Copayment Calculation Worksheet

INITIAL REDETERMINATION
Family Size Minimum Maximum Co-Pay CALCULATION Family Size Minimum Maximum Co-Pay
2 $0.00 - $1,526 $1.00 Family Size 2 $0.00 - $575.00 $2.00
2 $1,527 - $1,678.00 $3.00 Monthly Income 2 $576.00 - $719.00 $3.00
2 $720.00 - $862.00 $12.00 2 $720.00 - $862.00 $12.00
2 $863.00 - $1,006.00 $18.00 Initial 2 $863.00 - $1,006.00 $18.00
2 $1,007.00 - $1,150.00 $29.00 Co-Pay - Table A 2 $1,007.00 - $1,150.00 $29.00
2 $1,151.00 - $1,293.00 $41.00 #N/A 2 $1,151.00 - $1,293.00 $41.00
2 $1,294.00 - $1,437.00 $55.00 2 $1,294.00 - $1,437.00 $55.00
2 $1,438.00 - $1,581.00 $72.00 2 $1,438.00 - $1,581.00 $72.00
2 $1,582.00 - $1,724.00 $90.00 2 $1,582.00 - $1,724.00 $90.00
2 $1,725.00 - $1,868.00 $111.00 Redetermination 2 $1,725.00 - $1,868.00 $111.00
2 $1,869.00 - $2,012.00 $133.00 Co-Pay - Table A 2 $1,869.00 - $2,012.00 $133.00
2 $2,013.00 - $2,155.00 $146.00 #N/A 2 $2,013.00 - $2,155.00 $146.00
2 $2,156.00 - $2,299.00 $156.00 2 $2,156.00 - $2,299.00 $156.00
2 $2,300.00 - $2,443.00 $166.00 2 $2,300.00 - $2,443.00 $166.00
2 $2,444.00 - $2,586.00 $176.00 2 $2,444.00 - $2,586.00 $176.00
2 $2,587.00 - $2,730.00 $186.00 2 $2,587.00 - $2,730.00 $186.00
2 $2,731.00 - $2,874.00 $196.00 2 $2,731.00 - $2,874.00 $196.00
2 $2,875.00 - above OVER INCOME 2 $2,875.00 - $3,017.00 $206.00
3 $0.00 - $724.00 $2.00 2 $3,018.00 - $3,161.00 $216.00
3 $725.00 - $905.00 $3.00 2 $3,162.00 - $3,233.00 $224.00
3 $906.00 - $1,086.00 $15.00 2 $3,234.00 - $4,489.00 Grad. phase out - $224
3 $1,087.00 - $1,267.00 $23.00 2 $4,490.00 - above OVER INCOME
3 $1,268.00 - $1,448.00 $36.00 3 $0.00 - $724.00 $2.00
3 $1,449.00 - $1,629.00 $52.00 3 $725.00 - $905.00 $3.00
3 $1,630.00 - $1,810.00 $70.00 3 $906.00 - $1,086.00 $15.00
3 $1,811.00 - $1,991.00 $90.00 3 $1,087.00 - $1,267.00 $23.00
3 $1,992.00 - $2,172.00 $114.00 3 $1,268.00 - $1,448.00 $36.00
3 $2,173.00 - $2,353.00 $139.00 3 $1,449.00 - $1,629.00 $52.00
3 $2,354.00 - $2,534.00 $168.00 3 $1,630.00 - $1,810.00 $70.00
3 $2,535.00 - $2,715.00 $184.00 3 $1,811.00 - $1,991.00 $90.00
3 $2,716.00 - $2,896.00 $196.00 3 $1,992.00 - $2,172.00 $114.00
3 $2,897.00 - $3,077.00 $209.00 3 $2,173.00 - $2,353.00 $139.00
3 $3,078.00 - $3,258.00 $222.00 3 $2,354.00 - $2,534.00 $168.00
3 $3,259.00 - $3,439.00 $234.00 3 $2,535.00 - $2,715.00 $184.00
3 $3,440.00 - $3,620.00 $247.00 3 $2,716.00 - $2,896.00 $196.00
3 $3,621.00 - above OVER INCOME 3 $2,897.00 - $3,077.00 $209.00
4 $0.00 - $874.00 $2.00 3 $3,078.00 - $3,258.00 $222.00
4 $875.00 - $1,092.00 $3.00 3 $3,259.00 - $3,439.00 $234.00
