For clients without insurance coverage and those choosing confidential services, WUPHD offers Family planning and STD program on a sliding fee scale. Use your income and family size to determine contribution level.
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| Family Size | Income range for 0% contribution | Income range for 25% contribution | Income range for 50% contribution | Income range for 75% contribution | Range for 100% contribution | ||||||||
| 1 | 0-- | 14,580 | 14,581 | 21,870 | 21,871 | 29,160 | 29,161 | 36,450 | 36,451 | ||||
| 2 | 0-- | 19,720 | 19,721 | 29,580 | 29,581 | 39,440 | 39,441 | 49,300 | 49,301 | ||||
| 3 | 0-- | 24,860 | 24,861 | 37,290 | 37,291 | 49,720 | 49,721 | 62,150 | 62,151 | ||||
| 4 | 0-- | 30,000 | 30,001 | 45,000 | 45,001 | 60,000 | 60,001 | 75,000 | 75,001 | ||||
| 5 | 0-- | 35,140 | 35,141 | 52,710 | 52,711 | 70,280 | 70,281 | 87,850 | 87,851 | ||||
| 6 | 0-- | 40,280 | 40,281 | 60,420 | 60,421 | 80,560 | 80,561 | 100,700 | 100,701 | ||||
| 7 | 0-- | 45,420 | 45,421 | 68,130 | 68,131 | 90,870 | 90,841 | 113,550 | 113,551 | ||||
| 8 | 0-- | 50,560 | 50,561 | 75,840 | 75,841 | 101,120 | 101,121 | 126,400 | 126,401 | ||||
| Each additional family member | $5,140 | $7,710 | $10,280 | $12,850 | $12,851 | ||||||||
| % to charge | 0%/Donation | 25% | 50% | 75% | 100% | ||||||||
Once you’ve calculated your contribution level, the fee schedule below will help you calculate the cost of services at the health department.
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| Contraceptive Implant Insertion | $0.00 | $18.25 | $36.50 | $54.75 | $73.00 | |||||
| Contraceptive Implant Removal | $0.00 | $18.25 | $36.50 | $54.75 | $73.00 | |||||
| Diaphragm Fit Visit | $0.00 | $25.00 | $50.00 | $75.00 | $100.00 | |||||
| IUD Insertion | $0.00 | $17.50 | $35.00 | $52.50 | $70.00 | |||||
| IUD Removal | $0.00 | $13.25 | $26.50 | $39.75 | $53.00 | |||||
| NP Visit, New Pt, (Expanded Problem Focused/Low to Moderate) | $0.00 | $20.00 | $40.00 | $60.00 | $80.00 | |||||
| NP Visit, New Pt, (Detailed Problem Focused/Moderate) | $0.00 | $25.00 | $50.00 | $75.00 | $100.00 | |||||
| RN Visit | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 | |||||
| Supplies Only Visit or Treatment Visit (including EPT) | NC | NC | NC | NC | NC | |||||
| IUD Follow-up Visit | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 | |||||
| NP Visit, Est Pt, (Expanded Problem Focused/Low to Moderate) | $0.00 | $15.00 | $30.00 | $45.00 | $60.00 | |||||
| NP Visit, Est Pt, (Detailed Problem Focused/Moderate) | $0.00 | $20.00 | $40.00 | $60.00 | $80.00 | |||||
| Preventive Visit, New Pt 12-17y | $0.00 | $51.25 | $102.50 | $153.75 | $205.00 | |||||
| Preventive Visit, New Pt 18-39y | $0.00 | $51.25 | $102.50 | $153.75 | $205.00 | |||||
| Preventive Visit, New Pt 40-64y | $0.00 | $60.00 | $120.00 | $180.00 | $240.00 | |||||
| Preventive Visit, Est Pt, 12-17y | $0.00 | $48.75 | $97.50 | $146.25 | $195.00 | |||||
