CT abdomen and pelvis with contrast at Jones Memorial Hospital. CPT 74177.
What Jones Memorial Hospital publishes for this service, straight from its standard-charges file, last updated January 1, 2026.
Outpatient / ER
$680cash price (self-pay)
$1,359list price
$65.41–$1,166range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Amerigroup (Blue Cross Blue Shield Wny Alternate) 1720 | Amerigroup (B | $87.21 |
| Fidelis 5155 | Fidelis Metal Tiers 515501 | $87.21 |
| Fidelis Medicaid 1708 | Fidelis Medicaid 170801, Fidelis Child Health | $87.21 |
| Highmark Blue Cross Blue Shield Medicaid 5143 | Highmark BCBS Essentia | $87.21 |
| Independent Health Assoc Medicaid 1710 | Independent Health Medicaid 1 | $87.21 |
| United Healthcare Medicaid 1716 | United Healthcare Medicaid 171601, U | $87.21 |
| United Healthcare Medicaid 5158 | United Healthcare Essential 1-2 200- | $87.21 |
| Univera Healthcare 1706 | Univera Medicaid 170607, Univera Essential 3 | $87.21 |
| Mvp Medicaid 1712 | Mvp Option Medicaid 171201, Mvp Child Health Plus | $105 |
| Molina Healthcare 1723 | Molina Medicaid 172301, Molina Child Health | $120 |
| Mvp Medicaid 1712 | Mvp Essential 3-4 171204, Mvp Essential 1-2 200-25 | $179 |
| Fidelis Medicaid 1708 | Fidelis Essential 3-4 170804, Fidelis Essentia | $196 |
| Molina Healthcare 1723 | Molina Essential 3-4 172302, Molina Essential | $245 |
| Highmark Blue Cross Blue Shield Medicaid 1702 | Highmark BCBS Medicaid | $302 |
| Upmc Health Plan 5138 | Upmc Health Plan 513801 | $350 |
| Mvp 2900 | Mvp Premier Individual 290002 | $384 |
| Excellus Blue Cross Blue Shield 2201, Out Area Blue Cross Blue Shield, | $466 |
| Fidelis Medicare 1311 | Fidelis Medicare 131101 | $466 |
| Humana Medicare 1312 | Humana Medicare 131201 | $466 |
| Medicare Blue Choice 1306 | Medicare Blue Choice 130601 | $466 |
| United Healthcare Medicare 1309 | United Healthcare Medicare 130901 | $466 |
| Wellcare Medicare 1310 | Wellcare Medicare 131001 | $466 |
| Highmark Blue Cross Blue Shield Medicare 1301 | Highmark BCBS Medicare | $466 |
| Total Senior Care 1319 | Total Senior Care 131901 | $466 |
| Aetna Medicare 1300 | Aetna Medicare 130001 | $494 |
| Cdphp Medicare 1320 | Cdphp Medicare 132001 | $504 |
| Mvp Medicare 1307 | Mvp Medicare 130701 | $513 |
| Independent Health 5156 | Independent Health (Buffalo NY) 515601 | $698 |
| Independent Health Medicare 1305 | Independent Health Medicare 130501 | $698 |
| Highmark Blue Cross Blue Shield 5143 | Highmark BCBS 514301 HMO / POS | $748 |
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