EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural...
Transcript of EQUIPMENT EQUIPMENT PERCENT FIXED NON - …...XXdB Max Gain/1XX dB Max Output V5261 Binaural...
Price Schedule
BEHIND THE EAR TYPES - The total price shall be for a single hearing aid or two hearing aids and appropriate case. List model numbers/name and full range of the instrument has a T-coil or T-coil capability. For digital aids, indicate whether a remote control is required. For conventional aids, indicate whether it is a linear or compression circuit L = Linear, C = Compression.
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Audeo M70-312 Phonak 050-0493-H0 V5257 Monaural $1,649.00 54.579% $749.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $3,298.00 54.579% $1,498.00 $258.00 12 36
Audeo M50-312 Phonak 050-0492-H0V5257 Monaural $1,099.00 60.055% $439.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $2,198.00 60.055% $878.00 $258.00 12 36
Audeo M30-312 Phonak 050-0491-H0V5257 Monaural $749.00 53.004% $352.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $1,498.00 53.004% $704.00 $258.00 12 36
Audeo M70-312T Phonak 050-0497-H0V5257 Monaural $1,699.00 55.915% $749.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36
Audeo M50-312T Phonak 050-0496-H0V5257 Monaural $1,149.00 61.793% $439.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $2,298.00 61.793% $878.00 $258.00 12 36
Audeo M30-312T Phonak 050-0495-H0 V5257 Monaural $799.00 55.945% $352.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $1,598.00 55.945% $704.00 $258.00 12 36
Audeo M70-13T Phonak 050-0518-H0V5257 Monaural $1,699.00 55.915% $749.00 $129.00 12 36
XXdB Max Gain/1XX
dB Max Output V5261 Binaural $3,398.00 55.915% $1,498.00 $258.00 12 36
Audeo M50-13T Phonak 050-0517-H0V5257 Monaural $1,149.00 61.793% $439.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $2,298.00 61.793% $878.00 $258.00 12 36
Audeo M30-13T Phonak 050-0516-H0 V5257 Monaural $799.00 55.945% $352.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $1,598.00 55.945% $704.00 $258.00 12 36
Digital RIC - programmable 16 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 -
QuickSync - WhistleBlock - NoiseBlock - Speech in Loud Noise -
WindBlock - Sound Relax - Real Ear Sound - WaterResistant -
Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.
Mild/Moderate/Severe hearing loss
Digital RIC - programmable 12 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync -
WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant -
Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.
Mild/Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock -
NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance -
RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss
Digital RIC - programmable 16 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech
in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud
Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant
- Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.
Mild/Moderate/Severe hearing loss
Digital RIC - programmable 12 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone -
QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound -
WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size
312 Battery. Mild/Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync -
WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus
Balance - RogerDirect - Size 312 Battery. Mild/Moderate/Severe
hearing loss
Digital RIC - programmable 16 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech
in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud
Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant
- Datalogging - Tinnitus Balance - RogerDirect - Size 13 Battery.
