Contract Effective 9/1/17 MDHHS Contract Hearing …

1 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsBELTONEBELTONE BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LISTPRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)ALLY 3 64 DRW10 to 110 dB HL196267xxV5257$ $ $ 3 64 DRW10 to 110 dB HL196267xxV5261$1, $ $ 3 66 DWup to 80 dB HL196271xxV5257$ $ $ 3 66 DWup to 80 dB HL196271xxV5261$1, $ $ 3 76 DWup to 100 dB HL196276xxV5257$ $ $ 3 76 DWup to 100 dB HL196276xxV5261$1, $ $ 3 86DW20 to 115 dB HL196282xxV5257$ $ $ 3 86DW20 to 115 dB HL196282xxV5261$1, $ $ 6 64 DWup to 110 dB HL2056483xxV5257$1, $ $ 6 64 DWup to 110 dB HL2056483xxV5261$2, $ $ 3 95D60 to 120 dB HL188820xxV5257$ $ $ 3 95D60 to 120 dB HL188820xxV5261$1, $ $ MAX 9 86DW30 to 115 dB HL205574xxV5257$1, $ $ MAX 9 86DW30 to 115 dB HL205574xxV5261$2, $ $ MAX 9 95DW60 to 120 dB HL205572xxV5257$1, $ $ MAX 9 95DW60 to 120 dB HL205572xxV5261$2, $ $ 6 63 DRWup to 110 dB HL197055xxV5257$ $ $ 6 63 DRWup to 110 dB HL197055xxV5261$1.

2 $ $ 6 64 DRWup to 110 dB HL197052xxV5257$ $ $ 6 64 DRWup to 110 dB HL197052xxV5261$1, $ $ 1 of 4 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsBELTONEBELTONE BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LISTPRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)TRUST 6 66 DWup to 110 dB HL200949xxV5257$ $ $ 6 66 DWup to 110 dB HL200949xxV5261$1, $ $ 6 76 DWup to 110 dB HL197038xxV5257$ $ $ 6 76 DWup to 110 dB HL197038xxV5261$1, $ $ 6 86 DWup to 110 dB HL197033xxV5257$ $ $ 6 86 DWup to 110 dB HL197033xxV5261$1, $ $ 9 63 DRWup to 110 dB HL197054xxV5257$1, $ $ 9 63 DRWup to 110 dB HL197054xxV5261$2, $ $ 9 64 DRWup to 110 dB HL197050xxV5257$1, $ $ 9 64 DRWup to 110 dB HL197050xxV5261$2, $ $ 9 66 DWup to 110 dB HL200948xxV5257$1, $ $ 9 66 DWup to 110 dB HL200948xxV5261$2, $ $ 9 76 DWup to 110 dB HL197037xxV5257$1, $ $ 9 76 DWup to 110 dB HL197037xxV5261$2, $ $ 9 86 DWup to 110 dB HL197032xxV5257$1, $ $ 9 86 DWup to 110 dB HL197032xxV5261$2.

3 $ $ 2 of 4 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsBELTONEBELTONE FULL SHELL CONCHA IN THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LISTPRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)ALLY 3 ITE20 to 115 dB HLALY3-45-FSV5256$ $ $ 3 ITE20 to 115 dB HLALY3-45-FSV5260$1, $ $ 6 ITEup to 110 dB HLTST6-45-FSV5256$ $ $ 6 ITEup to 110 dB HLTST6-45-FSV5260$1, $ $ 9 ITEup to 110 dB HLTST9-45-FSV5256$1, $ $ 9 ITEup to 110 dB HLTST9-45-FSV5260$2, $ $ HALF SHELL CONCHA IN THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LISTPRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)ALLY 3 ITE20 to 115 dB HLALY3-45-HSV5256$ $ $ 3 ITE20 to 115 dB HLALY3-45-HSV5260$1, $ $ 6 ITEup to 110 dB HLTST6-45-HSV5256$ $ $ 6 ITEup to 110 dB HLTST6-45-HSV5260$1, $ $ 9 ITEup to 110 dB HLTST9-45-HSV5256$1, $ $ 9 ITEup to 110 dB HLTST9-45-HSV5260$2, $ $ 3 of 4 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsBELTONEBELTONE LOW PROFILE IN THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LISTPRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)