4 $1,093.00 - $1,310.00 $18.00 3 $3,440.00 - $3,620.00 $247.00
4 $1,311.00 - $1,529.00 $28.00 3 $3,621.00 - $3,801.00 $260.00
4 $1,530.00 - $1,747.00 $44.00 3 $3,802.00 - $3,982.00 $272.00
4 $1,748.00 - $1,965.00 $62.00 3 $3,983.00 - $4,073.00 $282.00
4 $1,966.00 - $2,184.00 $84.00 3 $4,074.00 - $5,546.00 Grad. phase out - $282
4 $2,185.00 - $2,402.00 $109.00 3 $5,547.00 - above OVER INCOME
4 $2,403.00 - $2,620.00 $137.00 4 $0.00 - $874.00 $2.00
4 $2,621.00 - $2,839.00 $168.00 4 $875.00 - $1,092.00 $3.00
4 $2,840.00 - $3,057.00 $202.00 4 $1,093.00 - $1,310.00 $18.00
4 $3,058.00 - $3,275.00 $222.00 4 $1,311.00 - $1,529.00 $28.00
4 $3,276.00 - $3,494.00 $237.00 4 $1,530.00 - $1,747.00 $44.00
4 $3,495.00 - $3,712.00 $252.00 4 $1,748.00 - $1,965.00 $62.00
4 $3,713.00 - $3,930.00 $268.00 4 $1,966.00 - $2,184.00 $84.00
4 $3,931.00 - $4,149.00 $283.00 4 $2,185.00 - $2,402.00 $109.00
4 $4,150.00 - $4,367.00 $298.00 4 $2,403.00 - $2,620.00 $137.00
4 $4,368.00 - above OVER INCOME 4 $2,621.00 - $2,839.00 $168.00
5 $0.00 - $1,023.00 $2.00 4 $2,840.00 - $3,057.00 $202.00
5 $1,024.00 - $1,279.00 $3.00 4 $3,058.00 - $3,275.00 $222.00
5 $1,280.00 - $1,534.00 $21.00 4 $3,276.00 - $3,494.00 $237.00
5 $1,535.00 - $1,790.00 $33.00 4 $3,495.00 - $3,712.00 $252.00
5 $1,791.00 - $2,046.00 $51.00 4 $3,713.00 - $3,930.00 $268.00
5 $2,047.00 - $2,301.00 $73.00 4 $3,931.00 - $4,149.00 $283.00
5 $2,302.00 - $2,557.00 $99.00 4 $4,150.00 - $4,367.00 $298.00
5 $2,558.00 - $2,813.00 $128.00 4 $4,368.00 - $4,585.00 $313.00
5 $2,814.00 - $3,068.00 $161.00 4 $4,586.00 - $4,804.00 $329.00
5 $3,069.00 - $3,324.00 $197.00 4 $4,805.00 - $4,913.00 $340.00
5 $3,325.00 - $3,580.00 $237.00 4 $4,914.00 - $6,602.00 Grad. phase out - $340
5 $3,581.00 - $3,835.00 $260.00 4 $6,603.00 - above OVER INCOME
5 $3,836.00 - $4,091.00 $277.00 5 $0.00 - $1,023.00 $2.00
5 $4,092.00 - $4,347.00 $295.00 5 $1,024.00 - $1,279.00 $3.00
5 $4,348.00 - $4,602.00 $313.00 5 $1,280.00 - $1,534.00 $21.00
5 $4,603.00 - $4,858.00 $331.00 5 $1,535.00 - $1,790.00 $33.00
5 $4,859.00 - $5,114.00 $349.00 5 $1,791.00 - $2,046.00 $51.00
5 $5,115.00 - above OVER INCOME 5 $2,047.00 - $2,301.00 $73.00
6 $0.00 - $1,172.00 $2.00 5 $2,302.00 - $2,557.00 $99.00
6 $1,173.00 - $1,465.00 $3.00 5 $2,558.00 - $2,813.00 $128.00
6 $1,466.00 - $1,758.00 $24.00 5 $2,814.00 - $3,068.00 $161.00
6 $1,759.00 - $2,051.00 $37.00 5 $3,069.00 - $3,324.00 $197.00
6 $2,052.00 - $2,344.00 $58.00 5 $3,325.00 - $3,580.00 $237.00
6 $2,345.00 - $2,637.00 $84.00 5 $3,581.00 - $3,835.00 $260.00
6 $2,638.00 - $2,930.00 $113.00 5 $3,836.00 - $4,091.00 $277.00
