per admit 750 annual OOP Max	1B IP Psych: 250 per admit 750 annual OOP Max	2 SNF: 250 per admit 750 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 15	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 15 14B Immunizations: 0 14C Routine Physical Exams: 15 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 15	7B Chiropractic: 15 7D Physician Specialist: 15 7F Podiatry: 15	7E Mental Health: 15 7H Psychiatric: 15 9C OP Substance Abuse: 15	7C Occupational Therapy: 15 7I Physical and Speech Therapy: 15	Included in i.2.	7G Other Health Care: 15 18A Medicare Covered Hearing Exams: 15	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-15 17A Medicare Covered Eye Exams: 15	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 15	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 15	13B Acupuncture: Not Covered											248.75	248.75	248.75	0	49.75	0	0	47.27	0	0	49.75	0	0	0	14.77	14.93	14.93	14.93	0	14.93	13.66	13.37	0	16.08	14.93	0	0	0	0	14.93	0											4.58	0.06	1.25	-	1	-	-	3.65	-	-	3.62	-	-	-	9.82	2.71	0.3	0.56	-	0.04	0.19	0.07	-	0.63	1.25	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	30.16	0	0.15	4.58	0.06	1.25	-	1	-	-	3.65	-	-	3.62	-	-	-	9.82	2.71	0.3	0.56	-	0.04	0.19	0.07	-	0.63	1.25	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	30.16	0																																																																																			-	0	0	4.58	0.06	1.25	-	1	-	-	3.65	-	-	3.62	-	-	-	9.82	2.71	0.3	0.56	-	0.04	0.19	0.07	-	0.63	1.25	-	-	-	-	0.42	-	-	-	-	-	-	-	-	-	-	-	30.16
H9001_016_0	2007	3																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	315	3.86	89.51	0	384.84	0	0	1418.37	0	0	1110.7	0	0	0	11302.62	3019.46	348.41	719.35	0	55.27	860.36	30.27	0	663.09	1415.88	0	0	0	0	474.78	0											PBP: 1A IP Acute: 100 per admit 300 annual OOP Max	1B IP Psych: 100 per admit 300 annual OOP Max	2 SNF: 100 per admit 300 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 10	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 10 14B Immunizations: 0 14C Routine Physical Exams: 10 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 10	7B Chiropractic: 10 7D Physician Specialist: 10 7F Podiatry: 10	7E Mental Health: 10 7H Psychiatric: 10 9C OP Substance Abuse: 10	7C Occupational Therapy: 10 7I Physical and Speech Therapy: 10	Included in i.2.	7G Other Health Care: 10 18A Medicare Covered Hearing Exams: 10	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10 17A Medicare Covered Eye Exams: 10	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 10	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 10	13B Acupuncture: Not Covered											99.5	99.5	99.5	0	49.75	0	0	47.33	0	0	49.75	0	0	0	9.84	9.95	9.95	9.95	0	9.95	11.47	5.74	0	15.87	9.95	0	0	0	0	9.95	0											2.61	0.03	0.74	-	1.6	-	-	5.59	-	-	4.6	-	-	-	9.27	2.5	0.29	0.6	-	0.05	0.82	0.01	-	0.88	1.17	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	31.17	0	0.15	2.61	0.03	0.74	-	1.6	-	-	5.59	-	-	4.6	-	-	-	9.27	2.5	0.29	0.6	-	0.05	0.82	0.01	-	0.88	1.17	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	31.17	0																																																																																			-	0	0	2.61	0.03	0.74	-	1.6	-	-	5.59	-	-	4.6	-	-	-	9.27	2.5	0.29	0.6	-	0.05	0.82	0.01	-	0.88	1.17	-	-	-	-	0.39	-	-	-	-	-	-	-	-	-	-	-	31.17
H9001_017_0	2007	5																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	269.18	3.29	76.49	0	328.86	0	0	1212.06	0	0	949.14	0	0	0	9658.6	2580.27	297.74	614.72	0	47.23	735.22	25.87	0	566.64	1209.93	0	0	0	0	405.72	0											PBP: 1A IP Acute: 100 per admit 300 annual OOP Max	1B IP Psych: 100 per admit 300 annual OOP Max	2 SNF: 100 per admit 300 annual OOP Max	6 Home Health: 0	10A Ambulance: 50 200 annual OOP Max	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 10	9A OP Hospital and 9B ASC Services: 0	8A OP C/D/T: 0	8B OP X-Ray: 50 150 annual OOP Max	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 10 14B Immunizations: 0 14C Routine Physical Exams: 10 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 10	7B Chiropractic: 10 7D Physician Specialist: 10 7F Podiatry: 10	7E Mental Health: 10 7H Psychiatric: 10 9C OP Substance Abuse: 10	7C Occupational Therapy: 10 7I Physical and Speech Therapy: 10	Included in i.2.	7G Other Health Care: 10 18A Medicare Covered Hearing Exams: 10	15 Part B Drugs: 5-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10 17A Medicare Covered Eye Exams: 10	10B Transportation: Not Covered	16A Preventive Dental Services: 10 16B Non-Medicare Covered Comprehensive Dental Services: 10-49	17A Routine Eye Exams: 10	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 10	13B Acupuncture: Not Covered											99.5	99.5	99.5	0	49.75	0	0	47.33	0	0	49.75	0	0	0	9.84	9.95	9.95	9.95	0	9.95	11.47	5.74	0	15.87	9.95	0	0	0	0	9.95	0											2.23	0.03	0.63	-	1.36	-	-	4.78	-	-	3.93	-	-	-	7.92	2.14	0.25	0.51	-	0.04	0.7	0.01	-	0.75	1	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	26.63	0	0.13	2.23	0.03	0.63	-	1.36	-	-	4.78	-	-	3.93	-	-	-	7.92	2.14	0.25	0.51	-	0.04	0.7	0.01	-	0.75	1	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	26.63	0																																																																																			-	0	0	2.23	0.03	0.63	-	1.36	-	-	4.78	-	-	3.93	-	-	-	7.92	2.14	0.25	0.51	-	0.04	0.7	0.01	-	0.75	1	-	-	-	-	0.34	-	-	-	-	-	-	-	-	-	-	-	26.63
H9001_801_0	2007	3																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	238.34	1.59	69.53	0	297.01	0	0	1039.11	492.86	0	1933.32	0	0	0	9014.72	2439.24	238.05	701.76	0	58.12	693.07	70.55	0	0	1118.51	0	0	0	0	738.44	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit	2 SNF: 450 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 20	9A OP Hospital and 9B ASC Services: 225	8A OP C/D/T: 0	8B OP X-Ray: 50	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 20	7B Chiropractic: 20 7D Physician Specialist: 25 7F Podiatry: 20	7E Mental Health: 20 7H Psychiatric: 25 9C OP Substance Abuse: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	Included in i.2.	7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 20-25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non-Medicare Covered Comprehensive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 20	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.48	223.88	0	49.75	0	0	0	19.66	23.59	19.9	19.9	0	19.9	10.54	18.62	0	0	19.9	0	0	0	0	19.9	0											8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11	0	0.29	8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11	0																																																																																			-	0	0	8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11
H9001_802_0	2007	4																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	238.34	1.59	69.53	0	297.01	0	0	1039.11	492.86	0	1933.32	0	0	0	9014.72	2439.24	238.05	701.76	0	58.12	693.07	70.55	0	0	1118.51	0	0	0	0	738.44	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit	2 SNF: 450 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 20	9A OP Hospital and 9B ASC Services: 225	8A OP C/D/T: 0	8B OP X-Ray: 50	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 20	7B Chiropractic: 20 7D Physician Specialist: 25 7F Podiatry: 20	7E Mental Health: 20 7H Psychiatric: 25 9C OP Substance Abuse: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	Included in i.2.	7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 20-25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non-Medicare Covered Comprehensive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 20	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.48	223.88	0	49.75	0	0	0	19.66	23.59	19.9	19.9	0	19.9	10.54	18.62	0	0	19.9	0	0	0	0	19.9	0											8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11	0	0.29	8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11	0																																																																																			-	0	0	8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11
H9001_803_0	2007	4																					3100											A	A	A	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	O	T	V	V	V	V	V	O	V	O											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	238.34	1.59	69.53	0	297.01	0	0	1039.11	492.86	0	1933.32	0	0	0	9014.72	2439.24	238.05	701.76	0	58.12	693.07	70.55	0	0	1118.51	0	0	0	0	738.44	0											PBP: 1A IP Acute: 450 per admit 1350 annual OOP Max	1B IP Psych: 450 per admit	2 SNF: 450 per admit	6 Home Health: 0	10A Ambulance: 50	11A DME: 0	11B Prosthetic Medical Supplies: 0 11C Diabetes Monitoring Supplies: 0	4A ER: 50 4B Urgent Care: 20	9A OP Hospital and 9B ASC Services: 225	8A OP C/D/T: 0	8B OP X-Ray: 50	Included in g.	12 Renal Dialysis: 0	3 CORF: 0 5 Partial Hosp: 0 9D Cardiac Rehab: 0	7A PCP: 20 14B Immunizations: 0 14C Routine Physical Exams: 20 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 20	7B Chiropractic: 20 7D Physician Specialist: 25 7F Podiatry: 20	7E Mental Health: 20 7H Psychiatric: 25 9C OP Substance Abuse: 20	7C Occupational Therapy: 20 7I Physical and Speech Therapy: 20	Included in i.2.	7G Other Health Care: 20 18A Medicare Covered Hearing Exams: 20	15 Part B Drugs: 0-40	13A Blood: 0 16B Medicare Covered Comprehensive Dental Services: 10-20 17A Medicare Covered Eye Exams: 20-25	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered 16B Non-Medicare Covered Comprehensive Dental Services: Not Covered	17A Routine Eye Exams: 20	17B Eye Wear: 0	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 20	13B Acupuncture: Not Covered											447.75	447.75	447.75	0	49.75	0	0	47.48	223.88	0	49.75	0	0	0	19.66	23.59	19.9	19.9	0	19.9	10.54	18.62	0	0	19.9	0	0	0	0	19.9	0											8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11	0	0.29	8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11	0																																																																																			-	0	0	8.89	0.06	2.59	-	1.23	-	-	4.11	9.19	-	8.02	-	-	-	14.77	4.79	0.39	1.16	-	0.1	0.61	0.11	-	-	1.85	-	-	-	-	1.22	-	-	-	-	-	-	-	-	-	-	-	59.11
H9003_001_0	2007	7											Travel Benefit										2500											D	D			T	Coin	Coin	V	V			Coin		V	V	V	V	V			Coin				V		V			V		Coin										0	0			0	0	0	0	0			0		0	0	0	0	0			0				0		0			0		0										-		816.9	29.21			286.84	5.59	0.47	438.96	557.64			0.26		240.24	4953.93	3664.21	252.52	263.31			11.9				676.43		30.26			14.04		0.5										200/day 1400max/admit	200/day 1400max/admit			100 copay	20 Coinsurance	20 Coinsurance	50 per visit	30 - 150 per visit			20 Coinsurance		10-30 per visit	5 -20 per visit or 20 coin	30 - 150 per visit	10 - 20 per visit	30 per visit			20 Coinsurance				20 per visit		30 per visit			8-155 per class		20 Coinsurance										200	200			100	0.2	0.2	50	127.33			0.2		29.91	19.76	30.45	18.66	30			0.2				20		30			74		0.2										13.61	0.49	-	-	2.39	1.12	0.09	1.83	5.92	-	-	0.05	-	0.6	8.16	9.3	0.39	0.66	-	-	2.38	-	-	-	1.13	-	0.08	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	48.38	0	0	13.61	0.49	-	-	2.39	1.12	0.09	1.83	5.92	-	-	0.05	-	0.6	8.16	9.3	0.39	0.66	-	-	2.38	-	-	-	1.13	-	0.08	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	48.38																																																																																				-			13.61	0.49	-	-	2.39	1.12	0.09	1.83	5.92	-	-	0.05	-	0.6	8.16	9.3	0.39	0.66	-	-	2.38	-	-	-	1.13	-	0.08	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	48.38
H9003_801_0	2007	6											Travel  Benefit										5500											D	D			T	Coin	Coin	V	V	Coin	Coin	Coin		V	V	V	V	V	Coin	Coin	Coin				V		V			V		Coin										0	0			0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0				0		0			0		0										-		763.7	16.4			263.47	5.77	0.4	402.82	567.06	24.29	27.1	0.09		244.92	5363.63	3969.77	219.71	329.45	23.83	18.37	7.89				804.67		44.04			14.59		0.5										400/day 2000max/admit	400/day 2000max/admit			100 copay	20 Coinsurance	20 Coinsurance	50 per visit	40 - 250 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance		20- 40 per visit	40 per visit or 20 coin	40 - 250 per visit	20 - 40 per visit	40 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance				40 per visit		40 per visit			8-155 per class		20 Coinsurance										400	400			100	0.2	0.2	50	209.45	0.2	0.2	0.2		39.99	39.75	40.33	36.44	40	0.2	0.2	0.2				40		40			74		0.2										25.46	0.55	-	-	2.2	1.15	0.08	1.68	9.9	4.86	5.42	0.02	-	0.82	17.77	13.34	0.67	1.1	4.77	3.67	1.58	-	-	-	2.68	-	0.15	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	98.03	0	0	25.46	0.55	-	-	2.2	1.15	0.08	1.68	9.9	4.86	5.42	0.02	-	0.82	17.77	13.34	0.67	1.1	4.77	3.67	1.58	-	-	-	2.68	-	0.15	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	98.03																																																																																				-			25.46	0.55	-	-	2.2	1.15	0.08	1.68	9.9	4.86	5.42	0.02	-	0.82	17.77	13.34	0.67	1.1	4.77	3.67	1.58	-	-	-	2.68	-	0.15	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	98.03
H9003_802_0	2007	6											Travel Benefit										5500											D	D			T	Coin	Coin	V	V	Coin	Coin	Coin		V	V	V	V	V	Coin	Coin	Coin				V		V			V		Coin										0	0			0	0	0	0	0	0	0	0		0	0	0	0	0	0	0	0				0		0			0		0										-		763.7	16.4			263.47	5.77	0.4	402.82	567.06	24.29	27.1	0.09		244.92	5363.63	3969.77	219.71	329.45	23.83	18.37	7.89				804.67		44.04			14.59		0.5										400/day 2500max/admit	400/day 2500max/admit			100 copay	20 Coinsurance	20 Coinsurance	50 per visit	40 - 250 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance		20- 40 per visit	40 per visit or 20 coin	40 - 250 per visit	20 - 40 per visit	40 per visit	20 Coinsurance	20 Coinsurance	20 Coinsurance				40 per visit		40 per visit			8-155 per class		20 Coinsurance										400	400			100	0.2	0.2	50	209.45	0.2	0.2	0.2		39.99	39.75	40.33	36.44	40	0.2	0.2	0.2				40		40			74		0.2										25.46	0.55	-	-	2.2	1.15	0.08	1.68	9.9	4.86	5.42	0.02	-	0.82	17.77	13.34	0.67	1.1	4.77	3.67	1.58	-	-	-	2.68	-	0.15	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	98.03	0	0	25.46	0.55	-	-	2.2	1.15	0.08	1.68	9.9	4.86	5.42	0.02	-	0.82	17.77	13.34	0.67	1.1	4.77	3.67	1.58	-	-	-	2.68	-	0.15	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	98.03																																																																																				-			25.46	0.55	-	-	2.2	1.15	0.08	1.68	9.9	4.86	5.42	0.02	-	0.82	17.77	13.34	0.67	1.1	4.77	3.67	1.58	-	-	-	2.68	-	0.15	-	-	0.09	-	0.1	-	-	-	-	-	-	-	-	-	98.03
H9005_007_0	2007	6																																					Coin		V									V				Coin							Coin																																																							-							18.44		323.88									183.91				4.07							0.23														1a: 0 coins	1b: 0 coins	2: 0 coins	6: 0 coins	10a: 0 coins	11a: 10 coinsurance	11b 11c: 10 coinsurance	4a: 30 copay; 4b: 0 copay	9a 9b: 0 coins	8a: 0 coins	8b: 0 coins	5: 0 coins	12: 0 coins	3 9c 9d: 0 coins	7a 14b 14c: 0 coins	7b 7d 7f: 0 coins	7e 7h: 5/10 Copay	7c 7i: 0 coins	7d: 0 coins	7g 14d 14e 14f 14g 14h 14i: 0 coins	15: 20 coinsurance	13a: 0 coinsurance	10b: 0 coinsurance	16a 16b: 0 coinsurance	17a: 0 coinsurance	17b: 0 coinsurance	18a: 0 coinsurance	18b: 50 up to 1000 max		14a: 0 coinsurance	13b: 0 coinsurance																0.1		28.68									8.41				0.19							0.48														-	-	-	-	-	1.77	-	0.77	-	-	-	-	-	-	-	-	0.13	-	-	-	0.78	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	3.56		0.16	-	-	-	-	-	1.77	-	0.77	-	-	-	-	-	-	-	-	0.13	-	-	-	0.78	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	3.56	3000	1a: 20 coins up to 100000 of Medicare Allowable chg	1b: 20 coins up to 100000 of Medicare Allowable chgs	2: 20 coins up to 100000 of Medicare Allowable chgs	6: 20 coins up to 100000 of Medicare Allowable chgs	10a: 20 coinsuance	11a: 20 coins up to 100000 of Medicare Allowable chgs	11b 11c: 20 coins up to 100000 of Medicare Allowable chgs	4a and 4b: 30 copay	9a 9b: 20 coins up to 100000 of Medicare Allowable chgs	8a: 20 coins up to 100000 of Medicare Allowable chgs	8b: 20 coins up to 100000 of Medicare Allowable chgs	5: 20 coins up to 100000 of Medicare Allowable chgs	12: 20 coins up to 100000 of Medicare Allowable chgs	3 9c 9d: 20 coins up to 100000 of Medicare Allowable chgs	7a: 20 coins up to 100000 of Medicare Allowable chgs	7b 7d 7f: 20 coins up to 100000 of Medicare Allowable chgs	7e 7h: 20 coins up to 100000 of Medicare Allowable chgs	7c 7i: 20 coins up to 100000 of Medicare Allowable chgs	7d: 20 coins up to 100000 of Medicare Allowable chgs	7g: 20 coins up to 100000 of Medicare Allowable chgs										14a: 20 coins up to 100000 of Medicare Allowable chgs												0		0.03	0.01	0	0		0.02	0	0.05					0.04																											0.16		0.17	0	-	0.03	0.01	0	1.77	-	0.8	0	0.05	-	-	-	-	0.04	-	0.13	-	-	-	0.78	-	-	-	-	-	-	0.11	-	-	-	-	-	-	-	-	-	-	-	-	-	3.72
H9005_804_0	2007	5																																					Coin		V							V		V				Coin																																																														-							14.23		414.43							4021.99		93.3				3.14																					1a: 0 coins	1b: 0 coins	2: 0 coins	6: 0 coins	10a: 0 coins	11a: 10 coinsurance	11b 11c: 10 coinsurance	4a: 30 copay; 4b: 10 copay	9a 9b: 0 coins	8a: 0 coins	8b: 0 coins	5: 0 coins	12: 0 coins	3 9c 9d: 0 coins	7a 14b 14c: 10 copay	7b 7d 7f: 0 coins	7e 7h: 10 Copay for individual MH sessions 5 Copay for group MH	7c 7i: 0 coins	7d: 0 coins	7g 14d 14e 14f 14g 14h 14i: 0 coins	15: 20 coinsurance																										0.09		18.89							8.66		7.62				0.17																					-	-	-	-	-	1.23	-	0.65	-	-	-	-	-	-	2.9	-	0.06	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.39		0.83	-	-	-	-	-	1.23	-	0.65	-	-	-	-	-	-	2.9	-	0.06	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.39	3000	1a: 20 coins up to 100000 of Medicare Allowable chg	1b: 20 coins up to 100000 of Medicare Allowable chgs	2: 20 coins up to 100000 of Medicare Allowable chgs	6: 20 coins up to 100000 of Medicare Allowable chgs	10a: 20 coinsuance	11a: 20 coins up to 100000 of Medicare Allowable chgs	11b 11c: 20 coins up to 100000 of Medicare Allowable chgs	4a and 4b: 30 copay	9a 9b: 20 coins up to 100000 of Medicare Allowable chgs	8a: 20 coins up to 100000 of Medicare Allowable chgs	8b: 20 coins up to 100000 of Medicare Allowable chgs	5: 20 coins up to 100000 of Medicare Allowable chgs	12: 20 coins up to 100000 of Medicare Allowable chgs	3 9c 9d: 20 coins up to 100000 of Medicare Allowable chgs	7a: 20 coins up to 100000 of Medicare Allowable chgs	7b 7d 7f: 20 coins up to 100000 of Medicare Allowable chgs	7e 7h: 20 coins up to 100000 of Medicare Allowable chgs	7c 7i: 20 coins up to 100000 of Medicare Allowable chgs	7d: 20 coins up to 100000 of Medicare Allowable chgs	7g: 20 coins up to 100000 of Medicare Allowable chgs																						0		0.02	0	0	0		0.02	0	0.04					0.03																											0.12		0.13	0	-	0.02	0	0	1.23	-	0.67	0	0.04	-	-	-	-	2.93	-	0.06	-	-	-	0.54	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	5.51
H9011_003_0	2007	5																					1950											D	D	D	V	T	Coin	Coin	V	V	P	P	O	Coin	O	V	V	V	P	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		0	45.76	0	0	197.03	20.75	7.76	238.39	0	0	0	0	0.25	0.13	0	0	0	0	0	0	20.62	0	0	0	0	0	0	0	0	0	0											0 (1a)	175 (1b)	0 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50/40 (4a 4b)	0 (9b)	0 (8a 8b)	0/0 (8a 8b)	0 (incl in h5)	30 (12)	0 (3 9d 9a); 60 (5); 0/0 (9c)	0 (7a 14c 14b 14d 14e 14f 14g 14h)	0 (7b 7d 7f 7g)	0/0 (7e 7h)	0 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17a 17b 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	0 (17a)	0 (17b1-17b5)	0 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											0	102.89	0	0	102.89	0.18	0.22	29.21	0	0	0	0	0.18	0	0	0	0	0	0	0	0.18	0	0	0	0	0	0	0	0	0	0											-	0.39	-	-	1.69	3.66	1.68	0.58	-	-	-	-	0.04	0	-	-	-	-	-	-	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.68		7.67	-	0.39	-	-	1.69	3.66	1.68	0.58	-	-	-	-	0.04	0	-	-	-	-	-	-	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.68																																																																																				-			-	0.39	-	-	1.69	3.66	1.68	0.58	-	-	-	-	0.04	0	-	-	-	-	-	-	3.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	11.68
H9011_011_0	2007	3	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1100	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T								O																																																				-		2704.62	427.95	1425.87		341.18	44.2	38.29	1179.19					5.44								28.65																					(1a) 25 per Day	(1b) 25 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 50 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/20 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 0 per Visit	(8a) 0 per Visit	(8b) 0 per Visit	(9a) 0 per Visit	(12) 20 Coinsurance	(9a) 0 per Visit	(7a) 0 per Visit	(7d) 0 per Visit	(7h) 0 per Visit	(7c) 0 per Visit	0 per Visit	(7g) 0 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip								(13a1) 0											16	16	23		32	13	13	25					13								13																					3.55	0.56	2.7	-	0.9	5.58	4.83	2.45	-	-	-	-	0.69	-	-	-	-	-	-	-	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.86		14.56	3.55	0.56	2.7	-	0.9	5.58	4.83	2.45	-	-	-	-	0.69	-	-	-	-	-	-	-	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.86																																																																																				-		0	3.55	0.56	2.7	-	0.9	5.58	4.83	2.45	-	-	-	-	0.69	-	-	-	-	-	-	-	3.61	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.86
H9011_012_0	2007	7																					1950											D	D	D	V	T	O	O	V	V	P	P	O	Coin	O	V	V	V	P	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		0	45.76	0	0	197.03	0	0	238.39	0	0	0	0	0.25	0.13	0	0	0	0	0	0	20.62	0	0	0	0	0	0	0	0	0	0											0 (1a)	175 (1b)	0 (2a)	0 (6a)	175 (10a)	0 (11a)	0 (11b 11c)	50/40 (4a 4b)	0 (9b)	0 (8a 8b)	0/0 (8a 8b)	0 (incl in h5)	30 (12)	0 (3 9d 9a); 60 (5); 0/0 (9c)	0 (7a 14c 14b 14d 14e 14f 14g 14h)	0 (7b 7d 7f 7g)	0/0 (7e 7h)	0 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17a 17b 18a 16b)	0 (10b)	0 (16a 16b1-16b5)	0 (17a)	0 (17b1-17b5)	0 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											0	126.62	0	0	126.62	0	0	35.95	0	0	0	0	0.22	0	0	0	0	0	0	0	0.22	0	0	0	0	0	0	0	0	0	0											-	0.48	-	-	2.08	-	-	0.71	-	-	-	-	0.06	0	-	-	-	-	-	-	4.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.81		2.98	-	0.48	-	-	2.08	-	-	0.71	-	-	-	-	0.06	0	-	-	-	-	-	-	4.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.81																																																																																				-			-	0.48	-	-	2.08	-	-	0.71	-	-	-	-	0.06	0	-	-	-	-	-	-	4.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	7.81
H9011_801_0	2007	3																					6500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1571.38	50.4	512.62	0	145.5	23.69	8.55	248.85	37.26	12578.87	57.4	0	0.14	22.68	12982.58	5384.31	207.61	6.63	0	0	22.36	1463.18	0	0	83.75	0	222.17	0	0	0	0											350 (1a)	350 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	40 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	50 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 50 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	50 (17a)	0 n/c (17b1-17b5)	50 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											273.33	273.33	124.95	0	136.67	0.2	0.22	39.05	0.2	4.69	0	0	0.23	0.2	40	50	37.5	0.2	0	0	0.23	50	0	0	50	0	50	0	0	0	0											35.79	1.15	5.34	-	1.66	4.62	1.88	0.81	7.28	4.91	0.24	-	0.03	4.43	43.28	22.43	0.65	1.3	-	-	5.24	6.1	-	-	0.35	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.39		20.67	35.79	1.15	5.34	-	1.66	4.62	1.88	0.81	7.28	4.91	0.24	-	0.03	4.43	43.28	22.43	0.65	1.3	-	-	5.24	6.1	-	-	0.35	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.39																																																																																				-			35.79	1.15	5.34	-	1.66	4.62	1.88	0.81	7.28	4.91	0.24	-	0.03	4.43	43.28	22.43	0.65	1.3	-	-	5.24	6.1	-	-	0.35	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.39
H9011_802_0	2007	2																					6500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-		1571.38	50.4	512.62	0	145.5	23.69	8.55	248.85	37.26	12578.87	57.4	0	0.14	22.68	13089.98	5384.31	207.61	6.63	0	0	22.36	1463.18	0	0	83.75	0	222.17	0	0	0	0											350 (1a)	350 (1b)	160 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	40 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	50 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 50 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	50 (17a)	0 n/c (17b1-17b5)	50 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											273.33	273.33	124.95	0	136.67	0.2	0.22	39.05	0.2	4.69	0	0	0.23	0.2	40	50	37.5	0.2	0	0	0.23	50	0	0	50	0	50	0	0	0	0											35.79	1.15	5.34	-	1.66	4.62	1.88	0.81	7.28	4.91	0.24	-	0.03	4.43	43.63	22.43	0.65	1.3	-	-	5.24	6.1	-	-	0.35	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.75		20.67	35.79	1.15	5.34	-	1.66	4.62	1.88	0.81	7.28	4.91	0.24	-	0.03	4.43	43.63	22.43	0.65	1.3	-	-	5.24	6.1	-	-	0.35	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.75																																																																																				-			35.79	1.15	5.34	-	1.66	4.62	1.88	0.81	7.28	4.91	0.24	-	0.03	4.43	43.63	22.43	0.65	1.3	-	-	5.24	6.1	-	-	0.35	-	0.93	-	-	-	-	-	-	-	-	-	-	-	-	-	-	148.75
H9016_002_0	2007	5																																																																																																																		-		0	17.82	0	0	1081.23	9287.08	896.65	239.58	238.02	0	0	0	10.04	1747.05	7799.85	6096.86	389.66	315.92		28165.08	119.2			788.67		339.18	254.28																																																									50			50	4	13	48.61	10				10	10	3	5	10	10		6.07	12.5			48.03		15	10															-	0.07	-	-	4.51	3.1	0.97	0.97	0.2	-	-	-	0.01	1.46	1.95	2.54	0.32	0.26	-	14.25	0.12	-	-	3.16	-	0.42	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.52			-	0.07	-	-	4.51	3.1	0.97	0.97	0.2	-	-	-	0.01	1.46	1.95	2.54	0.32	0.26	-	14.25	0.12	-	-	3.16	-	0.42	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.52																																																																																				-			-	0.07	-	-	4.51	3.1	0.97	0.97	0.2	-	-	-	0.01	1.46	1.95	2.54	0.32	0.26	-	14.25	0.12	-	-	3.16	-	0.42	0.21	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.52
H9016_006_0	2007	6																																																																																																																		-		0	22.53	0	0	1496.72	12853.03	1241.32	393.43	392.39	0	0	0	14.11	2553.86	5695.86	4444.5	267.76	313.26		14623.04	168.68			794.93		285.72	190.6																																																									50			50	4	13	48.61	10				10	10	3	5	10	10		6.07	12.5			48.03		15	10															-	0.09	-	-	6.24	4.28	1.34	1.59	0.33	-	-	-	0.01	2.13	1.42	1.85	0.22	0.26	-	7.4	0.18	-	-	3.18	-	0.36	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.05			-	0.09	-	-	6.24	4.28	1.34	1.59	0.33	-	-	-	0.01	2.13	1.42	1.85	0.22	0.26	-	7.4	0.18	-	-	3.18	-	0.36	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.05																																																																																				-			-	0.09	-	-	6.24	4.28	1.34	1.59	0.33	-	-	-	0.01	2.13	1.42	1.85	0.22	0.26	-	7.4	0.18	-	-	3.18	-	0.36	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	31.05
H9016_007_0	2007	6																																																																																																																		-		0	11.96	0	0	1181.92	10167.6	979.53	242	240.64	0	0	0	9.83	1248.91	5913.82	4620.62	313.14	259.16		3037.16	117.48			456.82		267.32	197.96																																																									50			50	4	13	48.61	10				10	10	3	5	10	10		6.07	12.5			48.03		15	10															-	0.05	-	-	4.92	3.39	1.06	0.98	0.2	-	-	-	0.01	1.04	1.48	1.93	0.26	0.22	-	1.54	0.12	-	-	1.83	-	0.33	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.52			-	0.05	-	-	4.92	3.39	1.06	0.98	0.2	-	-	-	0.01	1.04	1.48	1.93	0.26	0.22	-	1.54	0.12	-	-	1.83	-	0.33	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.52																																																																																				-			-	0.05	-	-	4.92	3.39	1.06	0.98	0.2	-	-	-	0.01	1.04	1.48	1.93	0.26	0.22	-	1.54	0.12	-	-	1.83	-	0.33	0.16	-	-	-	-	-	-	-	-	-	-	-	-	-	-	19.52
H9016_009_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H9016_010_0	2007	3																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H9016_011_0	2007	4																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H9047_001_0	2007	9																					2500											A				T	Coin		V	V		Coin			V	V				Coin		Coin				V					O												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-		237.1	0	0	0	284.84	19.62	0	462.97	437.74	0	31.78	0	0	109.9	10608.29	0	0	0	23.22	0	58.5	0	0	0	187.2	0	0	0	0	1.39	0	0	0	0	0	0	0	0	0	0	0	250/acute and MH admit	covered under a.1.	no cost sharing	no cost sharing	50/trip	10 coins. for non-diabetic DME/Pros./Supplies	covered under e.1.	50/ER visit; 25/urgent care visit	50/visit	no cost sharing	10 coins. for fac. radiology	no cost sharing	no cost sharing	15/visit; diab. training cardiac rehab clinic	15/visit for all prof. visits	covered under i.1.	covered under i.1.	covered under i.1.	10 coins. for prof. radiology	no cost sharing	10 coins.	no cost sharing	no covered services	no covered services	15/routine vision exam	no covered services	no covered services	no covered services	no covered services	plan pays up to 350 for classes; see PBP notes	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	220	0	0	0	44	0.09	0	40.13	44	0	0.09	0	0	13.2	13.2	0	0	0	0.09	0	0.09	0	0	0	15	0	0	0	0	450.07	0	0	0	0	0	0	0	0	0	0	0	4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34	0	4.4	4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34	2500	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34
H9047_013_0	2007	9																					2500											A				T	Coin		V	V		Coin			V	V				Coin		Coin				V					O												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-		237.1	0	0	0	284.84	19.62	0	462.97	437.74	0	31.78	0	0	109.9	10608.29	0	0	0	23.22	0	58.5	0	0	0	187.2	0	0	0	0	1.39	0	0	0	0	0	0	0	0	0	0	0	250/acute and MH admit	covered under a.1.	no cost sharing	no cost sharing	50/trip	10 coins. for non-diabetic DME/Pros./Supplies	covered under e.1.	50/ER visit; 25/urgent care visit	50/visit	no cost sharing	10 coins. for fac. radiology	no cost sharing	no cost sharing	15/visit; diab. training cardiac rehab clinic	15/visit for all prof. visits	covered under i.1.	covered under i.1.	covered under i.1.	10 coins. for prof. radiology	no cost sharing	10 coins.	no cost sharing	no covered services	no covered services	15/routine vision exam	no covered services	no covered services	no covered services	no covered services	plan pays up to 350 for classes; see PBP notes	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	220	0	0	0	44	0.09	0	40.13	44	0	0.09	0	0	13.2	13.2	0	0	0	0.09	0	0.09	0	0	0	15	0	0	0	0	450.07	0	0	0	0	0	0	0	0	0	0	0	4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34		4.4	4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34	2500	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-	0	0	4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34
H9047_024_0	2007	9																																A			Coin	T	Coin		V	V		Coin		Coin	V	V				Coin		Coin	Coin			V					O												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-		209.17	0	0	16	224.88	13.19	0	374.84	469.8	0	29.49	0	23.4	81.93	9115.99	0	0	0	18.17	0	37.33	35.14	0	0	164.76	0	0	0	0	1.37	0	0	0	0	0	0	0	0	0	0	0	350/acute and MH admit	covered under a.1.	no cost sharing	10 coins.	50/trip	10 coins. for non-diabetic DME/Pros./Supplies	covered under e.1.	50/ER visit; 25/urgent care visit	100/visit	no cost sharing	10 coins. for fac. radiology	covered under h.4.	10 coins.; all other OP Facility	20/visit; diab. training cardiac rehab clinic	20/visit for all prof. visits	covered under i.1.	covered under i.1.	covered under i.1.	10 coins. for prof. radiology	covered under i.1.	10 coins.	10 coins.; includes some prof. and some OP fac.	no covered services	no covered services	20/routine vision exam	no covered services	no covered services	no covered services	no covered services	plan pays up to 350 for classes; see PBP notes	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	322	0	0	0.09	46	0.09	0	39.09	92	0	0.09	0	0.09	18.4	18.4	0	0	0	0.09	0	0.09	0.09	0	0	20	0	0	0	0	445.64	0	0	0	0	0	0	0	0	0	0	0	5.61	-	-	1.47	0.86	1.21	-	1.22	3.6	-	2.71	-	2.15	0.13	13.98	-	-	-	1.67	-	3.43	3.23	-	-	0.27	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	41.62	0	3.59	5.61	-	-	1.47	0.86	1.21	-	1.22	3.6	-	2.71	-	2.15	0.13	13.98	-	-	-	1.67	-	3.43	3.23	-	-	0.27	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	41.62	3500	20 coins.	covered under a.1.	20 coins.	20 coins.	20 coins.	20 coins.	covered under e.1.	20 coins.	20 coins.	covered under h.5.	covered under h.5.	covered under h.5.	covered under h.5.	20 coins.	20 coins.	covered under i.1.	covered under i.1.	covered under i.1.	covered under i.1.	covered under i.1.	20 coins.	20 coins.	no covered services	no covered services	20 coins.	no covered services	no covered services	no covered services	no covered services	20 coins.	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	1.23	0	0.16	0.13	0.08	0.16	0	0.16	0.46	0	0	0	0	0.58	2.57	0	0	0	0	0	0.35	0	0	0	0.04	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	5.91	0	2.89	6.85	-	0.16	1.6	0.94	1.37	-	1.38	4.06	-	2.71	-	2.15	0.71	16.54	-	-	-	1.67	-	3.79	3.23	-	-	0.31	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	47.53
H9047_033_0	2007	4																					2500											A				T	Coin		V	V		Coin			V	V				Coin		Coin				V					O												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-		237.1	0	0	0	284.84	19.62	0	462.97	437.74	0	31.78	0	0	109.9	10608.29	0	0	0	23.22	0	58.5	0	0	0	187.2	0	0	0	0	1.39	0	0	0	0	0	0	0	0	0	0	0	250/acute and MH admit	covered under a.1.	no cost sharing	no cost sharing	50/trip	10 coins. for non-diabetic DME/Pros./Supplies	covered under e.1.	50/ER visit; 25/urgent care visit	50/visit	no cost sharing	10 coins. for fac. radiology	no cost sharing	no cost sharing	15/visit; diab. training cardiac rehab clinic	15/visit for all prof. visits	covered under i.1.	covered under i.1.	covered under i.1.	10 coins. for prof. radiology	no cost sharing	10 coins.	no cost sharing	no covered services	no covered services	15/routine vision exam	no covered services	no covered services	no covered services	no covered services	plan pays up to 350 for classes; see PBP notes	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	220	0	0	0	44	0.09	0	40.13	44	0	0.09	0	0	13.2	13.2	0	0	0	0.09	0	0.09	0	0	0	15	0	0	0	0	450.07	0	0	0	0	0	0	0	0	0	0	0	4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34	0	4.4	4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34	2500	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-			4.35	-	-	-	1.04	1.73	-	1.55	1.61	-	2.8	-	-	0.12	11.67	-	-	-	2.04	-	5.15	-	-	-	0.23	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	32.34
H9047_035_0	2007	6																																A			Coin	T	Coin		V	V		Coin		Coin	V	V				Coin		Coin	Coin			V					O												0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-		209.17	0	0	16	224.88	13.19	0	374.84	469.8	0	29.49	0	23.4	81.93	9115.99	0	0	0	18.17	0	37.33	35.14	0	0	164.76	0	0	0	0	1.37	0	0	0	0	0	0	0	0	0	0	0	350/acute and MH admit	covered under a.1.	no cost sharing	10 coins.	50/trip	10 coins. for non-diabetic DME/Pros./Supplies	covered under e.1.	50/ER visit; 25/urgent care visit	100/visit	no cost sharing	10 coins. for fac. radiology	covered under h.4.	10 coins.; all other OP Facility	20/visit; diab. training cardiac rehab clinic	20/visit for all prof. visits	covered under i.1.	covered under i.1.	covered under i.1.	10 coins. for prof. radiology	covered under i.1.	10 coins.	10 coins.; includes some prof. and some OP fac.	no covered services	no covered services	20/routine vision exam	no covered services	no covered services	no covered services	no covered services	plan pays up to 350 for classes; see PBP notes	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	322	0	0	0.09	46	0.09	0	39.09	92	0	0.09	0	0.09	18.4	18.4	0	0	0	0.09	0	0.09	0.09	0	0	20	0	0	0	0	445.64	0	0	0	0	0	0	0	0	0	0	0	5.61	-	-	1.47	0.86	1.21	-	1.22	3.6	-	2.71	-	2.15	0.13	13.98	-	-	-	1.67	-	3.43	3.23	-	-	0.27	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	41.62	0	3.59	5.61	-	-	1.47	0.86	1.21	-	1.22	3.6	-	2.71	-	2.15	0.13	13.98	-	-	-	1.67	-	3.43	3.23	-	-	0.27	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	41.62	3500	20 coins.	covered under a.1.	20 coins.	20 coins.	20 coins.	20 coins.	covered under e.1.	20 coins.	20 coins.	covered under h.5.	covered under h.5.	covered under h.5.	covered under h.5.	20 coins.	20 coins.	covered under i.1.	covered under i.1.	covered under i.1.	covered under i.1.	covered under i.1.	20 coins.	20 coins.	no covered services	no covered services	20 coins.	no covered services	no covered services	no covered services	no covered services	20 coins.	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	1.23	0	0.16	0.13	0.08	0.16	0	0.16	0.46	0	0	0	0	0.58	2.57	0	0	0	0	0	0.35	0	0	0	0.04	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	5.91	0	2.89	6.85	-	0.16	1.6	0.94	1.37	-	1.38	4.06	-	2.71	-	2.15	0.71	16.54	-	-	-	1.67	-	3.79	3.23	-	-	0.31	-	-	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	47.53
