Wisconsin Medicaid and BadgerCare Plus will approve only medically necessary hearing aid models available through a volume purchase contract. These 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.
Hearing aids are covered for members enrolled in Wisconsin Medicaid and the BadgerCare Plus Standard Plan.
Note: There is a five-year life expectancy on hearing aids for adults and a three-year life expectancy on hearing aids for children ages 17 and younger.
V5030 — Hearing aid, Monaural, Body Worn, Air-Conduction Hearing Aid (Applicable modifiers: LT, RR, RT) | ||||
Manufacturer and Style |
Model | Purchase Rate |
Repair Rate Per Unit |
Repair Warranty |
Rexton | Fusion PP+ (1 receiver) | $175.25 | $155.00 | 12 months |
V5040 — Hearing aid, Monaural, Body Worn, Bone-Conduction Hearing Aid (Applicable modifiers: LT, RR, RT) | ||||
Manufacturer and Style |
Model |
Purchase Rate |
Repair Rate Per Unit |
Repair Warranty |
Rexton | Fusion PP+ (1 receiver/headband) | $241.80 | $155.00 | 12 months |
V5100 — Hearing aid, Bilateral, Body Worn, Air-Conduction Hearing Aid (Applicable modifiers: LT, RR, RT) | ||||
Manufacturer and Style | Model |
Purchase Rate |
Repair Rate Per Unit |
Repair Warranty |
Rexton | Fusion PP+ (2 receivers with Y-cord or 2 straight cords) | $224.25 | $155.00 | 12 months |
V5170 — Hearing aid, CROS; in the ear (Applicable modifiers: LT, RR, RT) | ||||
Manufacturer and Style | Model | Purchase Rate | Repair Rate Per Unit | Repair Warranty |
Phonak Hearing Systems, LLC Note: The purchase rate includes the cost of the FM Transmitter ($379) and compatible hearing aid. Both standard and H20 models available. | Virto Q50 — CROS/BICROS FS | $764.00 | $110.00 | 12 months |
Virto Q50 — NW O CROS/BICROS HS | $764.00 |
V5180 — Hearing aid, CROS; behind the ear (Applicable modifiers: LT, RR, RT) | ||||
Manufacturer and Style | Model | Purchase Rate for CROS/BICROS | Repair Rate Per Unit |
Repair Warranty |
Oticon, Inc. | Acto CROS/BICROS | $425.00 | $80.00 $100.00 | 6 months 12 months |
Acto Power CROS/BICROS | $425.00 | |||
Chili SP5 CROS or BICROS | $425.00 | |||
Get CROS/BICROS | $274.00 | |||
Get Power CROS/BICROS | $274.00 | |||
GoPro CROS/BICROS | $274.00 | |||
GoPro VC CROS/BICROS | $274.00 | |||
GoPro Power CROS/BICROS | $274.00 | |||
GoPro Power Direct CROS/BICROS | $274.00 | |||
Ino CROS/BICROS | $350.00 | |||
Ino Power CROS/BICROS | $350.00 | |||
Ino Pro CROS/BICROS | $400.00 | |||
Ino Pro Power CROS/BICROS | $400.00 | |||
Nera CROS/BICROS | $425.00 | |||
Nera Power CROS/BICROS | $425.00 | |||
Safari 300 Super Power CROS/BICROS | $374.00 | |||
Sensei CROS/BICROS | $350.00 | |||
Sensei Pro CROS/BICROS | $474.00 | |||
Phonak Hearing Systems, LLC Note: The purchase rate includes the cost of the FM Transmitter ($379) and compatible hearing aid. | Audeo Q30 CROS/BICROS | $678.00 | $110.00 | 12 months |
Audeo Q30 T CROS/BICROS | $678.00 | |||