6 $2,931.00 - $3,223.00 $146.00 5 $4,092.00 - $4,347.00 $295.00
6 $3,224.00 - $3,516.00 $184.00 5 $4,348.00 - $4,602.00 $313.00
6 $3,517.00 - $3,809.00 $226.00 5 $4,603.00 - $4,858.00 $331.00
6 $3,810.00 - $4,102.00 $271.00 5 $4,859.00 - $5,114.00 $349.00
6 $4,103.00 - $4,395.00 $297.00 5 $5,115.00 - $5,369.00 $367.00
6 $4,396.00 - $4,688.00 $318.00 5 $5,370.00 - $5,625.00 $385.00
6 $4,689.00 - $4,981.00 $338.00 5 $5,626.00 - $5,753.00 $398.00
6 $4,982.00 - $5,274.00 $359.00 5 $5,754.00 - $7,658.00 Grad. phase out - $398
6 $5,275.00 - $5,567.00 $379.00 5 $7,659.00 - above OVER INCOME
6 $5,568.00 - $5,860.00 $400.00 6 $0.00 - $1,172.00 $2.00
6 $5,861.00 - above OVER INCOME 6 $1,173.00 - $1,465.00 $3.00
7 $0.00 - $1,322.00 $2.00 6 $1,466.00 - $1,758.00 $24.00
7 $1,323.00 - $1,652.00 $3.00 6 $1,759.00 - $2,051.00 $37.00
7 $1,653.00 - $1,982.00 $27.00 6 $2,052.00 - $2,344.00 $58.00
7 $1,983.00 - $2,313.00 $42.00 6 $2,345.00 - $2,637.00 $84.00
7 $2,314.00 - $2,643.00 $66.00 6 $2,638.00 - $2,930.00 $113.00
7 $2,644.00 - $2,973.00 $94.00 6 $2,931.00 - $3,223.00 $146.00
7 $2,974.00 - $3,304.00 $127.00 6 $3,224.00 - $3,516.00 $184.00
7 $3,305.00 - $3,634.00 $165.00 6 $3,517.00 - $3,809.00 $226.00
7 $3,635.00 - $3,964.00 $207.00 6 $3,810.00 - $4,102.00 $271.00
7 $3,965.00 - $4,295.00 $254.00 6 $4,103.00 - $4,395.00 $297.00
7 $4,296.00 - $4,625.00 $306.00 6 $4,396.00 - $4,688.00 $318.00
7 $4,626.00 - $4,955.00 $335.00 6 $4,689.00 - $4,981.00 $338.00
7 $4,956.00 - $5,286.00 $358.00 6 $4,982.00 - $5,274.00 $359.00
7 $5,287.00 - $5,616.00 $382.00 6 $5,275.00 - $5,567.00 $379.00
7 $5,617.00 - $5,946.00 $405.00 6 $5,568.00 - $5,860.00 $400.00
7 $5,947.00 - $6,277.00 $428.00 6 $5,861.00 - $6,153.00 $420.00
7 $6,278.00 - $6,607.00 $451.00 6 $6,154.00 - $6,446.00 $441.00
7 $6,608.00 - above OVER INCOME 6 $6,447.00 - $6,593.00 $456.00
8 $0.00 - $1,471.00 $2.00 6 $6,594.00 - $8,714.00 Grad. phase out - $456
8 $1,472.00 - $1,839.00 $3.00 6 $8,715.00 - above OVER INCOME
8 $1,840.00 - $2,206.00 $30.00 7 $0.00 - $1,322.00 $2.00
8 $2,207.00 - $2,574.00 $47.00 7 $1,323.00 - $1,652.00 $3.00
8 $2,575.00 - $2,942.00 $73.00 7 $1,653.00 - $1,982.00 $27.00
8 $2,943.00 - $3,309.00 $105.00 7 $1,983.00 - $2,313.00 $42.00
8 $3,310.00 - $3,677.00 $142.00 7 $2,314.00 - $2,643.00 $66.00
8 $3,678.00 - $4,045.00 $184.00 7 $2,644.00 - $2,973.00 $94.00
8 $4,046.00 - $4,412.00 $231.00 7 $2,974.00 - $3,304.00 $127.00
8 $4,413.00 - $4,780.00 $283.00 7 $3,305.00 - $3,634.00 $165.00
8 $4,781.00 - $5,148.00 $341.00 7 $3,635.00 - $3,964.00 $207.00
