Vagus Nerve Stimulation Cost in the USA: Pricing, Insurance, and Out-of-Pocket Expenses
Living with treatment-resistant depression or epilepsy can feel hopeless, but Vagus nerve stimulation offers a surgical option where a device sends electrical pulses to the brain via the vagus nerve. The total cost for Vagus nerve stimulation in the USA typically ranges from $20,000 to $40,000, covering the implant surgery, device, and initial programming. This upfront expense is often partially covered by insurance for approved conditions, though out-of-pocket costs vary by plan and deductible. Vagus nerve stimulation cost in the USA includes ongoing battery replacement surgeries every 3–5 years, adding to long-term financial planning.
Understanding the Financial Landscape of Vagus Nerve Therapy
Understanding the financial landscape of vagus nerve therapy in the USA means accepting that upfront costs are just the beginning. The VNS device itself typically ranges from $20,000 to $30,000, but the surgical implantation adds another $10,000 to $25,000. Insurance coverage is your biggest variable—Medicare and many private plans may cover FDA-approved VNS for epilepsy or depression, but off-label uses often fall entirely on you. A key question is: How do I estimate my true out-of-pocket cost?
First, call your insurer for a pre-authorization and ask for a detailed benefits breakdown, including your deductible, co-insurance, and any lifetime device caps. Then, ask the surgeon’s billing office for a “cash-pay” or “self-pay” discount if insurance denies coverage. Finally, factor in long-term costs: replacement batteries every 3–8 years (around $15,000) and annual programming visits ($500–$1,500). Without mapping these layers, a $25,000 device can easily become a $50,000 debt.
Upfront Costs: Surgical Implant vs. Non-Invasive Devices
The financial chasm between these two paths is immediate and dramatic. A surgical implant, such as the FDA-approved VNS device for epilepsy or depression, carries upfront costs ranging from $20,000 to $35,000, a figure that includes the device, surgeon fees, hospital stay, and device programming. In stark contrast, non-invasive devices like gammaCore or Nurosym present a much lower barrier to entry, with a single device unit costing roughly $600 to $1,000. This price, however, delivers no procedure or hospitalization costs. For a user without insurance coverage, the upfront sticker shock of a surgical implant can be prohibitive, while the entry-level price of non-invasive vagus nerve therapy offers a financially accessible starting point for trial, even though it requires a direct out-of-pocket purchase. The choice is therefore less about therapy efficacy and more about immediate cash flow versus a single, large medical expense.
Average Price Range for FDA-Approved Implantable Systems
The average price range for FDA-approved implantable systems for vagus nerve stimulation typically spans from **$15,000 to $35,000** for the device alone in the USA. This cost covers the pulse generator and lead set but excludes surgical fees. The variance depends on whether you choose a standard or advanced rechargeable model.
- Non-rechargeable systems generally fall between $15,000 and $25,000.
- Rechargeable, long-life systems range from $25,000 to $35,000.
- Full system replacement (new generator and leads) averages $20,000 to $40,000.
Cost Breakdown: Device Hardware, Surgery, and Hospital Fees
The total cost of Vagus nerve stimulation in the USA is split into three primary components. The device hardware—the implantable pulse generator and lead wire—typically accounts for the largest portion, ranging from $15,000 to $30,000. Surgery fees, covering the neurosurgeon’s procedure and anesthesia, usually add $5,000 to $12,000. Hospital fees, which include the operating room, recovery room, and overnight stay, frequently contribute another $10,000 to $20,000. Understanding this cost breakdown of VNS therapy is essential for financial planning.
- Device hardware alone often constitutes 40–50% of the total bill.
- Surgery fees vary widely based on the surgeon’s expertise and facility location.
- Hospital fees are the most variable, impacted by length of stay and facility tier.
Evaluating Ongoing Treatment Expenses
Evaluating ongoing treatment expenses for Vagus nerve stimulation (VNS) in the USA requires focusing on long-term device maintenance and clinical follow-up costs. You must account for battery replacements every 3–10 years, which can range from $5,000 to $15,000, and periodic reprogramming visits that typically cost $200–$500 per session. Prioritize a comprehensive cost projection that includes insurance co-pays for these recurring services; otherwise, a seemingly manageable upfront surgery cost can be undermined by surprise annual outlays. Even with high-deductible plans, negotiating a bundled rate with your provider for three years of follow-ups often yields significant savings. Always verify your insurance’s specific VNS maintenance coverage before committing, as policy exclusions for device checks or battery replacements are common. These steps ensure your budget realistically reflects the total VNS cost over time.
