Ordering Physician Name
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Ordering Physician Office
Physician Office Fax
We are requesting additional materials of:
New Patient Consultation Virtual/In Person - $100/$200
Roots Testing (Bloodwork, Ultrasound, Follow-up Visit) - $100
Fertility Monitoring Ultrasound - $150
Complete Semen Analysis - Count, Motility, and Morphology/ Home Collection Kit (i.e., infectious disease testing not required) -$199
Ultrasound Saline Tubal Patency Testing- $250
IUI Sample Preparation $300
Ovulation Induction (OI) - $250
Ovulation Induction (OI) and Intrauterine insemination (IUI) - $800
Annual Tissue Storage (Embryos, Eggs, Sperm) - $400
Egg Freezing - $5,000
Sperm Freezing and Storage - $500
Ovarian Platelet Rich Plasma - $2,200
IVF with Intracytoplasmic sperm injection (ICSI) - $10,000
Frozen Transfer/Fresh Embryo Transfer - $3,000/$2,500
Other
Date
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