Mild/Moderate/Severe hearing loss
Digital RIC - programmable 12 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone -
QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound -
WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size
13 Battery. Mild/Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync -
WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus
Balance - RogerDirect - Size 13 Battery. Mild/Moderate/Severe
hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 1 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Audeo M70-R Rechargeable (includes charger case) Phonak 050-0485-H0V5257 Monaural $1,749.00 55.746% $774.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $3,498.00 55.746% $1,548.00 $258.00 12 36
Audeo M50-R Rechargeable (includes charger case) Phonak 050-0440-H0 V5257 Monaural $1,199.00 62.469% $450.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $2,398.00 62.469% $900.00 $258.00 12 36
Audeo M30-R Rechargeable (includes charger case) Phonak 050-0439-H0 V5257 Monaural $849.00 55.595% $377.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $1,698.00 55.595% $754.00 $258.00 12 36
Audeo M70-RT Rechargeable (includes charger case) Phonak 050-0489-H0V5257 Monaural $1,799.00 56.976% $774.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $3,598.00 56.976% $1,548.00 $258.00 12 36
Audeo M50-RT Rechargeable (includes charger case) Phonak 050-0488-H0 V5257 Monaural $1,249.00 63.971% $450.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $2,498.00 63.971% $900.00 $258.00 12 36
Audeo M30-RT Rechargeable (includes charger case) Phonak 050-0487-H0 V5257 Monaural $899.00 58.065% $377.00 $129.00 12 36
67 dB Max Gain/130
dB Max Output V5261 Binaural $1,798.00 58.065% $754.00 $258.00 12 36
Sky M70-M Phonak 050-0647-H0 V5257 Monaural $1,649.00 54.579% $749.00 $129.00 12 36
68 dB Max Gain/134
dB Max Output V5261 Binaural $3,298.00 54.579% $1,498.00 $258.00 12 36
Sky M50-M Phonak 050-0635-H0V5257 Monaural $1,099.00 64.968% $385.00 $129.00 12 36
68 dB Max Gain/134
dB Max Output V5261 Binaural $2,198.00 64.968% $770.00 $258.00 12 36
Digital RIC - programmable 16 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 -
QuickSync - WhistleBlock - NoiseBlock - Speech in Loud Noise -
WindBlock - Sound Relax - Real Ear Sound - WaterResistant -
Datalogging - Tinnitus Balance - RogerDirect - Rechargeable
Battery. Mild/Moderate/Severe hearing loss
Digital RIC - programmable 12 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync -
WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant -
Datalogging - Tinnitus Balance - RogerDirect - Rechargeable Battery.
Mild/Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock -
NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance -
RogerDirect - Rechargeable Battery. Mild/Moderate/Severe hearing
loss
Digital RIC - programmable 16 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech
in 360 - QuickSync - WhistleBlock - NoiseBlock - Speech in Loud
Noise - WindBlock - Sound Relax - Real Ear Sound - WaterResistant
- Datalogging - Tinnitus Balance - RogerDirect - Rechargeable
Battery. Mild/Moderate/Severe hearing loss
Digital RIC - programmable 12 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - DuoPhone -
QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound -
WaterResistant - Datalogging - Tinnitus Balance - RogerDirect -
Rechargeable Battery. Mild/Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/6 programs, Telecoil.
Includes AutoSense OS 3.0 - SoundRecover2 - QuickSync -
WhistleBlock - NoiseBlock - WaterResistant - Datalogging - Tinnitus
Balance - RogerDirect - Rechargeable Battery.
Mild/Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 16 channels/6 programs.
