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.
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]) |
|||||
|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for CROS | Purchase Rate for BICROS | Repair Rate Per Unit | Repair Warranty |
| Phonak Hearing Systems, LLC — Full Shell | Quest ITE+30 (any 30 level aid) | $676.00 | $676.00 | $110.00 | 12 months |
| Quest ITE+50 (any 50 level aid) | $764.00 | $764.00 | |||
| Venture ITE Package 30 level | $651.64 | $651.64 | |||
| Venture ITE Package 50 level | $784.36 | $784.36 | |||
| Custom 30 level Belong Virto | $731.00 | $731.00 | |||
| Custom 50 level Belong Virto | $818.00 | $818.00 | |||
| Phonak Hearing Systems, LLC — Half Shell | Quest +30 (any 30 level aid) | $676.00 | $676.00 | ||
| Quest +50 (any 50 level aid) | $764.00 | $764.00 | |||
| Venture PKG 30 (Venture aids) | $678.00 | $678.00 | |||
| Venture PKG 50 (Venture aids) | $764.00 | $764.00 | |||
| 30 level Virto Belong | $731.00 | $731.00 | |||
| 50 level Virto Belong | $818.00 | $818.00 | |||
| Rexton | Sterling 60 Package | $562.20 | $562.20 | $95.00 | 12 months |
| Sterling 80 Package | $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]) |
|||||
|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for CROS | Purchase Rate for BICROS | Repair Rate Per Unit | Repair Warranty |
Phonak Hearing Systems, LLC Notes:
|
CROS B 30: Any model Belong Audeo and Bolero (excludes Audeo and Bolero B-R) | $731.00 | $731.00 | $110.00 | 12 months |
| CROS B 50: Any model Belong Audeo and Bolero (excludes Audeo and Bolero B-R) | $818.00 | $818.00 | |||
| Quest +30 | $676.00 | $676.00 | |||
| Quest +30 H2O | $676.00 | $676.00 | |||
| 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 | |||
| Rexton | CROS RIC +Emerald M 60 | $562.20 | $562.20 | $95.00 | 12 months |
| CROS RIC +Emerald M 80 | $749.40 | $749.40 | |||
| CROS RIC +Emerald S 60 | $562.20 | $562.20 | |||
| CROS RIC +Emerald S 80 | $749.40 | $749.40 | |||
| CROS RIC +Mosaic 60 | $562.20 | $562.20 | |||
| CROS RIC +Mosaic 80 | $749.40 | $749.40 | |||
| CROS RIC +Stellar Li 60 | $562.20 | $562.20 | |||
| CROS RIC +Stellar Li 80 | $749.40 | $749.40 | |||
| Signa | CROS+Carat 3px | $764.10 | $764.10 | $95.00 | 12 months |
| CROS+Cellion 3px | $764.10 | $764.10 | |||
| CROS+Pure 3px | $764.10 | $764.10 | |||
| CROS+Motion 3px | $764.10 | $764.10 | |||
Starkey Laboratories, Inc. Note: Includes CROS/BICROS transmitter. |
CrosMuse i1600, Micro, Mini, RIC | $738.00 | $738.00 | $84.99 | 12 months |
| CrosMuse i2000, Micro, Mini, RIC | $758.00 | $758.00 | |||
| CrosMuse i2400, Micro, Mini, RIC | $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 220 Fashion Power | $724.00 | $724.00 | |||
| Dream 330 | $814.00 | $814.00 | |||
| Dream 330 Fashion | $814.00 | $814.00 | |||
| Dream 330 Fashion Power | $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) (For binaural, use V5260 [Applicable modifier: RR].) |
|||||
|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
Beltone Electronics — Full Shell, Half Shell, and Low Profile Note: There is no charge for automatic noise reduction, directional microphone, or telecoil. |
Ally 3 | $349.00 | $698.00 | $100.00 | 12 months |
| Legend 6 | $399.00 | $798.00 | |||
| Legend 9 | $449.00 | $898.00 | |||
| Origin 2 | $249.00 | $498.00 | |||
| GN 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 | |||
Oticon, Inc. — Full 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 | |||
