Information is available for DOS before September 1, 2021.
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 B 30 Belong Virto | $664.00 | $664.00 | $110.00 | 12 months |
| CROS B 50 Belong Virto | $764.00 | $764.00 | |||
| CROS B 70 Belong Virto | $829.00 | $829.00 | |||
| Signia | CROS+Insio 3 Nx | $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 |
| Oticon, Inc. | CROS + Opn S 2 miniRite | $779.00 | $779.00 | $100.00 | 12 months |
| CROS + Opn S 2 minRite R PX miniRITE R | $779.00 | $779.00 | |||
| CROS + Opn Play 1 miniRite | $725.00 | $725.00 | |||
| CROS PX + Opn Play 1 miniRITE R | $725.00 | $725.00 | |||
| CROS + Ruby 1 miniRITE | $649.00 | $649.00 | |||
| CROS + Ruby 1 miniRITE R PX miniRITE | $649.00 | $649.00 | |||
| CROS + Ruby 2 miniRITE | $599.00 | $599.00 | |||
| CROS + Ruby 2 miniRITE R PX miniRITE | $599.00 | $599.00 | |||
| CROS + PX Transmitter with More 2 | $779.00 | $779.00 | |||
| CROS + PX Transmitter with More 3 | $699.00 | $699.00 | |||
| CROS + Xceed 2 miniRITE | $735.00 | $735.00 | |||
| CROS + Xceed 3 miniRITE | $649.00 | $649.00 | |||
| CROS + Xceed Play 1 miniRITE | $725.00 | $725.00 | |||
| CROS + Xceed Play 2 miniRITE | $689.00 | $689.00 | |||
| Phonak | CROS Audeo P-R RT 30 | $827.00 | $827.00 | $75.00 | 12 months |
| CROS Audeo P-R RT 50 | $888.00 | $888.00 | |||
| CROS Audeo P-R RT 70 | $900.00 | $900.00 | |||
| CROS Audeo P-T 30 | $749.00 | $749.00 | |||
| CROS Audeo P-T 50 | $849.00 | $849.00 | |||
| CROS Audeo P-T 70 | $900.00 | $900.00 | |||
| CROS B 30 RIC | $664.00 | $664.00 | |||
| CROS B 50 RIC | $764.00 | $764.00 | |||
| CROS B 70 RIC | $829.00 | $829.00 | |||
| CROS B R — Rechargeable 50 Level | $829.48 | $829.48 | |||
| CROS B R — Rechargeable 70 Level | $869.48 | $869.48 | |||
| Rexton | CROS R Li + RIC Li 60 | $683.00 | $683.00 | $95.00 | 12 months |
| CROS R Li + RIC Li 80 | $796.00 | $796.00 | |||
| CROS + M-CORE B Li 60 | $683.00 | $683.00 | |||
| CROS + M-CORE B Li 80 | $683.00 | $683.00 | |||
| Signia | CROS + Motion 3NX P | $683.00 | $683.00 | $95.00 | 12 months |
| CROS 2X + Pure 3X | $683.00 | $683.00 | |||
| CROS C&GX + MTN C&G 3X: P, SP | $796.00 | $796.00 | |||
| CROS C&G AX + C&G 3AX, 3TAX RIC | $796.00 | $796.00 | |||
| CROS C&G AX + C&G 5AX, 5TAX RIC | $848.00 | $848.00 | |||
| Starkey Lab, Inc. | CROS EVOLV AI 1200: RIC, R | $668.00 | $668.00 | $84.99 | 12 months |
| CROS EVOLV AI 1600: RIC, R | $738.00 | $738.00 | |||
| CROS EVOLV AI 2000: RIC, R | $758.00 | $758.00 | |||
| CROS EVOLV AI 2400: RIC, R | $778.00 | $778.00 | |||
| 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 | |||
| CROS Livio 2400: RIC, RIC R | $778.00 | $778.00 | |||
| CROS + Muse iQ i1600: P+, mRIC, RIC, RIC R | $738.00 | $738.00 | |||
| CROS + Muse iQ i2000: P+, mRIC, RIC, RIC R | $758.00 | $758.00 | |||
| CROS + Muse iQ i2400: P+, mRIC, 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. |
|---|
| 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 | Non-Warranty Repair Period |
Beltone — Full Shell, Half Shell, and Low Profile | AMAZE 6 | $397.00 | $794.00 | $95.00 | 12 months |
| AMAZE 9 | $448.00 | $896.00 | |||
| RELY 2 | $175.00 | $350.00 | |||
| RELY 3 | $225.00 | $450.00 | |||
