doi: 10. For the minimum dosage of 10 vials, snake bite therapy would cost at least $12,220, plus other associated costs with the hospital visit. Most patients recover. But, we had to act quickly or she would be gone. Total 40,000 units. We describe the first reported case of a copperhead envenomation resulting in a hand compartment syndrome with measured elevated. His hand started to swell immediately, and he had to be hospitalized overnight, The News. Historical Developments. The lethal liquid is used in antivenom production and laboratory research. Crofab (Crotalidae Polyvalent Immune Fab) · Crotalus atrox. More than one antivenom administration was necessary in thirty-nine (39%) patients that received only CroFab and 76 (69%) patients that received Anavip only. 1093/ajhp/zxz278. For the. Marks said it’s uncommon to give antivenom for a copperhead bite. Note: If a snakebite. Here’s what UNC Health, Duke Health and WakeMed charge for antivenom, plus insurance coverage and discounts available. 62 When tissue. How much is the rattlesnake vaccine for dogs? A single dose of the vaccine costs in the range of $25 to $50, and dogs need a second dose three to six weeks later. 6. But even Leslie Boyer, founding director of the University of Arizona’s VIPER Institute, was shocked that hospitals can pay up to $2,300 for a single vial of antivenom,. The swelling reduced, and Ali’s pain improved. Here’s why. Yes, Benedryl can help with snakes bites. The copperhead was only about 24 inches long. But the copperhead doesn’t wait for summer. If you are bitten by a snake, call 911 or go to the ER immediately, even if you don’t think the snake is venomous. Of these, there were 2035 copperhead, 753 rattlesnake, 255 cottonmouth, and 1,028 unknown crotalid bites. Doctors then kept her overnight to monitor her vital signs and make sure she felt better. View on Amazon. In addition, you may want to mark the edge of the swelling so that you can see how or if the swelling increases over time. Hospitals pay an estimated $2,300 per vial. Antivenin for Dogs, 10 ml Vial helps neutralize the venom in snakebites. 2011 Apr;212 (4):470-4; discussion 474-5. 1016/j. Image Above: “Coral snake” by MyFWC Florida Fish and Wildlife is licensed under CC BY-ND 2. UNC Health, Duke Health and WakeMed all carry antivenom treatments and administer it when needed. Strength and Speed When You Need It Most. Duke Health is a trial site for a drug that could be the first universal antivenom to treat any kind of snake bite — including North Carolina’s ubiquitous copperhead. Around 18 years in the wild. Average lifespan. At UNC Health: For a typical initial dose of four to six vials, the total charge for the antivenom treatment can range from $76,000 to $115,000, UNC Health’s pharmacy team said through local news. Opposums have an innate immunity to a variety of snake venoms. His hand started to swell immediately, and he had to be hospitalized overnight, The News. Antivenom at WakeMed costs between $11,000 and $14,000 per vial, spokesperson Kristin Kelly said. July 1, 2022 at 8:26 AM. 1 The pit viper family (Crotalidae) consists of rattlesnakes (FIGURE 1), cottonmouth moccasins (FIGURE 2), and copperheads, which are distinguished by their elliptical pupils, triangular heads, heat. Our center that sees primarily copperhead snake bites added the recently approved treatment as a second option for. One professor at Texas A&M University’s College of. He needed 12 vials of antivenom, which cost about $200,000, The N&O reported at the time. The incidence of infection in these envenomations is approximately 2%. The Arizona Republic has said in the past that Metro Phoenix hospitals in Arizona are billing as much as $12,467 per vial for antivenom. When all was said and done, the bill came out to $1,900. How much does snake antivenom cost? The N&O spoke with UNC Health and Duke Health for answers: At UNC Health: For a typical initial dose of four to six vials, the total charge for the antivenom treatment can range from $76,000 to $115,000, UNC Health’s pharmacy team said through local news director Alan Wolf. C. Comparison of F(ab′) 2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. In 2000, an FabAV antivenom (CroFab®) was introduced and in 2022, F(ab’)2AV (Anavip®) was approved for treatment of copperhead bites. Hospitals pay an estimated $2,300 per vial. . 8 million to 2. Antivenom costs an arm and a leg- you know- the ones you're trying to save from that snakebite. Antivenom is more effective when it is given within a short time after a snakebite. BMC Emerg Med. 1 percent,. 