Audeo Q50 CROS/BICROS | $764.00 | |||
Audeo Q50 T CROS/BICROS | $764.00 | |||
Bolero Q50 M13 CROS/BICROS | $764.00 | |||
Bolero Q50 P CROS/BICROS | $764.00 | |||
Bolero Q50 SP CROS/BICROS | $764.00 | |||
Naida Q30 RIC CROS/BICROS | $678.00 | |||
Nadia Q30 SP CROS/BICROS | $678.00 | |||
Naida Q30 UP CROS/BICROS | $678.00 | |||
Naida Q50 RIC CROS/BICROS | $764.00 | |||
Naida Q50 SP CROS/BICROS | $764.00 | |||
Naida Q50 UP CROS/BICROS | $764.00 | |||
Naida S I SP CROS/BICROS | $678.00 | |||
Naida S I UP CROS/BICROS | $678.00 | |||
Naida S III SP CROS/BICROS | $764.00 | |||
Naida S III UP CROS/BICROS | $764.00 | |||
Unitron Hearing, Inc. | Tandem 4 CROS/BICROS | $870.86 | $150.00 | 12 months |
V5220 — Refer to V5180. |
V5256 — Hearing aid, digital, monaural, ITE (Applicable modifiers: LT, RR, RT) | |||||
Manufacturer and Style | Model | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
Audina Hearing Instruments, Inc. — Full Shell and Half Shell | Intuition 2+ | $199.00 | $398.00 | $85.00 $100.00 | 6 months 12 months |
Intuition 2FC+ | $225.00 | $450.00 | |||
Intuition 4+ | $325.00 | $650.00 | |||
Intuition 4AD | $350.00 | $700.00 | |||
Intuition 12 | $400.00 | $800.00 | |||
Intuition 12AD | $425.00 | $850.00 | |||
Simplex | $160.00 | $320.00 | |||
Simplex FC | $175.00 | $350.00 | |||
Beltone Electronics — Full Shell | Origin 2-Optima | $201.00 | $402.00 | $97.30 | 12 months |
Origin 3-Optima | $317.25 | $634.50 | |||
True 3-Optima | $349.80 | $699.60 | |||
True 6-Optima | $366.50 | $733.00 | |||
Beltone Electronics — Half Shell | Origin 2-Optima | $238.50 | $477.00 | ||
Origin 3-Optima | $354.75 | $709.50 | |||
True 3-Optima | $379.80 | $759.60 | |||
True 6-Optima | $391.50 | $783.00 | |||
Beltone Electronics — Low Profile | Origin 2-Optima | $216.00 | $432.00 | ||
Origin 3-Optima | $332.25 | $664.50 | |||
True 3-Optima | $361.80 | $633.60 | |||
True 6-Optima | $376.50 | $753.00 | |||
Hansaton Acoustics, Inc. — Full Shell, Half Shell, and Low Profile | Cemia | $285.00 | $570.00 | $100.00 | 12 months |
Lumeo | $360.00 | $720.00 | |||
Veneto | $410.00 | $820.00 | |||
Oticon, Inc. — Full Shell | GO Pro | $199.00 | $398.00 | $80.00 $100.00 | 6 months 12 months |
Nera | $350.00 | $700.00 | |||
Nera Power | $350.00 | $700.00 | |||
Oticon, Inc. — Half Shell and Low Profile | Acto | $350.00 | $700.00 | $80.00 $100.00 | 6 months 12 months |
Acto Power | $350.00 | $700.00 | |||
Get | $199.00 | $398.00 | |||
Get Power | $199.00 | $398.00 | |||
GO Pro | $199.00 | $398.00 | |||
GO Pro Power | $199.00 | $398.00 | |||
Ino | $275.00 | $550.00 | |||
Ino Power | $275.00 | $550.00 | |||
Ino Pro | $325.00 | $650.00 | |||
Ino Pro Power | $325.00 | $650.00 | |||
Nera | $350.00 | $700.00 | |||
Nera Power | $350.00 | $700.00 | |||
Phonak Hearing Systems, LLC — Full Shell | Cassia 13 UZ | $385.00 | $770.00 | $110.00 | 12 months |
Dalia 13 UZ | $299.00 | $598.00 | |||
