Hawaii Administrative Rules › Title 12 - DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS › Chapter 15 - WORKERS COMPENSATION MEDICAL FEE SCHEDULE & EXHIBIT A › Exhibit A - Workers' Compensation Supplemental Medical Fee Schedule

Current through June,
			 2024
SURGERY
Integumentary System
Code
Maximum Fee
Code
Maximum Fee
Code
Maximum Fee
10060
$157.64
12007
$362.23
13133
$231.43
10061
$275.03
12011
$189.70
13151
$613.78
10120
$207.95
12013
$209.90
13152
$791.54
10121
$389.06
12014
$234.78
13153
$254.90
11000
$77.14
12015
$285.09
13160
$980.01
11001
$30.19
12031
$365.59
14040
$1,120.24
11010
$704.34
12032
$486.33
15004
$478.26
11043
$311.92
12034
$472.91
15050
$675.48
11044
$435.71
12035
$550.06
15100
$1,021.38
11055
$61.93
12041
$352.17
15101
$223.27
11056
$74.47
12042
$456.14
15120
$1,136.58
11601
$280.48
12044
$533.29
15240
$1,119.97
11602
$309.48
12051
$385.71
15260
$1,428.80
11719
$17.85
12052
$432.67
15738
$1,716.06
11730
$144.22
12053
$526.58
16000
$93.91
11740
$73.79
12054
$566.83
16020
$114.04
11750
$335.40
13100
$446.08
16025
$201.24
11760
$315.28
13101
$603.72
16030
$244.84
12001
$177.25
13121
$630.55
17003
$11.57
12002
$188.55
13122
$167.70
17004
$190.91
12004
$214.66
13131
$513.16
12005
$268.32
13132
$818.38
Musculoskeletal System
20520
$275.03
21407
$804.03
23130
$771.72
20525
$741.23
21408
$1,105.80
23350
$181.12
20526
$90.56
21423
$981.30
23405
$765.14
20550
$80.50
21470
$1,492.05
23410
$1,204.09
20551
$80.50
22551
$2,623.25
23412
$1,203.42
20552
$73.79
22552
$575.17
23420
$1,425.45
20553
$83.85
22554
$1,846.24
23430
$1,056.51
20600
$77.14
22558
$2,143.21
23440
$924.08
20605
$90.56
22585
$480.17
23455
$1,428.80
20610
$103.97
22600
$1,612.67
23500
$274.66
20612
$73.79
22612
$2,015.75
23552
$805.59
20900
$653.33
22614
$523.22
23570
$288.42
20902
$611.91
22630
$1,947.78
23620
$327.14
20924
$647.67
22632
$380.07
23650
$415.90
20926
$522.86
22633
$2,224.80
23655
$586.95
20930
$230.30
22634
$589.95
23700
$241.74
20931
$132.37
22830
$988.38
24149
$1,445.40
20936
$212.96
22840
$975.65
24305
$712.82
20937
$228.07
22842
$1,076.63
24340
$755.24
21310
$177.76
22845
$1,072.27
24341
$1,113.53
21320
$402.48
22849
$1,565.01
24342
$1,044.47
21360
$673.04
22850
$879.71
24343
$896.22
21365
$1,369.05
22852
$843.51
24344
$1,337.40
21390
$989.27
22856
$1,961.79
24357
$607.07
21395
$1,232.63
23120
$722.81
24358
$707.69
24359
$882.10
26541
$990.84
27724
$1,536.89
24366
$836.02
26548
$964.87
27750
$422.90
24515
$1,075.75
26560
$724.92
27758
$1,091.92
24600
$496.39
26567
$843.41
27759
$1,301.35
24605
$707.69
26600
$409.19
27760
$400.96
24665
$807.11
26605
$390.09
27766
$812.38
24666
$933.53
26608
$604.42
27786
$383.95
24685
$807.82
26686
$766.57
27792
$932.41
25000
$494.63
26720
$292.03
27810
$572.21
25024
$950.44
26725
$466.21
27814
$1,116.88
25105
$598.10
26727
$670.80
27823
$1,279.56
25111
$440.34
26735
$868.69
27827
$1,436.56
25118
$501.82
26742
$440.86
27828
$1,677.54
25240
$532.00
26750
$258.26
27840
$455.45
25246
$204.80
26756
$521.87
27842
$608.22
25260
$910.33
26765
$684.22
27870
$1,260.53
25270
$734.92
26770
$368.94
28002
$562.94
25272
$816.43
26860
$709.98
28008
$534.81
25290
$541.39
26951