Includes AutoSense Sky OS 3.0 - SoundRecover2 - DuoPhone -
Speech in 360 -QuickSync - Indicator Light - TamperProof Battery
Door - Tamper Proof mini ear hook - WhistleBlock - NoiseBlock -
Real Ear Sound - Speech in Loud Noise - WindBlock - Sound Relax -
WaterResistant - Datalogging - RogerDirect - Tinnitus Balance - Size
312 Battery. Mild/Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 12 channels/6 programs.
Includes AutoSense Sky OS 3.0 - SoundRecover2 - DuoPhone -
QuickSync - Indicator Light - TamperProof Battery Door - Tamper
Proof mini ear hook - WhistleBlock - NoiseBlock - Real Ear Sound -
WaterResistant - Datalogging - Tinnitus Balance - RogerDirect - Size
312 Battery. Mild/Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 2 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Bolero M70-M Phonak 050-0534-H0V5257 Monaural $1,649.00 54.579% $749.00 $129.00 12 36
68 dB Max Gain/134
dB Max Output V5261 Binaural $3,298.00 54.579% $1,498.00 $258.00 12 36
Bolero M50-M Phonak 050-0533-H0 V5257 Monaural $1,099.00 60.055% $439.00 $129.00 12 36
68 dB Max Gain/134
dB Max Output V5261 Binaural $2,198.00 60.055% $878.00 $258.00 12 36
Bolero M30-M Phonak 050-0532-H0V5257 Monaural $749.00 53.004% $352.00 $129.00 12 36
68 dB Max Gain/134
dB Max Output V5261 Binaural $1,498.00 53.004% $704.00 $258.00 12 36
Sky B70-M Phonak 050-0464-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
68dB Max Gain/134
dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Sky B70-P Phonak 050-0468-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
71dB Max Gain/135
dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Sky B70-SP Phonak 050-0472-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
83dB Max Gain/143
dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Sky B70-UP Phonak 050-0476-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
85dB Max Gain/145
dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Sky B70-RIC Phonak 050-0480-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
72dB Max Gain/136
dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Sky B70-PR Rechargeable (includes charger case) Phonak 050-0483-01V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36
71dB Max Gain/135
dB Max OutputV5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12
36
Digital BTE - programmable 8 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - QuickSync - WhistleBlock -
NoiseBlock - WaterResistant - Datalogging - Tinnitus Balance -
RogerDirect - Size 312 Battery. Mild/Moderate/Severe hearing loss
Digital BTE - programmable 16 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - DuoPhone - Speech in 360 -
QuickSync - WhistleBlock - NoiseBlock - Real Ear Sound - Speech in
Loud Noise - WindBlock - Sound Relax - WaterResistant -
Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.
Mild/Moderate/Severe hearing loss
Digital BTE - programmable 12 channels/6 programs. Includes
AutoSense OS 3.0 - SoundRecover2 - DuoPhone - QuickSync -
WhistleBlock - NoiseBlock - Real Ear Sound - WaterResistant -
Datalogging - Tinnitus Balance - RogerDirect - Size 312 Battery.
Mild/Moderate/Severe hearing loss
Pediatric Digital RIC - programmable 16 channels/7 programs.
Includes SoundRecover2 - UltraZoom Advanced-QuickSync -
WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -
UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-
Coil - Size13 Battery. Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 16 channels/7 programs.
Includes AutoSense Sky OS-SoundRecover2 -DuoPhone- UltraZoom
Advanced-QuickSync Indicator Light-TamperProof Battery Door-
Tamper Proof mini ear hook - WhistleBlock - NoiseBlock - Flex
Control - Zoom Control - UserPreference -Duo Phone- WindBlock-
Sound Relax- Roger Ready-WaterResistant - Datalogging - FM/DAI -
Cros/BiCros compatibility - T-Coil -RogerMy Link- Size312 Battery.
Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 16 channels/7 programs.
Includes AutoSense Sky OS-SoundRecover2 - DuoPhone-Roger
Ready-Indicator Light-Tamper Proof Battery Door-Tamper Proof Ear
Hook-UltraZoom Advanced-QuickSync - WhistleBlock - NoiseBlock -
Flex Control - UserPreference - Tinnitus Balance- WindBlock-Sound
Relax- WaterResistant - Datalogging - DuoPhone - FM/DAI -
Cros/BiCros compatibility - T-Coil -Roger My Link- Size 13 Battery.
