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 life expectancy on hearing aids for adults and a three-year life expectancy on hearing aids for children ages 20 and younger.
|
V5170 — Hearing aid, CROS; in the ear (Applicable modifiers: 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 Hearing Systems, LLC Note: Only full-shell available for all models. |
Quest +50 (any 50 level aid) | $764.00 | $764.00 | $110.00 | 12 months |
| Venture PKG 30 (Virto V aids) | $678.00 | $678.00 | |||
| Venture PKG 50 (Virto V aids) | $764.00 | $764.00 | |||
|
Siemens Hearing Instruments, Inc. |
Insio 3Px package | $768.60 | $768.60 | $95.00 | 12 months |
|
V5180 — Hearing aid, CROS; behind the ear (Applicable modifiers: 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 |
| Oticon, Inc. | Alta2, Alta2 + Power, Alta2 Power | $674.00 | Not Covered | $80.00 $100.00 |
6 months 12 months |
| Chili SP5 | $350.00 | $525.00 | |||
| Chili SP7 | $474.00 | $773.00 | |||
| Chili SP9 | $540.72 | Not Covered | |||
| Dynamo SP4 | $300.00 | $600.00 | |||
| Dynamo SP6 | $424.00 | $848.00 | |||
| Dynamo SP8 | $525.00 | Not Covered | |||
| Nera2, Nera2 + Power, Nera2 Power | $325.00 | $650.00 | |||
| Nera2 Pro, Nera2 Pro + Power, Nera2 Pro Power | $424.00 | $848.00 | |||
| Ria2, Ria2 + Power, Ria2 Power | $275.00 | $548.00 | |||
| Ria2 Pro, Ria2 Pro Power | $300.00 | $600.00 | |||
| Sensei | $350.00 | $525.00 | |||
| Sensei SP | $274.00 | $548.00 | |||
| Sensei SP Pro | $424.00 | $848.00 | |||
| Sensei Pro | $524.00 | $873.00 | |||
| Sumo DM | $524.00 | Not Covered | |||
|
Phonak Hearing Systems, LLC Notes:
|
Audeo B 30 | $731.00 | $731.00 | $110.00 | 12 months |
| Audeo B 50 | $818.00 | $818.00 | |||
| Quest +50 | $764.00 | $764.00 | |||
| Quest +50 H2O | $764.00 | $764.00 | |||
| Venture PKG 30 | $678.00 | $678.00 | |||
| Venture PKG 50 | $764.00 | $764.00 | |||
|
Siemens Hearing Instruments, Inc. Note: Includes wireless CROS transmitter. |
CROS + Motion 3Px | $768.60 | $768.60 | $95.00 | 12 months |
| CROS + Pure 3Px | $768.60 | $768.60 | |||
|
Starkey Laboratories, Inc. Note: Includes CROS/BICROS transmitter. |
CrosMuse i1600, Macro, Mini | $738.00 | $738.00 | $84.99 | 12 months |
| CrosMuse i2000, Macro, Mini | $758.00 | $758.00 | |||
| CrosMuse i2400, Macro, Mini | $778.00 | $778.00 | |||
| Widex USA Inc. | Dream 110 | $599.00 | $599.00 | $100.00 | 12 months |
| Dream 110 Fashion | $599.00 | $599.00 | |||
| Dream 220 | $724.00 | $724.00 | |||
| Dream 220 Fashion | $724.00 | $724.00 | |||
| Dream 330 | $814.00 | $814.00 | |||
| Dream 330 Fashion | $814.00 | $814.00 | |||
| Unique 110 | $689.00 | $689.00 | |||
| Unique 220 | $759.00 | $759.00 | |||
|
V5210 — Refer to V5170. |
|
V5220 — Refer to V5180. |
|
