CT abdomen and pelvis with contrast at Good Samaritan Hospital. CPT 74177.
What Good Samaritan Hospital publishes for this service, straight from its standard-charges file, last updated January 1, 2025.
Outpatient / ER
$1,199cash price (self-pay)
$1,844list price
$298–$2,632range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Peach State | Medicaid | $298 |
| Wellcare | Medicaid | $298 |
| UHC | Medicare Advantage | $498 |
| Aetna | Medicare Advantage | $498 |
| Ambetter | Medicare Advantage | $498 |
| Anthem BCBS | Medicare Advantage | $498 |
| Care Improvement Plus | Medicare Advantage | $498 |
| Caresource | Medicare Advantage | $498 |
| Centene | Medicare Advantage | $498 |
| Cigna HealthSpring | Medicare Advantage | $498 |
| Coventry | Medicare Advantage | $498 |
| Eon Health Plan | Medicare Advantage | $498 |
| Humana | Medicare Advantage | $498 |
| Kaiser Permanente | Medicare Advantage | $498 |
| Molina | Medicare Advantage | $498 |
| Pruitthealth Premier | Medicare Advantage | $498 |
| Todays Options PFFS | Medicare Advantage | $498 |
| Todays Options PPO | Medicare Advantage | $498 |
| VACCN United | Veterans Affairs | $498 |
| Wellcare | Medicare Advantage | $498 |
| Anthem | Pathway Program | $625 |
| Anthem | PPO | $1,332 |
| Anthem | HMO | $1,332 |
| COVENTRY | All Products | $1,383 |
| First Health | All Products | $1,383 |
| Humana | All Products | $1,383 |
| PHCS | All Products | $1,383 |
| Aetna | All Products | $1,475 |
| MERITAIN | All Products | $1,475 |
| Cigna | All products | $1,512 |
Inpatient
$1,199cash price (self-pay)
$1,844list price
$356–$1,844range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Anthem | Pathway Program | $356 |
| Anthem | HMO | $936 |
| Anthem | PPO | $936 |
| NOVA | All Products | $1,567 |
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