Information is available for DOS before September 1, 2019.
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 minimum 24-month manufacturer equipment 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.
| V5171 — Hearing aid, contralateral routing device, monaural, ITE (Applicable modifiers: LT, RR, RT) (For binaural ITE, use V5211 [Applicable modifier: LT, RR, RT]) |
|||||
|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
| Phonak — Full Shell and Half Shell | CROS II Venture 30 Level for Virto V | $678.00 | $678.00 | $110.00 | 12 months |
| CROS II Venture 50 Level for Virto V | $764.00 | $764.00 | |||
| CROS B Custom 30 Level for Belong Virto | $678.00 | $678.00 | |||
| CROS B Custom 50 Level for Belong Virto | $764.00 | $764.00 | |||
| Signia | CROS+Insio 3Nx | $683.00 | $683.00 | $95.00 | 12 months |
| V5181 — Hearing aid, contralateral routing device, monaural, BTE (Applicable modifiers: LT, RR, RT) (For binaural BTE, use V5221 [Applicable modifier: LT, RR, RT]) |
|||||
|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
| Phonak | CROS B 30 Level: For Belong Audeo/Bolero Excludes Rechargeable BTE/RIC | $678.00 | $678.00 | $110.00 | 12 months |
| CROS B R-Rechargeable 50 Level for Audeo B | $829.48 | $829.48 | |||
| CROS B 50 Level: For Belong Audeo/Bolero Excludes Rechargeable BTE/RIC | $764.00 | $764.00 | |||
| CROS II Venture 30 Level For Audeo V/Bolero V | $678.00 | $678.00 | |||
| CROS II Venture 50 Level For Belong Audeo V/Bolero V | $764.00 | $764.00 | |||
| Rexton | CROS + Emerald S 60 8c | $683.00 | $683.00 | $95.00 | 12 months |
| CROS + Emerald S 80 8c | $683.00 | $683.00 | |||
| CROS + Mosaic 60 8c | $683.00 | $683.00 | |||
| CROS + Mosaic 80 8c | $683.00 | $683.00 | |||
| Signa | CROS + Pure 3Nx RIC | $683.00 | $683.00 | $95.00 | 12 months |
| CROS Pure Charge & Go transmitter + Pure Charge & Go 3 Nx RIC | $796.00 | $796.00 | |||
| CROS Pure Charge & Go transmitter + Motion Charge & Go 3 Nx BTE | $796.00 | $796.00 | |||
| CROS + Motion 3Nx | $683.00 | $683.00 | |||
| Starkey Laboratories, Inc. | CrosMuse i1600, available as B, P+, mRIC, RIC, RIC-R (includes Muse IQ versions, RIC-R) | $738.00 | $738.00 | $84.99 | 12 months |
| CrosMuse i2000, available as B, P+, mRIC, RIC, RIC-R (includes Muse IQ versions, RIC-R) | $758.00 | $758.00 | |||
| CrosMuse i2400, available as B, P+, mRIC, RIC, RIC-R (includes Muse IQ versions, RIC-R) | $778.00 | $778.00 | |||
| CrosLivio 1000 RIC, RIC-R | $618.00 | $618.00 | |||
| CrosLivio 1200 RIC, RIC-R | $668.00 | $668.00 | |||
| CrosLivio 1600 RIC, RIC-R | $738.00 | $738.00 | |||
| CrosLivio 2000 RIC, RIC-R | $758.00 | $758.00 | |||
| CrosLivio 2400 RIC, RIC-R | $778.00 | $778.00 | |||
| Widex USA, LLC | Evoke 110 Fashion, Fashion Power, mini, RIC | $724.00 | $724.00 | $200.00 | 12 months |
| Evoke 220 Fashion, Fashion Power, mini, RIC | $814.00 | $814.00 | |||
| Unique 110 | $450.00 | $225.00 | |||
| Unique 220 | $760.00 | $760.00 | |||
| Unique 330 | $760.00 | $760.00 | |||
| V5211 — Refer to V5171. |
|---|
| V5221 — Refer to V5181. |
|---|
| 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 — 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 |
| 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 | |||
Oticon, Inc. — Full Shell and Half Shell Note: There is no charge for VC, TC, or Auto TC. |
Opn 2 | $449.00 | $898.00 | $100.00 | 12 months |
| Opn 3 | $349.00 | $698.00 | |||
| Siya 1 | $299.00 | $598.00 | |||
| Siya 2 | $199.00 | $398.00 | |||
| Phonak — Full Shell, Half Shell, and Low Profile | Virto B30 | $299.00 | $598.00 | $129.00 | 12 months |
| Virto B50 | $385.00 | $770.00 | |||
| Virto V30 | $299.00 | $598.00 | |||
