My Diabetes CGMS

Bye Bye Dex!

2008-02-18T14:22:00.002-05:00

I've been using the DexCom STS seven for several months now. It has been a great experience, I've seen some improvement in my HBA1C and managed avoiding more lows than pre CGM. Unfortunately, the $240 a month is too expensive for me to continue to pay out-of-pocket, so I've adjusted my last basal rate with Dex. Now that I'm stable, it's time to say bye bye to Dex.

I've put in an insurance claim with Federal BCBS, and I'm anxiously awaiting what I'm sure will the first of many rejections. So, until I'm approved, adios!

If you're interested in CGMs, check out http://groups.yahoo.com/group/diabetescgms/ to learn about CGMs and all about battling insurance companies to obtain coverage.

Blogging on hold ...

2007-03-03T18:01:00.000-05:00

Dex has been good to me lately, I've been managed to get on average 3 weeks out of a 3-day sensor. Not much else to report, other than my family, community, and work committments, not to mention recreation, are pushing blogging off to the side for now. I'll probably be only posting sporadically, until a new CGM is released.

I'm anxiously awaiting the Abbott Navigator, or the DexCom STS-7. I have not decided whether to stay with Dex, or to go with the Navigator when (I know it's always next month yada yada yada) it's released. Cost will be a big factor. All CGM costs for me are currently out of pocket; and that's the way it's going to be for some time.

If you are a CGM user, whether it's DexCom or MedTronic, or you're a diabetic interested in CGM, you might want to check out a discussion group on yahoo that I co-moderate with the leader of my Insulin Pump Support group:

http://health.groups.yahoo.com/group/diabetescgms/

Farewell until Dex or Abbott release their new products.

Cheers

-Gary

Down with HBA1C!

2006-12-18T16:59:00.000-05:00

Forgot to post this, things have been crazy since Thanksgiving getting ready for all of the holidays. I am happy to report that after 3 months of DexCom, I have dropped my HBA1C a full point. I initially purchased the DexCom to help me lower my HBA1C after losing focus on my diabetes, and to help me prevent hypos.

I have almost reached both goals: nary a hypo in sight, and the HBA1C is down from 8.3 to 7.3. Granted I've got a ways to get below my desired goal of 6.0, but I think I can make it; I've started Symlin along with my pump (more to report on that later). For me, I would not have gone on Symlin without CGM. This stuff really stomps on your BG and keeps it down low. I've been through some roller coasters with Symlin, and the CGM has been invaluable in helping me determine the correct dosage.

Back to more holiday activities; with 3 kids and everything else going on, life is swirling around.

From CGMS back to fingersticks...

2006-11-08T08:02:00.001-05:00

A *BAD* couple of D days for me.

I went to work out at the gym, and accidentally pulled my infusion set out. I replaced the set with one of the straight-in infusion sets(inset), and was in the 200s all day, haven't done that for awhile.

BS's continued to rise so I took several injections at work. Still in the 200s at home, pulled my infusion set, and you guessed it, that straight in cannula was bent at a 90 degree angle; hence little or no insulin delivery, hence the 200s.

I inserted one of the angled sets I have, the comfort short (which I
*WILL* be going back to), and BS's returned to normal, except that my DexCom receiver showed lots of *NOISE* in the morning, with readings all over the place.

I have been getting 10+ days recently; this is only one of a few sensors that have crapped out after 4 days.

No time to replace the sensor this morning, forgot to bring an extra sensor to work, so I'm back on lots of fingersticks for the first time in awhile. I'll probably end up testing every 2 hours or so depending on how busy I am at work, and then I'll insert a new sensor at home.

I've adjusted my Basal rates fairly well while on the DexCom CGMS, so I'm at 108; it will be interesting to see how I make out while I'm NAKED without my sensor the rest of my work day.

Tag Results: Don't Read if You Have a Weak Stomach

2006-11-07T20:01:00.000-05:00

1. For a midnight snack, I used to occasionally eat hotdogs without cooking them: my wife thought it was disgusting, but hey- aren't they already cooked? I've stopped that 'disgusting' habit ever since I started going to the gym a year ago. What's really in a hotdog, anyway?

2. I used to operate a nuclear reactor on a U.S. Navy ship 25 years ago. I don't have most of my hair any longer, but I was able to father 3 kids.