Moderate/Severe hearing loss
Pediatric Digital Power BTE - programmable 16 channels/7
programs. Includes AutoSense Sky OS-SoundRecover2 - UltraZoom
Advanced-QuickSync - WhistleBlock - NoiseBlock - Flex Control -
Zoom Control - UserPreference - Tinnitus Balance-Duo Phone-
WindBlock-Sound Relax- WaterResistant - Datalogging - FM/DAI -
Cros/BiCros compatibility - T-Coil -RogerMy Link-Indicator Light-
Tamperproof Battery Door-Tamperproof Mini ear hook - Size312
Battery. Moderate/Severe hearing loss
Pediatric Super Power Digital BTE - programmable 12 channels/4
programs. Includes AutoSense Sky OS-SoundRecover2 - UltraZoom -
QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance - Indicator
Light-TamperProof Battery Door-Tamper Proof mini ear hook -
WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros
compatibility - Size 675 Battery. Moderate/Severe hearing loss
Digital BTE - programmable 16 channels/4 Programs. Includes
SoundRecover2-Sound Relax-WindBlock-NoiseBlock-WhistleBlock-
TCoil/Roger MyLink-Roger(ComPIlotII/Roger X) - Speech in 360 -
Speech in Loud Noise - DuoPhone- Tinnitus Balance- Indicator Light-
Tamper Proof mini ear hook -WindBlock- Datalogging -
Rechargeable Battery. Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 3 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Sky B50-M Phonak 050-0463-01V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
68dB Max Gain/134
dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Sky B50-P Phonak 050-0467-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
71dB Max Gain/135
dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Sky B50-SP Phonak 050-0471-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
83dB Max Gain/143
dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Sky B50-UP Phonak 050-0475-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
85dB Max Gain/145
dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Sky B50-RIC Phonak 050-0479-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
72dB Max Gain/136
dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Sky B50-PR Rechargeable (includes charger case) Phonak 050-0482-01 V5257 Monaural $1,099.00 62.693% $410.00 $129.00 12 36
71dB Max Gain/135
dB Max Output V5261 Binaural $2,198.00 62.693% $820.00 $258.00 12 36
Naida B70-UP Phonak 050-0403-01 V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
85dB Max Gain/145
dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Naida B70-SP Phonak 050-0397-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
83dB Max Gain/143
dB Max Output V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Naida B70-R Rechargeable (includes charger case) Phonak 050-0436-01V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36
72dB Max Gain/136
dB Max Output V5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12 36
Digital Super Power BTE - programmable 16 channels/7 programs.
Includes APD Contrast-SoundRecover - UltraZoom Advanced-
QuickSync - WhistleBlock - NoiseBlock - Flex Volume - Zoom Control
- UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility - T-
Coil - Size 675 Battery. Moderate/Severe hearing loss
Digital BTE - programmable 12 channels/3 Programs. Includes
SoundRecover2-Real Ear Sound DuoPhone-QuickSync -
WhistleBlock - NoiseBlock - Flex Control- Tinnitus Balance - Indicator
Light-Tamper Proof mini ear hook -Tcoil/Roger/MyLink- Roger
(ComPilot II/Roger X) Datalogging- Rechargeable Battery.
Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 12 channels/4 programs.
Includes AutoSense Sky OS- SoundRecover2 - UltraZoom -
QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance
WaterResistant - Datalogging - EasyPhone - Indicator Light-
TamperProof Battery Door-Tamper Proof mini ear hook - FM/DAI -
Cros/BiCros compatibility - Size 312 Battery. Moderate/Severe
hearing loss
Pediatric Digital BTE - programmable 12 channels/4 programs.
Includes AutoSense Sky OS- SoundRecover2 - UltraZoom -
QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance
WaterResistant - Datalogging - EasyPhone - Indicator Light-
TamperProof Battery Door-Tamper Proof mini ear hook - FM/DAI -
Cros/BiCros compatibility - Size 13 Battery. Moderate/Severe hearing
loss
Pediatric Digital Power BTE - programmable 12 channels/4
programs. Includes AutoSense Sky OS- SoundRecover2 - UltraZoom
-QuickSync - DuoPhone-Flex Control-WhistleBlock - NoiseBlock -
Tinnitus Balance WaterResistant - Datalogging - Indicator Light-
TamperProof Battery Door-Tamper Proof mini ear hook - EasyPhone
- FM/DAI - Cros/BiCros compatibility - Size 13 Battery.
Moderate/Severe hearing loss
Pediatric Digital Super Power BTE - programmable 12 channels/4
programs. Includes AutoSense Sky OS- SoundRecover2 - UltraZoom
-QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance Indicator
Light-TamperProof Battery Door-Tamper Proof mini ear hook -
WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros
compatibility - Size 675 Battery. Moderate/Severe hearing loss
Pediatric Digital RIC - programmable 12 channels/4 programs.
