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 |
|---|---|---|---|---|
| Shoulder X-ray CPT 73030 | $226.20 | $348.00 | $19.81 – $19.81 | 1 |
| Shoulder X-ray (single view, both shoulders) CPT 73020 | $174.64 | $268.67 | $15.08 – $15.08 | 1 |
| Shuntogram nonvascular supervision & interpretation CPT 75809 | not published | not published | $62.59 – $62.59 | 1 |
| Sialidase enzyme assay CPT 87905 | not published | not published | $11.85 – $158.94 | 3 |
| Sialography s&i CPT 70390 | not published | not published | $78.74 – $78.74 | 1 |
| Sickling rbc CPT 85660 | $108.06 | $166.24 | $5.34 – $71.66 | 3 |
| Sildenafil citrate, 25 mg HCPCS S0090 | not published | not published | $0.26 – $0.72 | 2 |
| Sincalide 5 mcg solution for injection HCPCS J2805 | not published | not published | $121.40 – $143.26 | 2 |
| Sinus CT scan (with and without contrast) CPT 70488 | $1,606.54 | $2,471.60 | $246.50 – $246.50 | 1 |
| Sinus CT scan (with contrast) CPT 70487 | $1,449.78 | $2,230.43 | $202.67 – $202.67 | 1 |
| Sinus CT scan (without contrast) CPT 70486 | $1,199.23 | $1,844.97 | $196.52 – $196.52 | 1 |
| Sinus/juglr venogram s&i CPT 75860 | not published | not published | $136.06 – $136.06 | 1 |
| Sinus X-ray (complete) CPT 70220 | $184.47 | $283.80 | $24.82 – $24.82 | 1 |
| Sinus X-ray (limited) CPT 70210 | not published | not published | $19.88 – $19.88 | 1 |
| Sipuleucel-t - su HCPCS Q2043 | not published | not published | $77,820.00 – $77,820.00 | 1 |
| Sirolimus, oral HCPCS J7520 | not published | not published | $1.14 – $17.08 | 2 |
| Sirolimus-protein bound 100 mg intravenous suspension HCPCS J9331 | not published | not published | $81.42 – $117.63 | 2 |
| Skin barrier with flange HCPCS A4373 | not published | not published | $7.32 – $7.32 | 1 |
| Skin Biopsy CPT 11102 | $443.10 | $681.70 | not published | 0 |
| Skull X-ray (1 to 3 views) CPT 70250 | $280.72 | $431.87 | $23.73 – $23.73 | 1 |
| Skull X-ray (complete) CPT 70260 | $235.57 | $362.42 | $30.17 – $30.17 | 1 |
| Skyla, 13.5 mg HCPCS J7301 | $1,476.51 | $2,271.55 | $1,011.38 – $1,072.06 | 3 |
| Slco1b1 gene com variants CPT 81328 | not published | not published | $169.57 – $2,273.61 | 3 |
| Sleep Study (Polysomnography) CPT 95810 | $3,340.24 | $5,138.83 | not published | 0 |
| Sleeve irr assura 1pc disp HCPCS A4397 | not published | not published | $5.15 – $5.15 | 1 |
| Sm-153 lexidron ther HCPCS A9604 | not published | not published | $19,539.46 – $19,539.46 | 1 |
| Small animal inoculation CPT 87003 | not published | not published | $16.33 – $219.02 | 3 |
| Small Bowel Barium X-ray (Follow-Through) CPT 74250 | $222.80 | $342.77 | $68.28 – $68.28 | 1 |
| Smear fluorescent and/or acid fast stain CPT 87206 | $60.82 | $93.57 | $5.23 – $70.10 | 4 |
| Smear gram stain CPT 87205 | $57.16 | $87.94 | $3.43 – $55.54 | 4 |
| Smear nasal eosinophil CPT 89190 | not published | not published | $4.75 – $75.31 | 4 |
| Smear special stain inclusion bodies/parasites CPT 87207 | $71.81 | $110.48 | $5.81 – $77.91 | 4 |
| Smear wet mount CPT 87210 | not published | not published | $3.43 – $75.70 | 4 |
| Smn1 gene full gene sequence CPT 81336 | not published | not published | $292.31 – $3,919.42 | 3 |