Programming and Replacement Costs for Implanted Stimulators
Programming sessions for implanted vagus nerve stimulators typically occur every three to six months, with each visit costing between $200 and $800, depending on the clinic and the complexity of parameter adjustments. Ongoing replacement expenses arise when the stimulator’s battery depletes, usually every three to five years, requiring surgical replacement of the pulse generator at a cost of $15,000 to $30,000, including the device and procedure. The precise total depends on whether replacements are covered by insurance or paid out-of-pocket, significantly altering long-term budgeting. The sequential costs follow this pattern:
- Initial programming session post-implantation to set stimulation thresholds.
- Follow-up reprogramming visits every few months to optimize efficacy.
- One-time surgical replacement once battery lifespan is reached.
- Resumption of periodic programming after each replacement.
Monthly or Per-Session Fees for External Vagus Nerve Devices
Monthly or per-session fees for external vagus nerve devices represent a recurring cost distinct from the initial purchase price. Some providers, particularly for non-invasive tVNS or gammaCore devices, charge a monthly subscription for access to the device, software, and clinician support, often ranging from $50 to $150 per month. Alternatively, per-session fees apply when renting a device at a clinic or using a pay-per-use model, typically costing $25 to $75 per treatment session. These ongoing treatment expenses can accumulate quickly, making it essential to verify whether a plan involves a fixed monthly fee or a variable per-session charge to accurately budget for long-term therapy.
Battery Life and Long-Term Maintenance Charges
The battery in a VNS device typically lasts 3–10 years, with replacement surgery costing $15,000–$30,000 per device. Long-term maintenance charges include periodic programming adjustments ($200–500 per session) and potential lead revision if fractures occur. Battery depletion triggers abrupt therapy cessation, making scheduled battery replacement planning essential to avoid gaps in treatment. Annual monitoring fees for battery status and device function add $1,000–$2,000 to ongoing expenses. Some providers offer extended service contracts covering one battery replacement, but electrode integrity checks remain a separate cost.
Battery replacement costs $15,000–$30,000 every 3–10 years; annual maintenance adds $1,000–$2,000 for programming and monitoring.
Insurance Coverage Patterns Across the United States
Insurance coverage for vagus nerve stimulation varies sharply by state, directly impacting your out-of-pocket cost. In states like California and New York, many private insurers classify VNS as a covered benefit for treatment-resistant depression or epilepsy, significantly reducing patient liability. Conversely, in states with fewer mandated coverage laws, such as Alabama or Mississippi, policies routinely exclude VNS or apply high deductibles, leaving patients with costs exceeding $20,000. A critical question: does Medicaid in your state cover VNS? For example, in Michigan, Medicaid covers VNS for epilepsy, but in Texas it is denied for depression, creating a 50% price gap. Before proceeding, verify your insurance plan’s state-specific medical necessity criteria to avoid unexpected bills.
Medicare and Medicaid Reimbursement for Vagus Nerve Stimulation
Medicare and Medicaid reimbursement for Vagus Nerve Stimulation (VNS) varies significantly by plan and indication. Medicare typically covers VNS for treatment-resistant epilepsy and depression when specific criteria are met, but Medicare and Medicaid reimbursement for Vagus Nerve Stimulation often requires prior authorization and documented failure of multiple therapies. Medicaid coverage is state-dependent; some states fully cover VNS for approved indications, while others impose strict limitations or deny coverage for certain uses like depression. Out-of-pocket costs under these programs are generally lower than private insurance, though patients may still face deductibles or copays. Does Medicare or Medicaid cover VNS for off-label conditions? Usually not; coverage is limited to FDA-approved indications like refractory epilepsy and depression, with no guarantee for broader uses.
Private Insurer Policies: When Is VNS Considered Medically Necessary?
