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DIV. OF MATE?,NAL AND CHILD hT. ALTH SLIDING FEE SCALE <br />MON%~TLY GROSS INCOME <br />FOR USE IN FAMILY PLABNING AND MCH CLINICS <br /> <br /> CABARRUS COUNTY HEALTH DEPARMTNET <br />FAMILY PLANNING PROGRAM FEE SCALE - (GROSS INCOME) <br /> <br />100% OF FAMILY ZERO PAY T~NTY PERCENT FORTY PERL--aNT SIXTY PERCENT EIGHTY PERCENT FULL PAY <br />POVERTY SIZE PAY PAY PAY PAY BEGINS <br /> <br />$568 1 $0 TO $568 $569 TO $709 $710 TO $851 $852 TO $993 $994 TO $1134 $1135 <br />$766 2 $0 TO $766 $767 TO $957 $958 TO $1149 $1150 TO $1340 $1341 TO $1531 $1532 <br />$964 3 $0 TO $964 $965 TO $1205 $1206 TO $i446 $1447 TO $1687 $1688 TO $1927 $1928 <br />$1163 4 $0 TO $1163 $1164 TO $1453 $1454 TO $1744 $1745 TO $2034 $2035 TO $2324 $2325 <br />$1361 5 $0 TO $1361 $1362 TO $1701 $1702 TO $2041 $2042 TO $2381 $2382 TO 12721 $2722 <br />$1559 6 $0 TO $1559 $1560 TO $1949 $1950 TO $2339 $2340 TO $2729 $2730 TO $3117 $3118 <br />$1758 7 $0 TO $1758 $1759 TO $2197 $2198 TO $2636 $2637 TO $3076 $3077 TO $3514 $3515 <br />$1956 8 $0 TO $1956 $1957 TO $2445 $2446 TO $2934 $2935 TO $3423 $3424 TO $3911 $3912 <br />$2154 9 $O TO $2154 $2155 TO $2~93 $2694 TO $3231 $3232 TO $3770 $3771 TO $4307 $4308 <br />$2353 10 $0 TO $2353 $2354 TO $2941 $2942 TO $3529 $3530 TO $4117 $4118 TO $4704 $4705 <br />$2551 11 $0 TO $2551 $2552 TO $3189 $3190 TO $3826 $3827 TO $4464 $4465 TO $5101 $5102 <br />$2749 12 $0 TO $2749 $2750 TO $3436 $3437 TO $4124 $4125 TO $4811 $4812 TO $5497 $5498 <br /> <br />INSTRUCTIONS: A~%'~R DETERMINING SLIDING $CAL~ PAY CATEGORY, FIND DOLLAR AMOUNT <br /> <br />OF CH;%RG~ ON ;%PPROPRIATE SC}~DULE. <br /> <br />NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT IS M~DIC2%ID ELIGIBLe. IF YEARLY INCOM~ IS K~OWN, USE ANNUAL <br /> SCALE. ANNUALIZED MON~"%LLY iNCOME FIGURES MAY NOT EQUAL THOSE ON AN%r0AL SCALE DUE TO ROUNDING. <br /> <br />DIV. OF MCH <br />~/ls/92 <br /> <br /> ~ OF PATItAT (SELF-PAY OR PRIVATE PAY) (~i~ES <br /> WC~fl~'S PR~i'IVE HEALII{ S~RVICES (FAMILY PLANNIRE) <br /> <br />20% PAY 40% PAY 60% PAY <br /> <br />'Go.~lete FnysJem] $ 18.75 $ 37.50 $ 56.25 <br />(Initial or A~mual) <br />Lx%ended R~si% $ 7.85 $ 15.70 $ 23.85 <br />(~sit w/~c) <br />L~ ~sit $ 4.~ $ 8.~ $ 13.20 <br />(~slt w/o ~c) <br />~ F~ly P~ $ 8.~ $ 16.~ $ 24.~ <br /> <br />~t ~s~ $ 93.20 $186.40 $279.60 <br />~t ~ $ 25.~ $ ~.~ $ 75.~ <br />~t ~~s~fl~ $113.20 $~6.40 $339.~ <br /> <br />$80% PAY FULL PAY <br /> <br />$ 75.00 $ 93.75 <br />$ 31.40 $ 39.25 <br />$ 17.60 $ 22.00 <br />$ 32.00 $ 4O.0O <br /> <br />$372.80 $~66.00 <br />$100.00 $125.00 <br />$425.8O $566.00 <br /> <br /> <br />