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 |
|---|---|---|---|---|
| Whole blood for transfusion HCPCS P9010 | $655.78 | $1,008.89 | not published | 0 |
| Whole blood/red blood cells leukocytes reduced cmv negative each unit HCPCS P9051 | $532.45 | $819.16 | not published | 0 |
| Whole-Body Bone Scan (Nuclear Medicine) CPT 78306 | not published | not published | $162.08 – $162.08 | 1 |
| Whole mitochondrial genome CPT 81460 | $3,009.81 | $4,630.48 | $1,248.39 – $16,738.98 | 3 |
| Whole mitochondrial genome CPT 81465 | $2,182.72 | $3,358.03 | $907.92 – $12,173.80 | 3 |
| Whole Skeleton X-ray Survey CPT 77075 | $517.11 | $795.56 | $77.01 – $77.01 | 1 |
| Wilate injection HCPCS J7183 | not published | not published | $1.27 – $1.91 | 3 |
| Wipe adh remover univ ostomy adh/barrier remover HCPCS A4456 | not published | not published | $0.21 – $0.21 | 1 |
| Wound Cleaning and Dead Tissue Removal (up to 20 sq cm) CPT 97597 | $419.48 | $645.35 | $72.99 – $72.99 | 1 |
| Wound closure by adhesive HCPCS G0168 | $114.35 | $175.92 | not published | 0 |
| Woundfix biowound plus xplus HCPCS Q4217 | not published | not published | $1,054.01 – $1,054.01 | 1 |
| Wound therapy negative pressure per session <= 50 sq cm dme CPT 97605 | $443.10 | $681.70 | not published | 0 |
| Wound therapy negative pressure per session > 50 sq cm dme CPT 97606 | $859.90 | $1,322.92 | not published | 0 |
| Wrist X-ray CPT 73110 | $157.19 | $241.83 | $23.38 – $23.38 | 1 |
| Wrist X-ray (2 views, both wrists) CPT 73100 | $134.17 | $206.42 | $19.84 – $19.84 | 1 |
| Xcellistem, 1 mg HCPCS A2004 | not published | not published | $15.60 – $15.60 | 1 |
| Xe133 xenon 10mci HCPCS A9558 | not published | not published | $266.98 – $266.98 | 1 |
| Xfer tis f/c/c/m/n/a/g/h/f 10sq cm/< CPT 14040 | $4,771.98 | $7,341.50 | not published | 0 |
| X-linked intellectual dblt CPT 81470 | not published | not published | $886.58 – $11,887.67 | 3 |
| X-linked intellectual dblt CPT 81471 | not published | not published | $886.58 – $11,887.67 | 3 |
| X-ray abdomen >=3 views CPT 74021 | $386.34 | $594.37 | not published | 0 |
| X-ray arthrogram shoulder supervision & interpretation (both sides) CPT 73040 | not published | not published | $69.04 – $69.04 | 1 |
| X-ray assay calculus CPT 82370 | not published | not published | $12.14 – $162.84 | 4 |
| X-ray bone length studies CPT 77073 | not published | not published | $24.93 – $24.93 | 1 |
| X-ray bone survey infant CPT 77076 | $861.71 | $1,325.71 | $64.03 – $64.03 | 1 |
| X-ray consultation CPT 76140 | not published | not published | $11.86 – $11.86 | 1 |
| Xray endovasc thor ao repr CPT 75956 | not published | not published | $622.04 – $622.04 | 1 |
| Xray endovasc thor ao repr CPT 75957 | not published | not published | $230.11 – $230.11 | 1 |
| X-ray exam entire spi 4/5 vw CPT 72083 | not published | not published | $54.56 – $54.56 | 1 |
| X-ray exam entire spi 6/> vw CPT 72084 | $272.50 | $419.23 | $64.85 – $64.85 | 1 |
| X-ray exam of arm infant CPT 73092 | $296.89 | $456.76 | $19.67 – $19.67 | 1 |
| X-ray exam of femur 1 CPT 73551 | $237.78 | $365.82 | $22.46 – $22.46 | 1 |
| X-ray exam of jaw joint CPT 70328 | $199.93 | $307.59 | $23.63 – $23.63 | 1 |
| X-ray exam of jaw joint CPT 70332 | not published | not published | $75.68 – $75.68 | 1 |
| X-ray exam of mastoids CPT 70120 | not published | not published | $27.26 – $27.26 | 1 |
| X-ray exam of middle ear CPT 70134 | not published | not published | $29.52 – $29.52 | 1 |
| X-ray exam of penis CPT 74445 | not published | not published | $80.79 – $80.79 | 1 |
| X-ray exam of perineum CPT 74775 | not published | not published | $70.81 – $70.81 | 1 |
| X-ray exam of salivary gland CPT 70380 | not published | not published | $29.75 – $29.75 | 1 |
| X-ray exam of tear duct CPT 70170 | not published | not published | $42.37 – $42.37 | 1 |
| X-ray exam of teeth CPT 70300 | not published | not published | $11.75 – $11.75 | 1 |
| X-ray exam of teeth CPT 70310 | not published | not published | $24.89 – $24.89 | 1 |
| X-ray exam si joints CPT 72200 | not published | not published | $19.00 – $19.00 | 1 |
| X-ray exam thorac spine4/>vw CPT 72074 | not published | not published | $28.57 – $28.57 | 1 |
| X-ray eye detection foreign body (both sides) CPT 70030 | $237.78 | $365.82 | $18.35 – $18.35 | 1 |
