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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

IP

$1,094.00

Service Code	HCPCS 90840
Hospital Charge Code	87504050
Hospital Revenue Code	914
Min. Negotiated Rate	$164.10
Max. Negotiated Rate	$164.10
Rate for Payer: Qualcare PPO/HMO/WC	$164.10

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

OP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84518019
Hospital Revenue Code	914
Min. Negotiated Rate	$7.81
Max. Negotiated Rate	$137.50
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare Advantage	$82.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$70.12
Rate for Payer: Cigna Commercial	$137.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$71.50
Rate for Payer: Qualcare PPO/HMO/WC	$41.25
Rate for Payer: UnitedHealthcare Community & State	$8.69
Rate for Payer: Wellpoint Medicaid Managed Care	$7.81

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

IP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84518019
Hospital Revenue Code	914
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$41.25
Rate for Payer: Qualcare PPO/HMO/WC	$41.25

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

OP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84517019
Hospital Revenue Code	914
Min. Negotiated Rate	$7.81
Max. Negotiated Rate	$137.50
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare Advantage	$82.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$70.12
Rate for Payer: Cigna Commercial	$137.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$71.50
Rate for Payer: Qualcare PPO/HMO/WC	$41.25
Rate for Payer: UnitedHealthcare Community & State	$8.69
Rate for Payer: Wellpoint Medicaid Managed Care	$7.81

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

IP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84310095
Hospital Revenue Code	914
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$41.25
Rate for Payer: Qualcare PPO/HMO/WC	$41.25

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

IP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84517019
Hospital Revenue Code	914
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$41.25
Rate for Payer: Qualcare PPO/HMO/WC	$41.25

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

OP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84310095
Hospital Revenue Code	914
Min. Negotiated Rate	$7.81
Max. Negotiated Rate	$137.50
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare Advantage	$82.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$70.12
Rate for Payer: Cigna Commercial	$137.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$71.50
Rate for Payer: Qualcare PPO/HMO/WC	$41.25
Rate for Payer: UnitedHealthcare Community & State	$8.69
Rate for Payer: Wellpoint Medicaid Managed Care	$7.81

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

OP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84509019
Hospital Revenue Code	914
Min. Negotiated Rate	$7.81
Max. Negotiated Rate	$137.50
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare Advantage	$82.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$70.12
Rate for Payer: Cigna Commercial	$137.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$71.50
Rate for Payer: Qualcare PPO/HMO/WC	$41.25
Rate for Payer: UnitedHealthcare Community & State	$8.69
Rate for Payer: Wellpoint Medicaid Managed Care	$7.81

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

IP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84509019
Hospital Revenue Code	914
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$41.25
Rate for Payer: Qualcare PPO/HMO/WC	$41.25

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

OP

$1,094.00

Service Code	HCPCS 90840
Hospital Charge Code	87504050
Hospital Revenue Code	914
Min. Negotiated Rate	$31.07
Max. Negotiated Rate	$547.00
Rate for Payer: Aetna Commercial	$415.72
Rate for Payer: Aetna Medicare Advantage	$328.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$278.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$278.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$278.97
Rate for Payer: Cigna Commercial	$547.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$284.44
Rate for Payer: Qualcare PPO/HMO/WC	$164.10
Rate for Payer: UnitedHealthcare Community & State	$34.57
Rate for Payer: Wellpoint Medicaid Managed Care	$31.07

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

IP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84511019
Hospital Revenue Code	914
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$41.25
Rate for Payer: Qualcare PPO/HMO/WC	$41.25

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

OP

$1,094.00

Service Code	HCPCS 90840
Hospital Charge Code	97504050
Hospital Revenue Code	914
Min. Negotiated Rate	$31.07
Max. Negotiated Rate	$547.00
Rate for Payer: Aetna Commercial	$415.72
Rate for Payer: Aetna Medicare Advantage	$328.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$278.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$278.97
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$278.97
Rate for Payer: Cigna Commercial	$547.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$284.44
Rate for Payer: Qualcare PPO/HMO/WC	$164.10
Rate for Payer: UnitedHealthcare Community & State	$34.57
Rate for Payer: Wellpoint Medicaid Managed Care	$31.07

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

IP

$1,094.00

Service Code	HCPCS 90840
Hospital Charge Code	97504050
Hospital Revenue Code	914
Min. Negotiated Rate	$164.10
Max. Negotiated Rate	$164.10
Rate for Payer: Qualcare PPO/HMO/WC	$164.10

