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 |
|---|---|---|---|---|
| Leucovorin calcium 100 mg solution for injection (1 mg rounding) HCPCS J0640 | not published | not published | $3.51 – $12.00 | 2 |
| Leukocyte phagocytosis CPT 86344 | not published | not published | $10.08 – $135.13 | 3 |
| Leuprolide 30 mg (4 month) intramuscular syringe kit HCPCS J9217 | not published | not published | $172.29 – $542.03 | 2 |
| Leuprolide 3.75 mg intramuscular syringe kit HCPCS J1950 | not published | not published | $1,670.30 – $1,867.04 | 2 |
| Leuprolide acetate implant HCPCS J9219 | not published | not published | $3,855.86 – $3,855.86 | 1 |
| Leuprolide acetate injeciton HCPCS J9218 | not published | not published | $48.54 – $60.86 | 2 |
| Leuprolide depot cipla 7.5mg HCPCS J1954 | not published | not published | $220.74 – $220.74 | 1 |
| Leuprolide inj, camcevi, 1mg HCPCS J1952 | not published | not published | $52.38 – $111.43 | 2 |
| Levalbuterol comp unit HCPCS J7615 | not published | not published | $1.35 – $1.35 | 1 |
| Levalbuterol non-comp con HCPCS J7612 | not published | not published | $0.28 – $2.57 | 2 |
| Levalbuterol non-comp unit HCPCS J7614 | not published | not published | $0.09 – $1.52 | 2 |
| Levetiracetam 500 mg/5 ml intravenous solution HCPCS J1953 | not published | not published | $0.05 – $0.10 | 2 |
| Levetiracetam therapeutic drug level CPT 80177 | $216.49 | $333.06 | $10.61 – $172.33 | 4 |
| Levofloxacin 250 mg/50 ml in 5 % dextrose intravenous piggyback HCPCS J1956 | not published | not published | $1.03 – $9.84 | 2 |
| Levonorgestrel implant sys HCPCS J7306 | not published | not published | $406.00 – $406.00 | 1 |
| Levothyroxine 100 mcg intravenous powder for solution HCPCS J0650 | not published | not published | $7.26 – $7.26 | 1 |
| Lidocaine injection HCPCS J2001 | not published | not published | $0.05 – $0.05 | 1 |
| Lidocaine (pf) 10 mg/ml (1 %) injection solution HCPCS J2003 | not published | not published | $0.01 – $0.01 | 1 |
| Lidocaine (pf) 4 mg/ml (0.4 %) in 5 % dextrose intravenous solution HCPCS J2002 | not published | not published | $0.01 – $0.01 | 1 |
| Lidocaine therapeutic drug level CPT 80176 | $28.65 | $44.07 | $14.25 – $191.06 | 3 |
| Liletta, 52 mg HCPCS J7297 | not published | not published | $931.73 – $1,014.12 | 2 |
| Lincomycin injection HCPCS J2010 | not published | not published | $6.24 – $13.79 | 2 |
| Linezolid in 5% dextrose in water 600 mg/300 ml intravenous piggyback HCPCS J2020 | not published | not published | $3.47 – $16.00 | 2 |
| Lipase CPT 83690 | $93.80 | $144.30 | $5.81 – $89.61 | 4 |
| Lipoprotein blood high res frac & quant CPT 83701 | not published | not published | $32.84 – $440.39 | 3 |
| Lipoprotein blood quant CPT 83704 | $66.67 | $102.57 | $33.16 – $444.68 | 3 |
| Lipoprotein direct measurement hdl CPT 83718 | $27.79 | $42.75 | $5.08 – $106.52 | 4 |
| Lipoprotein direct measurement ldl CPT 83721 | $103.30 | $158.93 | $10.18 – $136.57 | 3 |
| Lipoprtn dir meas sd ldl chl CPT 83722 | not published | not published | $33.16 – $444.68 | 3 |
| Lisocabtagene mara car pos t HCPCS Q2054 | not published | not published | $492,360.00 – $492,360.00 | 1 |
| Listeria monocytogenes CPT 86723 | $26.80 | $41.23 | $8.11 – $171.55 | 4 |
| Lithium therapeutic drug level CPT 80178 | $64.49 | $99.21 | $6.41 – $85.97 | 4 |
