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 |
|---|---|---|---|---|
| Stress test pulmonary CPT 94618 | $212.56 | $327.01 | not published | 0 |
| Stress tte complete CPT 93351 | $1,621.45 | $2,494.54 | not published | 0 |
| Str markers spec anal addl CPT 81266 | not published | not published | $295.67 – $3,964.42 | 3 |
| Str markers specimen anal CPT 81265 | not published | not published | $226.08 – $3,031.36 | 3 |
| Succinylcholine chloride 20 mg/ml injection solution (wrapper) HCPCS J0330 | not published | not published | $0.79 – $1.04 | 2 |
| Sugars multiple quant CPT 84379 | not published | not published | $11.18 – $149.96 | 4 |
| Sugars single quant CPT 84378 | not published | not published | $11.18 – $149.96 | 4 |
| Sulfonylurea screen qn-sendout CPT 80377 | $123.45 | $189.93 | not published | 0 |
| Sumatriptan 6 mg/0.5 ml subcutaneous solution HCPCS J3030 | not published | not published | $30.00 – $35.52 | 2 |
| Supprelin la implant HCPCS J9226 | not published | not published | $45,212.04 – $54,215.03 | 2 |
| Surgical pathology level 1 gross examination only CPT 88300 | $52.67 | $81.03 | not published | 0 |
| Surgical pathology level 2 gross & microscopic examination CPT 88302 | $117.60 | $180.92 | $19.50 – $19.50 | 1 |
| Surgical pathology level 3 gross & microscopic examination CPT 88304 | $161.90 | $249.08 | $25.58 – $25.58 | 1 |
| Surgical pathology level 4 gross & microscopic examination CPT 88305 | $432.21 | $664.94 | $43.62 – $78.50 | 2 |
| Surgical pathology level 5 gross & microscopic examination CPT 88307 | $267.38 | $411.36 | $176.15 – $176.15 | 1 |
| Surgical pathology level 6 gross & microscopic examination CPT 88309 | not published | not published | $267.64 – $267.64 | 1 |
| Surgigraft, 1 sq cm HCPCS Q4183 | not published | not published | $100.00 – $100.00 | 1 |
| Susceptibility agar dilution per agent CPT 87181 | not published | not published | $4.55 – $61.78 | 4 |
| Susceptibility enzyme detection per enzyme CPT 87185 | $10.04 | $15.44 | $4.55 – $61.78 | 4 |
| Susceptibility mic per plate CPT 87186 | $93.05 | $143.15 | $6.66 – $112.50 | 4 |
| Suscept studies macrobroth dilution ea CPT 87188 | not published | not published | $4.55 – $86.36 | 4 |
| Svc venogram s&i CPT 75827 | not published | not published | $133.24 – $133.24 | 1 |
| Swallowing Evaluation (Bedside) CPT 92610 | $131.54 | $202.37 | $144.32 – $144.32 | 1 |
| Swallowing Therapy Session CPT 92526 | $83.87 | $129.03 | $172.59 – $172.59 | 1 |
| Sweat collection by iontophoresis CPT 89230 | not published | not published | $6.44 – $6.44 | 1 |
| Synch audio-only est high 40 CPT 98015 | $190.77 | $293.49 | not published | 0 |
| Synch audio-only est low 20 CPT 98013 | $138.14 | $212.53 | not published | 0 |
| Synch audio-only est mod 30 CPT 98014 | $155.60 | $239.39 | not published | 0 |
| Synch audio-only est sf 10 CPT 98012 | $134.14 | $206.37 | not published | 0 |
| Synch audio-only new high 60 CPT 98011 | $200.30 | $308.16 | not published | 0 |
| Synch audio-only new low 30 CPT 98009 | $145.05 | $223.16 | not published | 0 |
| Synch audio-only new mod 45 CPT 98010 | $163.38 | $251.36 | not published | 0 |
| Synch audio-only new sf 15 CPT 98008 | $140.85 | $216.69 | not published | 0 |
| Synojoynt, inj., 1 mg HCPCS J7331 | not published | not published | $8.43 – $27.94 | 2 |
