CT abdomen and pelvis with contrast at Suburban Behavioral Health Campus of Roxborough Memorial Hospital. CPT 74177.
What Suburban Behavioral Health Campus of Roxborough Memorial Hospital publishes for this service, straight from its standard-charges file, last updated September 1, 2026.
Outpatient / ER
$356cash price (self-pay)
$5,818list price
$193–$5,643range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Health Partners Plan | Health Partners Plan Medicaid | $193 |
| Traditional Medicaid | Traditional Medicaid | $193 |
| Keystone | Keystone First Medicaid | $204 |
| UHC | UHC Medicaid | $218 |
| Humana Military Tricare | Humana Military Tricare | $285 |
| Health Partners Plan | Health Partners Plan Medicare | $357 |
| Independence Blue Cross | IBC Medicare | $357 |
| PA Health & Wellness | PA Health & Wellness Medicare & Duals | $357 |
| Traditional Medicare | Traditional Medicare | $357 |
| Tricare | Tricare | $357 |
| UHC | UHC Medicare | $357 |
| UHC | UHC Va Ccn | $357 |
| Providers Partner Health Plan | Provider Partners Health Plan | $367 |
| Keystone | Keystone First Medicare | $371 |
| Ally-Align Medicare | Ally-Align Medicare | $374 |
| Spartan | Spartan Plan | $374 |
| Auto Insurance | Auto Insurance | $392 |
| Worker Compensation | Worker Compensation | $403 |
| PA Health & Wellness | PA Health & Wellness Commercial Insurance Excha | $428 |
| Employer Direct Healthcare | Employer Direct Healthcare | $499 |
| Health Partners Plan | Health Partners Plan Exchange | $535 |
| Naphcare | Naphcare | $553 |
| UHC | UHC Exchange | $561 |
| UHC | UHC Commercial All Payer | $745 |
| Independence Blue Cross | IBC Commercial HMO PPO | $772 |
| Independence Blue Cross | IBC Indemnity | $772 |
| Highmark | Highmark Commercial (02-01-2024 to 12-31-2026) | $777 |
| Cigna | Cigna Commercial (05-01-2023 to 12-31-2026) | $843 |
| Independence Blue Cross | IBC PPACA | $848 |
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All common services at Suburban Behavioral Health Campus of Roxborough Memorial Hospital