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 |
|---|---|---|---|---|
| Interferon beta-1a 30 mcg/0.5 ml im injection (wrapper) HCPCS Q3027 | not published | not published | $69.10 – $75.29 | 2 |
| Interferon beta-1a inj HCPCS J1826 | not published | not published | $2,073.07 – $2,258.79 | 2 |
| Interferon beta-1b / .25 mg HCPCS J1830 | not published | not published | $561.32 – $682.14 | 2 |
| Interferon gamma 1-b inj HCPCS J9216 | not published | not published | $8,121.26 – $9,050.79 | 2 |
| Interfyl, 1 mg HCPCS Q4171 | not published | not published | $39.00 – $39.00 | 1 |
| Interrog dev eval icpms ip CPT 93290 | $93.42 | $143.73 | not published | 0 |
| Interrog device eval heart CPT 93289 | $93.42 | $143.73 | not published | 0 |
| Interrog evl pm/ldls pm ip CPT 93288 | $93.42 | $143.73 | not published | 0 |
| Intracranial limited study CPT 93888 | $291.05 | $447.77 | not published | 0 |
| Intraoral i+d tongue/floor lingual 41000 CPT 41000 | $983.79 | $1,513.53 | not published | 0 |
| Intrinsic factor antibody CPT 86340 | $47.98 | $73.82 | $11.47 – $196.13 | 4 |
| Intro long gi tube w/mult fluo CPT 74340 | not published | not published | $87.40 – $87.40 | 1 |
| Intubation endotracheal emergency procedure CPT 31500 | $579.00 | $890.77 | not published | 0 |
| Iodine i-131 iobenguane 1mci HCPCS A9590 | not published | not published | $307.58 – $362.40 | 2 |
| Iopamidol 250 mg iodine/ml (51 %) intravenous solution HCPCS Q9966 | not published | not published | $0.36 – $0.36 | 1 |
| Iopamidol 300 mg iodine/ml (61 %) intravenous solution HCPCS Q9967 | $0.18 | $0.27 | $0.38 – $0.38 | 1 |
| Io radiation tx management CPT 77469 | not published | not published | $111.09 – $111.09 | 1 |
| Io rad tx deliver by elctrns CPT 77425 | not published | not published | $135.91 – $135.91 | 1 |
| Io rad tx delivery by x-ray CPT 77424 | not published | not published | $106.90 – $106.90 | 1 |
| Ipilimumab 5 mg/ml intravenous solution (wrapper) HCPCS J9228 | not published | not published | $180.22 – $192.97 | 2 |
| Ip/obs cnsltj new/est low 45 CPT 99253 | not published | not published | $58.38 – $58.38 | 1 |
| Ip/obs cnsltj new/est mod 60 CPT 99254 | not published | not published | $58.38 – $58.38 | 1 |
| Ip/obs consltj new/est hi 80 CPT 99255 | not published | not published | $58.38 – $58.38 | 1 |
| Ip/obs consltj new/est sf 35 CPT 99252 | not published | not published | $58.38 – $58.38 | 1 |
| Ipratropium bromide comp HCPCS J7645 | not published | not published | $0.05 – $0.05 | 1 |
| Ipratropium bromide non-comp HCPCS J7644 | not published | not published | $0.36 – $0.44 | 2 |
| Irinotecan 20 mg/ml intravenous solution (wrapper) HCPCS J9206 | not published | not published | $1.64 – $7.21 | 2 |
| Irinotecan liposomal 4.3 mg/ml intravenous HCPCS J9205 | not published | not published | $65.28 – $72.08 | 2 |
| Iron CPT 83540 | $16.13 | $24.82 | $5.08 – $84.15 | 4 |
| Iron binding capacity CPT 83550 | $60.82 | $93.57 | $5.08 – $113.67 | 4 |
| Iron dextran 50 mg/ml injection solution HCPCS J1750 | not published | not published | $17.23 – $19.32 | 2 |
| Iron stain peripheral blood CPT 85536 | not published | not published | $6.67 – $89.48 | 4 |
| Iron sucrose 20 mg iron/ml intravenous solution (wrapper) HCPCS J1756 | $0.52 | $0.80 | $0.24 – $0.43 | 2 |