Virto Q50 13 | $385.00 | $770.00 | |||
Phonak Hearing Systems, LLC — Half Shell | Cassia | $385.00 | $770.00 | $110.00 | 12 months |
Cassia UZ | $385.00 | $770.00 | |||
Dalia | $299.00 | $598.00 | |||
Dalia UZ | $299.00 | $598.00 | |||
Virto Q50 NW | $385.00 | $770.00 | |||
Phonak Hearing Systems, LLC — Low Profile | Cassia | $385.00 | $770.00 | ||
Dalia | $385.00 | $770.00 | |||
Virto Q50- NW O | $385.00 | $770.00 | |||
ReSound — Full Shell and Half Shell Note: All units are available in STD, DIR, PWR, or DIR/PWR. | VEA 2 | $247.50 | $495.00 | $95.00 Monaural $190.00 Binaural | 12 months |
VEA 3 | $277.50 | $555.00 | |||
Verso 5 | $397.00 | $794.00 | |||
Verso 7 | $448.00 | $896.00 | |||
Rexton — Full Shell and Half Shell Note: There is no charge for optional D-mic, telecoil, or switchless telecoil. | Arena 1S | $200.85 | $401.70 | $155.00 | 12 months |
Day 4+ | $252.85 | $505.70 | |||
Day 6+ | $311.35 | $622.70 | |||
Day 6+ Energy | $311.35 | $622.70 | |||
Siemens Hearing Instruments, Inc. — Full Shell and Half Shell * Available 11/1/13. | Insio 3mi* | $431.93 | $863.86 | $95.00 | 12 months |
Intuis | $234.53 | $469.06 | |||
Motion 301 | $417.83 | $835.66 | |||
Nitro 301 | $408.43 | $816.86 | |||
Nitro 3mi custom* | $431.93 | $863.86 | |||
Orion custom* | $328.53 | $659.06 | |||
Phoenix G3 | $225.13 | $450.26 | |||
Sirion custom* | $272.13 | $544.26 | |||
Sonic Innovations — Full Shell | Velocity 4 ITED | $209.00 | $418.00 | $145.00 Monaural $290.00 Binaural | 12 months |
Velocity 4 ITEPD | $209.00 | $418.00 | |||
Velocity 6 ITED | $259.00 | $518.00 | |||
Velocity 6 ITEPD | $259.00 | $518.00 | |||
Sonic Innovations — Half Shell | Velocity 4 HSD | $209.00 | $418.00 | ||
Velocity 6 HSD | $259.00 | $518.00 | |||
Starkey Laboratories, Inc. — Full Shell and Half Shell | Ignite 20 | $289.00 | $578.00 | $84.99 | 12 months |
Ignite i20 | $339.00 | $678.00 | |||
Ignite 30 | $319.00 | $638.00 | |||
Ignite i30 | $359.00 | $718.00 | |||
Wi Series i70 | $389.00 | $778.00 | |||
Wi Series i90 | $409.00 | $818.00 | |||
Wi Series i110 | $429.00 | $858.00 | |||
X Series 70 | $379.00 | $758.00 | |||
X Series 90 | $399.00 | $798.00 | |||
X Series 110 | $419.00 | $838.00 | |||
3 Series i20 | $339.00 | $678.00 | |||
3 Series i30 | $359.00 | $718.00 | |||
3 Series i70 | $389.00 | $778.00 | |||
3 Series i90 | $409.00 | $818.00 | |||
3 Series i110 | $429.00 | $858.00 | |||
3 Series 20 | $339.00 | $678.00 | |||
3 Series 30 | $359.00 | $718.00 | |||
3 Series 70 | $389.00 | $778.00 | |||
3 Series 90 | $409.00 | $818.00 | |||
3 Series 110 | $429.00 | $858.00 | |||
Unitron Hearing, Inc. — Full Shell, Half Shell, and Low Profile * Available in STD, PWR, and HP. | Quantum E* | $320.22 | $640.44 | $75.00 | 12 months |
Quantum 6* | $395.00 | $790.00 | |||
Quantum 12* | $447.86 | $895.72 | |||
Shine+ | $229.40 | $458.80 | |||
Shine+ Power | $229.40 | $458.80 | |||
