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2021 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 910-919 Routine Care Continuous Care Respite Care General Inpt Rev Code 820-859
Implied Decimal 2 (in dollars)
1063498541 391656 HOSPICE OF THE SACRED HEART 0 0 0 0 0 0 23054 134562 23934 102680 0
1528049160 391674 GRANE HOSPICE-PITTSBURGH 0 0 0 0 0 0 24138 140888 24814 107171 0
1972918878 391693 GRANE HOSPICE-HOLLIDAYSBURG 0 0 0 0 0 0 23358 136337 24180 103940 0
1316352214 391732 GRANE HOSPICE-LEMOYNE 0 0 0 0 0 0 24603 143602 25194 109099 0
1851706873 391765 GRANE HOSPICE-KING OF PRUSSIA 0 0 0 0 0 0 26271 153342 26555 116014 0
1962583922 392300 GEISINGER MEDICAL CENTER-ESRD 0 0 0 0 0 0 0 0 0 0 29814
1780831198 392632 FRESEBIUS MEDICAL CARE PENN HILLS 0 0 0 0 0 0 0 0 0 0 31333
1083677587 392691 DCA OF MECHANICSBURG 0 0 0 0 0 0 0 0 0 0 31084
1306808472 392723 DUNMORE DIALYSIS 0 0 0 0 0 0 0 0 0 0 29814
1265739411 392786 USRC ALTOONA DIALYSIS CENTER 0 0 0 0 0 0 0 0 0 0 30541
1023384013 392791 WESTTOWN DIALYSIS 0 0 0 0 0 0 0 0 0 0 33011
1811257108 392803 SUBURBAN CAMPUS DIALYSIS 0 0 0 0 0 0 0 0 0 0 31333
1538391248 393518 GEISINGER MEDICAL CENTER-ESRD 0 0 0 0 0 0 0 0 0 0 29814
1215922471 394527 TRINDLE REHAB MEDICINE ASSOC 23261 0 0 0 0 0 0 0 0 0 0
1619911914 396578 MONTGOMERY COUNTY REHAB AND SPORTS THERAPY 22888 0 0 0 0 0 0 0 0 0 0
1851563076 396582 DR. DAVID POTOKER 0 0 15812 0 0 0 0 0 0 0 0
1295992683 396603 THERAPEUTIC REHAB (TRAC) 12343 0 36201 0 0 0 0 0 0 0 0
1972501757 396616 MAHONING PT/TWOLICK VALLEY PT 12698 0 0 0 0 0 0 0 0 0 0
1235519398 396854 GENESIS PROSTEP LLC D/B/A ADULT SERVICES UNLIMITED 36765 34720 45799 0 0 34720 0 0 0 0 0
999996 999996 OUT-OF-STATE PROVIDER 23261 0 0 0 0 0 0 0 0 0 0