| Virto V50 | $385.00 | $770.00 | |||
| Signia — Full Shell | Insio 3 Nx | $398.00 | $796.00 | $95.00 | 12 months |
| Insio 1 Px | $283.00 | $566.00 | |||
| Insio 2 Px | $339.00 | $678.00 | |||
| Insio 3 Px | $398.00 | $796.00 | |||
| 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 | |||
| Picasso i1600 | $399.00 | $798.00 | |||
| Picasso i2000 | $419.00 | $838.00 | |||
| Picasso i2400 | $439.00 | $878.00 | |||
| Unitron Hearing — Full Shell | Insera 500 | $299.00 | $598.00 | $75.00 | 12 months |
| Insera 600 | $335.58 | $671.16 | |||
| Insera 700 | $400.60 | $801.20 | |||
| Unitron Hearing — Half Shell | Insera 500 | $299.00 | $598.00 | $75.00 | 12 months |
| Insera 600 | $335.58 | $671.16 | |||
| Insera 700 | $400.60 | $801.20 | |||
| 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 | $225.00 | $450.00 | |||
| 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 | Ally 2 | $329.00 | $658.00 | $100.00 | 12 months |
| Ally 3 | $349.00 | $698.00 | |||
| Amaze 64DW | $419.00 | $838.00 | |||
| 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 Mini, Power, Standard | $275.00 | $550.00 | $95.00 | 12 months |
| Enya 3 Mini, Power, Standard, Standard RIC | $300.00 | $600.00 | |||
| Enzo 3D 5 High Power, Super Power | $397.00 | $794.00 | |||
| Enzo 3D 7 High Power, Super Power | $448.00 | $896.00 | |||
| LINX 3D 5: Standard, Mini, Mini RIE, RIE, Power | $397.00 | $794.00 | |||
| LINX 3D 7: Standard, Mini, Mini RIE, RIE, Power | $448.00 | $896.00 | |||
| LINX Quattro 5 RIE | $448.00 | $896.00 | |||
| Oticon, Inc. | Opn 2 miniRITE, miniRITE-T, Plus Power | $449.00 | $898.00 | $100.00 | 12 months |
| Opn 3 miniRITE, miniRITE-T, Plus Power | $349.00 | $698.00 | |||
| Opn Play 1 miniRITE, miniRITE-T, PP | $449.00 | $898.00 | |||
| Opn Play 2 miniRITE, miniRITE-T, PP | $349.00 | $698.00 | |||
| Opn Play 2 miniRITE-R | $375.00 | $750.00 | |||
| Opn S 3 miniRITE, miniRITE-R, miniRITE-T, PP | $375.00 | $750.00 | |||
| Sensei, Sensei RITE, Sensei SP | $199.00 | $398.00 | |||
| Sensei Pro, Sensei Pro RITE, Sensei Pro SP | $349.00 | $698.00 | |||
| Siya 1 miniRITE, miniRITE-T, PP | $299.00 | $598.00 | |||
| Siya 2 miniRITE, miniRITE-T, PP | $199.00 | $398.00 | |||
| Xceed 2 SP, UP | $449.00 | $898.00 | |||
| Xceed 3 SP, UP | $349.00 | $698.00 | |||
| Xceed Play 1 SP, UP | $449.00 | $898.00 | |||
| Xceed Play 2 SP, UP | $349.00 | $698.00 | |||
| Phonak | Audeo B30 T | $299.00 | $598.00 | $129.00 | 12 months |
| Audeo B50: RIC, T | $385.00 | $770.00 | |||
| Audeo B50-R Rechargeable (includes charger case) | $410.00 | $820.00 | |||
| Audeo M30 | $352.00 | $704.00 | |||
| Audeo M30-R, RT Rechargeable (includes charger case) | $377.00 | $754.00 | |||
| Audeo M50 | $439.00 | $878.00 | |||
| Audeo M50-R, RT, Rechargeable (includes charger case) | $450.00 | $900.00 | |||
| Bolero B30: M, P, SP | $299.00 | $598.00 | |||
| Bolero M30-M | $352.00 | $704.00 | |||
| Bolero B50: M, P, SP | $385.00 | $770.00 | |||
| Bolero B50-R Rechargeable (includes charger case) | $410.00 | $820.00 | |||
| Bolero M50-M | $439.00 | $878.00 | |||
| Bolero V30: M, P, SP | $299.00 | $598.00 | |||
| Bolero V50: M, P, SP | $385.00 | $770.00 | |||
| Naida B30: SP, UP | $299.00 | $598.00 | |||
| Naida B50: SP, UP | $385.00 | $770.00 | |||
| Naida B50-R Rechargeable (includes charger case) | $410.00 | $820.00 | |||
| 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) | $410.00 | $820.00 | |||
| Sky M50-M | $385.00 | $770.00 | |||
| Sky V50: M, P, RIC, SP, UP | $385.00 | $770.00 | |||
| Rexton | Emerald M 60 | $339.00 | $678.00 | $95.00 | 12 months |
| Emerald M 80 | $398.00 | $796.00 | |||
| Emerald S 60 | $339.00 | $678.00 | |||