Includes AutoSense Sky OS- SoundRecover2 - UltraZoom
Advanced-QuickSync - WhistleBlock - NoiseBlock - Flex Volume -
Zoom Control - UserPreference - Tinnitus Balance- WindBlock
WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros
compatibility - T-Coil -Size 13 Battery. Moderate/Severe hearing loss
Digital Power BTE 16 Channels/4 programs - Includes APD
Contrast-SoundRecover2 - Sound Relax-Auto Sense OS- Music-
Wind Block- Speech in 360- Speech in Loud Noise- DuoPhone- Real
Ear Sound- Flex Control- Tinnitus Balance-Noise Block-QuickSync -
WhistleBlock - WaterResistant - Datalogging -Roger 18 Integrated
Receiver- Roger Ready- Cros B Compatibility - T-Coil/Roger MyLink-
Roger (ComPilotII/Roger X) - Size 13 Battery. Moderate/Severe
hearing loss
Digital Power RIC - programmable 16 channels/4 Programs.
Includes APD Contrast-SoundRecover2-Sound Relax-Real Ear
Sound-Flex Control-NoiseBlock-QuickSync-WhistleBlock-Roger
(ComPilotII/Roger X) - Speech in 360 - Speech in Loud Noise -
DuoPhone- Tinnitus Balance- WindBlock- Datalogging -
Rechargeable Battery. Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 4 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Naida B50-UP Phonak 050-0402-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
85dB Max Gain/145
dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Naida B50-SP Phonak 050-0319-01V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
83dB Max Gain/143
dB Max Output V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Naida B50-R Rechargeable (includes charger case) Phonak 050-0429-01V5257 Monaural $1,099.00 62.693% $410.00 $129.00 12 36
72dB Max Gain/136
dB Max Output V5261 Binaural $2,198.00 62.693% $820.00 $258.00 12 36
Naida B30 -UP Phonak 050-0399-01 V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
85dB Max Gain/145
dB Max Output V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Naida B30 -SP Phonak 050-0318-01 V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
83dB Max Gain/143
dB Max Output V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Audeo B70-R Rechargeable (includes charger case) Phonak 050-0235-01 V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36
65dB Max Gain/133
dB Max Output V5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12 36
Audeo B50-R Rechargeable (includes charger case) Phonak 050-0234-01
V5257 Monaural $1,099.00 62.693% $410.00 $129.00 12 36
65dB Max Gain/133
dB Max Output V5261 Binaural $2,198.00 62.693% $820.00 $258.00 12 36
Bolero B70-R BTE Rechargeable (includes charger case) Phonak 050-0375-01V5257 Monaural $1,649.00 56.095% $724.00 $129.00 12 36
65dB Max Gain/133
dB Max Output V5261 Binaural $3,298.00 56.095% $1,448.00 $258.00 12 36
Bolero B50-R BTE Rechargeable (includes charger case) Phonak 050-0374-01
V5257 Monaural $1,099.00 62.693% $410.00 $258.00 12 36
65dB Max Gain/133
dB Max OutputV5261 Binaural $2,198.00 62.693% $820.00 $129.00 12 36
Digital Super Power BTE - programmable 12 channels/4 programs.
Includes APD Contrast-SoundRecover2 - UltraZoom Advanced-
QuickSync - WhistleBlock - NoiseBlock - Flex Volume - Zoom Control
- UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-
Coil -Size 675 Battery. Moderate/Severe hearing loss
Digital Super Power BTE - programmable 8 channels/3 programs.
Includes APD Contrast- SoundRecover2 -everyday automatic -
QuickSync - WhistleBlock - Tinnitus Balance -WaterResistant -
Datalogging -Cros/BiCros compatibility - Size 675 Battery.
Moderate/Severe hearing loss
Digital Power BTE 12 Channels/3 Programs - Includes APD Contrast-
SoundRecover2-Auto Sense OS- DuoPhone-Real Ear Sound-Flex
Control- T Coil-/Roger MyLink- Roger Ready- Roger Integrated
Receiver -QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance-
WaterResistant - Datalogging - FM/DAI - CrosB compatibility - Size
13 Battery. Moderate/Severe hearing loss
Digital Power BTE 8 Channels/2 Programs- Includes APD Contrast-
AutoSense OS- Tinnitus Balance- Sound Recover2- Noise Block-
Quick Sync- Whistle Block- Cros B Compatible- T Coil/Roger MyLink-
Roger 18 Integrated Receiver-WaterResistant - Datalogging - Size
13 Battery. Moderate/Severe hearing loss
Digital Power RIC - programmable 12 channels/3 Programs.