| RELY 4 | $275.00 | $550.00 | |||
| GN ReSound — Full Shell and Half Shell | Key 2 | $175.00 | $350.00 | $95.00 | 12 months |
| Key 3 | $225.00 | $450.00 | |||
| Key 4 | $275.00 | $550.00 | |||
| LiNX Quattro 5 | $397.00 | $794.00 | |||
| LiNX Quattro 7 | $448.00 | $896.00 | |||
Oticon, Inc. — Full Shell and Half Shell |
Opn 2 | $409.00 | $818.00 | $100.00 | 12 months |
| Opn 3 | $319.00 | $638.00 | |||
| 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 B70 | $450.00 | $900.00 | |||
| Virto M30 | $285.00 | $570.00 | |||
| Virto M50 | $385.00 | $770.00 | |||
| 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 | Active X | $339.00 | $678.00 | $95.00 | 12 months |
| Insio 1 NX | $283.00 | $566.00 | |||
| Insio 2 NX | $339.00 | $678.00 | |||
| Insio 3 NX | $398.00 | $796.00 | |||
| Insio C&G 3AX | $398.00 | $796.00 | |||
| Insio C&G 5AX | $450.00 | $900.00 | |||
| Signia — Half Shell | Insio C&G 3AX | $398.00 | $796.00 | $95.00 | 12 months |
| Insio C&G 5AX | $450.00 | $900.00 | |||
| Starkey Lab, Inc. — Full Shell and Half Shell | EVOLV AI 1200 R | $329.00 | $658.00 | $84.99 | 12 months |
| EVOLV AI 1600 R | $399.00 | $798.00 | |||
| EVOLV AI 2000 R | $419.00 | $838.00 | |||
| EVOLV AI 2400 R | $439.00 | $878.00 | |||
| Livio 1000 | $279.00 | $558.00 | |||
| 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, Half Shell, and Low Profile | Insera Dx DIR 3 | $229.00 | $458.00 | $75.00 | 12 months |
| Insera Dx DIR 5 | $299.00 | $598.00 | |||
| Insera Dx DIR 7 | $419.00 | $838.00 | |||
| Insera Dx Omni 3 | $229.00 | $458.00 | |||
| Insera Dx Omni 5 | $299.00 | $598.00 | |||
| Insera Dx Omni 7 | $419.00 | $838.00 | |||
| Shine Rev+ W DIR | $199.00 | $398.00 | |||
| Widex USA, LLC — Full Shell and Half Shell | Evoke 110: IM, IP, XP | $199.00 | $398.00 | $100.00 | 12 months |
| Evoke 220: IM, IP, XP | $269.00 | $538.00 | |||
| Evoke 330: IM, IP, XP | $399.00 | $798.00 | |||
| Magnify 110: IM, IP, XP | $225.00 | $450.00 | |||
| Magnify 220: IM, IP, XP | $269.00 | $538.00 | |||
| Magnify 330: IM, IP, XP | $399.00 | $798.00 | |||
| 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 | |||
| 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 | Non-Warranty Repair Period |
| Beltone | Amaze 6 | $397.00 | $794.00 | $95.00 | 12 months |
| Amaze 9 | $448.00 | $896.00 | |||
| Boost Max 9 | $449.00 | $898.00 | |||
| Boost Ultra 6 | $397.00 | $794.00 | |||
| Boost Ultra 9 | $448.00 | $896.00 | |||
| Imagine 6 | $397.00 | $794.00 | |||
| Imagine 9 | $448.00 | $896.00 | |||
| Rely 2 | $175.00 | $350.00 | |||
| Rely 3 | $225.00 | $450.00 | |||
| Rely 4 | $275.00 | $550.00 | |||
| GN ReSound | Enzo Q 5: HP, SP | $397.00 | $794.00 | $95.00 | 12 months |
| Enzo Q 7: HP, SP | $448.00 | 896.00 | |||
| KEY 2: HP, Mini, RIE, SP, STD | $175.00 | $350.00 | |||
| KEY 3: HP, Mini, RIE, SP, STD | $225.00 | $450.00 | |||
| KEY 4: HP, Mini, RIE, SP, STD | $275.00 | $550.00 | |||
| LINX Quattro 5: STD, Mini, RIE, P, R | $397.00 | $794.00 | |||
| LINX Quattro 7: STD, Mini, RIE, P, R | $448.00 | $896.00 | |||
| ONE 5: Mini, R, RIE | $397.00 | $794.00 | |||
| ONE 7: Mini, R, RIE | $448.00 | $896.00 | |||
| Oticon, Inc. | More 2: miniRITE-R, miniRITE-T | $429.00 | $858.00 | $100.00 | 12 months |