4 ALLY 3 ITE20 to 115 dB HLALY3-45-LPV5256$ $ $ 3 ITE20 to 115 dB HLALY3-45-LPV5260$1, $ $ 6 ITEup to 110 dB HLTST6-45-LPV5256$ $ $ 6 ITEup to 110 dB HLTST6-45-LPV5260$1, $ $ 9 ITEup to 110 dB HLTST9-45-LPV5256$1, $ $ 9 ITEup to 110 dB HLTST9-45-LPV5260$2, $ $ 4 of 4 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsOTICONOTICON BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LIST PRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)Opn 2 miniRITE0-105 dB001-400-016V5257$1, $ $ 2 miniRITE0-105 dB001-400-016V5261$3, $ $ 2 miniRITE-T0-105 dB001-400-125V5257$1, $ $ 2 miniRITE-T0-105 dB001-400-125V5261$3, $ $ 2 Plus Power BTE25-106 dB001-400-100V5257$1, $ $ 2 Plus Power BTE25-106 dB001-400-100V5261$3, $ $ 3 miniRITE0-105 dB001-410-016V5257$1, $ $ 3 miniRITE0-105 dB001-410-016V5261$2, $ $ 3 miniRITE-T0-105 dB001-410-125V5257$1, $ $ 3 miniRITE-T0-105 dB001-410-125V5261$2, $ $ 3 Plus Power BTE25-106 dB001-410-100V5257$1, $ $ 3 Plus Power BTE25-106 dB001-410-100V5261$2, $ $ Play 1 miniRITE0-105 dB001-570-016V5261$2, $ $ Play 1 miniRITE 0-105 dB001-570-016V5257$1, $ $ Play 1 miniRITE-R0-105 dB001-570-130V5257$1, $ $ Play 1 miniRITE-R 0-105 dB001-570-130V5261$3, $ $ Play 1 miniRITE-T0-105 dB001-570-127V5257$1.

5 $ $ Play 1 miniRITE-T0-105 dB001-570-127V5261$2, $ $ 1 of 9 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsOTICONOTICON BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LIST PRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)Opn Play 1 Power Plus25-105 bD001-570-129V5257$1, $ $ Play 1 Power Plus 25-105 bD001-570-129V5261$2, $ $ Play 2 miniRITE0-105 dB001-560-016V5257$ $ $ Play 2 miniRITE0-105 dB001-560-016V5261$1, $ $ Play 2 miniRITE-R0-105 dB001-560-130V5257$ $ $ Play 2 miniRITE-R0-105 dB001-560-130V5261$1, $ $ Play 2 miniRITE-T0-105 dB001-560-127V5257$ $ $ Play 2 miniRITE-T0-105 dB001-560-127V5261$1, $ $ Play 2 Power Plus25-105 bD001-560-129V5257$ $ $ Play 2 Power Plus25-105 bD001-560-129V5261$1, $ $ S 2 BTE PP25-105 bD001-540-129V5257$1, $ $ S 2 BTE PP25-105 bD001-540-129V5261$3, $ $ S 2 miniRITE0-105 dB001-540-016V5257$1, $ $ S 2 miniRITE0-105 dB001-540-016V5261$3, $ $ S 2 miniRITE-R0-105 dB001-540-130V5257$2, $ $ S 2 miniRITE-R0-105 dB001-540-130V5261$4, $ $ S 2 miniRITE-T0-105 dB001-540-127V5257$1.

