One-Cycle Payment Plan

The traditional pay-as-you-go plan cost is not dependent on the patient’s age or medical qualifications.

What is included in one-cycle plan:

• Monitoring with ultrasounds and blood tests at Alta Bates IVF Program.
• One egg retrieval fees including anesthesia and operating room.
• Embryology laboratory including hatching or extended culture if appropriate.
• One embryo transfer with ultrasound guidance and post-transfer care.

What is not included in one-cycle plan:

• Pre-treatment work-up (semen analysis, HSG, saline infusion sono-hysterogram, hormone tests, infectious disease tests, prenatal panel, genetic testing)
• Medications
• Freezing of embryos and frozen embryo transfer
• Donor sperm
• Pregnancy diagnosis and management

In the one-cycle payment plan, financing of IVF cost through MedicalFinancing.com can be used to cover the professional fees of Dr. Chetkowski and the Alta Fertility Laboratory.

Standard deposits in the first treatment on the one-cycle plan:

All deposits are due on the day of your baseline ultrasound and consist of five checks: one to R. J. Chetkowski, M.D., Inc., one to Alta Fertility Laboratory, Inc., one to Anesthesia Group and two to Alta Bates Summit Medical Center.

Payees	No- ICSI- IVF	Split- ICSI- IVF	All- ICSI- IVF
R.J. Chetkowski, M.D., Inc.*	3,120	3,120	3,120
Alta Fertility Laboratory, Inc.*	3,240	4,040	4,440
Anesthesia Group	450	450	450
Alta Bates Summit Medical Center	1,885	1,885	1,885
Alta Bates Summit Medical Center	590	790	990
Totals	$9,285	$10,285	$10,885

Discount deposits in repeat IVF attempts on the one-cycle plan:

Recognizing the importance of timely treatments, we have also reduced charges for patients who return for a repeat IVF attempt within 6 months of a previous treatment on the one-cycle plan. Discount deposits are:

Payees	No- ICSI- IVF	Split- ICSI- IVF	All- ICSI- IVF
R.J. Chetkowski, M.D.	3,800	3,800	3,800
Alta Fertility, Laboratory, Inc.	2,160	2,760	2,960
Anesthesia Group	400	400	400
Alta Bates Summit Medical Center	1,660	1,660	1,660
Alta Bates Summit Medical Center	590	790	990
Totals	$8,690	$9,550	$10,150

Other expenses

The one-cycle payment plan does not include freezing of embryos and storage, or subsequent transfer of frozen-thawed embryos. Freezing of semen is also not included. If any of these services are performed, you will owe an additional amount. These charges are listed below.

Freezing of Semen	$150
Semen Storage (first year)	$150
Embryo Freezing	$600 -1,200
Storage (first year)	$150
Hospital fee for embryo freezing	$200
Embryo/Sperm Storage (second year)	$400
Frozen Embryo Transfer (FET, approximate cost)	$3,000

Pregnancy-related services

The above plans do not include the cost of the hCG blood tests to determine if you are pregnant and additional blood tests and ultrasounds done to evaluate the progress of the pregnancy. In our office blood tests are $107 per test and pregnancy ultrasounds are $330 per visit. We anticipate that you will have 2-4 blood tests and 2-4 ultrasounds in the first trimester. At 11-12 weeks you will be referred back to your obstetrician or, if you do not have one, we will recommend one to you.

The quoted prices are subject to change without prior notification.

Billing

You will receive a separate statement from R.J. Chetkowski, M.D., Inc., Alta Fertility Laboratory, Inc. and the Anesthesia Group. Alta Bates Summit Medical Center provides only a receipt for self-pay patients, not an itemized bill (which would be more suitable for submitting to insurance carriers). Please do not hesitate to call Ms. Maria Castillo at (510) 649-0440 with any billing question you may have regarding statements for Dr. Chetkowski's and for Alta Fertility Laboratory, Inc. services.

Inquiries regarding statements for anesthesia services should be directed to Bay Anesthesia Medical Group at (925) 951-1366

All balances should be paid in full within 90 days of the completion of treatment. The total cost of a previous treatment cycle must be paid in full before another one can begin. Thank you for your understanding and cooperation with these policies. We look forward to providing you with infertility care of the highest caliber.