Sliding Fee Schedule

Patient Info

	Discount Category
	A	B	C	D	E
Medical	$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	15,650	19,563	23,475	31,300	>31,300
	MONTH	1,304	1,631	1,957	2,609	>2,609
	WEEK	301	377	452	602	>602
2	YEAR	21,150	26,438	31,725	42,300	>42,300
	MONTH	1,763	2,204	2,644	3,525	>3,525
	WEEK	407	509	611	814	>814
3	YEAR	26,650	33,313	39,975	53,300	>53,300
	MONTH	2,221	2,777	3,332	4,442	>4,442
	WEEK	513	642	770	1026	>1,026
4	YEAR	32,150	40,188	48,225	64,300	>64,300
	MONTH	2,679	3,349	4,019	5,359	>5,359
	WEEK	619	774	929	1,238	>1,238
5	YEAR	37,650	47,063	56,475	75,300	>75,300
	MONTH	3,138	3,922	4,707	6,275	>6,275
	WEEK	725	907	1,088	1,450	>1,450
6	YEAR	43,150	53,938	64,725	86,300	>86,300
	MONTH	3,596	4,495	5,394	7,192	>7,192
	WEEK	830	1,038	1,245	1,660	>1,660
7	YEAR	48,650	60,813	72,975	97,300	>97,300
	MONTH	4,054	5,068	6,082	8,109	>8,109
	WEEK	936	1,170	1,404	1,872	>1,872
8	YEAR	54,150	67,688	81,225	108,300	>108,300
	MONTH	4,513	5,641	6,769	9,025	>9,025
	WEEK	1,042	1,303	1,563	2,084	>2,084
	Income as % of poverty guideline:	100% or Less	125%	150%	200%	>200%
	For each additional person add:	5,500 per YEAR	458 per MONTH	106 per WEEK