Private insurers typically consider VNS medically necessary for drug-resistant epilepsy only after you’ve tried and failed at least two or three antiseizure meds. For depression, many require a documented failure of four or more antidepressants plus psychotherapy. Some plans also demand a trial of electroconvulsive therapy before covering VNS. Even with approval, you might still face a sizable deductible or coinsurance tied to the device’s cost. Out-of-pocket expenses vary wildly by plan, so it’s worth calling your insurer to confirm their specific fail-first criteria and coverage tier.
| Condition | Typical Medical Necessity Criteria | Common Cost Impact |
|---|---|---|
| Epilepsy | Failed 2–3 meds; seizure frequency documented | Device cost often covered after deductible |
| Depression | Failed 4+ antidepressants, therapy, and often ECT | May require higher coinsurance or prior authorization |
Out-of-Network Providers and the Risk of Surprise Billing
When seeking vagus nerve stimulation, choosing an out-of-network provider can lead to significant financial exposure due to surprise billing risks. Even if your insurance plan covers VNS, an out-of-network surgeon or hospital may charge rates far above what your insurer will reimburse, leaving you responsible for the full difference—not just copays or coinsurance. This gap can amount to tens of thousands of dollars for a single implant procedure. A patient may verify facility coverage but overlook the anesthesiologist’s network status, triggering an unbilled balance. To avoid this, you must confirm that every provider involved in your VNS care is in-network, or you must explicitly accept the out-of-network cost structure in writing.
Comparing Costs by Condition and Diagnosis
When comparing Vagus nerve stimulation cost USA by condition and diagnosis, the most significant variable is whether the device is FDA-approved for epilepsy or treatment-resistant depression, as off-label applications like vagus nerve stimulation for rheumatoid arthritis or PTSD are rarely covered by insurance. For approved diagnoses, out-of-pocket costs typically include surgical implantation (ranging from $20,000 to $35,000) plus ongoing device maintenance, whereas unapproved indications require you to fund the entire procedure and generator replacements yourself. Additionally, diagnosing practitioners often order different preoperative workups—a more complex seizure workup may add $5,000–$10,000 compared to a depression evaluation—directly affecting your final cost. Always verify your specific diagnosis codes with your insurer to understand coverage tiers before committing to surgery.
Epilepsy Treatment Expenses: Resistant Seizures and VNS
For patients with drug-resistant epilepsy, Vagus Nerve Stimulation (VNS) often becomes a necessary expense after multiple medication failures. The upfront cost of the device and surgical implantation typically ranges from $20,000 to $50,000, with additional fees for the generator replacement every 3–8 years. Beyond the device, users must budget for ongoing programming visits to fine-tune stimulation settings. These expenses are frequently offset by significant reductions in emergency room visits and hospitalizations for breakthrough seizures. Chronic epilepsy management costs can drop sharply once VNS stabilizes seizure frequency, making it a financially strategic, long-term investment for refractory cases.
- Initial VNS surgery and device cost $20,000–$50,000, excluding anesthesia and hospital fees.
- Battery replacement surgery adds $15,000–$25,000 per cycle, typically every 3–8 years.
- Ongoing programming appointments cost $200–$500 per session, often required quarterly in the first year.
Depression Care Pricing: Vagus Nerve Stimulation for Major Depressive Disorder
For major depressive disorder, depression care pricing for Vagus Nerve Stimulation typically involves a surgical implantation costing between $20,000 and $40,000 in the USA, with the VNS device itself representing a significant portion. Follow-up programming sessions, often required monthly initially, add $200 to $500 per visit. Medicare and many private insurers may cover VNS therapy for treatment-resistant depression, but out-of-pocket expenses frequently include high deductibles and co-insurance, making the total annual cost for depression care highly variable based on individual insurance plans.
Emerging Indications: Cost of VNS for Cluster Headaches and Inflammatory Conditions
For emerging indications such as cluster headaches and inflammatory conditions, VNS therapy costs for new diagnoses remain experimental and often lack standardized insurance coverage. In cluster headache management, patients typically pay out-of-pocket for the nVNS (non-invasive vagus nerve stimulation) device, with initial costs ranging from $600 to $1,200, plus replacement stimulator pads. For inflammatory disorders like Crohn’s disease or rheumatoid arthritis, implanted VNS systems can total $25,000–$40,000, including surgical implantation, device programming, and follow-up visits. Insurance coverage for these diagnoses is seldom guaranteed, making pre-approval and cost-sharing negotiations essential. The sequence for patients typically includes:
- Confirming off-label or investigational status with a specialist
- Obtaining a letter of medical necessity
- Submitting to insurance for a single-case agreement or coverage determination
Without approval, patients face full device and procedural charges.