H9047_801_0	2007	4																					none											Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-	none	204.95	0	21.95	17.24	7.84	20.03	0	15.49	63.85	0	0	0	0	65.24	216.4	0	0	0	0	0	39.37	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	0.07	0	0.14	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0	0	0	0	0	0.24	0.24	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	14.86	-	3.01	-	1.85	4.73	-	3.66	15.07	-	-	-	-	15.4	51.07	-	-	-	-	-	9.29	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.93	0	0	14.86	-	3.01	-	1.85	4.73	-	3.66	15.07	-	-	-	-	15.4	51.07	-	-	-	-	-	9.29	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.93	none	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-	0	0	14.86	-	3.01	-	1.85	4.73	-	3.66	15.07	-	-	-	-	15.4	51.07	-	-	-	-	-	9.29	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.93
H9047_804_0	2007	4																					none											Coin		Coin		Coin	Coin		Coin	Coin					Coin	Coin						Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-	none	204.95	0	21.95	17.24	7.84	20.03	0	15.49	63.85	0	0	0	0	65.24	216.4	0	0	0	0	0	39.37	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	0.07	0	0.14	0	0.24	0.24	0	0.24	0.24	0	0	0	0	0.24	0.24	0	0	0	0	0	0.24	0.24	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	14.86	-	3.01	-	1.85	4.73	-	3.66	15.07	-	-	-	-	15.4	51.07	-	-	-	-	-	9.29	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.93	0	0	14.86	-	3.01	-	1.85	4.73	-	3.66	15.07	-	-	-	-	15.4	51.07	-	-	-	-	-	9.29	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.93	none	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	no covered services	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	-	0	0	14.86	-	3.01	-	1.85	4.73	-	3.66	15.07	-	-	-	-	15.4	51.07	-	-	-	-	-	9.29	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.93
H9101_007_0	2007	5																					3100											D	D	D	V	T	Coin	P	V	V	V	V	V	V	V	V	V	V	V	Coin	V	Coin	O	V	V	V	V	V	V	V	V	V																																																				-		3246.46		1767.54		712.47	7.8		223.67	166.64							34142.1	194.9	2843.98	47.94		10.65																					#1A 500 per Admit #1B 500 per Admit		#2 0/day days 1-10 50/day days 11-20 100/day days 21-100	#6 0 #13C 0	#10A 50 #10B 50	#11A 20 #11B 20 #11C 0		#4A 50 #4B 50	#9A 200 #9B 200				#12 0	#3 0 #5 0 #9D 0		#7A 0 #14B 0 #14C 0 #14D 0 #14E 0 #14F 0 #14G 0 #14H 0 #7B 20 #7D 20 #7F 20 #7G 0 #9C 20 #14I 25	#7E 20 #7H 20	#7C 10 #7I 10	#8A 20 #8B 20		#15 20																					51.63		53.34		50	0.18		36.12	131.3							3.08	4.53	2.91	0.12		0.2																					13.97	-	7.86	-	2.97	1.43	-	0.67	1.82	-	-	-	-	-	-	8.75	0.07	0.69	5.94	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.31		0	13.97	-	7.86	-	2.97	1.43	-	0.67	1.82	-	-	-	-	-	-	8.75	0.07	0.69	5.94	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.31																																																																																				-		0	13.97	-	7.86	-	2.97	1.43	-	0.67	1.82	-	-	-	-	-	-	8.75	0.07	0.69	5.94	-	2.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.31
H9103_001_0	2007	6											Expanded Care	Travel Benefit									2500											D	D			T	Coin	Coin	V	V			Coin		V	V	V	V	V			Coin				V		V			V		Coin	Coin									0	0			0	0	0	0	0			0		0	0	0	0	0			0				0		0			0		0	0									-		1642.7	50.03			790.4	8.39	0.44	588	566.33			0.01		570.91	6233.79	4562.7	222.29	270.88			10.58				805.85		46.19			17.3		7.42	0.5									150/day 1500max/admit	150/day 1500max/admit			100 copay	20 Coinsurance	20 Coinsurance	50 per visit	30 - 150 per visit			20 Coinsurance		10-30 per visit	5 -20 per visit or 20 coin	30 - 150 per visit	10 - 20 per visit	30 per visit			20 Coinsurance				20 per visit		30 per visit			8-155 per class		20 Coinsurance	20 Coinsurance									150	150			100	0.2	0.2	50	125.75			0.2		30	19.81	30.04	18.95	30			0.2				20		30			74		0.2	0.2									20.53	0.63	-	-	6.59	1.68	0.09	2.45	5.93	-	-	0	-	1.43	10.29	11.42	0.35	0.68	-	-	2.12	-	-	-	1.34	-	0.12	-	-	0.11	-	1.48	0.1	-	-	-	-	-	-	-	-	67.33	0	0	20.53	0.63	-	-	6.59	1.68	0.09	2.45	5.93	-	-	0	-	1.43	10.29	11.42	0.35	0.68	-	-	2.12	-	-	-	1.34	-	0.12	-	-	0.11	-	1.48	0.1	-	-	-	-	-	-	-	-	67.33																																																																																				-			20.53	0.63	-	-	6.59	1.68	0.09	2.45	5.93	-	-	0	-	1.43	10.29	11.42	0.35	0.68	-	-	2.12	-	-	-	1.34	-	0.12	-	-	0.11	-	1.48	0.1	-	-	-	-	-	-	-	-	67.33
H9104_006_0	2007	8																																D	D	D		T	Coin	Coin	V	V		Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V																																																								-		840.23	15.08	458.4	0	330.94	2.94	1.85	887.67	194.23		15.14	0	0	140.27	7993.13	7244.01	362.58	3113.13	57.1	3182.02	0.01	4060.86	0	0	270.25	184.89	86.8	0	0	0	0											copay/days 1-8	copay/days 1-8	copay/days 21-100		50/run	0-10 DME	0-10 Prosthetics 0 Diab Supplies	50 ER 25 urgent care	50/OP hospital and ASC visits		20 rad therapy 20 specialized			10/visit cardiac rehab	5/visit	10/visit	10/visit	10 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing podiatry & chiro	20 coinsurance	Copay for ILP benefits			10/visit	25/service	0-10/visit															50	50	20	0	50	0.05	0.05	42.5	50	0	0.09	0	0	10	5	10	10	11	0.09	10	0.2	8.5	0	0	10	25	5	0	0	0	0											3.5	0.06	0.76	-	1.38	0.15	0.08	3.14	0.81	-	1.33	-	-	0.12	3.33	6.04	0.3	2.85	5.02	2.65	0	2.88	-	-	0.23	0.39	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.06			3.5	0.06	0.76	-	1.38	0.15	0.08	3.14	0.81	-	1.33	-	-	0.12	3.33	6.04	0.3	2.85	5.02	2.65	0	2.88	-	-	0.23	0.39	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.06																																																																																				-			3.5	0.06	0.76	-	1.38	0.15	0.08	3.14	0.81	-	1.33	-	-	0.12	3.33	6.04	0.3	2.85	5.02	2.65	0	2.88	-	-	0.23	0.39	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.06
H9104_007_0	2007	7																																D	D	D		T	Coin	Coin	V	V	Coin	Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V																																																								-		908.79	16	506.91	0	279.9	1.97	1.23	760.26	231.22	8.66	24.07	0	0	196.96	6458.46	5852.58	306.46	2634.54	49.78	16589.85	0.02	5597.12	0	0	283.12	194.56	30.92	0	0	0	0											copay/days 1-10	copay/days 1-10	copay/days 21-100		50/run	0-10 DME	0-10 Prosthetics 0 Diab Supplies	50 ER 25 urgent care	50/OP hospital and ASC visits	10 lab	20 rad therapy 20 specialized			10/visit cardiac rehab	5/visit	10/visit	10/visit	10 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing podiatry & chiro 10 lab	20 coinsurance	Copay for ILP benefits			10/visit	25/service	0-10/visit															50	50	20	0	50	0.05	0.05	42.43	50	0.1	0.09	0	0	10	5	10	10	11	0.09	2.97	0.2	8.5	0	0	10	25	5	0	0	0	0											3.79	0.07	0.84	-	1.17	0.1	0.06	2.69	0.96	0.87	2.12	-	-	0.16	2.69	4.88	0.26	2.41	4.38	4.11	0	3.96	-	-	0.24	0.41	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.17			3.79	0.07	0.84	-	1.17	0.1	0.06	2.69	0.96	0.87	2.12	-	-	0.16	2.69	4.88	0.26	2.41	4.38	4.11	0	3.96	-	-	0.24	0.41	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.17																																																																																				-			3.79	0.07	0.84	-	1.17	0.1	0.06	2.69	0.96	0.87	2.12	-	-	0.16	2.69	4.88	0.26	2.41	4.38	4.11	0	3.96	-	-	0.24	0.41	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	36.17
H9104_008_0	2007	7																																D	D	D		T	Coin	Coin	V	V	Coin	Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V																																																								-		861	15.37	446.17	0	246.56	4.16	2.6	1030.64	277.94	5.21	14.37	0	0	151.3	7226.18	6541.82	304.19	2603.45	50.68	15243.65	0.01	3831.61	0	0	276.7	198.39	60.15	0	0	0	0											copay/days 1-10	copay/days 1-10	copay/days 21-100		75/run	0-10 DME	0-10 Prosthetics 0 Diab Supplies	50 ER 25 urgent care	50/OP hospital and ASC visits	10 lab	20 rad therapy 20 specialized			10/visit cardiac rehab	10/visit	10/visit	10/visit	10 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing podiatry & chiro 10 lab	20 coinsurance	Copay for ILP benefits			10/visit	25/service	0-10/visit															50	50	20	0	75	0.05	0.05	43.24	50	0.1	0.09	0	0	10	10	10	10	11	0.09	3.14	0.2	8.5	0	0	10	25	5	0	0	0	0											3.59	0.06	0.74	-	1.54	0.21	0.12	3.71	1.16	0.52	1.26	-	-	0.13	6.02	5.45	0.25	2.39	4.46	3.99	0	2.71	-	-	0.23	0.41	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.99			3.59	0.06	0.74	-	1.54	0.21	0.12	3.71	1.16	0.52	1.26	-	-	0.13	6.02	5.45	0.25	2.39	4.46	3.99	0	2.71	-	-	0.23	0.41	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.99																																																																																				-			3.59	0.06	0.74	-	1.54	0.21	0.12	3.71	1.16	0.52	1.26	-	-	0.13	6.02	5.45	0.25	2.39	4.46	3.99	0	2.71	-	-	0.23	0.41	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.99
H9104_009_0	2007	7																																D	D	D		T	Coin	Coin	V	V	Coin	Coin			V	V	V	V	V	Coin	V	Coin	V			V	P	V																																																								-		894.01	15.96	557.62	0	363.27	5.92	3.71	2019.98	187.44	4.95	13.65	0	0	143.66	7436.23	6731.97	313.04	2679.12	52.16	15686.75	0.01	4555.76	0	0	276.7	198.39	67.62	0	0	0	0											copay/days 1-10	copay/days 1-10	copay/days 21-100		75/run	0-10 DME	0-10 Prosthetics 0 Diab Supplies	50 ER 25 urgent care	50/OP hospital and ASC visits	10 lab	20 rad therapy 20 specialized			10/visit cardiac rehab	10/visit	10/visit	10/visit	10 PT & OT 20 CORF	20 rad therapy 20 specialized	10 hearing podiatry & chiro 10 lab	20 coinsurance	Copay for ILP benefits			10/visit	25/service	0-10/visit															50	50	20	0	75	0.05	0.05	43.24	50	0.1	0.09	0	0	10	10	10	10	11	0.09	3.14	0.2	8.5	0	0	10	25	5	0	0	0	0											3.73	0.07	0.93	-	2.27	0.3	0.17	7.28	0.78	0.49	1.2	-	-	0.12	6.2	5.61	0.26	2.46	4.59	4.1	0	3.23	-	-	0.23	0.41	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.45			3.73	0.07	0.93	-	2.27	0.3	0.17	7.28	0.78	0.49	1.2	-	-	0.12	6.2	5.61	0.26	2.46	4.59	4.1	0	3.23	-	-	0.23	0.41	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.45																																																																																				-			3.73	0.07	0.93	-	2.27	0.3	0.17	7.28	0.78	0.49	1.2	-	-	0.12	6.2	5.61	0.26	2.46	4.59	4.1	0	3.23	-	-	0.23	0.41	0.03	-	-	-	-	-	-	-	-	-	-	-	-	-	-	44.45
H9104_801_0	2007	4																																A	A	D					V	V	V	V				V	V	V	V	V	V		V			V	P	V																																																								-		229.49	2.98	422.39					770.78	187.47	1009.7	532.31				8930.24	8091.48	407.15	3495.72	8290.86	22644.34		4447.9			278.86	192.67	530.98															copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab		8.50/visit for ILP benefits			15/visit	20/service	0-15/visit															100	100	100					39.28	15	15	15				15	30	15	10	15	14.38		8.5			15	20	7.5															1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61																																																																																				-			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61
H9104_802_0	2007	4																																A	A	D					V	V	V	V				V	V	V	V	V	V		V			V	P	V																																																								-		229.49	2.98	422.39					770.78	187.47	1009.7	532.31				8930.24	8091.48	407.15	3495.72	8290.86	22644.34		4447.9			278.86	192.67	530.98															copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab		8.50/visit for ILP benefits			15/visit	20/service	0-15/visit															100	100	100					39.28	15	15	15				15	30	15	10	15	14.38		8.5			15	20	7.5															1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61																																																																																				-			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61
H9104_803_0	2007	7																																A	A	D					V	V	V	V				V	V	V	V	V	V		V			V	P	V																																																								-		229.49	2.98	422.39					770.78	187.47	1009.7	532.31				8930.24	8091.48	407.15	3495.72	8290.86	22644.34		4447.9			278.86	192.67	530.98															copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab		8.50/visit for ILP benefits			15/visit	20/service	0-15/visit															100	100	100					39.28	15	15	15				15	30	15	10	15	14.38		8.5			15	20	7.5															1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61																																																																																				-			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61
H9104_804_0	2007	7																																A	A	D					V	V	V	V				V	V	V	V	V	V		V			V	P	V																																																								-		229.49	2.98	422.39					770.78	187.47	1009.7	532.31				8930.24	8091.48	407.15	3495.72	8290.86	22644.34		4447.9			278.86	192.67	530.98															copay/admit	copay/admit	copay/days 21-100					50 ER 15 urgent care	15/OP hospital and ASC visits	15 copay	15 copay				15/visit	30/visit	15/visit	10/visit	15 copay	15 hearing pod chiro lab		8.50/visit for ILP benefits			15/visit	20/service	0-15/visit															100	100	100					39.28	15	15	15				15	30	15	10	15	14.38		8.5			15	20	7.5															1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61																																																																																				-			1.91	0.02	3.52	-	-	-	-	2.52	0.23	1.26	0.67	-	-	-	11.16	20.23	0.51	2.91	10.36	27.14	-	3.15	-	-	0.35	0.32	0.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	86.61
H9136_001_0	2007	7																																																																																																																		-																																																																																																																													-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-																																																																																				-			-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
H9313_001_0	2007	2																					4500											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	1119.2	15.59	1592.04	0	234.28	22.79	1.15	432.89	433.42	0	0	0	0.25	821.75	4315.15	5895.21	161.58	519.73	0	252.34	0	716.75	0	0	361.2	0	131.52	0	0	0	0											200/day for days 1-8Unlimited Days	200/day for days 1-8Limited Days	75/dayLimited Days	0/visit	75/trip	20 Coinsurance	20 Coinsurance	50/visit Emergency Room / 30/visit Urgent Care	150 ASC/250 HOSP	0 copay	0 copay	0 copay	0 Coinsurance	30 OP SA / 30 Cardiac Rehab	20 PCP;	30 Specialist	30/visit	30/visit	0 copay	30 Hearing Exams / 0 Preventive	0 copay	30 Vision Exams	Not Covered	Not Covered	30/visit	Not Covered	30/visit	Not Covered	Not Covered	Not Covered	Not Covered											176.42	176.43	66.16	0	66.16	0.18	0.18	38.14	150.2	0	0	0	0	26.46	17.64	26.43	26.47	24.27	0	10.06	0	26.47	0	0	26.46	0	26.47	0	0	0	0											16.45	0.23	8.78	-	1.29	4.02	0.2	1.38	5.42	-	-	-	-	1.81	6.34	12.98	0.36	1.05	-	0.21	-	1.58	-	-	0.8	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.2	0	8.44	16.45	0.23	8.78	-	1.29	4.02	0.2	1.38	5.42	-	-	-	-	1.81	6.34	12.98	0.36	1.05	-	0.21	-	1.58	-	-	0.8	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.2	4500	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable	not applicable											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	16.45	0.23	8.78	-	1.29	4.02	0.2	1.38	5.42	-	-	-	-	1.81	6.34	12.98	0.36	1.05	-	0.21	-	1.58	-	-	0.8	-	0.29	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.2
H9313_002_0	2007	2																					3000											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	290.36	2.78	1471.67	0	212.08	20.64	1.04	392.37	392.29	0	0	0	0.22	743.66	3997.24	5421.18	146.43	471.11	0	232.5	0	649.62	0	0	363.58	0	132.56	0	0	0	0											750/admitUnlimited Days	750/admitLimited Days	50/dayLimited Days	0/visit	50/trip	20 Coinsurance	20 Coinsurance	50/visit Emergency Room / 30/visit Urgent Care	100 ASC/150 HOSP	0 copay	0 copay	0 copay	0 Coinsurance	25 OP SA / 25 Cardiac Rehab	15 PCP;	25 Specialist	25/visit	25/visit	0 copay	25 Hearing Exams / 0 Preventive	0 copay	25 Vision Exams	Not Covered	Not Covered	25/visit	40 allowance / year	25/visit	250 allowance / 3 years	Not Covered	Not Covered	Not Covered											616.39	616.4	41.1	0	41.1	0.16	0.16	35.55	90.52	0	0	0	0	20.55	12.31	20.55	20.55	20.56	0	7.6	0	20.17	0	0	20.55	0	20.56	0	0	0	0											14.91	0.14	5.04	-	0.73	3.39	0.17	1.16	2.96	-	-	-	-	1.27	4.1	9.28	0.25	0.81	-	0.15	-	1.09	-	-	0.62	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.32	0	10.03	14.91	0.14	5.04	-	0.73	3.39	0.17	1.16	2.96	-	-	-	-	1.27	4.1	9.28	0.25	0.81	-	0.15	-	1.09	-	-	0.62	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.32	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											6.05	0.05	1.14	0.58	0.14	0.51	0	0.13	0.66	0.26	0.7	0	0	0.68	0.84	2.75	0.03	0.09	0.53	0.47	0.19	0.13	0	0	0	0	0	0	0	0	0											15.92	0	0	20.96	0.19	6.18	0.58	0.87	3.9	0.17	1.29	3.62	0.26	0.7	-	0	1.95	4.94	12.03	0.28	0.89	0.53	0.61	0.19	1.22	-	-	0.62	-	0.23	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.23
H9313_003_0	2007	2																					2000											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	296.85	2.84	1520.67	0	215.05	20.94	1.06	398.7	397.32	0	0	0	0.22	753.43	4187.4	5658.85	151.98	489.01	0	243.32	0	674.27	0	0	377.16	0	137.72	0	0	0	0											250/admitUnlimited Days	250/admitLimited Days	25/dayLimited Days	0/visit	50/trip	20 Coinsurance	20 Coinsurance	50/visit Emergency Room / 30/visit Urgent Care	75 ASC/100 HOSP	0 copay	0 copay	0 copay	0 Coinsurance	20 OP SA / 20 Cardiac Rehab	10 PCP;	20 Specialist	20/visit	20/visit	0 copay	20 Hearing Exams / 0 Preventive	0 copay	20 Vision Exams	Not Covered	Not Covered	20/visit	40 allowance / year	20/visit	250 allowance / 3 years	Not Covered	Not Covered	Not Covered											204.41	204.41	20.44	0	40.91	0.16	0.16	35.4	65.48	0	0	0	0	16.36	8.17	16.38	16.37	16.37	0	6.02	0	16	0	0	16.37	0	16.38	0	0	0	0											5.06	0.05	2.59	-	0.73	3.43	0.17	1.18	2.17	-	-	-	-	1.03	2.85	7.72	0.21	0.67	-	0.12	-	0.9	-	-	0.51	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.57	0	6.57	5.06	0.05	2.59	-	0.73	3.43	0.17	1.18	2.17	-	-	-	-	1.03	2.85	7.72	0.21	0.67	-	0.12	-	0.9	-	-	0.51	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	29.57	none	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	20 Coinsurance	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											6.05	0.05	1.14	0.58	0.14	0.51	0	0.13	0.66	0.26	0.7	0	0	0.68	0.8	2.79	0.03	0.09	0.53	0.47	0.19	0.13	0	0	0	0	0	0	0	0	0											15.92	0	0	11.1	0.09	3.73	0.58	0.88	3.94	0.17	1.31	2.83	0.26	0.7	-	0	1.7	3.65	10.51	0.23	0.75	0.53	0.59	0.19	1.03	-	-	0.51	-	0.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	45.49
H9313_801_0	2007	1																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	259.32	2.55	1239.11	0	192.88	18.55	0.92	336.49	348.17	2234.74	1146.54	0	0.19	659.12	3398.68	4385.67	128.41	414.27	0	211.61	0	564.77	0	0	0	0	0	0	0	0	0											750/admitUnlimited Days	750/admitLimited Days	75/dayLimited Days	0/visit	50/trip	20 Coinsurance	20 Coinsurance	50/visit Emergency Room / 50/visit Urgent Care	100 ASC/150 HOSP	15/test	50/proc	0 copay	20 Coinsurance	40 OP SA / 40 Cardiac Rehab	25 PCP;	40 Specialist	40/visit	40/visit	0 copay	40 Hearing Exams / 0 Preventive	0 copay	40 Vision Exams	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											750	750	75	0	50	0.2	0.2	50	110.13	15	50	0	0.2	40	24.95	39.16	40	27.25	0	12.64	0	39.23	0	0	0	0	0	0	0	0	0											16.21	0.16	7.74	-	0.8	3.71	0.18	1.4	3.2	2.79	4.78	-	0.04	2.2	7.07	14.31	0.43	0.94	-	0.22	-	1.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.03	0	0	16.21	0.16	7.74	-	0.8	3.71	0.18	1.4	3.2	2.79	4.78	-	0.04	2.2	7.07	14.31	0.43	0.94	-	0.22	-	1.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.03	none	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											10.47	0.08	1.88	0.97	0.25	0.9	0	0.2	1.14	0.44	1.21	0	0.01	1.17	1.4	4.62	0.04	0.14	0.89	0.78	0.33	0.22	0	0	0	0	0	0	0	0	0											27.12	0	0	26.68	0.24	9.62	0.97	1.06	4.61	0.18	1.6	4.33	3.24	5.99	-	0.05	3.37	8.47	18.93	0.47	1.08	0.89	1.01	0.33	2.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.15
H9313_802_0	2007	1																					none											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	P	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	none	259.32	2.55	1239.11	0	192.88	18.55	0.92	336.49	348.17	2234.74	1146.54	0	0.19	659.12	3398.68	4385.67	128.41	414.27	0	211.61	0	564.77	0	0	0	0	0	0	0	0	0											750/admitUnlimited Days	750/admitLimited Days	75/dayLimited Days	0/visit	50/trip	20 Coinsurance	20 Coinsurance	50/visit Emergency Room / 50/visit Urgent Care	100 ASC/150 HOSP	15/test	50/proc	0 copay	20 Coinsurance	40 OP SA / 40 Cardiac Rehab	25 PCP;	40 Specialist	40/visit	40/visit	0 copay	40 Hearing Exams / 0 Preventive	0 copay	40 Vision Exams	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											750	750	75	0	50	0.2	0.2	50	110.13	15	50	0	0.2	40	24.95	39.16	40	27.25	0	12.64	0	39.23	0	0	0	0	0	0	0	0	0											16.21	0.16	7.74	-	0.8	3.71	0.18	1.4	3.2	2.79	4.78	-	0.04	2.2	7.07	14.31	0.43	0.94	-	0.22	-	1.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.03	0	0	16.21	0.16	7.74	-	0.8	3.71	0.18	1.4	3.2	2.79	4.78	-	0.04	2.2	7.07	14.31	0.43	0.94	-	0.22	-	1.85	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	68.03	none	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	40 Coinsurance	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											10.47	0.08	1.88	0.97	0.25	0.9	0	0.2	1.14	0.44	1.21	0	0.01	1.17	1.4	4.62	0.04	0.14	0.89	0.78	0.33	0.22	0	0	0	0	0	0	0	0	0											27.12	0	0	26.68	0.24	9.62	0.97	1.06	4.61	0.18	1.6	4.33	3.24	5.99	-	0.05	3.37	8.47	18.93	0.47	1.08	0.89	1.01	0.33	2.06	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.15
H9385_001_0	2007	7																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin			V	P					V																																																				-		341.68	13.9	214.54	33.38	22.46	19.23	20.51	9.12	14.39	14.4	19.92	0	2.48	79.89	52.39	101.89	8.34	3.45	30.45	34.84	6.25	4.19	0	0	811	388.8	0	0	0	0	0											Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing		Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing	Medicare FFS Cost Sharing			10/visit	25/service																0.07	0.07	0.15	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	10	25	0	0	0	0	0											24.23	0.99	32.35	-	5.3	4.54	4.84	2.15	3.4	3.4	4.7	-	0.59	18.85	12.36	24.05	1.97	0.81	7.19	8.22	1.48	0.99	-	-	0.68	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	163.88			24.23	0.99	32.35	-	5.3	4.54	4.84	2.15	3.4	3.4	4.7	-	0.59	18.85	12.36	24.05	1.97	0.81	7.19	8.22	1.48	0.99	-	-	0.68	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	163.88																																																																																				-			24.23	0.99	32.35	-	5.3	4.54	4.84	2.15	3.4	3.4	4.7	-	0.59	18.85	12.36	24.05	1.97	0.81	7.19	8.22	1.48	0.99	-	-	0.68	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	163.88
H9418_001_0	2007	4	F2	H5a	H5b	I2a	O1a						OP Facility - Emergency	OP Facility - Other	OP Facility - Other	Professional	Hearing (Non-Covered)						1650	Urgent Care	Outpatient Substance Abuse Svcs	Cardiac Rehabilitation Services	Routine Podiatry	Routine Hearing Tests						D	D	D	P	T	Coin	Coin	V	V	V	V	V	P	V	V	V	V	V		V	Coin	V	T		V	P	V					V	V	V	V	V																																															-		1543.95	97.11	9517.65	63.93	898.69	17.99	3.52	209.33	135.47	3833.28	167.64	24.22	1.64	375.5	22373.71	1446.08	2253.04	7.34		113.81	120.63	1042.64	1481.87		54.78	157.7						628.32	0.1	0.03	365.68	280.44						(1a) 150/day	(1b) 150/day	(2a) 0/day	(6a) 0/proc	(10a) 75/trip	(11a) 20 coins	(11a/11c) 20 coins	(4a) 50/visit (waived if admitted)	(9a/9b) 25/visit	(8a) 0/visit	(8b) 0/visit	(9a) 25/visit	(12) 0/proc	(9a) 25/visit	(7a 14b-14i) 0/visit	(7b/7d/7f) 10/visit	(7e/7h) 0/visit 75/25 Ind/Grp Blended Copay	(7c/7i) 0/visit		(7g) 10/visit	(15) 0/proc	(16b/17a) 10/visit (13a/13a1/14a10/17b N/A 0 Copay)	(10b) 0/trip		(17a1) 0/visit	(17b2) 0/proc						(4b) 35/visit (waived if admitted)	(9c) 0/visit 75/25 Ind/Grp Blended Copay	(9d) 25/visit	(7f1) 0/visit	(18a1) 0/visit						136	136			68	18	18	45	23			23		23		9				9		9										32		23								17.49	1.1	-	-	5.09	3.26	0.64	0.79	0.26	-	-	0.05	-	0.71	-	1.09	-	-	-	0.09	-	0.79	-	-	-	-	-	-	-	-	-	1.66	-	0	-	-	-	-	-	-	-	33		3.42	17.49	1.1	-	-	5.09	3.26	0.64	0.79	0.26	-	-	0.05	-	0.71	-	1.09	-	-	-	0.09	-	0.79	-	-	-	-	-	-	-	-	-	1.66	-	0	-	-	-	-	-	-	-	33		30	30	30	30	30	30	30	50	30	30	30	30	30	30	30	30	30	30		30	30	30	30		30							35	30	30	30	30						2.04	0.05	0.94	0.03	0.66	0.28	0.06	0.05	0.17	0.56	0.68	0.02	0	0.14	0.01	2.09	0.2	0		0.15		0.12	0.09		0.01							0.1	0	0	0.05	0.02						8.5		0	19.53	1.15	0.94	0.03	5.75	3.54	0.69	0.84	0.42	0.56	0.68	0.07	0	0.84	0.01	3.18	0.2	0	-	0.24	-	0.91	0.09	-	0.01	-	-	-	-	-	-	1.76	0	0	0.05	0.02	-	-	-	-	-	41.5
H9418_002_0	2007	6	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1650	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T	V	V	P	V	P		O	O	V		V	V																																																-		2617.04	375.69	1768.36		324.54	29.84	24.9	934.6	379.37	2237.88	931.65	66.62	3.29	2066.93		3725.78		533.67		858.66	19.26											328.31		152.77	259.42							(1a) 150 per Day	(1b) 150 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit	(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							85	85	20		42	11	11	20	14	6	6	14	11	14		6		6		6	11											6		6	6							18.45	2.65	2.99	-	1.14	3.37	2.81	1.58	0.45	1.05	0.44	0.08	0.37	2.43	-	1.75	-	0.25	-	0.4	2.17	-	-	-	-	-	-	-	-	-	-	0.15	-	0.07	0.12	-	-	-	-	-	-	42.72		33.04	18.45	2.65	2.99	-	1.14	3.37	2.81	1.58	0.45	1.05	0.44	0.08	0.37	2.43	-	1.75	-	0.25	-	0.4	2.17	-	-	-	-	-	-	-	-	-	-	0.15	-	0.07	0.12	-	-	-	-	-	-	42.72		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 per Visit	30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.53	0.17	0.46	0.47	0.08	0.18	0.15	0.05	0.2	0.15	0.13	0.02	0.02	0.24	0.35	0.23	0.05	0.03	0.15	0.77	0.15	0																				6.57		0	20.97	2.82	3.45	0.47	1.23	3.55	2.96	1.63	0.64	1.2	0.57	0.1	0.39	2.67	0.35	1.98	0.05	0.28	0.15	1.17	2.32	0	-	-	-	-	-	-	-	-	-	0.15	-	0.07	0.12	-	-	-	-	-	-	49.29
H9519_001_0	2007	10																					0											A	A	A	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	205.08	4.35	113.21	1364.27	86.8	7.26	5.71	263.34	494.11	0	569.93	42.83	0	453.08	5663.24	3388.67	1.7	555.68	974.21	1192.79	12.1	722.39	0	0	577.7	577.72	0	0	0	0	0											PBP: 1A IP Acute: 250 per admit	1B IP Psych: 250 per admit	2 SNF: 250 per admit	6 Home Health: 5	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 5	9B ASC Services: 20	8A OP C/D/T: 0	8B OP X-Ray: 5	9C OP Hospital: 5	12 Renal Dialysis: 0	3 CORF: 5 5 Partial Hosp: 5 9C OP Substance Abuse: 50 9D Cardiac Rehab: 5	7A PCP: 5 14B Immunizations: 5 14C Routine Physical Exams: 5 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-5	7D Physician Specialist: 5	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 5 7I Physical and Speech Therapy: 5	8B OP X-Ray: 5	7B Chiropractic: 5 7F Podiatry: 5 7G Other Health Care: 5 18A Medicare Covered Hearing Exams: 5	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 5 17A Medicare Covered Eye Exams: 5	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	250	5	50	0.2	0.2	47.55	20	0	5	5	0	5	5	5	0.5	5	5	5	0.2	5	0	0	5	36.33	0	0	0	0	0											4.27	0.09	2.36	0.57	0.36	1.45	1.14	1.04	0.82	-	0.24	0.02	-	0.19	2.36	1.41	0.85	0.23	0.41	0.5	2.42	0.3	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03	0	0	4.27	0.09	2.36	0.57	0.36	1.45	1.14	1.04	0.82	-	0.24	0.02	-	0.19	2.36	1.41	0.85	0.23	0.41	0.5	2.42	0.3	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.27	0.09	2.36	0.57	0.36	1.45	1.14	1.04	0.82	-	0.24	0.02	-	0.19	2.36	1.41	0.85	0.23	0.41	0.5	2.42	0.3	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03
H9519_002_0	2007	7																					0											A	A	A	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	V	V	V	Coin	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	205.08	4.35	113.21	1364.27	86.8	7.26	5.71	263.34	494.11	0	569.93	42.83	0	453.08	5663.24	3388.67	1.7	555.68	974.21	1192.79	12.1	722.39	0	0	577.7	577.72	0	0	0	0	0											PBP: 1A IP Acute: 250 per admit	1B IP Psych: 250 per admit	2 SNF: 250 per admit	6 Home Health: 5	10A Ambulance: 50	11A DME: 20 11C Diabetes Monitoring Supplies: 20	11B Prosthetic Medical Supplies: 20	4A ER: 50 4B Urgent Care: 5	9B ASC Services: 20	8A OP C/D/T: 0	8B OP X-Ray: 5	9C OP Hospital: 5	12 Renal Dialysis: 0	3 CORF: 5 5 Partial Hosp: 5 9C OP Substance Abuse: 50 9D Cardiac Rehab: 5	7A PCP: 5 14B Immunizations: 5 14C Routine Physical Exams: 5 14D Pap Smears: 0 14D Pelvic Exams: 0 14E Prostate Screening: 0 14F Colorectal Screening: 0 14G Bone Mass Measurement: 0 14H Mammography: 0 14I Diabetes Monitoring: 0-5	7D Physician Specialist: 5	7E Mental Health: 50 7H Psychiatric: 50	7C Occupational Therapy: 5 7I Physical and Speech Therapy: 5	8B OP X-Ray: 5	7B Chiropractic: 5 7F Podiatry: 5 7G Other Health Care: 5 18A Medicare Covered Hearing Exams: 5	15 Part B Drugs: 20	13A Blood: 0 16B Comprehensive Dental Services: 5 17A Medicare Covered Eye Exams: 5	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: 5	17B Eye Wear: Various cost sharing	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											250	250	250	5	50	0.2	0.2	47.55	20	0	5	5	0	5	5	5	0.5	5	5	5	0.2	5	0	0	5	36.33	0	0	0	0	0											4.27	0.09	2.36	0.57	0.36	1.45	1.14	1.04	0.82	-	0.24	0.02	-	0.19	2.36	1.41	0.85	0.23	0.41	0.5	2.42	0.3	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03	0	0	4.27	0.09	2.36	0.57	0.36	1.45	1.14	1.04	0.82	-	0.24	0.02	-	0.19	2.36	1.41	0.85	0.23	0.41	0.5	2.42	0.3	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.27	0.09	2.36	0.57	0.36	1.45	1.14	1.04	0.82	-	0.24	0.02	-	0.19	2.36	1.41	0.85	0.23	0.41	0.5	2.42	0.3	-	-	0.24	1.75	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	23.03
H9519_801_0	2007	6																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	211.26	3.12	30.96	0	10.77	6.62	5.21	9.79	55.67	6.23	14.82	1.12	0.15	15.76	39.25	100.34	1.76	1.96	34.18	34.78	11.04	21.32	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	9C OP Hospital:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 5 Partial Hosp:  138 Ded and 20 Coinsurance 9C OP Substance Abuse:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 138 Ded and 20 Coinsurance 14B Immunizations: 0 14D Pap Smears:  138 Ded and 20 Coinsurance 14D Pelvic Exams:  138 Ded and 20 Coinsurance 14E Prostate Screening:  138 Ded and 20 Coinsurance 14F Colorectal Screening:  138 Ded and 20 Coinsurance 14G Bone Mass Measurement:  138 Ded and 20 Coinsurance 14H Mammography:  138 Ded and 20 Coinsurance 14I Diabetes Monitoring:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 20 Coinsurance 16B Comprehensive Dental Services:  138 Ded and 20 Coinsurance 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0.08	0.08	0.18	0	0.24	0.24	0.24	0.12	0.24	0.24	0.24	0.24	0.24	0.24	0.22	0.22	0.24	0.24	0.24	0.24	0.24	0.04	0	0	0	0	0	0	0	0	0											17.08	0.25	5.66	-	2.54	1.56	1.23	1.17	13.14	1.47	3.5	0.26	0.04	3.72	8.74	21.86	0.42	0.46	8.07	8.21	2.6	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.89	0	0	17.08	0.25	5.66	-	2.54	1.56	1.23	1.17	13.14	1.47	3.5	0.26	0.04	3.72	8.74	21.86	0.42	0.46	8.07	8.21	2.6	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.89	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	17.08	0.25	5.66	-	2.54	1.56	1.23	1.17	13.14	1.47	3.5	0.26	0.04	3.72	8.74	21.86	0.42	0.46	8.07	8.21	2.6	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.89
H9519_802_0	2007	4																					0											Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	211.26	3.12	30.96	0	10.77	6.62	5.21	9.79	55.67	6.23	14.82	1.12	0.15	15.76	39.25	100.34	1.76	1.96	34.18	34.78	11.04	21.32	0	0	0	0	0	0	0	0	0											PBP: 1A IP Acute: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	1B IP Psych: 1000 Ded 0/day for days 1-60 250/day for days 61-90 500/day for days 91-150	2 SNF: 125/day for days 21-100	6 Home Health: 0	10A Ambulance: 138 Ded and 20 Coinsurance	11A DME:  138 Ded and 20 Coinsurance 11C Diabetes Monitoring Supplies:  138 Ded and 20 Coinsurance	11B Prosthetic Medical Supplies:  138 Ded and 20 Coinsurance	4A ER: 50 4B Urgent Care:  138 Ded and 20 Coinsurance	9B ASC Services:  138 Ded and 20 Coinsurance	8A OP C/D/T:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	9C OP Hospital:  138 Ded and 20 Coinsurance	12 Renal Dialysis: 138 Ded and 20 Coinsurance	3 CORF:  138 Ded and 20 Coinsurance 5 Partial Hosp:  138 Ded and 20 Coinsurance 9C OP Substance Abuse:  138 Ded and 20 Coinsurance 9D Cardiac Rehab:  138 Ded and 20 Coinsurance	7A PCP: 138 Ded and 20 Coinsurance 14B Immunizations: 0 14D Pap Smears:  138 Ded and 20 Coinsurance 14D Pelvic Exams:  138 Ded and 20 Coinsurance 14E Prostate Screening:  138 Ded and 20 Coinsurance 14F Colorectal Screening:  138 Ded and 20 Coinsurance 14G Bone Mass Measurement:  138 Ded and 20 Coinsurance 14H Mammography:  138 Ded and 20 Coinsurance 14I Diabetes Monitoring:  138 Ded and 20 Coinsurance	7D Physician Specialist:  138 Ded and 20 Coinsurance	7E Mental Health:  138 Ded and 50 Coinsurance 7H Psychiatric:  138 Ded and 50 Coinsurance	7C Occupational Therapy:  138 Ded and 20 Coinsurance 7I Physical and Speech Therapy:  138 Ded and 20 Coinsurance	8B OP X-Ray:  138 Ded and 20 Coinsurance	7B Chiropractic:  138 Ded and 20 Coinsurance 7F Podiatry:  138 Ded and 20 Coinsurance 7G Other Health Care:  138 Ded and 20 Coinsurance 18A Medicare Covered Hearing Exams:  138 Ded and 20 Coinsurance	15 Part B Drugs:  138 Ded and 20 Coinsurance	13A Blood: 20 Coinsurance 16B Comprehensive Dental Services:  138 Ded and 20 Coinsurance 17A Medicare Covered Eye Exams:  138 Ded and 20 Coinsurance	10B Transportation: Not Covered	16A Preventive Dental Services: Not Covered	17A Routine Eye Exams: Not Covered	17B Eye Wear: Not Covered	18A Routine Hearing Exams: Not Covered	18B Hearing Aids: Not Covered	19 POS: N/A	14A Health Education/Wellness Programs: 0	13B Acupuncture: Not Covered											0.08	0.08	0.18	0	0.24	0.24	0.24	0.12	0.24	0.24	0.24	0.24	0.24	0.24	0.22	0.22	0.24	0.24	0.24	0.24	0.24	0.04	0	0	0	0	0	0	0	0	0											17.08	0.25	5.66	-	2.54	1.56	1.23	1.17	13.14	1.47	3.5	0.26	0.04	3.72	8.74	21.86	0.42	0.46	8.07	8.21	2.6	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.89	0	0	17.08	0.25	5.66	-	2.54	1.56	1.23	1.17	13.14	1.47	3.5	0.26	0.04	3.72	8.74	21.86	0.42	0.46	8.07	8.21	2.6	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.89	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	17.08	0.25	5.66	-	2.54	1.56	1.23	1.17	13.14	1.47	3.5	0.26	0.04	3.72	8.74	21.86	0.42	0.46	8.07	8.21	2.6	0.92	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	102.89
H9859_001_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P		P			V	V	V	V	V			S				V		V				Coin																																																				-		1766.02	92.87	1129.16	105.18	108.44	5.24	9.47	231.35	237.35		255.1			134.3	3377.74	5829.72	408.34	943.09			932.37				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50	50		0 for diagnostic tests and Lab 15 for X-rays			15 OP Rehab; MH 15 1st visit 50 after; SA 50	10	15	MH 15 1st visit 50 after; SA 50	15			15				10 Routine 15 Medical		15				30 Coin Travel Max 3000											13.5	7.16	32.36	4.66	50	0.2	0.2	49.96	50		15			28.62	10	15	28.4	15			15				10		15				0.3											1.99	0.06	3.04	0.04	0.45	1.05	1.89	0.96	0.99	-	0.32	-	-	0.32	2.81	7.29	0.97	1.18	-	-	1.17	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.1		0	1.99	0.06	3.04	0.04	0.45	1.05	1.89	0.96	0.99	-	0.32	-	-	0.32	2.81	7.29	0.97	1.18	-	-	1.17	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.1																																																																																				-		0	1.99	0.06	3.04	0.04	0.45	1.05	1.89	0.96	0.99	-	0.32	-	-	0.32	2.81	7.29	0.97	1.18	-	-	1.17	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.1
