The following modifiers are allowable for contracted hearing aid models.
| Modifier | Description |
|---|---|
| LT | Left side |
| RR* | Rental |
| RT | Right side |
| *The maximum allowable fee for all rentals is $27.34 per 30-day period. All rented hearing instruments require PA. Wisconsin Medicaid and BadgerCare Plus do not reimburse providers for dispensing fees for rental hearing instruments. | |
Wisconsin Medicaid and BadgerCare Plus will approve only medically necessary hearing aid models available through a volume purchase contract. The following procedure codes are allowable for the corresponding hearing aid models. Many of the manufacturers and models listed in this table are registered or trademarked by the manufacturer. All new hearing aid orders have a two-year manufacturer warranty.
Note: There is a five-year product life expectancy on hearing aids for adults and a three-year product life expectancy on hearing aids for children ages 20 and younger.
The vendor must continue to honor the repair pricing of the contract under which the hearing aid was sold for the life of the hearing aid, whether the hearing aid has been discontinued from the contract, the vendor has terminated their participation in the contract, or the contract has been cancelled or expired. An invoice must accompany the repaired hearing aid when returned to the audiologist or hearing instrument specialist from the vendor.
| V5170 — Hearing aid, CROS; in the ear (Applicable modifiers: LT, RR, RT) (For BICROS, use V5210 [Applicable modifier: LT, RR, RT]) |
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|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for CROS | Purchase Rate for BICROS | Repair Rate Per Unit | Repair Warranty |
| Phonak — Full Shell | CROS II Venture 30 Level for Virto V | $651.64 | $651.64 | $110.00 | 12 months |
| CROS II Venture 50 Level for Virto V | $784.36 | $784.36 | |||
| CROS B Custom 30 Level for Belong Virto | $731.00 | $731.00 | |||
| CROS B Custom 50 Level for Belong Virto | $818.00 | $818.00 | |||
| Phonak — Half Shell | CROS II Venture 30 Level for Virto V | $678.00 | $678.00 | ||
| CROS II Venture 50 Level for Virto V | $764.00 | $764.00 | |||
| CROS B Custom 30 Level for Virto Belong | $731.00 | $731.00 | |||
| CROS B Custom 50 Level for Virto Belong | $818.00 | $818.00 | |||
| Rexton | CROS + Sterling 60 6c | $562.20 | $562.20 | $95.00 | 12 months |
| CROS + Sterling 80 6c | $749.40 | $749.40 | |||
| Signia | CROS+Insio 3px | $764.10 | $764.10 | $95.00 | 12 months |
| V5180 — Hearing aid, CROS; behind the ear (Applicable modifiers: LT, RR, RT) (For BICROS, use V5220 [Applicable modifier: LT, RR, RT]) |
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|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for CROS | Purchase Rate for BICROS | Repair Rate Per Unit | Repair Warranty |
| Phonak | CROS B 30 Level: For Belong Audeo/Bolero Excludes Rechargeable | $731.00 | $731.00 | $110.00 | 12 months |
| CROS B 50 Level: For Belong Audeo/Bolero Excludes Rechargeable | $818.00 | $818.00 | |||