1) and charges to the patient (defined as the pharmacy reported per unit charge to the patient for each vial of the specific antivenom; Fig. The broad-banded copperhead snake (Agkistrodon laticinctus) is a venomous snake found widespread in the United States of America, from south of Nebraska up to Mexico border and east of Iowa up to Massachusetts. Vaccine — talk. Girl bitten by snake charged $68,000 for lifesaving antivenom which costs just $17,000. His father’s insurance brought the. If it were. Is A. The final cost is even higher for patients. What is the cost of antivenom? The average list price for CroFab is $3,198 per vial, according to the health care information tech company Connecture. [1]How much does anti-venom cost? Current Indian polyvalent antivenom costs approximately USD 6. Retrieval was limited to literature published from 1997 to the present in. Hospitals pay an estimated $2,300 per vial. She is on the mend after two days in the hospital and three rounds of anti-venom. Related searches to Can a dog survive a snake bite without antivenom? can a dog survive a copperhead. Hospital markups, which they say are generally discounted by health. 100+ bought in past month. If you add these up, a man bitten in the US by a venomous snake would have to pay $30,000 in pharmacy costs alone. And to learn more about going to the emergency room (and how to know if you need antivenom) for a copperhead bite,. Alligators can see clear at night. As dogs are not immune to Copperhead venom, they will start displaying symptoms that will give you an indication that they have been bitten by a venomous snake. 3 Flowchart for the management of snakebite* * Reproduced with permission from Toxicology and Wilderness Expert Group. Rattlesnake bites, by comparison, are approximately four times as likely to result in a death or major effects as a copperhead bite. —generally over 100 times what ICP antivenoms go for—the relative rarity of venomous bites and the esoteric, labor. Due to the fact that they spend a lot of their time in the water, they have eyes on the tops of their heads. He needed 12 vials of antivenom, which cost about $200,000, The N&O reported at the time. • In 2020, a teenager was bitten by a copperhead in Hillsborough. • In 2020, a teenager was bitten by a copperhead in Hillsborough. annemergmed. Several other veterinary hospitals throughout Denver said they offer the vaccine, too, if a patient asks. e. • Stay for observation: Envenomations (meaning bites that inject venom into the patient). The News & Observer reported last summer that antivenom at WakeMed costs between $11,000 and $14,000 per vial, spokesperson Kristin Kelly said. Published: Last year. This would include envenomation from all rattlesnakes, copperheads and cottonmouths/water moccasin snakes. buy rattlesnake antivenom for humans arrive at kindergarten healthy and ready to succeed. doi: 10. snake antivenom . Displaying data at 5 minute intervals. As of 2019, the wholesalers’ cost for one vial of antivenom are: $1,220 per vial for ANAVIP, said Paul Landes, vice president of sales at Rare Disease Theraputics. Although risk-benefit calculations favor antivenom administration in most clinical situations, both antivenom products are. 1093/ajhp/zxz278. S. Pure locality specific Western Diamondback Crotalus atrox!Fortunately, a venomous snake may bite and not inject venom. The number of vials needed depends on the swelling. You may need antivenom. The absolute most important thing you should do before anything else is call 9-1-1 or Poison Control. Their venom is highly toxic to humans and other mammals, but it is not lethal to birds, reptiles, amphibians, fish, or invertebrates. Do copperhead bites require antivenom? How much does antivenom cost for dogs? What should I do if my dog gets bitten? What does a non venomous snake bite look like on a. Even though copperhead envenomation is rarely fatal, virtually all patients experience pain and swelling of the envenomated limb [6,8-11]. Benadryl is safe to use on dogs and is a common home remedy for snake bites. Several thousand snakebites occur annually in the US, but fewer than 10 deaths occur. How much does a vial of copperhead. What are the long term effects of a copperhead bite? A Copperhead bite will cause your dog to become sick and can be fatal if not treated quickly. Pyle easily removed the copperhead by placing a large plastic trash can near the snake. Benadryl is safe to use on dogs and is a common home remedy for snake bites. By Kevin Keister. If your dog gets bitten by a Copperhead, the most important thing is to get him to a vet as soon as possible. A King Cobra bite could require 20 vials, although 50 is not unheard of. If you often spend time in wilderness areas, camp, hike, picnic, or live in snake-inhabited areas, learn the potential dangers posed by venomous snakes. Fun fact: Cottonmouth bites have about the same severity level as copperhead bites. The frequency of antivenom use for copperhead bites did not significantly increase between 2006 and 2016. Be aware that venom is eliminated from the body via lymphatics and proximal extension is to be expected. She and other antivenom experts walk us through how they create the antidote to the world's deadliest snakebites. Here’s what UNC Health, Duke Health and WakeMed charge for antivenom, plus insurance coverage and discounts available. I'm still tired and thirsty, but. I was recently bit by a copperhead on the ankle in two places, went to the hospital, treated with antivenom, then released about 18 hours after the initial bite. doi: 10. 