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The Cup/Dish Pessary is used for a first or a mild second-degree uterine prolapse and is available with or without a supporting membrane.

HCPCS Reimbursement Code for Pessary - A4562
Code for Office Visit - 99214
CPT Code for Fitting & Insertion - 57160
 
  SKU # Description Price  
 
1621050 Cup Pessary 50/18 Without Support #0 $45
 
 
1621055 Cup Pessary 55/23 Without Support #1 $45
 
 
1621060 Cup Pessary 60/28 Without Support #2 $45
 
 
1621065 Cup Pessary 65/33 Without Support #3 $45
 
 
1621070 Cup Pessary 70/38 Without Support #4 $45
 
 
1621075 Cup Pessary 75/43 Without Support #5 $45
 
 
1621080 Cup Pessary 80/48 Without Support #6 $45
 
 
1621085 Cup Pessary 85/52 Without Support #7 $45
 
 
1622050 Cup Pessary 50/18 With Support #0 $45
 
 
1622055 Cup Pessary 55/23 With Support #1 $45
 
 
1622060 Cup Pessary 60/28 With Support #2 $45
 
 
1622065 Cup Pessary 65/33 With Support #3 $45
 
 
1622070 Cup Pessary 70/38 With Support #4 $45
 
 
1622075 Cup Pessary 75/43 With Support #5 $45
 
 
1622080 Cup Pessary 80/48 With Support #6 $45
 
 
1622085 Cup Pessary 85/52 With Support #7 $45
 
 
 
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