| Liver ds alys 3 bmrk srm alg CPT 81517 | not published | not published | $105.72 – $2,291.56 | 4 |
| Liver Function Test CPT 80076 | $149.47 | $229.96 | $7.32 – $106.26 | 4 |
| Liver image (3d) with flow CPT 78206 | not published | not published | $257.11 – $257.11 | 1 |
| Liver imaging CPT 78201 | not published | not published | $125.03 – $125.03 | 1 |
| Liver imaging (3d) CPT 78205 | not published | not published | $145.63 – $145.63 | 1 |
| Liver imag w/vasclr flow CPT 78202 | not published | not published | $146.74 – $146.74 | 1 |
| Liver/spleen imag static only CPT 78215 | not published | not published | $123.16 – $123.16 | 1 |
| Liver/spleen imag w/vasclr flow CPT 78216 | not published | not published | $83.42 – $83.42 | 1 |
| Locm 100-199mg/ml iodine,1ml HCPCS Q9965 | not published | not published | $0.80 – $0.80 | 1 |
| Lomustine 10 mg HCPCS S0178 | not published | not published | $109.16 – $116.63 | 2 |
| Loncastuximab tesirine-lpyl 10 mg intravenous solution HCPCS J9359 | not published | not published | $212.00 – $217.14 | 2 |
| Lorazepam 2 mg/ml injection (wrapper) HCPCS J2060 | not published | not published | $1.41 – $1.57 | 2 |
| Low-Dose Lung Cancer Screening CT Scan CPT 71271 | $247.40 | $380.61 | not published | 0 |
| Lower Back (Lumbar Spine) CT scan (with and without contrast) CPT 72133 | $1,529.13 | $2,352.51 | $241.46 – $241.46 | 1 |
| Lower Back (Lumbar Spine) CT scan (with contrast) CPT 72132 | $2,047.53 | $3,150.04 | $199.04 – $199.04 | 1 |
| Lower Back (Lumbar Spine) CT scan (without contrast) CPT 72131 | $1,199.23 | $1,844.97 | $197.33 – $197.33 | 1 |
| Lower Back (Lumbar Spine) MRI (with and without contrast) CPT 72158 | $4,077.13 | $6,272.51 | $509.74 – $509.74 | 1 |
| Lower Back (Lumbar Spine) MRI (with contrast) CPT 72149 | $3,043.12 | $4,681.72 | $386.05 – $386.05 | 1 |
| Lower Back (Lumbar Spine) MRI (without contrast) CPT 72148 | $2,642.74 | $4,065.75 | $331.29 – $331.29 | 1 |
| Lower Back (Lumbar Spine) X-ray CPT 72100 | $307.13 | $472.51 | $26.11 – $26.11 | 1 |
| Lower Back (Lumbar Spine) X-ray (4 or more views) CPT 72110 | $414.03 | $636.97 | $35.63 – $35.63 | 1 |
| Lower Back (Lumbar Spine) X-ray (with bending views) CPT 72114 | $540.95 | $832.23 | $47.81 – $47.81 | 1 |
| Lower Leg (Shin) X-ray (both sides) CPT 73590 | $221.49 | $340.76 | $17.69 – $17.69 | 1 |
| Loxapine for inhalation 1 mg HCPCS J2062 | not published | not published | $14.40 – $18.00 | 2 |
| L/s ratio fetal lung CPT 83661 | not published | not published | $21.33 – $286.01 | 4 |
| Lubricant per ounce HCPCS A4402 | not published | not published | $2.07 – $2.07 | 1 |
| Lumbar diskogram s&i CPT 72295 | not published | not published | $82.91 – $82.91 | 1 |
| Lumizyme injection HCPCS J0221 | not published | not published | $201.57 – $214.02 | 2 |
| Lung Function Test Before and After an Inhaler CPT 94060 | $490.70 | $754.92 | not published | 0 |
| Lung function test (mbc/mvv) CPT 94200 | $87.78 | $135.04 | not published | 0 |
| Lung Function Test (Spirometry) CPT 94010 | $356.86 | $549.02 | not published | 0 |
| Lung perfusion imaging CPT 78580 | not published | not published | $135.98 – $135.98 | 1 |
| Lurbinectedin 4 mg intravenous solution HCPCS J9223 | not published | not published | $205.04 – $216.30 | 2 |
| Luspatercept-aamt 25 mg subcutaneous solution HCPCS J0896 | not published | not published | $41.24 – $43.83 | 2 |
