Date

Specialists In Reproductive
Medicine & Surgery, P.A.
www.DreamABaby.com • [email protected] Excellence, Experience & Ethics
Gestational Surrogacy
Price List (2016)
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 Plus Program" offering 20%/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
Gestational Surrogacy procedure under our new "Dream Discount Plus Program:"
ART Procedures
Dream Discount Plus Program
30% Off
40% Off
50% Off
Gestational Surrogacy (2014 fees: $19,800) The fees subject to the Dream Discount Program are highlighted Red in this Price List.
General:
The following are the charges incurred during a Gestational Surrogacy 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 Gestational Surrogacy. If
Gestational Surrogacy is a covered service, we will bill your insurance company and collect any co-
payments due at the time of service. If Gestational Surrogacy 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 as best as we can estimate in the following pages.
Gestational Surrogacy Legal Fees:
All legal fees need to be discussed in detail with your attorney and the attorney representing the Gestational
Surrogate (GS). We have, however, done our best to give you some rough estimates from the attorney we use
most frequently (Harold Eskin, Es as listed below:
Estimated Legal Fees:
Probable
Possible
Preliminary Discussions With Contract Negotiations Surrogate Legal Representation Accounting Services Reasonable Living and other Expenses For The Surrogate Reasonable Medical Expenses 12611 World Plaza Lane, Bldg. 53 • Fort Myers, Florida 33907 • 239-275-8118 • 239-275-5914 fax Gestational Surrogacy Price List (cont.) Post-Delivery Legal/Court Fees While we have done our best to estimate the costs of Gestational Surrogacy, there are potential costs that do not allow for clear estimates to be made:  Pregnancy complications costs (maternal/fetal/multiple pregnancy fees)  Costs for uterine evacuation procedures for spontaneous pregnancy losses  Costs for selective reduction in multi-fetal pregnancies (triplets or more)  Costs for genetic ultrasound/amniocentesis  Costs for termination of a genetically abnormal pregnancy (rare)  Ongoing psychologic counseling costs (pregnancy and post-partum)  Maternal complications The above fees will be best estimated though your attorney. Evaluation Fees

Commissioning Couple/Intended Parent Evaluation:
Preliminary Evaluation:
Probable
Possible
Criminal History Check *
Psychological Evaluation or Parenting Class*
Comprehensive New Female Patient Visit Comprehensive New Male Patient Visit Commissioning Couple/Intended Parent Cycle Management Fees (Paid at time of cycle registration) Evaluation is required of all individuals without partners requesting surrogacy.
Female Laboratory Studies:
Probable
Possible
HIV (Human Immunodeficiency Virus)* HBsAg (Hepatitis B) * HCsAb (Hepatitis C) * RPR (Syphilis) * DNA Gene Probe (Gonorrhea & Chlamydia) * ABO RH (Blood Type) FSH (Follicle Stimulating Hormone) Counsyl Genetic Test  Venipuncture (x3) As a precaution, the "*" tests above are repeated every six months to assure optimal safety during the Gestational Surrogacy process. Gestational Surrogacy Price List (cont.) CMV testing of the female will only be done if the surrogate is CMV IgG negative. : The Counsyl Test screens for whether the patient is a carrier of certain genetic diseases such as Cystic Fibrosis,
Spinal Muscular Atrophy, Tay-Sachs disease, and Sickle Cell disease, which can significantly impair a child's normal development or life expectancy. For some of these conditions, early diagnosis can alter pregnancy outcomes. We are using the screen that the American Congress of Obstetrics and Gynecology (ACOG) and the American College of Medical Genetics (ACMG) recommend for genetic carrier screening. Additional fees will be discussed with the Commissioning Couple/Intended Parent prior to being performed.
Male Laboratory Studies:
Probable
Possible
HIV (Human Immunodeficiency Virus) HBsAg (Hepatitis B) HCsAb (Hepatitis C) DNA Gene Probe (Gonorrhea & Chlamydia Urine evaluation)
CMV Total †
ABO RH (Blood Type) Venipuncture (x1) Semen Analysis/ASAS & SA SA/Cryopreservation Sperm

