Veterinary Surgical Centers

- Vienna Veterinary Surgical Centers - Veterinary Surgical Centers -

124 Park St SE, Lower Level Leesburg Winchester
and 165 Fort Evans Rd NE, 210 Costello Dr,
140 Park St SE, Leesburg, VA 20176 Winchester, VA 22602
Vienna, VA 22180 Ph: 703-771-2100 Ph: 540-450-0177
Ph: 703-242-6000 Fax: 571-209-1158 Fax: 877-344-9594
Fax: 703-242-4770

DESCRIPTION QTY TOTAL

AECC - Charges 1 → 1.2 $660.00 → $792.00

Biopsy with Microscopic Description (1 Site/Lesion)—Priority 1→1 $489.98 → $489.98

Buprenorphine Oral 0.3mg/mL 1→5 $71.90 → $231.48

Catheterization - Urinary - TomCat 1→1 $45.00 → $45.00

Cefazolin 10g 1 → 20 $30.32 → $36.46

Clavamox Drops 62.5mg/mL 1→1 $48.75 → $48.75

Cystectomy - Partial 1→1 $1475.00 → $1475.00

Diazepam 5mg/mL 1→3 $43.90 → $67.70

E-Collar - 30cm 1→1 $43.70 → $43.70

Fentanyl 50mcg/mL 1 → 20 $34.25 → $77.00

Fluid - IV - Pump Setup & Admin 1→1 $93.00 → $93.00

Fluid - IV - Pump Setup & Admin - CRI 1→1 $38.00 → $38.00

Glycopyrrolate 0.2mg/mL 1→5 $51.56 → $137.78

Hospitalization - VSC - < 23kgs 2→2 $244.00 → $244.00

Hospitalization - VSC - Nursing Care 1→1 $209.00 → $209.00

Hydromorphone 2mg/mL 1→5 $33.63 → $40.13

IDX - Aerobic & Anaerobic Cultures 0→1 $0.00 → $451.48

Isoflurane - Inhalant - 1st 60min 1→1 $180.00 → $180.00

IV Catheterization 1→1 $61.00 → $61.00

LAB - IH - TLC - Chem15/CBC/Electrolytes 1→1 $286.80 → $286.80

LAB - IH - TLC - ProBNP 1→1 $93.60 → $93.60

Lactated Ringers Solution 1L - LRS 1→1 $16.35 → $16.35

Monocryl 3-0 SH Y316H Taper 1→2 $15.89 → $31.78

Nocita >5kg 1→1 $315.00 → $315.00

OR Surgery Room Fee 1→1 $428.00 → $428.00

DESCRIPTION QTY TOTAL
PDS 3-0 FS-1 Z452H Cutting 3→4 $64.56 → $86.08

Propofol 10mg/mL 24hr 1→1 $39.19 → $39.19

Radiograph - 1st View 1→1 $190.00 → $190.00

Radiograph - Each Additional View 2→2 $230.00 → $230.00

Technician - Surgery 2→2 $458.00 → $458.00

Subtotal $5990.38 → $6936.26

Tax $0.00
Total $5990.38 →$6936.26
Required Deposit $6936.26

I understand that this estimate covers the first 24 hours of care for Graysen.

I understand that I can call to receive financial updates on a daily basis.

I understand if Graysen stays longer than the estimated time then additional cost will be incurred and I am financially
responsible for payment of these additional charges.

Please be advised this Surgical Estimate of Charge(s) does not include any additional visits for re-check appointments,
bandage changes, follow-up diagnostics or Rehabilitation appointments other than the initial consultation.

Procedure cancellations require a minimum of 24-hour advance notice, without notification they will be subject to a $189
fee.

This document lists procedures to be performed on Graysen. This estimate only approximates the cost of this visit and is only
valid for 30 days from the date created. It does not include any treatments that may be deemed necessary upon examination
and commencement of the included treatments. You are responsible for all fees incurred during this visit included or
not on this estimate.

Be assured that the health of Graysen is our highest concern and we will do everything possible to maintain that health.

As part of our ongoing commitment to Graysen's health, we encourage you to call us at 703-771-2100 if you have any
questions.

I have read, understand and accept the estimate and terms above.

05-10-2023
#WEBFORM-SIGNATURE#
Owner/Agent Signature Date