SELF-PAY FEE SCHEDULE FOR LEG VEIN



























NOTE:  Full payment is U.S. Dollars (cash or credit card) is required prior to scheduling the VNUS Closure
Procedure.  For all other in-office procedures/therapy, payment in full (U.S. dollars via cash or credit card) is
required at check-in.  This is a reduced schedule of charges for Self-Pay Patients Only.  No insurance billing,
claim adjudication, or financing is offered.  If insurance billing, referrals, or authorizations are needed, our
standard fee schedule and payment policies will apply to all services rendered.

I acknowledge this Fee Schedule and agree to make timely payment as indicated above.  
 

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Parent/Guardian Signature                                                                                Date


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INITIAL LEG VEIN CONSULT WITH VASCULAR SURGEON
Free
   
VNUS CLOSURE
 
Venous Insufficiency Diagnostic Ultrasound
$170
Office Visit to Determine Treatment Plan
$  50
Pre-Op Vein Mapping at DVL (If Surgeon deems Necessary)
$110
VNUS Closure Procedure
$2,500
Post-Op Ultrasound (DVL) & Follow-up Exam
$110
Package Total (Closure Only)
$2,940
   
VEIN THERAPY
 
First 30 Minutes
$250
Each Additional 15 Minute Interval
$100
   
SCLEROTHERAPY (Leg Vein Injections)                       
Fee determined at
consult with
Surgeon
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