| More 3: miniRITE-R, miniRITE-T | $349.00 | $698.00 | |||
| Opn 2: miniRITE, miniRITE-T, PP | $409.00 | $818.00 | |||
| Opn 3: miniRITE, miniRITE-T, PP | $319.00 | $638.00 | |||
| Opn Play 1: miniRITE, miniRITE-R, miniRITE-T, PP | $375.00 | $750.00 | |||
| Opn Play 2: miniRITE, miniRITE-R, miniRITE-T, PP | $339.00 | $678.00 | |||
| 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 | $339.00 | $678.00 | |||
| Opn S 3: miniRITE-R | $365.00 | $730.00 | |||
| 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 | $319.00 | $638.00 | |||
| 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 | $375.00 | $750.00 | |||
| Xceed Play 2: SP, UP | $339.00 | $678.00 | |||
| Phonak | Audeo M30: RIC, T | $285.00 | $570.00 | $75.00 | 12 months |
| Audeo M30-R, RT (includes charger case) | $299.00 | $598.00 | |||
| Audeo M50: R, RIC, RT, T (includes charger case) | $385.00 | $770.00 | |||
| Audeo M70: RIC, T | $450.00 | $900.00 | |||
| Audeo M70: R, RT Rechargeable (includes charger case) | $450.00 | $900.00 | |||
| Audeo P30: RIC, T | $299.00 | $598.00 | |||
| Audeo P30: R, RT (includes charger case) | $377.00 | $754.00 | |||
| Audeo P50 | $399.00 | $798.00 | |||
| Audeo P50: R, RT (includes charger case) | $438.00 | $876.00 | |||
| Audeo P70: RIC, T, R, RT (includes charger case) | $450.00 | $900.00 | |||
| Bolero M30: M | $285.00 | $570.00 | |||
| Bolero M30: PR (includes charger case) | $299.00 | $598.00 | |||
| Bolero M50: M, PR (includes charger case) | $385.00 | $770.00 | |||
| Bolero M70: M, PR (includes charger case) | $450.00 | $900.00 | |||
| Naida M30: SP | $285.00 | $570.00 | |||
| Naida M50: SP | $385.00 | $770.00 | |||
| Naida M70: SP | $450.00 | $900.00 | |||
| Naida P30: PR (includes charger case) | $377.00 | $754.00 | |||
| Naida P50: PR (includes charger case) | $438.00 | $876.00 | |||
| Naida P70: PR (includes charger case) | $450.00 | $900.00 | |||
| Naida P30 SP: UP BTE | $299.00 | $598.00 | |||
| Naida P50 SP: UP BTE | $399.00 | $798.00 | |||
| Naida P70 SP: UP BTE | $450.00 | $900.00 | |||
| Naida M Link (Power, Link to CI) | $450.00 | $900.00 | |||
| Sky B50: M, P, PR, RIC, SP, UP (pediatric; rechargeable includes charger case) | $385.00 | $770.00 | |||
| Sky B70: M, P, PR, RIC, SP, UP (pediatric; rechargeable includes charger case) | $450.00 | $900.00 | |||
| Sky M Link (pediatric, Link to CI) | $450.00 | $900.00 | |||
| Sky M50: M (pediatric) | $385.00 | $770.00 | |||
| Sky M50: PR (pediatric; includes charger case) | $385.00 | $770.00 | |||
| Sky M50: SP (pediatric) | $368.90 | $737.89 | |||
| Sky M70: M, SP, PR (pediatric; rechargeable includes charger case) | $450.00 | $900.00 | |||
| Sky M70-M (pediatric) | $450.00 | $900.00 | |||
| Rexton | M-CORE B Li 60: M, P, HP | $339.00 | $678.00 | $95.00 | 12 months |
| M-CORE B Li 80: M, P, HP | $398.00 | $796.00 | |||
| M-CORE RIC 60 | $339.00 | $678.00 | |||
| 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 | |||
| Signia | C&G 3 AX: RIC, R | $398.00 | $796.00 | $95.00 | 12 months |
| C&G 3 TAX: RIC, R, T | $398.00 | $796.00 | |||
| C&G 5 AX: RIC, R | $450.00 | $900.00 | |||
| C&G 5 TAX: RIC, R, T | $450.00 | $900.00 | |||
| Motion C&G 1X: P, SP, R | $283.00 | $566.00 | |||
