| Code | Description | States | Median rate |
|---|---|---|---|
| A5051 | Ostomy pouch, closed; with barrier attached (1 piece), each | 43 | $2.35 |
| A5052 | Ostomy pouch, closed; without barrier attached (1 piece), each | 43 | $1.67 |
| A5053 | Ostomy pouch, closed; for use on faceplate, each | 43 | $1.88 |
| A5054 | Ostomy pouch, closed; for use on barrier with flange (2 piece), each | 43 | $1.99 |
| A5055 | Stoma cap | 44 | $1.60 |
| A5056 | Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each | 41 | $5.33 |
| A5057 | Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each | 41 | $10.94 |
| A5061 | Ostomy pouch, drainable; with barrier attached, (1 piece), each | 42 | $4.03 |
| A5062 | Ostomy pouch, drainable; without barrier attached (1 piece), each | 43 | $2.42 |
| A5063 | Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each | 43 | $3.09 |
| A5071 | Ostomy pouch, urinary; with barrier attached (1 piece), each | 44 | $6.65 |
| A5072 | Ostomy pouch, urinary; without barrier attached (1 piece), each | 41 | $3.94 |
| A5073 | Ostomy pouch, urinary; for use on barrier with flange (2 piece), each | 44 | $3.52 |
| A5081 | Stoma plug or seal, any type | 40 | $3.44 |
| A5082 | Continent device; catheter for continent stoma | 41 | $12.18 |
| A5083 | Continent device, stoma absorptive cover for continent stoma | 24 | $0.76 |
| A5093 | Ostomy accessory; convex insert | 42 | $2.09 |
| A5102 | Bedside drainage bottle with or without tubing, rigid or expandable, each | 38 | $25.68 |
| A5105 | Urinary suspensory with leg bag, with or without tube, each | 40 | $42.30 |
| A5112 | Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each | 41 | $34.87 |
| A5113 | Leg strap; latex, replacement only, per set | 40 | $5.10 |
| A5114 | Leg strap; foam or fabric, replacement only, per set | 38 | $9.76 |
| A5120 | Skin barrier, wipes or swabs, each | 43 | $0.25 |
| A5121 | Skin barrier; solid, 6 x 6 or equivalent, each | 43 | $8.17 |
| A5122 | Skin barrier; solid, 8 x 8 or equivalent, each | 43 | $13.43 |
| A5126 | Adhesive or non-adhesive; disk or foam pad | 41 | $1.46 |
| A5131 | Appliance cleaner, incontinence and ostomy appliances, per 16 oz. | 38 | $16.07 |
| A5200 | Percutaneous catheter/tube anchoring device, adhesive skin attachment | 34 | $12.90 |
| A5500 | For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe | 38 | $72.50 |
| A5501 | For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe | 38 | $217.44 |
| A5503 | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe | 37 | $35.84 |
| A5504 | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe | 38 | $35.43 |
| A5505 | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe | 37 | $35.84 |
| A5506 | For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe | 37 | $35.84 |
| A5507 | For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe | 38 | $33.88 |
| A5510 | For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe | 11 | $28.47 |
| A5512 | For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each | 37 | $29.57 |
| A5513 | For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each | 37 | $44.13 |
| A5514 | For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each | 32 | $46.24 |
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.