IN VITRO FERTILIZATION PROGRAM
FEE SCHEDULE Effective June 1st 2008

Fee for IVF Procedure

$5,625.00 - 1st Cycle
$4,625.00 - 2nd Cycle
$3,625.00 - 3rd Cycle

PATIENT ASSESSMENT:

IVF Management Fee
Mock/Injection Teach/Cycle Monitoring

(99199)

$370.00 - 1st Cycle
$0.00    - 2nd Cycle
$0.00    - 3rd Cycle

EMBRYO RETRIEVAL:

(58970)

$1,430.00 - 1st Cycle
$1,400.00 - 2nd Cycle
$1,200.00 - 3rd Cycle

Ultrasound Guidance Aspiration Ovum

(76948)

$300.00 - 1st Cycle
$200.00 - 2nd Cycle
$100.00 - 3rd Cycle

Culture of Oocytes/Embryos

(89250 & 89272)

$1,750.00 - 1st Cycle
$1,600.00 - 2nd Cycle
$1,200.00 - 3rd Cycle

Insemination of Oocytes

(89268)

$500.00 - 1st Cycle
$400.00 - 2nd Cycle
$300.00 - 3rd Cycle

Oocyte ID Follicular Fluid

(89254)

$200.00 - 1st Cycle
$100.00 - 2nd Cycle
$100.00 - 3rd Cycle

Sperm Preparation

(89261)

$100.00 - 1st Cycle
$100.00 - 2nd Cycle
$100.00 - 3rd Cycle

EMBRYO TRANSFER:

(58974)

$700.00 - 1st Cycle
$600.00 - 2nd Cycle
$400.00 - 3rd Cycle

Preparation for Embryo Transfer

(89255)

$150.00 - 1st Cycle
$100.00 - 2nd Cycle
$100.00 - 3rd Cycle

Temporary Semen Storage: (short term storage - 4 to 6 weeks)

For IVF

(89343)

$100.00

For IUI

(89343)

$250.00

Ultrasound Scans**

$700.00

LABORATORY TESTS:**(Estradiol tests)

$450.00**

Note:
Additional laboratory tests might be required.
IVF Ultrasound Scans and Laboratory Tests might be
covered by your insurance (i.e. Univera, BC/BS, etc).
They will not be billed to your insurance unless
we have verified they are covered services…

MEDICATIONS**(Follistim/Gonal-F, etc.)

$2,400.00**

** These are approximate costs…

ADDITIONAL IVF Procedures (If Necessary):

ICSI/Assisted Oocyte Fertilization

(89280/89281)

$1,000.00

Partial ICSI/Assisted Oocyte Fertilization

(89280/89281)

$500.00

Assisted Hatching

(89253)

$500.00

Frozen Embryo Cycle:

$1100.00

FET Cycle Monitoring

(99211)

Thawing Cryopreserved Embryos

(89352)

Embryo Transfer

(58974)

Ultrasounds (approximately 2)

(76830)

$350.00**

Medications (purchased by patient)

$800.00**

Embryo Cryopreservation 1st year

(89258)

$500.00

Storage every 6 months after 1st year

(89346)

$150.00

Semen Cryopreservation 1st year

(89259)

$400.00

Storage every 6 months after 1st year

(89343)

$100.00

Testicular Semen Cryopreservation 1st Year

(89335)

$600.00

Complex Sperm Isolation

(89261)

Sperm Identification from Test Tissue

(89264)

Thawing Cryopreserved Testicular Sperm

(89354)

$50.00

Storage every 6 months after 1st year

(89344)

$100.00

** These are approximate costs...