3. My favorite class in high school was creative writing (I'm an engineer; hey did you know that engineers CAN write?).

4. After 20+ years of using a PC running Windoze, I finally upgraded to a MacBook Pro Duo, so now I can run Mac OS and Windoze. I know, I know, why bother to run Windoze on a MAC? Yech!

5. I want to sell my house and live in an RV, touring the country when I retire. "Yeah, Right!" says my other half.

Now I'll peruse the Diabetes OC for 5 more D's to tag.

What Happened to My Insulin Pump?

2006-11-07T17:56:00.000-05:00

So I'm driving to work this morning, I'm almost there, and I get this call from my wife:

"Your pump is sitting on a pile of clothes in the bathroom, are you coming home to get it?"

Oh Sxxx! What a way to start a Monday morning. I stay up late watching the Pats/Colts game, and look what happens; my mind turns to milk toast. No way I'm going to drive one hour in the opposite direction to get my pump. Fortunately, I've got backup insulin and syringes in my diabetes kit, along with my DexCom.

So far I've had to skip breakfast, and I have 4 used syringes on my desk. At least my BS hasn't gone above 200 this morning. I'm getting really hungry since it's lunchtime and a little weak, but I'm still too high to eat at BS = 171. The trend is headed downward; extrapolating the graph, I should be around 120 in another hour or so, and then I can eat.

If I didn't have CGMS, would I have turned around to get my pump? Probably ... I just don't have the time to do a fingerstick test every half-hour or so.

Where's my pump?

2006-11-06T12:54:00.000-05:00

So I'm driving to work this morning, I'm almost there, and I get this
call from my wife:

"Your pump is sitting on a pile of clothes in the bathroom, are you
coming home to get it?"

Oh Sxxx! What a way to start a Monday morning. I stay up late
watching the Pats/Colts game, and look what happens; my mind turns to
milk toast. No way I'm going to drive one hour in the opposite
direction to get my pump. Fortunately, I've got backup insulin and
syringes in my diabetes kit, along with my DexCom.

So far I've had to skip breakfast, and I have 4 used syringes on my
desk. At least my BS hasn't gone above 200 this morning. I'm getting
really hungry since it's lunchtime and a little weak, but I'm still
too high to eat at BS = 171. The trend is headed downward;
extrapolating the graph, I should be around 120 in another hour or so,
and then I can eat.

If I didn't have CGMS, would I have turned around to get my pump?
Probably ... I just don't have the time to do a fingerstick test every
half-hour or so.

New Sensor Longevity Record

2006-10-12T20:00:00.000-04:00

I've been away a few days, so haven't had a chance to blog. My family and I traveled to New Jersey over the long Columbus Day weekend to see Godspell at the Paper Mill Playhouse. Excellent show, updated for the current times. Rap wasn't around in the 70s. I was concerned during the show that my DexCom CGMS might sound off, but fortunately, it didn't! I wish they'd add a vibrate all feature, similar to my Verizon Razr phone. I'm paranoid about it going off in church, the theater, or a movie. So far, it hasn't happened, but it's only a matter of time.

Anyway, took a chance this past weekend and didn't bring an extra sensor. The sensor lasted the whole long weekend in addition to a week before that, for a total of 11 days inserted in my stomach. After removing the sensor, I saw only a tiny red bump, the same size and shape that I've seen after leaving the sensor in for 3 days. There was only a very mild pink area where the adhesive was; very encouraging; averaging that sensor cost over 11 days, that's less than $3.50 a day, very reasonable, at least for my pocketbook.

I think I'm going to change the sensors a max of every 10 days, even if some others have had them in longer. The last couple of days I thought that the sensor values were 50 or so points off from the Ultra meter, even after frequent calibration.

Only a month left until my next HBA1C; I've got my fingers crossed that this CGMS is really going to help me; I've modified my behaviors a great deal because of the CGMS; I'll be VERY DISAPPOINTED if I don't get some decent results!

I want my Raisin Bran Cereal

2006-10-02T17:49:00.000-04:00

I was Dx'd a type 1 diabetic late in life several years ago at age 39, so I've had at least 35 years of enjoying any cereal that I wanted to eat: Cap'n Crunch, Wheaties, Cheerios, Rice Krispies, Boo-berry, Franken-berry, etc., etc.