H9859_002_0	2007	7																																D	D	D	V	T	Coin	Coin	V	P		P			V	V	V	V	V			S				V		V				Coin																																																				-		1766.02	92.87	1129.16	105.18	108.44	5.24	9.47	231.35	237.35		255.1			134.3	3377.74	5829.72	408.34	943.09			932.37				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50	50		0 for diagnostic tests and Lab 15 for X-rays			15 OP Rehab; MH 15 1st visit 50 after; SA 50	10	15	MH 15 1st visit 50 after; SA 50	15			15				10 Routine 15 Medical		15				30 Coin Travel Max 3000											13.5	7.16	32.36	4.66	50	0.2	0.2	49.96	50		15			28.62	10	15	28.4	15			15				10		15				0.3											1.99	0.06	3.04	0.04	0.45	1.05	1.89	0.96	0.99	-	0.32	-	-	0.32	2.81	7.29	0.97	1.18	-	-	1.17	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.1		0	1.99	0.06	3.04	0.04	0.45	1.05	1.89	0.96	0.99	-	0.32	-	-	0.32	2.81	7.29	0.97	1.18	-	-	1.17	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.1																																																																																				-		0	1.99	0.06	3.04	0.04	0.45	1.05	1.89	0.96	0.99	-	0.32	-	-	0.32	2.81	7.29	0.97	1.18	-	-	1.17	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.1
H9859_003_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P		P			V	V	V	V	V			S				V		V				Coin																																																				-		1927.65	101.37	1232.51	114.81	118.37	6.24	11.28	252.41	259.07		278.45			146.59	3680	6363.28	445.71	1029.41			1017.7				127.72		228.66				0.62											500 per Admit	500 per Admit	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50	100		0 for diagnostic tests and Lab 30 for X-rays			30 OP Rehab; MH 20 1st visit 50 after; SA 50	15	30	MH 20 1st visit 50 after; SA 50	30			30				15 Routine 30 Medical		30				30 Coin Travel Max 3000											78.72	39.95	32.36	4.66	100	0.25	0.25	49.98	100		30			50.34	15	30	46.07	30			30				15		30				0.3											12.64	0.34	3.32	0.04	0.99	1.56	2.82	1.05	2.16	-	0.7	-	-	0.62	4.6	15.91	1.71	2.57	-	-	2.54	-	-	-	0.16	-	0.57	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	54.49		0	12.64	0.34	3.32	0.04	0.99	1.56	2.82	1.05	2.16	-	0.7	-	-	0.62	4.6	15.91	1.71	2.57	-	-	2.54	-	-	-	0.16	-	0.57	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	54.49																																																																																				-		0	12.64	0.34	3.32	0.04	0.99	1.56	2.82	1.05	2.16	-	0.7	-	-	0.62	4.6	15.91	1.71	2.57	-	-	2.54	-	-	-	0.16	-	0.57	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	54.49
H9859_004_0	2007	5																																D	D	D	V	T	Coin	Coin	V	P		P			V	V	V	V	V			S				V		V				Coin																																																				-		1927.65	101.37	1232.51	114.81	118.37	6.24	11.28	252.41	259.07		278.45			146.59	3680	6363.28	445.71	1029.41			1017.7				127.72		228.66				0.62											500 per Admit	500 per Admit	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50	100		0 for diagnostic tests and Lab 30 for X-rays			30 OP Rehab; MH 20 1st visit 50 after; SA 50	15	30	MH 20 1st visit 50 after; SA 50	30			30				15 Routine 30 Medical		30				30 Coin Travel Max 3000											78.72	39.95	32.36	4.66	100	0.25	0.25	49.98	100		30			50.34	15	30	46.07	30			30				15		30				0.3											12.64	0.34	3.32	0.04	0.99	1.56	2.82	1.05	2.16	-	0.7	-	-	0.62	4.6	15.91	1.71	2.57	-	-	2.54	-	-	-	0.16	-	0.57	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	54.49		0	12.64	0.34	3.32	0.04	0.99	1.56	2.82	1.05	2.16	-	0.7	-	-	0.62	4.6	15.91	1.71	2.57	-	-	2.54	-	-	-	0.16	-	0.57	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	54.49																																																																																				-		0	12.64	0.34	3.32	0.04	0.99	1.56	2.82	1.05	2.16	-	0.7	-	-	0.62	4.6	15.91	1.71	2.57	-	-	2.54	-	-	-	0.16	-	0.57	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	54.49
H9859_005_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V		P			V	V	V	V	V			S				V		V				Coin																																																				-		1805.23	94.93	1154.23	107.52	110.85	5.47	9.9	236.46	242.62		260.76			137.28	3451.06	5959.15	417.4	964.03			953.07				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50	50		0 for diagnostic tests and Lab 15 for X-rays			15 OP Rehab; MH 15 1st visit 50 after; SA 50	10	15	MH 15 1st visit 50 after; SA 50	15			15				10 Routine 15 Medical		15				30 Coin Travel Max 3000											13.5	7.16	32.36	4.66	50	0.2	0.2	49.96	50		15			28.99	10	15	29.03	15			15				10		15				0.3											2.03	0.06	3.11	0.04	0.46	1.09	1.98	0.98	1.01	-	0.33	-	-	0.33	2.88	7.45	1.01	1.21	-	-	1.19	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.74		0	2.03	0.06	3.11	0.04	0.46	1.09	1.98	0.98	1.01	-	0.33	-	-	0.33	2.88	7.45	1.01	1.21	-	-	1.19	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.74																																																																																				-		0	2.03	0.06	3.11	0.04	0.46	1.09	1.98	0.98	1.01	-	0.33	-	-	0.33	2.88	7.45	1.01	1.21	-	-	1.19	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.74
H9859_006_0	2007	5																																D	D	D	V	T	Coin	Coin	V	V		P			V	V	V	V	V			S				V		V				Coin																																																				-		1805.23	94.93	1154.23	107.52	110.85	5.47	9.9	236.46	242.62		260.76			137.28	3451.06	5959.15	417.4	964.03			953.07				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50	50		0 for diagnostic tests and Lab 15 for X-rays			15 OP Rehab; MH 15 1st visit 50 after; SA 50	10	15	MH 15 1st visit 50 after; SA 50	15			15				10 Routine 15 Medical		15				30 Coin Travel Max 3000											13.5	7.16	32.36	4.66	50	0.2	0.2	49.96	50		15			28.99	10	15	29.03	15			15				10		15				0.3											2.03	0.06	3.11	0.04	0.46	1.09	1.98	0.98	1.01	-	0.33	-	-	0.33	2.88	7.45	1.01	1.21	-	-	1.19	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.74		0	2.03	0.06	3.11	0.04	0.46	1.09	1.98	0.98	1.01	-	0.33	-	-	0.33	2.88	7.45	1.01	1.21	-	-	1.19	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.74																																																																																				-		0	2.03	0.06	3.11	0.04	0.46	1.09	1.98	0.98	1.01	-	0.33	-	-	0.33	2.88	7.45	1.01	1.21	-	-	1.19	-	-	-	0.11	-	0.29	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	25.74
H9859_801_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1679.85	76.39	1120.52	99.78	102.7	4.8	8.89	213.13			242.86			124.51	3230.75	5617.12	361.65	913.64			900.97				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.95			20			29.67	15	20	28.78	20			20				15		20				0.3											1.89	0.05	3.02	0.04	0.43	0.96	1.78	0.89	-	-	0.4	-	-	0.31	4.04	9.36	0.87	1.52	-	-	1.5	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.78		0	1.89	0.05	3.02	0.04	0.43	0.96	1.78	0.89	-	-	0.4	-	-	0.31	4.04	9.36	0.87	1.52	-	-	1.5	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.78																																																																																				-		0	1.89	0.05	3.02	0.04	0.43	0.96	1.78	0.89	-	-	0.4	-	-	0.31	4.04	9.36	0.87	1.52	-	-	1.5	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.78
H9859_802_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1679.85	76.39	1120.52	99.78	102.7	4.8	8.89	213.13			242.86			124.51	3230.75	5617.12	361.65	913.64			900.97				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.95			20			29.67	15	20	28.78	20			20				15		20				0.3											1.89	0.05	3.02	0.04	0.43	0.96	1.78	0.89	-	-	0.4	-	-	0.31	4.04	9.36	0.87	1.52	-	-	1.5	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.78		0	1.89	0.05	3.02	0.04	0.43	0.96	1.78	0.89	-	-	0.4	-	-	0.31	4.04	9.36	0.87	1.52	-	-	1.5	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.78																																																																																				-		0	1.89	0.05	3.02	0.04	0.43	0.96	1.78	0.89	-	-	0.4	-	-	0.31	4.04	9.36	0.87	1.52	-	-	1.5	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.78
H9859_803_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1832.14	83.32	1222.11	108.83	112.02	5.71	10.58	232.33			264.87			135.8	3516.83	6126.37	394.44	996.47			982.66				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.96			20			36.73	15	20	44.84	20			20				15		20				0.3											2.06	0.05	3.3	0.04	0.47	1.14	2.12	0.97	-	-	0.44	-	-	0.42	4.4	10.21	1.47	1.66	-	-	1.64	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	31.1		0	2.06	0.05	3.3	0.04	0.47	1.14	2.12	0.97	-	-	0.44	-	-	0.42	4.4	10.21	1.47	1.66	-	-	1.64	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	31.1																																																																																				-		0	2.06	0.05	3.3	0.04	0.47	1.14	2.12	0.97	-	-	0.44	-	-	0.42	4.4	10.21	1.47	1.66	-	-	1.64	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	31.1
H9859_804_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1832.14	83.32	1222.11	108.83	112.02	5.71	10.58	232.33			264.87			135.8	3516.83	6126.37	394.44	996.47			982.66				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.96			20			36.73	15	20	44.84	20			20				15		20				0.3											2.06	0.05	3.3	0.04	0.47	1.14	2.12	0.97	-	-	0.44	-	-	0.42	4.4	10.21	1.47	1.66	-	-	1.64	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	31.1		0	2.06	0.05	3.3	0.04	0.47	1.14	2.12	0.97	-	-	0.44	-	-	0.42	4.4	10.21	1.47	1.66	-	-	1.64	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	31.1																																																																																				-		0	2.06	0.05	3.3	0.04	0.47	1.14	2.12	0.97	-	-	0.44	-	-	0.42	4.4	10.21	1.47	1.66	-	-	1.64	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	31.1
H9859_805_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1694.55	77.06	1130.33	100.66	103.6	4.88	9.05	214.98			244.98			125.6	3258.38	5666.3	364.82	921.64			908.86				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.95			20			29.79	15	20	29.03	20			20				15		20				0.3											1.9	0.05	3.05	0.04	0.43	0.98	1.81	0.89	-	-	0.41	-	-	0.31	4.07	9.44	0.88	1.54	-	-	1.51	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	28.05		0	1.9	0.05	3.05	0.04	0.43	0.98	1.81	0.89	-	-	0.41	-	-	0.31	4.07	9.44	0.88	1.54	-	-	1.51	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	28.05																																																																																				-		0	1.9	0.05	3.05	0.04	0.43	0.98	1.81	0.89	-	-	0.41	-	-	0.31	4.07	9.44	0.88	1.54	-	-	1.51	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	28.05
H9859_806_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1694.55	77.06	1130.33	100.66	103.6	4.88	9.05	214.98			244.98			125.6	3258.38	5666.3	364.82	921.64			908.86				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.95			20			29.79	15	20	29.03	20			20				15		20				0.3											1.9	0.05	3.05	0.04	0.43	0.98	1.81	0.89	-	-	0.41	-	-	0.31	4.07	9.44	0.88	1.54	-	-	1.51	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	28.05		0	1.9	0.05	3.05	0.04	0.43	0.98	1.81	0.89	-	-	0.41	-	-	0.31	4.07	9.44	0.88	1.54	-	-	1.51	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	28.05																																																																																				-		0	1.9	0.05	3.05	0.04	0.43	0.98	1.81	0.89	-	-	0.41	-	-	0.31	4.07	9.44	0.88	1.54	-	-	1.51	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	28.05
H9859_807_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1654.36	75.23	1103.51	98.27	101.15	4.65	8.62	209.91			239.17			122.62	3182.86	5531.88	356.16	899.78			824.99				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.95			20			29.48	15	20	28.34	20			20				15		20				0.3											1.86	0.05	2.98	0.04	0.42	0.93	1.72	0.87	-	-	0.4	-	-	0.3	3.98	9.22	0.84	1.5	-	-	1.37	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.21		0	1.86	0.05	2.98	0.04	0.42	0.93	1.72	0.87	-	-	0.4	-	-	0.3	3.98	9.22	0.84	1.5	-	-	1.37	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.21																																																																																				-		0	1.86	0.05	2.98	0.04	0.42	0.93	1.72	0.87	-	-	0.4	-	-	0.3	3.98	9.22	0.84	1.5	-	-	1.37	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.21
H9859_808_0	2007	6																																D	D	D	V	T	Coin	Coin	V			P			V	V	V	V	V			S				V		V				Coin																																																				-		1654.36	75.23	1103.51	98.27	101.15	4.65	8.62	209.91			239.17			122.62	3182.86	5531.88	356.16	899.78			824.99				127.72		228.66				0.62											100 per Admit max 300 per year	100 per Admit max 300 per year	0 days 1-15 65 days 16-100	0 days 1-20 20 days 21+	50	0	0	50			0 for diagnostic tests and Lab 20 for X-rays			20 OP Rehab; MH 15 1st visit 50 after; SA 50	15	20	MH 15 1st visit 50 after; SA 50	20			20				15 Routine 20 Medical		20				30 Coin Travel Max 3000											13.49	7.26	32.36	4.66	50	0.2	0.2	49.95			20			29.48	15	20	28.34	20			20				15		20				0.3											1.86	0.05	2.98	0.04	0.42	0.93	1.72	0.87	-	-	0.4	-	-	0.3	3.98	9.22	0.84	1.5	-	-	1.37	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.21		0	1.86	0.05	2.98	0.04	0.42	0.93	1.72	0.87	-	-	0.4	-	-	0.3	3.98	9.22	0.84	1.5	-	-	1.37	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.21																																																																																				-		0	1.86	0.05	2.98	0.04	0.42	0.93	1.72	0.87	-	-	0.4	-	-	0.3	3.98	9.22	0.84	1.5	-	-	1.37	-	-	-	0.16	-	0.38	-	-	-	0.19	-	-	-	-	-	-	-	-	-	-	27.21
H9984_001_0	2007	7																																D	D	D	V	Coin	Coin	Coin	V	Coin	V	Coin	P	P	P	P	P	Coin	Coin	P	P	Coin	V	T	V	P	P	P	P	O	O	O																																																				-		1012.98	16.87	557.11	1671.59	4.44	5.19	6.92	195.36	8.96	1382.74	9.43	0	35.88	387.13	9045.97	16564.69	1.12	3.18	3161.32	12549.82	2.27	831.55	0	0	0	0	0	0	0	0	31.72											175 per day days 1 - 6	175 per day days 1 - 6	119 per day days 21 - 100	0 copay	20 coinsurance	20 coinsurance	20 coinsurance	25 or 50 copay	20 coinsurance	Effective copay 0 or 20 coinsurance	20 coinsurance		10 copay	Effective copay 0 or 20 coinsurance	Effective copay 0 or 20 coinsurance	Effective copay 0 or 20 coinsurance	20 coinsurance	20 coinsurance	Effective copay 0 or 20 coinsurance	Effective copay 0 or 20 coinsurance	20 coinsurance	Effective copay 0 or 20 coinsurance		0 copay							Effective copay 0 25 or 50											123.62	123.62	56.48	0	0.2	0.2	0.2	25.1	0.2	5.16	0.2	0	10	24.37	8.91	12.16	0.2	0.2	12.94	3.28	0.2	14.24	0	0	0	0	0	0	0	0	0.78											10.44	0.17	2.62	-	0.89	1.04	1.38	0.41	1.79	0.59	1.89	-	0.03	0.79	6.72	16.79	0.22	0.64	3.41	3.43	0.45	0.99	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	54.68			10.44	0.17	2.62	-	0.89	1.04	1.38	0.41	1.79	0.59	1.89	-	0.03	0.79	6.72	16.79	0.22	0.64	3.41	3.43	0.45	0.99	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	54.68																																																																																				-			10.44	0.17	2.62	-	0.89	1.04	1.38	0.41	1.79	0.59	1.89	-	0.03	0.79	6.72	16.79	0.22	0.64	3.41	3.43	0.45	0.99	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	54.68
H9984_002_0	2007	3																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1080.83	18.84	541.43	1697.96	59.6	5.51	21850.31	191.74	165.3	1374.77	578.53	0	34.62	375.47	7295.34	10201.85	160.32	461.42	3325.34	13318.81	261.25	930.75	200	1709	453.5	2.55	194.6	0.35	0	0	118.13											75 per day days 1 - 6	75 per day days 1 - 6	Effective copay -- 25 starting on day 21	0 copay	0 copay	20 coinsurance	0 copay	25 per visit	0 copay	0 copay	0 copay	0 copay	0 copay	Effective copay -- Range 0-15	Effective copay -- Range 0-15	Effective copay -- Range 0-15	15 per visit	10 per visit	0 copay	Effective copay -- Range 0-15	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Effective copay -- Range 0-25											54.55	52.98	23.37	0	0	0.2	0	25	0	0	0	0	0	6.62	0.1	6.7	15	10	0	0.49	0	0	0	0	0	0	0	0	0	0	0.21											4.91	0.08	1.05	-	-	1.1	-	0.4	-	-	-	-	-	0.21	0.06	5.69	0.2	0.38	-	0.54	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	14.64			4.91	0.08	1.05	-	-	1.1	-	0.4	-	-	-	-	-	0.21	0.06	5.69	0.2	0.38	-	0.54	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	14.64																																																																																				-			4.91	0.08	1.05	-	-	1.1	-	0.4	-	-	-	-	-	0.21	0.06	5.69	0.2	0.38	-	0.54	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	14.64
H9984_003_0	2007	3																																D	D	D	V	T	Coin	O	V	V	V	P	P	P	P	P	P	V	V	P	P	S	V	T	V	P	P	P	P	O	O	O																																																				-		1136.92	20.71	506.81	1697.85	61.64	5.73	22731.87	184.22	157.62	1323.32	555.83	0	32.58	355.66	7454.06	10336.1	163.63	475.16	3310.62	14042.52	247.41	950.24	200	2965.66	466.11	307.29	200.02	20.74	0	0	127.7											0 copay	0 copay	20 coinsurance days 21 - 100	0 copay	0 copay	10 coinsurance	0 copay	25 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	Effective copay 0 to 15	Effective copay 0 to 15	15 copay	10 copay	0 copay	Effective copay 0 or 10	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay	0 copay			Effective copay 0 or 25											0	0	22.58	0	0	0.1	0	25	0	0	0	0	0	0	0.1	6.71	15	10	0	0.5	0	0	0	0	0	0	0	0	0	0	0.2											-	-	0.95	-	-	0.57	-	0.38	-	-	-	-	-	-	0.06	5.78	0.2	0.4	-	0.59	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.94			-	-	0.95	-	-	0.57	-	0.38	-	-	-	-	-	-	0.06	5.78	0.2	0.4	-	0.59	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.94																																																																																				-			-	-	0.95	-	-	0.57	-	0.38	-	-	-	-	-	-	0.06	5.78	0.2	0.4	-	0.59	-	-	-	-	-	-	-	-	-	-	0	-	-	-	-	-	-	-	-	-	-	8.94
R3175_001_0	2007	5																					2800											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3600	1696.64	147.8	807.53	0	228.38	11.49	4.96	422.43	25.47	6089.66	35.43	0	0.17	19.38	2792.71	3272.48	561.71	1.48	0	0	17.78	569.04	0	0	128.16	0	177.58	0	0	0	0											295 (1a)	295 (1b)	150 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	5 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											165.37	165.37	84.09	0	98.1	0.17	0.19	28.03	0.14	1.12	0.11	0	0.17	0.14	10	25	37.5	0.14	0	0	0.17	25	0	0	25	0	25	0	0	0	0											23.38	2.04	5.66	-	1.87	1.93	0.95	0.99	3.57	0.57	3.79	-	0.03	2.72	2.33	6.82	1.76	0.21	-	-	2.99	1.19	-	-	0.27	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.41		39.51	23.38	2.04	5.66	-	1.87	1.93	0.95	0.99	3.57	0.57	3.79	-	0.03	2.72	2.33	6.82	1.76	0.21	-	-	2.99	1.19	-	-	0.27	-	0.37	-	-	-	-	-	-	-	-	-	-	-	-	-	-	63.41		40 (1a)	40 (1b)	40 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.7	0.13	0.43	0.63	0.38	0.39	0.2	0.2	1.16	0.46	1.23	0	0.01	0.88	1.63	2.1	0.44	0.07	0	0	0.61	0.36	0	0	0.08	0	0.11	0	0	0	0											15.2		9.09	27.08	2.17	6.09	0.63	2.25	2.32	1.15	1.19	4.73	1.03	5.02	-	0.03	3.6	3.96	8.91	2.19	0.28	-	-	3.6	1.55	-	-	0.35	-	0.48	-	-	-	-	-	-	-	-	-	-	-	-	-	-	78.61
R3175_002_0	2007	6																					2850											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3700	1696.64	147.8	807.53	0	228.38	11.49	4.96	422.43	25.47	6089.66	35.43	0	0.17	19.38	2792.71	3272.48	561.71	1.48	0	0	17.78	569.04	0	0	128.16	0	177.58	0	0	0	0											225 (1a)	225 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	15 (8a 8b)	15/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	20 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 20 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	20 (17a)	0 n/c (17b1-17b5)	20 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											136.35	136.35	75.75	0	106.05	0.18	0.2	30.3	0.12	3.64	0.1	0	0.18	0.12	10	20	37.5	0.12	0	0	0.18	20	0	0	20	0	20	0	0	0	0											19.28	1.68	5.1	-	2.02	2.09	1.01	1.07	3.09	1.85	3.37	-	0.03	2.35	2.33	5.45	1.76	0.18	-	-	3.23	0.95	-	-	0.21	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.33		29.94	19.28	1.68	5.1	-	2.02	2.09	1.01	1.07	3.09	1.85	3.37	-	0.03	2.35	2.33	5.45	1.76	0.18	-	-	3.23	0.95	-	-	0.21	-	0.3	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.33		290 (1a)	290 (1b)	125 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											2.15	0.19	0.44	0.48	0.44	0.46	0.22	0.23	1.01	0.54	1.11	0	0.01	0.77	1.29	2.1	0.44	0.06	0	0	0.71	0.36	0	0	0.08	0	0.11	0	0	0	0											13.19		5.43	21.43	1.87	5.54	0.48	2.46	2.54	1.23	1.3	4.1	2.38	4.48	-	0.04	3.12	3.62	7.55	2.19	0.24	-	-	3.94	1.31	-	-	0.3	-	0.41	-	-	-	-	-	-	-	-	-	-	-	-	-	-	70.52
R3175_003_0	2007	9	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					950	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	O	O	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T		V		V	P		O	O			V	V																																																-		1839.54	380.32			202.42			818.33	352.98			59.64		1772.96		3233.44				746.72														161.86	201.9							(1a) 75 per Day	(1b) 75 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 0	(11b/11c) 0/0	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 0 per Visit	(8b) 0 per Visit	(9a) 25 per Visit	(12) 0 per Visit	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 0 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit		(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0			(7b) 10 per Visit	(7f) 10 per Visit							51	51			51			34	17			17		17		7				7														7	7							7.87	1.63	-	-	0.87	-	-	2.33	0.5	-	-	0.09	-	2.53	-	1.84	-	-	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	0.09	0.12	-	-	-	-	-	-	18.29		8.43	7.87	1.63	-	-	0.87	-	-	2.33	0.5	-	-	0.09	-	2.53	-	1.84	-	-	-	0.43	-	-	-	-	-	-	-	-	-	-	-	-	-	0.09	0.12	-	-	-	-	-	-	18.29		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance		30 Coinsurance	0 per Procedure						30 Coinsurance	30 Coinsurance							1.65	0.14	0.16	0.25	0.05	0.13	0.11	0.04	0.16	0.11	0.11	0.01	0.01	0.17	0.31	0.17	0.04	0.03	0.12	0.53	0.12	0																				4.42		0	9.52	1.77	0.16	0.25	0.91	0.13	0.11	2.38	0.66	0.11	0.11	0.1	0.01	2.7	0.31	2.01	0.04	0.03	0.12	0.95	0.12	0	-	-	-	-	-	-	-	-	-	-	-	0.09	0.12	-	-	-	-	-	-	22.71
R3175_801_0	2007	4																					3000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3800	1781.48	155.19	847.9	0	239.79	12.06	5.21	443.55	26.74	6394.15	37.2	0	0.18	20.35	2932.34	3436.1	589.8	1.56	0	0	18.66	597.49	0	0	134.57	0	186.46	0	0	0	0											295 (1a)	295 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											164.68	164.68	89.32	0	97.69	0.17	0.19	27.91	0.14	3.35	0.11	0	0.17	0.14	15	25	37.5	0.14	0	0	0.17	25	0	0	25	0	25	0	0	0	0											24.45	2.13	6.31	-	1.95	2.02	1	1.03	3.73	1.78	3.96	-	0.03	2.84	3.67	7.16	1.84	0.22	-	-	3.13	1.24	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.17		42.96	24.45	2.13	6.31	-	1.95	2.02	1	1.03	3.73	1.78	3.96	-	0.03	2.84	3.67	7.16	1.84	0.22	-	-	3.13	1.24	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.17		40 (1a)	40 (1b)	40 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.89	0.14	0.45	0.67	0.4	0.41	0.21	0.21	1.22	0.49	1.3	0	0.01	0.93	1.72	2.2	0.46	0.07	0	0	0.64	0.38	0	0	0.09	0	0.12	0	0	0	0											15.98		9.52	28.34	2.27	6.76	0.67	2.35	2.43	1.21	1.24	4.95	2.27	5.26	-	0.04	3.77	5.38	9.36	2.3	0.29	-	-	3.76	1.63	-	-	0.37	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.15
R3175_802_0	2007	6																					3000											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3800	1781.48	155.19	847.9	0	239.79	12.06	5.21	443.55	26.74	6394.15	37.2	0	0.18	20.35	2932.34	3436.1	589.8	1.56	0	0	18.66	597.49	0	0	134.57	0	186.46	0	0	0	0											295 (1a)	295 (1b)	160 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	15 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											164.68	164.68	89.32	0	97.69	0.17	0.19	27.91	0.14	3.35	0.11	0	0.17	0.14	15	25	37.5	0.14	0	0	0.17	25	0	0	25	0	25	0	0	0	0											24.45	2.13	6.31	-	1.95	2.02	1	1.03	3.73	1.78	3.96	-	0.03	2.84	3.67	7.16	1.84	0.22	-	-	3.13	1.24	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.17		42.96	24.45	2.13	6.31	-	1.95	2.02	1	1.03	3.73	1.78	3.96	-	0.03	2.84	3.67	7.16	1.84	0.22	-	-	3.13	1.24	-	-	0.28	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.17		40 (1a)	40 (1b)	40 (2a)	40 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	40 (9b)	20 (8a 8b)	20/40 (8a 8b)	40 (incl in h5)	30 (12)	40 (3 9d 9a); 75 (5); 45/35 (9c)	25 (7a 14c); 40 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	40 (7c 7i)	40 (incl in h2)	40 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 40 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.89	0.14	0.45	0.67	0.4	0.41	0.21	0.21	1.22	0.49	1.3	0	0.01	0.93	1.72	2.2	0.46	0.07	0	0	0.64	0.38	0	0	0.09	0	0.12	0	0	0	0											15.98		9.52	28.34	2.27	6.76	0.67	2.35	2.43	1.21	1.24	4.95	2.27	5.26	-	0.04	3.77	5.38	9.36	2.3	0.29	-	-	3.76	1.63	-	-	0.37	-	0.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.15
R3444_001_0	2007	9																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	266.56	19.6	2540.07	0	27.84	66.21	39.55	9.42	23.52	3671.33	30.85	0	0	97.5	79.42	163.64	9.6	2.99	8954.97	51.72	25.6	5.71	0	0	104.76	359	0	0	0	0	1150											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	17B Eye Wear: Medicare Covered: 50 limit every two years Routine: Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.57	0.45	0.25	19.25	0.25	0	0	0.25	0.23	0.21	0.51	0.22	10.01	0.22	0.26	0.19	0	0	9.03	0	0	0	0	0	0											22.21	1.63	26.46	-	6.06	0.65	22.37	4.26	5.97	5.89	7.84	-	-	24.77	18.04	34.85	4.87	0.65	7.47	11.26	6.69	1.09	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	213.1	138	0	22.21	1.63	26.46	-	6.06	0.65	22.37	4.26	5.97	5.89	7.84	-	-	24.77	18.04	34.85	4.87	0.65	7.47	11.26	6.69	1.09	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	213.1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	22.21	1.63	26.46	-	6.06	0.65	22.37	4.26	5.97	5.89	7.84	-	-	24.77	18.04	34.85	4.87	0.65	7.47	11.26	6.69	1.09	-	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	213.1
R3444_002_0	2007	8																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1577.51	5.2	1533.65	0	340.66	38.26	22.98	408.64	341.42	0	391.83	0	0	339.86	6341.39	6517.52	238.57	477.1	0	831.66	0	675.72	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											60	1000	100	0	50	0	0.23	49.37	100	0	16.53	0	0	24.23	10	25	29	25	0	29.56	0	21.05	0	0	0	0	0	0	0	0	0											7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37
R3444_003_0	2007	8																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.2	0	0	340.66	38.26	22.98	408.64	0	0	391.83	0	0	92.43	5642.07	4358.06	0	0	0	757.93	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.23	48.74	0	0	16.53	0	0	8.78	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84	0	0	-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84
R3444_004_0	2007	9																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1577.51	5.2	1533.65	0	340.66	38.26	22.98	408.64	341.42	0	391.83	0	0	339.86	6341.39	6517.52	238.57	477.1	0	831.66	0	675.72	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											60	1000	100	0	50	0	0.23	49.37	100	0	16.53	0	0	24.23	10	25	29	25	0	29.56	0	21.05	0	0	0	0	0	0	0	0	0											7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37
R3444_005_0	2007	9																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1577.51	5.2	1533.65	0	340.66	38.26	22.98	408.64	341.42	0	391.83	0	0	339.86	6341.39	6517.52	238.57	477.1	0	831.66	0	675.72	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											60	1000	100	0	50	0	0.23	49.37	100	0	16.53	0	0	24.23	10	25	29	25	0	29.56	0	21.05	0	0	0	0	0	0	0	0	0											7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	7.89	0.43	12.78	-	1.42	0.15	5.28	1.68	2.85	-	0.54	-	-	0.69	5.28	13.58	0.58	0.99	-	2.05	-	1.19	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.37
R3444_006_0	2007	9																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.2	0	0	340.66	38.26	22.98	408.64	0	0	391.83	0	0	92.43	5642.07	4358.06	0	0	0	757.93	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.23	48.74	0	0	16.53	0	0	8.78	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84	0	0	-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84
R3444_007_0	2007	9																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	5.2	0	0	340.66	38.26	22.98	408.64	0	0	391.83	0	0	92.43	5642.07	4358.06	0	0	0	757.93	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.23	48.74	0	0	16.53	0	0	8.78	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84	0	0	-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.43	-	-	-	0.15	5.28	1.66	-	-	0.54	-	-	0.07	4.7	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	12.84
R3444_801_0	2007	7																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	163.04	5.7	1533.65	0	12.94	38.29	23	4.1	24.42	2409.98	24.37	0	0	64.89	66.8	155.64	2.65	3.6	7166.01	59.07	14	5.57	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.56	0.41	0.25	18.06	0.25	0	0	0.25	0.23	0.21	0.51	0.22	11.68	0.22	0.26	0.2	0	0	0	0	0	0	0	0	0											13.59	0.47	15.98	-	2.82	0.37	12.96	1.68	6.2	3.63	6.19	-	-	16.48	15.55	32.85	1.34	0.79	6.97	12.85	3.66	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.53	138	0	13.59	0.47	15.98	-	2.82	0.37	12.96	1.68	6.2	3.63	6.19	-	-	16.48	15.55	32.85	1.34	0.79	6.97	12.85	3.66	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.53	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	13.59	0.47	15.98	-	2.82	0.37	12.96	1.68	6.2	3.63	6.19	-	-	16.48	15.55	32.85	1.34	0.79	6.97	12.85	3.66	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.53
R3444_802_0	2007	7																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	163.04	5.7	1533.65	0	12.94	38.29	23	4.1	24.42	2409.98	24.37	0	0	64.89	66.8	155.64	2.65	3.6	7166.01	59.07	14	5.57	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.56	0.41	0.25	18.06	0.25	0	0	0.25	0.23	0.21	0.51	0.22	11.68	0.22	0.26	0.2	0	0	0	0	0	0	0	0	0											13.59	0.47	15.98	-	2.82	0.37	12.96	1.68	6.2	3.63	6.19	-	-	16.48	15.55	32.85	1.34	0.79	6.97	12.85	3.66	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.53	138	0	13.59	0.47	15.98	-	2.82	0.37	12.96	1.68	6.2	3.63	6.19	-	-	16.48	15.55	32.85	1.34	0.79	6.97	12.85	3.66	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.53	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	13.59	0.47	15.98	-	2.82	0.37	12.96	1.68	6.2	3.63	6.19	-	-	16.48	15.55	32.85	1.34	0.79	6.97	12.85	3.66	1.13	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	155.53
R5287_001_0	2007	8																					2900											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	7500	1592.16	93.22	950.7	0	119.56	14.04	8.98	308.46	42.9	10867.07	47.08	0	0.19	23.72	5364.04	4739.81	332.25	4.1	0	0	30.45	1739.28	0	0	37.3	0	186.93	0	0	0	0											250/325 (1a)	250 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20/30 (9b)	5 (8a 8b)	15/20/30 (8a 8b)	20/30 (incl in h5)	30 (12)	20/30 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20/30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											142.95	139.6	69.8	0	97.72	0.17	0.19	27.92	0.15	1.12	0.09	0	0.17	0.17	5	25	37.5	0.11	0	0	0.17	25	0	0	25	0	25	0	0	0	0											18.97	1.08	5.53	-	0.97	2.35	1.67	0.72	6.37	1.01	4.13	-	0.03	3.97	2.24	9.87	1.04	0.46	-	-	5.1	3.62	-	-	0.08	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.6		41.12	18.97	1.08	5.53	-	0.97	2.35	1.67	0.72	6.37	1.01	4.13	-	0.03	3.97	2.24	9.87	1.04	0.46	-	-	5.1	3.62	-	-	0.08	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	69.6		375 (1a)	375 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	30 (16a)/0 n/c (16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.12	0.18	0.74	0.64	0.28	0.67	0.45	0.2	2.03	1.15	1.75	0	0.01	1.12	4.25	3.47	0.26	0.19	0	0	1.44	1.27	0	0.07	0.03	0	0.14	0	0	0	0											23.47		5.15	22.08	1.27	6.27	0.64	1.25	3.02	2.12	0.92	8.41	2.16	5.88	-	0.04	5.1	6.49	13.34	1.3	0.65	-	-	6.54	4.9	-	0.07	0.1	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	93.07
R5287_002_0	2007	6																					2500											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	6900	1592.16	93.22	950.7	0	119.56	14.04	8.98	308.46	42.9	10867.07	47.08	0	0.19	23.72	5364.04	4739.81	332.25	4.1	0	0	30.45	1739.28	0	0	37.3	0	186.93	0	0	0	0											250/325 (1a)	250 (1b)	125 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20/30 (9b)	15 (8a 8b)	15/20/30 (8a 8b)	20/30 (incl in h5)	30 (12)	20/30 (3 9d 9a); 60 (5); 40/30 (9c)	5 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20/30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											131.1	128.02	64.01	0	89.62	0.15	0.17	25.6	0.14	3.07	0.08	0	0.15	0.15	5	25	37.5	0.1	0	0	0.15	25	0	0	25	0	25	0	0	0	0											17.39	0.99	5.07	-	0.89	2.16	1.56	0.66	5.84	2.78	3.79	-	0.03	3.64	2.24	9.87	1.04	0.42	-	-	4.68	3.62	-	-	0.08	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.15		47.19	17.39	0.99	5.07	-	0.89	2.16	1.56	0.66	5.84	2.78	3.79	-	0.03	3.64	2.24	9.87	1.04	0.42	-	-	4.68	3.62	-	-	0.08	-	0.39	-	-	-	-	-	-	-	-	-	-	-	-	-	-	67.15		375 (1a)	375 (1b)	150 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	30 (16a)/0 n/c (16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.03	0.18	0.72	0.64	0.27	0.65	0.44	0.2	1.98	1.11	1.71	0	0.01	1.09	4.25	3.47	0.26	0.19	0	0	1.41	1.27	0	0.07	0.03	0	0.14	0	0	0	0											23.11		5.51	20.43	1.17	5.8	0.64	1.16	2.81	2	0.86	7.82	3.9	5.49	-	0.04	4.74	6.49	13.34	1.3	0.61	-	-	6.08	4.9	-	0.07	0.1	-	0.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	90.26
R5287_003_0	2007	7	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					1000	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	Coin	V	T	V						O	O																																																				-		2130.72	440.43			234.4	27.65	24.52	947.98	408.92			69.09	3.15	2053.88							20.43																					(1a) 25 per Day	(1b) 25 per Day	(2a) 0 per Day	(6a) 0 per Visit	(10a) 50 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/35 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 10 per Visit	(8a) 0 per Visit	(8b) 0 per Visit	(9a) 10 per Visit	(12) 20 Coinsurance	(9a) 10 per Visit	(7a) 0 per Visit	(7d) 0 per Visit	(7h) 0 per Visit	(7c) 0 per Visit	0 per Visit	(7g) 0 per Visit	(15) 20 Coinsurance	0 per Visit	(10b) 0 per Trip	(16a/16b) 0 per Visit						(14a) 0	(13a1) 0											17	17			34	14	14	34	7			7	14	7							14																					3.06	0.63	-	-	0.67	3.81	3.38	2.72	0.23	-	-	0.04	0.43	1.18	-	-	-	-	-	-	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.99		8.55	3.06	0.63	-	-	0.67	3.81	3.38	2.72	0.23	-	-	0.04	0.43	1.18	-	-	-	-	-	-	2.82	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	18.99		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 35 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	0 per Visit																		2.22	0.19	0.21	0.33	0.06	0.17	0.15	0.06	0.22	0.15	0.15	0.02	0.02	0.23	0.34	0.23	0.05	0.03	0.16	0.71	0.16	0																				5.86		0	5.28	0.82	0.21	0.33	0.74	3.98	3.53	2.79	0.45	0.15	0.15	0.06	0.45	1.41	0.34	0.23	0.05	0.03	0.16	0.71	2.97	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	24.85
R5287_801_0	2007	4																					3600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	7500	1671.76	97.89	998.24	0	125.54	14.75	9.42	323.89	45.04	11410.42	49.43	0	0.19	24.9	5632.24	4976.8	348.86	4.31	0	0	31.97	1826.24	0	0	39.16	0	196.27	0	0	0	0											325/375 (1a)	325 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	30 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											185.42	183.17	84.54	0	98.63	0.14	0.16	28.18	0.14	3.38	0.11	0	0.17	0.14	30	35	37.5	0.14	0	0	0.17	35	0	0	35	0	35	0	0	0	0											25.83	1.49	7.03	-	1.03	2.08	1.47	0.76	6.35	3.22	5.31	-	0.03	3.51	14.08	14.52	1.09	0.61	-	-	5.41	5.33	-	-	0.11	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.83		49.4	25.83	1.49	7.03	-	1.03	2.08	1.47	0.76	6.35	3.22	5.31	-	0.03	3.51	14.08	14.52	1.09	0.61	-	-	5.41	5.33	-	-	0.11	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.83		425 (1a)	425 (1b)	175 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.6	0.21	0.89	0.67	0.28	0.68	0.46	0.21	2.08	1.17	1.74	0	0.01	1.15	4.47	3.64	0.27	0.2	0	0	1.47	1.34	0	0	0.03	0	0.14	0	0	0	0											24.7		6.02	29.44	1.71	7.92	0.67	1.31	2.76	1.93	0.97	8.42	4.38	7.05	-	0.04	4.65	18.55	18.16	1.36	0.81	-	-	6.88	6.66	-	-	0.14	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.53
