TN 21 (10-04)

HI 01005.011 Exhibit — Standard Hospital Insurance (HI) Premiums and Surcharges

INCLUSIVE PERIOD

HI PREMIUM AMOUNT

SURCHARGE AMOUNT

01/17–12/17

413.00

454.30

01/16–12/16

411.00

452.10

01/15-12/15

407.00

447.70

01/14–12/14

426.00

468.60

01/13-12/13

441.00

485.10

01/12-12/12

451.00

496.10

01/11-12/11

450.00

495.00

01/10-12/10

461.00

507.10

01/09-12/09

443.00

487.30

01/08-12/08

423.00

465.30

01/07-12/07

410.00

451.00

01/06-12/06

393.00

432.30

01/05-12/05

375.00

412.50

01/04-12/04

343.00

377.30

01/03-12/03

316.00

347.60

01/02-12/02

319.00

350.90

01/01-12/01

300.00

330.00

01/00-12/00

301.00

331.10

01/98-12/99

309.00

339.90

01/97-12/97

311.00

342.10

01/96-12/96

289.00

317.90

01/95-12/95

261.00

287.10

01/94-12/94

245.00

269.50

01/93-12/93

221.00

243.10

01/92-12/92

192.00

211.20

01/91-12/91

177.00

194.70

01/90-12/90

175.00

192.50

01/89-12/89

156.00

171.60

01/88-12/88

234.00

257.40

01/87-12/87

226.00

248.60