PA

!

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

Premier Plus 450G Premier Plus 450H

$95 $66

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

15

!

"#

TIER 1

Advantage 300

3

4

$0

$10

$45

$90

$101

$146

C

$0

Advantage 400 Advantage Plus 150A

2

$63

Advantage Plus 350B Advantage Plus 450G

$36

Advantage Plus 450I Advantage Plus 550B Advantage Plus 650B

$65 $0 $0

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

14