NC

TIER 1

2

3

4

Premier 200

$20

$50

$80

$120

Premier Plus 250A

$72

$112

$147

$187

Premier 400

$0

$20

$50

$84

Premier Plus 450B

$27

$59 $87

$121

Premier Plus 450C

C

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

12

!

TIER 1

2

3

4

5

6

Premier 200

$35

$60

$70

$95

$110

$125

Premier Plus 250A

$98

$119

$114

$139

$165

$159

Premier 400

$0

$25

$35

$60

$75

$90

Premier Plus 450B

$41

$60

Premier Plus 450C Premier Plus 450D Premier Plus 450E

$56

$102 $82 $108

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

25

TIER

Advantage Plus 250A

1

2

3

$62

$52

$122

Advantage Plus 450B

C

$36

Advantage Plus 450F Advantage Plus 650B

4

$51 $0

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

12