6 $ $ S 2 miniRITE-T0-105 dB001-540-127V5261$3, $ $ 2 of 9 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsOTICONOTICON BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LIST PRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)Opn S 3 BTE PP25-105 bD001-530-129V5257$1, $ $ S 3 BTE PP25-105 bD001-530-129V5261$2, $ $ S 3 miniRITE0-105 dB001-530-016V5257$1, $ $ S 3 miniRITE0-105 dB001-530-016V5261$2, $ $ S 3 miniRITE-R0-105 dB001-530-130V5257$1, $ $ S 3 miniRITE-R0-105 dB001-530-130V5261$2, $ $ S 3 miniRITE-T0-105 dB001-530-127V5257$1, $ $ S 3 miniRITE-T0-105 dB001-530-127V5261$2, $ $ BICROS Transmitter with Opn Play 10-105 dB001-589-132-001570V5221$2, $ $ BICROS Transmitter with Opn Play 1 miniRITE R0-105 dB001-589-132-001570RV5221$2, $ $ BICROS Transmitter with Opn S0-105 dB001-589-132-001540V5221$2, $ $ BICROS Transmitter with Opn S 2 miniRITE R0-105 dB001-589-132-001543V5181$2, $ $ BICROS Transmitter with Ruby 10-105 dB001-589-132-001594V5221$1, $ $ BICROS Transmitter with Ruby 20-105 dB001-589-132-001597V5221$1.

7 $ $ BICROS Transmitter with Xceed 230-120 dB001-589-132-001577V5221$2, $ $ BICROS Transmitter with Xceed 330-120 dB001-589-132-001580V5221$1, $ $ 3 of 9 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsOTICONOTICON BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LIST PRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)Oticon BICROS Transmitter with Xceed Play 130-120 dB001-589-132-001583V5221$2, $ $ BICROS Transmitter with Xceed Play 230-120 dB001-589-132-001586V5221$1, $ $ CROS Transmitter with Opn Play 10-105 dB001-589-132-001570V5181$2, $ $ CROS Transmitter with Opn Play 1 miniRITE R0-105 dB001-589-132-001570RV5181$2, $ $ CROS Transmitter with Opn S 20-105 dB001-589-132-001540V5181$2, $ $ CROS Transmitter with Opn S 2 miniRITE R0-105 dB001-589-132-001543V5181$2, $ $ CROS Transmitter with Ruby 10-105 dB001-589-132-001594V5181$1, $ $ CROS Transmitter with Ruby 20-105 dB001-589-132-001597V5181$1, $ $ CROS Transmitter with Xceed 230-120 dB001-589-132-001577V5181$2, $ $ CROS Transmitter with Xceed 330-120 dB001-589-132-001580V5181$1, $ $ CROS Transmitter with Xceed Play 130-120 dB001-589-132-001583V5181$2.

8 $ $ CROS Transmitter with Xceed Play 230-120 dB001-589-132-001586V5181$1, $ $ 1 BTE0-85 dB001-594-128V5257$ $ $ 1 BTE25-105 dB001-594-128V5261$1, $ $ 1 miniRITE0-105 dB001-594-016V5257$ $ $ 1 miniRITE0-105 dB001-594-016V5261$1, $ $ 1 miniRITE R0-105 dB001-594-130V5257$ $ $ 4 of 9 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsOTICONOTICON BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LIST PRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)Ruby 1 miniRITE R0-105 dB001-594-130V5261$1, $ $ 1 miniRITE T0-105 dB001-594-127V5257$ $ $ 1 miniRITE T0-105 dB001-594-127V5261$1, $ $ 1 Power Plus25-105 dB001-594-129V5257$ $ $ 1 Power Plus25-105 dB001-594-129V5261$1, $ $ 2 BTE0-85 dB001-597-128V5257$ $ $ 2 BTE25-105 dB001-597-128V5261$1, $ $ 2 miniRITE0-105 dB001-597-016V5257$ $ $ 2 miniRITE0-105 dB001-597-016V5261$1, $ $ 2 miniRITE R0-105 dB001-597-130V5257$ $ $ 2 miniRITE R0-105 dB001-597-130V5261$1, $ $ 2 miniRITE T0-105 dB001-597-127V5261$1, $ $ 2 miniRITE T 0-105 dB001-597-127V5257$ $ $ 2 Power Plus25-105 dB001-597-129V5257$ $ $ 2 Power Plus25-105 dB001-597-129V5261$1.