| CROS II Venture 30 Level For Audeo V/Bolero V | $678.00 | $678.00 | |||
| CROS II Venture 50 Level For Belong Audeo V/Bolero | $764.00 | $764.00 | |||
| Rexton | CROS + Emerald M 60 8c | $573.44 | $573.44 | $95.00 | 12 months |
| CROS + Emerald M 80 8c | $755.44 | $755.44 | |||
| CROS + Emerald S 60 8c | $573.44 | $573.44 | |||
| CROS + Emerald S 80 8c | $749.40 | $749.40 | |||
| CROS + Mosaic 60 8c | $573.44 | $573.44 | |||
| CROS + Mosaic 80 8c | $755.44 | $755.44 | |||
| CROS + Stellar Li 60 | $562.20 | $562.20 | |||
| CROS + Stellar Li 80 | $749.40 | $749.40 | |||
| Signa | CROS + Pure CG 3NX | $757.76 | $757.76 | $95.00 | 12 months |
| CROS + Pure 3NX | $683.76 | $683.76 | |||
| CROS + Motion 3NX | $683.76 | $683.76 | |||
| CROS + Motion p 3NX | $683.76 | $683.76 | |||
Starkey Laboratories, Inc. Note: Includes IQ versions. |
CrosMuse i1600, mRIC, P+, RIC, RICR | $738.00 | $738.00 | $84.99 | 12 months |
| CrosMuse i2000, mRIC, P+, RIC, RICR | $758.00 | $758.00 | |||
| CrosMuse i2400, mRIC, P+, RIC, RICR | $778.00 | $778.00 | |||
| Widex USA, LLC | Evoke 110 Fashion, Fashion Power, mini | $724.00 | $724.00 | $100.00 | 12 months |
| Evoke 220 Fashion, Fashion Power, mini | $814.00 | $814.00 | |||
| Unique 110 | $690.00 | $690.00 | |||
| Unique 220 | $760.00 | $760.00 | |||
| Unique 330 | $760.00 | $760.00 | |||
| V5210 — Refer to V5170. |
|---|
| V5220 — Refer to V5180. |
|---|
| V5256 — Hearing aid, digital, monaural, ITE (Applicable modifiers: LT, RR, RT) (For binaural, use V5260 [Applicable modifier: RR].) |
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|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
Beltone — Full Shell, Half Shell, and Low Profile Note: There is no charge for automatic noise reduction, directional microphone, or telecoil. |
Ally 2 | $329.00 | $658.00 | $100.00 | 12 months |
| Ally 3 | $349.00 | $698.00 | |||
| Legend 6 | $399.00 | $798.00 | |||
| Legend 9 | $449.00 | $898.00 | |||
| Origin 2 | $249.00 | $498.00 | |||
| Trust 6 | $399.00 | $798.00 | |||
| Trust 9 | $449.00 | $898.00 | |||
| GN ReSound — Full Shell and Half Shell | Enya 3: DIR HP; DIR MP; DIR UP; HP; MP; UP; Wireless or Non-Wireless | $300.00 | $600.00 | $95.00 | 12 months |
| LiNX2 5: DIR HP; DIR MP; DIR UP; HP; MP; UP; Wireless or Non-Wireless | $397.00 | $794.00 | |||
| LiNX2 7: DIR HP; DIR MP; DIR UP; HP; MP; UP; Wireless or Non-Wireless | $448.00 | $896.00 | |||
| LiNX3D 5: DIR HP; DIR MP; DIR UP; HP, MP, UP; Wireless or Non-Wireless | $397.00 | $794.00 | |||
| LiNX3D 7: DIR HP; DIR MP; DIR UP; HP; MP; UP; Wireless or Non-Wireless | $448.00 | $896.00 | |||
| Hansaton — Half Shell | Jam HD 3 HS | $253.00 | $506.00 | $100.00 | 12 months |
| Jam HD 5 HS | $298.00 | $596.00 | |||
| Jam HD 7 HS | $418.00 | $836.00 | |||
Oticon, Inc. — Full Shell and Half Shell Note: There is no charge for VC, TC, or Auto TC. |
Alta2 | $399.00 | $798.00 | $100.00 | 12 months |
| Alta2 Pro | $449.00 | $898.00 | |||
| Nera2 | $250.00 | $500.00 | |||
| Nera2 Pro | $349.00 | $698.00 | |||
| Opn 2 | $449.00 | $898.00 | |||
| Opn 3 | $349.00 | $698.00 | |||
