HCPCS L4055
Replace non-molded calf lacer, for custom fabricated orthosis only
Current codeBelow Knee Orthotic23 hospitals with prices
What Washington hospitals publish for this code
Medicare Advantage: Rate for a private Medicare Advantage plan. Applies only to members of that plan.
| Hospital | Medicare Advantage rates (lowest – highest) | Cash price | List price (before discounts) |
|---|---|---|---|
| Capital Medical Center | $305 – $336 | — | — |
| Deaconess Medical Center | $305 – $336 | — | — |
| Harborview Medical Center | $312 – $343 | $382 | $545 |
| Kadlec Regional Medical Center | $312 – $374 | — | — |
| Mary Bridge Children's Hospital | $305 – $336 | — | — |
| MultiCare Auburn Medical Center | $305 – $336 | — | — |
| MultiCare Covington Medical Center | $305 – $336 | — | — |
| MultiCare Good Samaritan Hospital | $305 – $336 | — | — |
| MultiCare Valley Hospital | $315 – $336 | — | — |
| Overlake Hospital Medical Center & Clinics | $312 – $324 | — | — |
| Prov Sacred HRT Med Ctr & Childs Hosp. | $312 – $374 | — | — |
| Providence Centralia Hospital | $312 – $499 | — | — |
| Providence Regional Medical Center Everett | $312 – $343 | — | — |
| Providence St Peter Hospital | $312 – $499 | — | — |
| Swedish Edmonds Hospital | $312 – $374 | — | — |
| Swedish Issaquah | $312 – $374 | — | — |
| Swedish Medical Center | $312 – $374 | — | — |
| Swedish Medical Center / Cherry Hill | $312 – $374 | — | — |
| Tacoma General Allenmore Hospital | $305 – $336 | — | — |
| University of Washington Medical Ctr | $312 – $343 | — | — |
| Virginia Mason Medical Center | $214 – $321 | — | — |
| Wellfound Behavioral Health Hospital | — | — | — |
| Yakima Valley Memorial | $305 – $342 | — | — |
Medicare (traditional) reference
Only for people on original Medicare. These are CMS’s 2026 amounts. They aren’t what private insurance or cash patients pay.
- Equipment fee, Washington
- $312 (fee)