Gouverneur Hospital
77 West Barney Street, Gouverneur, NY · Rochesterregional · · NPI 1629409925
Published prices by procedure
Cash price is what you pay without insurance. The negotiated range spans the lowest to highest rate this hospital agreed with insurers.
| Procedure | Cash price | Gross charge | Negotiated range | Payers |
|---|---|---|---|---|
| Dexametha opth insert 0.1 mg HCPCS J1096 | not published | not published | $110.68 – $166.50 | 2 |
| Dexamethasone 0.4 mg/0.1 ml intraocular injection - cnr HCPCS J1095 | not published | not published | $1.10 – $1.38 | 2 |
| Dexamethasone 4 mg tablet HCPCS J8540 | not published | not published | $0.06 – $0.09 | 2 |
| Dexamethasone in ns IV syringe 0.1 mg/ml (neonate) - cnr HCPCS J1100 | not published | not published | $0.09 – $0.25 | 2 |
| Dexamethasone intra implant HCPCS J7312 | not published | not published | $205.24 – $228.51 | 2 |
| Dexamethasone panel CPT 80420 | not published | not published | $65.45 – $2,105.44 | 4 |
| Dexrazoxane hcl 250 mg intravenous solution HCPCS J1190 | not published | not published | $80.96 – $329.11 | 2 |
| Dextran 40 infusion HCPCS J7100 | not published | not published | $35.19 – $41.22 | 2 |
| Dextran 75 infusion HCPCS J7110 | not published | not published | $11.62 – $11.62 | 1 |
| Dextroamphetamine HCPCS S0160 | not published | not published | $0.66 – $1.24 | 2 |
| Dextrose 5 % and 0.9 % sodium chloride intravenous solution HCPCS J7042 | not published | not published | $1.25 – $3.15 | 2 |
| Dextrose 5 % and lactated ringers intravenous solution HCPCS J7121 | not published | not published | $7.04 – $7.66 | 2 |
| Dextrose 5 % in water (d5w) intravenous solution (non-pvc) HCPCS J7060 | $5.19 | $7.99 | $1.82 – $4.94 | 2 |
| Dextrose 5 % IV bolus HCPCS J7070 | not published | not published | $3.64 – $6.20 | 2 |
| Dhea-s (dehydroepiand sulfate) CPT 82627 | $183.53 | $282.35 | $21.56 – $289.13 | 4 |
| Diabetes (HbA1c) Test CPT 83036 | $117.60 | $180.92 | $9.42 – $126.29 | 4 |
| Diagnostic anoscopy spx 46600 CPT 46600 | $348.09 | $535.52 | not published | 0 |
| Diagnostic digital breast tomosynthesis bil CPT 77062 | $74.11 | $114.01 | not published | 0 |
| Diagnostic digital breast tomosynthesis unil CPT 77061 | $79.23 | $121.89 | not published | 0 |
| Diagnostic laryngoscopy 31575 CPT 31575 | $243.15 | $374.08 | $130.30 – $130.30 | 1 |
| Diagnostic Mammogram (both breasts) CPT 77066 | $474.10 | $729.39 | $125.96 – $125.96 | 1 |
| Diagnostic Mammogram (one breast) CPT 77065 | $407.64 | $627.14 | $103.01 – $103.01 | 1 |
| Diatrizoate meglumine 18 % urethral solution HCPCS Q9958 | not published | not published | $0.13 – $0.13 | 1 |
| Diazepam 5 mg/ml injection solution (wrapper) HCPCS J3360 | not published | not published | $5.79 – $14.77 | 2 |
| Dicyclomine injection HCPCS J0500 | not published | not published | $12.86 – $46.80 | 2 |
| Difelikefalin, esrd on dialy HCPCS J0879 | not published | not published | $0.22 – $0.28 | 2 |
| Diffusing capacity CPT 94729 | $238.12 | $366.34 | not published | 0 |
| Digoxin 250 mcg/ml (0.25 mg/ml) injection solution HCPCS J1160 | not published | not published | $4.88 – $7.04 | 2 |
| Digoxin immune fab 40 mg intravenous solution HCPCS J1162 | not published | not published | $4,968.58 – $5,306.40 | 2 |
| Digoxin total therapeutic drug level CPT 80162 | $127.11 | $195.55 | $10.61 – $172.72 | 4 |
