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1 Specialists In Reproductive Medicine & Surgery, P.A. Excellence, Experience & Ethics In Vitro Fertilization Price List (2015) We here at Specialists in Reproductive Medicine & Surgery, P.A., (SRMS) want to offer you a Dreamy option that will make it easier for you to achieve your goals of building your family. We call it our Dream Discount Program offering 30%/40%/50% off of our 2014 prices for nearly all of your Assisted Reproductive Technology (ART) procedures! Below is a breakdown of the estimated self-pay costs of our IVF procedure under our new Dream Discount Program: ART Procedure In Vitro Fertilization (IVF) 30% Off Cycle 1 Dream Discount Program 40% Off Cycle 2 (2014 fees: $13,550) The fees subject to the Dream Discount Program are highlighted Red in this Price List. 50% Off Cycle 3 $ 9,900 $ 8,700 $ 7,500 General: The following are the charges incurred during an IVF procedure. We have done our very best to estimate the charges accurately, although patient variance will often occur. If we participate with your insurance company, we will verify benefits prior to IVF. If IVF is a covered service, we will bill your insurance company and collect any co-payments due at the time of service. If IVF is not a covered service or we do not participate with your insurance plan, no charges will be billed to your insurance company and all fees will be as listed below: Initial Intake: Possible Comprehensive New Female Patient Visit $ Intermediate New Male Patient Visit Subtotal: $ Female Studies: HSG or Hysteroscopy $ HIV (Human Immunodeficiency Virus) Rubella screen ABO RH (Blood Type) Antibody screen HBsAg (Hepatitis B) World Plaza Lane, Bldg. 53 Fort Myers, Florida fax

2 Hepatitis C Progesterone RPR (Syphilis) DNA Gene Probe (Gonorrhea & Chlamydia) PAP FSH (Follicle Stimulating Hormone) Trial Transfer CBC/Diff Electrolytes Venipuncture (x3) Subtotal: $2, Male Studies: Semen Analysis/Anti Sperm Antibody Screen Semen Analysis Semen Culture HIV (Human Immunodeficiency Virus) HBsAg (Hepatitis B) RPR (Syphilis) Venipuncture (x1) SA/Cryopreservation Sperm * Subtotal: $ $ * Some men may request that their semen be cryopreserved prior to the procedure. This will be discussed in your case management. [All Initial Intake, Female and Male Study fees ($3,770 $4,227) will be due at the time of service.] ART Medications: Possible Ovarian Stimulation Medications $2, $3, Ovidrel or HCG Progesterone (vaginal suppository) Lupron Antibiotics Ganirelix Letrozole Subtotal: $2, $4,061.00* * These prices may vary with respect to the amount of medication needed by an individual patient. At times, individual patients may require even more medications than listed. [All ART Medication fees ($2,671 $4,061) are paid directly to the pharmacy.] Case Management Fee: (Paid at time of cycle registration) $ Follicular Monitoring: Page 2 of 5 Ultrasounds (x4) $ Estradiol Blood Tests (x4) Progesterone Blood Test Venipuncture (x4) 96.00

3 Subtotal: $1, Egg Retrieval & Laboratory Fees: Anesthesia $ Egg Retrieval 1, Ultrasound Guidance Andrology/Embryology Lab Fees Preparation of Embryos for Transfer Embryo Transfer 1, Subtotal: $11, Post-Transfer Fees: Blood Pregnancy Test* Venipuncture* Subtotal: $ *The blood pregnancy test and venipuncture fees are not pre-collected with the initial deposit amount and will be due at the time services are rendered. [All Follicular Monitoring, Egg Retrieval, Andrology/Embryology Laboratory, Embryo Transfer fees ($13,183) must be paid to SRMS by cycle start date.] Total ART Fees: Possible Total $20, $21, Once Pregnancy Is Achieved: Potential Costs Following Successful ART Page 3 of 5 Blood Pregnancy Test (x2) $ Venipuncture (x2) Progesterone (vaginal suppository, paid to pharmacy) Pregnancy Ultrasounds (x2) Subtotal: $1, [Charges that occur Once Pregnancy is Achieved ($1,513) will be due at the time the services are rendered.] If pregnancy is not achieved, a follow-up visit is encouraged and will be charged in the usual and customary fashion. Long-term frozen embryo storage fees are separate issues, which will be discussed with all those patients who desire long-term storage of their embryos. Frozen Embryo Transfer (FET) Fees: ART Medications: Possible Urinary LH monitoring $55.00 Paid to pharmacy Ovidrel or HCG Paid to pharmacy Prometrium Paid to pharmacy

4 Subtotal: $ Natural Cycle FET: Cycle Fee $ Blood LH levels (X3) Estradiols (X3) Ultrasounds (X3) Venipuncture (X3) Preparation of Frozen Embryos for transfer Assisted Hatching Embryo Transfer 1, Blood Pregnancy Test (Not prepaid) Venipuncture (Not pre paid) Subtotal: $4, [Frozen Embryo Transfer fees ($4,855) will be prepaid before the initiation of the transfer cycle.] If a natural cycle FET is not possible (patient does not ovulate on her own), a replacement cycle will be performed with an estimated increase in fees of approx. $1,442. The replacement cycle fees are a bit more unpredictable, depending upon patient variability. Changes In Fees: The incurred costs estimated here are not guaranteed. Individual variability often results in an unpredictable number of ultrasounds, blood tests and medication vials administered. All fees listed here are subject to change without notice. For your convenience, Visa, Discover & MasterCard are accepted. Any funds that were collected for procedures that were not performed (i.e., the cycle was canceled) will be refunded upon request within thirty days of the conclusion of your cycle. Any funds not pre-collected for procedures performed that exceeded our original estimates, or for possible or post transfer fees, will be billed at the time of service with all monies owing to be paid within thirty days of embryo transfer. I have read the information above and our questions answered to our satisfaction. We agree to be responsible for the payment of charges as stated: Woman s Signature Woman s Name (print) Date Partner s Signature Partner s Name (print) Date Office Personnel Signature Office Personnel Name (print) Date Page 4 of 5

5 Practitioner s Signature Practitioner s Name (print) Date Updated: 1/14/15 K:\docs\forms\In Vitro Fertilization Price List.doc Copyright 2001, Specialists In Reproductive Medicine & Surgery, P.A., Page 5 of 5

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