$812.42
28090
$583.33
25295
$648.49
26952
$802.24
28122
$769.79
25310
$765.83
27096
$308.57
28222
$628.86
25320
$1,221.89
27130
$2,049.29
28238
$818.88
25337
$1,101.29
27216
$1,306.30
28300
$801.64
25390
$946.95
27227
$2,020.01
28400
$303.94
25400
$985.62
27228
$2,290.97
28415
$1,382.88
25405
$1,268.46
27235
$1,161.20
28445
$1,423.67
25440
$945.86
27236
$1,460.79
28475
$318.49
25447
$1,021.81
27245
$1,843.43
28485
$623.84
25505
$768.07
27248
$972.95
28510
$154.60
25545
$841.64
27350
$801.09
28725
$960.18
25605
$828.44
27370
$200.54
28730
$905.27
25606
$819.26
27380
$754.00
29065
$140.87
25607
$922.97
27385
$811.67
29075
$127.45
25608
$1,094.27
27403
$786.02
29105
$127.45
25609
$1,327.47
27405
$860.78
29125
$100.62
25628
$925.74
27427
$872.96
29130
$60.37
25645
$728.49
27446
$1,412.69
29200
$37.76
25825
$969.31
27447
$2,190.16
29240
$35.84
26020
$539.71
27457
$1,154.99
29260
$35.88
26035
$1,052.64
27486
$1,715.47
29280
$36.10
26055
$788.19
27487
$2,259.18
29405
$120.74
26075
$405.17
27506
$1,891.66
29425
$124.10
26080
$486.92
27524
$1,069.93
29445
$168.01
26105
$415.26
27530
$482.72
29515
$103.97
26110
$402.15
27535
$1,157.13
29520
$39.68
26115
$705.01
27536
$1,452.54
29530
$35.84
26145
$634.34
27560
$435.24
29540
$32.27
26320
$439.73
27570
$198.82
29550
$23.80
26340
$432.67
27603
$741.23
29580
$64.03
26350
$1,026.32
27625
$713.94
29581
$82.88
26356
$1,703.83
27640
$1,021.38
29584
$93.24
26410
$811.67
27650
$972.66
29700
$78.97
26418
$831.79
27652
$931.79
29806
$1,509.30
26426
$768.16
27658
$463.51
29807
$1,472.41
26433
$664.43
27675
$605.33
29820
$707.69
26440
$780.74
27680
$562.20
29821
$778.13
26445
$730.00
27687
$562.38
29822
$751.30
26480
$943.79
27691
$923.08
29823
$895.52
26525
$820.08
27695
$591.50
29824
$859.14
26540
$942.47
27698
$842.56
29825
$747.56
29826
$297.00
29873
$686.88
29888
$1,401.97
29827
$1,517.72
29874
$700.13
29891
$829.79
29828
$1,304.71
29875
$670.75
29897
$620.41
29835
$620.55
29876
$832.92
29898
$746.85
29837
$647.07
29877
$885.46
29905
$837.86
29838
$754.47
29879
$942.47
29906
$853.65
29844
$636.24
29880
$960.01
29914
$1,219.87
29846
$665.85
29881
$896.85
29915
$1,243.14
29848
$644.78
29882
$929.52
29916
$1,244.58
29862
$996.51
29884
$788.02
29867
$1,623.86
29887
$910.84
Respiratory System
31231
$295.15
31570
$408.32
32551
$187.59
31240
$195.12
31575
$139.42
Cardiovascular System
35206
$930.99
36247
$1,969.13
36569
$321.58
35207
$962.38
36410
$23.76
36600
$40.25
36245
$1,676.00
36415
$4.34
36620
$60.85
36246
$1,063.21
36430
$46.91
Digestive System
45378
$516.23
49568
$315.26
49652
$891.84
49505
$670.38
49585
$545.80
49653
$1,111.71
49507
$704.11
49587
$574.68
49520
$774.58
49650
$528.36
49560
$884.14
49651
$672.45
Urinary System
51700
$93.90
51798
$25.86
Male Genital System
55520
$550.26
Female Genital System
57288
$869.84
Maternity Care and Delivery
59025
$59.78
Nervous System
62270
$202.86
63047
$1,560.24
64421
$189.60
62362
$469.40
63048
$301.63
64445
$164.79
62368
$70.76
63075
$1,949.94
64450
$147.58
62369
$154.95
63655
$1,002.58
64455
$59.00
62370
$162.36
63663
$997.19
64479
$299.22
63030
$1,368.43
63685
$446.50
64480
$142.36
63035
$271.67
63688
$453.26
64483
$345.46