2017. But it. VetDepot is not a pharmacy. 2017. For insects that Copperhead Snakes prey upon, apply Supreme IT. 10. That works out to $16,989. For one, young copperheads have a distinct bright-yellow or green tail, which they keep for roughly a year before taking on a more natural color like the adults. The snake struck a 9-year-old hiker at dusk on a nature trail. In 2000, an FabAV antivenom (CroFab®) was introduced and in 2022, F(ab’) 2 AV (Anavip®) was approved for treatment of copperhead bites. antivenom only once . For the first time, healthcare providers were given a choice in 2019 between two antivenoms to treat pit viper envenomations in the United States — CroFab®, a product that has been used for over 20 years, and a newer equine-derived antivenom, Anavip®. Antivenom costs an arm and a leg- you know- the ones you're trying to save from that snakebite. The majority of studies and guidelines promoting or describing aggressive use of antivenom in copperhead bites have been published from 2010 onward, and there have been studies showing lack of. One prospective clinical trial evaluating this antivenom in dogs reported that 1. English. Although these envenomations (also known as envenomings) are rarely fatal, about 70 percent require antivenom therapy. 1 percent. I was bitten by a Copperhead Snake just below my left ankle 5/21/06 at 2320 hours. Note that this analysis excluded envenomation from copperhead (Agkistrodon) species as so few of these patients in the NASBR database received Anavip®. Copperheads have hemotoxic venom which often results in temporary tissue damage in the immediate area of the bite. Antivenom is expensive (current wholesale cost greatly exceeds US$1,000/vial) and associated with immunologic risk, and it is imperative for the physician to use this resource wisely. By Kevin Keister. He needed 12 vials of antivenom, which cost about $200,000, The N&O reported at the time. Copperheads are shy and their coloring and pattern is very similar to corn snakes, but the copperhead has a dark-colored hourglass shape sideways on its back. His hand started to swell immediately, and he had to be hospitalized overnight, The News. When asked for this report, Duke Health declined to. It is important to elevate the extremity as soon as the antivenom is started to minimize local swelling. Call the NC Poison Control: 1-800-222-1222. In the case of rattlesnakes, envenomation also causes thrombocytopenia, hypofibrinogenemia and coagulopathy. Cover the bite with a bandage. The Snakebite Severity Score may be useful to guide anti-venom administration. Presently, copperhead bites are treated with CroFab, a treatment tested and proven for cottonmouth and rattlesnake bites. Snake venom is mostly used to produce antivenom, which is essential for treating the estimated 1. “Copperhead bites can cause. Do call 9-1-1 immediately. How much does Copperhead anti venom cost? Antivenom costs an arm and a leg- you know- the ones you’re trying to save from that snakebite. Making the most common rattlesnake anti-venom, for instance, involves injecting sheep. Opioid-level pain control may be needed; however, antivenom treatment of envenomation from a copperhead snake (Agkistrodon contortrix) has been shown to reduce the use of opioids. Size. Copperhead bites rarely lead to systemic symptoms such as coagulopathy. Snake venom is mostly used to produce antivenom, which is essential for treating the estimated 1. 1) and charges to the patient (defined as the pharmacy reported per unit charge to the patient for each vial of the specific antivenom; Fig. Hospitals pay an estimated $2,300 per vial. 00. Their dens are often near the borders of marshes, creeks, rivers and lakes. 