Geographic Price Variations Within the Country
In the USA, the cost of vagus nerve stimulation surgery can swing by over $30,000 depending on where you live. A patient in San Francisco might receive a hospital bill for $85,000, while a similar procedure in Houston, Texas could land at just $52,000. Why does the same implant cost more in a coastal city than in the Midwest? It boils down to local hospital contracting rates with insurers and regional overhead. For a direct comparison: you ask, “If I live in New York City, is it worth traveling to Ohio for the surgery?” The answer often yes—savings, including travel, can reach $20,000, as facility fees in lower-cost regions are routinely 40% less, despite identical device pricing.
High-Cost Urban Centers vs. Lower-Cost Rural Hospitals
Urban centers impose significantly higher costs for Vagus nerve stimulation due to premium facility fees and specialist overhead, often inflating initial implantation and monitoring expenses by 30-50% compared to their rural counterparts. In Lower-Cost Rural Hospitals, you benefit from reduced operational charges and less aggressive billing practices, making the total procedure more affordable without sacrificing core device quality. This geographic split means you can secure the same neurostimulator hardware for thousands less by choosing a rural surgical site. The key is verifying that the rural hospital has experienced electrophysiologists, as their limited volume can affect long-term titration costs. Urban vs. rural hospital price differences thus hinge on location-driven overhead, not treatment efficacy.
Urban hospitals charge a premium for Vagus nerve stimulation due to higher overhead; lower-cost rural hospitals offer the same procedure with substantial savings via reduced facility and monitoring fees.
Regional Differences in Anesthesia and Surgeon Fees
Surgeon and anesthesia fees for VNS implantation vary significantly by region. In New York City or San Francisco, a neurosurgeon might charge 30-40% more than in a midwestern city like Cincinnati. Anesthesia cost also fluctuates: a private practice anesthesiologist in a high-cost metro area bills at a higher rate than a hospital-employed team in a Dallas suburb. These regional surgeon fee variations can shift your out-of-pocket total by several thousand dollars. When budgeting, always get itemized quotes from both the surgeon and the anesthesia provider for your specific zip code.
| Region Example | Typical Surgeon Fee Range | Typical Anesthesia Fee Range |
|---|---|---|
| Northeast (e.g., Boston) | $12,000–$16,000 | $2,500–$3,800 |
| Midwest (e.g., Columbus) | $8,000–$11,000 | $1,800–$2,500 |
| West Coast (e.g., Seattle) | $13,000–$17,500 | $2,800–$4,200 |
| South (e.g., Houston) | $9,000–$12,500 | $2,000–$3,000 |
State-Level Medicaid Coverage Variability
State-level Medicaid coverage variability directly impacts out-of-pocket costs for vagus nerve stimulation by determining whether the procedure is classified as a covered benefit. In states like California and New York, Medicaid may require prior authorization and documentation of treatment-resistant epilepsy or depression, while in Texas or Florida, the same therapy might be excluded entirely from state plan services. This divergence forces patients to either pay the full device implantation cost—often exceeding $30,000—or relocate. Even within states that cover VNS, local Medicaid managed care organizations can impose unique step-therapy protocols or facility restrictions, further altering the final price a patient faces.
Financial Assistance and Payment Strategies
Managing the high cost of Vagus nerve stimulation (VNS) therapy in the USA often hinges on navigating financial assistance and payment strategies directly through device manufacturers. Companies like LivaNova offer patient assistance programs that can subsidize out-of-pocket expenses for those denied insurance coverage. Many hospitals also provide income-based sliding scale fees or interest-free monthly payment plans for the surgical implantation, separating the device cost from the procedure.
Securing prior authorization and appealing initial denials with detailed medical necessity letters is often the most critical strategy to unlock coverage before exploring charity care funds.
Additionally, crowdfunding campaigns and negotiating a bundled “cash price” with your neurologist’s surgical center can significantly reduce the final bill, avoiding surprise facility fees.
