CT abdomen and pelvis with contrast at CHI Health Good Samaritan. CPT 74177.
What CHI Health Good Samaritan publishes for this service, straight from its standard-charges file, last updated February 28, 2026.
Outpatient / ER
$3,606cash price (self-pay)
$5,911list price
$291–$5,497range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Amerigroup | Medicaid|All Plans | $291 |
| Centene | Medicaid|IA Total Care | $291 |
| IAMolina | Medicaid|All Plans | $297 |
| BCBS - NE | Medicare|All Plans | $338 |
| Humana | Medicare|All Plans | $338 |
| Medica | Medicare|All Plans | $338 |
| PACE | Medicare|All Plans | $338 |
| United | Medicare|All Plans | $338 |
| Centene | Medicare|All Plans | $348 |
| Amerigroup | Medicare|All Plans | $355 |
| Great Plains | Medicare|All Plans | $355 |
| Medica | Commercial|ACO | $427 |
| Medica | Commercial|CHI Health | $611 |
| Medica | Commercial|All Other Plans | $640 |
| AMPS | Commercial|All Plans | $751 |
| United | Medicaid|Community Plan | $1,241 |
| Centene | Medicaid|NE Total Care | $1,254 |
| Greater Omaha Packing | Commercial|Narrow Network | $1,472 |
| Millard Public Schools | Commercial|Narrow Network | $1,472 |
| One World | Commercial|Narrow Network | $1,472 |
| Greater Omaha Packing | Commercial|Broad Network | $1,693 |
| Millard Public Schools | Commercial|Broad Network | $1,693 |
| One World | Commercial|Broad Network | $1,693 |
| Timpte | Commercial|Broad Network | $1,693 |
| Creighton University Employees | Commercial|All Plans | $2,896 |
| ELAP | Commercial|All Plans | $3,428 |
| United | Commercial|All Plans | $4,492 |
| Medica | Commercial|Open Access | $4,611 |
| Midlands Choice | Commercial|Premier | $4,611 |
| Midlands Choice | Commercial|Standard | $5,438 |
Inpatient
$3,606cash price (self-pay)
$5,911list price
$2,896–$5,497range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Creighton University Employees | Commercial|All Plans | $2,896 |
| United | Commercial|All Plans | $4,492 |
| Medica | Commercial|Open Access | $4,611 |
| Midlands Choice | Commercial|Premier | $4,611 |
| Midlands Choice | Commercial|Standard | $5,438 |
| MultiPlan PHCS | Commercial|All Plans | $5,497 |
Billed more than this?
Scan my billSnap a photo of your bill. We compare every line with these prices and coding rules, free.