63042
$1,654.98
64405
$129.38
64484
$187.82
63045
$1,545.83
64415
$146.81
64491
$113.76
64492
$115.25
64634
$243.72
64718
$805.79
64495
$104.69
64635
$531.08
64721
$607.07
64510
$163.33
64636
$222.21
64772
$691.03
64520
$236.08
64640
$169.41
64776
$505.52
64550
$23.48
64646
$182.63
64782
$561.69
64616
$153.36
64702
$622.43
64831
$906.97
64617
$222.68
64704
$448.22
64832
$410.15
64633
$536.70
64708
$601.10
64856
$1,236.90
Eye and Ocular Adnexa
65205
$80.50
65435
$107.33
68720
$946.84
65210
$97.27
67036
$1,125.88
68810
$200.71
65222
$100.62
67145
$650.54
68815
$514.53
65426
$972.66
67820
$62.56
65430
$137.61
67917
$767.01
Auditory System
69200
$191.18
69210
$73.79
Operating Microscope
69990
$305.21
RADIOLOGY
Fees include both the technical and professional components. In
				the absence of any prior agreement, the professional component shall be
				thirty-five percent of the scheduled fee.
Diagnostic Radiology (Diagnostic Imaging)
70030
$40.25
70547
$740.74
72074
$70.43
70100
$46.96
70548
$730.72
72080
$57.02
70110
$57.02
70551
$300.55
72100
$57.02
70140
$46.96
70553
$492.15
72110
$80.50
70150
$67.08
71010
$40.25
72114
$103.97
70160
$46.96
71020
$50.31
72120
$73.79
70200
$67.08
71035
$50.31
72125
$409.19
70220
$63.73
71100
$50.31
72128
$409.19
70250
$53.66
71101
$60.37
72131
$409.19
70260
$77.14
71110
$63.73
72132
$523.22
70330
$70.43
71111
$80.50
72133
$623.84
70336
$673.55
71120
$53.66
72141
$291.72
70355
$40.25
71130
$57.02
72142
$425.24
70360
$40.25
71250
$425.96
72146
$292.19
70450
$345.46
71260
$523.22
72148
$290.76
70470
$529.93
71270
$637.26
72149
$420.22
70480
$368.39
71275
$391.50
72156
$495.50
70486
$181.30
71550
$669.54
72157
$496.45
70488
$590.30
71552
$1,210.74
72158
$493.57
70491
$486.33
72020
$36.89
72170
$43.60
70496
$382.38
72040
$53.66
72190
$57.02
70498
$381.41
72050
$77.14
72192
$405.83
70540
$656.55
72052
$97.27
72193
$506.45
70543
$545.87
72070
$53.66
72195
$670.30
70544
$660.51
72072
$60.37
72197
$665.03
72200
$43.60
73220
$658.28
73723
$618.59
72202
$53.66
73221
$309.76
74000
$43.60
72220
$46.96
73222
$497.73
74020
$60.37
72265
$264.97
73223
$618.10
74022
$70.43
72275
$171.05
73525
$157.64
74150
$405.83
72295
$385.71
73560
$43.60
74160
$533.29
73000
$43.60
73562
$50.31
74175
$400.59
73010
$43.60
73564
$57.02
74176
$258.28
73020
$36.89
73565
$44.97
74178
$461.83
73030
$46.96
73580
$194.53
74181
$669.89
73040
$167.70
73590
$43.60
74183
$666.46
73050
$54.08
73600
$40.25
75635
$849.89
73060
$46.96
73610
$46.96
75710
$643.97
73070
$40.51
73620
$40.25
75716
$677.51
73080
$50.31
73630
$46.96
75736
$643.97
73090
$43.60
73650
$40.25
75774
$560.12
73100
$43.60
73660
$40.25
76000
$62.36
73110
$50.31
73700
$382.36
76001
$211.30
73115
$147.58
73701
$479.62
76100
$118.89
73120
$40.25
73706
$465.16
76376
$29.87
73130
$46.96
73718
$567.99
76377
$90.31
73200
$382.36
73720
$661.63
73201
$479.62
73721
$309.28
73218
$656.66
73722
$502.05
Diagnostic Ultrasound
76512
$164.55
76775
$150.93
76881
$151.10
76513
$150.93
76801
$160.58
76882
$43.49
76514
$19.06
76815
$110.54
76937
$40.24
76519
$122.71
76817
$126.92
76942
$76.68
76700
$197.89
76856
$167.70
76705
$147.58
76857
$61.49
76770
$187.82
76870
