| Code | Description | States | Median rate |
|---|---|---|---|
| L4000 | Replace girdle for spinal orthosis (ctlso or so) | 42 | $1,211.11 |
| L4002 | Replacement strap, any orthosis, includes all components, any length, any type | 20 | $15.00 |
| L4010 | Replace trilateral socket brim | 43 | $646.44 |
| L4020 | Replace quadrilateral socket brim, molded to patient model | 42 | $844.79 |
| L4030 | Replace quadrilateral socket brim, custom fitted | 42 | $489.73 |
| L4040 | Replace molded thigh lacer, for custom fabricated orthosis only | 42 | $391.90 |
| L4045 | Replace non-molded thigh lacer, for custom fabricated orthosis only | 43 | $301.55 |
| L4050 | Replace molded calf lacer, for custom fabricated orthosis only | 43 | $410.69 |
| L4055 | Replace non-molded calf lacer, for custom fabricated orthosis only | 44 | $246.98 |
| L4060 | Replace high roll cuff | 43 | $300.09 |
| L4070 | Replace proximal and distal upright for kafo | 43 | $274.88 |
| L4080 | Replace metal bands kafo, proximal thigh | 43 | $92.72 |
| L4090 | Replace metal bands kafo-afo, calf or distal thigh | 45 | $86.45 |
| L4100 | Replace leather cuff kafo, proximal thigh | 42 | $106.37 |
| L4110 | Replace leather cuff kafo-afo, calf or distal thigh | 45 | $82.82 |
| L4130 | Replace pretibial shell | 43 | $466.14 |
| L4205 | Repair of orthotic device, labor component, per 15 minutes | 41 | $21.33 |
| L4210 | Repair of orthotic device, repair or replace minor parts | 23 | $33.69 |
| L4350 | Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf | 43 | $89.76 |
| L4360 | Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 44 | $273.16 |
| L4361 | Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf | 40 | $256.97 |
| L4370 | Pneumatic full leg splint, prefabricated, off-the-shelf | 42 | $176.69 |
| L4386 | Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 43 | $152.13 |
| L4387 | Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf | 40 | $145.07 |
| L4392 | Replacement, soft interface material, static afo | 39 | $22.57 |
| L4394 | Replace soft interface material, foot drop splint | 40 | $16.46 |
| L4396 | Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise | 45 | $158.32 |
| L4397 | Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf | 38 | $150.31 |
| L4398 | Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf | 42 | $71.80 |
| L4631 | Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated | 38 | $1,492.93 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.