As I grew older, I settled on the healthier cereals, enjoying wheaties, and my all-time favorite, Raisin Bran. The sugar-bomb cereal no longer appealed to my palette, and I was no longer into Saturday morning cartoons, 3 feet away from the TV, stuffing my face with this un-healthy junk. When I was a kid, we weren't as health conscious as we are now. My dad, a type 1 diabetic from age 19, would also have wheaties or cheerios, sprinkled with a healthy dose of the most disgusting sweetener that I ever tasted, sweet-n-low (forgive me if you enjoy the stuff, but I could never get past the after-taste). He never had the tools we have now; if he did, and saw the cereal response pictured here, perhaps he would have skipped the cereal.

I tried my best to limit the post-prandial spike- it still shot up to around 280 as you can see. This despite a bolus 20 minutes prior to eating, and starting with my BG at 94. I limited the carbs to about 37 grams, using light soy milk with only 5 grams of CHO for an 8 oz. serving. It took almost 4 hours to get my BS back to 100!

I'm not giving up just yet. I'm going to add some low-carb peanut butter and crackers to the meal to delay the carb absorption. I feel that I deserve at least 50 grams of carbs per meal. I'm not willing to go the low carb route; heck I went on the pump so I could eat somewhat like I did prior to my diagnosis, I'm hoping that with some more tweaking, I can enjoy my Raisin Bran.

DiabetesMine.com Day, and what's up with J&J and their new CGMS

2006-10-01T21:03:00.000-04:00

To follow-up with my recent post on the CGMS dogfight cited in the Reuters article by Julie Steenhuysen, I'd like to direct you to another blogger that did an excellent piece on the same story. Please checkout Amy Tenderich's Article on DiabetesMine.

Amy serves up some enticing tidbits on what J&J is up to in their future CGMS due out in a couple of years, including a 15 minute warm-up time, no fingerstick calibrations, and improved accuracy.

Amy is a type 1 diabetic, a DexCom user, and a prolific diabetes journalist, who received the LillyforLife Achievement Award for Diabetes Journalism, and the 2006 Diabetes O.C. best blog award. Amy's site is a must read for any diabetic, including current and future CGMS users.

Dogfight in the Emerging CGMS Market?

2006-09-30T14:49:00.000-04:00

"Dogfight" in CGMS. According to a Reuters September 29th article by Julie Steenhuysen, this is what some analysts who monitor the Diabetes medical device market are saying about CGMS. I don't mind a good dogfight in CGMS; the more competition, the better for we type 1 diabetics, and type 2 as well: we really need these tools and the insurance industry needs to understand that; right now, they just don't get the message; their bottom line is: money, money, and more money. The more players in the market, and the more studies conducted that show the benefits of CGMS, the quicker the insurance companies will respond.

Dogfight over Features

The president of Abbott's diabetes unit, Ed Fiorentino, says:

"Better accuracy and longer-wearing sensors -- five days with the Abbott product vs. three days with the Medtronic and DexCom devices -- will give Abbott an edge."

Mr. Fiorentino may be right on when it comes to accuracy, though with DexCom I'm doing pretty well with accuracy compared to my somewhat accurate fingersticks. As far as sensor life goes, 3-days wear time is so far a minimum for me with DexCom. On the accuracy and non-calibration requirement (if you choose to use the Navigagor off-label), Abbott leapfrogs ahead of DexCom, if what abbott claims is true about completed studies and studies almost completed. DexCom had better get cooking on some new features, and stay away from the vaporware type of announcements we've seen with other companies, it's coming, it's coming, really, it is...

So we've got DexCom, MiniMed, Navigator, and now J&J jumping into the CGMS market. I am psyched!!!

DexCom Charger Replacement and New Sensors

2006-09-30T13:56:00.000-04:00

Got my new charger today after my latest accident with my CGMS gadgetry. It's not listed on the DexCom on-line store, but the charger costs $25, plus $5 for shipping, which is the going rate for these things.

I do try to be careful; my wife accuses me of 'sucking all of the fun out of a room', because I'm constantly pointing out accidents waiting to happen, which I'm sure all of you parents out there can relate to. Most of the time I see the accident before it happens; I just have to hold my tongue of course, since my kids need to learn from their behaviors. Now I need to learn from my behavior and stop plugging things in where people can trip over them.

