CT abdomen and pelvis with contrast at Intermountain Health Good Samaritan Medical Center. CPT 74177.
What Intermountain Health Good Samaritan Medical Center publishes for this service, straight from its standard-charges file, last updated March 22, 2026.
Outpatient / ER
—cash price (self-pay)
$8,431list price
$355–$7,563range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $1,560 |
| Cigna | Cigna Co Public Option | $1,563 |
| Cigna | Cigna Connect Exchange | $1,604 |
| Cigna | Cigna Surefit | $1,604 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $1,939 |
| Kaiser Perm HMO | Kaiser Out Of State | $1,939 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $1,939 |
| Aetna | Aetna Colorado Preferred | $1,948 |
| Aetna | Aetna HMO/EPO | $2,096 |
| Aetna | Aetna Indemnity | $2,096 |
| Aetna | Aetna Other | $2,096 |
| Aetna | Aetna POS/Qpos | $2,096 |
| Aetna | Aetna PPO | $2,096 |
| Aetna | Aetna Src | $2,096 |
| Geha | Geha-Asa | $2,096 |
| Preferred One | Preferred One | $2,096 |
| Allegiance | Cigna Sclhs Employees | $2,108 |
| Cigna Scl Employees | Cigna Sclhs Cdhp | $2,108 |
| BCBS/Anthem | BCBS Co Federal | $2,120 |
| BCBS/Anthem | BCBS Co HMO | $2,120 |
| BCBS/Anthem | BCBS Co PPO | $2,120 |
| Cigna | Cigna HMO | $3,136 |
| Cigna | Cigna Indemnity | $3,136 |
| Cigna | Cigna Local Plus | $3,136 |
| Cigna | Cigna Other | $3,136 |
| Cigna | Cigna POS/Qpos | $3,136 |
| Cigna | Cigna PPO | $3,136 |
| Cigna | Eighth Dist Elect Ben Pln | $3,136 |
| Cigna | Health-Partners | $3,136 |
| Choicecare Humana | Choicecare Humana HMO EPO | $3,541 |
Inpatient
—cash price (self-pay)
$8,431list price
$2,487–$8,431range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $2,487 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $3,552 |
| Kaiser Perm HMO | Kaiser Out Of State | $3,552 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $3,552 |
| Kaiser Self Funded | Kaiser Self Funded | $3,552 |
| Kaiser Perm PPO/POS | Kaiser Perm PPO/POS | $3,660 |
| Private Hlthcare Sys | Phcs Other | $6,324 |
| Private Hlthcare Sys | Phcs PPO | $6,324 |
| BCBS/Anthem | BCBS Co Indemnity | $7,098 |
| Multiplan Inc | Multiplan Inc Other | $7,167 |
| Multiplan Inc | Multiplan Inc PPO | $7,167 |
| Aetna | Aetna Nap | $7,563 |
| Cigna | Cigna HMO | $8,431 |
| Cigna | Cigna Indemnity | $8,431 |
| Cigna | Cigna Local Plus | $8,431 |
| Cigna | Cigna Other | $8,431 |
| Cigna | Cigna POS/Qpos | $8,431 |
| Cigna | Cigna PPO | $8,431 |
| Cigna | Eighth Dist Elect Ben Pln | $8,431 |
| Cigna | Health-Partners | $8,431 |
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All common services at Intermountain Health Good Samaritan Medical Center