CT abdomen and pelvis with contrast at Gundersen Palmer Lutheran Hospital and Clinic. CPT 74177.
What Gundersen Palmer Lutheran Hospital and Clinic publishes for this service, straight from its standard-charges file, last updated June 27, 2026.
Outpatient / ER
$1,913cash price (self-pay)
$3,220list price
$144–$3,123range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Amerigroup | Medicaid HMO | $144 |
| Molina Health | Managed Medicaid | $144 |
| Wellmark | HMO | $738 |
| Wellmark | Indemnity/PPO | $810 |
| Quartz | All Products | $1,362 |
| Quartz | All Other Self Funded | $1,417 |
| Alliance | Comprehensive/All Products | $1,426 |
| Alliance | Premier/All Products | $1,426 |
| Quartz | Self Funded | $1,513 |
| Quartz | Level Funded | $1,562 |
| UHC | All Payer Appendix | $1,597 |
| Health Partners | Medicaid HMO | $1,610 |
| Wellmark | All Products | $1,642 |
| Aetna | Medicare Advantage | $1,674 |
| Amerigroup | Medicare Advantage | $1,674 |
| Health Partners | Medicare Advantage | $1,674 |
| Humana | Medicare Advantage | $1,674 |
| Iowa Total Care | Medicaid | $1,674 |
| Managed Health Service | Managed Medicaid | $1,674 |
| Quartz | Medicaid_Badgercare | $1,674 |
| Quartz | Medicare Advantage | $1,674 |
| UHC | Medicare Advantage | $1,674 |
| Wellmark | Medicare Advantage | $1,674 |
| Quartz | Fully Insured | $1,755 |
| UCARE | Non-Dually Eligible | $1,771 |
| UCARE | Dually Eligible | $1,771 |
| UCARE | MSHO/Minnesota Special Needs | $1,771 |
| Health Partners | Medicare Cost | $1,932 |
| Medical Associates | CAH Specific | $2,576 |
| Trilogy | All Products | $2,576 |
Inpatient
$1,913cash price (self-pay)
$3,220list price
$1,362–$3,123range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Quartz | All Other Self Funded | $1,897 |
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All common services at Gundersen Palmer Lutheran Hospital and Clinic