CRISIS PSYCHOTHERAPY ADD30MINS

Facility

OP

$275.00

Service Code	HCPCS 90840
Hospital Charge Code	84511019
Hospital Revenue Code	914
Min. Negotiated Rate	$7.81
Max. Negotiated Rate	$137.50
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare Advantage	$82.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$70.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$70.12
Rate for Payer: Cigna Commercial	$137.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$71.50
Rate for Payer: Qualcare PPO/HMO/WC	$41.25
Rate for Payer: UnitedHealthcare Community & State	$8.69
Rate for Payer: Wellpoint Medicaid Managed Care	$7.81

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

IP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4822510
Hospital Revenue Code	914
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

IP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4535510
Hospital Revenue Code	914
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

IP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4509510
Hospital Revenue Code	914
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

OP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4535510
Hospital Revenue Code	914
Min. Negotiated Rate	$56.80
Max. Negotiated Rate	$764.93
Rate for Payer: Aetna Commercial	$573.57
Rate for Payer: Aetna Medicare Advantage	$683.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$210.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$111.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$764.93
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: Cigna Medicare Advantage	$210.87
Rate for Payer: Clover Medicare Advantage	$200.33
Rate for Payer: EmblemHealth Commercial	$632.61
Rate for Payer: Humana Medicare Advantage	$217.20
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$210.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$520.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00
Rate for Payer: UnitedHealthcare Community & State	$63.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$210.87
Rate for Payer: Wellcare Medicare Advantage	$210.87
Rate for Payer: Wellpoint Medicaid Managed Care	$56.80

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

IP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4832510
Hospital Revenue Code	914
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

OP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4832510
Hospital Revenue Code	914
Min. Negotiated Rate	$56.80
Max. Negotiated Rate	$764.93
Rate for Payer: Aetna Commercial	$573.57
Rate for Payer: Aetna Medicare Advantage	$683.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$210.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$111.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$764.93
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: Cigna Medicare Advantage	$210.87
Rate for Payer: Clover Medicare Advantage	$200.33
Rate for Payer: EmblemHealth Commercial	$632.61
Rate for Payer: Humana Medicare Advantage	$217.20
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$210.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$520.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00
Rate for Payer: UnitedHealthcare Community & State	$63.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$210.87
Rate for Payer: Wellcare Medicare Advantage	$210.87
Rate for Payer: Wellpoint Medicaid Managed Care	$56.80

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

OP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4822510
Hospital Revenue Code	914
Min. Negotiated Rate	$56.80
Max. Negotiated Rate	$764.93
Rate for Payer: Aetna Commercial	$573.57
Rate for Payer: Aetna Medicare Advantage	$683.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$210.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$111.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$764.93
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: Cigna Medicare Advantage	$210.87
Rate for Payer: Clover Medicare Advantage	$200.33
Rate for Payer: EmblemHealth Commercial	$632.61
Rate for Payer: Humana Medicare Advantage	$217.20
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$210.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$520.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00
Rate for Payer: UnitedHealthcare Community & State	$63.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$210.87
Rate for Payer: Wellcare Medicare Advantage	$210.87
Rate for Payer: Wellpoint Medicaid Managed Care	$56.80

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

OP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4502510
Hospital Revenue Code	914
Min. Negotiated Rate	$56.80
Max. Negotiated Rate	$764.93
Rate for Payer: Aetna Commercial	$573.57
Rate for Payer: Aetna Medicare Advantage	$683.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$764.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$210.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$111.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$764.93
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: Cigna Medicare Advantage	$210.87
Rate for Payer: Clover Medicare Advantage	$200.33
Rate for Payer: EmblemHealth Commercial	$632.61
Rate for Payer: Humana Medicare Advantage	$217.20
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$210.87
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$520.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00
Rate for Payer: UnitedHealthcare Community & State	$63.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$210.87
Rate for Payer: Wellcare Medicare Advantage	$210.87
Rate for Payer: Wellpoint Medicaid Managed Care	$56.80

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

IP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4504510
Hospital Revenue Code	914
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

IP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4818510
Hospital Revenue Code	914
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

CRISIS PSYCHOTX 1ST HOUR ADULT

Facility

IP

$2,000.00

Service Code	HCPCS 90839
Hospital Charge Code	4511510
Hospital Revenue Code	914
Min. Negotiated Rate	$300.00
Max. Negotiated Rate	$300.00
Rate for Payer: Qualcare PPO/HMO/WC	$300.00

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