$167.70
Radiologic Guidance
77001
$110.55
77012
$158.81
Bone/Joint Studies
77073
$45.95
77080
$53.78
Radiation Oncology
77290
$674.15
77334
$264.97
77336
$140.87
Nuclear Medicine
78104
$348.82
78305
$318.63
78452
$646.29
78122
$258.26
78306
$355.52
78805
$271.67
78300
$234.78
78320
$415.90
78806
$496.39
MEDICINE
Fees include both the technical and professional components. In
				the absence of any prior agreement, the professional component shall be
				thirty-five percent of the scheduled fee.
Vaccines, Toxoids
90636
$99.07
90715
$46.96
90746
$63.32
90714
$21.90
90732
$86.62
Psychiatry
90791
$154.68
90834
$99.69
90847
$151.70
90792
$173.73
90837
$167.74
90832
$84.86
90846
$126.80
Biofeedback
90901
$53.27
Gastroenterology
91035
$626.61
91110
$1,217.70
Ophthalmology
92002
$110.68
92071
$45.43
92225
$34.44
92004
$201.24
92082
$62.57
92235
$169.72
92012
$110.68
92083
$83.46
92250
$86.01
92014
$160.99
92132
$39.75
92284
$82.71
92015
$23.50
92133
$47.73
92285
$27.47
92020
$42.42
92134
$52.21
92286
$49.17
92025
$48.21
92136
$115.85
92310
$78.69
Special Otorhinolaryngologic Services
92507
$97.37
92550
$25.24
92590
$74.94
92511
$144.51
92551
$13.52
92591
$99.11
92526
$106.68
92557
$63.40
92592
$35.51
92541
$69.74
92567
$26.83
92595
$51.33
92542
$67.08
92570
$38.42
92610
$106.71
92545
$50.39
92577
$29.60
92611
$107.45
92547
$23.48
92587
$69.43
92548
$140.87
92588
$96.86
Cardiovascular
93000
$33.45
93040
$16.84
93289
$82.28
93005
$20.12
93042
$10.06
93306
$298.79
93010
$11.21
93224
$187.96
93308
$137.15
93015
$135.82
93225
$57.02
93325
$80.50
93016
$26.86
93226
$93.91
93351
$353.39
93017
$83.85
93280
$73.19
93018
$20.12
93282
$79.37
Noninvasive Vascular Diagnostic Studies
93926
$171.42
93971
$158.92
93976
$250.52
Pulmonary
94010
$46.80
94645
$18.48
94727
$54.02
94060
$80.14
94664
$23.22
94729
$69.46
94150
$47.46
94667
$35.44
94760
$6.71
94640
$24.64
94726
$69.18
94762
$43.60
Neurology and Neuromuscular Procedures
95805
$721.28
95907
$147.58
95929
$277.90
95810
$821.21
95908
$157.64
95930
$172.20
95811
$862.70
95909
$214.66
95951
$2,089.25
95851
$27.00
95910
$285.09
95957
$397.70
95852
$20.13
95911
$342.11
95971
$61.93
95861
$224.72
95912
$399.13
95972
$72.10
95885
$87.20
95913
$462.85
95887
$107.33
95925
$182.99
Central Nervous System Assessments/Tests
96101
$97.27
Health and Behavior Assessment/Intervention
96150
$25.59
96152
$23.15
Hydration, Therapeutic, Prophylactic, Diagnostic
				Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or
				Highly Complex Biologic Agent Administration
96360
$92.58
96366
$24.00
96376
$20.77
96361
$24.07
96367
$39.97
96365
$91.06
96375
$29.03
Physical Medicine and Rehabilitation
97010
$5.04
97116
$36.89
97542
$38.34
97012
$20.12
97124
$33.54
97545
$119.69
97014
$16.77
97140
$36.89
97546
$51.17
97016
$24.15
97150
$20.67
97605
$51.27
97024
$8.49
97530
$46.96
97606
$61.71
97032
$23.48
97532
$32.90
97750
$40.25
97110
$43.60
97535
$43.90
97760
$50.31
97112
$43.60
97537
$37.31
Acupuncture
97810
$52.39
97813
$55.95
97811
$35.31
97814
$39.55
Chiropractic Manipulative Treatment
98940
$30.19
Special Services, Procedures and Reports
99000
$8.17
99050
$48.25
99002
$10.89
99053
$70.50
