| 1st IVF Cost (NFC支払い分/全額自費） | ||
| 日付 | 内訳 | 支払分 |
| 6/18/2007 | 精子冷凍保存 | 675.00 |
| 7/25/2007 | IVF Class | 216.00 |
| 8/7/2007 | blood test | 15.00 |
| 8/14/2007 | blood test | 156.54 |
| 8/22/2007 | Embryology fees for retrieval and transfer (Lab) (ラボでの受精卵に関する費用） |
2,440.00 |
| 8/22/2007 | ICSI | 2,000.00 |
| 8/22/2007 | embyo crypreservation and one year storage (凍結胚冷凍保存費用〔1年間〕） |
1,000.00 |
| 8/22/2007 | physician fee for retrieval transfer （採卵医師技術料） |
2,155.00 |
| 8/22/2007 | surgery and anesthesia charge (手術・麻酔費用） |
2,590.00 |
| 8/28/2007 | monitor blood test and ultra sound | 340.00 |
| 9/4/2007 | monitor blood test and ultra sound | 246.00 |
| 9/7/2007 | monitor blood test and ultra sound | 246.00 |
| 9/8/2007 | monitor blood test and ultra sound | 246.00 |
| 9/10/2007 | monitor blood test and ultra sound | 246.00 |
| 9/11/2007 | monitor blood test | 76.00 |
| 9/19/2007 | blood test (progesteron) | 105.00 |
| 9/26/2007 | blood test (hcg) | 70.40 |
| 9/28/2007 | blood test (hcg) | 70.40 |
| 10/1/2007 | blood test (hcg) | 70.40 |
| 10/3/2007 | blood test (hcg) | 70.40 |
| 10/5/2007 | blood test (hcg) | 70.40 |
| 10/8/2007 | blood test (hcg) | 70.40 |
| 10/12/2007 | blood test (hcg) | 70.40 |
| 計 | $13,245.34 | |
| 1st IUI Cost (Vanderbilt Medical Center支払い分/全額自費） | ||
| 日付 | 内訳 | 支払分 |
| 6/25/2007 | Isemination Professional Fee | 250.00 |
| 6/25/2007 | Isemination Hospital/Clinic Fee | 80.00 |
| 6/25/2007 | IUI Semem Evaluation (sperm wash) | 244.00 |
| 計 | $574.00 | |
| 2nd IUI Cost (NFC支払い分/全額自費） | ||
| 日付 | 内訳 | 支払分 |
| 7/20/2007 | Ultrasound, HCG shot | 196.66 |
| 7/21/2007 | Sperm Isolation | 192.00 |
| 7/21/2007 | IUI | 164.80 |
| 8/11/2007 | Echography, Diagnostic | 156.54 |
| 計 | $710.00 | |
| 2nd IVF Cost (NFC支払い分/全額自費） | ||
| 日付 | 内訳 | 支払分 |
| 11/26/2007 | Suppression Check | 79.00 |
| 11/26/2007 | Suppreion Check, ultrasound | 280.00 |
| 11/27/2007 | Seamen Analysis | 160.00 |
| 12/3/2007 | Blood Test | 95.00 |
| 12/3/2007 | Physician Fees | 805.00 |
| 12/3/2007 | Embryology Fees | 1320.00 |
| 12/3/2007 | Hospital Facility Fees | 500.00 |
| 12/10/2007 | Ultrasound | 170.00 |
| 12/10/2007 | Blood Test | 54.00 |
| 12/26/2007 | Blood Test | 61.00 |
| 12/28/2007 | Blood Test | 76.80 |
| 12/31/2007 | Blood Test | 70.40 |
| 計 | $3671.20 | |
| 1st IVF Med Cost （Portland Professional Pharmacy支払分） | ||||
| 日付 | 内訳 | 自己負担分 | 保険負担分 | Total |
