CT abdomen and pelvis with contrast at WellSpan Good Samaritan Hospital. CPT 74177.
What WellSpan Good Samaritan Hospital publishes for this service, straight from its standard-charges file, last updated January 1, 2026.
Outpatient / ER
$438cash price (self-pay)
$3,012list price
$241–$2,410range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Blue_Cross | Capital_Blue_Performance_PPO | $241 |
| Highmark_Wholecare_Gateway_Medicaid | All_Plans | $329 |
| Geisinger_Medicaid | All_Plans | $329 |
| Health_Partners_Medicaid | All_Other_Plans | $329 |
| PA_Health_&_Wellness_Medicaid | All_Plans | $329 |
| UPMC_Medicaid | All_Plans | $329 |
| Blue_Cross_BlueJourney_Medicare | All_Plans | $353 |
| Highmark_Medicare | All_Plans | $356 |
| Aetna_Advantra_Medicare | All_Plans | $363 |
| Aetna_Medicare | All_Plans | $363 |
| Geisinger_Gold_Medicare | All_Plans | $370 |
| Devoted_Medicare | All_Plans | $370 |
| United_Medicare | ISNP_DSNP_Plans | $370 |
| Highmark_Wholecare_Gateway_Medicare | All_Plans | $372 |
| Amerihealth_Medicare | All_Plans | $372 |
| UPMC_Medicare | UPMC_for_Life_Community_HealthChoices | $372 |
| UPMC_Medicare | UPMC_for_Life_Complete_Care | $372 |
| Amerihealth_Caritas_Medicaid | All_Plans | $374 |
| Jefferson_Health_Medicare_Advantage | All_Plans | $381 |
| PA_Health_&_Wellness_Medicare | All_Plans | $381 |
| WellSpan_Capital_Blue_Cross | All_Plans | $395 |
| Highmark | Higmark_Healthy_Kids | $547 |
| Health_Partners_Medicaid | Kidz_Partners | $582 |
| United_Medicaid | Community_Plan_For_Kids | $617 |
| Aetna_Better_Health_Kids | All_Plans | $895 |
| Aetna | All_Plans | $957 |
| First_Health_Network | All_Plans | $1,052 |
| Highmark | Choice_Blue_PPO | $1,067 |
| Highmark | Performance_Blue | $1,067 |
| Highmark | Blue_Cross_High_Performance_Network | $1,067 |
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