Cost Form

COST FORM

Women's Health Center
555 Midtowne St.
Suite 300
Grand Rapids, MI 49503
(800) 695-5941
(616) 774-2030

In Vitro Fertilization (IVF)

IVF is an elective procedure which is seldom covered by any insurance carrier. Our office billing office will be glad to assist you to determine if your insurance will cover any of the monitoring leading up to the procedure, the procedure itself and/or both. For IVF, fees are listed and you are responsible for payment of all fees which include supplies, staff support, IVF lab and Dr. Daly's professional services. For these elective services, payment in full is required the first day you begin your ultrasound monitoring with Dr. Daly in the office. We will give you any receipts you need to submit to your insurance and/or a flex benefit for reimbursement. If any procedure is not performed for any reason, you will receive a refund of your payment for the procedure not performed.

Cryopreservation of Embryos

If you elect to cryopreserve, the consent must be signed and payment made for both the freezing and the two-year storage period at the start of your IVF cycle. If there is no consent filed or payment made, no extra eggs will be exposed to sperm for fertilization. IF no cryopreservation takes place due to physiological limitations of the eggs & sperm available, you will receive a 100% refund of both the laboratory and storage fees. payment for cryopreservation is made in this office along with your IVF payment on the first day you start your ultrasound monitoring with Dr. Daly.

IVF Cycle Fees for Grand Rapids Fertility (prepay) New Prices as of January 2010
IVF Cycle Monitoring Fees (selected insurance may cover these fees)
Office visits (4)		$410.00
Ultrasounds (4)		$625.00
Laboratory monitoring (8)		$440.00
FDA indicated STD testing (male and female required for freezing embryos)		$820.00	($410.00 each)
Subtotal		$2295.00

IVF basic procedure fees
Egg Retrieval Embryo Lab Charges Embryo Preparation and Transfer Supplies Sperm Prep		$2210.00 $1910.00 $850.00 $295.00 $100.00
Subtotal		$5365.00
Total for basic IVF cycle* * excluding medication, ICSI and cryopreservation	$7660.00
Additional charges that apply when indicated:
Sperm Thaw Sperm ID post Testicular Biopsy		$30.00 $500.00
ICSI (direct sperm injection) 10 or less oocytes ICSI (direct sperm injection 11 or more oocytes Blastocyst Culture (culture of embryos past 3 days		$850.00 $1200.00 $350.00
Cryopreservation laboratory fee* cost per additional freeze if indicated Cryopreservation storage fee (2 yrs.)* Embryo Thaw		$550.00 $275.00 $700.00 $600.00	**storage fee returned if all embryos are used within 4 months
Microdose Lupron		$80.00
Total for IVF cycle as planned		$-----------------------------
Cost of medications are a separate expense estimated at $2500.00 - $3000.00 for a single IVF cycle Total payment for IVF cycle charges is due on cycle start/baseline ultrasound day. PAYMENT METHODS: CASH, CREDIT CARD, MONEY ORDER, CASHIER'S CHECK. NO PERSONAL CHECKS
Tubal Reversal (Reanastomosis) New Prices as of January 2010
Associated Fees
Surgeon's Fee Prepaid to Grand Rapids Fertility & IVF 2 weeks prior to Surgery		$2800.00
Anesthesiologist's Fee* *Depends on length of surgery		$1700.00
Hospital Fee* Flat rate for next day discharge. For standard procedures, patients will be discharged the next day. If a longer stay is necessary, the hospital will charge a fee for each additional day.		$4100.00
Total Estimated Cost		$8600.00
* Please make arrangements with the hospital 2 weeks prior to surgery. For questions and payments arrangements, please call 1-800-968-0145 to speak with a financial counselor at the Spectrum Health Hospital Butterworth Campus.

GRAND RAPIDS
FERTILITY& IVF, P.C.

Women's Health Center
555 Midtowne St.
Suite 315
Grand Rapids, Michigan 49503
Tel: (616)774-2030 Fax: (616)774-2053
Toll Free 1 (800) 695-5941

Douglas C. Daly, M.D.

Board-Certified Reproductive Endocrinology/ Infertility Board-Certified Obstetrics/ Gynecology

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