2015 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
Contin-
uous
Care
Respite
Care
General
Inpt
Implied Decimal 2 (in dollars)
1063498541
391656
HOSPICE
OF THE
SACRED
HEART
0 0 0 0 0 0 0 19386 113157 20126 86346
1962583922
392300
GEISINGER
MEDICAL
CENTER-
ESRD
0 0 0 0 0 25071 0 0 0 0 0
1780831198
392632
FRESENIUS
MEDICAL
CARE
PENN
HILLS
0 0 0 0 0 26349 0 0 0 0 0
1083677587
392691
DCA OF
MECHANICS-
BURG
0 0 0 0 0 26139 0 0 0 0 0
1306808472
392723
DUNMORE
DIALYSIS
0 0 0 0 0 25071 0 0 0 0 0
1265739411
392786
USRC
ALTOONA
DIALYSIS
CENTER
0 0 0 0 0 25683 0 0 0 0 0
1023384013
392791
WEST-
TOWN
DIALYSIS
0 0 0 0 0 27759 0 0 0 0 0
1811257108
392803
SUBURB-
AN
CAMPUS
DIALYSIS
0 0 0 0 0 26349 0 0 0 0 0
1538391248
393518
GEISINGER
MEDICAL
CENTER-
ESRD
0 0 0 0 0 25071 0 0 0 0 0
394527
394527
TRINDLE
REHAB
MEDICINE
CENTER
19561 0 0 0 0 0 0 0 0 0 0
396522
396522
WILKES-
BARRE
SPEECH
AND
LANGUAGE
0 0 7886 0 0 0 0 0 0 0 0
396538
396538
JENKIN-
TOWN
REHAB
20010 14686 19317 0 0 0 0 0 0 0 0
396558
396558
SOUTH-
WEST
REHAB
ASSOC-
IATES
12587 13821 10643 0 0 0 0 0 0 0 0
396578
396578
MONTG-
OMERY
COUNTY
REHAB
19247 0 0 0 0 0 0 0 0 0 0
396581
396581
PROFESS-
IONAL
REHAB
ASSOC-
IATES,
INC.
10402 0 24053 0 0 0 0 0 0 0 0
396582
396582
DR. DAVID
POTOKER
0 0 13296 0 0 0 0 0 0 0 0
396603
396603
THERA-
PEUTIC
REHAB
(TRAC)
10379 0 30441 0 0 0 0 0 0 0 0
396611
396611
BRYN
MAWR
ORTHO-
PEDICS
13582 0 0 0 0 0 0 0 0 0 0
396616
396616
MAHONING
PT /
TWOLICK
VALLEY PT
10678 0 0 0 0 0 0 0 0 0 0
396625
396625
MANOA
SPORTS
AND
SPINAL
INSTITUTE
14975 0 0 0 0 0 0 0 0 0 0
1407838055
396850
HEALTH
POCONO,
INC
(RIVER-
SIDE
CENTER)
18588 12736 68290 0 0 0 12736 0 0 0 0
1275526725
396854
ADULT
SERVICES
UNLIMITED
30916 29196 38513 0 0 0 29196 0 0 0 0
999996
999996
OUT-OF-
STATE
PROVIDER
19561 0 0 0 0 0 0 0 0 0 0
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