| Motion C&G 2X: P, SP, R | $339.00 | $678.00 | |||
| Motion C&G 3X: P, SP, R | $398.00 | $796.00 | |||
| Motion C&G 5X: P, SP, R | $450.00 | $900.00 | |||
| Motion Nx3: P | $398.00 | $796.00 | |||
| Pure C&G 1X: RIC, R | $283.00 | $566.00 | |||
| Pure C&G 2X: RIC, R | $339.00 | $678.00 | |||
| Pure 3X: RIC | $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. |
EVOLV AI 1200: MRIC, P+, R, RIC | $329.00 | $658.00 | $84.99 | 12 months |
| EVOLV AI 1600: MRIC, P+, R, RIC | $399.00 | $798.00 | |||
| EVOLV AI 2000: MRIC, P+, R, RIC | $419.00 | $838.00 | |||
| EVOLV AI 2400: MRIC, P+, R, RIC | $439.00 | $878.00 | |||
| Livio 1000 mRIC, R | $279.00 | $558.00 | |||
| Livio 1200 mRIC, R | $329.00 | $658.00 | |||
| Livio 1600 mRIC, R | $399.00 | $798.00 | |||
| Livio 2000 mRIC, R | $419.00 | $838.00 | |||
| Livio 2400 mRIC, R | $439.00 | $878.00 | |||
| Muse iQ i1000 RIC R | $279.00 | $558.00 | |||
| Muse iQ i1200 RIC R | $329.00 | $658.00 | |||
| Muse iQ i1600: micro, PP, RIC, RIC R | $399.00 | $798.00 | |||
| Muse iQ i2000: micro, PP, RIC, RIC R | $419.00 | $838.00 | |||
| Muse iQ i2400: micro, PP, RIC, RIC R | $439.00 | $878.00 | |||
| Muse i2400 Power Plus | $439.00 | $878.00 | |||
| Unitron Hearing | Discover Next Moxi Fit 3 CRT | $229.00 | $458.00 | $75.00 | 12 months |
| Discover Next Moxi Fit 5 CRT | $299.00 | $598.00 | |||
| Discover Next Moxi Fit 7 CRT | $419.00 | $838.00 | |||
| Discover Next Moxi Jump R T 3 CRT (charger incl) | $229.00 | $458.00 | |||
| Discover Next Moxi Jump R T 5 CRT (charger incl) | $299.00 | $598.00 | |||
| Discover Next Moxi Jump R T 7 CRT (charger incl) | $419.00 | $838.00 | |||
| Discover Next Moxi Move R 3 CRT (charger incl) | $229.00 | $458.00 | |||
| Discover Next Moxi Move R 5 CRT (charger incl) | $299.00 | $598.00 | |||
| Discover Next Moxi Move R 7 CRT (charger incl) | $419.00 | $838.00 | |||
| Discover Next Stride P R 3 (charger incl) | $229.00 | $458.00 | |||
| Discover Next Stride P R 5 (charger incl) | $299.00 | $598.00 | |||
| Discover Next Stride P R 7 (charger incl) | $419.00 | $838.00 | |||
| DX Stride M 3 | $229.00 | $598.00 | |||
| DX Stride M 5 | $299.00 | $598.00 | |||
| DX Stride M 7 | $419.00 | $838.00 | |||
| Shine Rev+: RIC, M, P, UP | $199.00 | $398.00 | |||
| Moxi B R RT 3 CRT (charger incl) | $249.00 | $498.00 | |||
| Moxi B R RT 5 CRT (charger incl) | $359.00 | $718.00 | |||
| Moxi B R RT 7 CRT (charger incl) | $419.00 | $838.00 | |||
| 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: Fashion mini, Fashion power, Fusion, mini, power, RIC | $199.00 | $398.00 | $100.00 | 12 months |
| Evoke 220: Fashion mini, Fashion power, Fusion, mini, power, RIC | $269.00 | $538.00 | |||
| Evoke 330: D, Fashion mini, Fashion power, Fusion, mini, power, RIC | $399.00 | $798.00 | |||
| Magnify 110: D, mRIC, RIC, R | $225.00 | $450.00 | |||
| Magnify 220: D, mRIC, RIC, R | $269.00 | $538.00 | |||
| Magnify 330: D, mRIC, RIC, R | $399.00 | $798.00 | |||
| Moment 110: D, mRIC, RIC, R | $269.00 | $538.00 | |||
| Moment 220: D, mRIC, RIC, R | $399.00 | $798.00 | |||
| Moment 330: D, mRIC, RIC, R | $440.00 | $880.00 | |||
| V5260 — Refer to V5256. |
|---|
| V5261 — Refer to V5257. |
|---|