2016 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 19948 116439 20710 88850 0
1528049160 391674 GRANE
HOSPICE-
PITTSBURGH
0 0 0 0 0 0 20887 121912 21473 92737 0
1972918878 391693 GRANE
HOSPICE
HOLLIDAYS-
BURG
0 0 0 0 0 0 20212 117975 20924 89941 0
1316352214 391732 GRANE
HOSPICE-
LEMOYNE
0 0 0 0 0 0 21289 124262 21801 94406 0
1851706873 391765 GRANE
HOSPICE-
KING
OF
PRUSSIA
0 0 0 0 0 0 22733 132689 22978 100388 0
1962583922 392300 GEISINGER
MEDICAL
CENTER-
ESRD
0 0 0 0 0 0 0 0 0 0 25798
1780831198 392632 FRESENIUS
MEDICAL
CARE-
PENN
HILLS
0 0 0 0 0 0 0 0 0 0 27113
1083677587 392691 DCA
OF
MECHANICS-
BURG
0 0 0 0 0 0 0 0 0 0 26897
1306808472 392723 DUNMORE
DIALYSIS
0 0 0 0 0 0 0 0 0 0 25798
1265739411 392786 USRC
ALTOONA
DIALYSIS
CENTER
0 0 0 0 0 0 0 0 0 0 26428
1023384013 392791 WEST-
TOWN
DIALYSIS
0 0 0 0 0 0 0 0 0 0 28564
1811257108 392803

SUBURBAN
CAMPUS
DIALYSIS

0 0 0 0 0 0 0 0 0 0 27113
1538391248 393518 GEISINGER-
MEDICAL
CENTER
ESRD
0 0 0 0 0 0 0 0 0 0 25798
1215922471 394527 TRINDLE-
REHAB
MEDICINE
ASSOC
20128 0 0 0 0 0 0 0 0 0 0
1619911914 396578 MONT-
GOMERY
COUNTY
REHAB
SPORTS
THERAPY
19805 0 0 0 0 0 0 0 0 0 0
1851563076 396582 DR.
DAVID
POTOKER
0 0 13682 0 0 0 0 0 0 0 0
1295992683 396603 THERA-
PEUTIC-
REHAB
(TRAC)
10680 0 31324 0 0 0 0 0 0 0 0
1972501757 396616 MAHON-
ING PT/
TWOLICK
VALLEY PT
10988 0 0 0 0 0 0 0 0 0 0
1851771919 396850 HEALTH
POCONO,
INC
19127 13105 70270 0 0 13105 0 0 0 0 0
1235519398 396854 ADULT
SERVICES
UNLIMITED
31813 30043 39630 0 0 30043 0 0 0 0 0
999996 999996 OUT-
OF-
STATE
PROVIDER
20128 0 0 0 0 0 0 0 0 0 0
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