Annual Income </= 125% FPL / 14,588 / 19,663 / 24,738 / 29,813 / 34,888 / 39,963 / 45,038 / 50,113 / 55,188 / 60,263 / 65,338 / 70,413 / $10 / $5
Annual Income </= 175% / 20,423 / 27,528 / 34,633 / 41,738 / 48,843 / 55,948 / 63,053 / 70,158 / 77,263 / 84,368 / 91,473 / 98,578 / $20 / $10
Annual Income </= 200% / 23,340 / 31,460 / 39,580 / 47,700 / 55,820 / 63,940 / 72,060 / 80,180 / 88,300 / 96,420 / 104,540 / 112,660 / $30 / $15
Annual Income >200% / 23,341 / 31,461 / 39,581 / 47,701 / 55,821 / 63,941 / 72,061 / 80,181 / 88,301 / 96,421 / 104,541 / 112,661 / $110 / $55
# of people in household / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / Fee / Prompt Pay
Monthly Income </= 125% / 1,216 / 1,639 / 2,062 / 2,484 / 2,907 / 3,330 / 3,753 / 4,176 / 4,599 / 5,022 / 5,445 / 5,868 / $10 / $5
Monthly Income </= 175% / 1,702 / 2,294 / 2,886 / 3,478 / 4,070 / 4,662 / 5,254 / 5,847 / 6,439 / 7,030 / 7,623 / 8,215 / $20 / $10
Monthly Income </= 200% / 1,945 / 2,622 / 3,298 / 3,975 / 4,652 / 5,328 / 6,005 / 6,682 / 7,358 / 8,035 / 8,712 / 9,388 / $30 / $15
Monthly Income >200% / 1,946 / 2,623 / 3,299 / 3,976 / 4,653 / 5,329 / 6,006 / 6,683 / 7,359 / 8,036 / 8,713 / 9,389 / $110 / $55
# of people in household / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / Fee / Prompt Pay
Twice/month </= 125% / 608 / 820 / 1,031 / 1,242 / 1,454 / 1,665 / 1,877 / 2,088 / 2,300 / 2,511 / 2,723 / 2,934 / $10 / $5
Twice/month </= 175% / 851 / 1,147 / 1,443 / 1,739 / 2,035 / 2,331 / 2,627 / 2,924 / 3,220 / 3,515 / 3,812 / 4,108 / $20 / $10
Twice/month </= 200% / 973 / 1,311 / 1,649 / 1,988 / 2,326 / 2,664 / 3,003 / 3,341 / 3,679 / 4,018 / 4,356 / 4,694 / $30 / $15
Twice/month >200% / 974 / 1,312 / 1,650 / 1,989 / 2,327 / 2,665 / 3,004 / 3,342 / 3,680 / 4,019 / 4,357 / 4,695 / $110 / $55
# of people in household / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / Fee / Prompt Pay
Income every 2 wks </= 125% / 561 / 756 / 952 / 1,147 / 1,342 / 1,537 / 1,732 / 1,927 / 2,123 / 2,318 / 2,513 / 2,708 / $10 / $5
Income every 2 wks </= 175% / 786 / 1,058 / 1,332 / 1,606 / 1,878 / 2,152 / 2,425 / 2,698 / 2,972 / 3,245 / 3,518 / 3,791 / $20 / $10
Income every 2 wks </= 200% / 898 / 1,210 / 1,522 / 1,835 / 2,147 / 2,459 / 2,772 / 3,084 / 3,396 / 3,708 / 4,021 / 4,333 / $30 / $15
Income every 2 wks >200% / 899 / 1,211 / 1,523 / 1,836 / 2,148 / 2,460 / 2,773 / 3,085 / 3,397 / 3,709 / 4,022 / 4,334 / $110 / $55
# of people in household / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / Fee / Prompt Pay
Weekly income </= 125% / 281 / 378 / 476 / 573 / 671 / 769 / 866 / 964 / 1,061 / 1,159 / 1,257 / 1,354 / $10 / $5
Weekly income </= 175% / 393 / 529 / 666 / 803 / 939 / 1,076 / 1,213 / 1,349 / 1,486 / 1,622 / 1,759 / 1,896 / $20 / $10
Weekly income </= 200% / 449 / 605 / 761 / 917 / 1,073 / 1,230 / 1,386 / 1,542 / 1,698 / 1,854 / 2,010 / 2,167 / $30 / $15
Weekly income >200% / 450 / 606 / 762 / 918 / 1,074 / 1,231 / 1,387 / 1,543 / 1,699 / 1,855 / 2,011 / 2,168 / $110 / $55
* Fees include the cost of the visit and other services performed during the visit (e.g. labwork, immunizations, point of care tests). $110 is the cost of a Level 3 visit.
** Prompt pay means payment for the visit at the time of check-in, at a 50% discount. If a patient cannot pay the discounted fee on the same day as the visit, an invoice for the full fee will be mailed to the patient. Patients are encouraged to meet with our Financial Assistance Specialist to see if they qualify for public medical assistance or government subsidies to purchase health insurance. Payment plans for any outstanding balances can also be arranged on a case-by-case basis.