Includes APD Contrast-SoundRecover2 -Real Ear Sound- DuoPhone-
QuickSync - WhistleBlock - NoiseBlock - Flex Control- Tinnitus
Balance - Datalogging- Rechargeable Battery. Moderate/Severe
hearing loss
Digital BTE - programmable 16 channels/4 Programs. Includes
SoundRecover2-Sound Relax-Real Ear Sound-Flex Control-
NoiseBlock-QuickSync-WhistleBlock-Roger (ComPilotII/Roger X) -
Speech in 360 - Speech in Loud Noise - DuoPhone- Tinnitus
Balance- WindBlock- Datalogging - Rechargeable Battery.
Moderate/Severe hearing loss
Digital BTE - programmable 12 channels/3 Programs. Includes
SoundRecover2 -Real Ear Sound- DuoPhone-Roger
(ComPilotII/Roger X)QuickSync - WhistleBlock - NoiseBlock - Flex
Control- Tinnitus Balance - Datalogging- Rechargeable Battery.
Moderate/Severe hearing loss
Digital BTE - programmable 16 channels/4 Programs. Includes
SoundRecover2-Sound Relax-WindBlock-NoiseBlock-WhistleBlock-
TCoil/Roger MyLink-Roger(ComPIlotII/Roger X) - Speech in 360 -
Speech in Loud Noise - DuoPhone- Tinnitus Balance- WindBlock-
Datalogging - Rechargeable Battery. Moderate/Severe hearing loss
Digital BTE - programmable 12 channels/3 Programs. Includes
SoundRecover2-Real Ear Sound DuoPhone-QuickSync -
WhistleBlock - NoiseBlock - Flex Control- Tinnitus Balance -
Tcoil/Roger/MyLink- Roger (ComPilot II/Roger X) Datalogging-
Rechargeable Battery. Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 5 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Bolero B70 - P65db Max Gain - 133
Max Output Phonak 050-0368-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Bolero B70 - SP63db Max Gain - 133
Max OutputPhonak 050-0372-01
V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Bolero B70 - M31263db Max Gain - 133
Max OutputPhonak 050-0364-01
V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Bolero B50-SP70db Max Gain - 133
Max OutputPhonak
050-0371-01 V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Bolero B50 - P65db Max Gain - 133
Max OutputPhonak 050-0367-01
V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Bolero B50 - M31263db Max Gain - 133
Max OutputPhonak 050-0363-01
V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Bolero B30 - M31261db Max Gain - 132
Max OutputPhonak 050-0362-01
V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Bolero B30 -P65db Max Gain - 133
Max OutputPhonak 050-0366-01
V5257 Monaural $649.00 53.929% $299.00 $258.00 12 36
V5261 Binaural $1,298.00 53.929% $598.00 $129.00 12 36
Digital BTE 8 Channels/2 Programs- Includes AutoSense OS-
Tinnitus Balance- Sound Recover2- Noise Block- Quick Sync-
Whistle Block- Cros B Compatible- T Coil/Roger MyLink -
WaterResistant - Datalogging - Size 312 Battery. Moderate/Severe
hearing loss
Digital Power BTE 8 Channels/2 Programs- Includes AutoSense OS-
Tinnitus Balance- Sound Recover2- Noise Block- Quick Sync-
Whistle Block- Cros B Compatible- T Coil/Roger MyLink- Roger 18
Integrated Receiver- Roger Ready -WaterResistant - Datalogging -
Size 13 Battery. Moderate/Severe hearing loss
Digital Power BTE 16 Channels/4 programs - Includes
SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind Block-
Speech in 360- Speech in Loud Noise- DuoPhone- Real Ear Sound-
Flex Control- