Haw. Code R. tit. 12, ch. 15, exh. A - Workers' Compensation Supplemental Medical Fee Schedule

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.

Notes

Haw. Code R. tit. 12, ch. 15, exh. A

Eff 12/28/2017