R5287_802_0	2007	5																					3600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	7500	1671.76	97.89	998.24	0	125.54	14.75	9.42	323.89	45.04	11410.42	49.43	0	0.19	24.9	5632.24	4976.8	348.86	4.31	0	0	31.97	1826.24	0	0	39.16	0	196.27	0	0	0	0											325/375 (1a)	325 (1b)	150 (2a)	0 (6a)	175 (10a)	25 (11a)	25 (11b 11c)	50 (4a 4b)	25 (9b)	15 (8a 8b)	15/25 (8a 8b)	25 (incl in h5)	30 (12)	25 (3 9d 9a); 60 (5); 40/30 (9c)	30 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	25 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											185.42	183.17	84.54	0	98.63	0.14	0.16	28.18	0.14	3.38	0.11	0	0.17	0.14	30	35	37.5	0.14	0	0	0.17	35	0	0	35	0	35	0	0	0	0											25.83	1.49	7.03	-	1.03	2.08	1.47	0.76	6.35	3.22	5.31	-	0.03	3.51	14.08	14.52	1.09	0.61	-	-	5.41	5.33	-	-	0.11	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.83		49.4	25.83	1.49	7.03	-	1.03	2.08	1.47	0.76	6.35	3.22	5.31	-	0.03	3.51	14.08	14.52	1.09	0.61	-	-	5.41	5.33	-	-	0.11	-	0.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.83		425 (1a)	425 (1b)	175 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	40 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.6	0.21	0.89	0.67	0.28	0.68	0.46	0.21	2.08	1.17	1.74	0	0.01	1.15	4.47	3.64	0.27	0.2	0	0	1.47	1.34	0	0	0.03	0	0.14	0	0	0	0											24.7		6.02	29.44	1.71	7.92	0.67	1.31	2.76	1.93	0.97	8.42	4.38	7.05	-	0.04	4.65	18.55	18.16	1.36	0.81	-	-	6.88	6.66	-	-	0.14	-	0.72	-	-	-	-	-	-	-	-	-	-	-	-	-	-	124.53
R5342_001_0	2007	8																					3300											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	4200	1824.83	158.97	868.54	0	245.63	13.29	5.74	454.35	29.46	0	40.99	0	0.2	22.42	3003.71	3669.56	604.15	1.71	0	0	25.08	612.07	0	0	137.84	0	191	0	0	0	0											195 (1a)	195 (1b)	95 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	0 (8a 8b)	0/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											127.03	127.03	61.89	0	114	0.2	0.21	32.57	0.13	0	0.09	0	0.2	0.13	10	25	37.5	0.13	0	0	0.2	25	0	0	25	0	25	0	0	0	0											19.32	1.68	4.48	-	2.33	2.6	1.23	1.23	3.84	-	3.84	-	0.04	2.92	2.5	7.64	1.89	0.22	-	-	4.9	1.28	-	-	0.29	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.64		25.85	19.32	1.68	4.48	-	2.33	2.6	1.23	1.23	3.84	-	3.84	-	0.04	2.92	2.5	7.64	1.89	0.22	-	-	4.9	1.28	-	-	0.29	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	62.64		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.56	0.12	0.41	0.55	0.45	0.5	0.25	0.24	1.12	0.55	1.23	0	0.01	0.85	1.41	2.35	0.47	0.06	0	0	0	0.39	0	0	0.09	0	0.12	0	0	0	0											14.75		6.86	22.88	1.81	4.89	0.55	2.79	3.1	1.48	1.47	4.95	0.55	5.08	-	0.05	3.77	3.91	9.99	2.36	0.29	-	-	4.9	1.67	-	-	0.38	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.39
R5342_002_0	2007	4																					2700											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	3600	1824.83	158.97	868.54	0	245.63	13.29	5.74	454.35	29.46	0	40.99	0	0.2	22.42	3003.71	3669.56	604.15	1.71	0	0	25.08	612.07	0	0	137.84	0	191	0	0	0	0											195 (1a)	195 (1b)	95 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	20 (9b)	0 (8a 8b)	0/20 (8a 8b)	20 (incl in h5)	30 (12)	20 (3 9d 9a); 60 (5); 40/30 (9c)	10 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	25 (7b 7d 7f 7g)	40/30 (7e 7h)	20 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 25 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	25 (17a)	0 n/c (17b1-17b5)	25 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											117.18	117.18	57.09	0	105.16	0.18	0.2	30.05	0.12	0	0.09	0	0.18	0.12	10	25	37.5	0.12	0	0	0.18	25	0	0	25	0	25	0	0	0	0											17.82	1.55	4.13	-	2.15	2.4	1.16	1.14	3.54	-	3.55	-	0.04	2.7	2.5	7.64	1.89	0.21	-	-	4.52	1.28	-	-	0.29	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.9		29.6	17.82	1.55	4.13	-	2.15	2.4	1.16	1.14	3.54	-	3.55	-	0.04	2.7	2.5	7.64	1.89	0.21	-	-	4.52	1.28	-	-	0.29	-	0.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.9		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	20 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 35 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.33	0.12	0.39	0.55	0.42	0.47	0.24	0.22	1.04	0.52	1.15	0	0.01	0.79	1.41	2.35	0.47	0.06	0	0	0	0.39	0	0	0.09	0	0.12	0	0	0	0											14.13		7.47	21.15	1.67	4.52	0.55	2.58	2.87	1.4	1.36	4.58	0.52	4.7	-	0.04	3.49	3.91	9.99	2.36	0.27	-	-	4.52	1.67	-	-	0.38	-	0.52	-	-	-	-	-	-	-	-	-	-	-	-	-	-	73.03
R5342_003_0	2007	7	H.5	H.5	I.2	I.2	I.3	R.					OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Other Non-Covered					700	Rehab	MH/SA	Chiropractic	Podiatry	MH (non-MD)	Acupuncture					D	D	D	V	T	Coin	Coin	V	V	V	V	V	Coin	V	V	V	V	V	V	V	S	V	T		V	P	V	P		O	O	V		V	V																																																-		2045.31	422.78	787.76		225.01	25.48	22.59	909.97	392.53	1938.45	963.46	66.32	2.9	1971.54		3595.57		523.43		830.29												268.01		180	224.52							(1a) 75 per Day	(1b) 75 per Day	(2a) 120 per Day from day 21 until OOPM is met.	(6a) 0 per Visit	(10a) 75 per Trip	(11a) 20 Coinsurance	(11b/11c) 20/0 Coinsurance	(4a/4b) 50/10 per Visit (waived if hosp. w/in 24 hrs.)	(9b) 25 per Visit	(8a) 10 per Visit	(8b) 10 per Visit	(9a) 25 per Visit	(12) 20 Coinsurance	(9a) 25 per Visit	(7a) 0 per Visit	(7d) 10 per Visit	(7h) 0 per Visit	(7c) 10 per Visit	0 per Visit	(7g) 10 per Visit	(15) 0 per Script	0 per Visit	(10b) 0 per Trip		(17a1) 0 per Visit	(17b) 0 per Procedure	(18a1) 0 per Visit	(18b) 0 per Procedure		(14a) 0	(13a1) 0	(7i) 10 per Visit		(7b) 10 per Visit	(7f) 10 per Visit							37	37	18		37	10	10	18	12	5	5	12	10	12		5		5		5												5		5	5							6.24	1.29	1.15	-	0.69	2.49	2.21	1.33	0.4	0.79	0.39	0.07	0.28	2.01	-	1.46	-	0.21	-	0.34	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.07	0.09	-	-	-	-	-	-	21.63		22.66	6.24	1.29	1.15	-	0.69	2.49	2.21	1.33	0.4	0.79	0.39	0.07	0.28	2.01	-	1.46	-	0.21	-	0.34	-	-	-	-	-	-	-	-	-	-	-	0.11	-	0.07	0.09	-	-	-	-	-	-	21.63		30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	50 / 10 per Visit	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance	30 Coinsurance		30 Coinsurance	0 per Procedure	30 Coinsurance	0 per Procedure				30 Coinsurance		30 Coinsurance	30 Coinsurance							2.04	0.18	0.2	0.3	0.06	0.16	0.14	0.05	0.2	0.13	0.14	0.02	0.02	0.21	0.33	0.21	0.05	0.03	0.15	0.65	0.14	0																				5.41		0	8.29	1.47	1.35	0.3	0.75	2.65	2.35	1.38	0.6	0.92	0.53	0.08	0.3	2.22	0.33	1.67	0.05	0.24	0.15	0.99	0.14	0	-	-	-	-	-	-	-	-	-	0.11	-	0.07	0.09	-	-	-	-	-	-	27.04
R5342_801_0	2007	4																					3600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	4200	1910.27	166.41	909.2	0	257.13	13.87	5.99	475.62	30.75	6856.41	42.78	0	0.21	23.4	3144.34	3841.37	632.44	1.79	0	0	26.17	640.72	0	0	144.29	0	199.94	0	0	0	0											345 (1a)	345 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											189.01	189.01	98.61	0	95.87	0.16	0.19	27.39	0.16	3.29	0.13	0	0.16	0.16	20	35	37.5	0.16	0	0	0.16	35	0	0	35	0	35	0	0	0	0											30.09	2.62	7.47	-	2.05	2.28	1.13	1.09	5.05	1.88	5.52	-	0.03	3.85	5.24	11.2	1.98	0.29	-	-	4.3	1.87	-	-	0.42	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.96		55.56	30.09	2.62	7.47	-	2.05	2.28	1.13	1.09	5.05	1.88	5.52	-	0.03	3.85	5.24	11.2	1.98	0.29	-	-	4.3	1.87	-	-	0.42	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.96		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.65	0.13	0.42	0.57	0.47	0.52	0.25	0.25	1.14	0.57	1.27	0	0.01	0.87	2.05	2.81	0.49	0.07	0	0	0	0.47	0	0	0.11	0	0.15	0	0	0	0											16.25		7.34	33.74	2.75	7.89	0.57	2.52	2.8	1.39	1.33	6.2	2.45	6.78	-	0.04	4.72	7.29	14.01	2.47	0.36	-	-	4.3	2.34	-	-	0.53	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.21
R5342_802_0	2007	5																					3600											D	D	D	V	T	Coin	Coin	V	Coin	P	Coin	Coin	Coin	Coin	V	V	V	Coin	P	P	Coin	O	T	V	V	P	V	P	O	O	O																																																				-	4200	1910.27	166.41	909.2	0	257.13	13.87	5.99	475.62	30.75	6856.41	42.78	0	0.21	23.4	3144.34	3841.37	632.44	1.79	0	0	26.17	640.72	0	0	144.29	0	199.94	0	0	0	0											345 (1a)	345 (1b)	180 (2a)	0 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	15 (8a 8b)	15/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 60 (5); 40/30 (9c)	20 (7a 14c); 0 (14b 14d 14e 14f 14g 14h)	35 (7b 7d 7f 7g)	40/30 (7e 7h)	30 (7c 7i)	0 (incl in h2)	0 (14i)	30 (15)	0 (13a 17b); 35 (17a 18a 16b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	35 (17a)	0 n/c (17b1-17b5)	35 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											189.01	189.01	98.61	0	95.87	0.16	0.19	27.39	0.16	3.29	0.13	0	0.16	0.16	20	35	37.5	0.16	0	0	0.16	35	0	0	35	0	35	0	0	0	0											30.09	2.62	7.47	-	2.05	2.28	1.13	1.09	5.05	1.88	5.52	-	0.03	3.85	5.24	11.2	1.98	0.29	-	-	4.3	1.87	-	-	0.42	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.96		55.56	30.09	2.62	7.47	-	2.05	2.28	1.13	1.09	5.05	1.88	5.52	-	0.03	3.85	5.24	11.2	1.98	0.29	-	-	4.3	1.87	-	-	0.42	-	0.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	88.96		30 (1a)	30 (1b)	30 (2a)	30 (6a)	175 (10a)	30 (11a)	30 (11b 11c)	50 (4a 4b)	30 (9b)	20 (8a 8b)	20/30 (8a 8b)	30 (incl in h5)	30 (12)	30 (3 9d 9a); 75 (5); 45/35 (9c)	30 (7a 14c); 30 (14b 14d 14e 14f 14g 14h)	40 (7b 7d 7f 7g)	45/35 (7e 7h)	30 (7c 7i)	30 (incl in h2)	30 (14i)	30 (15)	0 (13a); 40 (17a 18a 16b); 30 (17b)	0 n/c (10b)	0 n/c (16a 16b1-16b5)	40 (17a)	0 n/c (17b1-17b5)	40 (18a)	0 n/c (18b)	0 n/c	0 (14a)	0 n/c (13b 13c 13d 13e)											3.65	0.13	0.42	0.57	0.47	0.52	0.25	0.25	1.14	0.57	1.27	0	0.01	0.87	2.05	2.81	0.49	0.07	0	0	0	0.47	0	0	0.11	0	0.15	0	0	0	0											16.25		7.34	33.74	2.75	7.89	0.57	2.52	2.8	1.39	1.33	6.2	2.45	6.78	-	0.04	4.72	7.29	14.01	2.47	0.36	-	-	4.3	2.34	-	-	0.53	-	0.73	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.21
R5553_001_0	2007	9																					0											D	D	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1031.73	13.79	838.59	0	262.77	24.68	1.24	354.03	365.74	2350.6	1204.99	0	0.22	25.75	4172.18	5313.88	148.98	480.31	0	257.34	666.22	759.28	0	0	0	0	0	0	0	0	0											150 per day 1-7	150 per day 1-7	0 days 1-5; 75 days 6-100		50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER and UC	50 ASC/ 100 OP Hosp	20 copay	20 copay		20 coins	30 OP SA/0 Cardiac Rehab	15 copay PCP	30 SCP/30 Chiro/30 Podiatrist	30 copay	30 Therapy		30 Hearing 0 Preventive	20 coins	30 vision and blood																				138.95	138.95	49.08	0	46.32	0.15	0.19	47.52	55.7	18.53	18.53	0	0.17	0.1	13.89	27.75	27.79	25.3	0	10.04	24.88	27.58	0	0	0	0	0	0	0	0	0											11.95	0.16	3.43	-	1.01	3.73	0.23	1.4	1.7	3.63	1.86	-	0.04	2.61	4.83	12.29	0.35	1.01	-	0.22	1.38	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.56	0	5.04	11.95	0.16	3.43	-	1.01	3.73	0.23	1.4	1.7	3.63	1.86	-	0.04	2.61	4.83	12.29	0.35	1.01	-	0.22	1.38	1.74	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.56	5000	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.89	0.01	0.17	0.21	0.05	0.26	0.01	0.05	0.2	0.07	0.2	0	0	0.19	0.26	0.94	0.02	0.03	0.19	0.15	0.06	0.04	0	0	0	0	0	0	0	0	0											4.98	750	0.79	13.83	0.17	3.6	0.21	1.06	3.99	0.24	1.45	1.9	3.7	2.06	-	0.04	2.8	5.08	13.23	0.36	1.04	0.19	0.37	1.44	1.78	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	58.54
R5553_002_0	2007	7																					0											A	A	D	V	T	coin	coin	V	V	P	P	O	coin	coin	V	V	V	V	P	V	S	O	T	P	V	P	V	P	O	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	303.27	2.86	852	0	262.87	24.62	1.24	355.27	345.64	2228.33	1138.67	0	0.23	25.69	4516.6	5735.86	159.23	513.59	0	277.82	632.41	797.31	0	0	0	0	0	0	0	0	0											0	0	0 days 1-5; 75 days 6-100	0	50 per trip	20 DME 0 Diab Monitoring	20 coins	50 ER/ 20 UC	25 ASC/ 50 OP Hosp	10 copay	10 copay	0	20 coins	20 OP SA/0 Cardiac Rehab	10 PCP copay	20 SCP/20 Chiro/20 Podiatrist	20 copay	20 copay	0	20 Hearing 0 Preventive	20 coins	20 vision and blood																				0	0	47.34	0	44.68	0.15	0.18	36.8	26.86	8.94	8.93	0	0.15	0.09	8.93	17.86	17.88	17.88	0	6.73	23.12	18.39	0	0	0	0	0	0	0	0	0											0	-	3.36	-	0.98	3.59	0.22	1.09	0.77	1.66	0.85	-	0.03	2.22	3.36	8.54	0.24	0.77	-	0.16	1.22	1.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.27	0	5.08	0	-	3.36	-	0.98	3.59	0.22	1.09	0.77	1.66	0.85	-	0.03	2.22	3.36	8.54	0.24	0.77	-	0.16	1.22	1.22	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	30.27	2500	20 coins	20 coins	20 coins	20 coins	50 per trip	20 coins	20 coins	50 ER and UC	20 ASC/30 OP Hosp	20 coins	20 coins	0	20 coins	20 coins	20 coins	20 SCP 50 Chiro 50 Podiatrist	50 coins	20 coins	20 coins	20 coins	20 coins	20 coins																				1.51	0.01	0.14	0.16	0.04	0.2	0.01	0.03	0.16	0.06	0.15	0	0	0.15	0.21	0.76	0.01	0.02	0.15	0.12	0.04	0.03	0	0	0	0	0	0	0	0	0											3.96	500	1.48	1.51	0.01	3.5	0.16	1.01	3.79	0.23	1.12	0.93	1.71	1	-	0.04	2.37	3.57	9.3	0.25	0.79	0.15	0.28	1.26	1.25	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	34.23
R5553_801_0	2007	3																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	none	262.1	1.96	26.57	0	6.98	24.83	1.18	4.59	23.91	9.26	25.23	0	0.21	23.57	41.4	120.19	1.12	3.79	27.14	21.12	6.57	5.73																				Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare																				0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				19.89	0.15	5.2	-	1.65	5.86	0.28	1.08	5.64	2.19	5.96	-	0.05	5.56	9.77	28.37	0.26	0.89	6.4	4.99	1.55	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.1	0	0	19.89	0.15	5.2	-	1.65	5.86	0.28	1.08	5.64	2.19	5.96	-	0.05	5.56	9.77	28.37	0.26	0.89	6.4	4.99	1.55	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.1	none	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare																				0.65	0.01	0.17	0	0.06	0.2	0.01	0.03	0.18	0.07	0.19	0	0	0.19	0.33	0.93	0.01	0.03	0.21	0.16	0.06	0.04																				3.53	0	0	20.55	0.15	5.37	-	1.7	6.06	0.29	1.12	5.82	2.26	6.15	-	0.05	5.75	10.1	29.3	0.27	0.92	6.61	5.15	1.6	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.62
R5553_802_0	2007	3																					none											coin	coin	coin	V	coin	coin	coin	coin	coin	coin	coin	O	coin	coin	coin	coin	coin	coin	coin	coin	coin	coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0																				-	none	262.1	1.96	26.57	0	6.98	24.83	1.18	4.59	23.91	9.26	25.23	0	0.21	23.57	41.4	120.19	1.12	3.79	27.14	21.12	6.57	5.73																				Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare																				0.08	0.08	0.2	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24																				19.89	0.15	5.2	-	1.65	5.86	0.28	1.08	5.64	2.19	5.96	-	0.05	5.56	9.77	28.37	0.26	0.89	6.4	4.99	1.55	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.1	0	0	19.89	0.15	5.2	-	1.65	5.86	0.28	1.08	5.64	2.19	5.96	-	0.05	5.56	9.77	28.37	0.26	0.89	6.4	4.99	1.55	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	107.1	none	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare	Standard Medicare																				0.65	0.01	0.17	0	0.06	0.2	0.01	0.03	0.18	0.07	0.19	0	0	0.19	0.33	0.93	0.01	0.03	0.21	0.16	0.06	0.04																				3.53	0	0	20.55	0.15	5.37	-	1.7	6.06	0.29	1.12	5.82	2.26	6.15	-	0.05	5.75	10.1	29.3	0.27	0.92	6.61	5.15	1.6	1.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	110.62
R5566_003_0	2007	2	h.5	h.5	i.1	h.1	i.2	i.2	i.2	i.2	r.	i.1	OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Other Non-Covered	Professional	2500	Other - Mental Health	Other - Substance Abuse	PCP - Periodic Exams	PCP - Office Visits	Specialist excl. MH - Office Visits	Specialist excl. MH - Consults	Specialist excl. MH - Cardiovascular	Specialist excl. MH - Chiropractic	Urgent Care	PCP - Immunizations	A	A	Coin	Coin	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin	P	P	V	V	V	V	V	V	V	Coin																																										-	7500	162.24	2.19	26.21	19.93	263.8	3.17	5.1	282.83	265.21	2.73	8.11	0	3.34	12.62	2.76	49.58	109.64	758.52	15.11	2358.29	14.74	0	0	0	601.79	0.13	42.65	0	0	0	0	18.77	0.04	72.23	2984.76	994.92	497.25	1282.64	544.59	0	1.91	500 per admit.  PBP Section B: #1A Inpatient Hospital-Acute.	500 per admit.  PBP Section B: #1B Inpatient Hospital - Psychiatric.	0 per day for first 20 days 100 per day for days 21-100 100 after 100 days.  PBP Section B: #2 Skilled Nursing Services.	0 percent.  PBP Section B: #6 Home Health Services.	100 per trip.  PBP Section B: #10A Ambulance.	20 percent.  PBP Section B: #11A Durable Medical Equipment.	20 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	150 per visit.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital.	0 percent for clinical and diagnostic radiology 20 percent for all other radiology services.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #12 Renal Dialysis.	0 per visit.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	0 percent.  PBP Section B: #7A Primary Care Physician Services.	0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	25 per visit.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	25 per visit.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	20 percent for global radiology and 0 percent for professional radiology.  PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	0 per visit.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	20 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	0 percent	0 percent.  PBP Section B: #10B Transportation.	25 per visit.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	25 per visit.  PBP Section B: #17A Eye Exams.	20 percent.  PBP Section B: #17B Eye Wear.	25 per visit.  PBP Section B: #18A Hearing Exams.	100 percent.  PBP Section B: #18B Hearing Aids.	0 percent. PBP Section B: #19 POS.	0 percent. PBP Section B: #14A Health Education/Wellness Programs.	0 percent	25 per visit.  PBP Section B: #9A Outpatient Hospital Services.	25 per visit.  PBP Section B: #9C Outpatient Substance Abuse Services.	25 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	25 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	25 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	25 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	25 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	25 per visit.  PBP Section B: #7B Chiropractic Services.	25 per visit.  PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	0 percent.  PBP Section B: #14B Immunizations.	500	500	0.08	0	100	0.2	0.2	50	150	0	0.19	0	0	0	0	0	25	25	0.2	0	0.2	0	0	25	25	0.2	25	1	0	0	0	25	25	25	25	25	25	25	25	0	0	6.76	0.09	2.1	-	2.2	0.63	1.02	1.18	3.32	-	1.51	-	-	-	-	-	0.23	1.58	3.02	-	2.95	-	-	-	1.25	0.03	0.09	-	-	-	-	0.04	0	0.15	6.22	2.07	1.04	2.67	1.13	-	-	41.28	0	4.21	6.76	0.09	2.1	-	2.2	0.63	1.02	1.18	3.32	-	1.51	-	-	-	-	-	0.23	1.58	3.02	-	2.95	-	-	-	1.25	0.03	0.09	-	-	-	-	0.04	0	0.15	6.22	2.07	1.04	2.67	1.13	-	-	41.28	7500	Out-of-Network: 40 percent for first 90 days 100 after 90 days.  PBP Section B: #1A Inpatient Hospital-Acute.	Out-of-Network: 40 percent for first 190 days 100 percent after 190 days. PBP Section B: #1B Inpatient Hospital - Psychiatric.	Out-of-Network: 40 percent for first 100 days 100 percent after 100 days. PBP Section B: #2 Skilled Nursing Services.	Out-of-Network: 40 percent.  PBP Section B: #6 Home Health Services.	Out-of-Network: 40 percent.  PBP Section B: #10A Ambulance.	Out-of-Network: 40 percent.  PBP Section B: #11A Durable Medical Equipment.	Out-of-Network: 40 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	Out-of-Network: 50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	Out-of-Network: 40 percent.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	Out-of-Network: 40 percent.  PBP Section B: #9A Outpatient Hospital.	Out-of-Network: 40 percent.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	Out-of-Network: 40 percent.  PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 40 percent.  PBP Section B: #12 Renal Dialysis.	Out-of-Network: 40 percent.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	Out-of-Network: 40 percent.  PBP Section B: #7A Primary Care Physician Services.	Out-of-Network: 40 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 40 percent.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	Out-of-Network: 40 percent.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	Out-of-Network: 40 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	Out-of-Network: 40 percent.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	Out-of-Network: 40 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	Out-of-Network: 40 percent	Out-of-Network: 40 percent.  PBP Section B: #10B Transportation.	Out-of-Network: 40 percent.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	Out-of-Network: 40 percent.  PBP Section B: #17A Eye Exams.	Out-of-Network: 40 percent.  PBP Section B: #17B Eye Wear.	Out-of-Network: 40 percent.  PBP Section B: #18A Hearing Exams.	Out-of-Network: 100 percent.  PBP Section B: #18B Hearing Aids.	Out-of-Network: 40 percent.  PBP Section B: #19 POS.	Out-of-Network: 40 percent. PBP Section B: #14A Health Education/Wellness Programs.	Out-of-Network: 40 percent.	Out-of-Network: 40 percent.  PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 40 percent.  PBP Section B: #9C Outpatient Substance Abuse Services.	Out-of-Network: 40 percent.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 40 percent.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 40 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	Out-of-Network: 40 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 40 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 40 percent.  PBP Section B: #7B Chiropractic Services.	Out-of-Network: 25 per visit. PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	Out-of-Network: 0 percent.  PBP Section B: #14B Immunizations.	5.38	0.06	1.05	0.78	0.14	0.12	0.2	0.12	0.78	0.11	0.32	0	0.13	0.18	0.11	1.94	0.03	0.12	0.73	0.72	0.58	0	0	0	0.18	0.01	0.01	0	0	0	0	0.01	0	0.03	0.74	0.25	0.25	0.25	0.07	0	0	15.37	0	6.73	12.14	0.15	3.15	0.78	2.34	0.76	1.22	1.3	4.1	0.11	1.82	-	0.13	0.18	0.11	1.94	0.26	1.7	3.75	0.72	3.53	-	-	-	1.43	0.03	0.1	-	-	-	-	0.05	0	0.18	6.96	2.32	1.29	2.92	1.2	-	-	56.65
R5566_005_0	2007	2	h.5	h.5	i.1	h.1	i.2	i.2	i.2	i.2	r.	i.1	OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Other Non-Covered	Professional	1000	Other - Mental Health	Other - Substance Abuse	PCP - Periodic Exams	PCP - Office Visits	Specialist excl. MH - Office Visits	Specialist excl. MH - Consults	Specialist excl. MH - Cardiovascular	Specialist excl. MH - Chiropractic	Urgent Care	PCP - Immunizations	A	Coin	Coin	Coin	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin	P	P	V	V	V	V	V	V	V	Coin																																										-	6000	156.32	1.42	25.35	19.27	254.17	3.06	4.93	272.51	255.53	2.64	7.84	0	3.23	12.21	2.67	47.94	105.64	730.84	14.61	2272.22	14.26	0	0	0	579.83	0.12	41.09	0	0	0	0	18.08	0.04	69.6	2875.82	958.61	479.1	1235.82	524.71	0	1.84	100 per admit.  PBP Section B: #1A Inpatient Hospital-Acute.	100 per admit 100 after 190 days.  PBP Section B: #1B Inpatient Psychiatric Hosp.	0 per day for first 20 days 50 per day for days 21-100 100 after 100 days.  PBP Section B: #2 Skilled Nursing Services.	0 percent.  PBP Section B: #6 Home Health Services.	100 per trip.  PBP Section B: #10A Ambulance.	10 percent.  PBP Section B: #11A Durable Medical Equipment.	10 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	50 per visit.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital.	50 for CT MRI MRA and PET; 10 for Therapeutic; 0 for all other radiological services.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #12 Renal Dialysis.	0 per visit.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	0 percent.  PBP Section B: #7A Primary Care Physician Services.	0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	10 per visit.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	0 percent.  PBP Section B: #8A Outpatient C/D/T #8B Outpatient X-Rays and #9A Outpatient Hospital.	0 per visit.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	10 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	0 percent	0 percent.  PBP Section B: #10B Transportation.	10 per visit.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	10 per visit.  PBP Section B: #17A Eye Exams.	10 percent.  PBP Section B: #17B Eye Wear.	10 per visit.  PBP Section B: #18A Hearing Exams.	100 percent.  PBP Section B: #18B Hearing Aids.	0 percent. PBP Section B: #19 POS.	0 percent. PBP Section B: #14A Health Education/Wellness Programs.	0 percent	10 per visit.  PBP Section B: #9A Outpatient Hospital Services.	10 per visit.  PBP Section B: #9C Outpatient Substance Abuse Services.	10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7B Chiropractic Services.	10 per visit.  PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	0 percent.  PBP Section B: #14B Immunizations.	100	0.03	0.05	0	100	0.1	0.1	50	50	0	0.02	0	0	0	0	0	10	10	0	0	0.1	0	0	10	10	0.1	10	1	0	0	0	10	10	10	10	10	10	10	10	0	0	1.3	0.04	1.17	-	2.12	0.31	0.49	1.14	1.06	-	0.16	-	-	-	-	-	0.09	0.61	-	-	1.43	-	-	-	0.48	0.01	0.03	-	-	-	-	0.02	0	0.06	2.4	0.8	0.4	1.03	0.44	-	-	15.58	0	2.63	1.3	0.04	1.17	-	2.12	0.31	0.49	1.14	1.06	-	0.16	-	-	-	-	-	0.09	0.61	-	-	1.43	-	-	-	0.48	0.01	0.03	-	-	-	-	0.02	0	0.06	2.4	0.8	0.4	1.03	0.44	-	-	15.58	6000	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 100 per admit.  PBP Section B: #1A Inpatient Hospital-Acute.	Out-of-Network: 20 percent for first 190 days 100 percent after 190 days.  Out-of-Area Travel Benefit: 100 per admit 100 after 190 days.  PBP Section B: #1B Inpatient Hospital - Psychiatric.	Out-of-Network: 20 percent for first 100 days 100 percent after 100 days.  Out-of-Area Travel Benefit: 0 per day for first 20 days 50 per day for days 21-100 100 after 100 days.  PBP Section B: #2 Skilled Nursing Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #6 Home Health Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 100 per trip.  PBP Section B: #10A Ambulance.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #11A Durable Medical Equipment.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	Out-of-Network: 50 per visit.  Out-of-Area Travel Benefit: 50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 50 per visit.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #9A Outpatient Hospital.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 50 for CT MRI MRA and PET; 10 for Therapeutic; 0 for all other radiological services.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #12 Renal Dialysis.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per visit.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent. PBP Section B: #7A Primary Care Physician Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per visit.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #10B Transportation.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #17A Eye Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #17B Eye Wear.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #18A Hearing Exams.	Out-of-Network: 100 percent.  Out-of-Area Travel Benefit: 100 percent.  PBP Section B: #18B Hearing Aids.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #19 POS.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent. PBP Section B: #14A Health Education/Wellness Programs.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #9C Outpatient Substance Abuse Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #7B Chiropractic Services.	Out-of-Network: 10 per visit.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	Out-of-Network: 0 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #14B Immunizations.	2.51	0.03	0.55	0.36	0.17	0.07	0.12	0.16	0.41	0.05	0.15	0	0.06	0.09	0.05	0.89	0.02	0.08	0.33	0.33	0.33	0	0	0	0.1	0	0	0	0	0	0	0	0	0.02	0.46	0.15	0.13	0.17	0.05	0	0	7.86	0	1.32	3.81	0.07	1.73	0.36	2.29	0.38	0.61	1.3	1.48	0.05	0.31	-	0.06	0.09	0.05	0.89	0.11	0.69	0.33	0.33	1.76	-	-	-	0.59	0.02	0.04	-	-	-	-	0.02	0	0.07	2.85	0.95	0.53	1.2	0.49	-	-	23.44
R5566_006_0	2007	2	h.5	h.5	i.1	h.1	i.2	i.2	i.2	i.2	r.	i.1	OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Other Non-Covered	Professional	1000	Other - Mental Health	Other - Substance Abuse	PCP - Periodic Exams	PCP - Office Visits	Specialist excl. MH - Office Visits	Specialist excl. MH - Consults	Specialist excl. MH - Cardiovascular	Specialist excl. MH - Chiropractic	Urgent Care	PCP - Immunizations	A	Coin	Coin	Coin	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin	P	P	V	V	V	V	V	V	V	Coin																																										-	6000	168.79	1.53	27.34	20.79	274.45	3.3	5.32	294.25	275.92	2.84	8.46	0	3.49	13.17	2.88	51.72	114.07	789.16	15.76	2453.53	15.38	0	0	0	626.09	0.13	44.37	0	0	0	0	19.53	0.04	75.15	3105.3	1035.1	517.33	1334.44	566.58	0	1.99	100 per admit.  PBP Section B: #1A Inpatient Hospital-Acute.	100 per admit 100 after 190 days.  PBP Section B: #1B Inpatient Psychiatric Hosp.	0 per day for first 20 days 50 per day for days 21-100 100 after 100 days.  PBP Section B: #2 Skilled Nursing Services.	0 percent.  PBP Section B: #6 Home Health Services.	100 per trip.  PBP Section B: #10A Ambulance.	10 percent.  PBP Section B: #11A Durable Medical Equipment.	10 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	50 per visit.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital.	50 for CT MRI MRA and PET; 10 for Therapeutic; 0 for all other radiological services.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #12 Renal Dialysis.	0 per visit.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	0 percent.  PBP Section B: #7A Primary Care Physician Services.	0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	10 per visit.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	0 percent.  PBP Section B: #8A Outpatient C/D/T #8B Outpatient X-Rays and #9A Outpatient Hospital.	0 per visit.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	10 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	0 percent	0 percent.  PBP Section B: #10B Transportation.	10 per visit.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	10 per visit.  PBP Section B: #17A Eye Exams.	10 percent.  PBP Section B: #17B Eye Wear.	10 per visit.  PBP Section B: #18A Hearing Exams.	100 percent.  PBP Section B: #18B Hearing Aids.	0 percent. PBP Section B: #19 POS.	0 percent. PBP Section B: #14A Health Education/Wellness Programs.	0 percent	10 per visit.  PBP Section B: #9A Outpatient Hospital Services.	10 per visit.  PBP Section B: #9C Outpatient Substance Abuse Services.	10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7B Chiropractic Services.	10 per visit.  PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	0 percent.  PBP Section B: #14B Immunizations.	100	0.02	0.04	0	100	0.1	0.1	50	50	0	0.02	0	0	0	0	0	10	10	0	0	0.1	0	0	10	10	0.1	10	1	0	0	0	10	10	10	10	10	10	10	10	0	0	1.41	0.04	1.19	-	2.29	0.33	0.53	1.23	1.15	-	0.17	-	-	-	-	-	0.1	0.66	-	-	1.54	-	-	-	0.52	0.01	0.04	-	-	-	-	0.02	0	0.06	2.59	0.86	0.43	1.11	0.47	-	-	16.74	0	3.03	1.41	0.04	1.19	-	2.29	0.33	0.53	1.23	1.15	-	0.17	-	-	-	-	-	0.1	0.66	-	-	1.54	-	-	-	0.52	0.01	0.04	-	-	-	-	0.02	0	0.06	2.59	0.86	0.43	1.11	0.47	-	-	16.74	6000	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 100 per admit.  PBP Section B: #1A Inpatient Hospital-Acute.	Out-of-Network: 20 percent for first 190 days 100 percent after 190 days.  Out-of-Area Travel Benefit: 100 per admit 100 after 190 days.  PBP Section B: #1B Inpatient Hospital - Psychiatric.	Out-of-Network: 20 percent for first 100 days 100 percent after 100 days.  Out-of-Area Travel Benefit: 0 per day for first 20 days 50 per day for days 21-100 100 after 100 days.  PBP Section B: #2 Skilled Nursing Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #6 Home Health Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 100 per trip.  PBP Section B: #10A Ambulance.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #11A Durable Medical Equipment.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	Out-of-Network: 50 per visit.  Out-of-Area Travel Benefit: 50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 50 per visit.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #9A Outpatient Hospital.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 50 for CT MRI MRA and PET; 10 for Therapeutic; 0 for all other radiological services.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #12 Renal Dialysis.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per visit.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent. PBP Section B: #7A Primary Care Physician Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per visit.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #10B Transportation.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #17A Eye Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #17B Eye Wear.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #18A Hearing Exams.	Out-of-Network: 100 percent.  Out-of-Area Travel Benefit: 100 percent.  PBP Section B: #18B Hearing Aids.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #19 POS.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent. PBP Section B: #14A Health Education/Wellness Programs.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #9C Outpatient Substance Abuse Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #7B Chiropractic Services.	Out-of-Network: 10 per visit.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	Out-of-Network: 0 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #14B Immunizations.	2.82	0.03	0.61	0.4	0.19	0.08	0.13	0.18	0.46	0.05	0.17	0	0.07	0.11	0.06	1	0.02	0.09	0.37	0.37	0.37	0	0	0	0.12	0	0	0	0	0	0	0	0	0.02	0.5	0.17	0.15	0.18	0.06	0	0	8.79	0	1.65	4.22	0.07	1.81	0.4	2.47	0.41	0.66	1.41	1.61	0.05	0.34	-	0.07	0.11	0.06	1	0.12	0.75	0.37	0.37	1.91	-	-	-	0.64	0.02	0.04	-	-	-	-	0.02	0	0.08	3.09	1.03	0.58	1.29	0.53	-	-	25.53
