L4090
Prosthetics & Orthotics
53 States
Replace metal bands kafo-afo, calf or distal thigh
Short Desc
Repl met band kafo-afo calf/
Coverage determined by local carrier discretion.
Added Date
1985-01-01
Effective From
1996-01-01
National Floor
$103.77
National Ceiling
$138.37
Fee Schedule Rates
Effective Jan 2026Official Medicare DMEPOS pricing for 2026.
| State | Modifier | Non-Rural | Rural |
|---|---|---|---|
|
AK
|
Base Rate |
$122.52
|
Same |
|
AL
|
Base Rate |
$108.72
|
Same |
|
AR
|
Base Rate |
$131.28
|
Same |
|
AZ
|
Base Rate |
$126.49
|
Same |
|
CA
|
Base Rate |
$126.49
|
Same |
|
CO
|
Base Rate |
$103.77
|
Same |
|
CT
|
Base Rate |
$120.73
|
Same |
|
DC
|
Base Rate |
$104.67
|
Same |
|
DE
|
Base Rate |
$104.67
|
Same |
|
FL
|
Base Rate |
$108.72
|
Same |
|
GA
|
Base Rate |
$108.72
|
Same |
|
HI
|
Base Rate |
$131.01
|
Same |
|
IA
|
Base Rate |
$133.07
|
Same |
|
ID
|
Base Rate |
$138.25
|
Same |
|
IL
|
Base Rate |
$103.88
|
Same |
|
IN
|
Base Rate |
$103.88
|
Same |
|
KS
|
Base Rate |
$133.07
|
Same |
|
KY
|
Base Rate |
$108.72
|
Same |
|
LA
|
Base Rate |
$131.28
|
Same |
|
MA
|
Base Rate |
$120.73
|
Same |
|
MD
|
Base Rate |
$104.67
|
Same |
|
ME
|
Base Rate |
$120.73
|
Same |
|
MI
|
Base Rate |
$103.88
|
Same |
|
MN
|
Base Rate |
$103.88
|
Same |
|
MO
|
Base Rate |
$133.07
|
Same |
|
MS
|
Base Rate |
$108.72
|
Same |
|
MT
|
Base Rate |
$103.77
|
Same |
|
NC
|
Base Rate |
$108.72
|
Same |
|
ND
|
Base Rate |
$103.77
|
Same |
|
NE
|
Base Rate |
$133.07
|
Same |
|
NH
|
Base Rate |
$120.73
|
Same |
|
NJ
|
Base Rate |
$123.50
|
Same |
|
NM
|
Base Rate |
$131.28
|
Same |
|
NV
|
Base Rate |
$126.49
|
Same |
|
NY
|
Base Rate |
$123.50
|
Same |
|
OH
|
Base Rate |
$103.88
|
Same |
|
OK
|
Base Rate |
$131.28
|
Same |
|
OR
|
Base Rate |
$138.25
|
Same |
|
PA
|
Base Rate |
$104.67
|
Same |
|
PR
|
Base Rate |
$142.76
|
Same |
|
RI
|
Base Rate |
$120.73
|
Same |
|
SC
|
Base Rate |
$108.72
|
Same |
|
SD
|
Base Rate |
$103.77
|
Same |
|
TN
|
Base Rate |
$108.72
|
Same |
|
TX
|
Base Rate |
$131.28
|
Same |
|
UT
|
Base Rate |
$103.77
|
Same |
|
VA
|
Base Rate |
$104.67
|
Same |
|
VI
|
Base Rate |
$123.50
|
Same |
|
VT
|
Base Rate |
$120.73
|
Same |
|
WA
|
Base Rate |
$138.25
|
Same |
|
WI
|
Base Rate |
$103.88
|
Same |
|
WV
|
Base Rate |
$104.67
|
Same |
|
WY
|
Base Rate |
$103.77
|
Same |