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 |
|---|---|---|---|---|
| Rh ig IV CPT 90386 | not published | not published | $11.66 – $11.66 | 1 |
| Rh ig minidose im CPT 90385 | not published | not published | $35.22 – $35.22 | 1 |
| Rho(d) immune globulin 1,500 unit (300 mcg)/2 ml injection syringe HCPCS J2791 | not published | not published | $4.88 – $11.66 | 2 |
| Rho d immune globulin 50 mcg HCPCS J2788 | not published | not published | $23.62 – $35.22 | 2 |
| Rho(d) immune globulin h, sd HCPCS J2792 | not published | not published | $32.51 – $43.19 | 2 |
| Rho d immune globulin inj HCPCS J2790 | $199.42 | $306.80 | $77.16 – $91.88 | 2 |
| Rho(d) immune globulin (rhig) human full dose im CPT 90384 | not published | not published | $91.88 – $91.88 | 1 |
| Rib and Chest X-ray (3 views, left side) CPT 71101 | $281.58 | $433.20 | $25.23 – $25.23 | 1 |
| Rib and Chest X-ray (4 or more views, both sides) CPT 71111 | $556.31 | $855.86 | $33.70 – $33.70 | 1 |
| Riboflavin 5'phos opth<=3ml HCPCS J2787 | not published | not published | $2,061.00 – $2,188.80 | 2 |
| Rib X-ray (3 views, both sides) CPT 71110 | $291.77 | $448.88 | $26.11 – $26.11 | 1 |
| Rilonacept injection HCPCS J2793 | not published | not published | $26.02 – $28.23 | 2 |
| Ring ostmy barr adapt 48mm HCPCS A4385 | not published | not published | $5.09 – $5.09 | 1 |
| Risankizumab-rzaa 60 mg/ml intravenous solution HCPCS J2327 | $24.75 | $38.07 | $14.86 – $18.27 | 2 |
| Risperidone microspheres 12.5 mg/2 ml inj HCPCS J2794 | $24.97 | $38.41 | $10.50 – $13.42 | 2 |
| Rituximab 10 mg/ml concentrate,intravenous HCPCS J9312 | not published | not published | $76.43 – $112.74 | 2 |
| Rituximab 1,400 mg/11.7 ml (120 mg/ml)-hyaluronidase subcutaneous soln HCPCS J9311 | not published | not published | $37.53 – $56.37 | 2 |
| Rituximab-abbs 10 mg/ml intravenous solution HCPCS Q5115 | not published | not published | $34.76 – $101.47 | 2 |
| Rituximab-arrx 10 mg/ml intravenous solution HCPCS Q5123 | not published | not published | $33.09 – $86.02 | 2 |
| Rituximab-pvvr 10 mg/ml intravenous solution HCPCS Q5119 | not published | not published | $24.94 – $86.02 | 2 |
| Rmvl fecal impaction/fb spx under anes CPT 45915 | $2,985.46 | $4,593.01 | not published | 0 |
| Rmvl ndwellg tun pleural cath CPT 32552 | $1,624.96 | $2,499.94 | not published | 0 |
| Rolapitant, oral, 1mg HCPCS J8670 | not published | not published | $1.79 – $4.42 | 2 |
| Romidepsin 10 mg/2 ml intravenous powder for solution HCPCS J9319 | not published | not published | $31.54 – $38.02 | 2 |
| Romiplostim 125 mcg subcutaneous solution HCPCS J2802 | not published | not published | $10.52 – $10.52 | 1 |
| Romiplostim injection HCPCS J2796 | not published | not published | $108.10 – $108.10 | 1 |
| Romosozumab-aqqg 105 mg/1.17 ml subcutaneous syringe (wrapper) HCPCS J3111 | not published | not published | $11.49 – $12.05 | 2 |
| Ropivacaine 0.2 % epidural pca - 1 hour dose limit HCPCS J2795 | not published | not published | $0.06 – $0.22 | 2 |
| Rotavirus antibody CPT 86759 | not published | not published | $14.73 – $237.10 | 4 |
| Rozanolixizumab-noli 140 mg/ml subcutaneous solution HCPCS J9333 | not published | not published | $22.84 – $22.84 | 1 |
| Rp loclzj tum 2+area 1+d img CPT 78801 | not published | not published | $161.73 – $161.73 | 1 |
| Rsv assay w/optic CPT 87807 | $26.62 | $40.95 | $12.71 – $170.38 | 4 |