R5566_008_0	2007	2	h.5	h.5	i.1	h.1	i.2	i.2	i.2	i.2	r.	i.1	OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Other Non-Covered	Professional	1000	Other - Mental Health	Other - Substance Abuse	PCP - Periodic Exams	PCP - Office Visits	Specialist excl. MH - Office Visits	Specialist excl. MH - Consults	Specialist excl. MH - Cardiovascular	Specialist excl. MH - Chiropractic	Urgent Care	PCP - Immunizations	A	Coin	Coin	Coin	T	Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	V	V	Coin	V	Coin	Coin	Coin	Coin	P	P	V	V	V	V	V	V	V	Coin																																										-	6000	195.37	1.79	31.95	24.29	317.66	3.86	6.22	340.58	319.36	3.32	9.88	0	4.07	15.38	3.37	60.42	132.03	913.4	18.41	2839.82	17.97	0	0	0	724.67	0.16	51.36	0	0	0	0	22.6	0.05	86.98	3594.2	1198.07	598.78	1544.53	655.78	0	2.32	100 per admit.  PBP Section B: #1A Inpatient Hospital-Acute.	100 per admit 100 after 190 days.  PBP Section B: #1B Inpatient Psychiatric Hosp.	0 per day for first 20 days 50 per day for days 21-100 100 after 100 days.  PBP Section B: #2 Skilled Nursing Services.	0 percent.  PBP Section B: #6 Home Health Services.	100 per trip.  PBP Section B: #10A Ambulance.	10 percent.  PBP Section B: #11A Durable Medical Equipment.	10 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	50 per visit.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital.	50 for CT MRI MRA and PET; 10 for Therapeutic; 0 for all other radiological services.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #9A Outpatient Hospital Services.	0 per procedure.  PBP Section B: #12 Renal Dialysis.	0 per visit.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	0 percent.  PBP Section B: #7A Primary Care Physician Services.	0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	10 per visit.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	0 percent.  PBP Section B: #8A Outpatient C/D/T #8B Outpatient X-Rays and #9A Outpatient Hospital.	0 per visit.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	10 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	0 percent	0 percent.  PBP Section B: #10B Transportation.	10 per visit.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	10 per visit.  PBP Section B: #17A Eye Exams.	10 percent.  PBP Section B: #17B Eye Wear.	10 per visit.  PBP Section B: #18A Hearing Exams.	100 percent.  PBP Section B: #18B Hearing Aids.	0 percent. PBP Section B: #19 POS.	0 percent. PBP Section B: #14A Health Education/Wellness Programs.	0 percent	10 per visit.  PBP Section B: #9A Outpatient Hospital Services.	10 per visit.  PBP Section B: #9C Outpatient Substance Abuse Services.	10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	10 per visit.  PBP Section B: #7B Chiropractic Services.	10 per visit.  PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	0 percent.  PBP Section B: #14B Immunizations.	100	0.02	0.04	0	100	0.1	0.1	50	50	0	0.02	0	0	0	0	0	10	10	0	0	0.1	0	0	10	10	0.1	10	1	0	0	0	10	10	10	10	10	10	10	10	0	0	1.63	0.04	1.25	-	2.65	0.39	0.62	1.42	1.33	-	0.2	-	-	-	-	-	0.11	0.76	-	-	1.8	-	-	-	0.6	0.02	0.04	-	-	-	-	0.02	0	0.07	3	1	0.5	1.29	0.55	-	-	19.28	0	4.32	1.63	0.04	1.25	-	2.65	0.39	0.62	1.42	1.33	-	0.2	-	-	-	-	-	0.11	0.76	-	-	1.8	-	-	-	0.6	0.02	0.04	-	-	-	-	0.02	0	0.07	3	1	0.5	1.29	0.55	-	-	19.28	6000	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 100 per admit.  PBP Section B: #1A Inpatient Hospital-Acute.	Out-of-Network: 20 percent for first 190 days 100 percent after 190 days.  Out-of-Area Travel Benefit: 100 per admit 100 after 190 days.  PBP Section B: #1B Inpatient Hospital - Psychiatric.	Out-of-Network: 20 percent for first 100 days 100 percent after 100 days.  Out-of-Area Travel Benefit: 0 per day for first 20 days 50 per day for days 21-100 100 after 100 days.  PBP Section B: #2 Skilled Nursing Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #6 Home Health Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 100 per trip.  PBP Section B: #10A Ambulance.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #11A Durable Medical Equipment.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #11B Prosthetics/Medical Supplis and #11C Diabetes Monitoring Supplies.	Out-of-Network: 50 per visit.  Out-of-Area Travel Benefit: 50 per visit.  PBP Section B: #4A Emergency Care/Post Stabilization Care	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 50 per visit.  PBP Section B: #9A Outpatient Hospital Services and #9B Ambulatory Surgical Center Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #9A Outpatient Hospital.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 50 for CT MRI MRA and PET; 10 for Therapeutic; 0 for all other radiological services.  PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services #8B Outpatient X-Ray and #9A Outpatient Hospital Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per procedure.  PBP Section B: #12 Renal Dialysis.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per visit.  PBP Section B: #3 Rehab Services (CORF) #5 Partial Hospitalization #9A Outpatient Hospital Services and #9D Cardiac Rehabilitation Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent. PBP Section B: #7A Primary Care Physician Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7E Mental Health Specialty Services - Non-Physician and #7H Psychiatric Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7C Independent Occupational Therapy Services and #7I Physical/Speech Therapy.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 per visit.  PBP Section B: #7G Other Health Care Professional Services #13A Blood #13B Acupuncture #14D Pap Smears and Pelvic Exam Screening #14E Prostate Cancer Screening #14F Colorectal Screening #14G Bone Mass Measurement. #14H Mammography Screening and #14I Diabetes Monitoring.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #10B Transportation.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #16A Dental: Preventative Services and #16B Dental: Comprehensive Services.	Out-of-Network: 20 percent. Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #17A Eye Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 percent.  PBP Section B: #17B Eye Wear.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #18A Hearing Exams.	Out-of-Network: 100 percent.  Out-of-Area Travel Benefit: 100 percent.  PBP Section B: #18B Hearing Aids.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #19 POS.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent. PBP Section B: #14A Health Education/Wellness Programs.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 0 percent.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #9A Outpatient Hospital Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #9C Outpatient Substance Abuse Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7A Primary Care Physician Services and #14C Routine Physical Exams.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology) #7F Podiatry Services.	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology).	Out-of-Network: 20 percent.  Out-of-Area Travel Benefit: 10 per visit. PBP Section B: #7B Chiropractic Services.	Out-of-Network: 10 per visit.  Out-of-Area Travel Benefit: 10 per visit.  PBP Section B: #4B Urgently Needed Care/Urgent Care Centers.	Out-of-Network: 0 percent.  Out-of-Area Travel Benefit: 0 percent.  PBP Section B: #14B Immunizations.	2.44	0.03	0.54	0.34	0.2	0.07	0.12	0.17	0.41	0.05	0.15	0	0.06	0.11	0.05	0.86	0.02	0.09	0.32	0.32	0.34	0	0	0	0.11	0	0	0	0	0	0	0	0	0.02	0.48	0.16	0.14	0.17	0.06	0	0	7.83	0	1.54	4.07	0.07	1.79	0.34	2.84	0.46	0.74	1.59	1.74	0.05	0.35	-	0.06	0.11	0.05	0.86	0.13	0.85	0.32	0.32	2.14	-	-	-	0.71	0.02	0.05	-	-	-	-	0.02	0	0.09	3.47	1.16	0.63	1.46	0.6	-	-	27.11
R5566_801_0	2007	3	i.1.										Professional										3100	PCP - Immunizations										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																			-	7500	125.21	1.34	23.81	18.27	3.38	2.9	4.67	246.75	18.35	2.5	7.42	0	3.06	11.72	19.79	64.42	0.81	2.74	16.96	17	13.5	0	0	0	0	0	0	0	0	0	0	1.74										ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture.	ffs Medicare cost sharing. PBP Section B: #14B Immunizations.										0.08	0.08	0.16	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	1	1	1	1	1	1	0.24	1	1	0.24										9.9	0.11	3.76	-	0.8	0.68	1.1	1.03	4.33	0.59	1.75	-	0.72	2.77	4.67	15.2	0.19	0.65	4	4.01	3.19	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	59.86	124	26.08	9.9	0.11	3.76	-	0.8	0.68	1.1	1.03	4.33	0.59	1.75	-	0.72	2.77	4.67	15.2	0.19	0.65	4	4.01	3.19	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	59.86	7500	50 percent. PBP Section B: #1A Inpatient Hospital-Acute.	50 percent. PBP Section B: #1B Inpatient Hospital-Psychiatric.	50 percent. PBP Section B: #2 Skilled Nursing Services.	50 percent. PBP Section B: #6 Home Health Services.	50 percent. PBP Section B: #10A Ambulance.	50 percent. PBP Section B: #11A Durable Medical Equipment.	50 percent. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	50 percent. PBP Section B: #9B Ambulatory Surgical Center Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	50 percent. PBP Section B: #9A Outpatient Hospital Services.	50 percent. PBP Section B: #12 Renal Dialysis.	50 percent. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	50 percent. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	50 percent.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	50 percent. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	50 percent. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	50 percent. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	0 percent for Pap Smears and Pelvic Exams Screening Prostate Cancer Screening and Medicare Covered Eyewear. 50 percent for everything else.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	50 percent. PBP Section B: #13A Blood.	100 percent. PBP Section B: #10B Transportation.	100 percent. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	50 percent. PBP Section B: #17A Eye Exams.	100 percent. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #18A Hearing Exams.	100 percent. PBP Section B: #18B Hearing Aids.	50 percent. PBP Section B: #19 POS.	100 percent. PBP Section B: #14A Health Education/Wellness Programs.	100 percent. PBP Section B: #13B Acupuncture.	0 percent. PBP Section B: #14B Immunizations.										4.82	0.05	0.92	0.7	0.13	0.11	0.18	0.08	0.71	0.1	0.29	0	0.12	0.45	0.76	2.48	0.03	0.11	0.65	0.65	0.52	0	0	0	0	0	0	0	0	0	0	0										13.84	0	8.65	14.71	0.16	4.68	0.7	0.93	0.8	1.28	1.11	5.04	0.69	2.04	-	0.84	3.22	5.43	17.68	0.22	0.75	4.66	4.66	3.71	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	73.7
R5566_802_0	2007	1	i.1.										Professional										3100	PCP - Immunizations										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																			-	7500	125.21	1.34	23.81	18.27	3.38	2.9	4.67	246.75	18.35	2.5	7.42	0	3.06	11.72	19.79	64.42	0.81	2.74	16.96	17	13.5	0	0	0	0	0	0	0	0	0	0	1.74										ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture.	ffs Medicare cost sharing. PBP Section B: #14B Immunizations.										0.08	0.08	0.16	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	1	1	1	1	1	1	0.24	1	1	0.24										9.9	0.11	3.76	-	0.8	0.68	1.1	1.03	4.33	0.59	1.75	-	0.72	2.77	4.67	15.2	0.19	0.65	4	4.01	3.19	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	59.86	124	26.08	9.9	0.11	3.76	-	0.8	0.68	1.1	1.03	4.33	0.59	1.75	-	0.72	2.77	4.67	15.2	0.19	0.65	4	4.01	3.19	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	59.86	7500	50 percent. PBP Section B: #1A Inpatient Hospital-Acute.	50 percent. PBP Section B: #1B Inpatient Hospital-Psychiatric.	50 percent. PBP Section B: #2 Skilled Nursing Services.	50 percent. PBP Section B: #6 Home Health Services.	50 percent. PBP Section B: #10A Ambulance.	50 percent. PBP Section B: #11A Durable Medical Equipment.	50 percent. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	50 percent. PBP Section B: #9B Ambulatory Surgical Center Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	50 percent. PBP Section B: #9A Outpatient Hospital Services.	50 percent. PBP Section B: #12 Renal Dialysis.	50 percent. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	50 percent. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	50 percent.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	50 percent. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	50 percent. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	50 percent. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	0 percent for Pap Smears and Pelvic Exams Screening Prostate Cancer Screening and Medicare Covered Eyewear. 50 percent for everything else.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	50 percent. PBP Section B: #13A Blood.	100 percent. PBP Section B: #10B Transportation.	100 percent. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	50 percent. PBP Section B: #17A Eye Exams.	100 percent. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #18A Hearing Exams.	100 percent. PBP Section B: #18B Hearing Aids.	50 percent. PBP Section B: #19 POS.	100 percent. PBP Section B: #14A Health Education/Wellness Programs.	100 percent. PBP Section B: #13B Acupuncture.	0 percent. PBP Section B: #14B Immunizations.										4.82	0.05	0.92	0.7	0.13	0.11	0.18	0.08	0.71	0.1	0.29	0	0.12	0.45	0.76	2.48	0.03	0.11	0.65	0.65	0.52	0	0	0	0	0	0	0	0	0	0	0										13.84	0	8.65	14.71	0.16	4.68	0.7	0.93	0.8	1.28	1.11	5.04	0.69	2.04	-	0.84	3.22	5.43	17.68	0.22	0.75	4.66	4.66	3.71	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	73.7
R5566_803_0	2007	2	i.1.										Professional										3100	PCP - Immunizations										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																			-	7500	121.63	1.3	23.32	17.73	3.28	2.82	4.54	243.68	17.82	2.42	7.21	0	2.97	11.39	19.23	62.6	0.79	2.66	16.48	16.52	13.11	0	0	0	0	0	0	0	0	0	0	1.7										ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture.	ffs Medicare cost sharing. PBP Section B: #14B Immunizations.										0.08	0.08	0.16	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	1	1	1	1	1	1	0.24	1	1	0.24										9.61	0.1	3.69	-	0.77	0.66	1.07	1.02	4.21	0.57	1.7	-	0.7	2.69	4.54	14.77	0.19	0.63	3.89	3.9	3.1	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	58.21	124	24.91	9.61	0.1	3.69	-	0.77	0.66	1.07	1.02	4.21	0.57	1.7	-	0.7	2.69	4.54	14.77	0.19	0.63	3.89	3.9	3.1	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	58.21	7500	50 percent. PBP Section B: #1A Inpatient Hospital-Acute.	50 percent. PBP Section B: #1B Inpatient Hospital-Psychiatric.	50 percent. PBP Section B: #2 Skilled Nursing Services.	50 percent. PBP Section B: #6 Home Health Services.	50 percent. PBP Section B: #10A Ambulance.	50 percent. PBP Section B: #11A Durable Medical Equipment.	50 percent. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	50 percent. PBP Section B: #9B Ambulatory Surgical Center Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	50 percent. PBP Section B: #9A Outpatient Hospital Services.	50 percent. PBP Section B: #12 Renal Dialysis.	50 percent. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	50 percent. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	50 percent.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	50 percent. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	50 percent. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	50 percent. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	0 percent for Pap Smears and Pelvic Exams Screening Prostate Cancer Screening and Medicare Covered Eyewear. 50 percent for everything else.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	50 percent. PBP Section B: #13A Blood.	100 percent. PBP Section B: #10B Transportation.	100 percent. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	50 percent. PBP Section B: #17A Eye Exams.	100 percent. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #18A Hearing Exams.	100 percent. PBP Section B: #18B Hearing Aids.	50 percent. PBP Section B: #19 POS.	100 percent. PBP Section B: #14A Health Education/Wellness Programs.	100 percent. PBP Section B: #13B Acupuncture.	0 percent. PBP Section B: #14B Immunizations.										4.68	0.05	0.9	0.68	0.13	0.11	0.17	0.08	0.69	0.09	0.28	0	0.11	0.44	0.74	2.41	0.03	0.1	0.63	0.63	0.51	0	0	0	0	0	0	0	0	0	0	0										13.47		8.27	14.3	0.15	4.58	0.68	0.9	0.77	1.25	1.1	4.89	0.67	1.98	-	0.82	3.13	5.28	17.18	0.22	0.73	4.52	4.53	3.6	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	71.68
R5566_804_0	2007	1	i.1.										Professional										3100	PCP - Immunizations										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																			-	7500	121.63	1.3	23.32	17.73	3.28	2.82	4.54	243.68	17.82	2.42	7.21	0	2.97	11.39	19.23	62.6	0.79	2.66	16.48	16.52	13.11	0	0	0	0	0	0	0	0	0	0	1.7										ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture.	ffs Medicare cost sharing. PBP Section B: #14B Immunizations.										0.08	0.08	0.16	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	1	1	1	1	1	1	0.24	1	1	0.24										9.61	0.1	3.69	-	0.77	0.66	1.07	1.02	4.21	0.57	1.7	-	0.7	2.69	4.54	14.77	0.19	0.63	3.89	3.9	3.1	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	58.21	124	24.91	9.61	0.1	3.69	-	0.77	0.66	1.07	1.02	4.21	0.57	1.7	-	0.7	2.69	4.54	14.77	0.19	0.63	3.89	3.9	3.1	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	58.21	7500	50 percent. PBP Section B: #1A Inpatient Hospital-Acute.	50 percent. PBP Section B: #1B Inpatient Hospital-Psychiatric.	50 percent. PBP Section B: #2 Skilled Nursing Services.	50 percent. PBP Section B: #6 Home Health Services.	50 percent. PBP Section B: #10A Ambulance.	50 percent. PBP Section B: #11A Durable Medical Equipment.	50 percent. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	50 percent. PBP Section B: #9B Ambulatory Surgical Center Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	50 percent. PBP Section B: #9A Outpatient Hospital Services.	50 percent. PBP Section B: #12 Renal Dialysis.	50 percent. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	50 percent. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	50 percent.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	50 percent. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	50 percent. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	50 percent. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	0 percent for Pap Smears and Pelvic Exams Screening Prostate Cancer Screening and Medicare Covered Eyewear. 50 percent for everything else.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	50 percent. PBP Section B: #13A Blood.	100 percent. PBP Section B: #10B Transportation.	100 percent. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	50 percent. PBP Section B: #17A Eye Exams.	100 percent. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #18A Hearing Exams.	100 percent. PBP Section B: #18B Hearing Aids.	50 percent. PBP Section B: #19 POS.	100 percent. PBP Section B: #14A Health Education/Wellness Programs.	100 percent. PBP Section B: #13B Acupuncture.	0 percent. PBP Section B: #14B Immunizations.										4.68	0.05	0.9	0.68	0.13	0.11	0.17	0.08	0.69	0.09	0.28	0	0.11	0.44	0.74	2.41	0.03	0.1	0.63	0.63	0.51	0	0	0	0	0	0	0	0	0	0	0										13.47		8.27	14.3	0.15	4.58	0.68	0.9	0.77	1.25	1.1	4.89	0.67	1.98	-	0.82	3.13	5.28	17.18	0.22	0.73	4.52	4.53	3.6	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	71.68
R5566_805_0	2007	2	i.1.										Professional										3100	PCP - Immunizations										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																			-	7500	121.63	1.3	23.32	17.73	3.28	2.82	4.54	243.68	17.82	2.42	7.21	0	2.97	11.39	19.23	62.6	0.79	2.66	16.48	16.52	13.11	0	0	0	0	0	0	0	0	0	0	1.7										ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture.	ffs Medicare cost sharing. PBP Section B: #14B Immunizations.										0.08	0.08	0.16	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	1	1	1	1	1	1	0.24	1	1	0.24										9.61	0.1	3.69	-	0.77	0.66	1.07	1.02	4.21	0.57	1.7	-	0.7	2.69	4.54	14.77	0.19	0.63	3.89	3.9	3.1	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	58.21	124	24.91	9.61	0.1	3.69	-	0.77	0.66	1.07	1.02	4.21	0.57	1.7	-	0.7	2.69	4.54	14.77	0.19	0.63	3.89	3.9	3.1	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	58.21	7500	50 percent. PBP Section B: #1A Inpatient Hospital-Acute.	50 percent. PBP Section B: #1B Inpatient Hospital-Psychiatric.	50 percent. PBP Section B: #2 Skilled Nursing Services.	50 percent. PBP Section B: #6 Home Health Services.	50 percent. PBP Section B: #10A Ambulance.	50 percent. PBP Section B: #11A Durable Medical Equipment.	50 percent. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	50 percent. PBP Section B: #9B Ambulatory Surgical Center Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	50 percent. PBP Section B: #9A Outpatient Hospital Services.	50 percent. PBP Section B: #12 Renal Dialysis.	50 percent. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	50 percent. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	50 percent.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	50 percent. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	50 percent. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	50 percent. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	0 percent for Pap Smears and Pelvic Exams Screening Prostate Cancer Screening and Medicare Covered Eyewear. 50 percent for everything else.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	50 percent. PBP Section B: #13A Blood.	100 percent. PBP Section B: #10B Transportation.	100 percent. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	50 percent. PBP Section B: #17A Eye Exams.	100 percent. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #18A Hearing Exams.	100 percent. PBP Section B: #18B Hearing Aids.	50 percent. PBP Section B: #19 POS.	100 percent. PBP Section B: #14A Health Education/Wellness Programs.	100 percent. PBP Section B: #13B Acupuncture.	0 percent. PBP Section B: #14B Immunizations.										4.68	0.05	0.9	0.68	0.13	0.11	0.17	0.08	0.69	0.09	0.28	0	0.11	0.44	0.74	2.41	0.03	0.1	0.63	0.63	0.51	0	0	0	0	0	0	0	0	0	0	0										13.47	0	8.27	14.3	0.15	4.58	0.68	0.9	0.77	1.25	1.1	4.89	0.67	1.98	-	0.82	3.13	5.28	17.18	0.22	0.73	4.52	4.53	3.6	-	-	-	-	-	-	-	-	-	-	0.4	-	-	-	-	-	-	-	-	-	71.68
R5566_806_0	2007	2	i.1.										Professional										3100	PCP - Immunizations										Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																			-	7500	125.21	1.34	23.81	18.27	3.38	2.9	4.67	246.75	18.35	2.5	7.42	0	3.06	11.72	19.79	64.42	0.81	2.74	16.96	17	13.5	0	0	0	0	0	0	0	0	0	0	1.74										ffs Medicare cost sharing. PBP Section B: #1A Inpatient Hospital-Acute.	ffs Medicare cost sharing. PBP Section B: #1B Inpatient Hospital-Psychiatric.	ffs Medicare cost sharing. PBP Section B: #2 Skilled Nursing Services.	ffs Medicare cost sharing. PBP Section B: #6 Home Health Services.	ffs Medicare cost sharing. PBP Section B: #10A Ambulance.	ffs Medicare cost sharing. PBP Section B: #11A Durable Medical Equipment.	ffs Medicare cost sharing. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	ffs Medicare cost sharing. PBP Section B: #9B Ambulatory Surgical Center Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	ffs Medicare cost sharing. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	ffs Medicare cost sharing. PBP Section B: #9A Outpatient Hospital Services.	ffs Medicare cost sharing. PBP Section B: #12 Renal Dialysis.	ffs Medicare cost sharing. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	ffs Medicare cost sharing. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	ffs Medicare cost sharing.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	ffs Medicare cost sharing. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	ffs Medicare cost sharing. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	ffs Medicare cost sharing. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	ffs Medicare cost sharing.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	ffs Medicare cost sharing. PBP Section B: #13A Blood.	ffs Medicare cost sharing. PBP Section B: #10B Transportation.	ffs Medicare cost sharing. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	ffs Medicare cost sharing. PBP Section B: #17A Eye Exams.	ffs Medicare cost sharing. PBP Section B: #17B Eye Wear.	ffs Medicare cost sharing. PBP Section B: #18A Hearing Exams.	ffs Medicare cost sharing. PBP Section B: #18B Hearing Aids.	ffs Medicare cost sharing. PBP Section B: #19 POS.	ffs Medicare cost sharing. PBP Section B: #14A Health Education/Wellness Programs.	ffs Medicare cost sharing. PBP Section B: #13B Acupuncture.	ffs Medicare cost sharing. PBP Section B: #14B Immunizations.										0.08	0.08	0.16	0	0.24	0.24	0.24	50	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	1	1	1	1	1	1	0.24	1	1	0.24										9.9	0.11	3.76	-	0.8	0.68	1.1	1.03	4.33	0.59	1.75	-	0.72	2.77	4.67	15.2	0.19	0.65	4	4.01	3.19	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	59.86	124	26.08	9.9	0.11	3.76	-	0.8	0.68	1.1	1.03	4.33	0.59	1.75	-	0.72	2.77	4.67	15.2	0.19	0.65	4	4.01	3.19	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	59.86	7500	50 percent. PBP Section B: #1A Inpatient Hospital-Acute.	50 percent. PBP Section B: #1B Inpatient Hospital-Psychiatric.	50 percent. PBP Section B: #2 Skilled Nursing Services.	50 percent. PBP Section B: #6 Home Health Services.	50 percent. PBP Section B: #10A Ambulance.	50 percent. PBP Section B: #11A Durable Medical Equipment.	50 percent. PBP Section B: #11B Prosthetics/Medical Supplies. PBP Section B: #11C Diabetes Monitoring Supplies.	50 per visit. PBP Section B: #4A Emergency Care/Post Stabilization Care.  PBP Section B: #4B Urgently Need Care/Urgent Care Centers.	50 percent. PBP Section B: #9B Ambulatory Surgical Center Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services.	50 percent. PBP Section B: #8A OP Clinical/Diagnostic/Therapy Radiological Lab Services. PBP Section B: #8B Outpatient X-Ray.	50 percent. PBP Section B: #9A Outpatient Hospital Services.	50 percent. PBP Section B: #12 Renal Dialysis.	50 percent. PBP Section B: #3 Rehab. Services (CORF).  PBP Section B: #5 Partial Hospitalization. PBP Section B: #9A Outpatient Hospital Services. PBP Section B: #9C Outpatient Substance Abuse Services. PBP Section B: #9D Cardiac Rehabilitation Services.	50 percent. PBP Section B: #7A Primary Care Physician Services.  PBP Section B: #7G Other Health Care Professional Services.  PBP Section B: #14C Routine Physical Exams.	50 percent.  PBP Section B: #7B Chiropractic Services. PBP Section B: #7D Physician Specialist Services Except Psych (excl Radiology). PBP Section B: #7F Podiatry Services.  PBP Section B: #7G Other Health Care Professional Services.	50 percent. PBP Section B: #7E Mental Health Specialty Services - Non-Physician. PBP Section B: #7H Psychiatric Services.	50 percent. PBP Section B: #7C Independent Occupational Therapy Services. PBP Section B: #7I Physical/Speech Therapy.	50 percent. PBP Section B: #7D Physician Specialist Services Except Psych (Radiology).	0 percent for Pap Smears and Pelvic Exams Screening Prostate Cancer Screening and Medicare Covered Eyewear. 50 percent for everything else.  PBP Section B: #7G Other Health Care Professional Services. PBP Section B: #14D Pap Smears and Pelvic Exams Screening. PBP Section B: #14E Prostate Cancer Screening. PBP Section B: #14F Colorectal Screening. PBP Section B: #14G Bone Mass Measurement.  PBP Section B: #14H Mammography Screening. PBP Section B: #14I Diabetes Monitoring. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #15 Outpatient Drugs and Biologicals/Prescription Drug.	50 percent. PBP Section B: #13A Blood.	100 percent. PBP Section B: #10B Transportation.	100 percent. PBP Section B: #16A Dental: Preventive Services. PBP Section B: #16B Dental: Comprehensive Services.	50 percent. PBP Section B: #17A Eye Exams.	100 percent. PBP Section B: #17B Eye Wear.	50 percent. PBP Section B: #18A Hearing Exams.	100 percent. PBP Section B: #18B Hearing Aids.	50 percent. PBP Section B: #19 POS.	100 percent. PBP Section B: #14A Health Education/Wellness Programs.	100 percent. PBP Section B: #13B Acupuncture.	0 percent. PBP Section B: #14B Immunizations.										4.82	0.05	0.92	0.7	0.13	0.11	0.18	0.08	0.71	0.1	0.29	0	0.12	0.45	0.76	2.48	0.03	0.11	0.65	0.65	0.52	0	0	0	0	0	0	0	0	0	0	0										13.84	0	8.65	14.71	0.16	4.68	0.7	0.93	0.8	1.28	1.11	5.04	0.69	2.04	-	0.84	3.22	5.43	17.68	0.22	0.75	4.66	4.66	3.71	-	-	-	-	-	-	-	-	-	-	0.41	-	-	-	-	-	-	-	-	-	73.7
R5595_001_0	2007	3																																D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V																																																								-	7500	1562.51		885.02	744.98	181.05	20.3		400.79	203.75	928.56	1366.35		71.61	384.86	2583.21	5300.13		1319.41			216.55				680.27		45.61															900 per stay		0/day 1-7 75/day 8-14 100/day 15-100	20	100	20		50 ER 35 urgent care	200	35	35 routine 125 complex	35	30	35	20	35 Specialist 30 Renal Dialysis	35	35	35	35	45				0		0															146.81		67.84	20	100	0.2		48.05	200	35	65.78	35	30	35	20	34.39	35	35	35	35	45				0		0															19.12	-	5	1.24	1.51	4.06	-	1.6	3.4	2.71	7.49	-	0.18	1.12	4.31	15.19	-	3.85	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.58			19.12	-	5	1.24	1.51	4.06	-	1.6	3.4	2.71	7.49	-	0.18	1.12	4.31	15.19	-	3.85	-	-	0.81	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	71.58		30		30	30	100	30		50 ER 35 urgent care	30	30	30 routine 30 complex	30	30	30	30	30	30	30	30	30	45				30		30															10.52		0.92	0.16	0.17	0.66		0.18	0.96	0.5	2.07	0	0.32	0.41	0.82	6.11	0	0.35	0	0	0.11				0.12		0.01															24.38	500	9.23	29.64	-	5.92	1.41	1.68	4.72	-	1.78	4.35	3.2	9.56	-	0.5	1.53	5.13	21.3	-	4.2	-	-	0.92	-	-	-	0.12	-	0.01	-	-	-	-	-	-	-	-	-	-	-	-	-	-	95.96
R5595_003_0	2007	4																					5000											D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1851.78		1016.11	803.73	87.02	32.84		501.27	250.02	1015.66	1649.24	0	34.95	472.26	2745.93	4470.42	0	1130.76	0	0	284.32				653.23		45.73															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.19 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.19	35	35	35	35	45				0		0															21.4	-	5.74	1.34	0.73	6.57	-	2.01	4.17	2.96	9.04	-	0.09	1.38	4.58	12.74	-	3.3	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.09	0	50.82	21.4	-	5.74	1.34	0.73	6.57	-	2.01	4.17	2.96	9.04	-	0.09	1.38	4.58	12.74	-	3.3	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.09	10000	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON		30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	100 per trip	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON		50 ER; 35 UC	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	45 per script				30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON		30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON															15.23		1.04	0.16	0.08	1.02		0.23	1.06	0.51	1.67	0	0.06	0.51	0.81	5.06	0	0.34	0	0	0.13				0.08		0															28	500	6.93	36.63	-	6.78	1.5	0.8	7.59	-	2.23	5.23	3.47	10.72	-	0.15	1.89	5.39	17.8	-	3.64	-	-	1.2	-	-	-	0.08	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.09
R5595_004_0	2007	4																					3500											D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1865.22		1023.48	809.56	87.65	33.08		504.9	251.83	1023.03	1661.21	0	35.2	475.69	2765.85	4502.86	0	1138.96	0	0	286.38				657.97		46.07															250 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	25 per visit	25 X-ray; 125 CATPETMRI	25 per visit	25 per visit	25 per visit	10 per visit	25 per visit	25 per visit	25 per visit	25 per visit	25 per visit	45 per script				0 per visit		0 per visit															40.78		67.84	20	100	0.2		48	200	25	59.2	25	25	25	10	25	25	25	25	25	45				0		0															6.34	-	5.79	1.35	0.73	6.62	-	2.02	4.2	2.13	8.2	-	0.07	0.99	2.3	9.38	-	2.37	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.56	0	28.94	6.34	-	5.79	1.35	0.73	6.62	-	2.02	4.2	2.13	8.2	-	0.07	0.99	2.3	9.38	-	2.37	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	53.56	7500	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON		20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	100 per trip	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON		50 ER; 35 UC	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON	45 per script				20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON		20 150 ded 3500 OOP max in network 7500 OOP max combined IN and OON															10.04		0.68	0.11	0.07	0.67		0.21	0.7	0.34	1.1	0	0.04	0.34	0.54	3.34	0	0.22	0	0	0.11				0.05		0															18.58	150	3.95	16.38	-	6.47	1.45	0.8	7.29	-	2.23	4.9	2.47	9.3	-	0.11	1.33	2.84	12.72	-	2.6	-	-	1.19	-	-	-	0.05	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	72.14
R5595_005_0	2007	5																					5000											D		D	V	T	Coin		V	P	V	V	V	V	V	V	V	V	V	V	V	S				V		V															0		0	0	0	0		0	0	0	0	0	0	0	0	0	0	0	0	0	0				0		0															-		1850.97		1015.66	803.38	86.98	32.83		501.05	249.91	1015.21	1648.52	0	34.93	472.06	2744.73	4468.47	0	1130.27	0	0	284.2				652.94		45.71															850 per Stay		0 for days 1-7 75 for days 8-14 100 for days 15-100	20 per visit	100 per trip	20 coinsurance		50 ER; 35 UC	200 per procedure	35 per visit	34.19 X-ray; 125 CATPETMRI	35 per visit	30 per visit	35 per visit	20 per visit	35 per visit; 30 per dialysis visit	35 per visit	35 per visit	35 per visit	35 per visit	45 per script				0 per visit		0 per visit															138.66		67.84	20	100	0.2		48	200	35	65.78	35	30	35	20	34.19	35	35	35	35	45				0		0															21.39	-	5.74	1.34	0.72	6.57	-	2	4.17	2.96	9.04	-	0.09	1.38	4.57	12.73	-	3.3	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.06	0	50.82	21.39	-	5.74	1.34	0.72	6.57	-	2	4.17	2.96	9.04	-	0.09	1.38	4.57	12.73	-	3.3	-	-	1.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	77.06	10000	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON		30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	100 per trip	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON		50 ER; 35 UC	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON	45 per script				30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON		30 500 ded 5000 OOP max in network 10000 OOP max combined IN and OON															15.22		1.04	0.16	0.08	1.02		0.23	1.06	0.51	1.67	0	0.06	0.51	0.81	5.06	0	0.34	0	0	0.13				0.08		0															27.99	500	6.93	36.61	-	6.78	1.5	0.8	7.59	-	2.23	5.23	3.47	10.71	-	0.15	1.89	5.39	17.79	-	3.64	-	-	1.2	-	-	-	0.08	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	105.05
R5595_801_0	2007	2																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1533.15		1356.87	859	195.45	19.83		370.81	256.01	12.86	60.52	0	0	483.58	2402.32	8800.04	0	1230.93	0	0	7.91																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.36	-	11.31	2.51	2.44	5.95	-	1.55	3.2	2.57	12.1	-	-	1.41	7.01	25.67	-	3.59	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24			18.36	-	11.31	2.51	2.44	5.95	-	1.55	3.2	2.57	12.1	-	-	1.41	7.01	25.67	-	3.59	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24		500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	150 per trip	500 deductible; 30 coins; no max OOP		50 per visit	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP				500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP															6.32		0.88	0.12	0.16	0.4		0.11	0.69	0.26	1.21	0	0	0.3	0.62	3.67	0	0.24	0	0	0.17				0.08		0															15.22	500		24.67	-	12.18	2.63	2.6	6.35	-	1.65	3.89	2.83	13.32	-	-	1.71	7.62	29.34	-	3.83	-	-	1.75	-	-	-	0.08	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.45
R5595_802_0	2007	2																																D		D	V	T	Coin		V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin				V		V																																																								-		1533.15		1356.87	859	195.45	19.83		370.81	256.01	12.86	60.52	0	0	483.58	2402.32	8800.04	0	1230.93	0	0	7.91																					200/day days 1-7		100/day	35 per visit	150 per trip	30 coinsurance		50 per visit	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance																					143.69		100	35	150	0.3		50	150	0.2	0.2	35	35	35	35	35	35	35	35	35	0.2																					18.36	-	11.31	2.51	2.44	5.95	-	1.55	3.2	2.57	12.1	-	-	1.41	7.01	25.67	-	3.59	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24			18.36	-	11.31	2.51	2.44	5.95	-	1.55	3.2	2.57	12.1	-	-	1.41	7.01	25.67	-	3.59	-	-	1.58	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	99.24		500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	150 per trip	500 deductible; 30 coins; no max OOP		50 per visit	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP	500 deductible; 30 coins; no max OOP				500 deductible; 30 coins; no max OOP		500 deductible; 30 coins; no max OOP															6.32		0.88	0.12	0.16	0.4		0.11	0.69	0.26	1.21	0	0	0.3	0.62	3.67	0	0.24	0	0	0.17				0.08		0															15.22	500		24.67	-	12.18	2.63	2.6	6.35	-	1.65	3.89	2.83	13.32	-	-	1.71	7.62	29.34	-	3.83	-	-	1.75	-	-	-	0.08	-	0	-	-	-	-	-	-	-	-	-	-	-	-	-	-	114.45
R5595_803_0	2007	2																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	150 per trip	30 500 ded unlimited OOP max	0	50 ER; 50 UC	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	20 coinsurance	0			30 500 ded unlimited OOP max		30 500 ded unlimited OOP max															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0			0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
R5595_804_0	2007	3																																D	D	D	V	T	Coin	Coin	V	P	Coin	Coin	V	V	V	V	V	V	V	V	V	Coin	P			V		V															0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0															-		1369.62	26.68	1118.74	1836.48	202.67	13.83	0.88	367.59	302.84	5.94	16.68	0	0	0	4776.46	6059.32	173.99	1006.82	1376.02	2495.73	15.9	0			0		0															200/Day 1-7; 0/Day 8 - Thereafter	200/Day 1-7; 0/Day 8 - Thereafter	100/Day 1 - 100	35 per visit	150 per trip	30 coinsurance	30 coinsurance	50 ER; 50 UC	150 per procedure	20 coinsurance	20 coinsurance	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	35 per visit	20 coinsurance	0			0 per visit		0 per visit															143.69	143.69	100	35	150	30	30	50	150	20	20	35	35	35	35	35	35	35	35	35	20	0			0		0															16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71			16.4	0.32	9.32	5.36	2.53	4.15	0.26	1.53	3.79	1.19	3.34	-	-	-	13.93	17.67	0.51	2.94	4.01	7.28	3.18	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	97.71		30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	150 per trip	30 500 ded unlimited OOP max	0	50 ER; 50 UC	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	30 500 ded unlimited OOP max	20 coinsurance	0			30 500 ded unlimited OOP max		30 500 ded unlimited OOP max															7.92	0	1.28	1.15	0.37	0.66	0	0.23	0.81	0.28	0.79	0	0.26	0.87	1.03	1.29	0.05	0.14	0.96	3.47	0.54	0			0.13		0.04															22.26	500		24.32	0.32	10.61	6.51	2.91	4.81	0.26	1.76	4.6	1.47	4.13	-	0.26	0.87	14.96	18.96	0.56	3.07	4.97	10.75	3.72	-	-	-	0.13	-	0.04	-	-	-	-	-	-	-	-	-	-	-	-	-	-	119.97