Gestational Surrogate Evaluation:
GS Preliminary Evaluation:
Probable
Criminal History Check Psychological Evaluation Comprehensive New Female Patient Visit Diagnostic Hysteroscopy (Uterine Cavity
GS Laboratory Studies:
Probable
Possible
HIV (Human Immunodeficiency Virus)* HBsAg (Hepatitis B) * HCsAb (Hepatitis C) * RPR (Syphilis) * DNA Gene Probe (Gonorrhea & Chlamydia) * CMV Total (Cytomegalovirus) ABO RH (Blood Type) Rubella vaccination if not immune (injection incl.) Varicella (Chicken Pox) Gestational Surrogacy Price List (cont.) Varicella vaccination if not immune (injection x2 incl.) Progesterone Urine Drug Testing Venipuncture (x3) As a precaution, the "*" tests above are repeated every six months to assure optimal safety during the Gestational Surrogacy process.
The frequency of testing any of the items above during pregnancy is at the discretion of the Commissioning
Couple/Intended Parent, GS and the Obstetrician and should be outlined in the legal contracts.
[All Gestational Surrogate Preliminary Evaluations & Laboratory Study fees ($3,497 – $3,967) will be
due prior to the initiation of the GS evaluation.]
Assisted Reproductive Technology Fees

Commissioning Couple/Intended Parent ART Fees:
ART Medications:
Probable
Possible
Ovarian Stimulation Medications 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 ($2,328 - $3,718) will be paid for when received from the pharmacy or via mail
order.]
Mandatory FDA Female Testing:
Probable
Possible
HIV (Human Immunodeficiency Virus) ** HBsAg (Hepatitis B) ** HCsAb (Hepatitis C) ** Anti-HBc IGG (Core Hep B) ** RPR (Syphilis) ** GC/Chlamydia (via urine) FDA Lab Shipping Fee Gestational Surrogacy Price List (cont.) Mandatory FDA Male Testing:
Probable
Possible
HIV (Human Immunodeficiency Virus) ** HBsAg (Hepatitis B) ** HCsAb (Hepatitis C) ** Anti-HBc IGG (Core Hep B) ** RPR (Syphilis) ** GC/Chlamydia (via urine) FDA Lab Shipping Fee **The FDA is now requiring additional testing prior to retrieval. Our current negotiated price for the lab tests
is $221 - $256. This is a direct cost from the out-sourced lab and is subject to change without notice.
Follicular Monitoring:
Probable
Possible
Ultrasounds (x4) Estradiol Blood Tests (x4) Venipuncture (x4)
Egg Retrieval and Laboratory Fees:
Probable
Ultrasound Guidance Andrology/Embryology Lab Fees Preparation of Embryos for Transfer
[All Follicular Monitoring, FDA, Egg Retrieval, Andrology/Embryology Laboratory, and Embryo
Transfer fees ($13,781) are due by cycle start date.]
There are a couple of embryo transfer possibilities which will need to be individually decided. The options
are as follow:
1. The GS has her cycle controlled and her uterus is prepared for a Fresh Embryo Transfer. This will be performed in conjunction with the ovarian stimulation/egg retrieval procedures as listed above. 2. All embryos are cryopreserved for future thaw and transfer in a natural (ovulatory) cycle. If the GS does not conceive with the first transfer, she may undergo one or more transfers in a later cycle. Interestingly, the options will be the same listed as above. If she does not ovulate, she will undergo the same preparation as the Fresh Embryo Transfer (Replacement Cycle) while if she does ovulate, the fees will be as stated for the natural (ovulatory cycle). Gestational Surrogacy Price List (cont.) The price list from this point forward is broken down into these various options. Transfer of Fresh Embryos or Transfer of Thawed Embryos
in The Anovulatory GS (Replacement Cycle)

