CT abdomen and pelvis with contrast at Good Samaritan Hospital (GSH). CPT 74177.
What Good Samaritan Hospital (GSH) publishes for this service, straight from its standard-charges file, last updated April 1, 2026.
Outpatient / ER
$2,459cash price (self-pay)
$4,099list price
$167–$4,099range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Aetna | Medicare Advantage | $369 |
| Allwell | MCR ADV/PPO/HMO | $369 |
| Anthem MCR | MCR ADV/PPO/HMO | $369 |
| Anthem MCR | Medicare Advantage | $369 |
| Anthem | MCR ADV/PPO/HMO | $369 |
| Cigna | Medicare Advantage | $369 |
| Humana | Medicare Advantage | $369 |
| Indiana University | MCR ADV/PPO/HMO | $369 |
| MHS Ambetter | Commercial | $369 |
| Encore Prime | Commercial | $428 |
| Alliance Coal | Commercial | $554 |
| CareSource | Commercial | $554 |
| Aetna | Medicaid | $632 |
| Anthem HIP | HIP | $632 |
| Anthem Pathways | Medicaid | $632 |
| Anthem | Medicaid | $632 |
| BCBS | Medicare Advantage | $632 |
| Caresource HIP | Medicaid | $632 |
| Caresource | Medicaid | $632 |
| Meridian | Medicaid | $632 |
| Hope Trust | Commercial | $738 |
| Anthem | HealthSync | $1,877 |
| Aetna | Commercial | $1,950 |
| Anthem | Exchange | $2,048 |
| Amish | Commercial | $2,050 |
| United Healthcare | Commercial | $2,689 |
| Anthem | Trad/PPO/HMO | $2,885 |
| Indiana University | Commercial | $2,908 |
| OneCare | Commercial | $3,133 |
| Direct Health | Direct Health | $3,144 |
Inpatient
$2,459cash price (self-pay)
$4,099list price
$2,385–$4,099range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Anthem | Exchange | $2,385 |
| United Healthcare | Commercial | $2,714 |
| Anthem | Trad/PPO/HMO | $2,981 |
| Direct Health | Direct Health | $3,144 |
| SIHO | Commercial | $3,144 |
| Cigna | Commercial | $3,238 |
| Sagamore | Commercial | $3,238 |
| Corvel | Workers Comp | $3,361 |
| Aetna | Commercial | $3,435 |
| Anthem | HealthSync | $3,525 |
| HealthLink | HMO | $3,607 |
| Encore Prime | Commercial | $3,689 |
| Humana | Commercial | $3,689 |
| HealthLink | PPO | $3,812 |
| Molina | Medicaid | $4,099 |
| Underwriters Safety | Commercial | $4,099 |
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