V5256 — Hearing aid, digital, monaural, ITE (Applicable modifiers: LT, RR, RT) |
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|
Manufacturer and Style |
Model(s) |
Purchase Rate for Monaural |
Purchase Rate for Binaural |
Repair Rate Per Unit |
Repair Warranty |
| Beltone Electronics — Full Shell | Ally 3 | $346.05 | $692.10 | $150.00 | 12 months |
| Legend 6 | $398.58 | $797.16 | |||
| Origin 2-Optima | $248.17 | $496.34 | |||
| Origin 3-Optima | $276.76 | $553.52 | |||
| Beltone Electronics — Half Shell and Low Profile | Origin 2-Optima | $248.17 | $496.34 | ||
| Origin 3-Optima | $276.76 | $553.52 | |||
|
Hansaton Acoustics, Inc. — Full Shell, Half Shell, and Low Profile Note: There is no charge for directional microphone, telecoil, volume control, or push button. |
Jam 3, JamHD3 | $253.00 | $506.00 | $100.00 | 12 months |
| Jam 5, JamHD 5 | $298.00 | $596.00 | |||
| Jam 7, JamHD 7 | $418.00 | $836.00 | |||
|
Oticon, Inc. — Full Shell Note: There is no charge for VC, TC, or Auto TC. |
Nera2, Nera2 Power | $250.00 | $500.00 | $80.00 $100.00 |
6 months 12 months |
| Nera2 Pro, Nera2 Pro Power | $349.00 | $698.00 | |||
| Ria2, Ria2 Power | $199.00 | $398.00 | |||
| Ria2 Pro, Ria2 Pro Power | $225.00 | $450.00 | |||
|
Oticon, Inc. — Half Shell Note: There is no charge for VC, TC, or Auto TC. |
Get, Get Power | $199.00 | $398.00 | ||
| Nera2, Nera2 Power | $250.00 | $500.00 | |||
| Nera2 Pro, Nera2 Pro HS Power | $349.00 | $698.00 | |||
| Ria2, Ria2 Power | $199.00 | $398.00 | |||
| Ria2 Pro, Ria2 Pro Power | $225.00 | $450.00 | |||
|
Oticon, Inc. — Low Profile Note: There is no charge for VC, TC, or Auto TC. |
Agil, Agil Power | $450.00 | $900.00 | ||
| Get, Get Power | $199.00 | $398.00 | |||
| Phonak Hearing Systems, LLC — Full Shell | Virto Q30 | $299.00 | $598.00 | $110.00 | 12 months |
| Virto Q50 | $385.00 | $770.00 | |||
| Virto V30 | $299.00 | $598.00 | |||
| Virto V50 | $385.00 | $770.00 | |||
| Phonak Hearing Systems, LLC — Half Shell | Virto Q30 or Q30 NW | $299.00 | $598.00 | ||
| Virto Q50 or Q50 NW | $385.00 | $770.00 | |||
| Virto V30 | $299.00 | $598.00 | |||
| Virto V50 | $385.00 | $770.00 | |||
| Phonak Hearing Systems, LLC — Low Profile | Virto Q50 or Q50 NW | $385.00 | $770.00 | ||
| Virto V50 | $385.00 | $770.00 | |||
| ReSound — Full Shell and Half Shell | Enya 3: DIR HP; DIR MP; DIR UP; Wireless or Non-Wireless | $300.00 | $600.00 | $95.00 |
12 months |
| LiNX2 5: DIR HP; DIR MP; DIR UP; Wireless or Non-Wireless | $397.00 | $794.00 | |||
| LiNX2 7: DIR HP; DIR MP; DIR UP; Wireless or Non-Wireless | $448.00 | $896.00 | |||
| Vea 2: DIR, DIR P, P | $247.50 | $495.00 | |||
| Vea 3: DIR, DIR P, P | $277.50 | $555.00 | |||
|
Rexton — Full Shell and Half Shell Note: There is no charge for directional microphone, telecoil, or switchless telecoil. |
