2017 Workers' Compensation Fee Schedule

Table G: Physical Therapy Per Visit Based Provider
& OP End Stage Renal Dialysis Table

NPI or
Provider
#
Prov.
#
Provider
Name
Rev
Code
420-429
Rev
Code
430-439
Rev
Code
440-449
Rev
Code
550-559
Rev
Code
560-569
Rev
Code
820-859
Rev
Code
910-919
Routine
Care
Continuous
Care
Respite
Care
General
Inpt
Implied Decimal 2 (in dollars)
1063498541 391656 HOSPICE OF THE SACRED HEART 0 0 0 0 0 0 20287 118418 21062 90360 0
1528049160 391674 GRANE HOSPICE- PITTSBURGH 0 0 0 0 0 0 21242 123985 21838 94314 0
1972918878 391693 GRANE HOSPICE- HOLLIDAYSBURG 0 0 0 0 0 0 20556 119981 21280 91470 0
1316352214 391732 GRANE HOSPICE- LEMOYNE 0 0 0 0 0 0 21651 126374 22172 96011 0
1851706873 391765 GRANE HOSPICE- KING OF PRUSSIA 0 0 0 0 0 0 23119 134945 23369 102095 0
1962583922 392300 GEISINGER MEDICAL CENTER- ESRD 0 0 0 0 0 0 0 0 0 0 26237
1780831198 392632 FRESENIUS MEDICAL CARE- PENN HILLS 0 0 0 0 0 0 0 0 0 0 27574
1083677587 392691 DCA OF MECHANICSBURG 0 0 0 0 0 0 0 0 0 0 27354
1306808472 392723 DUNMORE DIALYSIS 0 0 0 0 0 0 0 0 0 0 26237
1265739411 392786 USRC ALTOONA DIALYSIS CENTER 0 0 0 0 0 0 0 0 0 0 26877
1023384013 392791 WESTTOWN DIALYSIS 0 0 0 0 0 0 0 0 0 0 29050
1811257108 392803 SUBURBAN CAMPUS DIALYSIS 0 0 0 0 0 0 0 0 0 0 27574
1538391248 393518 GEISINGER MEDICAL CENTER- ESRD 0 0 0 0 0 0 0 0 0 0 26237
1215922471 394527 TRINDLE REHAB MEDICINE ASSOC 20470 0 0 0 0 0 0 0 0 0 0
1619911914 396578 MONTGOMERY COUNTY REHAB SPORTS THERAPY 20142 0 0 0 0 0 0 0 0 0 0
1851563076 396582 DR. DAVID POTOKER 0 0 13915 0 0 0 0 0 0 0 0
1295992683 396603 THERAPEUTIC REHAB (TRAC) 10862 0 31857 0 0 0 0 0 0 0 0
1972501757 396616 MAHONING PT/TWOLICK VALLEY PT 11175 0 0 0 0 0 0 0 0 0 0
1851771919 396850 GENESIS PROSTEP LLC D/B/A RIVERSIDE REHABILITATION 19452 13328 71465 0 0 13328 0 0 0 0 0
1235519398 396854 GENESIS PROSTEP LLC D/B/A RIVERSIDE REHABILITATION 32354 30554 40304 0 0 30554 0 0 0 0 0
999996 999996 OUT-OF-STATE PROVIDER 20470 0 0 0 0 0 0 0 0 0 0