8 $5,149.00 - $5,515.00 $373.00 7 $3,965.00 - $4,295.00 $254.00
8 $5,516.00 - $5,883.00 $399.00 7 $4,296.00 - $4,625.00 $306.00
8 $5,884.00 - $6,251.00 $425.00 7 $4,626.00 - $4,955.00 $335.00
8 $6,252.00 - $6,618.00 $450.00 7 $4,956.00 - $5,286.00 $358.00
8 $6,619.00 - $6,986.00 $476.00 7 $5,287.00 - $5,616.00 $382.00
8 $6,987.00 - $7,354.00 $502.00 7 $5,617.00 - $5,946.00 $405.00
8 $7,355.00 - above OVER INCOME 7 $5,947.00 - $6,277.00 $428.00
9 $0.00 - $1,620.00 $2.00 7 $6,278.00 - $6,607.00 $451.00
9 $1,621.00 - $2,025.00 $3.00 7 $6,608.00 - $6,937.00 $474.00
9 $2,026.00 - $2,430.00 $33.00 7 $6,938.00 - $7,268.00 $497.00
9 $2,431.00 - $2,835.00 $52.00 7 $7,269.00 - $7,433.00 $515.00
9 $2,836.00 - $3,240.00 $81.00 7 $7,434.00 - $8,912.00 Grad. phase out - $515
9 $3,241.00 - $3,645.00 $116.00 7 $8,913.00 - above OVER INCOME
9 $3,646.00 - $4,050.00 $156.00 8 $0.00 - $1,471.00 $2.00
9 $4,051.00 - $4,455.00 $202.00 8 $1,472.00 - $1,839.00 $3.00
9 $4,456.00 - $4,860.00 $254.00 8 $1,840.00 - $2,206.00 $30.00
9 $4,861.00 - $5,265.00 $312.00 8 $2,207.00 - $2,574.00 $47.00
9 $5,266.00 - $5,670.00 $375.00 8 $2,575.00 - $2,942.00 $73.00
9 $5,671.00 - $6,075.00 $411.00 8 $2,943.00 - $3,309.00 $105.00
9 $6,076.00 - $6,480.00 $439.00 8 $3,310.00 - $3,677.00 $142.00
9 $6,481.00 - $6,885.00 $468.00 8 $3,678.00 - $4,045.00 $184.00
9 $6,886.00 - $7,290.00 $496.00 8 $4,046.00 - $4,412.00 $231.00
9 $7,291.00 - $7,695.00 $525.00 8 $4,413.00 - $4,780.00 $283.00
9 $7,696.00 - $8,100.00 $553.00 8 $4,781.00 - $5,148.00 $341.00
9 $8,101.00 - above OVER INCOME 8 $5,149.00 - $5,515.00 $373.00
10 $0.00 - $1,770.00 $2.00 8 $5,516.00 - $5,883.00 $399.00
10 $1,771.00 - $2,212.00 $3.00 8 $5,884.00 - $6,251.00 $425.00
10 $2,213.00 - $2,654.00 $36.00 8 $6,252.00 - $6,618.00 $450.00
10 $2,655.00 - $3,097.00 $56.00 8 $6,619.00 - $6,986.00 $476.00
10 $3,098.00 - $3,539.00 $88.00 8 $6,987.00 - $7,354.00 $502.00
10 $3,540.00 - $3,981.00 $126.00 8 $7,355.00 - $7,721.00 $528.00
10 $3,982.00 - $4,424.00 $171.00 8 $7,722.00 - $8,089.00 $553.00
10 $4,425.00 - $4,866.00 $221.00 8 $8,090.00 - $8,273.00 $573.00
10 $4,867.00 - $5,308.00 $278.00 8 $8,274.00 - $9,110.00 Grad. phase out - $573
10 $5,309.00 - $5,751.00 $341.00 8 $9,111.00 - above OVER INCOME
10 $5,752.00 - $6,193.00 $410.00 9 $0.00 - $1,620.00 $2.00
10 $6,194.00 - $6,635.00 $449.00 9 $1,621.00 - $2,025.00 $3.00
10 $6,636.00 - $7,078.00 $480.00 9 $2,026.00 - $2,430.00 $33.00
10 $7,079.00 - $7,520.00 $511.00 9 $2,431.00 - $2,835.00 $52.00
10 $7,521.00 - $7,962.00 $542.00 9 $2,836.00 - $3,240.00 $81.00
