Please complete the following form to obtain your self-pay estimate. Please note this is an ESTIMATE ONLY. Name: Email Address: People in household: 1 2 3 4 5 6 7 8 Please indicate how many people are in your household. Annual Household Income : Choose income More than $75,300 Between $60,240 and $75,300 Between $45,180 and $60,240 Between $30,120 and $45,180 Between $15,060 and $30,120 Less than $15,060 Answer the question below: Is three < than two? (true/false)