Co-Pay Schedule
Bethesda Office Visit
Co-Pay Schedule 2025
Income Group by HOUSEHOLD Annual Income
# in Houshold
1
2
3
4
5+
Group A 75% or less
$11,738 or less
$15,773 or less
$19,808 or less
$27,755 or less
$31,790 or less
If new, refer to
Patient Care Manager
Group B 75% - 200%
$11,739 - $31,300
$15,774 - $42,060
$19,809 - $52,820
$27,756 - $63,580
$31,791 - $74,340
Medical $20
Dental - Tier 1
Group C 200% - 300%
$31,301 - $46,950
$42,061 - $63,090
$52,821 - $79,230
$63,581 - $95,370
$74,341 - $111,510
Medical $30
Dental - Tier 2
301% +
$46,951 or more
$63,091 or more
$79,231 or more
$95,371 or more
$111,511 or more
Refer to
Patient Care Manager
Income Group by HOUSEHOLD Monthly Income
# in Houshold
1
2
3
4
5+
Group A 75% or less
$978 or less
$1,314 or less
$1,651 or less
$2,313 or less
$2,649 or less
If new, refer to
Patient Care Manager
Group B 75% - 200%
$979 - $2,608
$1,315 - $3,505
$1,652 - $4,402
$2,314 - $5,298
$2,650 - $6,195
Medical $20
Dental - Tier 1
Group C 200% - 300%
$2,609 - $3,913
$3,506 - $5,258
$4,403 - $6,603
$5,299 - $7,948
$6,196 - $9,293
Medical $30
Dental - Tier 2
301% +
$3,914 or more
$5,259 or more
$6,604 or more
$7,949 or more
$9,294 or more
Refer to
Patient Care Manager
Income Group by HOUSEHOLD Weekly Income
# in Houshold
1
2
3
4
5+
Group A 75% or less
$226 or less
$303 or less
$381 or less
$534 or less
$611 or less
If new, refer to
Patient Care Manager
Group B 75% - 200%
$227 - $602
$304 - $809
$382 - $1,016
$535 - $1,223
$612 - $1,430
Medical $20
Dental - Tier 1
Group C 200% - 300%
$603 - $903
$810 - $1,213
$1,017 - $1,524
$1,224 - $1,834
$1,431 - $2,144
Medical $30
Dental - Tier 2
301% +
$904 or more
$1,214 or more
$1,525 or more
$1,835 or more
$2,145 or more
Refer to
Patient Care Manager
Bethesda Pediatrics Office Visit
Co-Pay Schedule 2025
Income Group by HOUSEHOLD Annual Income
# in Houshold
1
2
3
4
5+
Nominal Fee
Dental
Group A 75% or less
$11,738 or less
$15,773 or less
$19,808 or less
$27,755 or less
$31,790 or less
Medical & Counseling $15
Tier 1
Group B 75% - 200%
$11,739 - $31,300
$15,774 - $42,060
$19,809 - $52,820
$27,756 - $63,580
$31,791 - $74,340
Medical & Counseling $20
Tier 1
Group C 200% - 300%
$31,301 - $46,950
$42,061 - $63,090
$52,821 - $79,230
$63,581 - $95,370
$74,341 - $111,510
Medical & Counseling $30
Medicaid Cash Fees
301% +
$46,951 or more
$63,091 or more
$79,231 or more
$95,371 or more
$111,511 or more
Medicaid Cash Fees
Medicaid Cash Fees
Income Group by HOUSEHOLD Monthly Income
# in Houshold
1
2
3
4
5+
Nominal Fee
Dental
Group A 75% or less
$978 or less
$1,314 or less
$1,651 or less
$2,313 or less
$2,649 or less
Medical & Counseling $15
Tier 1
Group B 75% - 200%
$979 - $2,608
$1,315 - $3,505
$1,652 - $4,402
$2,314 - $5,298
$2,650 - $6,195
Medical & Counseling $20
Tier 1
Group C 200% - 300%
$2,609 - $3,913
$3,506 - $5,258
$4,403 - $6,603
$5,299 - $7,948
$6,196 - $9,293
Medical & Counseling $30
Medicaid Cash Fees
301% +
$3,914 or more
$5,259 or more
$6,604 or more
$7,949 or more
$9,294 or more
Medicaid Cash Fees
Medicaid Cash Fees
Income Group by HOUSEHOLD Weekly Income
# in Houshold
1
2
3
4
5+
Nominal Fee
Dental
Group A 75% or less
$226 or less
$303 or less
$381 or less
$534 or less
$611 or less
Medical & Counseling $15
Tier 1
Group B 75% - 200%
$227 - $602
$304 - $809
$382 - $1,016
$535 - $1,223
$612 - $1,430
Medical & Counseling $20
Tier 1
Group C 200% - 300%
$603 - $903
$810 - $1,213
$1,017 - $1,524
$1,224 - $1,834
$1,431 - $2,144
Medical & Counseling $30
Medicaid Cash Fees
301% +
$904 or more
$1,214 or more
$1,525 or more
$1,835 or more
$2,145 or more
Medicaid Cash Fees
Medicaid Cash Fees
Bethesda serves working uninsured patients who are within 100-300% of the Federal Poverty Level.
2024 Poverty Guideline $15,650
If your income is outside of the 100-300% Federal Poverty Level, please call our Patient Care Advocate (903-596-8353 ext 112) to discuss your options.
Questions?
If you have any questions regarding this process or what to bring, please contact our Admissions Department at
(903) 596-8353 ext. 112 or admissions@bethesdaclinic.org.