| 8/8/2007 | Syringes for Lupron | 7.52 | 7.52 | |
| 8/8/2007 | Needles for Lupron | 9.00 | 4.09 | 13.09 |
| 8/8/2007 | Tetracycline | 2.97 | 2.97 | |
| 8/8/2007 | methylprednisolone | 3.00 | 10.35 | 13.35 |
| 8/8/2007 | Syringes for Progesteron | 5.00 | 5.00 | |
| 8/8/2007 | Needles for Progesteron | 4.91 | 4.91 | |
| 8/8/2007 | Follistim （600IU×6） | 2520.00 | 2520.00 | |
| 8/8/2007 | Follistim （300IU×1） | 210.00 | 210.00 | |
| 8/8/2007 | Progesteron (2) | 3.00 | 62.04 | 65.04 |
| 8/8/2007 | Ovidrel (2) | 9.00 | 121.07 | 130.07 |
| 8/8/2007 | Lupron | 3.00 | 125.25 | 128.25 |
| 9/12/2007 | Oxicod/apap | 0.00 | 8.69 | 8.69 |
| 9/28/2007 | Progesteron (2) | 3.00 | 62.04 | 65.04 |
| 10/2/2007 | Crinone | 9.00 | 196.04 | 205.00 |
| 計 | $2789.40 | $589.57 | $3378.93 | |
| 2nd IVF Med Cost （Portland Professional Pharmacy支払分） | ||||
| 日付 | 内訳 | 自己負担分 | 保険負担分 | Total |
| 11/5/2007 | Syringes for Lupron | 7.17 | 7.17 | |
| 11/5/2007 | Estrace (1mg×150） | 304.10 | 304.10 | |
| 11/5/2007 | Lupron （2） | 249.77 | 249.77 | |
| 12/20/2007 | Progesteron (2) | 65.58 | 65.58 | |
| 12/28/2007 | Syringes for Progesteron | 4.00 | 4.00 | |
| 12/28/2007 | Estrace (1mg×100） | 217.88 | 217.88 | |
| 12/28/2007 | Progesteron (2) | 3.00 | 119.55 | 122.55 |
| 12/28/2007 | Needles for Progesteron | 4.00 | 4.00 | |
| 1/5/2008 | Estrace (1mg×100） | 217.88 | 217.88 | |
| $1073.38 | $119.55 | $1192.93 | ||
| 鍼・漢方治療 Green Hills Natural Health Clinic支払い分（全額自費） |
|
| 日付 | 支払額 |
| 5/11/2007 | 90.00 |
| 5/16/2007 | 160.00 |
| 6/29/2007 | 180.00 |
| 7/31/2007 | 130.00 |
| 8/7/2007 | 70.00 |
| 8/11/2007 | 70.00 |
| 8/16/2007 | 70.00 |
| 8/16/2007 | 150.00 |
| 8/21/2007 | 70.00 |
| 8/24/2007 | 70.00 |
| 9/4/2007 | 70.00 |
| 9/7/2007 | 70.00 |
| 9/11/2007 | 70.00 |
| 9/14/2007 | 70.00 |
| 9/17/2007 | 70.00 |
| 9/19/2007 | 70.00 |
| 10/31/2007 | 70.00 |
| 11/3/2007 | 70.00 |
| 11/6/2007 | 70.00 |
| 11/9/2007 | 70.00 |
| 11/13/2007 | 70.00 |
| 11/16/2007 | 70.00 |
| 11/23/2007 | 70.00 |
| 11/27/2007 | 70.00 |
| 12/4/2007 | 70.00 |
| 12/7/2007 | 70.00 |
| 12/11/2007 | 70.00 |
| 12/19/2007 | 70.00 |
| 計 | $2320.00 |
| 不妊治療自己負担分合計 | ||||
| 1回目 | 2回目 | 計 | ||
| IUI | 574.00 | 710.00 | 1284.00 | |
| IVF | NFC | 13245.34 | 3671.20 | 16916.54 |
| 薬代 | 2789.40 | 1073.38 | 3862.78 | |
| 鍼・漢方 | 1480.00 | 840.00 | 2320.00 | |
| 計 | 17514.74 | 5584.58 | 23099.32 | |
| 自己負担分総合計支払 | $24383.32 | |||