R5674_001_0	2007	9							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V																																												-	7500	268.1	1.23	185.81		83.59	17.8	4.45	607.46	612.31		5.82				5486.72	2366.02	209.7	3445.97	1160.68	8876.6	5.32																	45.29	3.8			100/Stay	100/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				None	20/visit	20/visit	20/visit	20/visit	None	0.25																	50	200			100	100	50		100	0.25	0.25	50	50		0.2				0	20	20	20	20		0.25																	50	200			2.23	0.01	0.77	-	0.7	4.45	1.11	2.53	2.55	-	1.16	-	-	-	-	3.94	0.35	5.74	1.93	-	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	29.08	0	0	2.23	0.01	0.77	-	0.7	4.45	1.11	2.53	2.55	-	1.16	-	-	-	-	3.94	0.35	5.74	1.93	-	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	29.08	7500	850/Stay	850/Stay	0.4	40 coins	40 - not l.t. 100	25 coins	25 coins	50	50	None	0.4	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.37	0.02	0.37	0.29	0.14	0.79	0.2	0.45	0.45	0	0.41	0	0	0	0	1.6	0.5	1.99	1.74	0	0.23	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		12.54	500	0	5.6	0.03	1.14	0.29	0.83	5.23	1.31	2.98	3	-	1.57	-	-	-	-	5.55	0.85	7.73	3.68	-	1.57	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.61
R5674_801_0	2007	7							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			0.92	0	0.15	0.02	0.04	0.08	0.02	0.1	0.07	0.03	0.03	0.03	0.03	0.03	0.11	0.11	0.11	0.11	0.11	0.11	0.02																					2.23	7500	268.1	1.23	185.81		83.59	17.8	4.45	607.46	612.31		5.82				6454.96	2366.02	209.7	3445.97	1160.68	10443.06	5.32																	45.29	3.8			400/Stay	400/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				None	25/visit	25/visit	25/visit	25/visit	None	0.25																	50	200			400	400	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			8.94	0.04	0.77	-	0.7	4.45	1.11	2.53	2.55	-	1.16	-	-	-	-	4.93	0.44	7.18	2.42	-	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	38.8	500	0	9.86	0.04	0.93	0.02	0.74	4.53	1.13	2.63	2.62	0.03	1.19	0.03	0.03	0.03	0.11	5.04	0.55	7.29	2.53	0.11	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.03	7500	912/Stay	912/Stay	0.4	40 coins	40 - not l.t. 100	25 coins	25 coins	50	50	None	0.4	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.47	0.29	0.15	0.79	0.2	0.46	0.46	0	0.41	0	0	0	0	1.61	0.5	2	1.75	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		14.96	500	0	13.46	0.06	3.4	0.31	0.88	5.32	1.33	3.09	3.09	0.03	1.6	0.03	0.03	0.03	0.11	6.65	1.05	9.3	4.28	0.11	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	55.99
R5674_802_0	2007	5							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			0.92	0	0.15	0.02	0.04	0.08	0.02	0.1	0.07	0.03	0.03	0.03	0.03	0.03	0.11	0.11	0.11	0.11	0.11	0.11	0.02																					2.23	7500	268.1	1.23	185.81		83.59	17.8	4.45	607.46	612.31		5.82				5486.72	2366.02	209.7	3445.97	1160.68	8876.6	5.32																	45.29	3.8			400/Stay	400/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				none	25/visit	25/visit	25/visit	25/visit	None	0.25																	50	200			400	400	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			8.94	0.04	0.77	-	0.7	4.45	1.11	2.53	2.55	-	1.16	-	-	-	-	4.93	0.44	7.18	2.42	-	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	38.8	500	0	9.86	0.04	0.93	0.02	0.74	4.53	1.13	2.63	2.62	0.03	1.19	0.03	0.03	0.03	0.11	5.04	0.55	7.29	2.53	0.11	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.03	7500	912/Stay	912/Stay	0.4	40 coins	40 - not l.t. 100	25 coins	25 coins	50	50	None	0.4	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.47	0.29	0.15	0.79	0.2	0.46	0.46	0	0.41	0	0	0	0	1.61	0.5	2	1.75	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		14.96	500	0	13.46	0.06	3.4	0.31	0.88	5.32	1.33	3.09	3.09	0.03	1.6	0.03	0.03	0.03	0.11	6.65	1.05	9.3	4.28	0.11	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	55.99
R5674_803_0	2007	6							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			0.92	0	0.15	0.02	0.04	0.08	0.02	0.1	0.07	0.03	0.03	0.03	0.03	0.03	0.11	0.11	0.11	0.11	0.11	0.11	0.02																					2.23	7500	268.1	1.23	185.81		83.59	17.8	4.45	607.46	612.31		5.82				5486.72	2366.02	209.7	3445.97	1160.68	8876.6	5.32																	45.29	3.8			400/Stay	400/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				None	25/visit	25/visit	25/visit	25/visit	None	0.25																	50	200			400	400	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			8.94	0.04	0.77	-	0.7	4.45	1.11	2.53	2.55	-	1.16	-	-	-	-	4.93	0.44	7.18	2.42	-	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	38.8	500	0	9.86	0.04	0.93	0.02	0.74	4.53	1.13	2.63	2.62	0.03	1.19	0.03	0.03	0.03	0.11	5.04	0.55	7.29	2.53	0.11	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.03	7500	912/Stay	912/Stay	0.4	40 coins	40 - not l.t. 100	25 coins	25 coins	50	50	None	0.4	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.47	0.29	0.15	0.79	0.2	0.46	0.46	0	0.41	0	0	0	0	1.61	0.5	2	1.75	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		14.96	500	0	13.46	0.06	3.4	0.31	0.88	5.32	1.33	3.09	3.09	0.03	1.6	0.03	0.03	0.03	0.11	6.65	1.05	9.3	4.28	0.11	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	55.99
R5674_804_0	2007	5							h.1.	h.2.									OP Facility - Other	OP Facility - Other			3500							Complex diag	PET scans			A	A	D		T	Coin	Coin	V	V		Coin					V	V	V	V	V	Coin																	P	V			0.92	0	0.15	0.02	0.04	0.08	0.02	0.1	0.07	0.03	0.03	0.03	0.03	0.03	0.11	0.11	0.11	0.11	0.11	0.11	0.02																					2.23	7500	268.1	1.23	185.81		83.59	17.8	4.45	607.46	612.31		5.82				5486.72	2366.02	209.7	3445.97	1160.68	8876.6	5.32																	45.29	3.8			400/Stay	400/Stay	50/Day > 20		100 Trip	0	0	50/visit	50/visit		0.2				None	25/visit	25/visit	25/visit	25/visit	None	0.25																	50	200			400	400	50		100	0.25	0.25	50	50		0.2					25	25	25	25		0.25																	50	200			8.94	0.04	0.77	-	0.7	4.45	1.11	2.53	2.55	-	1.16	-	-	-	-	4.93	0.44	7.18	2.42	-	1.33	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	38.8	500	0	9.86	0.04	0.93	0.02	0.74	4.53	1.13	2.63	2.62	0.03	1.19	0.03	0.03	0.03	0.11	5.04	0.55	7.29	2.53	0.11	1.35	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	41.03	7500	912/Stay	912/Stay	0.4	40 coins	40 - not l.t. 100	25 coins	25 coins	50	50	None	0.4	None	None	None	0	40 Coins	40 Coins	40 Coins	40 Coins	None	25  Coins	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	None	40 coins	40 coins	None	None	3.6	0.02	2.47	0.29	0.15	0.79	0.2	0.46	0.46	0	0.41	0	0	0	0	1.61	0.5	2	1.75	0	0.24	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0		14.96	500	0	13.46	0.06	3.4	0.31	0.88	5.32	1.33	3.09	3.09	0.03	1.6	0.03	0.03	0.03	0.11	6.65	1.05	9.3	4.28	0.11	1.59	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	0.19	0.06	-	-	55.99
R5826_001_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	254.83	1.92	452.9	2160.87	126	0.72	0.05	249.34	445.68	821.91	560.4	37.36	383.11	317.56	7223.25	8568.08			315.95		9.97			5.44								13.41	0.1	16.22								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								429.54	429.54	27.07	0	78.1	0.16	0.16	35.93	63.73	30.17	39.05	39.05	39.05	26.19	7.81	23.43			78.1		0.16			0.13								429.54	429.54	0.16								9.12	0.07	1.02	-	0.82	0.11	0.01	0.75	2.37	2.07	1.82	0.12	1.25	0.69	4.7	16.73	-	-	2.06	-	1.56	-	-	0.68	-	-	-	-	-	-	-	0.48	0	2.53	-	-	-	-	-	-	-	48.96	0	13.54	9.12	0.07	1.02	-	0.82	0.11	0.01	0.75	2.37	2.07	1.82	0.12	1.25	0.69	4.7	16.73	-	-	2.06	-	1.56	-	-	0.68	-	-	-	-	-	-	-	0.48	0	2.53	-	-	-	-	-	-	-	48.96	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.75	0.01	0.25	0.34	0.23	0.02		0.23	3.09	3.64			0.03		3.27	3.88					0.5			1.51										0.79								19.54	500	6.5	10.87	0.08	1.27	0.34	1.05	0.14	0.01	0.98	5.45	5.71	1.82	0.12	1.28	0.69	7.97	20.61	-	-	2.06	-	2.05	-	-	2.19	-	-	-	-	-	-	-	0.48	0	3.33	-	-	-	-	-	-	-	68.5
R5826_002_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin								A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	253.16	1.91	449.94	2146.74	125.18	0.71	0.05	247.71	442.77	816.54	556.73	37.12	380.61	315.48	7176.01	8512.04			313.89		9.86			3.3								13.32	0.1	16.04								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								430.34	430.34	27.12	0	78.24	0.16	0.16	35.99	63.85	30.23	39.12	39.12	39.12	26.23	7.82	23.47			78.24		0.16			0								430.34	430.34	0.16								9.08	0.07	1.02	-	0.82	0.11	0.01	0.74	2.36	2.06	1.82	0.12	1.24	0.69	4.68	16.65	-	-	2.05	-	1.54	-	-	-	-	-	-	-	-	-	-	0.48	0	2.51	-	-	-	-	-	-	-	48.03	0	13.36	9.08	0.07	1.02	-	0.82	0.11	0.01	0.74	2.36	2.06	1.82	0.12	1.24	0.69	4.68	16.65	-	-	2.05	-	1.54	-	-	-	-	-	-	-	-	-	-	0.48	0	2.51	-	-	-	-	-	-	-	48.03	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.74	0.01	0.25	0.34	0.23	0.02		0.23	3.06	3.61			0.03		3.26	3.87					0.49			1.01										0.79								18.94	500	6.41	10.82	0.08	1.26	0.34	1.05	0.13	0.01	0.97	5.42	5.67	1.82	0.12	1.27	0.69	7.94	20.52	-	-	2.05	-	2.04	-	-	1.01	-	-	-	-	-	-	-	0.48	0	3.3	-	-	-	-	-	-	-	66.97
R5826_003_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	246.12	1.86	437.42	2087.02	121.7	0.67	0.05	240.82	430.45	793.82	541.24	36.08	370.02	306.7	6976.36	8275.23			305.15		9.3			3.11								12.95	0.1	15.14								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								433.87	433.87	27.34	0	78.89	0.16	0.16	36.29	64.37	30.48	39.44	39.44	39.44	26.45	7.89	23.67			78.89		0.16			0								433.87	433.87	0.16								8.9	0.07	1	-	0.8	0.11	0.01	0.73	2.31	2.02	1.78	0.12	1.22	0.68	4.59	16.32	-	-	2.01	-	1.47	-	-	-	-	-	-	-	-	-	-	0.47	0	2.39	-	-	-	-	-	-	-	46.96	0	12.57	8.9	0.07	1	-	0.8	0.11	0.01	0.73	2.31	2.02	1.78	0.12	1.22	0.68	4.59	16.32	-	-	2.01	-	1.47	-	-	-	-	-	-	-	-	-	-	0.47	0	2.39	-	-	-	-	-	-	-	46.96	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.72	0.01	0.24	0.32	0.23	0.02		0.22	2.93	3.46			0.03		3.22	3.82					0.47			0.95										0.75								18.41	500	6.01	10.62	0.08	1.23	0.32	1.03	0.13	0.01	0.95	5.24	5.48	1.78	0.12	1.24	0.68	7.81	20.14	-	-	2.01	-	1.94	-	-	0.95	-	-	-	-	-	-	-	0.47	0	3.14	-	-	-	-	-	-	-	65.37
R5826_004_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	250.67	1.89	445.51	2125.62	123.95	0.69	0.05	245.27	438.41	808.5	551.25	36.75	376.86	312.38	7105.4	8428.28			310.8		9.65			2.84								13.19	0.1	15.7								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								431.57	431.57	27.2	0	78.47	0.16	0.16	36.1	64.03	30.32	39.23	39.23	39.23	26.31	7.85	23.54			78.47		0.16			0.25								431.57	431.57	0.16								9.02	0.07	1.01	-	0.81	0.11	0.01	0.74	2.34	2.04	1.8	0.12	1.23	0.68	4.65	16.53	-	-	2.03	-	1.51	-	-	0.71	-	-	-	-	-	-	-	0.47	0	2.46	-	-	-	-	-	-	-	48.36	0	13.07	9.02	0.07	1.01	-	0.81	0.11	0.01	0.74	2.34	2.04	1.8	0.12	1.23	0.68	4.65	16.53	-	-	2.03	-	1.51	-	-	0.71	-	-	-	-	-	-	-	0.47	0	2.46	-	-	-	-	-	-	-	48.36	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.74	0.01	0.24	0.33	0.23	0.02		0.23	3.01	3.56			0.03		3.25	3.85					0.49			0.71										0.77								18.47	500	6.26	10.75	0.08	1.25	0.33	1.04	0.13	0.01	0.96	5.35	5.6	1.8	0.12	1.26	0.68	7.89	20.39	-	-	2.03	-	2	-	-	1.42	-	-	-	-	-	-	-	0.47	0	3.24	-	-	-	-	-	-	-	66.83
R5826_005_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	260.28	1.96	462.6	2207.15	128.7	0.75	0.06	254.68	455.23	839.52	572.4	38.16	391.32	324.36	7377.94	8751.57			322.72		10.43			0.91								13.7	0.1	16.96								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								426.89	426.89	26.9	0	77.62	0.16	0.16	35.7	63.33	29.99	38.81	38.81	38.81	26.02	7.76	23.28			77.62		0.16			0								426.89	426.89	0.16								9.26	0.07	1.04	-	0.83	0.12	0.01	0.76	2.4	2.1	1.85	0.12	1.27	0.7	4.77	16.98	-	-	2.09	-	1.62	-	-	-	-	-	-	-	-	-	-	0.49	0	2.63	-	-	-	-	-	-	-	49.11	0	14.16	9.26	0.07	1.04	-	0.83	0.12	0.01	0.76	2.4	2.1	1.85	0.12	1.27	0.7	4.77	16.98	-	-	2.09	-	1.62	-	-	-	-	-	-	-	-	-	-	0.49	0	2.63	-	-	-	-	-	-	-	49.11	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.76	0.01	0.26	0.35	0.23	0.02		0.23	3.19	3.76			0.03		3.3	3.92					0.51			0.46										0.82								18.86	500	6.84	11.02	0.08	1.29	0.35	1.07	0.14	0.01	0.99	5.59	5.86	1.85	0.12	1.3	0.7	8.07	20.9	-	-	2.09	-	2.13	-	-	0.46	-	-	-	-	-	-	-	0.49	0	3.45	-	-	-	-	-	-	-	67.97
R5826_006_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	259.91	1.96	461.93	2203.97	128.52	0.75	0.06	254.31	454.57	838.31	571.57	38.1	390.75	323.89	7367.31	8738.97			322.25		10.38			3.49								13.68	0.1	16.89								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								427.08	427.08	26.92	0	77.65	0.16	0.16	35.72	63.36	30	38.83	38.83	38.83	26.04	7.77	23.3			77.65		0.16			0								427.08	427.08	0.16								9.25	0.07	1.04	-	0.83	0.12	0.01	0.76	2.4	2.1	1.85	0.12	1.26	0.7	4.77	16.96	-	-	2.09	-	1.61	-	-	-	-	-	-	-	-	-	-	0.49	0	2.62	-	-	-	-	-	-	-	49.05	0	14.12	9.25	0.07	1.04	-	0.83	0.12	0.01	0.76	2.4	2.1	1.85	0.12	1.26	0.7	4.77	16.96	-	-	2.09	-	1.61	-	-	-	-	-	-	-	-	-	-	0.49	0	2.62	-	-	-	-	-	-	-	49.05	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.76	0.01	0.26	0.35	0.23	0.02		0.23	3.18	3.75			0.03		3.3	3.92					0.51			2.12										0.82								20.49	500	6.81	11.01	0.08	1.29	0.35	1.06	0.14	0.01	0.99	5.58	5.84	1.85	0.12	1.29	0.7	8.07	20.88	-	-	2.09	-	2.12	-	-	2.12	-	-	-	-	-	-	-	0.49	0	3.44	-	-	-	-	-	-	-	69.54
R5826_007_0	2007	5	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	251.85	1.9	447.61	2135.62	124.53	0.7	0.05	246.43	440.48	812.31	553.85	36.92	378.63	313.85	7138.85	8467.96			312.26		9.74			2.97								13.26	0.1	15.84								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								430.99	430.99	27.16	0	78.36	0.16	0.16	36.05	63.94	30.28	39.18	39.18	39.18	26.27	7.84	23.51			78.36		0.16			0								430.99	430.99	0.16								9.05	0.07	1.01	-	0.81	0.11	0.01	0.74	2.35	2.05	1.81	0.12	1.24	0.69	4.66	16.59	-	-	2.04	-	1.53	-	-	-	-	-	-	-	-	-	-	0.48	0	2.48	-	-	-	-	-	-	-	47.83	0	13.21	9.05	0.07	1.01	-	0.81	0.11	0.01	0.74	2.35	2.05	1.81	0.12	1.24	0.69	4.66	16.59	-	-	2.04	-	1.53	-	-	-	-	-	-	-	-	-	-	0.48	0	2.48	-	-	-	-	-	-	-	47.83	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.74	0.01	0.24	0.33	0.23	0.02		0.23	3.03	3.58			0.03		3.26	3.86					0.49			1.65										0.78								19.49	500	6.33	10.78	0.08	1.26	0.33	1.04	0.13	0.01	0.97	5.38	5.63	1.81	0.12	1.26	0.69	7.92	20.45	-	-	2.04	-	2.01	-	-	1.65	-	-	-	-	-	-	-	0.48	0	3.26	-	-	-	-	-	-	-	67.31
R5826_008_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	251.4	1.9	446.8	2131.78	124.31	0.7	0.05	245.98	439.68	810.85	552.85	36.86	377.95	313.28	7126	8452.72			311.7		9.71			2.99								13.23	0.1	15.79								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								431.21	431.21	27.18	0	78.4	0.16	0.16	36.07	63.98	30.29	39.2	39.2	39.2	26.29	7.84	23.52			78.4		0.16			0								431.21	431.21	0.16								9.03	0.07	1.01	-	0.81	0.11	0.01	0.74	2.34	2.05	1.81	0.12	1.23	0.69	4.66	16.57	-	-	2.04	-	1.52	-	-	-	-	-	-	-	-	-	-	0.48	0	2.48	-	-	-	-	-	-	-	47.76	0	13.16	9.03	0.07	1.01	-	0.81	0.11	0.01	0.74	2.34	2.05	1.81	0.12	1.23	0.69	4.66	16.57	-	-	2.04	-	1.52	-	-	-	-	-	-	-	-	-	-	0.48	0	2.48	-	-	-	-	-	-	-	47.76	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.74	0.01	0.24	0.33	0.23	0.02		0.23	3.03	3.57			0.03		3.25	3.86					0.49			0.91										0.78								18.72	500	6.3	10.77	0.08	1.25	0.33	1.04	0.13	0.01	0.97	5.37	5.62	1.81	0.12	1.26	0.69	7.91	20.43	-	-	2.04	-	2.01	-	-	0.91	-	-	-	-	-	-	-	0.48	0	3.25	-	-	-	-	-	-	-	66.48
R5826_009_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	250.31	1.89	444.88	2122.62	123.77	0.69	0.05	244.93	437.79	807.36	550.48	36.7	376.33	311.94	7095.38	8416.4			310.36		9.63			3.49								13.17	0.1	15.67								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								431.74	431.74	27.21	0	78.5	0.16	0.16	36.11	64.05	30.33	39.25	39.25	39.25	26.32	7.85	23.55			78.5		0.16			0								431.74	431.74	0.16								9.01	0.07	1.01	-	0.81	0.11	0.01	0.74	2.34	2.04	1.8	0.12	1.23	0.68	4.64	16.52	-	-	2.03	-	1.51	-	-	-	-	-	-	-	-	-	-	0.47	0	2.46	-	-	-	-	-	-	-	47.6	0	13.04	9.01	0.07	1.01	-	0.81	0.11	0.01	0.74	2.34	2.04	1.8	0.12	1.23	0.68	4.64	16.52	-	-	2.03	-	1.51	-	-	-	-	-	-	-	-	-	-	0.47	0	2.46	-	-	-	-	-	-	-	47.6	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.73	0.01	0.24	0.33	0.23	0.02		0.23	3.01	3.55			0.03		3.25	3.85					0.49			1.06										0.77								18.8	500	6.25	10.74	0.08	1.25	0.33	1.04	0.13	0.01	0.96	5.35	5.59	1.8	0.12	1.26	0.68	7.89	20.37	-	-	2.03	-	2	-	-	1.06	-	-	-	-	-	-	-	0.47	0	3.23	-	-	-	-	-	-	-	66.4
R5826_010_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	251.9	1.9	447.71	2136.1	124.56	0.7	0.05	246.48	440.58	812.49	553.97	36.93	378.72	313.92	7140.44	8469.85			312.33		9.75			2.8								13.26	0.1	15.86								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								430.96	430.96	27.16	0	78.36	0.16	0.16	36.04	63.94	30.27	39.18	39.18	39.18	26.27	7.84	23.51			78.36		0.16			0								430.96	430.96	0.16								9.05	0.07	1.01	-	0.81	0.11	0.01	0.74	2.35	2.05	1.81	0.12	1.24	0.69	4.66	16.59	-	-	2.04	-	1.53	-	-	-	-	-	-	-	-	-	-	0.48	0	2.49	-	-	-	-	-	-	-	47.84	0	13.21	9.05	0.07	1.01	-	0.81	0.11	0.01	0.74	2.35	2.05	1.81	0.12	1.24	0.69	4.66	16.59	-	-	2.04	-	1.53	-	-	-	-	-	-	-	-	-	-	0.48	0	2.49	-	-	-	-	-	-	-	47.84	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.74	0.01	0.24	0.33	0.23	0.02		0.23	3.04	3.58			0.03		3.26	3.86					0.49			1.7										0.78								19.54	500	6.33	10.79	0.08	1.26	0.33	1.04	0.13	0.01	0.97	5.38	5.63	1.81	0.12	1.26	0.69	7.92	20.45	-	-	2.04	-	2.02	-	-	1.7	-	-	-	-	-	-	-	0.48	0	3.27	-	-	-	-	-	-	-	67.38
R5826_011_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	270.78	2.04	481.25	2296.13	133.89	0.81	0.06	264.95	473.58	873.36	595.47	39.7	407.09	337.44	7675.38	9104.39			335.73		11.28			2.74								14.25	0.11	18.35								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								421.9	421.9	26.59	0	76.71	0.15	0.15	35.29	62.59	29.64	38.35	38.35	38.35	25.72	7.67	23.01			76.71		0.15			0								421.9	421.9	0.15								9.52	0.07	1.07	-	0.86	0.12	0.01	0.78	2.47	2.16	1.9	0.13	1.3	0.72	4.91	17.46	-	-	2.15	-	1.73	-	-	-	-	-	-	-	-	-	-	0.5	0	2.82	-	-	-	-	-	-	-	50.67	0	15.39	9.52	0.07	1.07	-	0.86	0.12	0.01	0.78	2.47	2.16	1.9	0.13	1.3	0.72	4.91	17.46	-	-	2.15	-	1.73	-	-	-	-	-	-	-	-	-	-	0.5	0	2.82	-	-	-	-	-	-	-	50.67	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.79	0.01	0.27	0.37	0.24	0.03		0.23	3.37	3.98			0.03		3.36	3.98					0.54			0.84										0.87								19.92	500	7.49	11.31	0.09	1.34	0.37	1.09	0.15	0.01	1.01	5.84	6.14	1.9	0.13	1.33	0.72	8.27	21.44	-	-	2.15	-	2.27	-	-	0.84	-	-	-	-	-	-	-	0.5	0	3.68	-	-	-	-	-	-	-	70.59
R5826_012_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	267.5	2.02	475.43	2268.35	132.27	0.79	0.06	261.74	467.85	862.8	588.27	39.22	402.17	333.35	7582.53	8994.26			331.67		11			2.72								14.08	0.11	17.89								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								423.45	423.45	26.69	0	76.99	0.15	0.15	35.42	62.83	29.75	38.5	38.5	38.5	25.81	7.7	23.1			76.99		0.15			0								423.45	423.45	0.15								9.44	0.07	1.06	-	0.85	0.12	0.01	0.77	2.45	2.14	1.89	0.13	1.29	0.72	4.86	17.31	-	-	2.13	-	1.69	-	-	-	-	-	-	-	-	-	-	0.5	0	2.76	-	-	-	-	-	-	-	50.18	0	15	9.44	0.07	1.06	-	0.85	0.12	0.01	0.77	2.45	2.14	1.89	0.13	1.29	0.72	4.86	17.31	-	-	2.13	-	1.69	-	-	-	-	-	-	-	-	-	-	0.5	0	2.76	-	-	-	-	-	-	-	50.18	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.79	0.01	0.27	0.36	0.24	0.03		0.23	3.31	3.91			0.03		3.34	3.96					0.53			0.83										0.85								19.69	500	7.28	11.23	0.08	1.32	0.36	1.08	0.15	0.01	1.01	5.76	6.05	1.89	0.13	1.32	0.72	8.21	21.28	-	-	2.13	-	2.23	-	-	0.83	-	-	-	-	-	-	-	0.5	0	3.61	-	-	-	-	-	-	-	69.88
R5826_013_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	259.55	1.96	461.29	2200.91	128.34	0.75	0.06	253.96	453.94	837.14	570.78	38.05	390.21	323.44	7357.08	8726.82			321.81		10.35			2.8								13.66	0.1	16.84								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								427.25	427.25	26.93	0	77.68	0.16	0.16	35.73	63.39	30.01	38.84	38.84	38.84	26.05	7.77	23.3			77.68		0.16			0								427.25	427.25	0.16								9.24	0.07	1.04	-	0.83	0.12	0.01	0.76	2.4	2.09	1.85	0.12	1.26	0.7	4.76	16.95	-	-	2.08	-	1.61	-	-	-	-	-	-	-	-	-	-	0.49	0	2.62	-	-	-	-	-	-	-	48.99	0	14.08	9.24	0.07	1.04	-	0.83	0.12	0.01	0.76	2.4	2.09	1.85	0.12	1.26	0.7	4.76	16.95	-	-	2.08	-	1.61	-	-	-	-	-	-	-	-	-	-	0.49	0	2.62	-	-	-	-	-	-	-	48.99	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.76	0.01	0.25	0.35	0.23	0.02		0.23	3.17	3.74			0.03		3.3	3.91					0.51			0.86										0.82								19.21	500	6.78	11	0.08	1.29	0.35	1.06	0.14	0.01	0.99	5.57	5.84	1.85	0.12	1.29	0.7	8.06	20.86	-	-	2.08	-	2.12	-	-	0.86	-	-	-	-	-	-	-	0.49	0	3.43	-	-	-	-	-	-	-	68.2
R5826_014_0	2007	9	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-	10000	247.22	1.86	439.39	2096.4	122.24	0.68	0.05	241.9	432.39	797.39	543.68	36.25	371.68	308.08	7007.73	8312.44			306.53		9.39			3.19								13.01	0.1	15.27								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			0 - 0								550/admit	550/admit	20 Coins								433.3	433.3	27.31	0	78.78	0.16	0.16	36.24	64.29	30.44	39.39	39.39	39.39	26.42	7.88	23.63			78.78		0.16			0								433.3	433.3	0.16								8.93	0.07	1	-	0.8	0.11	0.01	0.73	2.32	2.02	1.78	0.12	1.22	0.68	4.6	16.37	-	-	2.01	-	1.48	-	-	-	-	-	-	-	-	-	-	0.47	0	2.41	-	-	-	-	-	-	-	47.13	0	12.69	8.93	0.07	1	-	0.8	0.11	0.01	0.73	2.32	2.02	1.78	0.12	1.22	0.68	4.6	16.37	-	-	2.01	-	1.48	-	-	-	-	-	-	-	-	-	-	0.47	0	2.41	-	-	-	-	-	-	-	47.13	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-50										30 Coins								1.72	0.01	0.24	0.32	0.23	0.02		0.23	2.95	3.49			0.03		3.23	3.83					0.48			2.57										0.76								20.1	500	6.07	10.65	0.08	1.24	0.32	1.03	0.13	0.01	0.96	5.27	5.51	1.78	0.12	1.25	0.68	7.83	20.2	-	-	2.01	-	1.95	-	-	2.57	-	-	-	-	-	-	-	0.47	0	3.17	-	-	-	-	-	-	-	67.22
R5826_018_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		249.87	1.88	444.1	2118.88	123.55	0.69	0.05	244.49	437.02	805.94	549.51	36.63	375.67	311.39	7082.89	8401.59			309.81		9.61			3.75								13.15	0.1	15.63								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			25 - 75								550/admit	550/admit	20 Coins								431.95	431.95	27.22	0	78.54	0.16	0.16	36.13	64.09	30.34	39.27	39.27	39.27	26.33	7.85	23.56			78.54		0.16			0.35								431.95	431.95	0.16								8.99	0.07	1.01	-	0.81	0.11	0.01	0.74	2.33	2.04	1.8	0.12	1.23	0.68	4.64	16.5	-	-	2.03	-	1.51	-	-	1.32	-	-	-	-	-	-	-	0.47	0	2.46	-	-	-	-	-	-	-	48.86	0	12.99	8.99	0.07	1.01	-	0.81	0.11	0.01	0.74	2.33	2.04	1.8	0.12	1.23	0.68	4.64	16.5	-	-	2.03	-	1.51	-	-	1.32	-	-	-	-	-	-	-	0.47	0	2.46	-	-	-	-	-	-	-	48.86	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-80										30 Coins								1.73	0.01	0.24	0.33	0.23	0.02		0.23	3	3.55			0.03		3.24	3.85					0.48			0.75										0.77								18.47	500	6.22	10.73	0.08	1.25	0.33	1.04	0.13	0.01	0.96	5.34	5.58	1.8	0.12	1.26	0.68	7.88	20.34	-	-	2.03	-	1.99	-	-	2.07	-	-	-	-	-	-	-	0.47	0	3.23	-	-	-	-	-	-	-	67.33
R5826_021_0	2007	7	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		241.52	1.82	429.26	2048.06	119.43	0.64	0.05	236.32	422.42	779.01	531.14	35.41	363.11	300.98	6846.16	8120.79			299.46		8.95			9.07								12.71	0.1	14.57								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			25-75								550/admit	550/admit	20 Coins								436.28	436.28	27.5	0	79.32	0.16	0.16	36.49	64.73	30.65	39.66	39.66	39.66	26.6	7.93	23.8			79.32		0.16			0.35								436.28	436.28	0.16								8.78	0.07	0.98	-	0.79	0.1	0.01	0.72	2.28	1.99	1.76	0.12	1.2	0.67	4.53	16.1	-	-	1.98	-	1.42	-	-	3.2	-	-	-	-	-	-	-	0.46	0	2.31	-	-	-	-	-	-	-	49.46	0	12.06	8.78	0.07	0.98	-	0.79	0.1	0.01	0.72	2.28	1.99	1.76	0.12	1.2	0.67	4.53	16.1	-	-	1.98	-	1.42	-	-	3.2	-	-	-	-	-	-	-	0.46	0	2.31	-	-	-	-	-	-	-	49.46	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-80										30 Coins								1.71	0.01	0.23	0.31	0.23	0.02		0.22	2.85	3.37			0.03		3.19	3.79					0.46			1.66										0.73								18.81	500	5.76	10.49	0.08	1.21	0.31	1.01	0.12	0.01	0.94	5.13	5.36	1.76	0.12	1.23	0.67	7.72	19.89	-	-	1.98	-	1.88	-	-	4.86	-	-	-	-	-	-	-	0.46	0	3.04	-	-	-	-	-	-	-	68.28
R5826_023_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		240.08	1.81	426.69	2035.82	118.71	0.64	0.05	234.91	419.89	774.35	527.97	35.2	360.94	299.18	6805.24	8072.25			297.67		8.86			8.88								12.64	0.1	14.42								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			25 - 75								550/admit	550/admit	20 Coins								437.04	437.04	27.54	0	79.46	0.16	0.16	36.55	64.84	30.7	39.73	39.73	39.73	26.64	7.95	23.84			79.46		0.16			0.35								437.04	437.04	0.16								8.74	0.07	0.98	-	0.79	0.1	0.01	0.72	2.27	1.98	1.75	0.12	1.2	0.66	4.51	16.04	-	-	1.97	-	1.41	-	-	3.13	-	-	-	-	-	-	-	0.46	0	2.29	-	-	-	-	-	-	-	49.19	0	11.9	8.74	0.07	0.98	-	0.79	0.1	0.01	0.72	2.27	1.98	1.75	0.12	1.2	0.66	4.51	16.04	-	-	1.97	-	1.41	-	-	3.13	-	-	-	-	-	-	-	0.46	0	2.29	-	-	-	-	-	-	-	49.19	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-80										30 Coins								1.7	0.01	0.23	0.31	0.22	0.02		0.22	2.83	3.34			0.03		3.18	3.78					0.46			1.63										0.73								18.7	500	5.68	10.44	0.08	1.21	0.31	1.01	0.12	0.01	0.94	5.1	5.32	1.75	0.12	1.22	0.66	7.69	19.81	-	-	1.97	-	1.86	-	-	4.76	-	-	-	-	-	-	-	0.46	0	3.02	-	-	-	-	-	-	-	67.88
R5826_026_0	2007	6	s.	t.	u.								Inpatient Facility	Inpatient Facility	Professional								5000	Acute Level 2	Mental Health Level 2	Physician Administered Injectibles								A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin			Coin						Coin		A	A	Coin								0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0			0								0	0	0								-		256.5	1.93	455.88	2175.11	126.83	0.73	0.05	250.98	448.62	827.33	564.09	37.61	385.64	319.65	7270.83	8624.52			318.03		10.11			5.97								13.5	0.1	16.45								550/admit	550/admit	0/day (1-3) 90/day (4-100)	0/Visit	100/ Trip	20 Coins	20 Coins	30-50/ Visit	75-95/ Visit	0-50/ Visit	50/ Visit	50/ Visit	50/ Procedure	30-50/ Visit	10/ Visit	30/ Visit			100/ Visit		20 Coins			25 - 75								550/admit	550/admit	20 Coins								428.72	428.72	27.02	0	77.95	0.16	0.16	35.86	63.61	30.12	38.97	38.97	38.97	26.14	7.79	23.38			77.95		0.16			0.35								428.72	428.72	0.16								9.16	0.07	1.03	-	0.82	0.11	0.01	0.75	2.38	2.08	1.83	0.12	1.25	0.7	4.72	16.81	-	-	2.07	-	1.58	-	-	2.11	-	-	-	-	-	-	-	0.48	0	2.56	-	-	-	-	-	-	-	50.64	0	13.73	9.16	0.07	1.03	-	0.82	0.11	0.01	0.75	2.38	2.08	1.83	0.12	1.25	0.7	4.72	16.81	-	-	2.07	-	1.58	-	-	2.11	-	-	-	-	-	-	-	0.48	0	2.56	-	-	-	-	-	-	-	50.64	10000	800/admit	800/admit	30 Coins	30 Coins	100/Trip	30 Coins		50/Visit	30 Coins	30 Coins			30 Coins		35/Visit	35/Visit					20 Coins			50-80										30 Coins								1.75	0.01	0.25	0.34	0.23	0.02		0.23	3.12	3.68			0.03		3.28	3.89					0.5			3.28										0.8								21.43	500	6.6	10.92	0.08	1.28	0.34	1.06	0.14	0.01	0.98	5.5	5.76	1.83	0.12	1.28	0.7	8	20.7	-	-	2.07	-	2.08	-	-	5.39	-	-	-	-	-	-	-	0.48	0	3.37	-	-	-	-	-	-	-	72.07
R5826_801_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		263.69	1.99	468.66	2236.04	130.39	0.77	0.06	258.01	461.19	850.51	579.89	38.66	396.44	328.61	7474.53	8866.14			326.94		10.68											13.88	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.18	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.21	0.32	-	1.03	15.57	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.71	0	0	13.18	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.21	0.32	-	1.03	15.57	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.71		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.34	0.02	0.4	0.55	0.27	0.05		0.27	5.01	5.91			0		1.87	4.51					0.61																					21.8	0	0	15.53	0.12	0.75	2.41	1.36	0.24	0.01	1.24	12.69	8.39	2.21	0.32	-	1.03	17.45	30.37	-	-	0.95	-	2.74	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	98.51
R5826_802_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		263.74	1.99	468.75	2236.5	130.41	0.77	0.06	258.07	461.28	850.68	580.01	38.67	396.52	328.67	7476.06	8867.96			327.01		10.7											13.88	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.19	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.22	0.32	-	1.03	15.58	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.73	0	0	13.19	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.22	0.32	-	1.03	15.58	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.73		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.34	0.02	0.4	0.55	0.27	0.05		0.27	5.02	5.92			0		1.88	4.52					0.61																					21.84	0	0	15.53	0.12	0.75	2.41	1.36	0.24	0.01	1.24	12.7	8.4	2.22	0.32	-	1.03	17.45	30.38	-	-	0.95	-	2.75	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	98.57
R5826_803_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.08	1.93	455.12	2171.47	126.62	0.72	0.05	250.56	447.87	825.95	563.15	37.54	384.99	319.12	7258.69	8610.12			317.5		10.07											13.48	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.8	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.12	25.11	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.43	0	0	12.8	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.12	25.11	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.43		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.72	5.57			0		1.77	4.25					0.57																					20.64	0	0	15.08	0.11	0.71	2.33	1.32	0.23	0.01	1.2	12.18	7.98	2.15	0.31	-	1	16.89	29.36	-	-	0.93	-	2.58	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.07
R5826_804_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.05	1.96	462.18	2205.17	128.59	0.75	0.06	254.45	454.82	838.76	571.88	38.13	390.96	324.07	7371.32	8743.72			322.43		10.38											13.69	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.58	2.45	2.18	0.32	-	1.02	15.36	25.5	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.62	0	0	13	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.58	2.45	2.18	0.32	-	1.02	15.36	25.5	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.62		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.53	0.27	0.05		0.27	4.87	5.75			0		1.82	4.38					0.59																					21.24	0	0	15.31	0.12	0.73	2.37	1.34	0.23	0.01	1.22	12.45	8.19	2.18	0.32	-	1.02	17.18	29.88	-	-	0.94	-	2.66	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	96.86
R5826_805_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		269.2	2.03	478.45	2282.79	133.11	0.8	0.06	263.41	470.83	868.29	592.01	39.47	404.73	335.47	7630.79	9051.5			333.78		11.16											14.17	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.46	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.85	2.53	2.26	0.33	-	1.05	15.9	26.4	-	-	0.97	-	2.23	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.37	0	0	13.46	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.85	2.53	2.26	0.33	-	1.05	15.9	26.4	-	-	0.97	-	2.23	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.37		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.39	0.02	0.42	0.57	0.28	0.05		0.27	5.23	6.18			0		1.96	4.71					0.63																					22.72	0	0	15.85	0.12	0.77	2.48	1.39	0.25	0.02	1.27	13.08	8.71	2.26	0.33	-	1.05	17.86	31.11	-	-	0.97	-	2.86	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	101.09
R5826_806_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		268.54	2.02	477.27	2277.16	132.78	0.8	0.06	262.76	469.67	866.14	590.55	39.37	403.73	334.65	7611.95	9029.15			332.96		11.08											14.13	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.43	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.83	2.53	2.26	0.33	-	1.05	15.86	26.34	-	-	0.97	-	2.22	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.17	0	0	13.43	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.83	2.53	2.26	0.33	-	1.05	15.86	26.34	-	-	0.97	-	2.22	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.17		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.39	0.02	0.42	0.57	0.28	0.05		0.27	5.2	6.13			0		1.94	4.68					0.63																					22.57	0	0	15.81	0.12	0.77	2.47	1.38	0.25	0.02	1.26	13.02	8.66	2.26	0.33	-	1.05	17.8	31.01	-	-	0.97	-	2.84	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	100.73
R5826_807_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.79	1.97	463.5	2211.46	128.95	0.75	0.06	255.18	456.12	841.16	573.51	38.23	392.08	324.99	7392.34	8768.65			323.35		10.44											13.73	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.84	0	0	13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.84		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.32	0.02	0.39	0.54	0.27	0.05		0.27	4.89	5.78			0		1.83	4.41					0.59																					21.35	0	0	15.36	0.12	0.73	2.38	1.34	0.24	0.01	1.23	12.5	8.23	2.19	0.32	-	1.02	17.23	29.98	-	-	0.94	-	2.68	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	97.19
R5826_808_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.31	1.96	462.65	2207.4	128.72	0.75	0.06	254.71	455.28	839.61	572.46	38.16	391.36	324.4	7378.77	8752.56			322.76		10.41											13.7	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.02	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.59	2.45	2.19	0.32	-	1.02	15.37	25.53	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.7	0	0	13.02	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.59	2.45	2.19	0.32	-	1.02	15.37	25.53	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.7		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.54	0.27	0.05		0.27	4.88	5.76			0		1.83	4.39					0.59																					21.29	0	0	15.33	0.12	0.73	2.38	1.34	0.23	0.01	1.22	12.47	8.21	2.19	0.32	-	1.02	17.2	29.92	-	-	0.94	-	2.67	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	96.99
R5826_809_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.85	1.97	463.6	2211.92	128.98	0.75	0.06	255.23	456.21	841.33	573.63	38.24	392.16	325.06	7393.88	8770.48			323.42		10.46											13.73	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.86	0	0	13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.86		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.32	0.02	0.39	0.54	0.27	0.05		0.27	4.91	5.79			0		1.84	4.42					0.59																					21.39	0	0	15.36	0.12	0.73	2.38	1.34	0.24	0.01	1.23	12.51	8.24	2.19	0.32	-	1.02	17.24	30	-	-	0.94	-	2.69	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	97.25
R5826_810_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		261.04	1.97	463.94	2213.56	129.08	0.75	0.06	255.42	456.55	841.95	574.06	38.27	392.45	325.3	7399.37	8776.99			323.66		10.47											13.74	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.05	0.1	0.34	1.84	1.08	0.19	0.01	0.96	7.61	2.46	2.19	0.32	-	1.02	15.42	25.6	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.92	0	0	13.05	0.1	0.34	1.84	1.08	0.19	0.01	0.96	7.61	2.46	2.19	0.32	-	1.02	15.42	25.6	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.92		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.32	0.02	0.39	0.54	0.27	0.05		0.27	4.91	5.79			0		1.84	4.42					0.59																					21.4	0	0	15.37	0.12	0.73	2.38	1.34	0.24	0.01	1.23	12.52	8.25	2.19	0.32	-	1.02	17.25	30.02	-	-	0.94	-	2.69	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	97.32
R5826_811_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		280.43	2.11	498.4	2377.96	138.66	0.87	0.07	274.39	490.46	904.49	616.7	41.11	421.6	349.46	7948.93	9428.87			347.7		12.1											14.76	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									14.02	0.11	0.37	1.98	1.16	0.22	0.02	1.03	8.17	2.64	2.36	0.34	-	1.1	16.56	27.5	-	-	1.01	-	2.42	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	81.74	0	0	14.02	0.11	0.37	1.98	1.16	0.22	0.02	1.03	8.17	2.64	2.36	0.34	-	1.1	16.56	27.5	-	-	1.01	-	2.42	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	81.74		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.49	0.02	0.46	0.62	0.29	0.05		0.29	5.67	6.69			0		2.12	5.1					0.69																					24.5	0	0	16.51	0.12	0.82	2.6	1.44	0.27	0.02	1.32	13.85	9.33	2.36	0.34	-	1.1	18.68	32.61	-	-	1.01	-	3.1	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	106.24
R5826_812_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		278.06	2.1	494.2	2357.91	137.49	0.86	0.06	272.08	486.32	896.86	611.5	40.77	418.04	346.51	7881.89	9349.35			344.76		11.88											14.63	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.9	0.1	0.36	1.96	1.15	0.21	0.02	1.02	8.11	2.62	2.34	0.34	-	1.09	16.42	27.27	-	-	1.01	-	2.38	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.03	0	0	13.9	0.1	0.36	1.96	1.15	0.21	0.02	1.02	8.11	2.62	2.34	0.34	-	1.09	16.42	27.27	-	-	1.01	-	2.38	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.03		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.47	0.02	0.45	0.61	0.29	0.05		0.28	5.57	6.58			0		2.09	5.02					0.67																					24.1	0	0	16.37	0.12	0.81	2.58	1.43	0.27	0.02	1.31	13.68	9.19	2.34	0.34	-	1.09	18.51	32.28	-	-	1.01	-	3.05	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	105.12