Sterling 60 | $399.06 | $798.00 | $155.00 | 12 months |
| Sterling 80 | $431.56 | $863.10 | |||
| Siemens Hearing Instruments, Inc. — Full Shell
|
Insio 3Px | $431.55 | $863.10 | $95.00 | 12 months |
| Nitro 3mi custom | $449.55 | $899.10 | |||
| Orion2 custom | $382.05 | $764.10 | |||
| Sirion2 custom | $283.05 | $566.10 | |||
| Siemens Hearing Instruments, Inc. — Half Shell
|
Insio 3Px | $422.74 | $845.48 | ||
| Nitro 3mi custom | $422.74 | $845.48 | |||
| Orion2 custom | $328.53 | $657.06 | |||
| Sirion2 custom | $272.13 | $544.26 | |||
| Starkey Laboratories, Inc. — Full Shell and Half Shell | 3 Series 20 | $299.00 | $598.00 | $84.99 | 12 months |
| 3 Series 30 | $329.00 | $658.00 | |||
| 3 Series 70 | $389.00 | $778.00 | |||
| 3 Series 90 | $409.00 | $818.00 | |||
| 3 Series 110 | $429.00 | $858.00 | |||
| Muse i1600 | $399.00 | $798.00 | |||
| Muse i2000 | $419.00 | $838.00 | |||
| Muse i2400 | $439.00 | $878.00 | |||
| Z Series i20 | $339.00 | $678.00 | |||
| Z Series i30 | $359.00 | $718.00 | |||
| Z Series i70 | $379.00 | $758.00 | |||
| Z Series i90 | $399.00 | $798.00 | |||
| Z Series i110 | $419.00 | $838.00 | |||
|
Unitron Hearing, Inc. — Full Shell, Half Shell, and Low Profile Note: Available in standard, power, or high power. |
Stride 500 | $299.00 | $598.00 | $75.00 | 12 months |
| Stride 600 | $385.00 | $770.00 | |||
| Stride 700 | $448.00 | $896.00 | |||
| Widex Hearing — Full Shell and Half Shell | Dream 110 | $225.00 | $450.00 | $100.00 | 12 months |
| Dream 220 | $350.00 | $700.00 | |||
| Dream 330 | $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) |
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|
Manufacturer and Style |
Model(s) |
Purchase Rate for Monaural |
Purchase Rate for Binaural |
Repair Rate Per Unit |
Repair Warranty |
| Beltone Electronics | Ally 3 | $392.19 | $784.38 | $150.00 | 12 months |
| Bold 3 95 D | $449.50 | $899.00 | |||
| Legend 6 | $398.58 | $797.16 | |||
| Origin 2-75D, 85D | $249.50 | $499.00 | |||
| Origin 3-64D, 65D, 75D, 85D | $283.05 | $566.10 | |||
| Turn TN1T75 | $209.30 | $418.60 | |||
| Turn TN3T85 | $259.35 | $518.70 | |||
| Turn TN3T95 | $324.35 | $648.70 | |||
| Hansaton Acoustics, Inc. | Beat 3 | $253.00 | $506.00 | $100.00 | 12 months |
| Beat 7 | $418.00 | $836.00 | |||
| Flow 1 | $191.25 | $382.50 | |||
| Flow 2 | $232.75 | $465.50 | |||
| Jam HD 3 | $253.00 | $506.00 | |||
| Jam HD 5 | $298.00 | $596.00 | |||
| Jam HD 7 | $418.00 | $836.00 | |||
| Sound HD 3 | $253.00 | $506.00 | |||
| Sound HD 5 | $298.00 | $596.00 | |||
| Sound HD 7 | $418.00 | $836.00 | |||
| Oticon, Inc. | Chili SP5 | $225.00 | $450.00 | $80.00 $100.00 |
6 months 12 months |
| Chili SP7 | $349.00 | $698.00 | |||
| Get; Get Power | $199.00 | $398.00 | |||