| Ria2 | $199.00 | $398.00 | |||
| Ria2 Pro | $225.00 | $450.00 | |||
Oticon, Inc. — Half Shell Note: There is no charge for VC, TC, or Auto TC. |
Alta2 | $399.00 | $798.00 | ||
| Alta2 Pro | $449.00 | $898.00 | |||
| Nera2 | $250.00 | $500.00 | |||
| Nera2 Pro | $349.00 | $698.00 | |||
| Ria2 | $225.00 | $450.00 | |||
| Ria2 Pro | $199.00 | $398.00 | |||
Oticon, Inc. — Low Profile Note: There is no charge for VC, TC, or Auto TC. |
Get | $199.00 | $398.00 | ||
| Phonak Hearing Systems, LLC — Full Shell, Half Shell, and Low Profile | Virto B30 | $352.00 | $704.00 | $129.00 | 12 months |
| Virto B50 | $439.00 | $878.00 | |||
| Virto Q30 or NW | $299.00 | $598.00 | |||
| Virto Q50 or NW | $385.00 | $769.99 | |||
| Virto V30 | $299.00 | $598.00 | |||
| Virto V50 or NW | $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 |
| 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 i1000 | $279.00 | $558.00 | |||
| Muse i1200 | $329.00 | $658.00 | |||
| 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 — Full Shell and Low Profile | Jam HD 3 | $242.00 | $484.00 | $100.00 | 12 months |
| Jam HD 5 | $340.00 | $680.00 | |||
| Stride 500 | $299.00 | $598.00 | $75.00 | 12 months | |
| Stride 600 | $385.00 | $770.00 | |||
| Stride 700 | $448.00 | $896.00 | |||
| Unitron Hearing — Half Shell | Jam HD 3 | $253.00 | $506.00 | $100.00 | 12 months |
| Jam HD 5 | $298.00 | $596.00 | |||
| Jam HD 7 | $418.00 | $836.00 | |||
| 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) (For binaural, use V5261 [Applicable modifier: RR].) |
|||||
|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
| Beltone Electronics | Ally 3 | $349.00 | $698.00 | $100.00 | 12 months |
| Bold 3 95 D | $399.00 | $798.00 | |||
| Boost Plus 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 | |||
| GN 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 | $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 | $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, or RITE | $250.00 | $500.00 | |||
| Nera2 Pro: Design RITE, Mini, Mini RITE, power, power plus, or RITE | $349.00 | $698.00 | |||
| Opn 2 mini, miniRITE, mini RITE-T, Plus Power, or RITE | $449.00 | $898.00 | |||
| Opn 3 mini, miniRITE, mini RITE-T, Plus Power, or RITE | $349.00 | $698.00 | |||
| Ria2: Mini, Mini RITE, power, power plus, or RITE | $199.00 | $398.00 | |||
| Ria2 Pro: Design RITE, Mini, Mini RITE, power, power plus, or 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 Hearing Systems, LLC | Audeo B30 or B30 T | $352.00 | $704.00 | $129.00 | 12 months |
| Audeo B50 or B50 T | $439.00 | $878.00 | |||
| Audeo B50-Direct or Audeo B50 Rechargeable (includes charger case) | $450.00 | $899.99 | |||
| Audeo V30 | $299.00 | $598.00 | |||
| Audeo V50 | $385.00 | $770.00 | |||
| Bolero B30 M312, P, SP | $352.00 | $628.06 | |||
| Bolero B50 M312, P, SP | $439.00 | $878.00 | |||
| Bolero B50 BTE 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 Q30 RIC, SP, or UP | $299.00 | $598.00 | |||
| Naida Q50: RIC, SP, UP | $385.00 | $769.99 | |||
| Naida V30: RIC, SP, UP | $299.00 | $598.00 | |||
| Nadia V50: RIC, UP, SP | $385.00 | $770.00 | |||
| Sky Q50: M, RIC, SP, UP | $385.00 | $769.99 | |||
| Sky V50: M, P, RIC, SP, UP | $385.00 | $770.00 | |||
| Rexton | Emerald M 60 | $390.25 | $780.50 | $95.00 | 12 months |
| Emerald M 80 | $419.76 | $839.52 | |||
| Emerald S 60 | $390.25 | $780.50 | |||
| Emerald S 80 | $419.76 | $839.52 | |||
| Mosaic HP 60 | $393.75 | $787.50 | |||