Qualifying Circumstances for Anesthesia
99100
$44.79
Other Services and Procedures
99173
$3.42
99183
$131.33
DENTAL SERVICES
Diagnostic
D0120
$41.81
D0210
$94.66
D0272
$30.96
D0140
$52.13
D0220
$19.29
D0330
$83.69
D0150
$57.69
D0230
$15.07
D0470
$64.96
Preventive
D1110
$68.87
Restorative
D2160
$115.71
D2335
$183.74
D2940
$73.72
D2330
$84.86
D2391
$106.64
D2950
$179.19
D2331
$127.28
D2740
$837.28
D2954
$204.42
D2332
$158.31
D2750
$789.63
Endodontics
D3310
$412.71
Periodontics
D4211
$211.85
Prosthodontics, Removable
D5110
$988.75
D5211
$776.37
D5820
$395.17
D5130
$1,048.91
D5212
$806.73
Implant Services
D6010
$1,712.90
D6059
$1,131.93
D6104
$296.69
D6057
$566.15
D6065
$1,074.45
Prosthodontics, Fixed
D6240
$752.13
D6245
$756.50
D6750
$786.07
Oral and Maxillofacial Surgery
D7140
$92.58
D7880
$490.00
D7210
$198.03
D7953
$307.20
Adjunctive General Services
D9110
$76.43
D9430
$55.53
D9942
$102.80
D9310
$91.08
D9940
$408.83
EVALUATION AND MANAGEMENT
Office or Other Outpatient Services
99201
$70.36
99205
$304.83
99214
$158.77
99202
$114.00
99211
$37.07
99215
$212.24
99203
$165.55
99212
$66.32
99204
$245.01
99213
$107.83
Hospital Inpatient Services
99232
$124.79
Consultations
99241
$66.58
99245
$237.19
99254
$183.81
99242
$99.81
99251
$53.76
99255
$222.85
99243
$143.46
99252
$83.10
99244
$186.63
99253
$126.71
Emergency Department Services
99281
$50.31
99283
$133.00
99285
$322.51
99282
$90.19
99284
$225.58
Critical Care Services
99292
$147.36
Case Management Services
99366
$65.67
99367
$85.93
99368
$55.55
Preventive Medicine Services
99395
$116.14
99408
$40.23
Non-Face-to-Face Services
99441
$22.23
99443
$60.50
99442
$40.98
Special Evaluation and Management Services
Code
Description
Maximum Fee
99456A*
Complex consultation pursuant to Section
						  386-79,
						  HRS - work related or medical disability examination by other than the treating
						  physician that includes:
* completion of a medical history commensurate with the
						  patient's condition;
* performance of an examination commensurate with the
						  patient's condition;
* formulation of a diagnosis, assessment of
						  capabilities and stability, and calculation of impairment;
* development of future medical treatment plan;
* completion of necessary documentation/certificates
						  and report; and
* review of records relating to the patient's
						  condition.
First
						  hour...........................................................................................................................................
$207.25
99456B*
Each additional 30 minute increment (an increment must
						  be at least 30 minutes.)............................
$103.63
*Department of Labor Code
Bundled Services:
Certain codes, such as telephone
				calls, are considered by the Health Care Financing Administration (HCFA) to be
				"bundled" services. Bundled services are not payable, nor should they be
				billed, when performed incident to or in conjunction with another service even
				if the other service is performed on a different day. When services that are
				designated as bundled are denied, the physician may not collect from the
				patient.