I'd say you have your work cut out for you, but you've actually got a good shot at matching. You've played the improvement game perfectly: you crushed the second Step and your MS3 and 4 grades must be good to have placed you so highly in the class. Hopefully you'll be in the running for AOA. Has your school told you you're top 10? We had a bunch of "top 10ers" in my class that ended up in the middle quartile because they assumed they were better than they actually were.
On top of applying broadly, I'd recommend calling the programs you really wanna go to if you don't get the interviews that you want. Don't stalk anyone, but my thought is that you do indeed get a little extra mileage out of a personal phone call to show your interest in the program. BE NICE and BE POLITE. I hope you had a good reason/bizarre life moment that allows you to explain away the Step 1 score as a fluke. You may even wanna throw that in when you're talking to the programs. It's also VERY VERY MUCH a "who you know" world: if you have faculty at your place that will call program directors and chairmen to vouch for you, you're at an advantage.
Some of the programs, assuredly, will NOT interview you with that part one score. My Step 1 was below 225, and although I did much better than 225 on Step 2, two programs told me they wouldn't interview me because of not making that 225 cutoff on Step 1. So that sucks for you (as it did for me). That said, some very good programs have cutoffs set as averages of the two Steps, which will end up hurting you a bit, but it's better than being associated with a 190-something. Lastly, some of the places want either score above a certain mark, and you're in the money at those places. Also, remember that the biggest name isn't necessarily the best program (for you). Go into these interviews with an open mind. If you're happy in the area you're in, and you think your home program treats and trains residents well, strongly consider staying there. Things get tougher - with any Step score - if you think that you can ONLY go to anesthesiology programs in Manhattan/NYC.
Research or other standout feature (AOA, Gold Humanism, etc) will also be to your benefit if you've got it.
I'll shut up now. Whatever happens, apply where you wanna go, and good luck with things. It was an expensive but very fun and exciting time for me, and I hope you enjoy things as well.
dc
