L1904
Prosthetics & Orthotics
53 States
Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated
Short Desc
Afo molded ankle gauntlet
Coverage determined by local carrier discretion.
Added Date
1988-01-01
Effective From
2016-01-01
National Floor
$540.36
National Ceiling
$720.48
Fee Schedule Rates
Effective Jan 2026Official Medicare DMEPOS pricing for 2026.
| State | Modifier | Non-Rural | Rural |
|---|---|---|---|
|
AK
|
Base Rate |
$926.53
|
Same |
|
AL
|
Base Rate |
$540.36
|
Same |
|
AR
|
Base Rate |
$540.36
|
Same |
|
AZ
|
Base Rate |
$720.48
|
Same |
|
CA
|
Base Rate |
$720.48
|
Same |
|
CO
|
Base Rate |
$540.36
|
Same |
|
CT
|
Base Rate |
$720.48
|
Same |
|
DC
|
Base Rate |
$644.19
|
Same |
|
DE
|
Base Rate |
$644.19
|
Same |
|
FL
|
Base Rate |
$540.36
|
Same |
|
GA
|
Base Rate |
$540.36
|
Same |
|
HI
|
Base Rate |
$990.72
|
Same |
|
IA
|
Base Rate |
$543.22
|
Same |
|
ID
|
Base Rate |
$540.36
|
Same |
|
IL
|
Base Rate |
$554.72
|
Same |
|
IN
|
Base Rate |
$554.72
|
Same |
|
KS
|
Base Rate |
$543.22
|
Same |
|
KY
|
Base Rate |
$540.36
|
Same |
|
LA
|
Base Rate |
$540.36
|
Same |
|
MA
|
Base Rate |
$720.48
|
Same |
|
MD
|
Base Rate |
$644.19
|
Same |
|
ME
|
Base Rate |
$720.48
|
Same |
|
MI
|
Base Rate |
$554.72
|
Same |
|
MN
|
Base Rate |
$554.72
|
Same |
|
MO
|
Base Rate |
$543.22
|
Same |
|
MS
|
Base Rate |
$540.36
|
Same |
|
MT
|
Base Rate |
$540.36
|
Same |
|
NC
|
Base Rate |
$540.36
|
Same |
|
ND
|
Base Rate |
$540.36
|
Same |
|
NE
|
Base Rate |
$543.22
|
Same |
|
NH
|
Base Rate |
$720.48
|
Same |
|
NJ
|
Base Rate |
$558.83
|
Same |
|
NM
|
Base Rate |
$540.36
|
Same |
|
NV
|
Base Rate |
$720.48
|
Same |
|
NY
|
Base Rate |
$558.83
|
Same |
|
OH
|
Base Rate |
$554.72
|
Same |
|
OK
|
Base Rate |
$540.36
|
Same |
|
OR
|
Base Rate |
$540.36
|
Same |
|
PA
|
Base Rate |
$644.19
|
Same |
|
PR
|
Base Rate |
$590.09
|
Same |
|
RI
|
Base Rate |
$720.48
|
Same |
|
SC
|
Base Rate |
$540.36
|
Same |
|
SD
|
Base Rate |
$540.36
|
Same |
|
TN
|
Base Rate |
$540.36
|
Same |
|
TX
|
Base Rate |
$540.36
|
Same |
|
UT
|
Base Rate |
$540.36
|
Same |
|
VA
|
Base Rate |
$644.19
|
Same |
|
VI
|
Base Rate |
$558.83
|
Same |
|
VT
|
Base Rate |
$720.48
|
Same |
|
WA
|
Base Rate |
$540.36
|
Same |
|
WI
|
Base Rate |
$554.72
|
Same |
|
WV
|
Base Rate |
$644.19
|
Same |
|
WY
|
Base Rate |
$540.36
|
Same |