10 $7,963.00 - $8,405.00 $573.00 9 $3,241.00 - $3,645.00 $116.00
10 $8,406.00 - $8,847.00 $604.00 9 $3,646.00 - $4,050.00 $156.00
10 $8,848.00 - above OVER INCOME 9 $4,051.00 - $4,455.00 $202.00
11 $0.00 - $1,919.00 $2.00 9 $4,456.00 - $4,860.00 $254.00
11 $1,920.00 - $2,399.00 $3.00 9 $4,861.00 - $5,265.00 $312.00
11 $2,400.00 - $2,878.00 $39.00 9 $5,266.00 - $5,670.00 $375.00
11 $2,879.00 - $3,358.00 $61.00 9 $5,671.00 - $6,075.00 $411.00
11 $3,359.00 - $3,838.00 $96.00 9 $6,076.00 - $6,480.00 $439.00
11 $3,839.00 - $4,317.00 $137.00 9 $6,481.00 - $6,885.00 $468.00
11 $4,318.00 - $4,797.00 $185.00 9 $6,886.00 - $7,290.00 $496.00
11 $4,798.00 - $5,277.00 $240.00 9 $7,291.00 - $7,695.00 $525.00
11 $5,278.00 - $5,756.00 $301.00 9 $7,696.00 - $8,100.00 $553.00
11 $5,757.00 - $6,236.00 $369.00 9 $8,101.00 - $8,505.00 $581.00
11 $6,237.00 - $6,716.00 $444.00 9 $8,506.00 - $8,910.00 $610.00
11 $6,717.00 - $7,195.00 $487.00 9 $8,911.00 - $9,113.00 $631.00
11 $7,196.00 - $7,675.00 $521.00 9 $9,114.00 - $9,308.00 Grad. phase out - $631
11 $7,676.00 - $8,155.00 $554.00 9 $9,309.00 - above OVER INCOME
11 $8,156.00 - $8,634.00 $588.00 10 $0.00 - $1,770.00 $2.00
11 $8,635.00 - $9,114.00 $621.00 10 $1,771.00 - $2,212.00 $3.00
11 $9,115.00 - $9,594.00 $655.00 10 $2,213.00 - $2,654.00 $36.00
11 $9,595.00 - above OVER INCOME 10 $2,655.00 - $3,097.00 $56.00
12 $0.00 - $2,068.00 $2.00 10 $3,098.00 - $3,539.00 $88.00
12 $2,069.00 - $2,585.00 $3.00 10 $3,540.00 - $3,981.00 $126.00
12 $2,586.00 - $3,102.00 $42.00 10 $3,982.00 - $4,424.00 $171.00
12 $3,103.00 - $3,619.00 $66.00 10 $4,425.00 - $4,866.00 $221.00
12 $3,620.00 - $4,136.00 $103.00 10 $4,867.00 - $5,308.00 $278.00
12 $4,137.00 - $4,653.00 $148.00 10 $5,309.00 - $5,751.00 $341.00
12 $4,654.00 - $5,170.00 $199.00 10 $5,752.00 - $6,193.00 $410.00
12 $5,171.00 - $5,687.00 $258.00 10 $6,194.00 - $6,635.00 $449.00
12 $5,688.00 - $6,204.00 $325.00 10 $6,636.00 - $7,078.00 $480.00
12 $6,205.00 - $6,721.00 $398.00 10 $7,079.00 - $7,520.00 $511.00
12 $6,722.00 - $7,238.00 $479.00 10 $7,521.00 - $7,962.00 $542.00
12 $7,239.00 - $7,755.00 $525.00 10 $7,963.00 - $8,405.00 $573.00
12 $7,756.00 - $8,272.00 $561.00 10 $8,406.00 - $8,847.00 $604.00
12 $8,273.00 - $8,789.00 $597.00 10 $8,848.00 - $9,289.00 $635.00
12 $8,790.00 - $9,306.00 $633.00 10 $9,290.00 - $9,732.00 $666.00
12 $9,307.00 - $9,823.00 $670.00 10 $9,733.00 - $9,953.00 $689.00
12 $9,824.00 - $10,340.00 $706.00 10 $9,954.00 - above OVER INCOME
12 $10,341.00 - above OVER INCOME 11 $0.00 - $1,919.00 $2.00
13 $0.00 - $2,218.00 $2.00 11 $1,920.00 - $2,399.00 $3.00
