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 June 29, 2026.
Outpatient / ER
$7,115cash price (self-pay)
$7,115list price
$267–$10,773range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Beacon Medicare | Beacon Medicare | $433 |
| Hamaspik (Mcr) | Hamaspik (Mcr) | $433 |
| Medicare Managed | Medicare Managed | $433 |
| Mvp Gold (Mcr) | Mvp Gold (Mcr) | $433 |
| Tricare | Tricare | $435 |
| Medicare | Medicare | $435 |
| Emblem Ghi/Hip Medicare | Emblem Ghi/Hip Medicare | $442 |
| Affinity By Molina Mcr | Affinity By Molina Mcr | $455 |
| Health First Medicare | Health First Medicare | $464 |
| Emblem Select Care (Exchange) | Emblem Select Care (Exchange) | $497 |
| Beacon Exchange | Beacon Exchange | $520 |
| Beacon Commercial | Beacon Commercial | $563 |
| Emblem Ghi/Hip PPO | Emblem Ghi/Hip PPO | $585 |
| Cigna PPO | Cigna PPO | $883 |
| Mvp Exchange | Mvp Exchange | $925 |
| Geisinger Health Commercial/Exchange | Geisinger Health Commercial/Exc | $1,430 |
| Blue Cross Connection/Exchange | Blue Cross Connection/Exchange | $1,745 |
| Mvp HMO/PPO | Mvp HMO/PPO | $1,800 |
| Self-Pay | Self-Pay | $1,931 |
| Oxford Commercial | Oxford Commercial | $1,931 |
| Blue Cross Small Group | Blue Cross Small Group | $2,095 |
| SELF-PAY - CC 30% | SELF-PAY - CC 30 PerCent | $2,135 |
| Aetna HP Network | Aetna HP Network | $2,144 |
| Aetna Employee | Aetna Employee | $2,153 |
| Blue Cross HMO | Blue Cross HMO | $2,153 |
| Aetna | Aetna | $2,185 |
| Oxford Exchange | Oxford Exchange | $2,532 |
| UHC Exchange | UHC Exchange | $2,532 |
| UHC Commercial | UHC Commercial | $2,979 |
| UHC Empire | UHC Empire | $2,979 |
Inpatient
$7,115cash price (self-pay)
$7,115list price
$2,135–$4,981range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| SELF-PAY - CC 30% | SELF-PAY - CC 30 PerCent | $2,135 |
| Cdphp | Cdphp | $3,558 |
| Self-Pay - Cc 50% | Self-Pay - Cc 50 | $3,558 |
| Magnacare Standard | Magnacare Standard | $4,981 |
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