| Smn1 gen nown famil seq vrnt CPT 81337 | not published | not published | $94.17 – $2,408.75 | 4 |
| Smpd1 gene common variants CPT 81330 | not published | not published | $45.59 – $611.29 | 3 |
| Snrpn/ube3a gene CPT 81331 | $125.40 | $192.93 | $49.54 – $664.23 | 3 |
| Sodium 24 hour urine CPT 84300 | $78.75 | $121.15 | $4.91 – $65.81 | 4 |
| Sodium chloride 0.9 % intravenous solution HCPCS J7030 | $4.24 | $6.53 | $2.47 – $6.30 | 2 |
| Sodium chloride 0.9 % IV bolus HCPCS J7040 | not published | not published | $1.24 – $5.32 | 2 |
| Sodium chloride 0.9 % IV bolus HCPCS J7050 | not published | not published | $0.62 – $4.80 | 2 |
| Sodium chloride 3 % ivpb HCPCS J7131 | not published | not published | $0.09 – $0.16 | 2 |
| Sodium ferric gluconate complex in sucrose 62.5 mg/5 ml intravenous HCPCS J2916 | $2.92 | $4.49 | $1.94 – $7.63 | 2 |
| Sodium hyaluronate 20 mg/2 ml syringe HCPCS J7321 | $321.10 | $494.00 | $73.96 – $114.00 | 2 |
| Sodium serum/plasma/whole blood CPT 84295 | $58.99 | $90.76 | $4.67 – $62.56 | 4 |
| Sodium thiosulfate 12.5 gram/50 ml (250 mg/ml) intravenous solution HCPCS J0209 | not published | not published | $0.77 – $0.77 | 1 |
| So gsap cl fr cpy nmbr&mcrst CPT 81463 | not published | not published | $1,304.95 – $17,497.37 | 3 |
| So gsap cll fr dna/dna&rna CPT 81462 | not published | not published | $1,159.96 – $15,553.20 | 3 |
| So gsap cll fr mcrstl ins CPT 81464 | not published | not published | $3,189.85 – $42,771.02 | 3 |
| So gsap dna cpy nmbr&mcrstl CPT 81458 | not published | not published | $1,014.96 – $13,609.04 | 3 |
| Solid skin barrier HCPCS A4362 | not published | not published | $4.28 – $4.28 | 1 |
| Somatropin injection HCPCS J2941 | not published | not published | $149.23 – $182.17 | 2 |
| So neo gsap dna/dna&rna CPT 81459 | not published | not published | $2,899.86 – $38,882.69 | 3 |
| So neo gsap dna mcrstl ins CPT 81457 | not published | not published | $869.96 – $11,664.87 | 3 |
| Sotalol hydrochloride IV HCPCS C9482 | not published | not published | $21.87 – $21.87 | 1 |
| Spacer bag/reservoir HCPCS A4627 | not published | not published | $22.05 – $22.05 | 1 |
| Special radiation dosimetry CPT 77331 | not published | not published | $39.51 – $39.51 | 1 |
| Special radiation treatment CPT 77470 | $1,404.72 | $2,161.10 | $127.39 – $127.39 | 1 |
| Special teletx port plan CPT 77321 | not published | not published | $67.66 – $67.66 | 1 |
| Specific gravity body fluid CPT 84315 | not published | not published | $3.18 – $42.66 | 3 |
| Specimen fat stain CPT 89125 | $12.43 | $19.12 | $5.70 – $76.48 | 3 |
| Speech and Language Evaluation (comprehensive) CPT 92523 | $169.99 | $261.53 | $382.90 – $382.90 | 1 |
| Speech evaluation complex CPT 70371 | not published | not published | $59.93 – $59.93 | 1 |
| Speech Therapy Session (one-on-one) CPT 92507 | $83.87 | $129.03 | $156.79 – $156.79 | 1 |
| Sperm antibody test CPT 89325 | not published | not published | $10.35 – $138.78 | 3 |
| Sperm evaluation test CPT 89329 | not published | not published | $19.00 – $254.79 | 3 |
