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 |
|---|---|---|---|---|
| Urine Culture Test CPT 87086 | $72.55 | $111.62 | $7.83 – $104.96 | 4 |
| Urine ost pouch w faucet/tap HCPCS A4428 | not published | not published | $7.35 – $7.35 | 1 |
| Urine pregnancy test CPT 81025 | $84.24 | $129.60 | $2.02 – $111.98 | 4 |
| Urine screen for bacteria CPT 81007 | not published | not published | $2.02 – $389.93 | 4 |
| Urine specimen collect mult HCPCS P9615 | not published | not published | $9.06 – $121.48 | 3 |
| Urofollitropin, 75 iu HCPCS J3355 | not published | not published | $120.14 – $120.14 | 1 |
| Urography, antegrade CPT 74425 | not published | not published | $46.40 – $46.40 | 1 |
| Urography inf drip &/or bolus CPT 74410 | not published | not published | $89.94 – $89.94 | 1 |
| Urokinase 250,000 iu inj HCPCS J3365 | not published | not published | $414.54 – $414.54 | 1 |
| Urokinase 5000 iu injection HCPCS J3364 | not published | not published | $8.29 – $8.29 | 1 |
| Ustekinumab 130 mg/26 ml intravenous solution HCPCS J3358 | not published | not published | $12.81 – $17.11 | 2 |
| Ustekinumab 45 mg/0.5 ml subcutaneous solution HCPCS J3357 | not published | not published | $310.95 – $339.96 | 2 |
| Vaccine Administration (one shot) CPT 90471 | $62.26 | $95.78 | not published | 0 |
| Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml CPT 91322 | $184.16 | $283.32 | $161.65 – $161.65 | 5 |
| Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml CPT 91321 | $169.03 | $260.05 | $147.06 – $147.06 | 5 |
| Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im CPT 91320 | $191.10 | $294.00 | $168.37 – $168.37 | 5 |
| Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im CPT 91319 | $122.85 | $189.00 | $94.80 – $94.80 | 5 |
| Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im CPT 91318 | $91.57 | $140.87 | $65.55 – $65.55 | 5 |
| Vaccine dtap < 7 years im CPT 90700 | $46.85 | $72.08 | $31.99 – $31.99 | 1 |
| Vaccine dtap-hep b-ipv im CPT 90723 | $101.67 | $156.41 | $107.30 – $107.30 | 1 |
| Vaccine dtap-ipv 4-6 years im CPT 90696 | $73.05 | $112.39 | $68.06 – $68.06 | 1 |
| Vaccine dtap-ipv-hib-hepb im CPT 90697 | $205.71 | $316.48 | $166.88 – $166.88 | 1 |
| Vaccine dtap-ipv/hib im CPT 90698 | $144.44 | $222.21 | $126.66 – $126.66 | 1 |
| Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im CPT 90647 | $41.94 | $64.52 | $34.49 – $34.49 | 1 |
| Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im CPT 90648 | $19.17 | $29.49 | $14.25 – $14.25 | 1 |
| Vaccine hepatitis a (hepa) adult im CPT 90632 | $58.44 | $89.90 | $91.86 – $91.86 | 1 |
| Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im CPT 90636 | $368.60 | $567.07 | $139.85 – $139.85 | 1 |
| Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im CPT 90633 | $43.62 | $67.11 | $41.67 – $41.67 | 1 |
| Vaccine hepatitis b (hepb) adolescent 2 dose im CPT 90743 | not published | not published | $75.15 – $75.15 | 5 |
| Vaccine hepatitis b (hepb) adult 3 dose im CPT 90746 | $104.40 | $160.62 | $74.08 – $75.15 | 5 |
| Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im CPT 90739 | not published | not published | $160.08 – $177.56 | 5 |
| Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im CPT 90744 | $51.88 | $79.81 | $31.45 – $33.20 | 5 |
| Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im CPT 90651 | $444.91 | $684.47 | $322.38 – $322.38 | 1 |
| Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im CPT 90649 | $424.75 | $653.46 | not published | 0 |
