Information is available for DOS before September 1, 2020.
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]) |
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|---|---|---|---|---|---|
| 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 B 30 Belong Virto | $664.00 | $664.00 | $110.00 | 12 months |
| CROS B 50 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]) |
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|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
| Oticon, Inc. | CROS + Opn S 2 | $779.00 | $779.00 | $100.00 | 12 months |
| CROS + Opn S 2 minRite R | $799.00 | $799.00 | |||
| CROS + Opn Play 1 | $735.00 | $735.00 | |||
| CROS + Opn Play 1 miniRite R | $799.00 | $799.00 | |||
| CROS + Ruby 1 | $649.00 | $649.00 | |||
| CROS + Ruby 2 | $599.00 | $599.00 | |||
| CROS + Xceed 2 | $735.00 | $735.00 | |||
| CROS + Xceed 3 | $649.00 | $649.00 | |||
| CROS + Xceed Play 1 | $735.00 | $735.00 | |||
| CROS + Xceed Play 2 | $699.00 | $699.00 | |||
| Phonak | CROS B 30 Level | $664.00 | $664.00 | $110.00 | 12 months |
| CROS B 50 Level | $764.00 | $764.00 | |||
| CROS B R — Rechargeable 50 Level | $829.48 | $829.48 | |||
| Rexton | CROS + Mosaic 60 | $683.00 | $683.00 | $95.00 | 12 months |
| CROS + Mosaic 80 | $683.00 | $683.00 | |||
| CROS R Li + Li80 RIC | $796.00 | $796.00 | |||
| CROS R + M–Core 80 RIC | $796.00 | $796.00 | |||
| CROS R Li + M–Core 60 RIC | $683.00 | $683.00 | |||
| Signia | CROS + Motion 3Nx P | $683.00 | $683.00 | $95.00 | 12 months |
| CROS + Motion NX3: C & G | $796.00 | $796.00 | |||
| CROS + Pure 3X (RIC) | $683.00 | $683.00 | |||
| CROS + Pure 3X: C & G | $796.00 | $796.00 | |||
| Starkey Lab, Inc. | CROS + Muse i1600, available as P+, mRIC, RIC, RIC-R (includes Muse IQ versions, RIC-R) | $738.00 | $738.00 | $84.99 | 12 months |
| CROS + Muse i2000, available as P+, mRIC, RIC, RIC-R (includes Muse IQ versions, RIC-R) | $758.00 | $758.00 | |||
| CROS + Muse i2400, available as P+, mRIC, RIC, RIC-R (includes Muse IQ versions, RIC-R) | $778.00 | $778.00 | |||
| CROS + Livio 1000 RIC, RIC-R | $618.00 | $618.00 | |||
| CROS + Livio 1200 RIC, RIC-R | $668.00 | $668.00 | |||
| CROS + Livio 1600 RIC, RIC-R | $738.00 | $738.00 | |||
| CROS + Livio 2000 RIC, RIC-R | $758.00 | $758.00 | |||
| CROS + Livio 2400 RIC, RIC-R | $778.00 | $778.00 | |||
| Widex USA, LLC | CROS + Unique 110 RIC | $450.00 | $450.00 | $200.00 | 12 months |
| CROS + Unique 220 RIC | $760.00 | $760.00 | |||
| CROS + Unique 330 RIC | $760.00 | $760.00 | |||
| V5211 — Refer to V5171. |
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| V5221 — Refer to V5181. |
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| V5256 — Hearing aid, digital, monaural, ITE (Applicable modifiers: LT, RR, RT) (For binaural, use V5260 [Applicable modifier: RR].) |
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|---|---|---|---|---|---|
| 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 | Ally 3 | $349.00 | $698.00 | $100.00 | 12 months |
| 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 |
| LiNX 3D 5: DIR HP, DIR MP, DIR UP, HP, MP, UP, Wireless or Non-Wireless | $397.00 | $794.00 | |||
| LiNX 3D 7: DIR HP, DIR MP, DIR UP, HP, MP, UP, Wireless or Non-Wireless | $448.00 | $896.00 | |||