9, 10, 17, 19-21 This debate has been influenced by the low mortality associated with these bites, questionable effects on coagulation, the high cost of the drug, and the prior uncertainty. Carnivorous, eating insects, frogs, and lizards. Licensing fees legal costs: About 28 percent of the cost. Here’s what UNC Health, Duke Health and WakeMed charge for antivenom, plus insurance coverage and discounts available. According to Boyer's model, a single vial of antivenom that would cost more than $14,000 in the United States would cost $100 to $200 in Mexico. Jr, et al. Crotalidae envenomation represents an uncommon but clinically important illness that can result in significant morbidity and rarely mortality. Is A. Fortunately it is a much cheaper antivenom (though also not as effective as others either) at just $40 per vial. possibly increased cost for these patients. Carotenuto. For the typical initial dose of four to six vials. Step 5. April 20, 2023 · 11 min read. But, you need to make sure that it does not contain two ingredients; acetaminophen and pseudoephedrine. UNC Healthcare added that anti-venom "can save a patient's limb, or life, depending on the type of snake and location of the bite. 8 million to 2. Antivenom is still produced by much the same method that was developed in the 1890s to. 2017. These moisture-loving snakes can exist in some of the wettest and coldest parts of the country and although venomous, they are shy and rarely bite without being continuously provoked. Hospital bill Billed amount: $335,441 of which $321,000 was the anti-venom. Hospitals pay an estimated $2,300 per vial. The market price of antivenom ranges from $11,000 to $14,000 per vial at UNC Health and WakeMed in 2023, according to spokespeople. The purpose of this study is to examine the time course of recovery from copperhead snake (Agkistrodon contortrix) envenomation patients managed with and without the use of. Desert death adder Native to Australia, the desert death adder (Acanthophis pyrrhus) comes in two fiery shades — brick red and yellow — and is one of the world’s most virulent land snakes. We submitted the claim online to our pet insurance carrier two days later, and within a week, we had a check in our hand for 90% of the total cost. 2 meters) and a maximum weight of over 1,000 pounds (454 kilograms). Cousin to the Cobra. 7 percent of the overall cost and clinical trials made up just 2. [7] What Do They Do For A Copperhead Bite? Lay or sit the person down with the bite below the level of the heart. They have the largest venom glands of any snake, and can inject up to 1,000 milligrams (mg) of venom in a single bite. 64 was charged for air ambulance transport . Recent NASBR data suggests that the difference in total treatment cost between antivenom products is probably much less than healthcare providers think. 67. • Last year, a Raleigh woman. The majority of studies and guidelines promoting or describing aggressive use of antivenom in copperhead bites have been published from 2010 onward,. 12. 2 mg phenol, 8 mg sodium chloride and water for injections to 1 mL in an aqueous solution. Here’s how much that costs in NC May 05, 2023 7:00 AMAccording to the data, 39% of patients treated with CroFab ® required more than one dose and 69% of patients treated with Anavip ® required more than 1 dose (P<0. " WakeMed told us they charge $11,765 per vial, and again pointed. Cottonmouths (water moccasins) More than 60,000 bites and stings are reported to poison centers and result in about 100 deaths each year in the US. Total Bill: $142,938, including $67,957 for four vials of antivenin. For example, an observational study of 81 adult and pediatric patients who were managed without antivenom therapy after snakebite (45 copperhead, 12 water moccasin [cottonmouth], 10 rattlesnake, and 14 unknown) reported no fatalities or long-term morbidity . Most insurance plans cover anti-venom treatment, and uninsured patients both receive a discount and may apply for financial aid. But the copperhead doesn’t wait for summer. At Duke Health: The N&O reported in 2020 that a 12 vials of antivenom — double the typical initial dose, per UNC Health — cost $200,000. Copperheads are the most venomous snake in the United States. Each vial. East Texas Medical Center, Crockett, Texas 75835, USA. Product Description. Antivenom costs an arm and a leg- you know- the ones you’re trying to save from that snakebite. So for a single, smaller rattlesnake bite that would need four vials of antivenin, the cost is $9,200. How Much Does The Stinnett Copperhead Cane Cost. However, as of April 1, 2021, Anavip®’s approved indication has expanded to include copperheads and cottonmouth/water moccasin envenomation. Several thousand snakebites occur annually in the US, but fewer than 10 deaths occur. Their venom is highly toxic to humans and other mammals, but it is not lethal to birds, reptiles, amphibians, fish, or invertebrates. Ian’s hand healed completely, and his father’s insurance helped bring the family’s cost down to $175, Carabetta said. Antivenom (or antivenin) is the only treatment that can directly fight the effects of snake venom. Crotalidae Polyvalent Immune Fab (ovine), sold under the brandname CroFab, is a snake antivenin, indicated for North American Crotalid (Rattlesnake, Copperhead and Cottonmouth/Water moccasin) snake envenomation. 