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FOR U~E ~N raMI~ PL~NINO ~NO ~CH CtINTCS <br /> <br />FAMILY PLANNING PROGRAM FEE SCALE - (GROSS INCOME) <br /> <br />100% OF ' FAMILY ZERO PAY TWENTY PERCENT FORTY PERCENT SIXTY PERCENT EIGHTY PERCENT FULL PAY <br />POVERTY SIZE PAY PAY PAY PAY BEGINS <br /> <br />$623 1 SO.TO $623 $624 TO $778 $779 TO $934 $935 TO $1089 $1090 TO $1244 $1245 <br />$836 2 $0 TO $836 $837 TO S1045 $1046 TO $1254 $1255 TO $1463 11464 TO $1671 11672 <br />$1049 3 $0 TO $1049 $1050 TO $1311 $1312 TO $1574 $1575 TO $1836 $1837 TO $2097 $2098 <br />$1263 4 SO.TO $1263 $1264 TO $1578 $1579 TO $1894 $1895 TO $2209 $2210 TO $2524 $2525 <br />$1476 5 $0 TO $1476 $1477 TO $1845 $1846 TO $2214 $2215 TO $2583 $2584 TO $2951 $2952 <br />$1689 6 S0 TO $1689 $1690 TO $2111 $2112 TO $2534 $2535 70 $2956 $2957 TO $3377 S3378 <br />$1903 7 $0 TO $1903 $1904 TO $2378 $2379 TO. $2854 $2855 TO $3329 $3330 TO $3804 $3805 <br />$2116 8 $0 TO.$2116 $2117 TO $2645 $2646 TO $3174 $3175 TO $3703 53764 TO $4231 $4232 <br />$2329 9 $0 TO $2329 $2330 TO $2911 $2912 TO $3494 $3495 TO $4076 $4077 TO $4657 $4658 <br />$2543 10 $0 TO $2543 $2544 TO $3178 $3179 TO $3814 $3815 TO $4449 $4450 TO $5084 $5085 <br />$2756 11 $0 TO $2756 $2757 TO $3445 $3446 TO $4134 $4135 TO $4823 $4824 TO $5511 $5512 <br />$2969 12 $0 TO $2969 $2970 TO $3711 $3712 TO $4454 $4455 TO $5196 $5197 TO $5937 $5938 <br /> <br />INSTRU6~IONS: AFTER DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT OF CHARGE ON APPROPRIATE SCiIEDULE. <br /> <br />NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT IS HEDICA£D ELIGIBLE. IF YEARLY INCOME IS KNOWN, USE ANNUAL <br /> SCALE. ANNUALIZED MONTHLY INCOME FIGURES MAY NO? EQUAL THOSE ON ANNDAL SCALE DUE TO ROUNDING. <br /> <br />D~~. OF DI¥,'?~F:MC[{i= .'~.. <br />~f~;n~' 711195 <br /> <br />,S~rvlce 20Z Pay. <br />Initial Physicial $ 27.28 <br />Aanual Physicial $ 17.56 <br />Extended Revisit (Revisit v/pelvic) $ 14%:83 <br />Limited Revisit (Revisit w/o pelvic) $ 8.66 <br />Natural Family Planning (HFP Services) $ 8.00 <br />Norplant Insertion $101.00 <br />Norpla~t Removal $ 40.00 <br />Norplaut Removal/Retnsertion $141.00 <br />Depo Provera Injection $ 5.00 <br /> <br />402 Pay 602 Pay 80Z Pay Full Pay <br />$ 54.55 $ 81.83 $109.10 $136.38 <br />$ 35.12 $ 52.68 $ 70.24 $ 87.80 <br />$ 29.66 $ 44.48 $ 59.31 $ 74.14 <br />$ 17.31 $ 25.97 $ 34.62 $ 43.28 <br />$ 16.00 $ 24.00 $ 32.00 $ 40.00 <br />$202.00 $303.00 $404.00 $505.00 <br />$ 80.00 $120.00 $160.00 $200.00 <br />$282.00 $423.00 $564.00 $705.00 <br />$ 10.00 $ 15.O0 $ 20.00 $ 25.00 <br /> <br />03-16-92: Approved by Board of Ccnmtssio~rs <br />08-03-92: Approved by Board of C<xm~isslo~r~ .. <br />12-07~92: Approved by Board of Ccxnnissior~rs .. <br /> <br /> Approved by Board of Commissioners on 7-Dj-9.4. <br /> <br /> <br />