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2022 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 24576 143443 25514 109457 0
1669986824 391670 THREE RIVERS HOSPICE 0 0 0 0 0 0 25731 150187 26452 114244 0
1528049160 391674 GRANE HOSPICE-PITTSBURGH 0 0 0 0 0 0 25731 150187 26452 114244 0
1972918878 391693 GRANE HOSPICE-HOLLIDAYSBURG 0 0 0 0 0 0 24900 145335 25776 110800 0
1316352214 391732 GRANE HOSPICE-LEMOYNE 0 0 0 0 0 0 26227 153080 26857 116300 0
1851706873 391765 GRANE HOSPICE-KING OF PRUSSIA 0 0 0 0 0 0 28005 163463 28308 123671 0
1962583922 392300 GEISINGER MEDICAL CENTER-ESRD 0 0 0 0 0 0 0 0 0 0 31782
1780831198 392632 FRESEBIUS MEDICAL CARE PENN HILLS 0 0 0 0 0 0 0 0 0 0 33401
1083677587 392691 DCA OF MECHANICSBURG 0 0 0 0 0 0 0 0 0 0 33136
1306808472 392723 DUNMORE DIALYSIS 0 0 0 0 0 0 0 0 0 0 31782
1265739411 392786 USRC ALTOONA DIALYSIS CENTER 0 0 0 0 0 0 0 0 0 0 32557
1023384013 392791 WESTTOWN DIALYSIS 0 0 0 0 0 0 0 0 0 0 35190
1811257108 392803 SUBURBAN CAMPUS DIALYSIS 0 0 0 0 0 0 0 0 0 0 33401
1538391248 393518 GEISINGER MEDICAL CENTER-ESRD 0 0 0 0 0 0 0 0 0 0 31782
1215922471 394527 TRINDLE REHAB MEDICINE ASSOC 24796 0 0 0 0 0 0 0 0 0 0
1619911914 396578 MONTGOMERY COUNTY REHAB AND SPORTS THERAPY 24399 0 0 0 0 0 0 0 0 0 0
1851563076 396582 DR. DAVID POTOKER 0 0 16856 0 0 0 0 0 0 0 0
1295992683 396603 THERAPEUTIC REHAB (TRAC) 13158 0 38590 0 0 0 0 0 0 0 0
1972501757 396616 MAHONING PT/TWOLICK VALLEY PT 13536 0 0 0 0 0 0 0 0 0 0
1235519398 396854 GENESIS PROSTEP LLC D/B/A ADULT SERVICES UNLIMITED 39191 37012 48822 0 0 37012 0 0 0 0 0
999996 999996 OUT-OF-STATE PROVIDER 24796 0 0 0 0 0 0 0 0 0 0