13 $2,219.00 - $2,772.00 $3.00 11 $2,400.00 - $2,878.00 $39.00
13 $2,773.00 - $3,326.00 $45.00 11 $2,879.00 - $3,358.00 $61.00
13 $3,327.00 - $3,881.00 $71.00 11 $3,359.00 - $3,838.00 $96.00
13 $3,882.00 - $4,435.00 $111.00 11 $3,839.00 - $4,317.00 $137.00
13 $4,436.00 - $4,989.00 $158.00 11 $4,318.00 - $4,797.00 $185.00
13 $4,990.00 - $5,544.00 $214.00 11 $4,798.00 - $5,277.00 $240.00
13 $5,545.00 - $6,098.00 $277.00 11 $5,278.00 - $5,756.00 $301.00
13 $6,099.00 - $6,652.00 $348.00 11 $5,757.00 - $6,236.00 $369.00
13 $6,653.00 - $7,207.00 $427.00 11 $6,237.00 - $6,716.00 $444.00
13 $7,208.00 - $7,761.00 $513.00 11 $6,717.00 - $7,195.00 $487.00
13 $7,762.00 - $8,315.00 $563.00 11 $7,196.00 - $7,675.00 $521.00
13 $8,316.00 - $8,870.00 $602.00 11 $7,676.00 - $8,155.00 $554.00
13 $8,871.00 - $9,424.00 $640.00 11 $8,156.00 - $8,634.00 $588.00
13 $9,425.00 - $9,978.00 $679.00 11 $8,635.00 - $9,114.00 $621.00
13 $9,979.00 - $10,533.00 $718.00 11 $9,115.00 - $9,594.00 $655.00
13 $10,534.00 - $11,087.00 $757.00 11 $9,595.00 - $10,073.00 $688.00
13 $11,088.00 - above OVER INCOME 11 $10,074.00 - $10,553.00 $722.00
14 $0.00 - $2,367.00 $2.00 11 $10,554.00 - $10,793.00 $747.00
14 $2,368.00 - $2,959.00 $3.00 11 $10,794.00 - above OVER INCOME
14 $2,960.00 - $3,550.00 $48.00 12 $0.00 - $2,068.00 $2.00
14 $3,551.00 - $4,142.00 $75.00 12 $2,069.00 - $2,585.00 $3.00
14 $4,143.00 - $4,734.00 $118.00 12 $2,586.00 - $3,102.00 $42.00
14 $4,735.00 - $5,325.00 $169.00 12 $3,103.00 - $3,619.00 $66.00
14 $5,326.00 - $5,917.00 $228.00 12 $3,620.00 - $4,136.00 $103.00
14 $5,918.00 - $6,509.00 $296.00 12 $4,137.00 - $4,653.00 $148.00
14 $6,510.00 - $7,100.00 $372.00 12 $4,654.00 - $5,170.00 $199.00
14 $7,101.00 - $7,692.00 $456.00 12 $5,171.00 - $5,687.00 $258.00
14 $7,693.00 - $8,284.00 $548.00 12 $5,688.00 - $6,204.00 $325.00
14 $8,285.00 - $8,875.00 $601.00 12 $6,205.00 - $6,721.00 $398.00
14 $8,876.00 - $9,467.00 $642.00 12 $6,722.00 - $7,238.00 $479.00
14 $9,468.00 - $10,059.00 $683.00 12 $7,239.00 - $7,755.00 $525.00
14 $10,060.00 - $10,650.00 $725.00 12 $7,756.00 - $8,272.00 $561.00
14 $10,651.00 - $11,242.00 $766.00 12 $8,273.00 - $8,789.00 $597.00
14 $11,243.00 - $11,834.00 $808.00 12 $8,790.00 - $9,306.00 $633.00
14 $11,835.00 - above OVER INCOME 12 $9,307.00 - $9,823.00 $670.00
15 $0.00 - $2,516.00 $2.00 12 $9,824.00 - $10,340.00 $706.00
15 $2,517.00 - $3,145.00 $3.00 12 $10,341.00 - $10,857.00 $742.00
15 $3,146.00 - $3,774.00 $51.00 12 $10,858.00 - $11,374.00 $778.00
15 $3,775.00 - $4,403.00 $80.00 12 $11,375.00 - $11,633.00 $805.00
