IL

TIER 1

2

3

Premier 200

$20

$80

Plus 250A

$72

$147

Premier 400

$0

$50

Plus 450B

$27

Plus 450C

4

C

$87

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

4

TIER 1

2

3

4

5

6

Premier 200

$95

$110

$125

Premier Plus 250A

$139

$165

$159

Premier 400

$60

$75

$90

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

$102 $82 $108

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

9