| Mosaic HP 80 | $427.20 | $854.40 | |||
| Mosaic M 60 | $390.25 | $780.50 | |||
| Mosaic M 80 | $419.76 | $839.52 | |||
| Mosaic M NR 60 | $390.25 | $780.50 | |||
| Mosaic M NR 80 | $419.76 | $839.52 | |||
| Mosaic P60 | $390.25 | $780.50 | |||
| Mosaic P80 | $419.76 | $839.52 | |||
| Stellar Li 60 | $402.69 | $805.38 | |||
| Stellar Li 80 | $428.78 | $857.56 | |||
| Signia | Carat 3px | $427.05 | $854.10 | $95.00 | 12 months |
| Cellion 2px | $373.56 | $747.12 | |||
| Cellion 3px | $431.64 | $863.28 | |||
| Motion P 1px | $283.05 | $566.10 | |||
| Motion P 2px | $339.60 | $679.20 | |||
| Motion P 3px | $427.05 | $854.10 | |||
| Motion S 1px | $283.05 | $566.10 | |||
| Motion S 2px | $339.60 | $679.20 | |||
| Motion S 3px | $427.05 | $854.10 | |||
| Motion SA 1px | $283.05 | $566.10 | |||
| Motion SA 2px | $339.60 | $679.20 | |||
| Motion SA 3px | $427.05 | $854.10 | |||
| Motion SP 1px | $283.05 | $566.10 | |||
| Motion SP 2px | $339.60 | $679.20 | |||
| Motion SP 3px | $427.05 | $854.10 | |||
| Motion SX 3px | $427.05 | $854.10 | |||
| Pure 1px | $283.05 | $566.10 | |||
| Pure 2px | $399.60 | $799.20 | |||
| Pure BT 3px | $431.64 | $863.28 | |||
| Pure 3px | $427.05 | $854.10 | |||
| Starkey Laboratories, Inc. | 3 Series 20: Mini, P+, or RIC | $299.00 | $598.00 | $84.99 | 12 months |
| 3 Series 30: Mini, P+, or RIC | $329.00 | $658.00 | |||
| 3 Series 70: Mini, P+, or RIC | $389.00 | $778.00 | |||
| 3 Series 90: Mini, P+, or RIC | $409.00 | $818.00 | |||
| 3 Series 110: Mini, P+, or RIC | $429.00 | $858.00 | |||
| 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 i1000 mRIC | $429.00 | $858.00 | |||
| Muse i1200 (excludes i1200 mRIC 312 tR) | $329.00 | $658.00 | |||
| Muse i1600 (excludes i1600 mRICt R) | $399.00 | $798.00 | |||
| Muse i2000 (excludes i1200 mRIC 312t R) | $419.00 | $838.00 | |||
| Muse i2400 (excludes i2400 mRIC 312t R) | $439.00 | $878.00 | |||
| Z Series i20: Mini, Micro, P+, or RIC | $349.00 | $698.00 | |||
| Z Series i30: Mini, Micro, P+, or RIC | $369.00 | $738.00 | |||
| Z Series i70: Mini, Micro, P+, or RIC | $399.00 | $798.00 | |||
| Z Series i90: Mini, Micro, P+, or RIC | $409.00 | $818.00 | |||
| Z Series i110: Mini, Micro, P+, or RIC | $429.00 | $858.00 | |||
| Unitron Hearing | AQ Sound SHD 5 | $439.60 | $879.20 | $100.00 | 12 months |
| Beat 3 | $253.00 | $506.00 | |||
| Flow 1 | $180.00 | $360.00 | |||
| Flow 2 | $281.75 | $563.50 | |||
| Sound 3 | $199.00 | $398.00 | |||
| Sound SHD 3 | $242.00 | $484.00 | |||
| Sound SHD 5 | $340.00 | $680.00 | |||
| MAX E SP or SP M | $352.43 | $704.86 | $75.00 | 12 months | |
| MAX 6: SP or SPM | $448.00 | $896.00 | |||
| 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 600 | $385.00 | $770.00 | |||
| Tempus Moxi Fit 700 | $448.00 | $896.00 | |||
| Tempus Moxi Fit R 500 | $399.85 | $679.70 | |||
| Tempus Moxi Fit R 600 | $421.14 | $842.27 | |||
| 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 600 M | $385.00 | $770.00 | |||
| Tempus Stride 700 M | $448.00 | $896.00 | |||
| Widex Hearing | Beyond 220 | $385.00 | $770.00 | $100.00 | 12 months |
| Dream 110 | $225.00 | $450.00 | |||
| Dream 110 Fashion | $225.00 | $450.00 | |||
| Dream 220 | $350.00 | $700.00 | |||
| Dream 220 Fashion | $350.00 | $700.00 | |||
| Dream 220 Fashion Power | $350.00 | $700.00 | |||
| Dream 330 | $440.00 | $880.00 | |||
| Dream 330 Fashion | $440.00 | $880.00 | |||
| Dream 330 Fashion Power | $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. |
|---|