| Preventive Visit, Est Pt, 18-39y | $0.00 | $48.75 | $97.50 | $146.25 | $195.00 | |||||
| Preventive Visit, Est Pt, 40-64y | $0.00 | $48.75 | $97.50 | $146.25 | $195.00 | |||||
| Lab/Procedure | ||||||||||
| Pap Test (obtaining specimen for screening) | NC | NC | NC | NC | NC | |||||
| Venipuncture | $0.00 | $5.00 | $10.00 | $15.00 | $20.00 | |||||
| Destruction of lesions, male | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 | |||||
| Destruction of lesions, female | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 | |||||
| Urinalysis Dipstick | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 | |||||
| Pregnancy Test Urine | $0.00 | $3.00 | $6.00 | $9.00 | $12.00 | |||||
| Hemoglobin | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 | |||||
| Syphilis Panel (sent to State Lab) | NC | NC | NC | NC | NC | |||||
| HIV Test (Rapid) | NC | NC | NC | NC | NC | |||||
| Hep C Test | NC | NC | NC | NC | NC | |||||
| Wet Prep | $0.00 | 3.00 | 6.00 | 9.00 | 12.00 | |||||
| Herpes Simplex Virus PCR | $0.00 | 25.00 | 50.00 | 75.00 | 100.00 | |||||
| Trichomonas Amp | $0.00 | $3.00 | $6.00 | $9.00 | $12.00 | |||||
| Injection Administration | $0.00 | $7.50 | $15.00 | $22.50 | $30.00 | |||||
| Chlamydia & Gonorrhea Lab Test | $0.00 | $15.00 | $30.00 | $45.00 | $60.00 | |||||
| HPV Testing (added to pap test) | $0.00 | $12.50 | $25.00 | $37.50 | $50.00 | |||||
| HBV (Hep B) Test | NC | NC | NC | NC | NC | |||||
| Contraceptive Supplies | ||||||||||
| Condoms, 1 doz. | NC | NC | NC | NC | NC | |||||
| Diaphragm 1 unit | $0.00 | $15.00 | $30.00 | $45.00 | $60.00 | |||||
| Jelly, Cream or Foam | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 | |||||
| Depo Provera | $0.00 | $9.00 | $18.00 | $27.00 | $36.00 | |||||
| Emergency Contraceptive (Plan B) | $0.00 | $5.00 | $10.00 | $15.00 | $20.00 | |||||
| Intrauterine Device (Paragard, Mirena, Kyleena) | Based on Cost of device | |||||||||
| Nexplanon | Based on Cost of device | |||||||||
| Nuvaring | $0.00 | $10.00 | $20.00 | $30.00 | $40.00 | |||||
| Oral Contraceptives (per package) | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 | |||||
| Pharmaceutical Supplies | ||||||||||
| Hep B Vaccine (if MIAVP eligible) | NC | NC | NC | NC | NC | |||||
| Rocephin Injection | NC | NC | NC | NC | NC | |||||
| Fluconazole 150 mg #1 | NC | NC | NC | NC | NC | |||||
| Acyclovir 400 mg | $0.00 | $2.50 | $5.00 | $7.50 | $10.00 | |||||
| Amoxicillin 500 mg | $0.00 | $3.75 | $7.50 | $11.25 | $15.00 | |||||
| Bactrim DS | $0.00 | $3.75 | $7.50 | $11.25 | $15.00 | |||||
| Penicillin G Injection | NC | NC | NC | NC | NC | |||||
| Cefixime 400 mg | NC | NC | NC | NC | NC | |||||
| Clindamycin 150 mg | NC | NC | NC | NC | NC | |||||
| Doxycycline 100 mg | NC | NC | NC | NC | NC | |||||
| Metronidazole #4 | NC | NC | NC | NC | NC | |||||
| Metronidazole #14 | NC | NC | NC | NC | NC | |||||
| Metronidazole Gel 0.75% 70gm Tube | $0.00 | $5.00 | $10.00 | $15.00 | $20.00 | |||||
| Zithromax 1 gm | NC | NC | NC | NC | NC | |||||