00 per vial. Beyond the normal costs of emergency care, the average vial of antivenom costs $600 to $1000, and your pet may need more than one. However, there are several challenges associated with administering antivenom to a dog. In fact, North Carolina leads the nation as the state with the most snake bites. Ultimately you are going to need antivenom because antivenom is the only definitive treatment for a snake envenomation, but the tips below are designed to help you get to the hospital alive and leave the hospital in one piece. We hypothesized that the frequency of antivenom use for copperhead envenomation in Ohio has increased as benefits of administration became more widely known. Our venom extraction practices are focused on maintaining the health of our animals above all else. UNC Health’s pharmacy team estimates that the cost of antivenom treatment ranges between $76,000 and $115,000. He needed 12 vials of antivenom, which cost about $200,000, The N&O reported at the time. The market price of antivenom ranges from $11,000 to $14,000 per vial at UNC Health and WakeMed in 2023, according to spokespeople. Ethical considerations in design of a study to evaluate a US Food and Drug Administration–approved indication: antivenom versus placebo for copperhead. Back to insights. Available in single dose, ready to use 10 ml vials. For the first time, healthcare providers were given a choice in 2019 between two antivenoms to treat pit viper envenomations in the United States — CroFab®, a product that has been used for over 20 years, and a newer equine-derived antivenom, Anavip®. In fact, North Carolina leads the nation as the state with the most snake bites. Anavip® is an equine-derived F (ab)2 fragment product and was originally FDA approved only for the treatment of North American rattlesnake envenomations. It is also one of the largest snakes in North America, with a body length of up to 4 feet (1. “At a minimum, call and get a consult,” Marks said. The existing American coral snake antivenom stock technically expired in 2008, but the U. I was bitten by a Copperhead Snake just below my left ankle 5/21/06 at 2320 hours. Can you buy copperhead antivenom? Most patients bitten by copperhead snakes do not currently receive antivenom. 4 In 1998, Anderson updated this review. Double-click to zoom out. For patients who need to be in the emergency room, the final cost is higher. 1996;41(2):219-221. Duke Health is a trial site for a drug that could be the first universal antivenom to treat any kind of snake bite — including North Carolina’s ubiquitous copperhead. How much does copperhead antivenom cost? Antivenom costs an arm and a leg- you know- the ones you're trying to save from that snakebite. 2015;53:37-45. His father’s insurance brought the out-of-pocket cost to $175. 3% in 2020 as compared to 2019. The treatment of CroFab costs about $2,300 a vial, and many snake bite victims can require up to 18 vials for a full treatment. Some hospitals/doctors will only administer antivenom for 'serious' envenomations (typically meaning either systematic symptoms like nausea or local effects spreading beyond a major joint, sometimes two joints) though, sometimes due to the cost of antivenom/hospital observation and sometimes out of concern about allergic reactions to the. 5 per 1,500 person years for all other snakes (1). Rattlesnake bite dog survival rates. Each 1 mL of product also contains 2. 0 Patient Case. His father’s insurance brought the out. One stated indication for antivenom administration is, “swelling that is more than minimal and that is progressing,” and this is troublingly subjective. Call 9-1-1 or the Texas Poison Center Network at 1-800-222-1222 for information about which medical centers in your. Antivenom is. pain and. Although antivenom administration is the standard of care for rattlesnake envenomation, its use in copperhead envenomation has been controversial. Introduction In 2018, Anavip became available for the treatment of rattlesnake envenomations in the USA. 2004; 43 (2):200–6. How much does snake antivenom cost for a dog?. Here’s what UNC Health, Duke Health and WakeMed charge for antivenom, plus insurance coverage and discounts available. At UNC Health: For a typical initial dose of four to six vials, the total charge for the antivenom treatment can range from $76,000 to $115,000, UNC Health’s pharmacy. The four vials of anti-venom medication Ferguson received reportedly cost about $20,000 each. He needed 12 vials of antivenom, which cost about $200,000, The N&O reported at the time. If you need more than 30 minutes to get to the vet, you will need to start the treatment at home, before you drive to the vet. Jad Pollom was camping with his family in Highlands, North Carolina, just across the Georgia border. Comparing cost of F(. He said it costs about $35 dollars. Data reported by the National Poison Data System from 2017 revealed 4071 pit viper envenomations. According to estimates published online, the survival rate of a dog after a rattlesnake bite is between 80% to 95%. The cottonmouth is more aggressive, but. Most patients recover. 