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WOMEN'S HEALTH SECTION SLIDING FEE SCALE <br />MONTHLY GROSS INCOME <br />FOR USE IN FAMILY PLANNING AND MCH PROGRAMS <br /> <br />CABARRUS COUNTY HEALTH DEPARTMENT FAMILY PLANNING PROGRAM <br /> <br />100% OF FAMILY ZERO PAY <br />POVERTY SIZ~ <br /> <br />TWENTY PERCENT FORTY PERCENT SIXTY PERCENT EIGHTY PERCENT FULL PAY <br /> PAY PAY PAY PAY BEGINS <br /> <br />$552 1 $0 to $552 <br />$740 2 $0 to $740 <br />$928 3 $0 to $928 <br />$1117 4 $0 to $1117 <br />$1305 5 $0 to $1305 <br />$1493 6 $0 to $1493 <br />$1682 7 $0 to $1682 <br />$1870 8 $0 to $1870 <br />$2058 9 $0 to $2058 <br />$2247 10 $0 to $2247 <br />$2435 11 $0 to $2435 <br />$2623 12 $0 to $2623 <br /> <br />$553 to $690 <br />$741 to $925 <br />$929 to $1160 <br />$1118 to $1396 <br />$1306 to $1631 <br />$1494 to $1867 <br />$1683 to $2102 <br />$1871 to $2338 <br />$2059 to $2573 <br />$2248 to $2808 <br />$2436 to $3044 <br />$2624 to $3279 <br /> <br />$691 to $828 <br />$926 to $1110 <br />$1161 to $1393 <br />$1397 to $1675 <br />$1632 to $1958 <br />$1868 to $2240 <br />$2103 to $2523 <br />$2339 to $2805 <br />$2574 to $3088 <br />$2809 to $3370 <br />$3045 to $3653 <br />$3280 to $3935 <br /> <br />$829 to $965 <br />$1111 to $1295 <br />$1394 to $1625 <br />$1676 to $1954 <br />$1959 to $2284 <br />$2241 to $2613 <br />$2524 to $2943 <br />$2806 to $3273 <br />$3089 to $3602 <br />$3371 to $3932 <br />$3654 to $4261 <br />$3936 to $4591 <br /> <br />$ 966 to $1102 $1103 <br />$1296 to $1479 $1480 <br />$1626 to $1856 $1857 <br />$1955 to $2232 $2233 <br />$2285 to $2609 $2610 <br />$2614 to $2986 $2987 <br />$2944 to $3362 $3363 <br />$3274 to $3739 $3740 <br />$3603 to $4116 $4117 <br />$3933 to $4492 $4493 <br />$4262 to $4869 $4870 <br />$4592 to $5246 $5247 <br /> <br />INSTRUCTIONS: AFTER DETERMINING SLIDING SCALE PAY CATEGORY, FIND DOLLAR AMOUNT OF CHARGE ON APPROPRIATE SCHEDULE. <br />NOTE: NO CHARGES MAY BE ASSESSED IF PATIENT IS MEDICAID ELIGIBLE. <br />WOMEN'S HEALTH SECTION <br />7/2/91 SCHEDULE OF PATIENT (SELF-PAY OR PRIVATE PAY) CHARGES <br /> WOMEN'S PREVENTIVE HEALTH SERVICES (FAMILY PLANNING) <br /> <br /> SERVICE <br />Complete Physical <br /> (Initial or Annual) <br />Extended Revisit <br /> (Revisit w/pelvic) <br />Limited Revisit <br /> (Revisit w/o pelvic) <br />Natural Family Planning <br /> (NFP Services) <br />Norplant Insertion <br />Norplant Removal <br />Norplant Removal/Reinsertion <br /> 01/01/92 <br /> <br />20% PAY 40% PAY 60% PAY 80% PAY FULL PAY <br /> <br />$ 18.75 $ 37.50 $ 56.25 $ 75.00 $ 93.75 <br />$ 7.85 $ 15.70 $ 23.85 $ 31.40 $ 39.25 <br />$ 4.40 $ 8.80 $ 13.20 $ 17.60 $ 22.00 <br />$ 8.00 $ 16.00 $ 24.00 $ 32.00 $ 40.00 <br /> <br />$ 93.20 $186.40 $279.60 $372.80 $466.00 <br />$ 25.00 $ 50.00 $ 75.00 $100.00 $125.00 <br />$113.20 $226.40 $339.60 $452.80 $566.00 <br /> <br /> <br />