CT abdomen and pelvis with contrast at HSHS St. Mary's Hospital Medical Center. CPT 74177.
What HSHS St. Mary's Hospital Medical Center publishes for this service, straight from its standard-charges file, last updated March 24, 2026.
Outpatient / ER
$3,017cash price (self-pay)
$4,571list price
$67.20–$4,571range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Anthem | Antehm Medicaid | $134 |
| Community Care Family Care | Community Care Family Care Medicaid Manag | $134 |
| Continuus Medicaid Managed | Continuus Medicaid Managed | $134 |
| Managed Health Services | Managed Health Services Medicaid | $134 |
| Meridian Health Plan | Meridian HMO Mcd | $134 |
| Molina Healthcare | Molina Medicaid | $142 |
| Aetna | Aetna Medicare | $341 |
| Anthem | Anthem Medicare Advantage HMO | $341 |
| Humana | Humana Medicare Advantage | $341 |
| Medicare Managed | Managed Medicare No Sequestration | $341 |
| Molina Healthcare | Molina Medicare | $341 |
| Naphcare | All Commerical Naphcare | $767 |
| P360 Small Group | Prevea 360 Small Group Commercial Plan | $1,215 |
| Prevea Health Network | Prevea Employees | $1,215 |
| Prevea Health Network | Prevea360 | $1,215 |
| Prevea Health Network | Prevea360 - Network | $1,215 |
| Anthem | Anthem POS/HMO | $1,239 |
| Anthem | Anthem PPO | $1,239 |
| Humana | Humana Choice Care HMO | $1,273 |
| Humana | Humana Natiional POS HMO | $1,273 |
| Hshs Employees | Hshs Employees | $2,222 |
| Molina Healthcare Of Wi | All Commerical Molina Marketplace | $2,286 |
| Cigna | All Commercial Cigna | $3,200 |
| Health Eos | All Commercial Health Eos | $3,245 |
| Healthsmart | All Commercial Healthsmart | $3,337 |
| Interplan | All Commercial Interplan Health Group | $3,337 |
| Network Health Plan | All Commerical Network Health Plan | $3,428 |
| Health Care Alliance | The Alliance | $3,840 |
| Multiplan/Phcs | All Commercial Multiplan | $3,840 |
| Choicecare | All Commercial Choice Care | $3,885 |
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All common services at HSHS St. Mary's Hospital Medical Center