| Dynamo SP4 | $225.00 | $450.00 | |||
| Dynamo SP6 | $349.00 | $698.00 | |||
| Dynamo SP8 | $450.00 | $900.00 | |||
| Nera2; Nera2 Mini, Mini RITE, Power, or RITE | $250.00 | $500.00 | |||
| Nera2 Pro; Nera2 Pro Design RITE, Mini, Mini RITE, Power, or RITE | $349.00 | $698.00 | |||
| Ria2; Ria2 Mini, Mini RITE, Power, or RITE | $199.00 | $398.00 | |||
| Ria2 Pro; Ria2 Pro Design RITE, Mini, Mini RITE, Power, or RITE | $225.00 | $450.00 | |||
| Sensei; Sensei RITE | $225.00 | $450.00 | |||
| Sensei Pro, Sensei Pro RITE | $399.00 | $798.00 | |||
| Sensei SP | $199.00 | $398.00 | |||
| Sensei SP Pro | $349.00 | $698.00 | |||
| Sumo DM | $399.00 | $798.00 | |||
| Phonak Hearing Systems, LLC | Audeo B30-10 | $308.51 | $617.02 | $110.00 | 12 months |
| Audeo B30-13, B30-312, B30-312 T | $352.00 | $704.00 | |||
| Audeo B50 | $439.00 | $878.00 | |||
| Audeo Q30 or Q30T | $299.00 | $598.00 | |||
| Audeo Q50 or Q50T | $385.00 | $770.00 | |||
| Audeo V30 | $299.00 | $598.00 | |||
| Audeo V50 | $385.00 | $770.00 | |||
| Bolero Q30 M, Q30 P, or Q30 SP | $299.00 | $598.00 | |||
| Bolero Q50 M, Q50 P, or Q50 SP | $385.00 | $770.00 | |||
| Bolero V30: M, P | $299.00 | $598.00 | |||
| Bolero V50: M, P, S | $385.00 | $770.00 | |||
| Nadia Q30 RIC, Q30 SP, or Q30 UP | $299.00 | $598.00 | |||
| Nadia Q50 RIC, Q50 SP, or Q50 UP | $385.00 | $770.00 | |||
| Nadia V30: RIC, UP, SP | $299.00 | $598.00 | |||
| Nadia V50: RIC, UP, SP | $385.00 | $770.00 | |||
| Sky Q50 M, Q50 RIC, Q50 SP, or Q50 UP | $385.00 | $770.00 | |||
| Sky V50: RIC, M, P, UP, SP | $385.00 | $770.00 | |||
| ReSound | Enya 2 Standard, Mini, Power | $275.00 | $550.00 | $95.00 | 12 months |
| Enya 3 Standard, Mini, Power | $300.00 | $600.00 | |||
| Enzo2 5 High Power | $397.00 | $794.00 | |||
| Enzo2 5 Super Power | $397.00 | $794.00 | |||
| Enzo2 7 High Power | $448.00 | $896.00 | |||
| Enzo2 7 Super Power | $448.00 | $896.00 | |||
| LiNX2 5 Standard, Mini, RIE, Power | $397.00 | $794.00 | |||
| LiNX2 7 Mini RIE, Power, Standard | $448.00 | $896.00 | |||
| Vea 2 Standard or Power | $247.50 | $495.00 | |||
| Vea 3 Standard, Mini, or Power | $277.50 | $555.00 | |||
| 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 | $448.00 | $896.00 | |||
| Rexton | Emerald M 60 4c | $399.00 | $798.00 | $155.00 | 12 months |
| Emerald M 80 4c | $431.55 | $863.10 | |||
| Emerald S 60 4c | $399.00 | $798.00 | |||
| Emerald S 80 4c | $431.55 | $863.10 | |||
| Mosaic M 60 4c | $399.00 | $798.00 | |||
| Mosaic M 80 4c | $431.55 | $863.10 | |||
| Mosaic P60 4c | $399.00 | $798.00 | |||
| Mosaic P80 4c | $431.55 | $863.10 | |||
| Siemens Hearing Instruments, Inc. |
Motion SX 3Px | $431.55 | $863.10 | $95.00 | 12 months |
| Motion SA 3PX | $431.55 | $863.10 | |||
| Motion PX 3BX | $431.55 | $863.10 | |||