R5826_813_0	2007	2	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		267.35	2.02	475.16	2267.08	132.2	0.79	0.06	261.59	467.59	862.31	587.94	39.2	401.94	333.17	7578.26	8989.19			331.48		10.98											14.07	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.37	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.79	2.52	2.25	0.33	-	1.05	15.79	26.22	-	-	0.97	-	2.2	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.81	0	0	13.37	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.79	2.52	2.25	0.33	-	1.05	15.79	26.22	-	-	0.97	-	2.2	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.81		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.38	0.02	0.41	0.57	0.28	0.05		0.27	5.15	6.08			0		1.93	4.63					0.62																					22.38	0	0	15.74	0.12	0.76	2.45	1.38	0.25	0.01	1.26	12.94	8.59	2.25	0.33	-	1.05	17.72	30.85	-	-	0.97	-	2.82	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	100.19
R5826_814_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		257.39	1.94	457.45	2182.6	127.27	0.73	0.06	251.85	450.17	830.18	566.03	37.74	386.96	320.75	7295.87	8654.22			319.13		10.17											13.55	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.87	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.2	25.24	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.82	0	0	12.87	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.2	25.24	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.82		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.29	0.02	0.38	0.52	0.27	0.05		0.26	4.77	5.63			0		1.78	4.29					0.58																					20.83	0	0	15.16	0.11	0.72	2.34	1.33	0.23	0.01	1.21	12.27	8.05	2.16	0.31	-	1.01	16.98	29.53	-	-	0.93	-	2.61	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.66
R5826_815_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		259.74	1.96	461.63	2202.52	128.43	0.75	0.06	254.15	454.28	837.76	571.2	38.08	390.5	323.68	7362.47	8733.22			322.04		10.36											13.67	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.47	-	-	0.94	-	2.07	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.53	0	0	12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.47	-	-	0.94	-	2.07	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.53		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.53	0.27	0.05		0.26	4.86	5.73			0		1.82	4.37					0.59																					21.19	0	0	15.3	0.12	0.73	2.37	1.34	0.23	0.01	1.22	12.43	8.18	2.18	0.32	-	1.02	17.16	29.84	-	-	0.94	-	2.66	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	96.72
R5826_816_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		259.8	1.96	461.73	2203.02	128.46	0.75	0.06	254.2	454.38	837.95	571.33	38.09	390.58	323.75	7364.15	8735.21			322.12		10.38											13.67	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.48	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.55	0	0	12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.48	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.55		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.53	0.27	0.05		0.26	4.87	5.74			0		1.82	4.38					0.59																					21.23	0	0	15.3	0.12	0.73	2.37	1.34	0.23	0.01	1.22	12.44	8.19	2.18	0.32	-	1.02	17.16	29.86	-	-	0.94	-	2.66	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	96.78
R5826_817_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		252.03	1.9	447.93	2137.16	124.62	0.7	0.05	246.6	440.8	812.9	554.25	36.95	378.91	314.07	7144	8474.08			312.49		9.75											13.26	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.6	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.88	24.72	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.22	0	0	12.6	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.88	24.72	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.22		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.37	0.5	0.26	0.04		0.26	4.57	5.4			0		1.71	4.12					0.55																					20.04	0	0	14.84	0.11	0.7	2.28	1.3	0.22	0.01	1.19	11.92	7.77	2.12	0.31	-	0.99	16.59	28.83	-	-	0.91	-	2.5	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	93.25
R5826_818_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.17	1.93	455.28	2172.25	126.67	0.73	0.05	250.65	448.03	826.24	563.35	37.56	385.13	319.23	7261.27	8613.18			317.62		10.08											13.48	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.13	25.12	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.46	0	0	12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.13	25.12	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.46		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.72	5.57			0		1.77	4.25					0.57																					20.65	0	0	15.09	0.11	0.71	2.33	1.32	0.23	0.01	1.21	12.19	7.98	2.15	0.31	-	1	16.9	29.37	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.11
R5826_819_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		259.66	1.96	461.49	2201.87	128.39	0.76	0.06	254.07	454.14	837.51	571.03	38.07	390.38	323.58	7360.29	8730.63			321.95		10.59											13.67	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.98	0.1	0.34	1.83	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.33	25.46	-	-	0.94	-	2.12	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.56	0	0	12.98	0.1	0.34	1.83	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.33	25.46	-	-	0.94	-	2.12	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.56		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.4	0.55	0.27	0.05		0.26	4.97	5.86			0		1.86	4.47					0.6																					21.61	0	0	15.29	0.12	0.74	2.38	1.34	0.24	0.01	1.22	12.54	8.31	2.18	0.32	-	1.02	17.19	29.94	-	-	0.94	-	2.72	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	97.17
R5826_820_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		267.17	2.01	474.84	2265.54	132.11	0.79	0.06	261.42	467.27	861.73	587.54	39.17	401.67	332.94	7573.14	8983.11			331.26		10.97											14.06	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.36	0.1	0.35	1.89	1.1	0.2	0.01	0.98	7.79	2.51	2.24	0.33	-	1.04	15.78	26.2	-	-	0.97	-	2.19	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.76	0	0	13.36	0.1	0.35	1.89	1.1	0.2	0.01	0.98	7.79	2.51	2.24	0.33	-	1.04	15.78	26.2	-	-	0.97	-	2.19	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.76		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.37	0.02	0.41	0.56	0.28	0.05		0.27	5.14	6.07			0		1.92	4.63					0.62																					22.35	0	0	15.73	0.12	0.76	2.45	1.38	0.25	0.01	1.26	12.93	8.58	2.24	0.33	-	1.04	17.7	30.83	-	-	0.97	-	2.82	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	100.11
R5826_821_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.34	1.92	452.04	2156.77	125.76	0.71	0.05	248.87	444.84	820.35	559.33	37.29	382.38	316.95	7209.53	8551.81			315.35		9.93											13.39	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91	0	0	12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.66	5.49			0		1.74	4.19					0.56																					20.38	0	0	14.98	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.07	7.89	2.14	0.31	-	0.99	16.76	29.13	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.29
R5826_822_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.49	1.93	455.86	2174.99	126.83	0.73	0.05	250.97	448.6	827.28	564.06	37.6	385.61	319.63	7270.44	8624.05			318.02		10.1											13.5	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.82	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.15	0.31	-	1	15.15	25.15	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.55	0	0	12.82	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.15	0.31	-	1	15.15	25.15	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.55		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.74	5.59			0		1.77	4.26					0.57																					20.71	0	0	15.1	0.11	0.71	2.33	1.32	0.23	0.01	1.21	12.21	8	2.15	0.31	-	1	16.92	29.42	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.26
R5826_823_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.32	1.92	452.01	2156.61	125.75	0.72	0.05	248.85	444.81	820.29	559.29	37.29	382.36	316.93	7209.01	8551.19			315.33		9.95											13.39	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91	0	0	12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.66	5.5			0		1.75	4.2					0.56																					20.41	0	0	14.98	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.08	7.9	2.14	0.31	-	0.99	16.76	29.14	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.31
R5826_824_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		257.28	1.94	457.26	2181.65	127.21	0.73	0.06	251.74	449.97	829.82	565.79	37.72	386.8	320.61	7292.72	8650.48			318.99		10.17											13.54	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.86	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.19	25.23	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.79	0	0	12.86	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.19	25.23	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.79		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.29	0.02	0.38	0.52	0.27	0.05		0.26	4.77	5.63			0		1.78	4.29					0.58																					20.83	0	0	15.15	0.11	0.72	2.34	1.33	0.23	0.01	1.21	12.27	8.05	2.16	0.31	-	1.01	16.98	29.52	-	-	0.93	-	2.61	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.62
R5826_825_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		278.9	2.1	495.69	2365.03	137.91	0.86	0.06	272.9	487.79	899.57	613.34	40.89	419.31	347.56	7905.71	9377.6			345.8		11.96											14.68	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.95	0.11	0.36	1.97	1.15	0.22	0.02	1.03	8.13	2.62	2.34	0.34	-	1.09	16.47	27.35	-	-	1.01	-	2.39	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.28	0	0	13.95	0.11	0.36	1.97	1.15	0.22	0.02	1.03	8.13	2.62	2.34	0.34	-	1.09	16.47	27.35	-	-	1.01	-	2.39	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.28		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.48	0.02	0.45	0.62	0.29	0.05		0.28	5.61	6.62			0		2.1	5.05					0.68																					24.25	0	0	16.42	0.12	0.81	2.59	1.44	0.27	0.02	1.31	13.74	9.24	2.34	0.34	-	1.09	18.57	32.4	-	-	1.01	-	3.07	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	105.53
R5826_826_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		270.91	2.04	481.48	2297.24	133.95	0.81	0.06	265.08	473.81	873.79	595.76	39.72	407.29	337.6	7679.11	9108.81			335.89		11.28											14.26	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.55	0.1	0.35	1.91	1.12	0.2	0.02	1	7.9	2.55	2.28	0.33	-	1.06	16	26.57	-	-	0.98	-	2.26	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.88	0	0	13.55	0.1	0.35	1.91	1.12	0.2	0.02	1	7.9	2.55	2.28	0.33	-	1.06	16	26.57	-	-	0.98	-	2.26	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.88		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.41	0.02	0.42	0.58	0.28	0.05		0.28	5.29	6.24			0		1.98	4.76					0.64																					22.95	0	0	15.95	0.12	0.78	2.49	1.4	0.25	0.02	1.27	13.19	8.79	2.28	0.33	-	1.06	17.98	31.33	-	-	0.98	-	2.9	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	101.83
R5826_827_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		263.43	1.99	468.18	2233.8	130.26	0.77	0.06	257.75	460.73	849.65	579.31	38.62	396.04	328.27	7467.02	8857.23			326.62		10.66											13.86	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.17	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.68	2.48	2.21	0.32	-	1.03	15.56	25.83	-	-	0.95	-	2.13	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.63	0	0	13.17	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.68	2.48	2.21	0.32	-	1.03	15.56	25.83	-	-	0.95	-	2.13	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.63		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.34	0.02	0.4	0.55	0.27	0.05		0.27	5	5.9			0		1.87	4.5					0.6																					21.77	0	0	15.51	0.12	0.74	2.41	1.36	0.24	0.01	1.24	12.68	8.38	2.21	0.32	-	1.03	17.43	30.33	-	-	0.95	-	2.74	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	98.4
R5826_828_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		253.54	1.91	450.61	2149.93	125.37	0.71	0.05	248.08	443.43	817.75	557.56	37.17	381.17	315.95	7186.68	8524.71			314.35		9.87											13.34	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.68	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.39	2.13	0.31	-	0.99	14.97	24.86	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.67	0	0	12.68	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.39	2.13	0.31	-	0.99	14.97	24.86	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.67		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.25	0.02	0.37	0.51	0.26	0.04		0.26	4.63	5.46			0		1.73	4.16					0.56																					20.26	0	0	14.93	0.11	0.7	2.3	1.31	0.22	0.01	1.19	12.02	7.85	2.13	0.31	-	0.99	16.7	29.03	-	-	0.92	-	2.53	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	93.93
R5826_831_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		263.74	1.99	468.75	2236.5	130.41	0.77	0.06	258.07	461.28	850.68	580.01	38.67	396.52	328.67	7476.06	8867.96			327.01		10.7											13.88	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.19	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.22	0.32	-	1.03	15.58	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.73	0	0	13.19	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.22	0.32	-	1.03	15.58	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.73		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.34	0.02	0.4	0.55	0.27	0.05		0.27	5.02	5.92			0		1.88	4.52					0.61																					21.84	0	0	15.53	0.12	0.75	2.41	1.36	0.24	0.01	1.24	12.7	8.4	2.22	0.32	-	1.03	17.45	30.38	-	-	0.95	-	2.75	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	98.57
R5826_832_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.08	1.93	455.12	2171.47	126.62	0.72	0.05	250.56	447.87	825.95	563.15	37.54	384.99	319.12	7258.69	8610.12			317.5		10.07											13.48	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.8	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.12	25.11	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.43	0	0	12.8	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.46	2.41	2.15	0.31	-	1	15.12	25.11	-	-	0.93	-	2.01	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.43		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.72	5.57			0		1.77	4.25					0.57																					20.64	0	0	15.08	0.11	0.71	2.33	1.32	0.23	0.01	1.2	12.18	7.98	2.15	0.31	-	1	16.89	29.36	-	-	0.93	-	2.58	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.07
R5826_833_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.05	1.96	462.18	2205.17	128.59	0.75	0.06	254.45	454.82	838.76	571.88	38.13	390.96	324.07	7371.32	8743.72			322.43		10.38											13.69	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.58	2.45	2.18	0.32	-	1.02	15.36	25.5	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.62	0	0	13	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.58	2.45	2.18	0.32	-	1.02	15.36	25.5	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.62		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.53	0.27	0.05		0.27	4.87	5.75			0		1.82	4.38					0.59																					21.24	0	0	15.31	0.12	0.73	2.37	1.34	0.23	0.01	1.22	12.45	8.19	2.18	0.32	-	1.02	17.18	29.88	-	-	0.94	-	2.66	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	96.86
R5826_834_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		269.2	2.03	478.45	2282.79	133.11	0.8	0.06	263.41	470.83	868.29	592.01	39.47	404.73	335.47	7630.79	9051.5			333.78		11.16											14.17	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.46	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.85	2.53	2.26	0.33	-	1.05	15.9	26.4	-	-	0.97	-	2.23	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.37	0	0	13.46	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.85	2.53	2.26	0.33	-	1.05	15.9	26.4	-	-	0.97	-	2.23	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.37		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.39	0.02	0.42	0.57	0.28	0.05		0.27	5.23	6.18			0		1.96	4.71					0.63																					22.72	0	0	15.85	0.12	0.77	2.48	1.39	0.25	0.02	1.27	13.08	8.71	2.26	0.33	-	1.05	17.86	31.11	-	-	0.97	-	2.86	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	101.09
R5826_835_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		263.69	1.99	468.66	2236.04	130.39	0.77	0.06	258.01	461.19	850.51	579.89	38.66	396.44	328.61	7474.53	8866.14			326.94		10.68											13.88	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.18	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.21	0.32	-	1.03	15.57	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.71	0	0	13.18	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.69	2.48	2.21	0.32	-	1.03	15.57	25.86	-	-	0.95	-	2.14	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.71		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.34	0.02	0.4	0.55	0.27	0.05		0.27	5.01	5.91			0		1.87	4.51					0.61																					21.8	0	0	15.53	0.12	0.75	2.41	1.36	0.24	0.01	1.24	12.69	8.39	2.21	0.32	-	1.03	17.45	30.37	-	-	0.95	-	2.74	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	98.51
R5826_836_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		268.54	2.02	477.27	2277.16	132.78	0.8	0.06	262.76	469.67	866.14	590.55	39.37	403.73	334.65	7611.95	9029.15			332.96		11.08											14.13	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.43	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.83	2.53	2.26	0.33	-	1.05	15.86	26.34	-	-	0.97	-	2.22	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.17	0	0	13.43	0.1	0.35	1.9	1.11	0.2	0.02	0.99	7.83	2.53	2.26	0.33	-	1.05	15.86	26.34	-	-	0.97	-	2.22	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.17		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.39	0.02	0.42	0.57	0.28	0.05		0.27	5.2	6.13			0		1.94	4.68					0.63																					22.57	0	0	15.81	0.12	0.77	2.47	1.38	0.25	0.02	1.26	13.02	8.66	2.26	0.33	-	1.05	17.8	31.01	-	-	0.97	-	2.84	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	100.73
R5826_837_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.79	1.97	463.5	2211.46	128.95	0.75	0.06	255.18	456.12	841.16	573.51	38.23	392.08	324.99	7392.34	8768.65			323.35		10.44											13.73	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.84	0	0	13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.84		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.32	0.02	0.39	0.54	0.27	0.05		0.27	4.89	5.78			0		1.83	4.41					0.59																					21.35	0	0	15.36	0.12	0.73	2.38	1.34	0.24	0.01	1.23	12.5	8.23	2.19	0.32	-	1.02	17.23	29.98	-	-	0.94	-	2.68	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	97.19
R5826_838_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.31	1.96	462.65	2207.4	128.72	0.75	0.06	254.71	455.28	839.61	572.46	38.16	391.36	324.4	7378.77	8752.56			322.76		10.41											13.7	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.02	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.59	2.45	2.19	0.32	-	1.02	15.37	25.53	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.7	0	0	13.02	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.59	2.45	2.19	0.32	-	1.02	15.37	25.53	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.7		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.54	0.27	0.05		0.27	4.88	5.76			0		1.83	4.39					0.59																					21.29	0	0	15.33	0.12	0.73	2.38	1.34	0.23	0.01	1.22	12.47	8.21	2.19	0.32	-	1.02	17.2	29.92	-	-	0.94	-	2.67	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	96.99
R5826_839_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		260.85	1.97	463.6	2211.92	128.98	0.75	0.06	255.23	456.21	841.33	573.63	38.24	392.16	325.06	7393.88	8770.48			323.42		10.46											13.73	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.86	0	0	13.04	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.6	2.45	2.19	0.32	-	1.02	15.4	25.58	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.86		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.32	0.02	0.39	0.54	0.27	0.05		0.27	4.91	5.79			0		1.84	4.42					0.59																					21.39	0	0	15.36	0.12	0.73	2.38	1.34	0.24	0.01	1.23	12.51	8.24	2.19	0.32	-	1.02	17.24	30	-	-	0.94	-	2.69	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	97.25
R5826_840_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		261.04	1.97	463.94	2213.56	129.08	0.75	0.06	255.42	456.55	841.95	574.06	38.27	392.45	325.3	7399.37	8776.99			323.66		10.47											13.74	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.05	0.1	0.34	1.84	1.08	0.19	0.01	0.96	7.61	2.46	2.19	0.32	-	1.02	15.42	25.6	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.92	0	0	13.05	0.1	0.34	1.84	1.08	0.19	0.01	0.96	7.61	2.46	2.19	0.32	-	1.02	15.42	25.6	-	-	0.94	-	2.09	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	75.92		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.32	0.02	0.39	0.54	0.27	0.05		0.27	4.91	5.79			0		1.84	4.42					0.59																					21.4	0	0	15.37	0.12	0.73	2.38	1.34	0.24	0.01	1.23	12.52	8.25	2.19	0.32	-	1.02	17.25	30.02	-	-	0.94	-	2.69	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	97.32
R5826_841_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		280.43	2.11	498.4	2377.96	138.66	0.87	0.07	274.39	490.46	904.49	616.7	41.11	421.6	349.46	7948.93	9428.87			347.7		12.1											14.76	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									14.02	0.11	0.37	1.98	1.16	0.22	0.02	1.03	8.17	2.64	2.36	0.34	-	1.1	16.56	27.5	-	-	1.01	-	2.42	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	81.74	0	0	14.02	0.11	0.37	1.98	1.16	0.22	0.02	1.03	8.17	2.64	2.36	0.34	-	1.1	16.56	27.5	-	-	1.01	-	2.42	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	81.74		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.49	0.02	0.46	0.62	0.29	0.05		0.29	5.67	6.69			0		2.12	5.1					0.69																					24.5	0	0	16.51	0.12	0.82	2.6	1.44	0.27	0.02	1.32	13.85	9.33	2.36	0.34	-	1.1	18.68	32.61	-	-	1.01	-	3.1	-	-	-	-	-	-	-	-	-	-	0.74	0.01	-	-	-	-	-	-	-	-	106.24
R5826_842_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		278.06	2.1	494.2	2357.91	137.49	0.86	0.06	272.08	486.32	896.86	611.5	40.77	418.04	346.51	7881.89	9349.35			344.76		11.88											14.63	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.9	0.1	0.36	1.96	1.15	0.21	0.02	1.02	8.11	2.62	2.34	0.34	-	1.09	16.42	27.27	-	-	1.01	-	2.38	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.03	0	0	13.9	0.1	0.36	1.96	1.15	0.21	0.02	1.02	8.11	2.62	2.34	0.34	-	1.09	16.42	27.27	-	-	1.01	-	2.38	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.03		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.47	0.02	0.45	0.61	0.29	0.05		0.28	5.57	6.58			0		2.09	5.02					0.67																					24.1	0	0	16.37	0.12	0.81	2.58	1.43	0.27	0.02	1.31	13.68	9.19	2.34	0.34	-	1.09	18.51	32.28	-	-	1.01	-	3.05	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	105.12
R5826_843_0	2007	3	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		267.35	2.02	475.16	2267.08	132.2	0.79	0.06	261.59	467.59	862.31	587.94	39.2	401.94	333.17	7578.26	8989.19			331.48		10.98											14.07	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.37	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.79	2.52	2.25	0.33	-	1.05	15.79	26.22	-	-	0.97	-	2.2	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.81	0	0	13.37	0.1	0.35	1.89	1.1	0.2	0.01	0.99	7.79	2.52	2.25	0.33	-	1.05	15.79	26.22	-	-	0.97	-	2.2	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.81		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.38	0.02	0.41	0.57	0.28	0.05		0.27	5.15	6.08			0		1.93	4.63					0.62																					22.38	0	0	15.74	0.12	0.76	2.45	1.38	0.25	0.01	1.26	12.94	8.59	2.25	0.33	-	1.05	17.72	30.85	-	-	0.97	-	2.82	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	100.19
R5826_844_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		257.39	1.94	457.45	2182.6	127.27	0.73	0.06	251.85	450.17	830.18	566.03	37.74	386.96	320.75	7295.87	8654.22			319.13		10.17											13.55	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.87	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.2	25.24	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.82	0	0	12.87	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.2	25.24	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.82		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.29	0.02	0.38	0.52	0.27	0.05		0.26	4.77	5.63			0		1.78	4.29					0.58																					20.83	0	0	15.16	0.11	0.72	2.34	1.33	0.23	0.01	1.21	12.27	8.05	2.16	0.31	-	1.01	16.98	29.53	-	-	0.93	-	2.61	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.66
R5826_845_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		259.8	1.96	461.73	2203.02	128.46	0.75	0.06	254.2	454.38	837.95	571.33	38.09	390.58	323.75	7364.15	8735.21			322.12		10.38											13.67	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.48	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.55	0	0	12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.48	-	-	0.94	-	2.08	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.55		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.53	0.27	0.05		0.26	4.87	5.74			0		1.82	4.38					0.59																					21.23	0	0	15.3	0.12	0.73	2.37	1.34	0.23	0.01	1.22	12.44	8.19	2.18	0.32	-	1.02	17.16	29.86	-	-	0.94	-	2.66	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	96.78
R5826_846_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		252.03	1.9	447.93	2137.16	124.62	0.7	0.05	246.6	440.8	812.9	554.25	36.95	378.91	314.07	7144	8474.08			312.49		9.75											13.26	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.6	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.88	24.72	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.22	0	0	12.6	0.1	0.33	1.78	1.04	0.18	0.01	0.93	7.35	2.37	2.12	0.31	-	0.99	14.88	24.72	-	-	0.91	-	1.95	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	73.22		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.24	0.02	0.37	0.5	0.26	0.04		0.26	4.57	5.4			0		1.71	4.12					0.55																					20.04	0	0	14.84	0.11	0.7	2.28	1.3	0.22	0.01	1.19	11.92	7.77	2.12	0.31	-	0.99	16.59	28.83	-	-	0.91	-	2.5	-	-	-	-	-	-	-	-	-	-	0.66	0.01	-	-	-	-	-	-	-	-	93.25
R5826_847_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.17	1.93	455.28	2172.25	126.67	0.73	0.05	250.65	448.03	826.24	563.35	37.56	385.13	319.23	7261.27	8613.18			317.62		10.08											13.48	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.13	25.12	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.46	0	0	12.81	0.1	0.33	1.81	1.06	0.18	0.01	0.94	7.47	2.41	2.15	0.31	-	1	15.13	25.12	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.46		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.72	5.57			0		1.77	4.25					0.57																					20.65	0	0	15.09	0.11	0.71	2.33	1.32	0.23	0.01	1.21	12.19	7.98	2.15	0.31	-	1	16.9	29.37	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.11
R5826_848_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		259.66	1.96	461.49	2201.87	128.39	0.76	0.06	254.07	454.14	837.51	571.03	38.07	390.38	323.58	7360.29	8730.63			321.95		10.59											13.67	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.98	0.1	0.34	1.83	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.33	25.46	-	-	0.94	-	2.12	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.56	0	0	12.98	0.1	0.34	1.83	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.33	25.46	-	-	0.94	-	2.12	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.56		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.4	0.55	0.27	0.05		0.26	4.97	5.86			0		1.86	4.47					0.6																					21.61	0	0	15.29	0.12	0.74	2.38	1.34	0.24	0.01	1.22	12.54	8.31	2.18	0.32	-	1.02	17.19	29.94	-	-	0.94	-	2.72	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	97.17
R5826_849_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		259.74	1.96	461.63	2202.52	128.43	0.75	0.06	254.15	454.28	837.76	571.2	38.08	390.5	323.68	7362.47	8733.22			322.04		10.36											13.67	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.47	-	-	0.94	-	2.07	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.53	0	0	12.99	0.1	0.34	1.84	1.07	0.19	0.01	0.96	7.57	2.44	2.18	0.32	-	1.02	15.34	25.47	-	-	0.94	-	2.07	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	75.53		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.31	0.02	0.39	0.53	0.27	0.05		0.26	4.86	5.73			0		1.82	4.37					0.59																					21.19	0	0	15.3	0.12	0.73	2.37	1.34	0.23	0.01	1.22	12.43	8.18	2.18	0.32	-	1.02	17.16	29.84	-	-	0.94	-	2.66	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	96.72
R5826_850_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		267.17	2.01	474.84	2265.54	132.11	0.79	0.06	261.42	467.27	861.73	587.54	39.17	401.67	332.94	7573.14	8983.11			331.26		10.97											14.06	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.36	0.1	0.35	1.89	1.1	0.2	0.01	0.98	7.79	2.51	2.24	0.33	-	1.04	15.78	26.2	-	-	0.97	-	2.19	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.76	0	0	13.36	0.1	0.35	1.89	1.1	0.2	0.01	0.98	7.79	2.51	2.24	0.33	-	1.04	15.78	26.2	-	-	0.97	-	2.19	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	77.76		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.37	0.02	0.41	0.56	0.28	0.05		0.27	5.14	6.07			0		1.92	4.63					0.62																					22.35	0	0	15.73	0.12	0.76	2.45	1.38	0.25	0.01	1.26	12.93	8.58	2.24	0.33	-	1.04	17.7	30.83	-	-	0.97	-	2.82	-	-	-	-	-	-	-	-	-	-	0.7	0.01	-	-	-	-	-	-	-	-	100.11
R5826_851_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.34	1.92	452.04	2156.77	125.76	0.71	0.05	248.87	444.84	820.35	559.33	37.29	382.38	316.95	7209.53	8551.81			315.35		9.93											13.39	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91	0	0	12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.66	5.49			0		1.74	4.19					0.56																					20.38	0	0	14.98	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.07	7.89	2.14	0.31	-	0.99	16.76	29.13	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.29
R5826_852_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		256.49	1.93	455.86	2174.99	126.83	0.73	0.05	250.97	448.6	827.28	564.06	37.6	385.61	319.63	7270.44	8624.05			318.02		10.1											13.5	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.82	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.15	0.31	-	1	15.15	25.15	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.55	0	0	12.82	0.1	0.33	1.81	1.06	0.18	0.01	0.95	7.48	2.41	2.15	0.31	-	1	15.15	25.15	-	-	0.93	-	2.02	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	74.55		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.28	0.02	0.38	0.52	0.26	0.05		0.26	4.74	5.59			0		1.77	4.26					0.57																					20.71	0	0	15.1	0.11	0.71	2.33	1.32	0.23	0.01	1.21	12.21	8	2.15	0.31	-	1	16.92	29.42	-	-	0.93	-	2.59	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	95.26
R5826_853_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		254.32	1.92	452.01	2156.61	125.75	0.72	0.05	248.85	444.81	820.29	559.29	37.29	382.36	316.93	7209.01	8551.19			315.33		9.95											13.39	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91	0	0	12.72	0.1	0.33	1.8	1.05	0.18	0.01	0.94	7.41	2.39	2.14	0.31	-	0.99	15.02	24.94	-	-	0.92	-	1.99	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.91		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.26	0.02	0.37	0.51	0.26	0.04		0.26	4.66	5.5			0		1.75	4.2					0.56																					20.41	0	0	14.98	0.11	0.71	2.31	1.31	0.22	0.01	1.2	12.08	7.9	2.14	0.31	-	0.99	16.76	29.14	-	-	0.92	-	2.55	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	94.31
R5826_854_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		257.28	1.94	457.26	2181.65	127.21	0.73	0.06	251.74	449.97	829.82	565.79	37.72	386.8	320.61	7292.72	8650.48			318.99		10.17											13.54	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.86	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.19	25.23	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.79	0	0	12.86	0.1	0.34	1.82	1.06	0.18	0.01	0.95	7.5	2.42	2.16	0.31	-	1.01	15.19	25.23	-	-	0.93	-	2.03	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	74.79		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.29	0.02	0.38	0.52	0.27	0.05		0.26	4.77	5.63			0		1.78	4.29					0.58																					20.83	0	0	15.15	0.11	0.72	2.34	1.33	0.23	0.01	1.21	12.27	8.05	2.16	0.31	-	1.01	16.98	29.52	-	-	0.93	-	2.61	-	-	-	-	-	-	-	-	-	-	0.68	0.01	-	-	-	-	-	-	-	-	95.62
R5826_855_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		278.9	2.1	495.69	2365.03	137.91	0.86	0.06	272.9	487.79	899.57	613.34	40.89	419.31	347.56	7905.71	9377.6			345.8		11.96											14.68	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.95	0.11	0.36	1.97	1.15	0.22	0.02	1.03	8.13	2.62	2.34	0.34	-	1.09	16.47	27.35	-	-	1.01	-	2.39	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.28	0	0	13.95	0.11	0.36	1.97	1.15	0.22	0.02	1.03	8.13	2.62	2.34	0.34	-	1.09	16.47	27.35	-	-	1.01	-	2.39	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	81.28		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.48	0.02	0.45	0.62	0.29	0.05		0.28	5.61	6.62			0		2.1	5.05					0.68																					24.25	0	0	16.42	0.12	0.81	2.59	1.44	0.27	0.02	1.31	13.74	9.24	2.34	0.34	-	1.09	18.57	32.4	-	-	1.01	-	3.07	-	-	-	-	-	-	-	-	-	-	0.73	0.01	-	-	-	-	-	-	-	-	105.53
R5826_856_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		270.91	2.04	481.48	2297.24	133.95	0.81	0.06	265.08	473.81	873.79	595.76	39.72	407.29	337.6	7679.11	9108.81			335.89		11.28											14.26	0.11									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.8	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.55	0.1	0.35	1.91	1.12	0.2	0.02	1	7.9	2.55	2.28	0.33	-	1.06	16	26.57	-	-	0.98	-	2.26	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.88	0	0	13.55	0.1	0.35	1.91	1.12	0.2	0.02	1	7.9	2.55	2.28	0.33	-	1.06	16	26.57	-	-	0.98	-	2.26	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	78.88		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.41	0.02	0.42	0.58	0.28	0.05		0.28	5.29	6.24			0		1.98	4.76					0.64																					22.95	0	0	15.95	0.12	0.78	2.49	1.4	0.25	0.02	1.27	13.19	8.79	2.28	0.33	-	1.06	17.98	31.33	-	-	0.98	-	2.9	-	-	-	-	-	-	-	-	-	-	0.71	0.01	-	-	-	-	-	-	-	-	101.83
R5826_857_0	2007	4	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		263.43	1.99	468.18	2233.8	130.26	0.77	0.06	257.75	460.73	849.65	579.31	38.62	396.04	328.27	7467.02	8857.23			326.62		10.66											13.86	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									13.17	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.68	2.48	2.21	0.32	-	1.03	15.56	25.83	-	-	0.95	-	2.13	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.63	0	0	13.17	0.1	0.34	1.86	1.09	0.19	0.01	0.97	7.68	2.48	2.21	0.32	-	1.03	15.56	25.83	-	-	0.95	-	2.13	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	76.63		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.34	0.02	0.4	0.55	0.27	0.05		0.27	5	5.9			0		1.87	4.5					0.6																					21.77	0	0	15.51	0.12	0.74	2.41	1.36	0.24	0.01	1.24	12.68	8.38	2.21	0.32	-	1.03	17.43	30.33	-	-	0.95	-	2.74	-	-	-	-	-	-	-	-	-	-	0.69	0.01	-	-	-	-	-	-	-	-	98.4
R5826_858_0	2007	5	s.	t.									Inpatient Facility	Inpatient Facility										Acute Level 2	Mental Health Level 2									A	A	D	V	T	Coin	Coin	V	V	V	V	V	P	V	V	V			V		Coin											A	A									0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0			0		0											0	0									-		253.54	1.91	450.61	2149.93	125.37	0.71	0.05	248.08	443.43	817.75	557.56	37.17	381.17	315.95	7186.68	8524.71			314.35		9.87											13.34	0.1									600/admit	600/admit	0/day (1-20) 100/day (21-100)	10/Visit	100/ Trip	25 Coins	25 Coins	25-50/ Visit	200/ Visit	35/ Visit	35-100/ Visit	100/ Visit	0/ Procedure	25-100/ Visit	25/ Visit	35/ Visit			35/ Visit		20 Coins											600/admit	600/admit									600	600	8.81	10	100	0.25	0.25	45.2	200	35	45.83	100	0	37.65	25	35			35		0.2											600	600									12.68	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.39	2.13	0.31	-	0.99	14.97	24.86	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.67	0	0	12.68	0.1	0.33	1.79	1.04	0.18	0.01	0.93	7.39	2.39	2.13	0.31	-	0.99	14.97	24.86	-	-	0.92	-	1.97	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	73.67		912/admit	912/admit	40 Coins	40 Coins	100/Trip	50 Coins		50/Visit	40 Coins	40 Coins			0/Procedure		20 Coins	40 Coins					20 Coins																					2.25	0.02	0.37	0.51	0.26	0.04		0.26	4.63	5.46			0		1.73	4.16					0.56																					20.26	0	0	14.93	0.11	0.7	2.3	1.31	0.22	0.01	1.19	12.02	7.85	2.13	0.31	-	0.99	16.7	29.03	-	-	0.92	-	2.53	-	-	-	-	-	-	-	-	-	-	0.67	0.01	-	-	-	-	-	-	-	-	93.93