Anyway, I'm off on a tangent here; I also got my second box of sensors, so to date, with two months of DexCom usage, I'm out of pocket about $350. Oops, make that around $400, if you include shipping.

I'm trying to calculate out-of-pocket expenses for next year so that I can at least re-coup some cost from my medical savings account. Might change if I decide to switch CGMS, we'll see ...

How long do YOUR DexCom batteries last?

2006-09-28T05:45:00.000-04:00

Okay, I've got to get over this obsession with looking at the DexCom receiver all of the time. It's either the constant looking at the receiver that's draining the batteries, or my receiver batteries just doesn't hold a charge. My DexCom rep told me initially that her batteries lasted five days between charges, but my batteries seem to last a paltry day-and-a-half, MAX. Seems like I'm charging it too much. Maybe I should take it off of belt clip and just hide it in my pocket, that way I'll be less tempted to look at the darn thing.

Had a scare last night- because it always seems like I'm charging it, I plugged it in by the dinner table, with the cord running behind me to the receptacle. One of my daughters, helpful and polite that she is, got up to get me a drink of water, and, you guessed it: she tripped over the cord. Luckily, she wasn't hurt; can't say the same for the Dex charger however. It had an odd looking, sickly, angled position on the wall receptacle. Oh S..., another accident. First I drown the receiver, now I've broken the charger.

I carefully pulled it out of the wall socket, and one of the plug prongs drops to the floor. Groan. Fortunately, I used my pliers to insert the plug prong back into the charger, and it seems to charge the Dex, but now I'm afraid to unplug it from the receptacle.

I wonder how much a replacement charger costs? It's not listed for sale on their web site.

Hmmm, what other DexCom component can I break? There's not much left ...

The Ups and Downs of CGMS

2006-09-26T19:25:00.000-04:00

What a day for ups and downs! This morning I headed to the gym for my daily workout, pushed it a little harder than normal, but decided to skip the normal temp basal adjustment, since I've been getting by without it for the moderate workouts. Boy, did I pay for that! I've hit below 70 four times today. Fortunately, Dex warned me with the Dex low alarm before my BGs got too out of hand.

Coupled with skipping the temp bolus, I had whole-wheat raisin bran, and a cup of Soy milk, for a total of 50 grams of carbs. Dex showed me that my BGs shot way, way, up, and I over-corrected since I normally need more insulin when I go up into the 300s. I'm really trying hard to minimize those peaks, using delayed boluses and limiting myself to no more than 50 grams of carbs at a sitting, but those high glycemic foods don't want to cooperate. Thinking more and more about Symilin, ... sigh.

DexCom Noisy Night Readings and a Hairy Conundrum

2006-09-24T15:33:00.000-04:00

I've noticed that I am a noisy person at a night (and no, that doesn't mean that I snore, although my wife will argue that point). With the current DexCom sensor site, I've been having night readings jump all over the place. Below is an example of what a noisy night is; stark contrast between night and day. I tend to toss and turn a lot at night, and I sleep on either my right or left side, and I've located the sensor on my right side. Apparently I am disturbing the sensor so much that I'm generating all of this noise. I haven't had this problem with previous placements.

I'll have to find sites that don't see as much action during the night, which means I'll have to locate the sensor in the stomach area. I don't have a lot of bare areas on my stomach, which means I'll either have to place the sensor pod over the the stomach hair, which makes for a fun time when I remove the pod (ouch), or I'll have to shave the area. Hmmm, maybe some of those bare-chested Baywatch models are going to get some competition!

Creating My Own Glycemic Index

2006-09-23T22:40:00.000-04:00

I have a love/hate relationship with my carbs. I love them for their taste, that satisfying, luxurious, feeling I get after ingesting them, and I hate what they do to my sugars.

I used the DexCom software to chart my response to one of my favorite carbs, a Dunkin' Donuts blueberry muffin for breakfast (73g CHO). The GI value is listed as medium for this food, but the DexCom software shows me shooting up well into the 300s, even with a combo/square wave bolus, taken 15 minutes prior to eating the muffin. Is Symlin in my future if I want to enjoy a muffin? Next time I'll go for half a muffin!

I was in a rush for lunch, as usual, so I enjoyed a Smart Ones Fiesta Chicken; not bad tasting, and quick (47 grams CHO). For dinner, we sometimes celebrate Friday night with pizza; this time I opted for a gyro (55g CHO). Total carbs for the day- 175 grams. Wouldn't it be something if the software had an expert system component that could suggest basal rates, carb/ins ratios, correction factors, and insulin sensitivity factors?