049. Never attempt to self-treat a copperhead bite by cutting an X across the puncture wounds and attempting to suck out the poison. As for the remaining 70. The hospital cost for the patients receiving F(ab’) 2 AV was $13,054. A single vial of Boomslang antivenom costs $5500 and one could require up to 3 vials to counteract a serious bite. 1 day. 10. Current management of copperhead snakebite. tivenom was not administered or antivenom was administered for copperhead envenom-ation. Copperhead bites are more likely to be fatal than those of other species, with a rate of 1. Each vial. For instance, a typical antivenom vial costs $1,500 to $2,200, but a snakebite requires between 20 and 25 vials to be neutralized. How much does copperhead antivenom cost? Antivenom costs an arm and a leg- you know- the ones you're trying to save from that snakebite. 00 Add to cart; Cobra Snake Antivenom $ 199. Pit viper envenomation is a common emergency in many areas of the United States, with an estimated 150 000 annual cases in dogs and cats. . com. 2. Some articles refer to weeks/months of recovery. Examine the Data. After that, your vet will address the snake bite location itself. You can also call the Texas Poison Center Network at 1-800-222-1222 for information about which medical centers in your area have the appropriate antivenom. Last year, a Raleigh woman received a copperhead bite on her finger. How long before a snake bite kills a dog? The average lifespan of a dog is 10-12 years. Gerardo CJ, Quackenbush E, Lewis B, Rose SR, Greene S, Toschlog EA, et al. By Ashad Hajela Updated June 23, 2020 2:39 PM A snake later identified as a corn snake crosses. CroFab is even more expensive, according to KHN , coming in. The amount may surprise you. The proportion of copperhead victims receiving antivenom has increased significantly, from 21% in 2001 to 36% in 2007, with significant regional variations . Gators also have a very strong sense of. Carotenuto. How much is the rattlesnake vaccine for dogs? A single dose of the vaccine costs in the range of $25 to $50, and dogs need a second dose three to six weeks later. The final cost is even higher for patients. For the typical initial dose of four to six vials. If someone has been bitten by a venomous snake, it is important to seek medical attention promptly. At UNC Health: For a typical initial dose of four to six vials, the total charge for the antivenom treatment can range from $76,000 to $115,000, UNC Health’s pharmacy team said. If you add these up, a man bitten in the US by a venomous snake would have to pay $30,000 in pharmacy costs alone. The Crotalinae subfamily of snakes is responsible for 98% of the nearly 9,000 venomous bites in the United States per year. 00 per vial. The antivenom specific to King Cobra, i. Finally, cost is an important consideration with modern antivenom use, and this study was not designed to support a pharmacoeconomic analysis. Beyond the risk to your pet, the treatment is expensive—often more than $2,500. Copperhead snakes frequently hibernate in dens made up of rocks. Frequent stomach cramping. Thevelein said antivenom is usually saved for severe cases since the hospital doesn't have a large reserve. While the mean number of total vials of antivenom was significantly different between the CroFab (10. 2020 was also busy, with 137 total calls. Antivenom contains antibodies that neutralize venom’s toxic effects. Increasing the dose can, in turn, affect the cost of treatment and the risk of developing adverse reactions to the antivenom . Because copperhead envenomations are usually self-limited, some physicians are reluctant to use this costly treatment routinely, while others follow a more liberal approach. . Antivenom can be very. Shorten hospital stays, reducing non-antivenom costs regarding snake bite care. The first one came in March, and the last one was in November. Supplemental oxygen — to help if the dog is having trouble breathing on its own. Most deaths are from envenomations by rattlesnakes (Crotalus species), but. The patient should be monitored closely. As of August 16, BRPC — which addresses poison concerns for much of central and western Virginia — had helped with more than 85 venomous snakebite cases. The bill includes $67,957 for four.