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. 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.
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.
V5170 — Hearing aid, CROS; in the ear (Applicable modifiers: LT, RR, RT) | ||||
Manufacturer and Style | Model(s) | Purchase Rate | Repair Rate Per Unit | Repair Warranty |
Phonak Hearing Systems, LLC Notes:
|
Dalia 13 UZ — FS | $678.00 | $110.00 | 12 months |
| Virto Q30 13 — FS | $678.00 | |||
| Virto Q30 312 — HS | $678.00 | |||
| Virto Q50 13 — FS | $764.00 | |||
| Virto Q50 312 — HS | $764.00 | |||
V5180 — Hearing aid, CROS; behind the ear (Applicable modifiers: LT, RR, RT) | ||||
Manufacturer and Style | Model(s) | Purchase Rate for CROS/BICROS | Repair Rate Per Unit |
Repair Warranty |
Oticon, Inc. Note: All models listed are wired models. |
Agil: Agil, Mini, Mini RITE, Power, or RITE | $450.00 | $80.00 $100.00 | 6 months 12 months |
| Chili SP5 | $225.00 | |||
| Chili SP7 | $349.00 | |||
| Get or Get Power | $199.00 | |||
| Nera: Nera, Mini, Mini RITE, Power, or RITE | $349.00 | |||
| Nera Pro: Nera Pro, Design RITE, Mini, Mini RITE, Power, or RITE | $450.00 | |||
| Ria: Ria, Mini, Mini RITE, Power, or RITE | $225.00 | |||
| Ria Pro: Ria Pro, Design RITE, Mini, Mini RITE, Power, or RITE | $250.00 | |||
| Safari 300 Super Power | $225.00 | |||
| Safari 600 Super Power | $349.00 | |||
| Safari 900 Super Power | $399.00 | |||
| Sensei or Sensei RITE | $225.00 | |||
| Sensei Pro or Sensei Pro RITE | $399.00 | |||
| Sumo DM | $399.00 | |||
Phonak Hearing Systems, LLC (+ 30 Models) Notes:
|
Audeo: Q30 10, Q30 312, or Q30 312T | $678.00 | $110.00 | 12 months |
| Bolero: Q30 M13, Q30 M312, Q30 P, or Q30 SP | $678.00 | |||
| Dalia: Micro M, Micro P, or SP | $678.00 | |||
| Nadia: Q30 RIC, Q30 SP, or Q30 UP | $678.00 | |||
Phonak Hearing Systems, LLC (+ 50 Models) Notes:
|
Audeo: Q50, Q50 10, Q50 312, or Q50 312T | $764.00 | ||
| Bolero: Q50 M13, Q50 M312, Q50 P, or Q50 SP | $764.00 | |||
| Nadia: Q50 RIC, Q50 SP, or Q50 UP | $764.00 | |||
| Unitron Hearing, Inc. | Tandem 4 | $870.86 | $150.00 | 12 months |
| Widex USA Inc. | Dream: D1-9, D1-9 VC, D1-FA VC, or D1-MR CB | $848.40 | $100.00 | 12 months |
| Dream D1-FS | $780.96 | |||
V5210 — Refer to V5170. |
V5220 — Refer to V5180. |
V5256 — Hearing aid, digital, monaural, ITE (Applicable modifiers: LT, RR, RT) | |||||
Manufacturer and Style | Model(s) | 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 2ER | $251.65 | $503.30 | |||
| Intuition 2FC+ | $225.00 | $450.00 | |||
| Intuition 4+ | $325.00 | $650.00 | |||
| Intuition 4AD | $350.00 | $700.00 | |||
| Intuition 6 | $350.00 | $700.00 | |||
| Intuition 6AD | $374.81 | $749.62 | |||
| 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 | |||
| Promise 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 | |||