| Irrigation implantable venous access device for drug delivery systems CPT 96523 | $141.04 | $216.98 | not published | 0 |
| Isatuximab-irfc 20 mg/ml intravenous solution HCPCS J9227 | not published | not published | $78.86 – $86.05 | 2 |
| Ivc venogram s&i CPT 75825 | not published | not published | $131.68 – $131.68 | 1 |
| IV Fluids (each additional hour) CPT 96361 | $171.19 | $263.37 | not published | 0 |
| IV Fluids (first hour) CPT 96360 | $349.45 | $537.61 | not published | 0 |
| Ivig non-lyophilized, nos HCPCS J1599 | not published | not published | $119.30 – $143.04 | 2 |
| IV infusion therapy/prophylaxis/diagnosis concurrent infusion CPT 96368 | $134.34 | $206.67 | not published | 0 |
| IV Medicine Infusion (additional drug) CPT 96367 | $110.58 | $170.13 | not published | 0 |
| IV Medicine Infusion (each additional hour) CPT 96366 | $106.48 | $163.82 | not published | 0 |
| IV Medicine Infusion (first hour) CPT 96365 | $338.08 | $520.12 | not published | 0 |
| IV Push Injection (each additional drug) CPT 96375 | $122.05 | $187.77 | not published | 0 |
| IV Push Injection (first drug) CPT 96374 | $267.03 | $410.82 | not published | 0 |
| Ivp w/nephrotomography CPT 74415 | not published | not published | $87.52 – $87.52 | 1 |
| Ivp w/wo kub w/wo tomography CPT 74400 | not published | not published | $71.75 – $71.75 | 1 |
| Ixabepilone 15 mg intravenous solution HCPCS J9207 | not published | not published | $136.21 – $141.31 | 2 |
| Jak2 targeted sequence analysis CPT 81279 | $391.36 | $602.09 | $112.23 – $2,408.75 | 4 |
| Jaw Joint (TMJ) X-ray (both sides, open and closed) CPT 70330 | $355.25 | $546.54 | $30.96 – $30.96 | 1 |
| Jaw (Mandible) X-ray (complete) CPT 70110 | $195.53 | $300.81 | $25.25 – $25.25 | 1 |
| John cunningham antibody CPT 86711 | $45.82 | $70.50 | $16.38 – $219.67 | 3 |
| Ketamine and metabolite screen - quest CPT 80357 | $314.20 | $483.39 | not published | 0 |
| Ketogenic steroids fract CPT 83582 | not published | not published | $15.01 – $201.21 | 3 |
| Ketone body(s) beta-hydroxybutyrate quantitative CPT 82010 | $72.55 | $111.62 | $7.92 – $106.26 | 3 |
| Ketorolac (Toradol) Pain Shot, 15 mg HCPCS J1885 | $0.95 | $1.46 | $0.50 – $1.97 | 2 |
| Kidney function study CPT 78725 | not published | not published | $79.04 – $79.04 | 1 |
| Kidney imaging (3d) CPT 78710 | not published | not published | $202.01 – $202.01 | 1 |
| Kidney imaging morphology CPT 78700 | not published | not published | $112.91 – $112.91 | 1 |
| Kidney imag w/bld flow multi CPT 78709 | not published | not published | $234.22 – $234.22 | 1 |
| Kidney img w/bldflw sgl without rx CPT 78707 | not published | not published | $151.88 – $151.88 | 1 |
| Kidney (Retroperitoneal) Ultrasound (complete) CPT 76770 | $995.44 | $1,531.44 | $101.83 – $101.83 | 1 |
| Kidney (Retroperitoneal) Ultrasound (limited) CPT 76775 | $736.47 | $1,133.03 | $71.42 – $71.42 | 1 |
| Kit cast tcc 3in w/2reg boots total contact cast HCPCS Q4038 | $58.82 | $90.50 | not published | 0 |
| Kit cath f 8f w/glv + wipe ster HCPCS A4353 | not published | not published | $5.44 – $5.44 | 1 |
| Kit gene analys d816 variant CPT 81273 | $321.96 | $495.32 | $121.12 – $1,624.08 | 3 |