Widex Hearing — Full Shell and Half Shell | Clear 220 C2 | $400.00 | $800.00 | $100.00 | 12 months |
Dream 110 | $377.00 | $754.00 | |||
Mind 220 M2 | $350.00 | $700.00 | |||
Menu 3 ME3 | $199.00 | $398.00 |
V5257 — Hearing aid, digital, monaural, BTE (Applicable modifiers: LT, RR, RT) | |||||
Manufacturer and Style | Model | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
Audina Hearing Instruments, Inc. | 478 | $245.00 | $490.00 | $150.00 | 12 months |
478P+ | $245.00 | $490.00 | |||
Intuition 2 | $200.00 | $400.00 | |||
Intuition 2FC | $225.00 | $450.00 | |||
Intuition 4+ | $300.00 | $600.00 | |||
Intuition 4AD | $325.00 | $650.00 | |||
Opti-Trim | $175.00 | $350.00 | |||
Simplex | $200.00 | $400.00 | |||
Simplex 2P+ | $175.00 | $350.00 | |||
Sparo | $325.00 | $650.00 | $200.00 | 12 months | |
Sparo 2+ | $250.00 | $500.00 | |||
Beltone Electronics | Change 62D | $341.25 | $682.50 | $97.30 | 12 months |
Origin 2-75D | $337.35 | $674.70 | |||
Origin 2-85D | $395.85 | $791.70 | |||
Origin 3-65D | $369.85 | $739.70 | |||
Origin 3-75D | $369.85 | $739.70 | |||
Origin 3-85D | $367.95 | $735.90 | |||
True 3-66DW | $391.28 | $782.56 | |||
Turn TN1T75 | $160.30 | $320.60 | |||
Turn TN3T85 | $226.85 | $453.70 | |||
Turn TN3T95 | $317.85 | $635.70 | |||
Hansaton Acoustics, Inc. * Available in Mini, Power, and Slim. | Base HP | $200.00 | $400.00 | $100.00 | 12 months |
Base MP | $200.00 | $400.00 | |||
Cemia* | $250.00 | $500.00 | |||
Cemia X Mini RIC | $250.00 | $500.00 | |||
Lumeo* | $325.00 | $650.00 | |||
Lumeo X Mini RIC | $325.00 | $650.00 | |||
Oticon, Inc. | Acto | $350.00 | $700.00 | $80.00 $100.00 | 6 months 12 months |
Acto Mini | $350.00 | $700.00 | |||
Acto RITE | $350.00 | $700.00 | |||
Acto Mini RITE | $350.00 | $700.00 | |||
Acto Power | $350.00 | $700.00 | |||
Chili SP5 | $350.00 | $700.00 | |||
Get | $199.00 | $398.00 | |||
Get Power | $199.00 | $398.00 | |||
GoPro | $199.00 | $398.00 | |||
GoPro VC | $199.00 | $398.00 | |||
GoPro Power | $199.00 | $398.00 | |||
GoPro Power Direct | $199.00 | $398.00 | |||
Ino | $275.00 | $550.00 | |||
Ino Mini | $275.00 | $550.00 | |||
Ino RITE | $275.00 | $550.00 | |||
Ino Mini RITE | $275.00 | $550.00 | |||
Ino Power | $275.00 | $550.00 | |||
Ino Pro | $325.00 | $650.00 | |||
Ino Pro Mini | $325.00 | $650.00 | |||
Ino Pro Mini RITE | $325.00 | $650.00 | |||
Ino Pro Power | $325.00 | $650.00 | |||
Ino Pro RITE | $325.00 | $650.00 | |||
Nera | $350.00 | $700.00 | |||
Nera Mini | $350.00 | $700.00 | |||
Nera Mini RITE | $350.00 | $700.00 | |||
Nera Power | $350.00 | $700.00 | |||
Nera RITE | $350.00 | $700.00 | |||
Safari 300 Super Power | $299.00 | $598.00 | |||
Sensei | $275.00 | $550.00 | |||
Sensei Pro | $399.00 | $798.00 | |||
Sensei Pro RITE | $399.00 | $798.00 | |||
Sensei RITE | $275.00 | $550.00 | |||
Phonak Hearing Systems, LLC | Audeo Q 30 | $299.00 | $598.00 | $110.00 | 12 months |
Audeo Q 30 T | $299.00 | $598.00 | |||
