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 |
|---|---|---|---|---|
| Ost pch drain 2 piece system HCPCS A4426 | not published | not published | $3.98 – $3.98 | 1 |
| Ost pch drain for barrier fl HCPCS A4425 | not published | not published | $3.40 – $3.40 | 1 |
| Ost pch drain w bar & filter HCPCS A4424 | not published | not published | $4.89 – $4.89 | 1 |
| Ost pch for bar w flange/flt HCPCS A4419 | not published | not published | $1.84 – $1.84 | 1 |
| Ost skn barr extnd >4 sq HCPCS A4410 | not published | not published | $11.18 – $11.18 | 1 |
| Ost urine pch w b/bltin conv HCPCS A4430 | not published | not published | $9.56 – $9.56 | 1 |
| Other immunoelectrophoresis CPT 86325 | not published | not published | $22.44 – $300.83 | 4 |
| Ot management orthotic(s)/prosthetic subsequent encounter each 15 minutes CPT 97763 | $58.77 | $90.42 | $103.46 – $103.46 | 1 |
| Ot re-evaluation patient/family CPT 97168 | $78.47 | $120.72 | $123.27 – $123.27 | 1 |
| Ot therapeutic interventions cognitive skills direct patient contact each additional 15 minutes CPT 97130 | $96.92 | $149.11 | $45.54 – $45.54 | 1 |
| Ot therapeutic interventions cognitive skills direct patient contact initial 15 minutes CPT 97129 | $96.92 | $149.11 | $46.97 – $46.97 | 1 |
| Ovine, 1000 usp units HCPCS J3472 | not published | not published | $130.00 – $130.00 | 1 |
| Ovulation tests CPT 84830 | not published | not published | $12.32 – $165.18 | 3 |
| Oxacillin in ns IV syringe 40 mg/ml (neo/ped) - cnr HCPCS J2700 | not published | not published | $0.64 – $3.50 | 2 |
| Oxaliplatin 5 mg/ml desensitization HCPCS J9263 | not published | not published | $0.05 – $0.60 | 2 |
| Oxymorphone hcl injection HCPCS J2410 | not published | not published | $3.00 – $3.00 | 1 |
| Oxytetracycline injection HCPCS J2460 | not published | not published | $0.88 – $0.88 | 1 |
| Oxytocin 10 unit/ml injection solution HCPCS J2590 | not published | not published | $1.04 – $1.34 | 2 |
| P-32 chromic phos ther per mci HCPCS A9564 | not published | not published | $167.04 – $167.04 | 1 |
| P-32 sod phosphate ther per mci HCPCS A9563 | not published | not published | $292.68 – $365.85 | 2 |
| Pabpn1 gene detc abnor allel CPT 81312 | not published | not published | $83.83 – $1,781.85 | 4 |
| Paclitaxel 6 mg/ml concentrate,intravenous HCPCS J9267 | not published | not published | $0.13 – $0.40 | 2 |
| Paclitaxel protein-bound 100 mg intravenous suspension HCPCS J9264 | not published | not published | $13.06 – $17.54 | 2 |
| Palb2 gene full gene seq CPT 81307 | not published | not published | $656.20 – $8,798.69 | 3 |
| Palb2 gene known famil vrnt CPT 81308 | not published | not published | $94.17 – $3,919.42 | 4 |
| Palifermin injection HCPCS J2425 | not published | not published | $28.45 – $33.99 | 2 |
| Palingen or palingen xplus HCPCS Q4173 | not published | not published | $480.00 – $480.00 | 1 |
| Palingen or promatrx HCPCS Q4174 | not published | not published | $1,494.00 – $1,494.00 | 1 |
| Paliperidone 117 mg/0.75 ml inj HCPCS J2426 | not published | not published | $14.74 – $16.37 | 2 |
| Palivizumab 50 mg/0.5 ml inj CPT 90378 | not published | not published | $2,090.71 – $2,090.71 | 1 |
| Palonosetron hcl HCPCS J2469 | not published | not published | $0.50 – $6.00 | 2 |
| Pamidronate 30 mg/10 ml (3 mg/ml) intravenous solution HCPCS J2430 | not published | not published | $13.88 – $24.61 | 2 |
