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

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

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

31231

$295.15

31570

$408.32

32551

$187.59

31240

$195.12

31575

$139.42

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

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

51700

$93.90

51798

$25.86

55520

$550.26

57288

$869.84

59025

$59.78

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

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

69200

$191.18

69210

$73.79

69990

$305.21

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

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

77001

$110.55

77012

$158.81

77073

$45.95

77080

$53.78

77290

$674.15

77334

$264.97

77336

$140.87

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

90636

$99.07

90715

$46.96

90746

$63.32

90714

$21.90

90732

$86.62

90791

$154.68

90834

$99.69

90847

$151.70

90792

$173.73

90837

$167.74

90832

$84.86

90846

$126.80

90901

$53.27

91035

$626.61

91110

$1,217.70

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

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

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

93926

$171.42

93971

$158.92

93976

$250.52

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

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

96101

$97.27

96150

$25.59

96152

$23.15

96360

$92.58

96366

$24.00

96376

$20.77

96361

$24.07

96367

$39.97

96365

$91.06

96375

$29.03

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

97810

$52.39

97813

$55.95

97811

$35.31

97814

$39.55

98940

$30.19

99000

$8.17

99050

$48.25

99002

$10.89

99053

$70.50

99100

$44.79

99173

$3.42

99183

$131.33

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

D1110

$68.87

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

D3310

$412.71

D4211

$211.85

D5110

$988.75

D5211

$776.37

D5820

$395.17

D5130

$1,048.91

D5212

$806.73

D6010

$1,712.90

D6059

$1,131.93

D6104

$296.69

D6057

$566.15

D6065

$1,074.45

D6240

$752.13

D6245

$756.50

D6750

$786.07

D7140

$92.58

D7880

$490.00

D7210

$198.03

D7953

$307.20

D9110

$76.43

D9430

$55.53

D9942

$102.80

D9310

$91.08

D9940

$408.83

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

99232

$124.79

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

99281

$50.31

99283

$133.00

99285

$322.51

99282

$90.19

99284

$225.58

99292

$147.36

99366

$65.67

99367

$85.93

99368

$55.55

99395

$116.14

99408

$40.23

99441

$22.23

99443

$60.50

99442

$40.98

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