| Vaccine influenza (iiv) preservative free antigen content im CPT 90662 | $111.51 | $171.55 | $73.62 – $98.16 | 5 |
| Vaccine influenza inactivated adjuvant im CPT 90653 | not published | not published | $62.67 – $98.16 | 5 |
| Vaccine influenza nos 0.5ml dose im CPT 90658 | $29.39 | $45.22 | $22.07 – $22.07 | 5 |
| Vaccine influenza preservative free trivalent (iiv3) 0.5ml dose im CPT 90656 | $31.49 | $48.45 | $23.22 – $23.22 | 5 |
| Vaccine influenza quadrivalent (iiv4) 0.5ml dose im CPT 90688 | $26.44 | $40.67 | $21.56 – $21.56 | 1 |
| Vaccine influenza quadrivalent (iiv4) inactivated adjuvanted preservative free 0.5ml dose im CPT 90694 | not published | not published | $75.46 – $75.46 | 1 |
| Vaccine influenza quadrivalent (iiv4) preservative free 0.25ml dose im CPT 90685 | not published | not published | $22.78 – $22.78 | 1 |
| Vaccine influenza quadrivalent (iiv4) preservative free 0.5ml dose im CPT 90686 | $91.73 | $141.13 | $22.65 – $22.65 | 1 |
| Vaccine influenza quadrivalent (iiv4) split virus 0.25 ml im CPT 90687 | not published | not published | $10.78 – $10.78 | 1 |
| Vaccine influenza quadrivalent live (laiv4) intranasal CPT 90672 | $37.25 | $57.31 | $27.54 – $27.54 | 1 |
| Vaccine influenza quadrivalent (riv4) rdna antibiotic/preservative free im CPT 90682 | $91.25 | $140.39 | $73.62 – $73.62 | 1 |
| Vaccine influenza trivalent (cciiv3) cell cultures subunit antibiotic free 0.5 ml im CPT 90661 | $49.35 | $75.92 | $49.50 – $49.50 | 5 |
| Vaccine influenza trivalent (iiv3) 0.25ml dose im CPT 90657 | not published | not published | $11.03 – $11.03 | 5 |
| Vaccine mengingoccocal serogroup b 2 dose im CPT 90620 | $268.13 | $412.51 | $241.40 – $241.40 | 1 |
| Vaccine mengingoccocal serogroup b 2 or 3 dose im CPT 90621 | not published | not published | $201.63 – $201.63 | 1 |
| Vaccine menigococcal serogroups a/c/w/y quadrivalent tetanus toxoid(menacwy-tt) im CPT 90619 | $218.91 | $336.79 | $178.30 – $178.30 | 1 |
| Vaccine meningococcal serogroups a/c/w/y quadrivalent diphtheria toxoid(menacwy-d/menacwy-crm) im CPT 90734 | $228.85 | $352.08 | $169.89 – $169.89 | 1 |
| Vaccine mmr live subcutaneous CPT 90707 | $176.90 | $272.16 | $104.33 – $104.33 | 1 |
| Vaccine mmrv live subcutaneous CPT 90710 | $401.65 | $617.93 | $314.24 – $314.24 | 1 |
| Vaccine pneumococcal 23 valent (ppsv23) subcutaneous/im CPT 90732 | $184.29 | $283.52 | $133.47 – $133.47 | 5 |
| Vaccine pneumococcal conjugate 13 valent (pcv13) im CPT 90670 | $363.83 | $559.74 | $257.99 – $257.99 | 5 |
| Vaccine pneumonococcal conjugate 15 valent (pcv15) im CPT 90671 | $338.10 | $520.15 | $259.15 – $269.31 | 5 |
| Vaccine pneumonococcal conjugate 20 valent (pcv20) im CPT 90677 | $404.11 | $621.71 | $298.65 – $312.90 | 5 |
| Vaccine polio (ipv) subcutaneous/im CPT 90713 | $87.34 | $134.37 | $46.34 – $46.34 | 1 |
| Vaccine rabies im CPT 90675 | $512.02 | $787.73 | $454.85 – $454.85 | 1 |
| Vaccine respiratory syncytial virus bivalent subunit/preservative free im CPT 90678 | $391.27 | $601.95 | not published | 0 |
| Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 0.5 ml im CPT 90380 | $779.44 | $1,199.14 | not published | 0 |
| Vaccine respiratory syncytial virus monoclonal antibody seasonal dose 1 ml im CPT 90381 | $779.44 | $1,199.14 | not published | 0 |
| Vaccine respiratory syncytial virus recombinant subunit adjuvanted/preservative free im CPT 90679 | $407.74 | $627.30 | not published | 0 |
| Vaccine rotavirus attenuated (rv1) live 2 dose oral CPT 90681 | $167.78 | $258.13 | $156.83 – $156.83 | 1 |
| Vaccine rotavirus pentavalent (rv5) live 3 dose oral CPT 90680 | $125.58 | $193.20 | $108.45 – $108.45 | 1 |