| Synvisc or synvisc-one HCPCS J7325 | $47.53 | $73.12 | $9.25 – $34.24 | 2 |
| Syphilis test non-treponemal antibody quantitative rpr CPT 86593 | $32.96 | $50.71 | $3.74 – $57.23 | 4 |
| T3 (triiodothyronine) free CPT 84481 | $131.16 | $201.78 | $9.09 – $220.33 | 4 |
| T3 (triiodothyronine) total CPT 84480 | $131.16 | $201.78 | $5.76 – $184.43 | 4 |
| T4 (thyroxine) free CPT 84439 | $70.33 | $108.20 | $8.75 – $117.32 | 4 |
| T4 (thyroxine) total CPT 84436 | $51.28 | $78.89 | $5.76 – $89.35 | 4 |
| Tacrol astagraf ex rel oral HCPCS J7508 | not published | not published | $0.57 – $0.62 | 2 |
| Tacrol envarsus ex rel oral HCPCS J7503 | not published | not published | $1.81 – $1.84 | 2 |
| Tacrolimus 1 mg capsule, immediate-release HCPCS J7507 | not published | not published | $0.19 – $0.99 | 2 |
| Tacrolimus 5 mg/ml intravenous solution HCPCS J7525 | not published | not published | $255.06 – $272.14 | 2 |
| Tacrolimus therapeutic drug level CPT 80197 | $283.17 | $435.64 | $10.61 – $178.58 | 4 |
| Tafasitamab-cxix 200 mg intravenous solution HCPCS J9349 | not published | not published | $13.93 – $15.06 | 2 |
| Tailbone (Sacrum and Coccyx) X-ray CPT 72220 | $265.80 | $408.92 | $18.79 – $18.79 | 1 |
| Talimogene laherparepvec 10exp6 (1 million) pfu/ml susp for injection HCPCS J9325 | not published | not published | $70.38 – $71.80 | 2 |
| Talquetamab-tgvs 2 mg/ml subcutaneous solution HCPCS J3055 | not published | not published | $70.00 – $70.00 | 1 |
| Talymed HCPCS Q4127 | not published | not published | $60.00 – $60.00 | 1 |
| Tamoxifen 10 mg tabs 60 each bottle HCPCS S0187 | not published | not published | $0.18 – $0.46 | 2 |
| Target gsa panel hmtlmph neop CPT 81450 | not published | not published | $736.74 – $9,878.60 | 3 |
| Target gsa panel organ/hmtlmph neop CPT 81455 | not published | not published | $2,832.01 – $37,972.90 | 3 |
| Target gsa panel organ neop CPT 81445 | not published | not published | $579.97 – $7,776.54 | 3 |
| Tarlatamab-dlle 10 mg intravenous solution HCPCS J9026 | not published | not published | $1,570.77 – $1,570.77 | 1 |
| Tbo-filgrastim 300 mcg/0.5 ml subcutaneous syringe HCPCS J1447 | not published | not published | $0.37 – $1.00 | 2 |
| Tbp gene detc abnor alleles CPT 81344 | not published | not published | $83.83 – $1,781.85 | 4 |
| Tb test cell mediated immunity antigen response enumeration gamma interferon t-cells CPT 86481 | $187.19 | $287.99 | $50.50 – $1,300.62 | 4 |
| Tb test cell mediated immunity antigen response gamma interferon CPT 86480 | $187.19 | $287.98 | $50.50 – $806.12 | 4 |
| Tc-99m bicisate HCPCS A9557 | not published | not published | $446.51 – $446.51 | 1 |
| Tc-99m exame autol wbc diag per dose HCPCS A9569 | not published | not published | $1,834.52 – $1,834.52 | 1 |
| Tc-99m exametazime diag HCPCS A9521 | not published | not published | $1,834.52 – $1,834.52 | 1 |
| Tc-99m labeled rbc HCPCS A9560 | not published | not published | $112.08 – $112.08 | 1 |
| Tc-99m maa HCPCS A9540 | not published | not published | $36.00 – $36.00 | 1 |
| Tc-99m mebrofenin HCPCS A9537 | not published | not published | $66.38 – $66.38 | 1 |
| Tc-99m medronate HCPCS A9503 | not published | not published | $15.60 – $15.60 | 1 |
| Tc-99m pertechnetate per mci HCPCS A9512 | not published | not published | $1.92 – $1.92 | 1 |