| Spine X-ray (single view, one level) CPT 72020 | $201.96 | $310.70 | $15.31 – $15.31 | 1 |
| Spleen imaging CPT 78185 | not published | not published | $129.01 – $129.01 | 1 |
| Sputum specimen collection CPT 89220 | $290.37 | $446.73 | not published | 0 |
| Sr-89 stront chlor ther / mci HCPCS A9600 | not published | not published | $3,600.00 – $4,500.00 | 2 |
| Srsf2 gene common variants CPT 81348 | not published | not published | $106.29 – $2,281.29 | 4 |
| Srs linear based CPT 77372 | not published | not published | $548.76 – $548.76 | 1 |
| Srs multisource CPT 77371 | not published | not published | $929.98 – $929.98 | 1 |
| St analysis behavior qualitative voice/resonance CPT 92524 | $183.09 | $281.67 | $178.00 – $178.00 | 1 |
| Staph a dna amp probe CPT 87640 | not published | not published | $21.64 – $456.39 | 4 |
| St cognitve performance testing healthcare professional each hour CPT 96125 | $197.70 | $304.15 | $215.48 – $215.48 | 1 |
| Stem cells total count CPT 86367 | not published | not published | $23.40 – $1,011.62 | 4 |
| Stereotactic radiation trmt CPT 77432 | not published | not published | $251.83 – $251.83 | 1 |
| Sterile needle HCPCS A4215 | not published | not published | $0.31 – $0.31 | 1 |
| Sterile water/saline, 10 ml HCPCS A4216 | not published | not published | $1.11 – $1.11 | 1 |
| Sterile water/saline, 500 ml HCPCS A4217 | not published | not published | $4.70 – $4.70 | 1 |
| St evaluate speech sound production CPT 92522 | $348.02 | $535.42 | $182.09 – $182.09 | 1 |
| St evaluation motion fluoroscopic swallow function cine/video CPT 92611 | $218.48 | $336.13 | $181.33 – $181.33 | 1 |
| Stimulants synthetic CPT 80371 | $127.90 | $196.77 | not published | 0 |
| Stomach Emptying Scan (Nuclear Medicine) CPT 78264 | not published | not published | $204.83 – $204.83 | 1 |
| Strapping of ankle and/or ft 29540 CPT 29540 | $357.66 | $550.25 | $35.48 – $35.48 | 1 |
| Strapping of chest CPT 29200 | not published | not published | $37.73 – $37.73 | 1 |
| Strapping of elbow or wrist 29260 CPT 29260 | $113.65 | $174.84 | $38.89 – $38.89 | 1 |
| Strapping of hand or finger CPT 29280 | $116.93 | $179.89 | $41.22 – $41.22 | 1 |
| Strapping of knee CPT 29530 | $185.96 | $286.09 | $37.73 – $37.73 | 1 |
| Strapping of toes 29550 CPT 29550 | $180.03 | $276.97 | not published | 0 |
| Strep a ag ia CPT 87430 | $118.98 | $183.05 | $5.25 – $218.63 | 4 |
| Strep a dna dir probe CPT 87650 | not published | not published | $6.65 – $260.77 | 4 |
| Strep a dna quant CPT 87652 | not published | not published | $40.51 – $543.14 | 3 |
| Strep b assay w/optic CPT 87802 | not published | not published | $12.35 – $165.57 | 3 |
| Strep b dna amp probe CPT 87653 | not published | not published | $21.64 – $456.39 | 4 |
| Streptokinase 1.5 m-units inj HCPCS J2995 | not published | not published | $75.00 – $75.00 | 1 |
| Streptokinase antibody CPT 86590 | not published | not published | $12.28 – $164.66 | 3 |
| Streptomycin injection HCPCS J3000 | not published | not published | $25.59 – $93.75 | 2 |
| Streptozocin injection HCPCS J9320 | not published | not published | $335.26 – $419.08 | 2 |
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.