FORT LOUDOUN MEDICAL CENTER — Hospital Ledger

Code	Description	Gross	Cash	Min payer	Max payer	# insurers
J7330	IMPLANT MACI GRAFT VERICEL	$228,480	$73,114	$47,981	$205,632	30
790151090	SYS TRICUSPID EVOQUE VALVE SZ44	$215,000	$68,800	$47,300	$107,500	7
790151091	SYS TRICUSPID EVOQUE VALVE SZ48	$215,000	$68,800	$47,300	$107,500	7
790151092	SYS TRICUSPID EVOQUE VALVE SZ52	$215,000	$68,800	$47,300	$107,500	7
790147383	SET PUMP SZ5.5 IMPELLA	$205,000	$65,600	—	—	0
790151782	SYS TRICLIP G4 STEER CATH GUIDE	$195,000	$62,400	$42,900	$97,500	7
790146439	KIT VALVE SAPIEN 3 ULTRA THV SZ20	$170,000	$54,400	$37,400	$85,000	7
790146438	KIT VALVE SAPIEN 3 ULTRA THV SZ23	$170,000	$54,400	$37,400	$85,000	7
790146437	KIT VALVE SAPIEN 3 ULTRA THV SZ26	$170,000	$54,400	$37,400	$85,000	7
790146436	KIT VALVE SAPIEN 3 ULTRA THV SZ29	$170,000	$54,400	$37,400	$85,000	7
790140302	KIT VALVE COMMANDER+S3 ULTRA SZ20	$162,500	$52,000	$35,750	$81,250	7
790140303	KIT VALVE COMMANDER+S3 ULTRA SZ23	$162,500	$52,000	$35,750	$81,250	7
790140304	KIT VALVE COMMANDER+S3 ULTRA SZ26	$162,500	$52,000	$35,750	$81,250	7
790133755	VALVE AORTIC TRNSCATH 23 SAPIEN	$162,500	$52,000	$35,750	$81,250	7
790133756	VALVE AORTIC TRNSCATH 26 SAPIEN	$162,500	$52,000	$35,750	$81,250	7
790128801	VALVE THV SZ3-29 SAPIEN COMMANDER	$162,500	$52,000	$35,750	$81,250	7
720207517	UPLINZA 100MG/10ML INJ	$155,740	$49,837	—	—	0
J1823	UPLINZA 100MG/10ML INJ	$155,740	$49,837	$225	$140,166	57
790142866	SYS MITRACLIP G4 STEER CATH GUIDE	$150,000	$48,000	$33,000	$75,000	7
790152255	VALVE AORTIC TRANSCATH FX+ SZ23	$150,000	$48,000	$33,000	$75,000	7
790152256	VALVE AORTIC TRANSCATH FX+ SZ26	$150,000	$48,000	$33,000	$75,000	7
790152257	VALVE AORTIC TRANSCATH FX+ SZ29	$150,000	$48,000	$33,000	$75,000	7
790152258	VALVE AORTIC TRANSCATH FX+ SZ34	$150,000	$48,000	$33,000	$75,000	7
720207438	TREMELIMUMAB ACTL 300MG/15ML INJ	$132,912	$42,532	—	—	0
J9347	TREMELIMUMAB ACTL 300MG/15ML INJ	$132,912	$42,532	$124	$119,621	56
790148689	SET PUMP FLEX RP W SMART ASSIST	$125,000	$40,000	—	—	0
790150199	SET PUMP LP CP SZ3.5 IMPELLA	$125,000	$40,000	—	—	0
790144048	SET PUMP RP SZ11 IMPELLA	$125,000	$40,000	—	—	0
720007040	AMMONUL 10%-10% 50ML INJ	$124,392	$39,805	—	—	0
720205742	IPILIMUMAB 200MG/40ML INJ	$116,315	$37,221	—	—	0
J9228	IPILIMUMAB 200MG/40ML INJ	$116,315	$37,221	$71.3	$104,683	57
790147117	KIT MRI PERC INTELLIS	$104,980	$33,594	$23,096	$52,490	7
C2624	SENSOR PULMONARY ART W DEL SYS	$100,250	$32,080	$21,053	$90,225	25
C1820	DEVICE STIMULATION IPG ETERNA	$97,500	$31,200	$20,475	$87,750	25
790113529	VALVE PULMONARY W CONDUIT SZ29	$96,425	$30,856	$21,214	$48,213	7
C1822	KIT IPG SENZA OMNIA	$92,500	$29,600	$19,425	$83,250	25
L8614	IMPLANT COCHLEAR MODEL CI612	$88,500	$28,320	$18,585	$79,650	51
790148600	STENT FLOW DIVERT 4.5X20 FREDX 27	$86,750	$27,760	$19,085	$43,375	7
790143872	STENT FLOW DIVERT 4.5X20 FRED 27	$86,600	$27,712	$19,052	$43,300	7
790151926	DEVICE WATCHMAN FLX PRO	$85,000	$27,200	$18,700	$42,500	7
720207381	ZYNLONTA 10MG INJ	$81,009	$25,923	—	—	0
J9359	ZYNLONTA 10MG INJ	$81,009	$25,923	$93.42	$72,908	57
C1767	DEVICE PULSE GENERATOR PROCLAIM	$81,000	$25,920	$17,010	$72,900	25
720207456	RAVULIZUMAB-CWVZ 100MG/ML 11ML IN	$80,024	$25,608	—	—	0
C1882	DEFIB QUAD POLAR HF-T RIVACOR	$80,000	$25,600	$16,800	$72,000	25
790071089	VALVE AORTIC W CONDUIT SZ23-30	$79,650	$25,488	$17,523	$39,825	7
790148800	STENT FLOW DIVERT 5X36 FREDX 27	$78,500	$25,120	$17,270	$39,250	7
C1876	GRAFT ENDO 36X20-30X120 ZENITH	$77,976	$24,952	$16,375	$70,179	25
790145652	CONDUIT AORTIC VALVE SZ21 KONECT	$75,000	$24,000	$16,500	$37,500	7
790148093	CONDUIT AORTIC VALVE SZ23 KONECT	$75,000	$24,000	$16,500	$37,500	7

Showing top 50 of 28,531 priced procedures, sorted by gross charge.

Data straight from this hospital's federally-mandated machine-readable file (45 CFR § 180). The compliance grade reflects how completely the hospital published the six required data elements, not the quality of care.