| LiNX Quattro 5: T | $448.00 | $896.00 | |||
Oticon, Inc. — Full Shell and Half Shell |
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 | $285.00 | $570.00 | $129.00 | 12 months |
| Virto B50 | $385.00 | $770.00 | |||
| Virto M30 | $299.00 | $598.00 | |||
| Virto M50 full shell and half shell | $399.00 | $798.00 | |||
| Virto M50 low profile | $438.00 | $876.00 | |||
| Virto M70 | $450.00 | $900.00 | |||
| Rexton — Full Shell | Sterling 60 8C | $339.00 | $678.00 | $95.00 | 12 months |
| Sterling 80 8C | $398.00 | $796.00 | |||
| Signia — Full Shell | Insio 1 NX | $283.00 | $566.00 | $95.00 | 12 months |
| Insio 2 NX | $339.00 | $678.00 | |||
| Insio 3 NX | $398.00 | $796.00 | |||
| Starkey Lab, Inc. — Full Shell and Half Shell | Livio 1000 | $279.00 | $558.00 | $84.99 | 12 months |
| Livio 1200 | $329.00 | $658.00 | |||
| Livio 1600 | $399.00 | $798.00 | |||
| Livio 2000 | $419.00 | $838.00 | |||
| Livio 2400 | $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 and Half Shell | Insera 500 | $189.00 | $378.00 | $75.00 | 12 months |
| Insera 600 | $199.00 | $398.00 | |||
| Insera 700 | $299.00 | $598.00 | |||
| Insera 800 | $398.00 | $796.00 | |||
| Insera Pro | $438.00 | $876.00 | |||
| Widex USA, LLC — Full Shell and Half Shell | Evoke 110: IM, IP, XP | $225.00 | $450.00 | $100.00 | 12 months |
| Evoke 220: IM, IP, XP | $350.00 | $700.00 | |||
| Evoke 330: IM, IP, XP | $440.00 | $880.00 | |||
| Moment 110: IM, IP, XP | $269.00 | $538.00 | |||
| Moment 220: IM, IP, XP | $399.00 | $798.00 | |||
| Moment 330: IM, IP, XP | $440.00 | $880.00 | |||
| Unique 110 | $199.00 | $398.00 | |||
| Unique 220 | $385.00 | $770.00 | |||
| V5257 — Hearing aid, digital, monaural, BTE (Applicable modifiers: LT, RR, RT) (For binaural, use V5261 [Applicable modifier: RR].) |
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|---|---|---|---|---|---|
| Manufacturer and Style | Model(s) | Purchase Rate for Monaural | Purchase Rate for Binaural | Repair Rate Per Unit | Repair Warranty |
| Beltone | Ally 3 | $349.00 | $698.00 | $100.00 | 12 months |
| Amaze 6 64DW | $419.00 | $838.00 | |||
| Bold 3 95D | $399.00 | $798.00 | |||
| Boost Max 9 | $449.00 | $898.00 | |||
| Trust 6 | $399.00 | $798.00 | |||
| Trust 9 | $449.00 | $898.00 | |||
| GN ReSound | Enya 2: Mini, Power, RIC, Standard | $275.00 | $550.00 | $95.00 | 12 months |
| Enya 3: Mini, Power, RIC, Standard | $300.00 | $600.00 | |||
| Enzo 3D 5: HP, SP | $397.00 | $794.00 | |||
| Enzo 3D 7: HP, SP | $448.00 | $896.00 | |||
| Enzo Q 5: HP, SP | $448.00 | $896.00 | |||
| LINX 3D 5: STD, Mini, RIE, P, R | $397.00 | $794.00 | |||
| LINX 3D 7: STD, Mini, RIE, P, R | $448.00 | $896.00 | |||
| LINX Quattro 5: STD, Mini, RIE, P, R | $448.00 | $896.00 | |||
| Oticon, Inc. | Opn 2: miniRITE, miniRITE-T, PP | $449.00 | $898.00 | $100.00 | 12 months |
| Opn 3: miniRITE, miniRITE-T, PP | $349.00 | $698.00 | |||
| Opn Play 1: miniRITE, miniRITE-T, PP | $385.00 | $770.00 | |||
| Opn Play 1 miniRITE-R | $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 2: miniRITE, miniRITE-T, PP | $429.00 | $858.00 | |||
| Opn S 2 miniRITE-R | $449.00 | $898.00 | |||