Manufacturer Patient Assistance Programs and Rebates
For VNS devices, manufacturer patient assistance programs can directly slash your out-of-pocket costs. LivaNova, maker of the VNS Therapy system, often offers a copay savings card that applies towards your deductible or coinsurance. You might also qualify for a rebate if you pay upfront for the entire surgery or device. To check, just call the manufacturer’s patient support line with your insurance details—they’ll verify your plan’s benefits and tell you exactly what discounts you’re eligible for.
How do I apply for a VNS manufacturer rebate? Most manufacturers require you to submit proof of payment (like an invoice or EOB) within 90 days of your procedure. Contact the company’s patient assistance team directly—they’ll walk you through the form and mail you a check or prepaid card for a set amount.
Negotiating Self-Pay Rates and Cash Discounts
For VNS, negotiating a self-pay cash discount requires directly contacting the hospital’s billing department before the procedure. First, request an itemized, bundled “cash price” for the entire VNS package. Second, explicitly ask if they offer a discount for paying the negotiated amount in full on the day of service. Third, confirm that the discounted rate covers all surgeon, facility, and device fees, with no surprise balance billing. Finally, secure written confirmation of the final self-pay rate.
- Request a bundled cash price quote.
- Ask for a prompt-pay discount.
- Verify full coverage of all VNS components.
- Obtain written confirmation.
Health Savings Accounts and Flexible Spending Account Eligibility
For thync global, Inc. many patients evaluating Vagus nerve stimulation in the USA, determining Health Savings Accounts and Flexible Spending Account eligibility can significantly impact out-of-pocket exposure. Because VNS implantation is typically a qualified medical expense under IRS Section 213(d), both HSAs and FSAs generally reimburse co-pays, deductibles, and device-related costs. Before scheduling, verify with your plan administrator that the specific neurostimulator codes qualify, as some FSAs require a Letter of Medical Necessity for durable equipment. If you have an HSA, you can also use those pre-tax funds for post-surgical follow-ups and programming visits, effectively stretching your VNS budget further.
Hidden and Ancillary Costs to Anticipate
Beyond the initial device or procedure cost, anticipate ongoing expenses for replacement consumables like electrode gels and adhesive pads, which can accumulate monthly. Programming sessions to fine-tune stimulation parameters often incur separate fees, as do follow-up appointments with a neurologist or specialist. Battery replacement for an implanted stimulator, typically required every three to five years, represents a significant surgical cost not covered by the initial implantation fee. Additionally, transportation and lost wages for these recurring visits add a practical financial burden that is rarely quoted upfront.
Pre-Surgical Evaluations, Imaging, and Neurological Consultations
Before VNS implantation, pre-surgical evaluation costs often exceed the device price. You will likely pay for multiple neurological consultations to assess seizure focus and candidacy, each ranging from $200 to $500. Required imaging includes high-resolution MRI with epilepsy protocols ($1,000–$3,000) and possibly video-EEG monitoring for seizure localization ($5,000–$15,000 per multi-day stay). Neuropsychological testing to map brain function adds $1,500–$3,000. These consultations and scans are typically billed separately and may not be fully covered by insurance until deductibles are met, creating significant upfront out-of-pocket expenses.
Post-Operative Care, Device Adjustments, and Rehabilitation
Post-operative care, device adjustments, and rehabilitation for vagus nerve stimulation (VNS) generate significant hidden costs. Frequent office visits for VNS device programming are necessary to titrate stimulation parameters, often requiring multiple adjustments in the first year, each carrying a specialist copay. Rehabilitation may include voice therapy for hoarseness or dysphagia, while physical therapy can address rare but costly complications like vocal cord paresis. Remote monitoring fees for device checks also add recurring charges.
- Copays for 4–8 initial programming sessions within 12 months post-implant.
- Voice or swallowing therapy sessions for managing side effects.
- Physical therapy for cervical or vagal nerve injury rehabilitation.
- Monthly or quarterly remote monitoring subscription fees.
Battery Replacement Surgery and Device Migration Repairs
Beyond the initial implant, you must plan for battery replacement surgery for VNS devices, a recurring expense occurring every 3–8 years. This procedure, often costing $15,000–$30,000, involves anesthesia, operating room fees, and a new pulse generator. Additionally, device migration repairs arise when the lead wire moves out of position, requiring surgical adjustment or lead replacement—each event adding unforeseen thousands to your total. These hardware-specific interventions are unavoidable, forcing patients to budget for repeated hospital visits and surgeon fees throughout the device’s lifespan.