| Emerald S 80 | $398.00 | $796.00 | |||
| Mosaic HP 60 | $339.00 | $678.00 | |||
| Mosaic HP 80 | $398.00 | $796.00 | |||
| Mosaic M 60 | $339.00 | $678.00 | |||
| Mosaic M 80 | $398.00 | $796.00 | |||
| Mosaic P 60 | $339.00 | $678.00 | |||
| Mosaic P 80 | $398.00 | $796.00 | |||
| Stellar Li 60 | $339.00 | $678.00 | |||
| Stellar Li 80 | $398.00 | $796.00 | |||
| Signia | Motion 1Px P, S, SA, SP | $283.00 | $566.00 | $95.00 | 12 months |
| Motion 2Px P, S, SA, SP | $339.00 | $678.00 | |||
| Motion Charge & Go 1 Nx | $283.00 | $566.00 | |||
| Motion Charge & Go 2 Nx | $339.00 | $678.00 | |||
| Motion Charge & Go 3 Nx | $398.00 | $796.00 | |||
| Motion Nx 3, P Nx 3 | $398.00 | $796.00 | |||
| Pure 1Px RIC | $283.00 | $566.00 | |||
| Pure 2Px RIC | $339.00 | $678.00 | |||
| Pure NX 3 | $398.00 | $796.00 | |||
| Pure Charge & Go 1 Nx | $283.00 | $566.00 | |||
| Pure Charge & Go 2 Nx | $339.00 | $678.00 | |||
| Pure Charge & Go Nx 3 | $398.00 | $796.00 | |||
| Styletto 1 Nx | $283.00 | $566.00 | |||
| Styletto Connect 3 NX | $398.00 | $796.00 | |||
Starkey Laboratories, Inc. |
3 Series 20: Mini, P+, or RIC | $299.00 | $598.00 | $84.99 | 12 months |
| Livio 1000 (includes RIC-R) | $279.00 | $558.00 | |||
| Livio 1200 (includes RIC-R) | $329.00 | $658.00 | |||
| Livio 1600 (includes RIC-R) | $399.00 | $798.00 | |||
| Livio 2000 (includes RIC-R) | $419.00 | $838.00 | |||
| Livio 2400 (includes RIC-R) | $439.00 | $878.00 | |||
| Muse i1000 (includes Muse IQ versions, RIC-R) | $279.00 | $558.00 | |||
| Muse i1200 (includes Muse IQ versions, RIC-R) | $329.00 | $658.00 | |||
| Muse i1600 (includes Muse IQ versions, RIC-R) | $399.00 | $798.00 | |||
| Muse i2000 (includes Muse IQ versions, RIC-R) | $419.00 | $838.00 | |||
| Muse i2400 (includes Muse IQ versions, RIC-R) | $439.00 | $878.00 | |||
| Unitron Hearing | Discover Moxi Fit 3 | $350.46 | $700.92 | $75.00 | 12 months |
| Discover Moxi Fit 5 | $437.16 | $874.32 | |||
| Discover Moxi Jump 3 | $374.50 | $749.00 | |||
| Discover Moxi Jump 5 | $445.04 | $890.08 | |||
| Tempus Moxi Dura 500 | $299.00 | $598.00 | |||
| Tempus Moxi Dura 600 | $375.53 | $751.06 | |||
| Tempus Moxi Dura 700 | $439.56 | $879.12 | |||
| Tempus Moxi Fit 500 | $299.00 | $598.00 | |||
| Tempus Moxi Fit 600 | $375.53 | $751.06 | |||
| Tempus Moxi Fit 700 | $439.56 | $879.12 | |||
| Tempus Moxi Kiss 500 | $299.00 | $598.00 | |||
| Tempus Moxi Kiss 600 | $375.53 | $751.06 | |||
| Tempus Moxi Kiss 700 | $439.56 | $879.12 | |||
| Tempus Moxi Now 500 | $299.00 | $598.00 | |||
| Tempus Moxi Now 600 | $375.53 | $751.06 | |||
| Tempus Moxi Now 700 | $439.56 | $879.12 | |||
| Tempus 500: P, P Dura | $299.00 | $598.00 | |||
| Tempus 600: P, P Dura | $375.53 | $751.06 | |||
| Tempus 700: P, P Dura | $439.56 | $879.12 | |||
| Tempus Stride M 500 | $299.00 | $598.00 | |||
| Tempus Stride M 600 | $375.53 | $751.06 | |||
| Tempus Stride M 700 | $439.56 | $879.12 | |||
| T Max 500 SP, UP | $299.00 | $598.00 | |||
| T Max 600 SP, UP | $375.53 | $751.06 | |||
| T Max 700 SP, UP | $439.56 | $879.12 | |||
| Widex USA, LLC | Beyond 220 | $385.00 | $770.00 | $100.00 | 12 months |
| Beyond 330 | $440.00 | $880.00 | |||
| Evoke 110 Fashion, Fashion mini, Fashion power | $350.00 | $700.00 | |||
| Evoke 220 Fashion, Fashion mini, Fashion power | $440.00 | $880.00 | |||
| Unique 110 Fashion, Fashion Power | $225.00 | $450.00 | |||
| Unique 220 | $385.00 | $770.00 | |||
| Unique 220 Fashion, Fashion Power | $385.00 | $770.00 | |||
| Unique 330 | $385.00 | $770.00 | |||
| Unique 330 Fashion, Fashion Power | $385.00 | $770.00 | |||
| V5260 — Refer to V5256. |
|---|
| V5261 — Refer to V5257. |
|---|