CT abdomen and pelvis with contrast at Nicholas H Noyes Memorial Hospital. CPT 74177.
What Nicholas H Noyes Memorial Hospital publishes for this service, straight from its standard-charges file, last updated January 1, 2026.
Outpatient / ER
$528cash price (self-pay)
$1,057list price
$65.41–$1,036range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Amerigroup (Blue Cross Blue Shield Wny Alternate) 1720 | Amerigroup (B | $87.21 |
| Excellus Blue Cross Blue Shield Medicaid 1706 | Blue Choice Option Med | $87.21 |
| Excellus Blue Cross Blue Shield Medicaid 1706 | Excellus Essential 3-4 | $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 1702 | Highmark BCBS Medicaid | $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 |
| Mvp Medicaid 1712 | Mvp Option Medicaid 171201, Mvp Child Health Plus | $105 |
| Molina Healthcare 1723 | Molina Medicaid 172301, Molina Child Health | $109 |
| 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 |
| Medicare Blue Choice 1306 | Medicare Blue Choice 130601 | $357 |
| Aetna Medicare 1300 | Aetna Medicare 130001 | $435 |
| Humana Medicare 1312 | Humana Medicare 131201 | $435 |
| Fidelis Medicare 1311 | Fidelis Medicare 131101 | $435 |
| United Healthcare Medicare 1309 | United Healthcare Medicare 130901 | $435 |
| Wellcare Medicare 1310 | Wellcare Medicare 131001 | $435 |
| Independent Health Medicare 1305 | Independent Health Medicare 130501 | $435 |
| Cdphp Medicare 1320 | Cdphp Medicare 132001 | $470 |
| Mvp Medicare 1307 | Mvp Medicare 130701 | $610 |
| Empire Plan 5179 | Empire Plan 517901 | $700 |
| Excellus Blue Cross Blue Shield 2201, Out Area Blue Cross Blue Shield, | $754 |
| United Healthcare 5158 | United Healthcare 515803 | $856 |
| Pomco Ins Co 5157 | Pomco Ins Co 515701 | $928 |
| Mvp 2900 | Mvp Premier Individual 290002 | $976 |
| Mvp 2900 | Mvp Health Care 290001, Mvp Premier Group 290003 | $1,003 |
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