Audeo Q 50 | $385.00 | $770.00 | |||
Audeo Q 50 T | $385.00 | $770.00 | |||
Audeo S Mini III | $385.00 | $770.00 | |||
Audeo S Smart I | $299.00 | $598.00 | |||
Audeo S Smart III | $385.00 | $770.00 | |||
Audeo S Yes III | $385.00 | $770.00 | |||
Bolero Q50-M13 | $385.00 | $770.00 | |||
Bolero Q50-SP | $385.00 | $770.00 | |||
Bolero Q50-P | $385.00 | $770.00 | |||
Cassia M H2O | $385.00 | $770.00 | |||
Cassia Micro M | $385.00 | $770.00 | |||
Cassia Micro P | $385.00 | $770.00 | |||
Cassia SP | $385.00 | $770.00 | |||
Cassia Petite | $385.00 | $770.00 | |||
Dalia M H2O | $299.00 | $598.00 | |||
Dalia Micro M | $299.00 | $598.00 | |||
Dalia Micro P | $299.00 | $598.00 | |||
Dalia SP | $299.00 | $598.00 | |||
Naida Q-30 RIC | $299.00 | $598.00 | |||
Naida Q-30 SP | $299.00 | $598.00 | |||
Naida Q-30 UP | $299.00 | $598.00 | |||
Naida Q-50 RIC | $385.00 | $770.00 | |||
Naida Q-50 SP | $385.00 | $770.00 | |||
Naida Q-50 UP | $385.00 | $770.00 | |||
Naida S CRT III | $385.00 | $770.00 | |||
Naida S I SP | $299.00 | $598.00 | |||
Naida S III SP | $385.00 | $770.00 | |||
Naida S I UP | $299.00 | $598.00 | |||
Naida S III UP | $385.00 | $770.00 | |||
NIOS S H20 III | $385.00 | $770.00 | |||
ReSound | Sparx Super Power VI | $312.75 | $625.50 | $95.00 Monaural $190.00 Binaural | 12 months |
VEA 2 Power | $247.50 | $495.00 | |||
VEA 2 Standard | $247.50 | $495.00 | |||
VEA 3 Mini | $277.50 | $555.00 | |||
VEA 3 Power | $277.50 | $555.00 | |||
VEA 3 Standard | $277.50 | $555.00 | |||
Verso 5 | $397.00 | $794.00 | |||
Verso 5 Micro RIE | $397.00 | $794.00 | |||
Verso 5 Mini | $397.00 | $794.00 | |||
Verso 5 Mini RIE | $397.00 | $794.00 | |||
Verso 5 Power | $397.00 | $794.00 | |||
Verso 5 RIE | $397.00 | $794.00 | |||
Rexton | Arena 1S | $200.85 | $401.70 | $89.00 | 12 months |
Cobalt 6 ECO+ RIC | $311.35 | $622.70 | $165.00 | ||
Day 4+ Free | $252.85 | $505.70 | $135.00 | ||
Day 4+ HP | $252.85 | $505.70 | |||
Day 4+ Open | $252.85 | $505.70 | |||
Day 4+ P | $252.85 | $505.70 | |||
Day 6+ Free | $311.35 | $604.50 | |||
Day 6+ HP | $311.35 | $622.70 | |||
Day 6+ Open | $311.35 | $622.70 | |||
Day 6+ P | $311.35 | $622.70 | |||
Onyx EOC+RIC | $324.35 | $648.70 | |||
Siemens Hearing Instruments, Inc. * Available 11/1/13. | Orion M | $328.53 | $657.06 | $95.00 | 12 months |
Orion P | $328.53 | $657.06 | |||
Orion RIC* | $328.53 | $657.06 | |||
Orion S* | $328.53 | $657.06 | |||
Pure 101 Xcel | $286.23 | $657.06 | |||
Sirion M* | $272.13 | $544.26 | |||
Sirion P* | $272.13 | $544.26 | |||
Sirion S* | $272.13 | $544.26 | |||
Sonic Innovations | Endura 6 | $285.00 | $570.00 | $145.00 Monaural $290.00 Binaural | 12 months |
Flip 60 Mini RIC | $285.00 | $570.00 | |||
Ion | $169.00 | $338.00 | |||
Velocity 4 | $209.00 | $418.00 | |||
Velocity 6 | $259.00 | $518.00 | |||
Velocity 6 Mini | $259.00 | $518.00 | |||