Sensor Probe Size

2006-09-23T11:34:00.000-04:00

So, how big is the sensor probe that goes under your skin? In case you're concerned about the size, here is a side by side comparison of a 0.5 mm pencil lead, a Paradigm Silhouette insertion needle, a 31 gauge, 5/16" (8mm) syringe needle, and the the sensor probe. The vertical part of the probe goes under your skin, and the horizontal part is attached to the 'sensor pod' that holds the transmitter and the sensor part that connects to the transmitter. You feel a slight pinch as you would with an infusion set insertion, but the probe feels comfortable under the skin, at least for me.

Get More Life Out of a DexCom Shower Cover, and Yet Another Use for Saran Wrap

2006-09-22T17:43:00.001-04:00

Thanks to the tip from a fellow CGMS user: she suggested that I try wearing a DexCom shower cover for 3 days, instead of just one day. Two days worked for her, but my friend noted that since I'm a male, I will probably spend less time in the shower , so 3 days might just work.

So ..., the results are in, drumroll please... Yes I was able to get 3 showers out of one cover, so now my shower cover costs are reduced from 60 cents a shower to 20 cents a shower , or if I take one shower a day, just six dollars a month. A small price to pay for not getting the Sensor wet so I can get good readings after a shower.

Thanks for the tip: Any CGMS users out there with money-saving tips, please send them my way.

By the way, my friend is going to try that wonderful product with 10,000 uses... Saran Wrap!

DexCom Single Day Glucose Trend Screen Shot

2006-09-21T12:03:00.000-04:00

Okay, here we have another type of screen shot that the DexCom software will give you. You can choose to have up to 7 days displayed, but that's too much data to display here, so I just chose one day. The blue circles are sensor BGs, and the red stars are uploaded values from the ultra meter. Those values are used to calibrate the DexCom, and to check to make sure it's tracking along with the ultra BG values. The largest delta is between the first red star to the right, over from the mg/dl Y-axis. The delta is 17 points, which I consider acceptable.

What I can't explain, is the drop in BG from 3:11 am to 3:21 am. The graph shows that I dropped 59 points in 10 minutes, an obvious hiccup. I do a lot of tossing and turning at night, and the sensor is installed on my side, I'm wondering if I somehow disturbed it and the transmitter in such a manner as to cause this glitch.

Anyhow, you can determine from the graph when my meals occured, how high my post-prandial spikes went, how much time I spent between the lower and upper limits of 80 and 200, respectively, and that I need to tune-up my basal rates.

DexCom Modal Day Screen Shot Sample

2006-09-21T09:11:00.000-04:00

Here is a sample modal screen shot of my BGs over Monday, Tuesday, and Wednesday. It's hard to see, but see if you can guess when I had my meals.

Sensor Site After 10 Days, and a New, Flaky Sensor

2006-09-21T07:43:00.000-04:00

Ok, so I was somewhat concerned about leaving the sensor in the site for 10 days, given that you're only supposed to do it for 3, and a trial is underway to get FDA approval for 7, but I tried it anyway, risk taker that I am. I will probably end up using them for 7 - 10 days, but no longer. I know some others that are using the same sensor past 10 days, but I'm not going that far.

Anyway, the site looked beautiful: no irritation, only a very slight, almost undetectable, faint hint of redness. The puncture site was almost invisible: except for the tape residue, I would not have known that a sensor was ever there. Looked a lot better than some of my infusion sites after 3 days. I put some Aquaphor over the area to moisturize the skin, inserted a new sensor, and am on my way, probably 7 days this time, although I've had a couple of sensors stop working after 2 days.

Another tip about starting a new sensor session: start it in the MORNING, not the evening, so you can deal with the inaccuracies while you're awake, and not trying to sleep. The new sensor was flaky for a few hours, and woke me up with 2 low alarms, whereas the ultra read 101, and 105.

Dex Software Has Arrived!

2006-09-21T07:33:00.000-04:00

DexCom delivered the software via priority overnight yesterday. I installed it last night, uploaded my data (the last 7 days are supported), and played around with it a little.