9 $ $ BTE 13 -Pediatric0-90 dB001-052-031V5257$ $ $ BTE 13 -Pediatric0-90 dB001-052-031V5261$ $ $ BTE 312 - Pediatric 0-75 dB001-052-015V5261$ $ $ 5 of 9 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsOTICONOTICON BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LIST PRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)Sensei BTE 312 - Pediatric0-75 dB001-052-015V5257$ $ $ Pro BTE 13 - Pediatric0-90 dB001-053-031V5257$ $ $ Pro BTE 13 - Pediatric0-90 dB001-053-031V5261$1, $ $ Pro BTE 312 - Pediatric 0-75 dB001-053-015V5257$ $ $ Pro BTE 312 Pediatric0-75 dB001-053-015V5261$1, $ $ Pro RITE Pediatric 0-100 dB001-053-009V5257$ $ $ Pro RITE Pediatric0-100 dB001-053-009V5261$1, $ $ Pro SP BTE20-110 dB001-063-014V5257$1, $ $ Pro SP BTE 20-110 dB001-063-014V5261$2, $ $ RITE - Pediatric0-100 dB001-052-009V5257$ $ $ RITE - Pediatric 0-100 dB001-052-009V5261$ $ $ SP BTE - Pediatric 20-110 dB001-062-014V5257$ $ $ SP BTE - Pediatric 20-110 dB001-062-014V5261$1, $ $ 1 BTE0-85 dB001-520-128V5257$ $ $ 1 BTE25-105 dB001-520-128V5261$1, $ $ 1 BTE PP25-105 dB001-520-129V5257$ $ $ 1 BTE PP25-105 dB001-520-129V5261$1.

10 $ $ 1 miniRITE0-105 dB001-520-016V5257$ $ $ 6 of 9 Contract Effective 9/1/2020 MDHHS Hearing Aid Contract ModelsOTICONOTICON BEHIND THE EARdb RANGEMODEL NUMBERHCPCS CODE(S)EQUIPMENT PUBLISHED LIST PRICEEQUIPMENT PERCENT DISCOUNT OFF LIST PRICEEQUIPMENT TOTAL PRICEFIXED NON - WARRANTY REPAIR PRICENON - WARRANTY REPAIR PERIOD (MONTHS)WARRANTY REPAIR PERIOD (MONTHS)Siya 1 miniRITE0-105 dB001-520-016V5261$1, $ $ 1 miniRITE-T0-105 dB001-520-127V5257$ $ $ 1 miniRITE-T0-105 dB001-520-127V5261$1, $ $ 2 BTE0-85 dB001-510-128V5257$ $ $ 2 BTE25-105 dB001-510-128V5261$1, $ $ 2 BTE PP25-105 dB001-510-129V5257$ $ $ 2 BTE PP25-105 dB001-510-129V5261$1, $ $ 2 miniRITE0-105 dB001-510-016V5257$ $ $ 2 miniRITE0-105 dB001-510-016V5261$1, $ $ 2 miniRITE-T0-105 dB001-510-127V5257$ $ $ 2 miniRITE-T0-105 dB001-510-127V5261$1, $ $ 2 BTE SP30-110 dB001-577-134V5257$1, $ $ 2 BTE SP30-110 dB001-577-134V5261$2, $ $ 2 BTE UP30-120 dB001-577-135V5257$1, $ $ 2 BTE UP30-120 dB001-577-135V5261$2, $ $ 3 BTE SP30-110 dB001-580-134V5257$ $ $ 3 BTE SP30-110 dB001-580-134V5261$1, $ $ 3 BTE UP30-120 dB001-580-135V5257$ $ $ 7 of 9 Contract Effective 9/1