SC

"

TIER 1

2

3

4

Premier 200

$50

$80

$120

Premier Plus 250A

$112

$147

$187

Premier 400

$20

$50

$84

Premier Plus 450B

$59 $87

$121

Premier Plus 450C

C

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

16

$

TIER 1

2

3

Advantage Plus 250A

$52

$122

Advantage Plus 450B

$36

Advantage Plus 450F

4

C

$51

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

15