| Promise 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 | |||
| Promise 6-Optima | $376.50 | $753.00 | |||
Hansaton Acoustics, Inc. — Full Shell, Half Shell, and Low Profile Note: There is no charge for directional microphone, telecoil, volume control, or push button. |
Linnea | $276.00 | $552.00 | $100.00 | 12 months |
| Sorino | $357.60 | $715.20 | |||
| Oticon, Inc. — Full Shell | Nera or Nera Power | $349.00 | $698.00 | $80.00 $100.00 |
6 months 12 months |
| Nera Pro or Nera Pro Power | $450.00 | $900.00 | |||
| Ria or Ria Power | $225.00 | $450.00 | |||
| Ria Pro or Ria Pro Power | $250.00 | $500.00 | |||
| Oticon, Inc. — Half Shell | Agil HS or Agil HS Power | $450.00 | $900.00 | ||
| Get or Get Power | $199.00 | $398.00 | |||
| Nera or Nera HS Power | $349.00 | $698.00 | |||
| Nera Pro or Nera Pro HS Power | $349.00 | $698.00 | |||
| Ria or Ria HS Power | $225.00 | $450.00 | |||
| Ria Pro or Ria Pro Power | $250.00 | $500.00 | |||
| Oticon, Inc. — Low Profile | Acto or Acto Power | $349.00 | $698.00 | ||
| Acto Pro or Acto Pro Power | $399.00 | $798.00 | |||
| Agil LP or Agil LP Power | $450.00 | $900.00 | |||
| Get or Get Power | $199.00 | $398.00 | |||
| Ino or Ino Power | $199.00 | $398.00 | |||
| Ino Pro or Ino Pro Power | $225.00 | $450.00 | |||
| Phonak Hearing Systems, LLC — Full Shell | Dalia 13 UZ | $225.00 | $450.00 | $110.00 | 12 months |
| Virto Q30 13 | $299.00 | $598.00 | |||
| Virto Q50 13 | $385.00 | $770.00 | |||
| Phonak Hearing Systems, LLC — Half Shell | Dalia 312 | $225.00 | $450.00 | ||
| Dalia UZ | $225.00 | $450.00 | |||
| Virto Q30 or Virto Q30 NW | $299.00 | $598.00 | |||
| Virto Q50 or Virto Q50 NW | $385.00 | $770.00 | |||
| Phonak Hearing Systems, LLC — Low Profile | Dalia 10 Petite | $225.00 | $450.00 | ||
| Virto Q50 NW O or Virto Q50 Nano NW O | $385.00 | $770.00 | |||
ReSound — Full Shell and Half Shell Note: Available in standard, directional, power, or directional power. |
VEA 2 | $247.50 | $495.00 | $95.00 |
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 directional microphone, telecoil, or switchless telecoil. |
Arena 1S | $200.71 | $401.42 | $155.00 | 12 months |
| Joy 6 2c | $272.13 | $544.26 | |||
| Joy 8 2c | $328.53 | $657.06 | |||
| Siemens Hearing Instruments, Inc. — Full Shell and Half Shell |
Insio 3mi | $422.74 | $845.48 | $95.00 | 12 months |
| Intuis | $229.54 | $459.08 | |||
| Nitro 3mi custom | $422.74 | $845.48 | |||
| Orion custom | $328.53 | $659.06 | |||
| Phoenix G3 | $220.34 | $440.68 | |||
| Sirion custom | $272.13 | $544.26 | |||
| Sonic Innovations — Full Shell | Charm 40 D | $418.00 | $836.00 | $175.00 |
12 months |
| Starkey Laboratories, Inc. — Full Shell and Half Shell | 3 Series 20 | $339.00 | $678.00 | $84.99 | 12 months |
| 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 | |||
| 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 | |||
