WI

& '

TIER 1

2

3

Premier 200

$20

$50

$80

$85

Premier Plus 250A

$72

$112

$147

$157

Premier 400

$0

$20

$50

$40

Premier Plus 450B

$27

$59

Premier Plus 450C Premier Plus 450D

4

C

$87 $101

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

19

+

TIER 1

2

3

4

5

Premier 200

$60

$95

$110

Plus 250A

$119

$139

$165

Premier 400

$25

$60

$75

Plus 450B

$60

Plus 450D Plus 450E

6

$82 $108

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

33

+ ,

TIER

Advantage Plus 250A

1

2

3

'

-

(

$62

$52

$122

Advantage Plus 450B

C

$132

$36

Advantage Plus 450F

$51

Advantage Plus 450H Advantage Plus 650B

4

$62 $0

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

18