CT abdomen and pelvis with contrast at SSM Health St. Agnes Hospital - Fond du Lac. CPT 74177.
What SSM Health St. Agnes Hospital - Fond du Lac publishes for this service, straight from its standard-charges file, last updated April 1, 2026.
Outpatient / ER
$1,713cash price (self-pay)
$3,115list price
$259–$755range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| MOLINA | Medicare Managed Care Plan | $259 |
| BCBS | Anthem Medicare Managed Care Plan | $345 |
| Wellcare | Medicare Managed Care Plan | $352 |
| DOC | Government | $666 |
| BCBS | Blue Preferred / Blue Preferred Plus HMO/POS | $729 |
| BCBS | Blue Access PPO | $755 |
| BCBS | Blue Traditional Traditional | $755 |
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All common services at SSM Health St. Agnes Hospital - Fond du Lac