| Ignite 20 | $289.00 | $578.00 | |||
| Ignite 30 | $319.00 | $638.00 | |||
| Ignite i20 | $339.00 | $678.00 | |||
| 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 | |||
Unitron Hearing, Inc. — Full Shell, Half Shell, and Low Profile
|
Quantum2E | $320.22 | $640.44 | $75.00 | 12 months |
| Quantum2 10 | $395.00 | $790.00 | |||
| Quantum2 16 | $447.86 | $895.72 | |||
| Widex Hearing — Full Shell and Half Shell | Clear 220 | $400.00 | $800.00 | $100.00 | 12 months |
| Dream 110 | $377.00 | $754.00 | |||
| Menu 3 ME3 | $199.00 | $398.00 | |||
| Mind 220 m2 | $350.00 | $700.00 | |||
V5257 — Hearing aid, digital, monaural, BTE (Applicable modifiers: LT, RR, RT) | |||||
Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
| Audina Hearing Instruments, Inc. | 478 or 478P+ | $245.00 | $490.00 | $150.00 | 12 months |
| BTE 6 AD | $300.00 | $600.00 | |||
| FLX: 4, 6, or 12 | $400.00 | $800.00 | |||
| Intuition 2 | $200.00 | $400.00 | |||
| Intuition 2FC | $225.00 | $450.00 | |||
| Intuition 4+ | $300.00 | $600.00 | |||
| 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 | |||
| Sparo 12 | $400.00 | $800.00 | |||
| Sparo AD | $350.00 | $700.00 | |||
| Beltone Electronics | Bold 3 95 D | $404.50 | $809.00 | $97.30 | 12 months |
| Origin 2-75D | $337.35 | $674.70 | |||
| Origin 2-85D | $395.85 | $791.70 | |||
| Origin 3-64D | $341.25 | $682.50 | |||
| Origin 3-65D | $369.85 | $739.70 | |||
| Origin 3-75D | $369.85 | $739.70 | |||
| Origin 3-85D | $367.95 | $735.90 | |||
| Promise 6 62 D | $431.20 | $862.40 | |||
| Promise 6 63 DW | $422.95 | $845.90 | |||
| Promise 6 64 DW | $444.95 | $889.90 | |||
| Promise 6 66 DW | $410.40 | $820.80 | |||
| Promise 6 78 DW | $403.70 | $807.40 | |||
| 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. |
Inara: Mini, Power, or Slim | $418.00 | $836.00 | $100.00 | 12 months |
| Inara X Mini RIC | $438.90 | $877.80 | |||
| Linnea Classic or Linnea Power | $253.00 | $506.00 | |||
| Linnea X Mini RIC | $253.00 | $506.00 | |||
| Salto Classic | $191.25 | $382.50 | |||
| Salto Super Power | $232.75 | $465.50 | |||
| Sorino: Mini, Power, or Slim | $312.90 | $625.80 | |||
| Sorino X Mini RIC | $312.90 | $625.80 | |||
| Oticon, Inc. | Agil: Agil, Mini, Mini RITE, Power, or RITE | $450.00 | $900.00 | $80.00 $100.00 |
6 months 12 months |
| Chili SP5 | $225.00 | $450.00 | |||
| Chili SP7 | $349.00 | $698.00 | |||
| Get or Get Power | $199.00 | $398.00 | |||
| Nera: Nera, Mini, Mini RITE, Power, or RITE | $349.00 | $698.00 | |||
| Nera Pro: Nera Pro, Design RITE, Mini, Mini RITE, Power, or RITE | $450.00 | $900.00 | |||
| Ria: Ria, Mini, Mini RITE, Power, or RITE | $225.00 | $450.00 | |||
| Ria Pro: Ria Pro, Design RITE, Mini, Mini RITE, Power, or RITE | $250.00 | $500.00 | |||
| Safari 300 Super Power | $225.00 | $450.00 | |||
| Safari 600 Super Power | $349.00 | $698.00 | |||