R5863_001_0	2007	9																					3100											A	D	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	P	V	V	V	Coin	O	O	V																																																				-		223.11	3.06	333.9	0	181.44	11.64	7.2	282.33	189.63	0	612.99	0	0	360.36	3927.06	3360.96	166.14	1439.19	4077.9	1324.62	0	566.46	0	0	0	0	0	3.05	0	0	0											300/Admit	956 ded 239 days 60-90; 478 days 91-190	100/Day days 21-100	No copay	100/Trip	30 Coinsurance	30 Coinsurance; 0 Monitoring Supplies	50 ER; 35 Urgent Care	150/Visit	No Copay	15/Visit	No Copay	No Copay	35 PT/OT; 10 Cardiovascular	10/Visit	35/Visit	35/Visit	35/Visit	15/Visit	35/Visit	No Copay	35/Visit	No Copay	No Copay	No Copay	No Copay	No Copay	30 Coinsurance	No Copay	No Copay	No Copay											300	773.18	100	0	100	0.3	0.27	44.95	150	0	15	0	0	23.05	10	35	35	12.93	15	34.83	0	35	0	0	0	0	0	0.3	0	0	0											5.58	0.2	2.78	-	1.51	3.49	1.97	1.06	2.37	-	0.77	-	-	0.69	3.27	9.8	0.48	1.55	5.1	3.85	-	1.65	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	47.04		0.1	5.58	0.2	2.78	-	1.51	3.49	1.97	1.06	2.37	-	0.77	-	-	0.69	3.27	9.8	0.48	1.55	5.1	3.85	-	1.65	-	-	-	-	-	0.91	-	-	-	-	-	-	-	-	-	-	-	-	-	47.04	10000	600/admit	956 ded 239 days 60-90; 478 days 91-190	100/Day	No copay	100/Trip	30 Coinsurance	30 Coinsurance; 0 Monitoring Supplies	50 ER; 40 Urgent Care	300/Visit	30 Coinsurance	20/Visit	No Copay	No Copay	40/Visit	20/Visit	40/Visit	40/Visit	40/Visit	20/Visit	30 Coinsurance	No Copay	30 Coinsurance	No Copay	No Copay	No Copay	No Copay	No Copay	30 Coinsurance	No Copay	No Copay	No Copay											1.35	0.03	0.64	0	0.19	0.45	0.25	0.12	0.54	0.23	0.12	0	0	0.1	0.7	1.26	0.07	0.21	0.81	0.95	0	0.14	0	0	0	0	0	0.1	0	0	0											8.25			6.92	0.22	3.43	-	1.7	3.94	2.22	1.18	2.91	0.23	0.88	-	-	0.79	3.98	11.07	0.55	1.76	5.91	4.79	-	1.79	-	-	-	-	-	1.02	-	-	-	-	-	-	-	-	-	-	-	-	-	55.29
R5863_801_0	2007	4																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		245.95	2.64	25.32	18.87	6.55	14.58	8.9	4.68	19.39	7.58	20.61	0	0.32	19.8	42.48	122.93	1.79	4.98	42.23	51.75	5.39	6.09	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06																																																																																				-			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06
R5863_803_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		245.95	2.64	25.32	18.87	6.55	14.58	8.9	4.68	19.39	7.58	20.61	0	0.32	19.8	42.48	122.93	1.79	4.98	42.23	51.75	5.39	6.09	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06																																																																																				-			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06
R5863_804_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		245.95	2.64	25.32	18.87	6.55	14.58	8.9	4.68	19.39	7.58	20.61	0	0.32	19.8	42.48	122.93	1.79	4.98	42.23	51.75	5.39	6.09	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06																																																																																				-			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06
R5863_806_0	2007	3																																Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																																																				-		245.95	2.64	25.32	18.87	6.55	14.58	8.9	4.68	19.39	7.58	20.61	0	0.32	19.8	42.48	122.93	1.79	4.98	42.23	51.75	5.39	6.09	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing		Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing																				0.07	0.07	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.23	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06																																																																																				-			17.23	0.19	3.95	-	1.55	3.44	2.1	1.11	4.58	1.79	4.86	-	0.07	4.67	10.03	29.01	0.42	1.17	9.97	12.21	1.27	1.44	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	111.06
R5941_001_0	2007	10	H.	H.	I.	I.	I.	I.	I.	I.	I.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Professional		none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Eyewear		D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V	V																																											-	none	1632.67	40.6	423.26		230.02	8.53	2.87	257.91	329.14	673.99	808.44	36.22	23.01	0.65	4218.08	1396.84	3.48	336.53			161.47				15.69		129.6					755.9	15.31	60.46	286.08	84.44	0.03	633.64	1.79	480		175/day (1-5) with 1750 yearly max	175/day (1-5) with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay	25 copay		91.84	82.42	71.75		71.75	0.19	0.19	47.83	167.42	48.85	57.01	167.42	33.13	23.92	9.57	23.92	23.92	23.92			28.94				23.92		23.92					23.92	47.83	23.92	23.92	9.57	0.19	23.92	23.92	23.92		12.5	0.28	2.53	-	1.38	1.63	0.55	1.03	4.59	2.74	3.84	0.51	0.06	0	3.36	2.78	0.01	0.67	-	-	0.39	-	-	-	0.03	-	0.26	-	-	-	-	1.51	0.06	0.12	0.57	0.07	0.01	1.26	0	0.96	-	43.69		1.98	12.5	0.28	2.53	-	1.38	1.63	0.55	1.03	4.59	2.74	3.84	0.51	0.06	0	3.36	2.78	0.01	0.67	-	-	0.39	-	-	-	0.03	-	0.26	-	-	-	-	1.51	0.06	0.12	0.57	0.07	0.01	1.26	0	0.96	-	43.69	4000	200/day (1-5) with no yearly max	200/day (1-5) with no yearly max	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	250 copay	20 coinsurance	20 coinsurance	250 copay	15/35 copay for in-home/facility	35 copay	15 copay	35 copay	35 copay	35 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					35 copay	20 coinsurance	35 copay	35 copay	15 copay	20 coinsurance	35 copay	35 copay	35 copay		4.55	0.1	1.69		0.38	0.68	0.23	0.29	1.82	0.33	0.83	0.2	0.02	0	1.38	1.06	0	0.26			0.11				0.01		0.02					0	0.02	0	0	0.03	0	0.01	0	0.34		14.36		0.49	17.05	0.38	4.22	-	1.76	2.31	0.78	1.31	6.42	3.08	4.67	0.71	0.08	0	4.74	3.85	0.01	0.93	-	-	0.5	-	-	-	0.04	-	0.28	-	-	-	-	1.51	0.08	0.12	0.57	0.09	0.01	1.27	0	1.3	-	58.05
R5941_002_0	2007	10	H.	H.	I.	I.	I.	I.	I.	I.	I.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Professional		none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Eyewear		D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V	V																																											-	none	1713.83	42.62	444.3		241.46	8.95	3.01	270.74	345.51	707.5	848.62	38.02	24.15	0.68	4466.87	1479.23	3.68	356.38			169.5				16.62		129.6					793.48	16.07	64.03	302.96	89.42	0.03	671.02	1.89	480		175/day with 1750 yearly max	175/day with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	20 copay	10 copay	20 copay	20 copay	20 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 copay	50 copay	20 copay	20 copay	10 copay	20 coinsurance	20 copay	20 copay	20 copay		107.88	110.05	71.9		71.9	0.19	0.19	47.93	143.8	48.95	57.13	143.8	33.2	19.17	9.59	19.17	19.17	19.17			29				19.17		19.17					19.17	47.93	19.17	19.17	9.59	0.19	19.17	19.17	19.17		15.41	0.39	2.66	-	1.45	1.72	0.58	1.08	4.14	2.89	4.04	0.46	0.07	0	3.57	2.36	0.01	0.57	-	-	0.41	-	-	-	0.03	-	0.21	-	-	-	-	1.27	0.06	0.1	0.48	0.07	0.01	1.07	0	0.77	-	45.86		1.98	15.41	0.39	2.66	-	1.45	1.72	0.58	1.08	4.14	2.89	4.04	0.46	0.07	0	3.57	2.36	0.01	0.57	-	-	0.41	-	-	-	0.03	-	0.21	-	-	-	-	1.27	0.06	0.1	0.48	0.07	0.01	1.07	0	0.77	-	45.86	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		12.39	0.11	2.01		0.41	0.81	0.27	0.3	1.53	0.4	0.98	0.05	0.02	0	3.99	2.54	0	0.23			0.12				0		0					0.34	0.02	0.01	0.13	0.04	0	0.67	0	0.33		27.7		0.49	27.79	0.5	4.67	-	1.85	2.53	0.85	1.39	5.67	3.28	5.02	0.51	0.09	0	7.55	4.9	0.01	0.8	-	-	0.52	-	-	-	0.03	-	0.21	-	-	-	-	1.6	0.09	0.12	0.61	0.11	0.01	1.74	0	1.1	-	73.57
R5941_003_0	2007	10	H.	H.	I.	I.	I.	I.	I.	I.	I.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Professional		none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Eyewear		D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V	V																																											-	none	1632.67	40.6	423.26		230.02	8.53	2.87	257.91	329.14	673.99	808.44	36.22	23.01	0.65	4218.08	1396.84	3.48	336.53			161.47				15.69		129.6					755.9	15.31	60.46	286.08	84.44	0.03	633.64	1.79	480		175/day (1-5) with 1750 yearly max	175/day (1-5) with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay	25 copay		93.62	84.02	73.14		73.14	0.2	0.2	48.76	170.66	49.8	58.11	170.66	33.77	24.38	9.75	24.38	24.38	24.38			29.5				24.38		24.38					24.38	48.76	24.38	24.38	9.75	0.2	24.38	24.38	24.38		12.74	0.28	2.58	-	1.4	1.66	0.56	1.05	4.68	2.8	3.92	0.52	0.06	0	3.43	2.84	0.01	0.68	-	-	0.4	-	-	-	0.03	-	0.26	-	-	-	-	1.54	0.06	0.12	0.58	0.07	0.01	1.29	0	0.98	-	44.54		1.13	12.74	0.28	2.58	-	1.4	1.66	0.56	1.05	4.68	2.8	3.92	0.52	0.06	0	3.43	2.84	0.01	0.68	-	-	0.4	-	-	-	0.03	-	0.26	-	-	-	-	1.54	0.06	0.12	0.58	0.07	0.01	1.29	0	0.98	-	44.54	5000	250/day (1-5) with no yearly max	250/day (1-5) with no yearly max	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	250 copay	20 coinsurance	20 coinsurance	250 copay	15/35 copay for in-home/facility	35 copay	15 copay	35 copay	35 copay	35 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					35 copay	20 coinsurance	35 copay	35 copay	15 copay	20 coinsurance	35 copay	35 copay	35 copay		5.79	0.12	1.72		0.39	0.69	0.23	0.29	1.85	0.34	0.84	0.2	0.02	0	1.4	1.08	0	0.26			0.11				0.01		0.02					0	0.02	0	0	0.03	0	0.01	0	0.34		15.77		0.28	18.52	0.41	4.3	-	1.79	2.36	0.79	1.34	6.53	3.14	4.75	0.72	0.08	0	4.83	3.92	0.01	0.94	-	-	0.51	-	-	-	0.04	-	0.28	-	-	-	-	1.54	0.08	0.12	0.58	0.1	0.01	1.3	0	1.32	-	60.31
R5941_004_0	2007	9	H.	H.	I.	I.	I.	I.	I.	I.	I.		OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional	Professional		none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic	Eyewear		D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V	V																																											-	none	1713.83	42.62	444.3		241.46	8.95	3.01	270.74	345.51	707.5	848.62	38.02	24.15	0.68	4466.87	1479.23	3.68	356.38			169.5				16.62		129.6					793.48	16.07	64.03	302.96	89.42	0.03	671.02	1.89	480		175/day with 1750 yearly max	175/day with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	150 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	150 copay	15/35 copay for in-home/facility	20 copay	10 copay	20 copay	20 copay	20 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 copay	50 copay	20 copay	20 copay	10 copay	20 coinsurance	20 copay	20 copay	20 copay		107.88	110.05	71.9		71.9	0.19	0.19	47.93	143.8	48.95	57.13	143.8	33.2	19.17	9.59	19.17	19.17	19.17			29				19.17		19.17					19.17	47.93	19.17	19.17	9.59	0.19	19.17	19.17	19.17		15.41	0.39	2.66	-	1.45	1.72	0.58	1.08	4.14	2.89	4.04	0.46	0.07	0	3.57	2.36	0.01	0.57	-	-	0.41	-	-	-	0.03	-	0.21	-	-	-	-	1.27	0.06	0.1	0.48	0.07	0.01	1.07	0	0.77	-	45.86		1.98	15.41	0.39	2.66	-	1.45	1.72	0.58	1.08	4.14	2.89	4.04	0.46	0.07	0	3.57	2.36	0.01	0.57	-	-	0.41	-	-	-	0.03	-	0.21	-	-	-	-	1.27	0.06	0.1	0.48	0.07	0.01	1.07	0	0.77	-	45.86	4000	20 coinsurance	20 coinsurance	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	15/35 copay for in-home/facility	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance	20 coinsurance		12.61	0.12	2.05		0.42	0.82	0.28	0.31	1.56	0.41	1	0.05	0.02	0	4.06	2.58	0	0.24			0.12				0		0					0.34	0.02	0.02	0.13	0.04	0	0.68	0	0.33		28.2		0.49	28.01	0.51	4.71	-	1.86	2.54	0.85	1.39	5.7	3.29	5.04	0.51	0.09	0	7.63	4.95	0.01	0.81	-	-	0.53	-	-	-	0.03	-	0.21	-	-	-	-	1.61	0.09	0.12	0.61	0.12	0.01	1.75	0	1.1	-	74.06
R5941_801_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	1691.91	26.98	253.01		0.2	10.62	4.82	241.08	432.77	763.1	991.98	34.21	8.53	0	5273.82	1789.36	2.21	589.17			201.95				24.88		129.6					902.43	19.73	117.31	383.58	127.52	0.04	811.05	2.53			175/day (1-5) with 1750 yearly max	175/day (1-5) with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			94.72	97.62	73.3		73.3	0.2	0.2	48.86	171.02	50.12	59.13	171.02	34.2	24.43	9.77	24.43	24.43	24.43			36.84				24.43		24.43					24.43	48.86	24.43	24.43	9.77	0.2	24.43	24.43			13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.29	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66		1.13	13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.29	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66	5000	250/day (1-5) with no yearly max	250/day (1-5) with no yearly max	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	250 copay	20 coinsurance	20 coinsurance	250 copay	15/35 copay for in-home/facility	35 copay	15 copay	35 copay	35 copay	35 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					35 copay	20 coinsurance	35 copay	35 copay	15 copay	20 coinsurance	35 copay	35 copay			5.97	0.09	1.6		0	0.86	0.39	0.27	2.44	0.41	1.11	0.19	0.01	0	1.78	1.41	0	0.46			0.17				0.02		0.02					0	0.03	0	0	0.04	0	0.01	0			17.32		0.28	19.33	0.31	3.15	-	0	2.94	1.33	1.25	8.61	3.6	6	0.68	0.03	0	6.08	5.06	0.01	1.66	-	-	0.79	-	-	-	0.07	-	0.29	-	-	-	-	1.84	0.11	0.24	0.78	0.15	0.01	1.66	0.01	-	-	65.98
R5941_802_0	2007	7	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	1691.94	26.98	253.02		0.2	10.62	4.82	241.08	432.78	763.11	992	34.21	8.53	0	5273.92	1789.39	2.21	589.18			201.95				24.88		129.6					902.45	19.73	117.31	383.59	127.52	0.04	811.06	2.53			175/day (1-5) with 1750 yearly max	175/day (1-5) with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			94.72	97.62	73.3		73.3	0.2	0.2	48.86	171.02	50.12	59.13	171.02	34.2	24.43	9.77	24.43	24.43	24.43			36.84				24.43		24.43					24.43	48.86	24.43	24.43	9.77	0.2	24.43	24.43			13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.3	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66		1.13	13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.3	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66	5000	250/day (1-5) with no yearly max	250/day (1-5) with no yearly max	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	250 copay	20 coinsurance	20 coinsurance	250 copay	15/35 copay for in-home/facility	35 copay	15 copay	35 copay	35 copay	35 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					35 copay	20 coinsurance	35 copay	35 copay	15 copay	20 coinsurance	35 copay	35 copay			5.97	0.09	1.6		0	0.86	0.39	0.27	2.44	0.41	1.11	0.19	0.01	0	1.78	1.41	0	0.46			0.17				0.02		0.02					0	0.03	0	0	0.04	0	0.01	0			17.32		0.28	19.33	0.31	3.15	-	0	2.94	1.33	1.25	8.61	3.6	6	0.68	0.03	0	6.08	5.06	0.01	1.66	-	-	0.79	-	-	-	0.07	-	0.29	-	-	-	-	1.84	0.11	0.24	0.78	0.15	0.01	1.66	0.01	-	-	65.98
R5941_805_0	2007	4	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	1691.91	26.98	253.01		0.2	10.62	4.82	241.08	432.77	763.1	991.98	34.21	8.53	0	5273.82	1789.36	2.21	589.17			201.95				24.88		129.6					902.43	19.73	117.31	383.58	127.52	0.04	811.05	2.53			175/day (1-5) with 1750 yearly max	175/day (1-5) with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			94.72	97.62	73.3		73.3	0.2	0.2	48.86	171.02	50.12	59.13	171.02	34.2	24.43	9.77	24.43	24.43	24.43			36.84				24.43		24.43					24.43	48.86	24.43	24.43	9.77	0.2	24.43	24.43			13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.29	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66		1.13	13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.29	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66	5000	250/day (1-5) with no yearly max	250/day (1-5) with no yearly max	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	250 copay	20 coinsurance	20 coinsurance	250 copay	15/35 copay for in-home/facility	35 copay	15 copay	35 copay	35 copay	35 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					35 copay	20 coinsurance	35 copay	35 copay	15 copay	20 coinsurance	35 copay	35 copay			5.97	0.09	1.6		0	0.86	0.39	0.27	2.44	0.41	1.11	0.19	0.01	0	1.78	1.41	0	0.46			0.17				0.02		0.02					0	0.03	0	0	0.04	0	0.01	0			17.32		0.28	19.33	0.31	3.15	-	0	2.94	1.33	1.25	8.61	3.6	6	0.68	0.03	0	6.08	5.06	0.01	1.66	-	-	0.79	-	-	-	0.07	-	0.29	-	-	-	-	1.84	0.11	0.24	0.78	0.15	0.01	1.66	0.01	-	-	65.98
R5941_806_0	2007	4	H.	H.	I.	I.	I.	I.	I.	I.			OP Facility - Other	OP Facility - Other	Professional	Professional	Professional	Professional	Professional	Professional			none	Rehab Services	Bone Mass Measurement	Chiropractic	Podiatric	Physical Exam	Diabetes Education	Vision Exam Diagnostic	Hearing Exam Diagnostic			D	D	D		T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V			S				V		V					V	V	V	V	V	Coin	V	V																																												-	none	1691.94	26.98	253.02		0.2	10.62	4.82	241.08	432.78	763.11	992	34.21	8.53	0	5273.92	1789.39	2.21	589.18			201.95				24.88		129.6					902.45	19.73	117.31	383.59	127.52	0.04	811.06	2.53			175/day (1-5) with 1750 yearly max	175/day (1-5) with 1750 yearly max	75/day for days 21 to 100		75 copay	20 coinsurance	20 coinsurance	50 copay	175 copay	50/100 copay for Lower/Higher Tier	50/100 copay for Lower/Higher Tier	175 copay	15/35 copay for in-home/facility	25 copay	10 copay	25 copay	25 copay	25 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					25 copay	50 copay	25 copay	25 copay	10 copay	20 coinsurance	25 copay	25 copay			94.72	97.62	73.3		73.3	0.2	0.2	48.86	171.02	50.12	59.13	171.02	34.2	24.43	9.77	24.43	24.43	24.43			36.84				24.43		24.43					24.43	48.86	24.43	24.43	9.77	0.2	24.43	24.43			13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.3	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66		1.13	13.35	0.22	1.55	-	0	2.08	0.94	0.98	6.17	3.19	4.89	0.49	0.02	0	4.3	3.64	0	1.2	-	-	0.62	-	-	-	0.05	-	0.26	-	-	-	-	1.84	0.08	0.24	0.78	0.1	0.01	1.65	0.01	-	-	48.66	5000	250/day (1-5) with no yearly max	250/day (1-5) with no yearly max	20 coinsurance		75 copay	30 coinsurance	30 coinsurance	50 copay	250 copay	20 coinsurance	20 coinsurance	250 copay	15/35 copay for in-home/facility	35 copay	15 copay	35 copay	35 copay	35 copay			15/22.50/40/100 copay levels				50 max w/specialist copay		50 max w/specialist copay					35 copay	20 coinsurance	35 copay	35 copay	15 copay	20 coinsurance	35 copay	35 copay			5.97	0.09	1.6		0	0.86	0.39	0.27	2.44	0.41	1.11	0.19	0.01	0	1.78	1.41	0	0.46			0.17				0.02		0.02					0	0.03	0	0	0.04	0	0.01	0			17.32		0.28	19.33	0.31	3.15	-	0	2.94	1.33	1.25	8.61	3.6	6	0.68	0.03	0	6.08	5.06	0.01	1.66	-	-	0.79	-	-	-	0.07	-	0.29	-	-	-	-	1.84	0.11	0.24	0.78	0.15	0.01	1.66	0.01	-	-	65.98
R6801_001_0	2007	14																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	244.64	15.58	2518.76	0	33.12	62.15	38.78	8.34	22.57	2531.49	25.67	0	0	90.88	100.39	194.19	8.2	3.54	9674.03	66.91	19.93	7.33	0	0	64.58	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.54	0.38	0.25	25.19	0.25	0	0	0.25	0.23	0.21	0.51	0.22	12.01	0.22	0.26	0.2	0	0	8.97	0	0	0	0	0	0											20.39	1.3	26.24	-	7.12	0.6	21.11	3.19	5.75	5.31	6.53	-	-	23.14	22.7	40.66	4.16	0.77	9.68	14.39	5.22	1.46	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	219.77	138	0	20.39	1.3	26.24	-	7.12	0.6	21.11	3.19	5.75	5.31	6.53	-	-	23.14	22.7	40.66	4.16	0.77	9.68	14.39	5.22	1.46	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	219.77	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	20.39	1.3	26.24	-	7.12	0.6	21.11	3.19	5.75	5.31	6.53	-	-	23.14	22.7	40.66	4.16	0.77	9.68	14.39	5.22	1.46	-	-	0.05	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	219.77
R6801_002_0	2007	8																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1686.67	3.48	1350.33	0	497.71	41.99	26.28	410.7	299.89	0	358.29	0	0	303.47	7652.67	8503.19	317.19	391.9	0	592.65	0	868.03	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											80	1000	100	0	50	0	0.22	49.26	100	0	17.19	0	0	25.21	10	25	29.25	25	0	29.14	0	22.66	0	0	0	0	0	0	0	0	0											11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01	0	0	11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01
R6801_003_0	2007	8																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	3.48	0	0	497.71	41.99	26.28	410.7	0	0	358.29	0	0	74.97	6479.77	5005.11	0	0	0	490.25	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.22	48.53	0	0	17.19	0	0	10.6	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99	0	0	-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99
R6801_004_0	2007	9																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1686.67	3.48	1350.33	0	497.71	41.99	26.28	410.7	299.89	0	358.29	0	0	303.47	7652.67	8503.19	317.19	391.9	0	592.65	0	868.03	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											80	1000	100	0	50	0	0.22	49.26	100	0	17.19	0	0	25.21	10	25	29.25	25	0	29.14	0	22.66	0	0	0	0	0	0	0	0	0											11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01	0	0	11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01
R6801_005_0	2007	8																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1686.67	3.48	1350.33	0	497.71	41.99	26.28	410.7	299.89	0	358.29	0	0	303.47	7652.67	8503.19	317.19	391.9	0	592.65	0	868.03	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											80	1000	100	0	50	0	0.22	49.26	100	0	17.19	0	0	25.21	10	25	29.25	25	0	29.14	0	22.66	0	0	0	0	0	0	0	0	0											11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01	0	0	11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	11.24	0.29	11.25	-	2.07	0.17	5.89	1.69	2.5	-	0.51	-	-	0.64	6.38	17.71	0.77	0.82	-	1.44	-	1.64	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	65.01
R6801_006_0	2007	9																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	3.48	0	0	497.71	41.99	26.28	410.7	0	0	358.29	0	0	74.97	6479.77	5005.11	0	0	0	490.25	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.22	48.53	0	0	17.19	0	0	10.6	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99	0	0	-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99
R6801_007_0	2007	8																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	3.48	0	0	497.71	41.99	26.28	410.7	0	0	358.29	0	0	74.97	6479.77	5005.11	0	0	0	490.25	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.22	48.53	0	0	17.19	0	0	10.6	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99	0	0	-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.29	-	-	-	0.17	5.89	1.66	-	-	0.51	-	-	0.07	5.4	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.99
R6801_801_0	2007	7																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	153.92	3.35	1350.33	0	15.06	41.99	26.28	4.48	25.19	1843.61	23.09	0	0	65.69	83.98	188.18	3.71	2.91	8020.96	69.52	15.88	7.52	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.54	0.37	0.25	23.05	0.25	0	0	0.25	0.23	0.21	0.51	0.22	15.68	0.22	0.26	0.2	0	0	0	0	0	0	0	0	0											12.83	0.28	14.07	-	3.24	0.41	14.28	1.68	6.41	3.54	5.88	-	-	16.72	19.45	39.09	1.88	0.63	10.48	14.96	4.16	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.51	138	0	12.83	0.28	14.07	-	3.24	0.41	14.28	1.68	6.41	3.54	5.88	-	-	16.72	19.45	39.09	1.88	0.63	10.48	14.96	4.16	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.51	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	12.83	0.28	14.07	-	3.24	0.41	14.28	1.68	6.41	3.54	5.88	-	-	16.72	19.45	39.09	1.88	0.63	10.48	14.96	4.16	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.51
R6801_802_0	2007	7																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	153.92	3.35	1350.33	0	15.06	41.99	26.28	4.48	25.19	1843.61	23.09	0	0	65.69	83.98	188.18	3.71	2.91	8020.96	69.52	15.88	7.52	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.54	0.37	0.25	23.05	0.25	0	0	0.25	0.23	0.21	0.51	0.22	15.68	0.22	0.26	0.2	0	0	0	0	0	0	0	0	0											12.83	0.28	14.07	-	3.24	0.41	14.28	1.68	6.41	3.54	5.88	-	-	16.72	19.45	39.09	1.88	0.63	10.48	14.96	4.16	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.51	138	0	12.83	0.28	14.07	-	3.24	0.41	14.28	1.68	6.41	3.54	5.88	-	-	16.72	19.45	39.09	1.88	0.63	10.48	14.96	4.16	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.51	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	12.83	0.28	14.07	-	3.24	0.41	14.28	1.68	6.41	3.54	5.88	-	-	16.72	19.45	39.09	1.88	0.63	10.48	14.96	4.16	1.53	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	171.51
R9896_001_0	2007	9																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	236.48	17.27	2910.35	0	26.66	61.93	40.68	9.88	21.97	3088.86	28.08	0	0	81.01	84.91	173.4	4.68	3.02	8334.92	54.41	22.53	5.79	0	0	92.27	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.53	0.42	0.25	20.08	0.25	0	0	0.25	0.23	0.21	0.51	0.22	10.38	0.22	0.26	0.19	0	0	9.36	0	0	0	0	0	0											19.71	1.44	30.32	-	5.79	0.6	21.7	4.11	5.59	5.17	7.15	-	-	20.63	19.46	36.68	2.37	0.66	7.21	11.83	5.9	1.13	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	207.5	138	0	19.71	1.44	30.32	-	5.79	0.6	21.7	4.11	5.59	5.17	7.15	-	-	20.63	19.46	36.68	2.37	0.66	7.21	11.83	5.9	1.13	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	207.5	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	19.71	1.44	30.32	-	5.79	0.6	21.7	4.11	5.59	5.17	7.15	-	-	20.63	19.46	36.68	2.37	0.66	7.21	11.83	5.9	1.13	-	-	0.07	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	207.5
R9896_002_0	2007	6																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1324.65	4.1	721.87	0	329.68	36.48	23	379.53	350.35	0	364.81	0	0	253.21	7465.88	7608.88	214.35	508.37	0	598.95	0	749.52	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											110	1000	100	0	50	0	0.22	49.51	100	0	17.85	0	0	25.31	10	25	29.25	25	0	29.3	0	21.82	0	0	0	0	0	0	0	0	0											12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19	0	0	12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19
R9896_003_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.1	0	0	329.68	36.48	23	379.53	0	0	364.81	0	0	57.28	6608.22	5104.33	0	0	0	514.73	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.22	49.01	0	0	17.85	0	0	9.28	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26	0	0	-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26
R9896_004_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1324.65	4.1	721.87	0	329.68	36.48	23	379.53	350.35	0	364.81	0	0	253.21	7465.88	7608.88	214.35	508.37	0	598.95	0	749.52	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											110	1000	100	0	50	0	0.22	49.51	100	0	17.85	0	0	25.31	10	25	29.25	25	0	29.3	0	21.82	0	0	0	0	0	0	0	0	0											12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19	0	0	12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19
R9896_005_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	1324.65	4.1	721.87	0	329.68	36.48	23	379.53	350.35	0	364.81	0	0	253.21	7465.88	7608.88	214.35	508.37	0	598.95	0	749.52	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											110	1000	100	0	50	0	0.22	49.51	100	0	17.85	0	0	25.31	10	25	29.25	25	0	29.3	0	21.82	0	0	0	0	0	0	0	0	0											12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19	0	0	12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	12.14	0.34	6.02	-	1.37	0.15	5.13	1.57	2.92	-	0.54	-	-	0.53	6.22	15.85	0.52	1.06	-	1.46	-	1.36	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	57.19
R9896_006_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.1	0	0	329.68	36.48	23	379.53	0	0	364.81	0	0	57.28	6608.22	5104.33	0	0	0	514.73	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.22	49.01	0	0	17.85	0	0	9.28	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26	0	0	-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26
R9896_007_0	2007	7																					0											D	A	D	V	T	Coin	Coin	V	V	V	V	V	V	V	V	V	V	V	V	V	S	V	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	4.1	0	0	329.68	36.48	23	379.53	0	0	364.81	0	0	57.28	6608.22	5104.33	0	0	0	514.73	0	0	0	0	0	0	0	0	0	0	0											0 (PBP #1A)	0 (PBP #1B)	0 (PBP #2)	0 (PBP #6)	0 (PBP #10A)	0 (PBP #11A)	0 (PBP #11B/11C)	0 (PBP #4A/4B)	0 (PBP #9B)	0 (PBP #8A/9A)	0 (PBP #8B/9A)	0 (PBP #5/9A)	0 (PBP #12/9A)	0 (PBP #3/5/9A/9C/9D)	0 (PBP #7A/14B-14I)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #7E/7H)	0 (PBP #7C/7I)	0 (PBP #7D)	0 (PBP #7B/7D/7F/7G/14D-14I)	0 (PBP #15)	0 (PBP #10B)	0 (PBP #10B)	0 (PBP #16A/16B)	0 (PBP# 17A)	0 (PBP# 17B)	0 (PBP# 18A)	0 (PBP# 18B)	N/A	0 (PBP# 14A)	0 (PBP# 13C/13D)											0	1000	0	0	0	0	0.22	49.01	0	0	17.85	0	0	9.28	10	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26	0	0	-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	0	-	0.34	-	-	-	0.15	5.13	1.55	-	-	0.54	-	-	0.04	5.51	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	13.26
R9896_801_0	2007	8																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	135.63	4.56	721.87	0	9.44	36.49	23.01	3.79	25.24	1991.05	24.46	0	0	49.67	69	157.72	2.46	3.88	6834.91	58.62	15.36	6.56	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.55	0.41	0.25	18.22	0.25	0	0	0.25	0.23	0.21	0.51	0.22	13.82	0.22	0.26	0.2	0	0	0	0	0	0	0	0	0											11.3	0.38	7.52	-	2.05	0.36	12.58	1.56	6.43	3.02	6.23	-	-	12.65	16.06	33.21	1.25	0.85	7.87	12.74	4.02	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.41	138	0	11.3	0.38	7.52	-	2.05	0.36	12.58	1.56	6.43	3.02	6.23	-	-	12.65	16.06	33.21	1.25	0.85	7.87	12.74	4.02	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.41	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	11.3	0.38	7.52	-	2.05	0.36	12.58	1.56	6.43	3.02	6.23	-	-	12.65	16.06	33.21	1.25	0.85	7.87	12.74	4.02	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.41
R9896_802_0	2007	8																					0											A	A	D	V	Coin	Coin	Coin	Coin	Coin	V	Coin	V	V	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin	T	V	V	V	V	V	Coin	O	V											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	0	135.63	4.56	721.87	0	9.44	36.49	23.01	3.79	25.24	1991.05	24.46	0	0	49.67	69	157.72	2.46	3.88	6834.91	58.62	15.36	6.56	0	0	0	0	0	0	0	0	0											Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Medicare Cost Sharing	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered	Not Covered											1000	1000	125	0	0.22	0.01	0.55	0.41	0.25	18.22	0.25	0	0	0.25	0.23	0.21	0.51	0.22	13.82	0.22	0.26	0.2	0	0	0	0	0	0	0	0	0											11.3	0.38	7.52	-	2.05	0.36	12.58	1.56	6.43	3.02	6.23	-	-	12.65	16.06	33.21	1.25	0.85	7.87	12.74	4.02	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.41	138	0	11.3	0.38	7.52	-	2.05	0.36	12.58	1.56	6.43	3.02	6.23	-	-	12.65	16.06	33.21	1.25	0.85	7.87	12.74	4.02	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.41	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-	138	0	11.3	0.38	7.52	-	2.05	0.36	12.58	1.56	6.43	3.02	6.23	-	-	12.65	16.06	33.21	1.25	0.85	7.87	12.74	4.02	1.34	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	141.41
R9943_001_0	2007	8																					3000											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin		Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin			V		V															22.69	0.24	3.45	2.38	0.68	2.33	0.11	0	1.96	0.77	2.08	0	0.58	2.06	0	2.26	0.2	0.56	3.67	13.21	2.76	0.31	0	0	0	0	0	0	0	0	0											62.3	3000	182.42	1.95	27.74	19.11	5.48	18.77	0.86	252.54	15.74	6.15	16.72	0	4.66	16.56	4082.17	5439.29	1.63	4.52	29.52	110.38	22.19	2.94	0	0	333.44	0	142.9	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g			PBP 17a		PBP 18a															0.07	0.07	0.07	0.07	0.07	0.07	0.07	29.49	0.07	0.07	0.07	0	0.07	0.07	6.64	7.53	0.07	0.07	0.07	0.06	0.07	0.07	0	0	13.28	0	6.64	0	0	0	0											12.11	0.13	1.84	1.27	0.36	1.25	0.06	0.62	1.04	0.41	1.11	-	0.31	1.1	2.26	3.41	0.11	0.3	1.96	7.05	1.47	0.2	-	-	0.37	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	38.82	1000	19.65	34.8	0.37	5.29	3.65	1.05	3.58	0.16	0.62	3	1.17	3.19	-	0.89	3.16	2.26	5.68	0.31	0.86	5.63	20.26	4.23	0.5	-	-	0.37	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	101.12	3000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g			PBP 17a		PBP 18a															1.76	0.02	0.35	0.24	0.06	0.21	0.01	0.03	0.15	0.08	0.2	0	0.06	0.18	0.15	0.33	0.02	0.05	0.32	1.16	0.24	0.03	0	0	0.02	0	0	0	0	0	0											5.67	1000	1.98	36.56	0.39	5.64	3.89	1.11	3.79	0.17	0.65	3.15	1.25	3.39	-	0.95	3.34	2.41	6	0.33	0.91	5.95	21.43	4.48	0.53	-	-	0.38	-	0.08	-	-	-	-	-	-	-	-	-	-	-	-	-	-	106.78
R9943_002_0	2007	8																					3000											Coin	Coin	Coin	Coin	Coin	Coin	Coin	V	Coin	Coin	Coin		Coin	Coin	V	V	Coin	Coin	Coin	Coin	Coin	Coin			V		V															12.63	0.13	1.92	1.32	0.38	1.3	0.06	0	1.09	0.43	1.16	0	0.32	1.15	0	1.26	0.11	0.31	2.04	7.35	1.54	0.17	0	0	0	0	0	0	0	0	0											34.68	3000	198.98	2.13	30.26	20.85	5.98	20.47	0.94	260.54	17.17	6.71	18.24	0	5.09	18.06	4211.62	5734.28	1.78	4.93	32.2	120.16	24.2	3.18	0	0	344.02	0	147.44	0	0	0	0											PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g			PBP 17a		PBP 18a															0.07	0.07	0.07	0.07	0.07	0.07	0.07	32.42	0.07	0.07	0.07	0	0.07	0.07	7.3	8.26	0.07	0.07	0.07	0.07	0.07	0.07	0	0	14.59	0	7.3	0	0	0	0											14.52	0.16	2.21	1.52	0.44	1.49	0.07	0.7	1.25	0.49	1.33	-	0.37	1.32	2.56	3.95	0.13	0.36	2.35	8.46	1.77	0.23	-	-	0.42	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	46.18	500	17.1	27.15	0.29	4.13	2.84	0.82	2.79	0.13	0.7	2.34	0.92	2.49	-	0.69	2.46	2.56	5.21	0.24	0.67	4.39	15.81	3.3	0.4	-	-	0.42	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	80.86	3000	PBP 1a	PBP 1b	PBP 2	PBP 6	PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g			PBP 17a		PBP 18a															1.34	0.01	0.3	0.21	0.05	0.18	0.01	0.03	0.11	0.06	0.18	0	0.05	0.15	0.18	0.32	0.02	0.04	0.28	1.01	0.21	0.03	0	0	0.02	0	0	0	0	0	0											4.79	500	1.81	28.49	0.3	4.43	3.05	0.87	2.97	0.14	0.74	2.45	0.98	2.67	-	0.74	2.62	2.74	5.53	0.26	0.72	4.67	16.82	3.51	0.43	-	-	0.44	-	0.09	-	-	-	-	-	-	-	-	-	-	-	-	-	-	85.64
R9943_801_0	2007	7																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		221.82	2.38	33.9	0	6.7	22.93	1.05	4.28	19.23	7.52	20.43	0	5.7	20.24	32.27	49.64	1.99	5.53	36.07	134.29	27.11	3.53	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2		PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g																				0.06	0.06	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.03	0.15	5.27	-	1.58	5.41	0.25	1.01	4.54	1.77	4.82	-	1.34	4.78	7.62	11.72	0.47	1.3	8.51	31.69	6.4	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5	0	0	14.03	0.15	5.27	-	1.58	5.41	0.25	1.01	4.54	1.77	4.82	-	1.34	4.78	7.62	11.72	0.47	1.3	8.51	31.69	6.4	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5		PBP 1a	PBP 1b	PBP 2		PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g																				0.73	0.01	0.27	0	0.07	0.25	0.01	0.05	0.23	0.09	0.24	0	0.07	0.24	0.35	0.53	0.02	0.06	0.39	1.44	0.29	0.04	0	0	0	0	0	0	0	0	0											5.37	0	0	14.76	0.16	5.54	-	1.65	5.66	0.26	1.06	4.77	1.86	5.07	-	1.41	5.02	7.96	12.25	0.49	1.36	8.9	33.13	6.69	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.87
R9943_802_0	2007	4																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		221.82	2.38	33.9	0	6.7	22.93	1.05	4.28	19.23	7.52	20.43	0	5.7	20.24	32.27	49.64	1.99	5.53	36.07	134.29	27.11	3.53	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2		PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g																				0.06	0.06	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.03	0.15	5.27	-	1.58	5.41	0.25	1.01	4.54	1.77	4.82	-	1.34	4.78	7.62	11.72	0.47	1.3	8.51	31.69	6.4	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5	0	0	14.03	0.15	5.27	-	1.58	5.41	0.25	1.01	4.54	1.77	4.82	-	1.34	4.78	7.62	11.72	0.47	1.3	8.51	31.69	6.4	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5		PBP 1a	PBP 1b	PBP 2		PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g																				0.73	0.01	0.27	0	0.07	0.25	0.01	0.05	0.23	0.09	0.24	0	0.07	0.24	0.35	0.53	0.02	0.06	0.39	1.44	0.29	0.04	0	0	0	0	0	0	0	0	0											5.37	0	0	14.76	0.16	5.54	-	1.65	5.66	0.26	1.06	4.77	1.86	5.07	-	1.41	5.02	7.96	12.25	0.49	1.36	8.9	33.13	6.69	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.87
R9943_803_0	2007	7																																Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin		Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin	Coin																				0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0											-		221.82	2.38	33.9	0	6.7	22.93	1.05	4.28	19.23	7.52	20.43	0	5.7	20.24	32.27	49.64	1.99	5.53	36.07	134.29	27.11	3.53	0	0	0	0	0	0	0	0	0											PBP 1a	PBP 1b	PBP 2		PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g																				0.06	0.06	0.16	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0.24	0	0	0	0	0	0	0	0	0											14.03	0.15	5.27	-	1.58	5.41	0.25	1.01	4.54	1.77	4.82	-	1.34	4.78	7.62	11.72	0.47	1.3	8.51	31.69	6.4	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5	0	0	14.03	0.15	5.27	-	1.58	5.41	0.25	1.01	4.54	1.77	4.82	-	1.34	4.78	7.62	11.72	0.47	1.3	8.51	31.69	6.4	0.83	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	113.5		PBP 1a	PBP 1b	PBP 2		PBP 10a	PBP 11a	PBP 11b 11c	PBP 4a 4b	PBP 9a 9b	PBP 8a	PBP 8b		PBP 12	PBP 3 5 9a 9c 9d 13a 13b	PBP 4b 7a 14b-i	PBP 4b 7b 7d 7f 7g 14d-i 17a 18a	PBP 7e 7h	PBP 7c 7i	PBP 7d	PBP 7d 7g	PBP 15	PBP 7g																				0.73	0.01	0.27	0	0.07	0.25	0.01	0.05	0.23	0.09	0.24	0	0.07	0.24	0.35	0.53	0.02	0.06	0.39	1.44	0.29	0.04	0	0	0	0	0	0	0	0	0											5.37	0	0	14.76	0.16	5.54	-	1.65	5.66	0.26	1.06	4.77	1.86	5.07	-	1.41	5.02	7.96	12.25	0.49	1.36	8.9	33.13	6.69	0.87	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	118.87
