NY

TIER 1

2

3

4

Premier 100

$20

$47

$70

$110

Premier Plus 150A

$72

$100

$102

$152

Premier 300

$0

Premier Plus 350B

$21

Premier 400

$0

$30

$59

Premier Plus 450B

$35 $95

Premier Plus 450G Premier Plus 450H

$66

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

11

TIER 1

Advantage 300

Advantage Plus 650B

4

$63

$0

$45

$90

$146

Advantage Plus 450I Advantage Plus 550B

3

C

$0

Advantage 400 Advantage Plus 150A

2

$65 $0 $0

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

11