Sliding Fee Schedule

Patient Info

	Discount Category
	A	B	C	D	E
Medical / Behavioral Health	$20.00	$25.00	$30.00	$35.00	No Discount
Imaging	Included	Included	Included	Included	No Discount
Laboratory	Included	Included	Included	Included	No Discount
Laboratory (Sent Out)	Included	90% OFF	85% OFF	80% OFF	No Discount
Physical Therapy	$10.00/visit	90% OFF	85% OFF	80% OFF	No Discount
Audiology (includes eval. selection and fitting)	$20.00	90% OFF	85% OFF	80% OFF	No Discount
Pharmacy	At Cost	At Cost + $1.00/Rx	At Cost + $2.00/Rx	At Cost + $3.00/Rx	No Discount

		MAXIMUM Household Income for each DISCOUNT CATEGORY
Household Members		A	B	C	D	E
1	YEAR	15,960	19,950	23,940	31,920	>31,920
	MONTH	1,330	1,663	1,995	2,660	>2,660
	WEEK	307	384	461	614	>614
2	YEAR	21,640	27,050	32,460	43,280	>43,280
	MONTH	1,803	2,255	2,705	3,607	>3,607
	WEEK	417	522	626	834	>834
3	YEAR	27,320	34,150	40,980	54,640	>54,640
	MONTH	2,277	2,846	3,415	4,554	>4,554
	WEEK	526	658	789	1,052	>1,052
4	YEAR	33,000	41,250	49,500	66,000	>66,000
	MONTH	2,750	3,438	4,125	5,500	>5,500
	WEEK	635	794	953	1,270	>1,270
5	YEAR	38,680	48,350	58,020	77,360	>77,360
	MONTH	3,223	4,030	4,835	6,447	>6,447
	WEEK	744	930	1,116	1,488	>1,488
6	YEAR	44,360	55,450	66,540	88,720	>88,720
	MONTH	3,697	4,621	5,545	7,394	>7,394
	WEEK	854	1,068	1,281	1,708	>1,708
7	YEAR	50,040	62,550	75,060	100,080	>100,080
	MONTH	4,170	5,213	6,082	8,340	>8,340
	WEEK	963	1,204	1,445	1,926	>1,926
8	YEAR	55,720	69,650	83,580	111,440	>111,440
	MONTH	4,643	5,805	6,965	9,287	>9,287
	WEEK	1,072	1,340	1,608	2,144	>2,144
	Income as % of poverty guideline:	100% or Less	125%	150%	200%	>200%
	For each additional person add:	5,680 per YEAR	473 per MONTH	109 per WEEK