| Panitumumab 20 mg/ml intravenous solution (wrapper) HCPCS J9303 | not published | not published | $164.92 – $177.84 | 2 |
| Pantoprazole in ns IV syringe 0.8 mg/ml (neo/ped) - cnr HCPCS J2470 | not published | not published | $4.37 – $4.37 | 1 |
| Papaverin hcl injection HCPCS J2440 | not published | not published | $36.00 – $45.00 | 2 |
| Parathormone (pth) intact CPT 83970 | $306.98 | $472.27 | $40.04 – $536.90 | 4 |
| Parathyroid planar imaging CPT 78070 | not published | not published | $105.64 – $105.64 | 1 |
| Parathyroid planar img w/tomo spect CPT 78071 | not published | not published | $287.27 – $287.27 | 1 |
| Paricalcitol HCPCS J2501 | not published | not published | $0.81 – $2.40 | 2 |
| Paring/cutting benign hyperkeratotic lesion single CPT 11055 | $443.10 | $681.70 | not published | 0 |
| Partial excision bone tars/metatars exc talus/calcaneus (both sides) (rest meth ii cah) CPT 28122 | $7,058.36 | $10,859.02 | not published | 0 |
| Particle matristem matrix 1000mg micron-q4118-cost per mg HCPCS Q4118 | not published | not published | $3.84 – $3.84 | 1 |
| Paste skin barrier .5oz adapt HCPCS A4406 | not published | not published | $4.82 – $4.82 | 1 |
| Path clin consltj high 41-60 CPT 80505 | not published | not published | $58.51 – $58.51 | 1 |
| Path clin consltj mod 21-40 CPT 80504 | not published | not published | $32.29 – $32.29 | 1 |
| Path clin consltj prolng svc CPT 80506 | not published | not published | $26.22 – $26.22 | 1 |
| Path clin consltj sf 5-20 CPT 80503 | not published | not published | $16.15 – $16.15 | 1 |
| Pca3/klk3 antigen CPT 81313 | not published | not published | $247.40 – $3,317.23 | 3 |
| Pcv21 vaccine im CPT 90684 | not published | not published | $324.25 – $324.25 | 5 |
| Pdgfra gene CPT 81314 | not published | not published | $199.69 – $4,285.67 | 4 |
| Pegademase bovine, 25 iu HCPCS J2504 | not published | not published | $333.25 – $333.25 | 1 |
| Pegaptanib sodium injection HCPCS J2503 | not published | not published | $711.40 – $889.25 | 2 |
| Pegaspargase injection HCPCS J9266 | not published | not published | $26,690.95 – $27,070.53 | 2 |
| Pegfilgrastim 6 mg/0.6 ml (deliverable) wearable subcutaneous injector HCPCS J2506 | not published | not published | $19.98 – $641.80 | 2 |
| Pegfilgrastim-apgf 6 mg/0.6 ml subcutaneous syringe HCPCS Q5122 | not published | not published | $134.25 – $392.50 | 2 |
| Pegfilgrastim-cbqv 6 mg/0.6 ml subcutaneous syringe HCPCS Q5111 | not published | not published | $163.60 – $417.50 | 2 |
| Pegfilgrastim-jmdb 6 mg/0.6 ml subcutaneous syringe HCPCS Q5108 | not published | not published | $112.90 – $417.50 | 2 |
| Peginesatide injection HCPCS J0890 | not published | not published | $10.38 – $10.38 | 1 |
| Peg interferon alfa-2a/180 HCPCS S0145 | not published | not published | $1,068.88 – $1,225.79 | 2 |
| Pegloticase 8 mg/ml intravenous solution HCPCS J2507 | not published | not published | $3,565.32 – $3,999.78 | 2 |
| Pegunigalsidase alfa-iwxj HCPCS J2508 | not published | not published | $226.93 – $226.93 | 1 |
| Pelvic CT scan (with and without contrast) CPT 72194 | not published | not published | $242.18 – $242.18 | 1 |
| Pelvic CT scan (with contrast) CPT 72193 | $1,309.46 | $2,014.56 | $188.83 – $188.83 | 1 |
| Pelvic CT scan (without contrast) CPT 72192 | $759.34 | $1,168.21 | $155.69 – $155.69 | 1 |
| Pelvic MRI (with and without contrast) CPT 72197 | $3,696.93 | $5,687.59 | $506.57 – $506.57 | 1 |
