 |
| YEARLY INCOME |
|
|
|
|
|
Category A |
Category B |
Category C |
Category D |
Family size |
100% and below |
101%-125% |
126%-150% |
151%-200% |
1 |
$10,830.00 |
$13,538.00 |
$16,245.00 |
$21,660.00 |
2 |
$14,570.00 |
$18,213.00 |
$21,855.00 |
$29,140.00 |
3 |
$19,310.00 |
$24,138.00 |
$28,965.00 |
$38,620.00 |
4 |
$22,050.00 |
$27,563.00 |
$33,075.00 |
$44,100.00 |
5 |
$25,790.00 |
$32,238.00 |
$38,685.00 |
$51,580.00 |
6 |
$29,530.00 |
$36,913.00 |
$44,295.00 |
$59,060.00 |
7 |
$33,270.00 |
$41,588.00 |
$49,905.00 |
$66,540.00 |
8 |
$37,010.00 |
$46,263.00 |
$55,515.00 |
$74,020.00 |
|
|
|
|
|
| MONTHLY INCOME |
|
|
|
|
|
Category A |
Category B |
Category C |
Category D |
Family Size |
100% and below |
101%-125% |
126%-150% |
151%-200% |
1 |
$903.00 |
$1,128.00 |
$1,354.00 |
$1,805.00 |
2 |
$1,214.00 |
$1,518.00 |
$1,821.00 |
$2,428.00 |
3 |
$1,609.00 |
$2,012.00 |
$2,414.00 |
$3,218.00 |
4 |
$1,838.00 |
$2,297.00 |
$2,756.00 |
$3,675.00 |
5 |
$2,149.00 |
$2,687.00 |
$3,224.00 |
$4,298.00 |
6 |
$2,461.00 |
$3,076.00 |
$3,691.00 |
$4,922.00 |
7 |
$2,773.00 |
$3,466.00 |
$4,159.00 |
$5,545.00 |
8 |
$3,084.00 |
$3,855.00 |
$4,626.00 |
$6,168.00 |
|
|
|
|
|
|
| SLIDING SCALE FEES |
|
|
|
|
|
Category A |
Category B |
Category C |
Category D |
New Patient |
Standard $20.00 |
25% |
50% |
75% |
99202 |
$ 20.00 |
$ 20.00 |
$ 38.00 |
$ 56.00 |
99203 |
$ 20.00 |
$ 25.00 |
$ 50.00 |
$ 75.00 |
99204 |
$ 20.00 |
$ 35.00 |
$ 70.00 |
$ 105.00 |
99205 |
$ 20.00 |
$ 48.00 |
$ 95.00 |
$ 143.00 |
|
|
|
|
|
Established Patient |
Standard $20.00 |
25% |
50% |
75% |
99212 |
$ 20.00 |
$ 20.00 |
$ 23.00 |
$ 34.00 |
99213 |
$ 20.00 |
$ 20.00 |
$ 33.00 |
$ 49.00 |
99214 |
$ 20.00 |
$ 23.00 |
$ 45.00 |
$ 68.00 |
99215 |
$ 20.00 |
$ 34.00 |
$ 68.00 |
$ 102.00 |
|
