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DIV, DP ~TF. RNAL AND CHILD ItEALIII SLIDING FEE SCALE <br />~ONTHLY CROSS INCOME <br />FOR USE {N FAMILY PLANNING ANO N~U CLINICS <br /> <br />[00% OF F)d~ILY ZERO PAY TWENTY PERCENT FORTY PF~RCENT <br />POVERTY SIZE PAY PAY <br /> <br />CABARRUS COUNTY HEALTH DEPARTMENT <br /> <br />FAMILY PLANNING PROGRAM FEE SCALE - (GROSS INCOME) <br /> <br />SIXTY PERCENT EIGHTY PERCENT FULL PAY <br />PAY PAY BEG I NS <br /> <br />5613 1 $O TO $613 $614 30 $767 $768 TO 5920 $921 <br />582{) 2 $0 TO $820 5821 lO $1025 $1026 TO $1230 $1231 <br />51027 3 $0 TO ~1027 51028 TO $)283 $128G TO $15G0 $1541 <br />$12')3 4 $0 TO $1233 $[234 TO $1542 513i3 TO $1850 51851 <br />$1440 5 $0 TO $1/,40 $1461 TO $1~{00 51801 TO $2160 $2161 <br />$16/,7 6 $0 TO $1L/,7 $16~8 TO 52058 12059 TO $2470 $2~71 <br />$18511 7 $0 lO 51M33 $1854 TO 52317 $2318 TO. 52780 . $2~81 <br />$2060 8 10 TO $2060 12061 To $2~75 12576 TO 53090 13091 <br />$2267 9 $0 TO $2267 $2268 TO $2833 $2834 TO $3400 ~0~ <br />$2~73 10 $0 TO $2673 $2474 TO $3092 $3093 TO $3710 $3711 <br />52680 11 $0 TO 12680 $2681 TO 13350 S3351 TO 14020 $4021 <br />$2887 12 $0 TO $2887 $2888 TO $3608 13609 TO $4330 $i331 <br /> <br />INSTRUCTIONS: AI"'I'I:'R DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT <br /> <br />NOTE: NO CIL~RGES NAY ~E ASSESSED TF PAI'IENT IS MEDICAID ELIGI8LE. IF YE/d~LY <br /> SCALE, ANNllALIZED MONTHLY INCONE FIGURES ~AY NOT EQUAL THOSE ON ANNUAL <br /> <br />DIV. OF MCH <br />6/10/9h <br /> <br /> TO $1.073 $1074 TO ~122G 5]227 <br /> TO $1435 $t~36 TO $1639 $1640 <br />TO 11797 $1798 TO $2052 ,/' $2053 <br />TO $2158 52159 TO $2~66" 52467 <br />TO 52520 52521 TO $2879 $2880 <br />TO $2882 52883 TO $3292 $3293 <br />TO $3243 53244 TO $3706 $3707 <br />TO 13605 13606 TO $~/19 $4120 <br />TO 13967 53968 TO 54532 $4533 <br />TO $4328 $4329 TO 14946 $49~7 <br />TO 14690 54691 TO $5359 $5360 <br />~O 15052 15053 TO 55772 15773 <br /> <br />OF CHARGE ON APPROPRIATE SCHEDULE. <br /> <br />INCOME I$ KNOWN, USE ANNUAL <br />SCALB DUE TO ROUNDING. <br /> <br />SCHEDULE OF PATIENT (SELF-PAY OR PRIVATE PAY) CHARGES <br />WOMEN'S PREVENTIVE HEALTH SERVICES {FAMILY PLANNING) <br /> <br />Service 20% Pay <br />Initial Physicial $ 27.;28 <br />Annual Physicial $ 17.56 <br />Extended Revisit (Revisit w/pelvic) $ 14.83 <br />Limited Revisit (Revisit w/o pelvic) $ 8.66 <br />Natural Family Planning (NFP Services) $ 8.00 <br />Norplant Insertion $111.16 <br />Norplant Removal $ 46.49 <br />Norplant Removal/Reinsertion $140.62 <br />Depo Provera Injection $ 5.27 <br /> <br />40% Pay 60% Pay 80% 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 />$222.32 $333.48 $444.64 $555.80 <br />$ 92.99 $139.48 $285.98 $232.47 <br />$281.24 $421.87 $562.49 $703.11 <br />$ 10.54 $ 15.81 $ 21.08 $ 26.35 <br /> <br />03-16-92: Approved by I3oard of C~nmissionars <br />08-03-92: Approved by Board of Conmissionars <br /> <br />{ ( { <br /> <br /> <br />