| Rubella antibody igg CPT 86762 | $98.55 | $151.61 | $13.96 – $187.16 | 4 |
| Rubeola ag if CPT 87283 | not published | not published | $58.98 – $790.78 | 3 |
| Rubeola antibody igg CPT 86765 | $51.28 | $78.89 | $12.49 – $167.52 | 4 |
| Runx1 gene targeted seq alys CPT 81334 | not published | not published | $319.62 – $4,285.67 | 3 |
| Russell viper venom diluted CPT 85613 | $129.68 | $199.50 | $7.90 – $124.60 | 4 |
| Rx metab gen seq alys pnl 6 CPT 81418 | $3,707.14 | $5,703.30 | $889.57 – $11,927.73 | 3 |
| Sacituzumab govitecan-hziy 180 mg intravenous solution HCPCS J9317 | not published | not published | $35.80 – $37.20 | 2 |
| Sacroiliac Joint X-ray (3 or more views) CPT 72202 | $314.79 | $484.29 | $22.26 – $22.26 | 1 |
| Salivary gland function exam CPT 78232 | not published | not published | $75.01 – $75.01 | 1 |
| Salivary gland imaging CPT 78230 | not published | not published | $115.79 – $115.79 | 1 |
| Salivary glnd img serial img CPT 78231 | not published | not published | $82.23 – $82.23 | 1 |
| Salmonella antibody CPT 86768 | not published | not published | $9.14 – $171.55 | 4 |
| Saquinavir, 200 mg HCPCS S0140 | not published | not published | $1.17 – $1.17 | 1 |
| Sargramostim injection HCPCS J2820 | not published | not published | $59.88 – $72.58 | 2 |
| Sars-cov-2 antb quantitative CPT 86413 | not published | not published | $49.89 – $668.91 | 3 |
| Sarscov2 vac 5mcg/0.5ml im CPT 91304 | not published | not published | $191.92 – $191.92 | 5 |
| Sarscov coronavirus ag ia CPT 87426 | $100.35 | $154.39 | $27.14 – $459.51 | 4 |
| Sarscov & inf vir a&b ag ia CPT 87428 | not published | not published | $18.56 – $914.21 | 4 |
| Sbrt management CPT 77435 | not published | not published | $417.35 – $417.35 | 1 |
| Sbsq nurs facil care/day unstabl/new prob 35 min 99310 CPT 99310 | not published | not published | $131.20 – $131.20 | 1 |
| Sbsq nursing facil care/day minor complj 15 min CPT 99308 | not published | not published | $65.60 – $65.60 | 1 |
| Sbsq nursing facil care/day new problem 25 min CPT 99309 | not published | not published | $96.21 – $96.21 | 1 |
| Scan duplex aorta/ivc/iliac or bypass grafts complete CPT 93978 | $641.21 | $986.48 | not published | 0 |
| Scan duplex extremity veins unilateral/limited study CPT 93971 | $634.65 | $976.38 | not published | 0 |
| Scan duplex lower extremity arteries unilateral/limited study left CPT 93926 | $634.65 | $976.38 | not published | 0 |
| Scan duplex upper extremity arteries unilateral/limited study left CPT 93931 | $291.05 | $447.77 | not published | 0 |
| Scr c/v cyto, automated sys HCPCS G0147 | not published | not published | $17.98 – $241.13 | 3 |
| Scr c/v cyto, autosys, rescr HCPCS G0148 | not published | not published | $30.98 – $415.42 | 3 |
| Scr c/v cyto,thinlayer,rescr HCPCS G0144 | not published | not published | $42.65 – $571.88 | 3 |
| Scr c/v cyto,thinlayer,rescr HCPCS G0145 | not published | not published | $25.70 – $344.53 | 3 |
| Scr c/v cyto,thinlayer,rescr HCPCS G0143 | not published | not published | $26.24 – $351.82 | 3 |
| Screen cerv/vag thin layer HCPCS G0123 | $80.59 | $123.98 | $19.65 – $263.51 | 3 |
| Screening colorectal cancer fecal occult blood immunoassay 1-3 simultaneous determinations HCPCS G0328 | $73.26 | $112.70 | $17.51 – $234.76 | 3 |
