Income Guidelines
The same income guidelines and proof requirements still apply for the discount program. Acceptable proof of income includes: 30 day paystub, last years taxes, SSI/SSDI benefit letter, child support, and retirement benefits.
These charges will be collected before the visit.
| Medical Services | Dental Hygentist Services | Standard Dental Services | Oral Surgery / Endodontic Services |
|---|---|---|---|
| Level A $15.00 | Level A $15.00 | Level A $30.00 | Level A $60.00 |
| Level B $30.00 | Level B $30.00 | Level B $60.00 | Level B $120.00 |
| Level C $45.00 | Level C $45.00 | Level C $90.00 | Level C $180.00 |
| Level D $60.00 | Level D $60.00 | Level D $120.00 | Level D $240.00 |
| Level E $75.00 | Level E $75.00 | Level E $150.00 | Level E $300.00 |
| Level F Full Charge | Level F Full Charge | Level F Full Charge | Level F Full Charge |
| Level G $0.00 General Beadle School Patients |
|||
| Level H $0.00 Homeless Patients |
Annual Income Before Taxes
| Family Size | 0% Level A | 20% Level B | 40% Level C | 60% Level D | 80% Level E | 100% Level F |
|---|---|---|---|---|---|---|
| From To | From To | From To | From To | From To | ||
| 1 | $0 $12,760 |
$12,761 $15,950 |
$15,951 $19,140 |
$19,414 $22,330 |
$22,331 $25,521 |
Income over guideline OR Proof of income not provided |
| 2 | $0 $17,240 |
$17,241 $21,550 |
$21,551 $25,860 |
$25,861 $30,170 |
$30,171 $34,481 |
|
| 3 | $0 $21,720 |
$21,721 $27,150 |
$27,151 $32,580 |
$32,581 $38,010 |
$38,011 $43,441 |
|
| 4 | $0 $26,200 |
$26,201 $32,750 |
$32,751 $39,300 |
$39,301 $45,850 |
$45,851 $52,401 |
|
| 5 | $0 $30,680 |
$30,681 $38,350 |
$38,351 $46,020 |
$46,021 $53,690 |
$53,691 $61,361 |
|
| 6 | $0 $35,160 |
$35,161 $43,950 |
$43,951 $52,740 |
$52,741 $61,530 |
$61,531 $70,321 |