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.