| Safari 900 Super Power | $399.00 | $798.00 | |||
| Sensei or Sensei RITE | $225.00 | $450.00 | |||
| Sensei Pro or Sensei Pro RITE | $399.00 | $798.00 | |||
| Sumo DM | $399.00 | $798.00 | |||
| Phonak Hearing Systems, LLC | Audeo Q30 or Audeo Q30 T | $299.00 | $598.00 | $110.00 | 12 months |
| Audeo Q50 or Audeo Q50 T | $385.00 | $770.00 | |||
| Bolero: Q30, Q30 M, Q30 P, or Q30 SP | $299.00 | $598.00 | |||
| Bolero: Q50 M, Q50 P, or Q50 SP | $385.00 | $770.00 | |||
| Dalia M H2O | $225.00 | $450.00 | |||
| Dalia: Micro M, Micro P, or SP | $225.00 | $450.00 | |||
| Nadia: Q30 RIC, Q30 SP, or Q30 UP | $299.00 | $598.00 | |||
| Nadia: Q50 RIC, Q50 SP, or Q50 UP | $385.00 | $770.00 | |||
Sky: Q50 M, Q50 RIC, Q50 SP, or Q50 UP |
$385.00 | $770.00 | |||
| ReSound | Magna Super Power DVI | $397.00 | $794.00 | $95.00 |
12 months |
| Vea 2 Standard or Vea 2 Power | $247.50 | $495.00 | |||
| Vea 3: Standard, Mini, or Power | $277.50 | $555.00 | |||
| Verso 5: Verso 5, Micro RIE, Mini, Mini RIE, Power, or RIE | $397.00 | $794.00 | |||
| Verso 7: Verso 7, Micro RIE, Mini, Mini RIE, Power, or RIE | $448.00 | $896.00 | |||
| Verso 7 TS: Verso 7 TS, Micro RIE, Mini, Mini RIE, Power, or RIE | $448.00 | $896.00 | |||
| Rexton | Arena 1S | $200.85 | $401.70 | $155.00 | 12 months |
| Joy 6: M 2c, P 2c, or S 2c | $272.13 | $544.26 | |||
| Joy 8: M 2c, P 2c, or S 2c | $328.53 | $657.06 | |||
| Strata 6 2c RIC | $328.53 | $657.06 | |||
| Onyx 8+ RIC | $441.35 | $882.70 | |||
| Onyx EOC+RIC | $324.35 | $648.70 | |||
| Siemens Hearing Instruments, Inc. |
Acquaris 3mi | $422.74 | $845.48 | $95.00 | 12 months |
| Life 3mi | $422.74 | $845.48 | |||
| Motion 3mi: M, P, PX, or SX | $422.74 | $845.48 | |||
| Nitro 3mi | $422.74 | $845.48 | |||
| Orion: M, P, RIC, or S | $328.53 | $657.06 | |||
| Pure 3mi | $422.74 | $845.48 | |||
| Sirion: M, P, or S | $272.13 | $544.26 | |||
| Sonic Innovations | Endura 6 P | $285.00 | $570.00 | $175.00 |
12 months |
| Charm 40 or Charm 40 Mini | $237.50 | $475.00 | |||
| Charm 60 | $332.50 | $665.00 | |||
| Charm 60 Mini | $259.00 | $518.00 | |||
| Flip 60 Mini RIC | $332.50 | $665.00 | |||
| Starkey Laboratories, Inc. | 3 Series 20: 3 Series 20, Mini, Power+, or RIC | $299.00 | $598.00 | $84.99 | 12 months |
| 3 Series 30: 3 Series 30, Mini, Power+, or RIC | $329.00 | $658.00 | |||
| 3 Series 70: 3 Series 70, Mini, Power+, or RIC | $389.00 | $798.00 | |||
| 3 Series 90: 3 Series 90, P+, or RIC | $409.00 | $818.00 | |||
| 3 Series 110: 3 Series 110, m, P+, or RIC | $429.00 | $858.00 | |||
| 3 Series i20: 3 Series i20, Mini, Power+, or RIC | $349.00 | $698.00 | |||
| 3 Series i30: 3 Series i30, Mini, Power+, or RIC | $369.00 | $738.00 | |||
| 3 Series i70: 3 Series i70, Mini, or Power+ | $399.00 | $798.00 | |||
| 3 Series i90: 3 Series i90, m, P+, or RIC | $419.00 | $838.00 | |||
