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DIV. OF MATERNAL AND CHILD HEALTH 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 />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 PAY BEGINS <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 $1446 $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 $2721 $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 $0 to $2154 $2155 to $2693 $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: 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. IF YEARLY INCOME IS KNOWN, USE ANNUAL SCALE. <br /> ANNUALIZED MONTHLY INCOME FIGURES MAY NOT EQUAL THOSE ON ANNUAL SCALE DUE TO ROUNDING. <br />DIV. OF MCH. SCHEDULE OF PATIENT (SELF-PAY OR PRIVATE PAY) CHARGES <br />6/15/92 WOMEN'S PREVENTIVE HEALTH SERVICES (FAMILY PLANNING) <br /> <br /> SERVICE <br />Complete Physical <br />(Initial or Annual) <br /> <br />20% PAY 40% PAY 60% PAY 80% PAY FULL PAY <br /> <br />$18.75 $37.50 $56.25 $75.00 $93.75 <br /> <br />Extended Revisit <br />(Revisit w/pelvic) <br /> <br />$ 7.85 $15.70 $23.85 $31.40 $39.25 <br /> <br />Limited Revisit <br />(Revisit w/o pelvic) <br /> <br />$ 4.40 $ 8.80 $13.20 $17.60 $22.00 <br /> <br />Natural Family Planning <br />(NFP Services) <br />Norplant Insertion <br />Norplant Removal <br />Norplant Removal/Reinsertion <br /> <br />$ 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 />