| Dihydroergotamine 0.05 mg/ml IV syringe - cnr HCPCS J1110 | not published | not published | $85.75 – $101.05 | 2 |
| Dimecaprol injection HCPCS J0470 | not published | not published | $51.34 – $64.18 | 2 |
| Dimenhydrinate injection HCPCS J1240 | not published | not published | $8.35 – $12.04 | 2 |
| Dimethyl sulfoxide 50% 50 ml HCPCS J1212 | $1,105.00 | $1,700.00 | $714.72 – $742.31 | 2 |
| Diphenhydramine 12.5 mg/5 ml oral elixir HCPCS Q0163 | not published | not published | $0.02 – $0.02 | 2 |
| Diphenhydramine 50 mg/ml injection (wrapper) HCPCS J1200 | not published | not published | $0.66 – $2.28 | 2 |
| Diphtheria-tetanus toxoids 0.5 ml (peds) CPT 90702 | not published | not published | $75.32 – $75.32 | 1 |
| Dipyridamole injection HCPCS J1245 | not published | not published | $3.84 – $4.75 | 2 |
| Disability dlco CPT 94727 | $256.02 | $393.87 | not published | 0 |
| Disaccharidases CPT 82657 | not published | not published | $21.50 – $288.35 | 3 |
| Discography cerv/thor spine CPT 72285 | not published | not published | $200.18 – $200.18 | 1 |
| Dis site tele svcs rhc/fqhc HCPCS G2025 | $216.27 | $332.72 | $97.53 – $97.53 | 3 |
| Dmd dup/delet analysis CPT 81161 | not published | not published | $168.67 – $3,628.73 | 4 |
| Dmpk gene charac alleles CPT 81239 | not published | not published | $166.55 – $3,574.49 | 4 |
| Dmpk gene detc abnor allele CPT 81234 | not published | not published | $83.83 – $1,781.85 | 4 |
| Dna antibody native/double stranded CPT 86225 | $251.64 | $387.14 | $5.25 – $178.71 | 4 |
| Dna gardnerella CPT 87510 | $42.37 | $65.19 | $14.09 – $260.77 | 4 |
| Dna probe chlamydia CPT 87490 | not published | not published | $8.11 – $295.89 | 4 |
| Dna probe gc CPT 87590 | not published | not published | $8.11 – $349.61 | 4 |
| Dna trichomonas CPT 87660 | $42.37 | $65.19 | $14.09 – $260.77 | 4 |
| Dobutamine 250 mg/20 ml (12.5 mg/ml) intravenous solution HCPCS J1250 | $10.08 | $15.50 | $6.76 – $8.15 | 2 |
| Docetaxel 20 mg/ml intravenous solution (wrapper) HCPCS J9171 | not published | not published | $0.61 – $2.86 | 2 |
| Docetaxel (docivyx), 1 mg HCPCS J9172 | not published | not published | $51.62 – $51.62 | 1 |
| Dolasetron mesylate HCPCS J1260 | not published | not published | $5.63 – $5.63 | 1 |
| Dolasetron mesylate oral HCPCS Q0180 | not published | not published | $57.90 – $72.38 | 2 |
| Dopamine 40 mg/ml intravenous solution (wrapper) HCPCS J1265 | not published | not published | $0.70 – $0.71 | 2 |
| Doppler echo complete CPT 93320 | $325.84 | $501.30 | not published | 0 |
| Doppler upper/lower extremity arteries complete bilateral CPT 93923 | $356.86 | $549.02 | not published | 0 |
| Doppler upper/lower extremity arteries limited bilateral CPT 93922 | $284.91 | $438.33 | not published | 0 |
| Doripenem 50 mg/ml inj 10 ml HCPCS J1267 | not published | not published | $0.76 – $0.76 | 1 |
| Dornase alfa non-comp unit HCPCS J7639 | not published | not published | $53.59 – $57.92 | 2 |
| Dostarlimab-gxly 50 mg/ml intravenous solution HCPCS J9272 | not published | not published | $240.14 – $258.91 | 2 |
| Doxorubicin 2 mg/ml intravenous solution (wrapper) HCPCS J9000 | not published | not published | $3.15 – $8.46 | 2 |
| Doxorubicin, pegylated liposomal 2 mg/ml intravenous suspension HCPCS Q2050 | not published | not published | $150.41 – $397.80 | 2 |
| Dpyd gene common variants CPT 81232 | $429.25 | $660.39 | $169.57 – $2,273.61 | 3 |