| Kit irrigator stoma cone 7721 HCPCS A4398 | not published | not published | $32.81 – $32.81 | 1 |
| Kit omnigraft 2.5x2.5cm dermal regeneration matrix - q4105-cost per sq cm HCPCS Q4105 | not published | not published | $57.82 – $57.82 | 1 |
| Knee MRI (with and without contrast) CPT 73723 | $4,929.48 | $7,583.81 | $502.83 – $502.83 | 1 |
| Knee MRI (with contrast) CPT 73722 | $2,282.34 | $3,511.29 | $380.24 – $380.24 | 1 |
| Knee MRI (without contrast) CPT 73721 | $3,043.12 | $4,681.72 | $326.75 – $326.75 | 1 |
| Knee X-ray CPT 73564 | $299.88 | $461.35 | $26.99 – $26.99 | 1 |
| Knee X-ray (1 to 2 views, both knees) CPT 73560 | $257.69 | $396.45 | $19.61 – $19.61 | 1 |
| Knee X-ray (3 views, both knees) CPT 73562 | $215.10 | $330.92 | $23.54 – $23.54 | 1 |
| Knee X-ray (standing, both knees) CPT 73565 | not published | not published | $21.80 – $21.80 | 1 |
| Kras gene addl variants CPT 81276 | not published | not published | $119.49 – $2,513.45 | 4 |
| Kras gene variants exon 2 CPT 81275 | not published | not published | $187.45 – $2,513.45 | 4 |
| Kyleena, 19.5 mg HCPCS J7296 | $1,611.43 | $2,479.13 | $1,214.63 – $1,259.09 | 2 |
| Labetalol 5 mg/ml IV (wrapper) HCPCS J1920 | not published | not published | $0.42 – $0.42 | 1 |
| Lacosamide 200 mg/20 ml intravenous solution HCPCS C9254 | not published | not published | $0.19 – $0.39 | 2 |
| Lactate dehydrogenase (ldh) CPT 83615 | $65.93 | $101.43 | $5.08 – $78.56 | 4 |
| Lactated ringers intravenous solution HCPCS J7120 | $427.64 | $657.90 | $2.30 – $11.07 | 2 |
| Lactic acid CPT 83605 | $58.99 | $90.76 | $9.39 – $150.48 | 4 |
| Lactoferrin fecal qualitative CPT 83630 | $106.61 | $164.01 | $5.25 – $256.22 | 4 |
| Lactoferrin fecal quant CPT 83631 | not published | not published | $11.39 – $255.31 | 4 |
| Lanreotide 120 mg/0.5 ml subcutaneous syringe HCPCS J1930 | $64.64 | $99.44 | $39.55 – $108.11 | 2 |
| Lanthanum carbonate oral 5mg HCPCS J0607 | not published | not published | $0.04 – $0.04 | 1 |
| Large Joint Injection or Fluid Draw (both sides) CPT 20610 | $667.15 | $1,026.39 | not published | 0 |
| Largsc w/rmvl foreign bdy(s) CPT 31577 | $420.87 | $647.49 | not published | 0 |
| Laronidase injection HCPCS J1931 | not published | not published | $38.61 – $40.96 | 2 |
| Laryngoscopy telescopic CPT 31579 | not published | not published | $233.63 – $233.63 | 1 |
| Lead capillary CPT 83655 | $93.05 | $143.15 | $11.75 – $157.51 | 4 |
| Leg Artery Ultrasound (complete, both legs) CPT 93925 | $1,032.51 | $1,588.47 | not published | 0 |
| Leg CT Scan (with contrast, both legs) CPT 73701 | $1,309.46 | $2,014.56 | $193.87 – $193.87 | 1 |
| Leg CT Scan (without contrast, both legs) CPT 73700 | $759.34 | $1,168.21 | $195.06 – $195.06 | 1 |
| Legion pneumo dna dir prob CPT 87540 | $41.54 | $63.91 | $19.45 – $260.77 | 3 |
| Legion pneumo dna quant CPT 87542 | not published | not published | $40.51 – $543.14 | 3 |
| Leg Vein Ultrasound (DVT study, both legs) CPT 93970 | $1,032.51 | $1,588.47 | not published | 0 |
| Leishmania antibody CPT 86717 | not published | not published | $8.11 – $159.33 | 4 |
| Lepirudin HCPCS J1945 | not published | not published | $118.71 – $118.71 | 1 |
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.