Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
Repl met band kafo-afo calf/
Maple Grove, MN
See all hospitals reporting HCPCS L4090 →Price type
Fairview Maple Grove Surgery Center’s median price of $114 is 1% below the median hospital's median price ($115), higher than 45% of the 819 hospitals reporting HCPCS L4090. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 5 payers, 22 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | Blue Cross Blue Shield federal fee schedule · outpatient | $87 | $87 | — | — | — | $87 – $87 |
| 2 | Blue Cross Blue Shield commercial fee schedule · outpatient | $89 | $89 | — | — | — | $89 – $89 |
| 3 | Blue Cross Blue Shield medicaid fee schedule · outpatient | $89 | $89 | — | — | — | $89 – $89 |
| 4 | Blue Cross Blue Shield federal fee schedule · both | $94 | $94 | — | — | — | $94 – $94 |
| 5 | Blue Cross Blue Shield commercial fee schedule · both | $96 | $96 | — | — | — | $96 – $96 |
| 6 | Medica accessability fee schedule · both | $99 | $99 | — | — | — | $99 – $99 |
| 7 | Medica medicaid fee schedule · both | $99 | $99 | — | — | — | $99 – $99 |
| 8 | Medica ma non-snp fee schedule · both | $108 | $108 | — | — | — | $108 – $108 |
| 9 | Medica ma snp fee schedule · both | $108 | $108 | — | — | — | $108 – $108 |
| 10 | Medica prime solution fee schedule · both | $108 | $108 | — | — | — | $108 – $108 |
| 11 | Medica vantage fee schedule · both | $108 | $108 | — | — | — | $108 – $108 |
| 12 | Blue Cross Blue Shield medicaid fee schedule · both | $108 | $108 | — | — | — | $108 – $108 |
| 13 | Ucare mhcp fee schedule · both | $111 | $111 | — | — | — | $111 – $111 |
| 14 | Cigna commercial fee schedule · both | $133 | $133 | $12 | 9% | — | $122 – $145 |
| 15 | Ucare ifp with fairview fee schedule · outpatient | $179 | $179 | — | — | — | $179 – $179 |
| 16 | Medica bold fee schedule · both | $188 | $188 | — | — | — | $188 – $188 |
| 17 | Medica choice without / elect fee schedule · both | $208 | $208 | — | — | — | $208 – $208 |
| 18 | Medica city of st paul / essential uplan fee schedule · both | $208 | $208 | — | — | — | $208 – $208 |
| 19 | Medica choice with fee schedule · both | $216 | $216 | — | — | — | $216 – $216 |
| 20 | UnitedHealthcare commercial fee schedule · both | $218 | $218 | — | — | — | $218 – $218 |
| 21 | Ucare ifp fee schedule · outpatient | $239 | $239 | — | — | — | $239 – $239 |
| 22 | Cigna commercial fee schedule · outpatient | $280 | $280 | $24 | 9% | — | $256 – $305 |
Last updated: May 18, 2026
See Replacement of metal bands on leg brace pricing across every hospital in the network reporting it, or ask Claude or any MCP client directly — see how to connect.