| Drainage external ear simple 69000 CPT 69000 | $1,738.83 | $2,675.13 | not published | 0 |
| Drainage mouth roof lesion CPT 42000 | $549.65 | $845.61 | not published | 0 |
| Drainage of arm bursa 23931 CPT 23931 | $4,292.42 | $6,603.72 | not published | 0 |
| Drainage of mouth lesion CPT 41008 | $5,357.45 | $8,242.23 | not published | 0 |
| Drain blood from under nail 11740 CPT 11740 | $150.03 | $230.82 | not published | 0 |
| Drain finger abscess;simple 26010 CPT 26010 | $443.10 | $681.70 | not published | 0 |
| Drain neck/chest lesion 21501 CPT 21501 | $7,435.50 | $11,439.23 | not published | 0 |
| Drain ostomy pouch w/flange HCPCS A5063 | not published | not published | $2.67 – $2.67 | 1 |
| Dress/debride pt-tck burn/5-10% bs 16025 CPT 16025 | $371.16 | $571.02 | not published | 0 |
| Dress/debride pt-thick burn/<5% bs 16020 CPT 16020 | $443.10 | $681.70 | not published | 0 |
| Dressing wound matrix 2x2in 25sqcm-q4108-cost per sq cm HCPCS Q4108 | not published | not published | $55.93 – $55.93 | 1 |
| Drng of eyelid abscess 67700 CPT 67700 | $726.00 | $1,116.92 | not published | 0 |
| Drng of finger abscess comp 26011 CPT 26011 | $2,967.69 | $4,565.67 | not published | 0 |
| Dronabinol 2.5mg oral HCPCS Q0167 | not published | not published | $1.48 – $2.03 | 2 |
| Droperidol 2.5 mg/ml injection solution HCPCS J1790 | not published | not published | $8.57 – $10.33 | 2 |
| Drsg oasis fen mesh thick 3x7cm 21sqcm -cost per sq cm HCPCS Q4102 | not published | not published | $13.50 – $13.50 | 1 |
| Drsg oasis ultr ster 3lyr 7x10 70sqcm -cost per sq cm HCPCS Q4124 | not published | not published | $15.00 – $15.00 | 1 |
| Drsg sht 5.625x4.625in std HCPCS A6025 | not published | not published | $41.99 – $41.99 | 1 |
| Drsg wnd hyalomatrix 10x10cm -cost per sq cm HCPCS Q4117 | not published | not published | $28.69 – $28.69 | 1 |
| Drsg wnd mesh bovine bilayer 4x10in matrix-q4104-cost per sq cm HCPCS Q4104 | not published | not published | $55.48 – $55.48 | 1 |
| Drug assay caffeine CPT 80155 | $94.36 | $145.17 | $37.41 – $501.65 | 3 |
| Drug assay posaconazole CPT 80187 | $66.58 | $102.43 | $10.61 – $352.60 | 4 |
| Drug assay rufinamide CPT 80210 | $59.82 | $92.03 | $16.43 – $352.60 | 4 |
| Drug assay vedolizumab CPT 80280 | $96.06 | $147.79 | $10.61 – $501.65 | 4 |
| Drug assay voriconazole CPT 80285 | $63.17 | $97.18 | $10.61 – $352.60 | 4 |
| Drug asy hydroxychloroquine CPT 80220 | $38.62 | $59.42 | $10.61 – $242.44 | 4 |
| Drug of abuse screen urine CPT 80305 | $24.57 | $37.80 | $5.05 – $163.88 | 4 |
| Drug screening tapentadol CPT 80372 | $92.85 | $142.84 | not published | 0 |
| Drug screen quant tiagabine CPT 80199 | not published | not published | $10.61 – $352.60 | 4 |
| Drug/substance nos 4-6 CPT 80376 | $602.26 | $926.55 | not published | 0 |
| Drug test def 15-21 classes HCPCS G0482 | $512.42 | $788.34 | $192.78 – $2,584.85 | 3 |
| Drug test def 1-7 classes HCPCS G0480 | $157.66 | $242.56 | $15.15 – $1,488.30 | 4 |
| Drug test def 22+ classes HCPCS G0483 | not published | not published | $239.51 – $3,211.49 | 3 |
| Drug test def 8-14 classes HCPCS G0481 | $330.90 | $509.08 | $151.89 – $2,036.64 | 3 |
| Drug test def simple all cl HCPCS G0659 | not published | not published | $60.28 – $808.21 | 3 |
A missing value means the hospital did not publish that price — it never means the price is zero. Real bills can add facility fees, supplies and professional fees; see our methodology.