| Ria2 | $199.00 | $398.00 | |||
| Ria2 Pro | $225.00 | $450.00 | |||
| Phonak — Full Shell, Half Shell, and Low Profile | Virto B30 | $352.00 | $704.00 | $129.00 | 12 months |
| Virto B50 | $439.00 | $878.00 | |||
| Virto V30 | $299.00 | $598.00 | |||
| Virto V50 | $385.00 | $770.00 | |||
Rexton — Full Shell and Half Shell Note: There is no charge for directional microphone, telecoil, or switchless telecoil. |
Sterling 60 | $390.25 | $780.50 | $95.00 | 12 months |
| Sterling 80 | $419.76 | $839.52 | |||
| Signia — Full Shell, Half Shell, and Low Profile | Insio 1px | $283.05 | $566.10 | $95.00 | 12 months |
| Insio 2px | $339.60 | $679.20 | |||
| Insio 3px | $427.05 | $854.10 | |||
| Starkey Laboratories, Inc. — Full Shell and Half Shell | 3 Series 20 | $299.00 | $598.00 | $84.99 | 12 months |
| Muse i1000 | $279.00 | $558.00 | |||
| Muse i1200 | $329.00 | $658.00 | |||
| Muse i1600 | $399.00 | $798.00 | |||
| Muse iQ i1600 | $399.00 | $798.00 | |||
| Muse i2000 | $419.00 | $838.00 | |||
| Muse iQ i2000 | $419.00 | $838.00 | |||
| Muse i2400 | $439.00 | $878.00 | |||
| Muse iQ i2400 | $439.00 | $878.00 | |||
| Unitron Hearing — Full Shell and Half Shell | Insera 500 | $299.00 | $598.00 | $75.00 | 12 months |
| Insera 600 | $385.00 | $770.00 | |||
| Insera 700 | $448.00 | $896.00 | |||
| Widex USA, LLC — Full Shell and Half Shell | Evoke 110 | $350.00 | $700.00 | $100.00 | 12 months |
| Evoke 220 | $440.00 | $880.00 | |||
| Unique 110 | $315.00 | $630.00 | |||
| Unique 220 | $385.00 | $770.00 | |||
| V5257 — Hearing aid, digital, monaural, BTE (Applicable modifiers: LT, RR, RT) (For binaural, use V5261 [Applicable modifier: RR].) |
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|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
| Beltone | Ally 2 | $329.00 | $658.00 | $100.00 | 12 months |
| Ally 3 | $349.00 | $698.00 | |||
| Bold 2 95D | $329.00 | $658.00 | |||
| Bold 3 95D | $399.00 | $798.00 | |||
| Boost Max 9 | $449.00 | $898.00 | |||
| Legend 6 | $399.00 | $798.00 | |||
| Legend 9 | $449.00 | $898.00 | |||
| Origin 2-75D, 85D | $249.00 | $498.00 | |||
| Origin 3-64D | $289.00 | $578.00 | |||
| Trust 6 | $399.00 | $798.00 | |||
| Trust 9 | $449.00 | $898.00 | |||
| GN ReSound | Enya 2 Standard, Mini, Power | $275.00 | $550.00 | $95.00 | 12 months |
| Enya 3 Standard, Mini, Power, RIC | $300.00 | $600.00 | |||
| Enzo2 5 High Power, Super Power | $397.00 | $794.00 | |||
| Enzo2 7 High Power, Super Power | $448.00 | $896.00 | |||
| Enzo 3D 5 High Power, Super Power | $397.00 | $794.00 | |||
| Enzo 3D 7 High Power, Super Power | $448.00 | $896.00 | |||
| LiNX2 5 Standard, Mini, RIE, Power | $397.00 | $794.00 | |||
| LiNX2 7 Standard, Mini, RIE, Power | $448.00 | $896.00 | |||
| LINX 3D 5: Standard, Mini, RIE, Power | $397.00 | $794.00 | |||
| LINX 3D 7: Standard, Mini, RIE, Power | $448.00 | $896.00 | |||
| Up 7 Mini BTE | $397.00 | $794.00 | |||
| Up Smart 5 Standard, Power, Super Power | $397.00 | $794.00 | |||
| Up Smart 7 Standard, Power, Super Power | $397.00 | $794.00 | |||