| X-ray fallopian tube CPT 74742 | not published | not published | $95.56 – $95.56 | 1 |
| X-ray head for orthodontia CPT 70350 | not published | not published | $17.18 – $17.18 | 1 |
| X-ray hip uni w/wo pelvis min 4 views CPT 73503 | $267.93 | $412.20 | $41.72 – $41.72 | 1 |
| X-ray hip with pelvis when performed bilateral >= 5 views CPT 73523 | $278.99 | $429.22 | $45.68 – $45.68 | 1 |
| X-ray joint survey 1 view CPT 77077 | $272.50 | $419.23 | $26.85 – $26.85 | 1 |
| X-ray lower extremities infant > 2 views (both sides) CPT 73592 | $251.74 | $387.30 | $19.89 – $19.89 | 1 |
| X-ray l/s-spine bend vw only 2-3 vw CPT 72120 | $278.17 | $427.95 | $33.12 – $33.12 | 1 |
| X-ray male genital tract CPT 74440 | not published | not published | $63.49 – $63.49 | 1 |
| X-ray mandible ltd <4 views CPT 70100 | $215.10 | $330.92 | $21.18 – $21.18 | 1 |
| X-ray measurement of pelvis CPT 74710 | not published | not published | $38.63 – $38.63 | 1 |
| X-ray nose to rectum for foreign body child CPT 76010 | $238.98 | $367.66 | $17.68 – $17.68 | 1 |
| X-ray of mammary ducts CPT 77054 | not published | not published | $135.70 – $135.70 | 1 |
| X-ray optic foramina CPT 70190 | not published | not published | $28.46 – $28.46 | 1 |
| Xray place dist ext thor ao CPT 75959 | not published | not published | $133.83 – $133.83 | 1 |
| Xray place prox ext thor ao CPT 75958 | not published | not published | $152.90 – $152.90 | 1 |
| X-ray retrograde pyelogram with or without kidney ureter bladder w/supervision & interpretation CPT 74420 | not published | not published | $81.81 – $81.81 | 1 |
| X-ray ribs 2 views left CPT 71100 | $310.93 | $478.36 | $20.69 – $20.69 | 1 |
| X-ray sella turcica CPT 70240 | not published | not published | $18.98 – $18.98 | 1 |
| X-ray sinus tract/fistula/abscess CPT 76080 | $1,500.73 | $2,308.81 | $39.73 – $39.73 | 1 |
| X-ray slg plne bdy sect without urogr CPT 76100 | not published | not published | $81.29 – $81.29 | 1 |
| X-ray small intestine follow-through study CPT 74248 | $241.52 | $371.57 | not published | 0 |
| X-ray sternoclavicular joint(s) > 3 views CPT 71130 | $168.25 | $258.84 | $23.98 – $23.98 | 1 |
| X-ray surgical specimen CPT 76098 | $134.79 | $207.37 | $12.23 – $12.23 | 1 |
| X-ray thoracolumbar spine including skull cervical & sacral spine 1 view CPT 72081 | $120.13 | $184.82 | $31.34 – $31.34 | 1 |
| X-ray upper gi delay w/kub CPT 74241 | not published | not published | $75.89 – $75.89 | 1 |
| X-ray upper gi&small intest CPT 74245 | not published | not published | $113.44 – $113.44 | 1 |
| X-ray xm phrnx&/crv esoph c+ CPT 74210 | $333.59 | $513.22 | $50.29 – $50.29 | 1 |
| Xwrap 1 sq cm HCPCS Q4204 | not published | not published | $540.00 – $540.00 | 1 |
| Xylose absorption test blood &/or urine CPT 84620 | not published | not published | $12.52 – $167.91 | 4 |
| Xyntha inj HCPCS J7185 | not published | not published | $1.49 – $1.91 | 3 |
| Yersinia antibody CPT 86793 | not published | not published | $8.11 – $171.55 | 4 |
| Yttrium y-90 ibritumomab ther HCPCS A9543 | not published | not published | $74,124.43 – $74,124.43 | 1 |
| Zenith amniotic membrane psc HCPCS Q4253 | not published | not published | $1,140.00 – $1,140.00 | 1 |
| Ziconotide injection HCPCS J2278 | not published | not published | $9.70 – $11.31 | 2 |
| Zidovudine in d5w IV syringe 4 mg/ml (neo/peds) - cnr HCPCS J3485 | not published | not published | $1.51 – $1.75 | 2 |
| Zidovudine, oral, 100 mg HCPCS S0104 | not published | not published | $1.31 – $1.46 | 2 |
| Zika virus dna/rna amp probe CPT 87662 | $107.07 | $164.72 | $49.77 – $667.35 | 4 |
| Zika virus igm antibody CPT 86794 | not published | not published | $16.07 – $219.15 | 4 |
| Ziprasidone 20 mg/ml (final concentration) intramuscular solution HCPCS J3486 | not published | not published | $5.18 – $19.67 | 2 |
| Ziv-aflibercept 25 mg/ml intravenous solution (wrapper) HCPCS J9400 | not published | not published | $8.30 – $19.20 | 2 |
| Zoledronic acid 4 mg/5 ml intravenous solution HCPCS J3489 | not published | not published | $9.52 – $24.30 | 2 |
| Zoster vaccine-live inj CPT 90736 | not published | not published | $255.20 – $255.20 | 1 |
| Zrsr2 gene common variants CPT 81360 | not published | not published | $117.11 – $2,513.45 | 4 |
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.