| Vaccine tdap >=7 years im CPT 90715 | $184.29 | $283.52 | $53.31 – $53.31 | 1 |
| Vaccine td preservative free >= 7 years im CPT 90714 | not published | not published | $32.60 – $32.60 | 1 |
| Vaccine typhoid vicps im CPT 90691 | not published | not published | $96.35 – $96.35 | 1 |
| Vaccine varicella live subcutaneous CPT 90716 | not published | not published | $191.84 – $191.84 | 1 |
| Vaccine yellow fever live subcutaneous CPT 90717 | not published | not published | $168.79 – $168.79 | 1 |
| Valproic acid total therapeutic drug level CPT 80164 | $128.58 | $197.82 | $10.61 – $176.10 | 4 |
| Valrubicin injection HCPCS J9357 | not published | not published | $1,444.55 – $1,687.20 | 2 |
| Vancomycin hcl injection HCPCS J3370 | $15.96 | $24.55 | $1.95 – $7.46 | 2 |
| Vancomycin peak therapeutic drug level CPT 80202 | $127.85 | $196.69 | $10.61 – $176.10 | 4 |
| Vanomycin dna amp probe CPT 87500 | not published | not published | $21.64 – $456.39 | 4 |
| Vantas implant HCPCS J9225 | not published | not published | $4,678.90 – $5,848.63 | 2 |
| Varicella zoster antibody igg CPT 86787 | $127.85 | $196.69 | $8.11 – $167.52 | 4 |
| Varicella-zoster immue globin im CPT 90396 | not published | not published | $2,619.08 – $2,619.08 | 1 |
| Vasopressin 20 unit/ml intravenous solution HCPCS J2598 | not published | not published | $1.42 – $1.42 | 1 |
| Vedolizumab 300 mg intravenous solution HCPCS J3380 | not published | not published | $21.16 – $30.85 | 2 |
| Vein x-ray adrenal gland CPT 75840 | not published | not published | $294.68 – $294.68 | 1 |
| Vein x-ray adrenal glands CPT 75842 | not published | not published | $317.20 – $317.20 | 1 |
| Vein x-ray eye socket CPT 75880 | not published | not published | $88.17 – $88.17 | 1 |
| Vein x-ray kidney CPT 75831 | not published | not published | $295.33 – $295.33 | 1 |
| Vein x-ray liver CPT 75891 | not published | not published | $295.36 – $295.36 | 1 |
| Vein x-ray liver w/hemodynam CPT 75885 | not published | not published | $306.84 – $306.84 | 1 |
| Vein x-ray liver w/hemodynam CPT 75889 | not published | not published | $134.12 – $134.12 | 1 |
| Vein x-ray liver without hemodyn CPT 75887 | not published | not published | $310.53 – $310.53 | 1 |
| Vein x-ray skull CPT 75870 | not published | not published | $299.36 – $299.36 | 1 |
| Vein x-ray skull epidural CPT 75872 | not published | not published | $313.27 – $313.27 | 1 |
| Vein x-ray spleen/liver CPT 75810 | not published | not published | $452.00 – $452.00 | 1 |
| Velaglucerase alfa 400 unit intravenous solution HCPCS J3385 | not published | not published | $374.36 – $425.49 | 2 |
| Ven blood coll snf/hha HCPCS G0471 | not published | not published | $11.00 – $147.49 | 3 |
| Venipuncture >= 3 years diagnostic/therapeutic (not to be used for routine venipuncture) CPT 36410 | $110.81 | $170.47 | not published | 0 |
| Venogram ext bil s&i CPT 75822 | not published | not published | $98.09 – $98.09 | 1 |
| Venogram extremity supervision & interpretation unilateral CPT 75820 | not published | not published | $80.23 – $80.23 | 1 |
| Venous sampling s&i CPT 75893 | not published | not published | $273.61 – $273.61 | 1 |
| Venous thrombosis imaging CPT 78457 | not published | not published | $141.07 – $141.07 | 1 |
| Ven thrombosis images bilat CPT 78458 | not published | not published | $166.19 – $166.19 | 1 |
| Ventilator each subsequent day CPT 94003 | $373.74 | $574.99 | not published | 0 |
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.