| Opn S 3: miniRITE, miniRITE-T, PP | $349.00 | $698.00 | |||
| Opn S 3 miniRITE-R | $375.00 | $750.00 | |||
| Ruby 1: miniRITE, miniRITE-R, miniRITE-T, PP | $299.00 | $598.00 | |||
| Ruby 2: miniRITE, miniRITE-R, miniRITE-T, PP | $249.00 | $498.00 | |||
| Sensei, Sensei RITE, Sensei SP, pediatric | $199.00 | $398.00 | |||
| Sensei Pro, Sensei Pro RITE, Sensei Pro SP, pediatric | $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 | $385.00 | $770.00 | |||
| Xceed 3: SP, UP | $299.00 | $598.00 | |||
| Xceed Play 1: SP, UP | $385.00 | $770.00 | |||
| Xceed Play 2: SP, UP | $349.00 | $698.00 | |||
| Phonak | Audeo B30: RIC, T | $285.00 | $570.00 | $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: RIC, T | $299.00 | $598.00 | |||
| Audeo M30-R, RT Rechargeable (includes charger case) | $377.00 | $754.00 | |||
| Audeo M50: RIC, T | $399.00 | $798.00 | |||
| Audeo M50-R, RT, Rechargeable | $438.00 | $876.00 | |||
| Audeo M70: RIC | $450.00 | $900.00 | |||
| Audeo M70: R, RIC, RT Rechargeable (includes charger case) | $450.00 | $900.00 | |||
| Bolero B30: M, P, SP | $285.00 | $570.00 | |||
| Bolero B50: M, P, SP | $285.00 | $770.00 | |||
| Bolero B50-R Rechargeable (includes charger case) | $410.00 | $820.00 | |||
| Bolero M30: M | $299.00 | $598.00 | |||
| Bolero M30: PR | $377.00 | $754.00 | |||
| Bolero M50: M | $399.00 | $798.00 | |||
| Bolero M50: PR | $438.00 | $876.00 | |||
| Bolero M70: M, PR | $450.00 | $900.00 | |||
| Naida B30: SP, UP | $285.00 | $570.00 | |||
| Naida B50: SP, UP | $385.00 | $770.00 | |||
| Naida B50-R power RIC | $410.00 | $820.00 | |||
| Naida M30: SP | $299.00 | $598.00 | |||
| Naida M50: SP | $399.00 | $798.00 | |||
| Naida M70: SP | $450.00 | $900.00 | |||
| Sky B50-M: P, RIC, SP, UP (pediatric) | $385.00 | $770.00 | |||
| Sky B50-PR: R (pediatric) | $410.00 | $820.00 | |||
| Sky M50: M (pediatric) | $385.00 | $770.00 | |||
| Sky M50: SP (pediatric) | $399.00 | $798.00 | |||
| Sky M50: P R (pediatric) | $438.00 | $876.00 | |||
| Sky M70: M, SP, P R (pediatric) | $450.00 | $900.00 | |||
| Rexton | M-CORE RIC 60 | $339.00 | $678.00 | $95.00 | 12 months |
| M-CORE RIC 80 | $398.00 | $796.00 | |||
| M-CORE RIC-Li 60 | $339.00 | $678.00 | |||
| M-CORE RIC-Li 80 | $398.00 | $796.00 | |||
| M-CORE SR 60 | $339.00 | $678.00 | |||
| M-CORE SR 80 | $398.00 | $796.00 | |||
| Mosaic 60: M, HP, P | $339.00 | $678.00 | |||
| Mosaic 80: M, HP, P | $398.00 | $796.00 | |||
| Signia | Motion P 1 Px | $283.00 | $566.00 | $95.00 | 12 months |
| Motion P 2 Px | $339.00 | $678.00 | |||
| Motion S 1 Px | $283.00 | $566.00 | |||
| Motion S 2 Px | $339.00 | $678.00 | |||
| Motion SA 1 Px | $283.00 | $566.00 | |||
| Motion SA 2 Px | $339.00 | $678.00 | |||
| Motion SP 1 Px | $283.00 | $566.00 | |||
| Motion SP 2 Px | $339.00 | $678.00 | |||
| Motion 1 NX C & G | $283.00 | $566.00 | |||
| Motion 2 NX C & G | $339.00 | $678.00 | |||
| Motion 3 NX C & G | $398.00 | $796.00 | |||
| Pure 1 X: C & G, RIC | $283.00 | $566.00 | |||
| Pure 2 X: C & G, RIC | $339.00 | $678.00 | |||
| Pure 3 X: C & G, RIC | $398.00 | $796.00 | |||
| Pure NX 3 | $398.00 | $796.00 | |||
| Styletto 1 X RIC | $283.00 | $566.00 | |||
| Styletto 2 X RIC | $339.00 | $678.00 | |||
| Styletto 3 X RIC | $398.00 | $796.00 | |||
