CT abdomen and pelvis with contrast at Samaritan Lebanon Community Hospital. CPT 74177.
What Samaritan Lebanon Community Hospital publishes for this service, straight from its standard-charges file, last updated January 31, 2026.
Outpatient / ER
$242cash price (self-pay)
$302list price
$73.55–$2,328range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Devoted Health | Medicare Advantage - Midlevel - Fac | $81.58 |
| Devoted Health | Medicare Advantage - Midlevel - Nonfac | $81.58 |
| Healthnet | Medicare Advantage - Midlevel - Nonfac | $81.58 |
| DEVOTED HEALTH | Medicare Advantage-FAC | $94.30 |
| DEVOTED HEALTH | Medicare Advantage-NONFAC | $94.30 |
| Healthnet | Medicare Advantage - Nonfac | $95.97 |
| Cigna | Nonfacility | $126 |
| Cigna | Facility | $126 |
| Aetna | Nonfac - Midlevel Lcsw/Lpc/Rdn | $146 |
| Aetna | Fac - Midlevel Lcsw/Lpc/Rdn | $146 |
| Aetna | Fac - Optometrists - Pyschologists- Pt-St-Ot | $166 |
| Aetna | Fac - Midlevel Np-Pa-Cnm | $166 |
| Aetna | Nonfac - Optometrists - Pyschologists- Pt-St-Ot | $166 |
| Aetna | Nonfac - Midlevel Np-Pa-Cnm | $166 |
| Providence | Medicare Adv. - Physician | $181 |
| Aetna | Fac - Md-Do | $195 |
| Aetna | Fac - Psychiatric Np | $195 |
| Aetna | Nonfac - Md-Do | $195 |
| Aetna | Nonfac - Psychiatric Np | $195 |
| First Choice | Nonfacility | $195 |
| First Choice | Facility | $195 |
| Healthnet | Facility | $195 |
| Healthnet | Nonfacility | $195 |
| Providence | MA-Behavioral Health | $696 |
| Providence | Medicare Adv. | $696 |
| Samaritan | Medicare Adv. | $703 |
| Healthnet | Medicare Adv. | $766 |
| Regence | Medicare Adv. | $766 |
| Pacificsource | Medicare Adv. | $780 |
| Devoted Health | Devoted Health Mcr Advantage | $800 |
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