| Pelvic MRI (with contrast) CPT 72196 | $3,057.03 | $4,703.12 | $384.31 – $384.31 | 1 |
| Pelvic MRI (without contrast) CPT 72195 | $2,282.34 | $3,511.29 | $330.79 – $330.79 | 1 |
| Pelvic Ultrasound (complete) CPT 76856 | $944.78 | $1,453.51 | $79.83 – $79.83 | 1 |
| Pelvic Ultrasound (limited) CPT 76857 | $486.02 | $747.73 | $63.21 – $63.21 | 1 |
| Pelvis X-ray (1 to 2 views) CPT 72170 | $227.06 | $349.33 | $17.42 – $17.42 | 1 |
| Pelvis X-ray (complete, 4 or more views) CPT 72190 | $338.63 | $520.97 | $27.00 – $27.00 | 1 |
| Pembrolizumab 25 mg/ml intravenous solution HCPCS J9271 | $23.03 | $35.43 | $59.35 – $64.10 | 2 |
| Pemetrexed disodium 100 mg intravenous powder for solution HCPCS J9305 | not published | not published | $3.77 – $19.08 | 2 |
| Peng benzathine/procaine inj HCPCS J0558 | not published | not published | $16.61 – $17.37 | 2 |
| Penicillin g benzathine 1,200,000 unit/2 ml intramuscular syringe HCPCS J0561 | not published | not published | $20.83 – $26.98 | 2 |
| Penicillin g potassium in ns IV syringe 100,000 units/ml (neo/ped) - cnr HCPCS J2540 | not published | not published | $0.78 – $1.83 | 2 |
| Penicillin g procaine inj HCPCS J2510 | not published | not published | $44.11 – $50.12 | 2 |
| Pentamidine non-comp unit HCPCS J2545 | not published | not published | $79.50 – $180.50 | 2 |
| Pentastarch 10% solution HCPCS J2513 | not published | not published | $12.72 – $12.72 | 1 |
| Pentazocine injection HCPCS J3070 | not published | not published | $98.16 – $98.16 | 1 |
| Pentobarbital sodium inj HCPCS J2515 | not published | not published | $50.71 – $54.17 | 2 |
| Pentostatin 10 mg intravenous solution HCPCS J9268 | not published | not published | $2,673.43 – $2,926.88 | 2 |
| Perflutren lipid microspheres 1.1 mg/ml intravenous suspension HCPCS Q9957 | not published | not published | $41.88 – $171.64 | 2 |
| Peripheral vascular rehab CPT 93668 | $171.48 | $263.82 | not published | 0 |
| Peritoneogram rs&i CPT 74190 | not published | not published | $60.56 – $60.56 | 1 |
| Perit-vens shunt pat tst CPT 78291 | not published | not published | $161.59 – $161.59 | 1 |
| Perphenazine 4mg oral HCPCS Q0175 | not published | not published | $0.45 – $0.65 | 2 |
| Perphenazine injeciton HCPCS J3310 | not published | not published | $6.01 – $6.01 | 1 |
| Perq rplcmt g-tube req revsn gstrst trk CPT 43763 | $317.86 | $489.02 | not published | 0 |
| Pertussis ag if CPT 87265 | not published | not published | $8.11 – $155.81 | 4 |
| Pertuzumab 30 mg/ml desensitization HCPCS J9306 | not published | not published | $16.23 – $16.84 | 2 |
| Pertuzu, trastuzu, 10 mg HCPCS J9316 | not published | not published | $62.99 – $84.71 | 2 |
| Pessary reusable rub anytype HCPCS A4561 | $49.72 | $76.50 | not published | 0 |
| Pet CT skull-mid thgh initial CPT 78815 | not published | not published | $541.00 – $541.00 | 1 |
| Pet CT whole body initial CPT 78816 | not published | not published | $696.00 – $696.00 | 1 |
| Pet fdg brain metoblic eval sb CPT 78608 | not published | not published | $594.00 – $594.00 | 1 |
| Pet image full body CPT 78813 | not published | not published | $847.00 – $847.00 | 1 |
| Pet image ltd area CPT 78811 | not published | not published | $569.00 – $569.00 | 1 |
| Pet image skull-thigh CPT 78812 | not published | not published | $255.00 – $255.00 | 1 |
| Pet image w/ct lmtd CPT 78814 | not published | not published | $310.00 – $310.00 | 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.