Starkey Laboratories, Inc. | 3 Series 20 mini | $299.00 | $598.00 | $84.99 | 27 months |
3 Series 20 RIC | $299.00 | $598.00 | |||
3 Series 30 mini | $329.00 | $658.00 | |||
3 Series 30 RIC | $329.00 | $658.00 | |||
3 Series 70 RIC | $389.00 | $798.00 | |||
3 Series i20 13 | $349.00 | $698.00 | |||
3 Series i20 mini | $349.00 | $698.00 | |||
3 Series i20 RIC | $349.00 | $698.00 | |||
3 Series i30 | $369.00 | $738.00 | |||
3 Series i30 mini | $369.00 | $738.00 | |||
3 Series i30 RIC | $369.00 | $738.00 | |||
3 Series i70 BTE | $399.00 | $798.00 | |||
3 Series i70 mini | $399.00 | $798.00 | |||
3 Series i70 RIC | $399.00 | $798.00 | |||
3 Series 70 mini | $389.00 | $778.00 | |||
Ignite 20 mini | $289.00 | $578.00 | $84.99 | 27 months | |
Ignite 20 RIC | $289.00 | $578.00 | |||
Ignite 20 Stnd, Power, or Power Plus | $289.00 | $578.00 | |||
Ignite i20 RIC | $339.00 | $678.00 | |||
Ignite 30 mini | $319.00 | $638.00 | |||
Ignite 30 RIC | $319.00 | $638.00 | |||
Ignite 30 Stnd, Power, or Power Plus | $319.00 | $638.00 | |||
Ignite i30 RIC | $359.00 | $718.00 | |||
Wi Series i70 RIC | $389.00 | $778.00 | |||
X Series 70 m | $379.00 | $758.00 | |||
X Series 70 RIC | $379.00 | $758.00 | |||
X Series 70 Stnd, Power, or Power Plus | $379.00 | $758.00 | |||
X Series 90 m | $399.00 | $798.00 | |||
X Series 90 RIC | $399.00 | $798.00 | |||
X Series 90 Stnd, Power, or Power Plus | $399.00 | $798.00 | |||
Xino 70 RIC | $389.00 | $778.00 | |||
Xino i70 micro RIC | $399.00 | $798.00 | |||
Unitron Hearing, Inc. | MAXe SP M | $352.43 | $704.86 | $75.00 | 12 months |
MAXe SP | $352.43 | $704.86 | |||
Moxi 6 CRT HP | $395.00 | $790.00 | |||
Moxi 6 CRT P | $395.00 | $790.00 | |||
Moxi 6 CRT S | $395.00 | $790.00 | |||
Moxi 6 Kiss CRTP | $395.00 | $790.00 | |||
Moxi 6 Kiss CRTS | $395.00 | $790.00 | |||
Moxi 6 Kiss CRTSP | $395.00 | $790.00 | |||
Moxi E CRT | $320.22 | $640.44 | |||
Moxi E CRT P | $320.22 | $640.44 | |||
Moxi E CRT SP | $320.22 | $640.44 | |||
Moxi E Kiss CRTP | $320.22 | $640.44 | |||
Moxi E Kiss CRTS | $320.22 | $640.44 | |||
Moxi E Kiss CRTSP | $320.22 | $640.44 | |||
Quantum 6 | $395.00 | $790.00 | |||
Quantum 6 HP | $395.00 | $790.00 | |||
Quantum 6 Micro | $395.00 | $790.00 | |||
Quantum E HP | $320.22 | $640.44 | |||
Quantum E M | $320.22 | $640.44 | |||
Quantum E S | $320.22 | $640.44 | |||
Shine+ | $229.40 | $458.80 | |||
Shine+ HP | $229.40 | $458.80 | |||
Shine+ Moda II | $229.40 | $458.80 | |||
Widex Hearing | Dream 110 9 | $377.00 | $754.00 | $100.00 | 12 months |
Dream 110 D1-FS RIC | $377.00 | $754.00 | |||
Dream 110 Fashion | $377.00 | $754.00 | |||
Dream 110 m-CB micro ClearBand | $377.00 | $754.00 | |||
Menu ME3-M | $199.00 | $398.00 | |||
Menu ME3-9 | $199.00 | $398.00 | |||
Menu ME3-19 | $199.00 | $398.00 | |||
Mind 220 m2-9 | $350.00 | $700.00 | |||
Mind 220 m2-19 | $350.00 | $700.00 | |||
Mind 220 m2-m | $350.00 | $700.00 |
V5260 — Refer to V5256. |
V5261 — Refer to V5257. |