| Lutetium lu 177 dotatat ther HCPCS A9513 | not published | not published | $287.08 – $319.56 | 2 |
| Lutetium lu 177 vipivotide HCPCS A9607 | not published | not published | $233.78 – $255.00 | 2 |
| Lyme dis dna dir probe CPT 87475 | not published | not published | $19.45 – $260.77 | 3 |
| Lymphatics/lymph node imaging CPT 78195 | not published | not published | $241.00 – $241.00 | 1 |
| Lymphocyte culture mixed CPT 86821 | not published | not published | $35.46 – $475.51 | 3 |
| Lymphocyte transformation mitogen CPT 86353 | $166.21 | $255.71 | $47.56 – $637.69 | 3 |
| Lymphocytotoxicity assay CPT 86805 | not published | not published | $183.82 – $2,464.80 | 3 |
| Lymphocytotoxicity assay CPT 86806 | not published | not published | $46.16 – $618.97 | 3 |
| Lymph vessel x-ray arm/leg CPT 75801 | not published | not published | $208.02 – $208.02 | 1 |
| Lymph vessel x-ray arms/legs CPT 75803 | not published | not published | $219.38 – $219.38 | 1 |
| Lymph vessel x-ray trunk CPT 75805 | not published | not published | $229.53 – $229.53 | 1 |
| Lymph vessel x-ray trunk CPT 75807 | not published | not published | $240.17 – $240.17 | 1 |
| Lyumjev for insulin pump use HCPCS J1813 | not published | not published | $15.33 – $15.33 | 1 |
| Macroscopic exam arthropod CPT 87168 | not published | not published | $4.14 – $55.54 | 3 |
| Macroscopic exam parasite CPT 87169 | $8.76 | $13.47 | $2.02 – $56.06 | 4 |
| Magnesium CPT 83735 | $108.80 | $167.38 | $5.08 – $87.14 | 4 |
| Magnesium sulfate 2 gram/50 ml (4 %) in water intravenous piggyback HCPCS J3475 | not published | not published | $0.49 – $0.57 | 2 |
| Magnetic image bone marrow CPT 77084 | not published | not published | $309.14 – $309.14 | 1 |
| Makena, 10 mg HCPCS J1726 | not published | not published | $19.41 – $32.76 | 2 |
| Malaria antibody CPT 86750 | not published | not published | $12.79 – $171.55 | 4 |
| Manipulat palm cord post inj CPT 26341 | $75.78 | $116.59 | not published | 0 |
| Mannitol 12.5 gm/50 ml inj HCPCS J2150 | not published | not published | $2.26 – $2.67 | 2 |
| Mannitol for inhaler HCPCS J7665 | not published | not published | $6.31 – $7.89 | 2 |
| Manual diff wbc count b-coat CPT 85009 | not published | not published | $4.92 – $65.94 | 3 |
| Margetuximab-cmkb 25 mg/ml intravenous solution HCPCS J9353 | not published | not published | $48.53 – $51.61 | 2 |
| Marker biop eviva buckle ss HCPCS A4648 | $479.38 | $737.50 | not published | 0 |
| Mastoids complete CPT 70130 | $237.53 | $365.43 | $35.87 – $35.87 | 1 |
| Matrion 1 sq cm HCPCS Q4201 | not published | not published | $335.50 – $335.50 | 1 |
| Matrix bone cryomatrix 2.0ml HCPCS Q4162 | not published | not published | $2,200.00 – $2,200.00 | 1 |
| Matrix tissue 15x10cm gentrix extra-gynecological clgn strl-cost per sq cm HCPCS Q4166 | not published | not published | $19.70 – $19.70 | 1 |
| M.avium-intra dna amp prob CPT 87561 | not published | not published | $34.04 – $456.39 | 4 |
| M.avium-intra dna dir prob CPT 87560 | $57.67 | $88.72 | $26.47 – $354.94 | 3 |
| M.avium-intra dna quant CPT 87562 | not published | not published | $41.55 – $557.19 | 3 |
| Mayo a1app alpha 1 antitrypsin phenotype CPT 82104 | $172.54 | $265.45 | $13.86 – $188.07 | 4 |
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.