Weighing the Value: Cost vs. Long-Term Effectiveness
When weighing the value of Vagus nerve stimulation in the USA, the upfront cost—often between $20,000 and $30,000 for the implant plus surgery—can feel staggering. Yet the long-term effectiveness against drug-resistant epilepsy or depression frequently justifies the expense, as users avoid years of failed medication trials. Does the steep initial price outweigh potential decades of improved quality of life? For many, the answer hinges on insurance coverage and out-of-pocket caps, since maintenance costs (battery replacements every 3–5 years) add up but remain lower than chronic treatment failures.
Quality-Adjusted Life Years and Cost-Effectiveness Data
Quality-Adjusted Life Years (QALYs) provide a standardized metric to gauge the real-world value of Vagus Nerve Stimulation (VNS) by weighing both lifespan extension and symptom relief against its upfront implant cost. Cost-effectiveness data translates this into a ratio, often comparing VNS to continued medication or alternative therapies. For patients in the USA, a lower cost-per-QALY indicates stronger long-term justification for the expense, particularly for treatment-resistant conditions. However, thresholds for what constitutes “cost-effective” vary, meaning personal insurance coverage decisions can hinge on this specific data. The analysis fundamentally frames the device not as a surgery cost, but as an investment in sustained quality of life.
- QALY calculations quantify whether reduced seizure burden or depression episodes justify the tens of thousands in initial VNS costs.
- Cost-effectiveness data reveals if VNS remains favorable across standard 5- to 10-year treatment horizons versus escalating drug regimens.
- These metrics help patients directly compare VNS to alternatives like deep brain stimulation on a per-improved-year-of-life basis.
Comparing VNS to Alternative Treatments Like Deep Brain Stimulation
When weighing VNS against alternatives like deep brain stimulation (DBS), the upfront cost difference is stark—VNS surgery is generally less invasive and cheaper, often under $30,000, while DBS can exceed $50,000. However, DBS often provides more precise control for conditions like severe epilepsy or depression, though it carries higher surgical risks. For some, this trade-off means DBS’s long-term effectiveness justifies its higher price, especially if VNS fails. Your choice really depends on your specific condition and how much tweaking you’re willing to endure. Comparing VNS to alternative treatments like deep brain stimulation highlights that while VNS is more affordable upfront, DBS may offer better outcomes for certain hard-to-treat cases, making the cost-value equation deeply personal.
| Aspect | VNS | Deep Brain Stimulation (DBS) |
|---|---|---|
| Typical Initial Cost | ~$20,000–$30,000 | ~$40,000–$60,000+ |
| Procedure Invasiveness | Chest implant, less brain tissue disruption | Skull-anchored electrodes, more risk |
| Adjustability | Limited to vagus nerve settings | Highly customizable electrode targeting |
| Long-Term Effectiveness | Gradual improvement over months | Often quicker, more dramatic results |
Potential Savings from Reduced Medication and Hospitalizations
While the upfront cost of VNS therapy in the USA is high, the real win comes from slashing ongoing medical bills. Many patients see a dramatic drop in seizure frequency, which directly cuts down on expensive ER visits and long hospital stays. You also might rely less on multiple daily medications, some of which have hefty co-pays and side-effect management costs. Over a few years, those avoided emergency trips and pharmacy refills can offset the initial device expense, making it a smarter financial move for your long-term health budget.
- Fewer emergency room visits from breakthrough seizures saves thousands per year.
- Reduced need for multiple daily prescriptions lowers your monthly pharmacy spending.
- Less frequent hospital admissions for epilepsy monitoring or drug adjustments reduces out-of-pocket costs.
- Potential to taper off high-cost specialty medications after successful VNS implantation.
What Factors Drive the Price of Vagus Nerve Stimulation in the United States
How Device Type (Implantable vs. Non-Invasive) Shapes Your Total Cost
Why the Number of Required Sessions Affects Your Long-Term Expenses
Breaking Down the Upfront and Recurring Fees for Vagus Nerve Stimulation
What the Initial Consultation and Device Purchase Typically Costs
Ongoing Maintenance, Replacement Parts, and Programming Fees Explained
Ways to Make Vagus Nerve Stimulation More Affordable in the USA
How Health Insurance Coverage Can Offset the Implant Cost
Using Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs) to Pay