| Oticon, Inc. | Alta2: mini, miniRITE, power, power plus, RITE | $399.00 | $798.00 | $100.00 | 12months |
| Alta2 Pro: designRITE, mini, miniRITE, power, power plus, RITE | $449.00 | $898.00 | |||
| Dynamo SP4 | $225.00 | $450.00 | |||
| Dynamo SP6 | $299.00 | $598.00 | |||
| Dynamo SP8 | $349.00 | $698.00 | |||
| Dynamo SP10 | $449.00 | $898.00 | |||
| Nera2: Mini, Mini RITE, power, power plus, RITE | $250.00 | $500.00 | |||
| Nera2 Pro: designRITE, Mini, Mini RITE, power, power plus, RITE | $349.00 | $698.00 | |||
| Opn 2 mini, miniRITE, mini RITE-T, Plus Power, RITE | $449.00 | $898.00 | |||
| Opn 3 mini, miniRITE, mini RITE-T, Plus Power, RITE | $349.00 | $698.00 | |||
| Ria2: Mini, Mini RITE, power, power plus, RITE | $199.00 | $398.00 | |||
| Ria2 Pro: designRITE, Mini, Mini RITE, power, power plus, RITE | $225.00 | $450.00 | |||
| Sensei; Sensei RITE | $199.00 | $398.00 | |||
| Sensei Pro, Sensei Pro RITE | $349.00 | $698.00 | |||
| Sensei SP | $199.00 | $398.00 | |||
| Sensei Pro SP | $349.00 | $698.00 | |||
| Sumo DM | $399.00 | $798.00 | |||
| Phonak | Audeo B30 T | $352.00 | $704.00 | $129.00 | 12 months |
| Audeo B50 Direct | $450.00 | $899.99 | |||
| Audeo B50 RIC, T | $439.00 | $878.00 | |||
| Audeo B50 Rechargeable (includes charger case) | $450.00 | $899.99 | |||
| Audeo V30; T | $299.00 | $598.00 | |||
| Audeo V50: T | $385.00 | $770.00 | |||
| Bolero B30 M, P, SP | $352.00 | $628.06 | |||
| Bolero B50 SP, P, M | $439.00 | $878.00 | |||
| Bolero B50 Rechargeable (includes charger case) | $450.00 | $899.99 | |||
| Bolero V30: M, P, SP | $299.00 | $598.00 | |||
| Bolero V50: M, P, SP | $385.00 | $770.00 | |||
| Naida B30 SP, UP | $352.00 | $704.00 | |||
| Naida B50 SP, UP | $439.00 | $878.00 | |||
| Naida B50-R Rechargeable (includes charger case) | $450.00 | $900.00 | |||
| Naida V30: RIC, SP, UP | $299.00 | $598.00 | |||
| Naida V50: RIC, SP, UP | $385.00 | $770.00 | |||
| Sky B50: M, P, RIC, SP, UP | $385.00 | $770.00 | |||
| Sky B50-PR Rechargeable (includes charger case) | $450.00 | $900.00 | |||
| Sky V50: M, P, RIC, SP, UP | $385.00 | $770.00 | |||
| Rexton | Emerald M 60 | $389.70 | $779.40 | $95.00 | 12 months |
| Emerald M 80 | $428.78 | $857.56 | |||
| Emerald S 60 | $389.70 | $779.40 | |||
| Emerald S 80 | $428.78 | $857.40 | |||
| Mosaic HP 60 | $393.75 | $787.50 | |||
| Mosaic HP 80 | $427.20 | $854.40 | |||
| Mosaic M 60 | $389.70 | $779.40 | |||
| Mosaic M 80 | $428.78 | $857.40 | |||
| Mosaic M NR 60 | $390.25 | $780.50 | |||
| Mosaic M NR 80 | $419.76 | $839.52 | |||
| Mosaic P 60 | $390.25 | $780.50 | |||
| Mosaic P 80 | $419.76 | $839.52 | |||
| Stellar Li 60 | $402.69 | $805.38 | |||
| Stellar Li 80 | $428.78 | $857.56 | |||
| Signia | Motion 1px P, S, SA, SP | $283.05 | $566.10 | $95.00 | 12 months |
| Motion 2px P, S, SA, SP | $339.60 | $679.20 | |||
| Motion NX 3 | $428.61 | $857.22 | |||
| Motion PNX 3 | $428.61 | $857.22 | |||
| Pure 1px RIC | $283.05 | $566.10 | |||
| Pure 2px RIC | $339.60 | $679.20 | |||
| Pure NX 3 | $428.61 | $857.22 | |||
| Pure CG NX 3 | $428.61 | $857.22 | |||