| Nitro 3mi | $429.57 | $859.14 | |||
| Orion2: RIC, M, P, S | $382.05 | $764.10 | |||
| Pure 3Bx Carat RIC | $431.55 | $863.10 | |||
| Pure 3Bx Carat A RIC | $431.55 | $863.10 | |||
| Pure 3Px RIC | $431.55 | $863.10 | |||
| Sirion2: M, P, S | $283.05 | $566.10 | |||
| Starkey Laboratories, Inc. | 3 Series 20; 3 Series 20 Mini, P+, or RIC | $299.00 | $598.00 | $84.99 | 12 months |
| 3 Series 30; 3 Series 30 Mini, P+, or RIC | $329.00 | $658.00 | |||
| 3 Series 70; 3 Series 70 Mini, P+, or RIC | $389.00 | $778.00 | |||
| 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 | |||
| Halo i70 and Halo i70 RIC | $389.00 | $778.00 | |||
| Halo i90 and Halo i90 RIC | $409.00 | $818.00 | |||
| Halo i110 and Halo i110 RIC | $429.00 | $858.00 | |||
| Halo 2 i1600 RIC 13 | $399.00 | $798.00 | |||
| Halo 2 i2000 RIC 13 | $419.00 | $838.00 | |||
| Halo 2 i2400 RIC 13 | $439.00 | $878.00 | |||
| Muse i1600 | $399.00 | $798.00 | |||
| Muse i2000 | $419.00 | $838.00 | |||
| Muse i2400 | $439.00 | $878.00 | |||
| Z Series i20: Z Series i20, m, mRIC, P+, RIC | $349.00 | $698.00 | |||
| Z Series i30: Z Series i30, m, mRIC, P+, RIC | $369.00 | $738.00 | |||
| Z Series i70: Z Series i70, m, mRIC, P+, RIC | $399.00 | $798.00 | |||
| Z Series i90: Z Series i90, m, mRIC, P+, RIC | $409.00 | $818.00 | |||
| Z Series i110: Z Series, RIC, m, mRIC, P+ | $429.00 | $858.00 | |||
| Unitron Hearing, Inc. | MAX E SP or SP M | $352.43 | $704.86 | $75.00 | 12 months |
| Max 6: SP or SPM | $448.00 | $896.00 | |||
| North Moxi Dura 500 | $299.00 | $598.00 | |||
| North Moxi Dura 600 | $385.00 | $770.00 | |||
| North Moxi Dura 700 | $448.00 | $896.00 | |||
| North Moxi Fit 500 | $299.00 | $598.00 | |||
| North Moxi Fit 600 | $385.00 | $770.00 | |||
| North Moxi Fit 700 | $448.00 | $896.00 | |||
| North Moxi Kiss 500 | $299.00 | $598.00 | |||
| North Moxi Kiss 600 | $385.00 | $770.00 | |||
| North Moxi Kiss 700 | $448.00 | $896.00 | |||
| North Moxi Now 500 | $299.00 | $598.00 | |||
| North Moxi Now 600 | $385.00 | $770.00 | |||
| North Moxi Now 700 | $448.00 | $896.00 | |||
| Stride 500: CRT, M, P, P Dura | $299.00 | $598.00 | |||
| Stride 600: M, P, P Dura | $385.00 | $770.00 | |||
| Stride 700: M, P, P Dura | $448.00 | $896.00 | |||
| Widex Hearing | Dream 110 | $225.00 | $450.00 | $100.00 | 12 months |
| Dream 110 Fashion | $225.00 | $450.00 | |||
| Dream 220 | $350.00 | $700.00 | |||
| Dream 220 Fashion | $350.00 | $700.00 | |||
| Dream 330 | $440.00 | $880.00 | |||
| Dream 330 Fashion | $440.00 | $880.00 | |||
| Super 220 | $400.00 | $800.00 | |||
| Unique 110 | $315.00 | $630.00 | |||
| Unique 110 Fashion | $315.00 | $630.00 | |||
| Unique 220 | $385.00 | $770.00 | |||
| Unique 220 Fashion | $385.00 | $770.00 | |||
|
V5260 — Refer to V5256. |
|
V5261 — Refer to V5257. |