I'm thinking I'm going to get some valuable data out of this software, although the GUI (Graphical User Interface), looks outdated; but hey, I had to complain about something. I emailed the patient files to work, and I'll see if I can open them with the DexCom software installed at work. Would be nice if I could email the data to my doc, but of course Harvard Vanguard has this nifty little system for email that does not allow for attachments. I'm sure the I.T. police are responsible for that one, wouldn't want to allow some sneaky virus to get in there and shut down their system. I'll just do it the old fashioned way, print out the reports and then FAX them in. I'm sure my endo will be delighted to receive them. I'll probably mark up the data to explain what a 'shower spike' is, amongst other things.

I plan to post some screen shots here in the future, but first, more playing around with the software. It looks exactly like the software that my DexCom rep had, as it allows multiple patient entries, similarly to other meter software packages. It seems as if all of the diabetes software packages have these quirky looking somewhat outdated GUIs, but I'd rather have the data than some slick GUI where the most important simple features don't seem to work (a.k.a. Microsoft).

CGMS Sensor Life

2006-09-20T12:09:00.000-04:00

DexCom says to use a sensor no longer than 3 days, and that they're working on getting FDA approval for a 7-day sensor. I've been browsing the internet to find out what others are experiencing for sensor life. One CGMS user I know seems to get a couple of weeks out of one sensor. That seemed a little extreme to me, and when I mentioned it to my DexCom rep, she said that 2 weeks was way to long to leave a sensor in.

I decided to see how long I could go with one sensor, and to date, my current sensor has been in for 10 days. I'm sure I could go longer, but I'm going to pull the plug on it tonight. The sensor seems to get more accurate after a couple of days, and the past few days, this sensor has been right on target, except of course, for rapidly changing BGs.

Went to the eye doctor for my annual dialated pupil exam last night, and got some good news; no sign of any retinopathy or other damage. I'm concerned about that, as my sister has severe diabetic retinopathy, as did my father. After the eye exam, I played softball in our backyard with my 3 girls: boy did I look like a real geek with those wrap-around glasses on, or so my daughters tell me.

So far it has been about 4 weeks on the DexCom CGMS, and I'm finally getting used to it, and also getting used to the fact that I don't need to look at all of the time! Still no word from DexCom on when they're sending me my software. They said I would get an email when it shipped, but nothing yet.

BTW, tried to wear the shower cover for an extra day on the suggestion of a CGMS user friend, and it worked! She suggested that since I was male, I might try to get three days out of a cover. I'll give that a shot, too.

On another blog technical note, I've been trying to post to other OC blogs, but since I switched to the *beta* template, I'm not allowed to. Once again, I pay the price for being an early adopter .

Update on fingerstick frequency: Less sticks!

2006-09-17T08:20:00.000-04:00

I'm doing less fingersticks now that I'm becoming more comfortable with CGMS. I don't think I'm going to go below 8 sticks a day, assuming this would be a typical day. I would add a couple on top of this for additional calibration requirements and other variables:

Stick 1: calibration in the morning/Pre-Prandial prior to breakfast
Stick 2: Post-Prandial Breakfast
Stick 3: Pre-Prandial Lunch
Stick 4: Post-Prandial Lunch
Stick 5: Pre-Prandial Dinner
Stick 7: Post-Prandial Dinner
Stick 8: Bed Time BG

This is my fingerstick frequency over the last few days, averaging to a little more than 8 per day:

DATE	Number of Fingersticks
Tuesday, September 12	8
Wednesday, September 13	7
Thursday, September 14	11
Friday, September 15	11
Saturday, September 16	6

How much are annual out-of-pocket costs for CGMS?

2006-09-15T13:16:00.000-04:00

How much does it cost me for annual out-of-pocket expenses for CGMS? Here is what I estimate CGMS will cost me in the next year, provided I can get 7 days out of one sensor. Note that the figures vary by individual; some folks don't use shower covers, and some may get more or less wear-time on a sensor. Question for the insurance companies: How much does it cost for an ER hospital visit to treat one episode of extreme hypoglycemia? $5000, $10,000? Do the math: CGMS pays for itself if only ONE ER visit is eliminated.

Item	Annual Cost
DexCom STS Receiver	$550
DexCom Transmitter, 2/yr	$500
Sensors, 1/wk	$1976
Shower Covers, 1/day	$225
Total Annual Costs	$3001