| Tc-99m pyroph diag per dose up to 25 mci HCPCS A9538 | not published | not published | $76.86 – $76.86 | 1 |
| Tc-99m succimer (dmsa) HCPCS A9551 | not published | not published | $719.30 – $719.30 | 1 |
| Tc-99m sulfur colloid HCPCS A9541 | not published | not published | $320.84 – $320.84 | 1 |
| Tc-99m tetrofosmin p study dose HCPCS A9502 | not published | not published | $102.33 – $102.33 | 1 |
| Tc-99m tilmanocept diag HCPCS A9520 | $1,549.94 | $2,384.53 | $563.76 – $563.76 | 1 |
| T cells absolute cd4/cd8 including ratio CPT 86360 | $185.72 | $285.72 | $45.57 – $611.03 | 4 |
| T cells absolute cd 4 count CPT 86361 | $56.59 | $87.06 | $23.40 – $348.31 | 4 |
| T cells total count CPT 86359 | $116.12 | $178.64 | $23.40 – $490.72 | 4 |
| Tebentafusp-tebn 100 mcg/0.5 ml intravenous solution HCPCS J9274 | not published | not published | $214.76 – $225.12 | 2 |
| Telavancin injection HCPCS J3095 | not published | not published | $7.09 – $9.54 | 2 |
| Telethx isodose plan cplx CPT 77307 | not published | not published | $189.00 – $189.00 | 1 |
| Telethx isodose plan simple CPT 77306 | not published | not published | $97.02 – $97.02 | 1 |
| Temozolomide HCPCS J8700 | not published | not published | $0.38 – $3.19 | 2 |
| Temozolomide 100 mg intravenous solution HCPCS J9328 | not published | not published | $10.41 – $12.04 | 2 |
| Temsirolimus 30 mg/3 ml (10 mg/ml) (first dilution) intravenous soln HCPCS J9330 | not published | not published | $30.32 – $61.91 | 2 |
| Tenecteplase 5 mg/ml intravenous solution for ischemic stroke (50 mg vial) HCPCS J3101 | not published | not published | $162.46 – $166.27 | 2 |
| Teniposide, 50 mg HCPCS Q2017 | not published | not published | $2,396.11 – $2,995.14 | 2 |
| Terbutaline 1 mg/ml subcutaneous solution HCPCS J3105 | not published | not published | $1.41 – $4.80 | 2 |
| Teriparatide injection HCPCS J3110 | not published | not published | $48.32 – $59.88 | 2 |
| Tert gene targeted seq alys CPT 81345 | not published | not published | $94.17 – $2,408.75 | 4 |
| Test for chlorohydrocarbons CPT 82441 | $12.98 | $19.97 | $5.83 – $78.17 | 3 |
| Test for porphobilinogen CPT 84106 | not published | not published | $4.92 – $75.70 | 4 |
| Test for urine cystines CPT 82615 | not published | not published | $7.07 – $124.21 | 4 |
| Testicular imaging w/vasc flow CPT 78761 | not published | not published | $154.31 – $154.31 | 1 |
| Testosterone pellet 75 mg HCPCS S0189 | not published | not published | $100.93 – $126.16 | 2 |
| Testosterone response panel CPT 80414 | not published | not published | $50.09 – $671.64 | 4 |
| Testosterone undecanoate 1mg HCPCS J3145 | not published | not published | $2.02 – $2.49 | 2 |
| Test urine for lactose CPT 83633 | not published | not published | $10.91 – $146.32 | 3 |
| Test urine for porphyrins CPT 84119 | not published | not published | $6.06 – $173.76 | 4 |
| Test urine urobilinogen CPT 84578 | not published | not published | $4.34 – $58.14 | 3 |
| Tetanus ig im CPT 90389 | not published | not published | $734.28 – $734.28 | 1 |
| Tetanus immune globulin inj HCPCS J1670 | not published | not published | $575.76 – $734.28 | 2 |
| Tezepelumab-ekko 210 mg/1.91 ml (110 mg/ml) subcutaneous syringe HCPCS J2356 | $25.14 | $38.68 | $17.77 – $20.76 | 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.