| 3 Series i110: 3 Series i110, m, P+, or RIC | $439.00 | $878.00 | |||
| Ignite 20: Standard, Mini, Power, Power+, or RIC | $289.00 | $578.00 | |||
| Ignite 30: Standard, Mini, Power, Power+, or RIC | $319.00 | $638.00 | |||
| Ignite i20 RIC | $339.00 | $678.00 | |||
| Ignite i30 RIC | $359.00 | $718.00 | |||
| Wi Series i70 RIC | $389.00 | $778.00 | |||
| Wi Series i90 RIC | $409.00 | $818.00 | |||
| Wi Series i110 RIC | $429.00 | $858.00 | |||
| X Series 70: Standard, Mini, Power, Power+, or RIC | $379.00 | $758.00 | |||
| X Series 90: Standard, Mini, Power, Power+, or RIC | $399.00 | $798.00 | |||
| X Series 110: X Series 110, m, Power, Power+, or RIC | $419.00 | $838.00 | |||
| Xino 20 RIC | $299.00 | $598.00 | |||
| Xino 30 RIC or Xino 30 Tinnitus RIC | $329.00 | $658.00 | |||
| Xino 70 RIC | $389.00 | $778.00 | |||
| Xino 90 Micro RIC | $409.00 | $818.00 | |||
| Xino 110 Micro RIC | $429.00 | $858.00 | |||
| Xino i20 Micro RIC | $349.00 | $698.00 | |||
| Xino i30 Micro RIC | $369.00 | $738.00 | |||
| Xino i70 Micro RIC | $399.00 | $798.00 | |||
| Xino i90 Micro RIC | $419.00 | $838.00 | |||
| Xino i110 Micro RIC | $439.00 | $878.00 | |||
| Xino Classic 20 RIC | $299.00 | $598.00 | |||
| Xino Classic 30 RIC | $329.00 | $658.00 | |||
| Xino Classic 70 RIC | $389.00 | $778.00 | |||
| Xino Classic 90 RIC | $409.00 | $818.00 | |||
| Xino Classic 110 RIC | $429.00 | $858.00 | |||
| Xino Tinnitus | $409.00 | $818.00 | |||
| Unitron Hearing, Inc. | MAX E SP or Max E SP M | $352.43 | $704.86 | $75.00 | 12 months |
| Moxi 2E: CRT S, CRT P, or CRT SP | $320.22 | $640.44 | |||
| Moxi 2E Kiss P or Moxi 2E Kiss SP | $320.22 | $640.44 | |||
| Moxi 210: CRT S, CRT P, or CRT SP | $395.00 | $790.00 | |||
| Moxi 210: Dura S, Dura P, or Dura SP | $395.00 | $790.00 | |||
| Moxi 210: Kiss S, Kiss P, or Kiss SP | $395.00 | $790.00 | |||
| Moxi 216: CRT S, CRT P, or CRT SP | $448.00 | $896.00 | |||
| Moxi 216: Dura S, Dura P, or Dura SP | $448.00 | $896.00 | |||
| Moxi 216: Kiss S, Kiss P, or Kiss SP | $448.00 | $896.00 | |||
| Quantum 2E P or Quantum 2E HP | $320.22 | $640.44 | |||
| Quantum 210 S or Quantum 210 HP | $395.00 | $790.00 | |||
| Quantum 216 or Quantum 216 HP | $448.00 | $896.00 | |||
| Widex Hearing | Clear: C2 FS, C2 MR, C2 MR CB, or C2 PA | $400.00 | $800.00 | $100.00 | 12 months |
| Clear C29 or Clear C29 VC | $400.00 | $800.00 | |||
| Dream: D1-9, D1-9 VC, D1-FS, or D1-MR CB | $377.00 | $754.00 | |||
| Dream Fashion D1-FA VC | $377.00 | $754.00 | |||
| Menu: ME 3-m, ME 3-9, or ME 3-19 | $199.00 | $398.00 | |||
| Mind m2-9 or Mind m2-9 VC | $350.00 | $700.00 | |||
| Mind m2-19 or Mind m2-19 VC | $350.00 | $700.00 | |||
| Mind m2-m | $350.00 | $700.00 | |||
| Super S2-VS-P or Super S2-VS-SP | $400.00 | $800.00 | |||
| Super S2-VSD-P or Super S2-VSD-SP | $400.00 | $800.00 | |||
V5260 — Refer to V5256. |
V5261 — Refer to V5257. |