ND

!

&

TIER 1

2

3

4

5

Premier 200

$35

$60

$70

$95

$110

Premier Plus 250A

$98

$119 $114 $139 $165

Premier 400

$0

$25

Premier Plus 450B

$41

$60

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

$35

$60

6

$75

$56 $82 $108

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

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