Starkey Laboratories, Inc. Note: Includes IQ versions. |
3 Series 20: Mini, P+, or RIC | $299.00 | $598.00 | $84.99 | 12 months |
| Halo i70 | $389.00 | $778.00 | |||
| Halo i90 | $409.00 | $818.00 | |||
| Halo i110 | $429.00 | $858.00 | |||
| Halo 2 i1600 RIC | $399.00 | $798.00 | |||
| Halo 2 i2000 RIC | $419.00 | $838.00 | |||
| Halo 2 i2400 RIC | $439.00 | $878.00 | |||
| Muse i1000 | $279.00 | $558.00 | |||
| Muse i1200 | $329.00 | $658.00 | |||
| Muse i1600 (excludes IQ i1600 RIC R) | $399.00 | $798.00 | |||
| Muse i2000 (excludes IQ i2000 RIC R) | $419.00 | $838.00 | |||
| Muse i2400 (excludes IQ i2400 RIC R) | $439.00 | $878.00 | |||
| Unitron Hearing | MAX E SP, SPm | $350.00 | $700.00 | $75.00 | 12 months |
| MAX 6: SP, SPm | $430.71 | $861.42 | |||
| Tempus Moxi Dura 500 | $299.00 | $598.00 | |||
| Tempus Moxi Dura 600 | $385.00 | $770.00 | |||
| Tempus Moxi Dura 700 | $448.00 | $896.00 | |||
| Tempus Moxi Fit 500 | $299.00 | $598.00 | |||
| Tempus Moxi Fit-R 500 (includes charger case & battery) | $299.00 | $598.00 | |||
| Tempus Moxi Fit 600 | $385.00 | $770.00 | |||
| Tempus Moxi Fit-R 600 (includes charger case & battery) | $385.00 | $770.00 | |||
| Tempus Moxi Fit 700 | $448.00 | $896.00 | |||
| Tempus Moxi Fit 700 (includes charger case & battery) | $448.00 | $896.00 | |||
| Tempus Moxi All 500 CRT | $299.00 | $598.00 | |||
| Tempus Moxi All-R 500 (includes charger case & battery) | $299.00 | $598.00 | |||
| Tempus Moxi All 600 CRT | $385.00 | $769.99 | |||
| Tempus Moxi All-R 600 (includes charger case & battery) | $385.00 | $770.01 | |||
| Tempus Moxi All 700 CRT | $448.00 | $895.99 | |||
| Tempus Moxi All-R 700 (includes charger case & battery) | $448.00 | $896.00 | |||
| Tempus Moxi Kiss 500 | $299.00 | $598.00 | |||
| Tempus Moxi Kiss 600 | $385.00 | $770.00 | |||
| Tempus Moxi Kiss 700 | $448.00 | $896.00 | |||
| Tempus Moxi Now 500 | $299.00 | $598.00 | |||
| Tempus Moxi Now 600 | $385.00 | $770.00 | |||
| Tempus Moxi Now 700 | $448.00 | $896.00 | |||
| Tempus 500: P, P Dura | $299.00 | $598.00 | |||
| Tempus 600: P, P Dura | $385.00 | $770.00 | |||
| Tempus 700: P, P Dura | $448.00 | $896.00 | |||
| Tempus Stride 500 M | $299.00 | $598.00 | |||
| Tempus Stride M-R 500 (includes charger case & battery) | $299.00 | $598.00 | |||
| Tempus Stride 600 M | $385.00 | $770.00 | |||
| Tempus Stride M-R 600 (includes charger case & battery) | $385.00 | $770.00 | |||
| Tempus Stride 700 M | $448.00 | $896.00 | |||
| Tempus Stride M-R 700 (includes charger case & battery) | $448.00 | $896.00 | |||
| Widex USA, LLC | Beyond 220 | $385.00 | $770.00 | $100.00 | 12 months |
| Beyond 330 | $440.00 | $880.00 | |||
| Evoke 110 | $350.00 | $700.00 | |||
| Evoke 220 | $440.00 | $880.00 | |||
| Super 220 | $400.00 | $800.00 | |||
| Unique 110 | $315.00 | $630.00 | |||
| Unique 220 | $385.00 | $770.00 | |||
| Unique 220 Fashion Power | $350.00 | $700.00 | |||
| Unique 330 | $385.00 | $770.00 | |||
| Unique 330 Fashion Power | $385.00 | $770.00 | |||
| V5260 — Refer to V5256. |
|---|
| V5261 — Refer to V5257. |
|---|