AZ

TIER 1

2

Premier 200

$35

Premier Plus 250A

4

5

$60

$95

$110

$98

$119

$139

$165

Premier 400

$0

$25

$60

$75

Premier Plus 450B

$41

$60

Premier Plus 450D Premier Plus 450E

3

6

$82 $108

Please note the figures quoted herein are subject to the Final Bid Approval by CMS.

2