15 $4,404.00 - $5,032.00 $125.00 12 $11,634.00 - above OVER INCOME
15 $5,033.00 - $5,661.00 $180.00 13 $0.00 - $2,218.00 $2.00
15 $5,662.00 - $6,290.00 $243.00 13 $2,219.00 - $2,772.00 $3.00
15 $6,291.00 - $6,919.00 $314.00 13 $2,773.00 - $3,326.00 $45.00
15 $6,920.00 - $7,548.00 $395.00 13 $3,327.00 - $3,881.00 $71.00
15 $7,549.00 - $8,177.00 $484.00 13 $3,882.00 - $4,435.00 $111.00
15 $8,178.00 - $8,806.00 $583.00 13 $4,436.00 - $4,989.00 $158.00
15 $8,807.00 - $9,435.00 $638.00 13 $4,990.00 - $5,544.00 $214.00
15 $9,436.00 - $10,064.00 $683.00 13 $5,545.00 - $6,098.00 $277.00
15 $10,065.00 - $10,693.00 $727.00 13 $6,099.00 - $6,652.00 $348.00
15 $10,694.00 - $11,322.00 $771.00 13 $6,653.00 - $7,207.00 $427.00
15 $11,323.00 - $11,951.00 $815.00 13 $7,208.00 - $7,761.00 $513.00
15 $11,952.00 - $12,580.00 $859.00 13 $7,762.00 - $8,315.00 $563.00
15 $12,581.00 - above OVER INCOME 13 $8,316.00 - $8,870.00 $602.00
13 $8,871.00 - $9,424.00 $640.00
13 $9,425.00 - $9,978.00 $679.00
13 $9,979.00 - $10,533.00 $718.00
13 $10,534.00 - $11,087.00 $757.00
13 $11,088.00 - $11,641.00 $796.00
13 $11,642.00 - $12,196.00 $834.00
13 $12,197.00 - $12,473.00 $863.00
13 $12,474.00 - above OVER INCOME
14 $0.00 - $2,367.00 $2.00
14 $2,368.00 - $2,959.00 $3.00
14 $2,960.00 - $3,550.00 $48.00
14 $3,551.00 - $4,142.00 $75.00
14 $4,143.00 - $4,734.00 $118.00
14 $4,735.00 - $5,325.00 $169.00
14 $5,326.00 - $5,917.00 $228.00
14 $5,918.00 - $6,509.00 $296.00
14 $6,510.00 - $7,100.00 $372.00
14 $7,101.00 - $7,692.00 $456.00
14 $7,693.00 - $8,284.00 $548.00
14 $8,285.00 - $8,875.00 $601.00
14 $8,876.00 - $9,467.00 $642.00
14 $9,468.00 - $10,059.00 $683.00
14 $10,060.00 - $10,650.00 $725.00
14 $10,651.00 - $11,242.00 $766.00
14 $11,243.00 - $11,834.00 $808.00
14 $11,835.00 - $12,425.00 $849.00
14 $12,426.00 - $13,017.00 $891.00
14 $13,018.00 - $13,313.00 $922.00
14 $13,314.00 - above OVER INCOME
15 $0.00 - $2,516.00 $2.00
15 $2,517.00 - $3,145.00 $3.00
15 $3,146.00 - $3,774.00 $51.00
15 $3,775.00 - $4,403.00 $80.00
15 $4,404.00 - $5,032.00 $125.00
15 $5,033.00 - $5,661.00 $180.00
15 $5,662.00 - $6,290.00 $243.00
15 $6,291.00 - $6,919.00 $314.00
15 $6,920.00 - $7,548.00 $395.00
15 $7,549.00 - $8,177.00 $484.00
15 $8,178.00 - $8,806.00 $583.00
15 $8,807.00 - $9,435.00 $638.00
15 $9,436.00 - $10,064.00 $683.00
15 $10,065.00 - $10,693.00 $727.00
15 $10,694.00 - $11,322.00 $771.00
15 $11,323.00 - $11,951.00 $815.00
15 $11,952.00 - $12,580.00 $859.00
15 $12,581.00 - $13,209.00 $903.00
15 $13,210.00 - $13,838.00 $947.00
15 $13,839.00 - $14,153.00 $980.00
15 $14,154.00 - above OVER INCOME