Starkey Lab, Inc. |
Livio 1000 (includes RIC-R) | $279.00 | $558.00 | $84.99 | 12 months |
| 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 DMF 3 | $199.00 | $398.00 | $75.00 | 12 months |
| Discover Next Moxi Fit 3 | $249.00 | $498.00 | |||
| Discover Next Moxi Fit 5 | $359.00 | $718.00 | |||
| Discover Next Moxi Fit 7 | $419.00 | $838.00 | |||
| Discover Moxi Jump R T 3 | $199.00 | $398.00 | |||
| Discover Next Moxi Jump 3 T, R | $249.00 | $498.00 | |||
| Discover Next Moxi Jump 5 T, R | $359.00 | $718.00 | |||
| Discover Next Moxi Jump 7 T, R | $419.00 | $838.00 | |||
| Discover Next Moxi Move R 3 | $249.00 | $498.00 | |||
| Discover Next Moxi Move R 5 | $359.00 | $718.00 | |||
| Discover Next Moxi Move R 7 | $419.00 | $838.00 | |||
| Discover Next Stride P R 3 | $249.00 | $498.00 | |||
| Discover Next Stride P R 5 | $359.00 | $718.00 | |||
| Discover Next Stride P R 7 | $419.00 | $838.00 | |||
| Discover Stride P R 3 | $199.00 | $398.00 | |||
| Tempus Moxi Fit 500 | $189.00 | $378.00 | |||
| Tempus Moxi Fit 600 | $199.00 | $398.00 | |||
| Tempus Moxi Fit 700 | $299.00 | $796.00 | |||
| Tempus Moxi Fit 800 | $398.00 | $796.00 | |||
| Tempus Moxi Fit Pro | $438.00 | $876.00 | |||
| Tempus Moxi Now 500 | $189.00 | $378.00 | |||
| Tempus Moxi Now 600 | $199.00 | $398.00 | |||
| Tempus Moxi Now 700 | $299.00 | $598.00 | |||
| Tempus Moxi Now 800 | $398.00 | $796.00 | |||
| Tempus Moxi Now Pro | $438.00 | $876.00 | |||
| Tempus P 500 | $189.00 | $378.00 | |||
| Tempus P 600 | $199.00 | $398.00 | |||
| Tempus P 700 | $299.00 | $598.00 | |||
| Tempus P 800 | $398.00 | $796.00 | |||
| Tempus P Pro | $438.00 | $876.00 | |||
| Tempus Stride M 500 | $189.00 | $378.00 | |||
| Tempus Stride M 600 | $199.00 | $398.00 | |||
| Tempus Stride M 700 | $299.00 | $598.00 | |||
| Tempus Stride M 800 | $389.00 | $796.00 | |||
| Tempus Stride M Pro | $438.00 | $876.00 | |||
| T Max 500: SP, UP | $189.00 | $378.00 | |||
| T Max 600: SP, UP | $199.00 | $398.00 | |||
| T Max 700: SP, UP | $299.00 | $598.00 | |||
| T Max 800: SP, UP | $398.00 | $796.00 | |||
| T Max Pro: SP, UP | $438.00 | $876.00 | |||
| Widex USA, LLC | Evoke 110 | $225.00 | $450.00 | $100.00 | 12 months |
| Evoke 110 Fashion | $255.00 | $510.00 | |||
| Evoke 110 Fashion mini, Fashion power | $225.00 | $450.00 | |||
| Evoke 220 | $350.00 | $700.00 | |||
| Evoke 220 Fashion, Fashion mini, Fashion power | $350.00 | $700.00 | |||
| Evoke 220 Fusion, RIC | $350.00 | $700.00 | |||
| Evoke 330 | $440.00 | $880.00 | |||
| Moment 110, mRIC, RIC, R | $269.00 | $538.00 | |||
| Moment 220, mRIC, RIC, R | $399.00 | $798.00 | |||
| Moment 330, mRIC, RIC, R | $440.00 | $880.00 | |||
| Unique 110 Fashion, Fashion Power | $199.00 | $398.00 | |||
| Unique 110 Passion RIE | $199.00 | $398.00 | |||
| Unique 220 | $385.00 | $770.00 | |||
| Unique 220 Fashion, Fashion Power | $385.00 | $770.00 | |||
| Unique 220 Passion RIE | $385.00 | $770.00 | |||
| Unique 330 | $385.00 | $770.00 | |||
| Unique 330 Fashion, Fashion Power | $385.00 | $770.00 | |||
| V5260 — Refer to V5256. |
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| V5261 — Refer to V5257. |
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