GS Medications:
Probable
Possible **
Estradiol Valerate Progesterone / Vaginal Lupron will not be needed if the patient is in menopause. If additional medications are required, these will be paid to the pharmacy as needed GS Recipient Monitoring:
Probable
Estrogen Levels (x9) Ultrasounds (x3) Venipuncture (x9)
GS Post Transfer Fees:
Probable
Possible
Blood Pregnancy Test (Not Prepaid) Venipuncture (Not Prepaid)
The GS medications ($1293 - $1643) will be purchased at the pharmacy and will be due upon time of
service. GS Monitoring Fees ($1,770) will be due by cycle start date.
It is possible that another less costly replacement protocol would be advised with a potential savings of
approximately $1556 on medications and monitoring prior to the embryo transfer and another $1374 once
pregnancy is achieved. We are randomizing patients between protocols at this time so there is no guarantee
which protocol will be recommended for you.
Positive Pregnancy In a Replacement Cycle

Once Pregnancy Is Achieved:
Probable
Possible
Blood Pregnancy Test (x2) Progesterone / Vaginal (Paid to Pharmacy) Estradiol Valerate (Paid to Pharmacy) Progesterone Level Estrogen Level (x5) Venipuncture (x7) Pregnancy Ultrasounds (x2) Gestational Surrogacy Price List (cont.)
Charges that occur Once Pregnancy Is Achieved will be due at the time of service.
Transfer of Thawed Embryos in The Ovulatory GS
(Natural Cycle)

ART Medications:
Probable
Possible
Urinary LH monitoring Paid to pharmacy Paid to pharmacy Paid to pharmacy
As part of the Dream Discount Plus Program, there is a 20% discount on Frozen Embryo Transfer Fees. Please see the Dream
Discount Plus Flyer for more details.
Natural Cycle FET:
Probable
Blood LH levels (X3) Ultrasounds (X3) Venipuncture (X3) Preparation of Frozen Embryos for transfer Thawing of Cryopreserved Embryo(s) Assisted Hatching Blood Pregnancy Test (Not prepaid) Venipuncture (Not pre paid) [Frozen Embryo Transfer fees ($4,865) will be prepaid before the initiation of the transfer cycle.]
Positive Pregnancy In a Natural Cycle GS-FET Procedure

Once Pregnancy Is Achieved:
Probable
Possible
Blood Pregnancy Test (x2) Venipuncture (x2) Progesterone Level Paid to pharmacy Pregnancy Ultrasounds (x2) Subtotal:
$1,412.00

[Charges that occur Once Pregnancy is Achieved ($1,292.00) will be due when the GS has a positive
pregnancy test.]
Summary of Financial Responsibilities
Gestational Surrogacy Price List (cont.) Fee Category
Estimated Fees
Payment Timing
Commissioning Couple/Intended Parent
At Time of Service
Evaluation Fees
Gestational Surrogate Evaluation Fees
Prepayment
Commisssioning Couple Medications
Paid to Pharmacy
Commissioning Couple/Intended Parent
Prepayment
ART Fees
(Variable)
Fee Category
Estimated Fees
Payment Timing
Gestational Surrogate Replacement Meds
Paid to Pharmacy
Replacement Cycle Monitoring Fees (Fresh)
Prepayment
Replacement Cycle Transfer Fees (Frozen)
Prepayment
(Variable)
Fee Category
Estimated Fees
Payment Timing
Gestational Surrogate Natural Cycle Meds
Paid to Pharmacy
Natural Cycle GS-FET
Prepayment

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 and 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 seven 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/We have read the information above and all our questions have been answered to our satisfaction. We agree
to be responsible for the payment of charges as stated:
_
Intended Parent Signature Intended Parent Name (print) Partner Signature Partner Name (print) Office Personnel Signature Office Personnel Name (print) Physician Signature Physician Name (print) Updated 02/02/2016 K: Docs Forms Gestational Surrogacy Price List.doc Copyright  2001, Specialists In Reproductive Medicine & Surgery, P.A.

Source: http://bdfund.org/wp-content/uploads/2016/05/Gestational-Surrogacy-Price-List.pdf