| Screening hepatitis b non-obstetric high risk HCPCS G0499 | not published | not published | $27.42 – $367.69 | 3 |
| Screening hepatitis c antibody high risk HCPCS G0472 | not published | not published | $44.96 – $602.84 | 3 |
| Screening HIV antigen/antibody combination assay HCPCS G0475 | not published | not published | $23.36 – $313.19 | 3 |
| Screening Mammogram CPT 77067 | $319.04 | $490.83 | $103.39 – $103.39 | 1 |
| Screening prostate cancer PSA HCPCS G0103 | $163.00 | $250.77 | $18.73 – $251.15 | 3 |
| Screen pap by tech w md supv HCPCS P3000 | not published | not published | $17.98 – $241.13 | 3 |
| Screen/visual acuity/bilat/quant 99173 CPT 99173 | $32.81 | $50.47 | not published | 0 |
| Scrotal (Testicle) Ultrasound CPT 76870 | $619.34 | $952.83 | $79.43 – $79.43 | 1 |
| Sedimentation rate erythrocyte automated CPT 85652 | $8.14 | $12.52 | $2.02 – $35.12 | 4 |
| Seg acet and eth estr yearly HCPCS J7294 | not published | not published | $2,323.73 – $2,633.40 | 2 |
| Self-Care and Home Skills Training (each 15 minutes) CPT 97535 | $96.92 | $149.11 | $67.24 – $67.24 | 1 |
| Semen analysis HCPCS G0027 | not published | not published | $6.30 – $84.54 | 3 |
| Semen analysis presence/motility CPT 89321 | $85.73 | $131.89 | $6.87 – $156.72 | 4 |
| Semen analysis w/count CPT 89310 | not published | not published | $8.35 – $111.98 | 3 |
| Sept9 promoter methylation analysis CPT 81327 | not published | not published | $186.24 – $2,497.19 | 3 |
| Sermorelin acetate injection HCPCS Q0515 | not published | not published | $1.44 – $1.44 | 1 |
| Serpina1 gene CPT 81332 | not published | not published | $42.34 – $567.72 | 4 |
| Set radiation therapy field CPT 77280 | not published | not published | $120.76 – $120.76 | 1 |
| Set radiation therapy field CPT 77285 | not published | not published | $212.00 – $212.00 | 1 |
| Set radiation therapy field CPT 77290 | not published | not published | $339.40 – $339.40 | 1 |
| Sevelamer carbonate 800 mg tablet HCPCS J0601 | not published | not published | $0.01 – $0.01 | 1 |
| Sevelamer carbonate pdr 20mg HCPCS J0602 | not published | not published | $0.05 – $0.05 | 1 |
| Sex chromatin identification CPT 88130 | not published | not published | $17.44 – $233.85 | 3 |
| Sex chromatin identification CPT 88140 | not published | not published | $7.75 – $103.92 | 3 |
| Sf3b1 gene common variants CPT 81347 | not published | not published | $117.11 – $2,513.45 | 4 |
| Shave sgl skin lsn f/e/e/n/l/m 0.5cm/< CPT 11310 | $443.10 | $681.70 | not published | 0 |
| Shave sgl skin lsn t/a/l 0.6-1.0cm CPT 11301 | $426.75 | $656.54 | not published | 0 |
| Shave sgl skin lsn t/a/l 1.1-2.0cm CPT 11302 | $155.95 | $239.93 | not published | 0 |
| Shigella antibody CPT 86771 | not published | not published | $8.11 – $318.39 | 4 |
| Shot (Injection into Muscle or Under the Skin) CPT 96372 | $184.33 | $283.59 | $10.00 – $19.23 | 2 |
| Shoulder AC Joint X-ray (both sides) CPT 73050 | $240.99 | $370.76 | $24.61 – $24.61 | 1 |
| Shoulder Blade (Scapula) X-ray (both sides) CPT 73010 | $157.19 | $241.83 | $19.61 – $19.61 | 1 |
| Shoulder MRI (with and without contrast) CPT 73223 | $3,043.12 | $4,681.72 | $502.52 – $502.52 | 1 |
| Shoulder MRI (with contrast) CPT 73222 | not published | not published | $380.24 – $380.24 | 1 |
| Shoulder MRI (without contrast) CPT 73221 | $2,088.20 | $3,212.62 | $326.75 – $326.75 | 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.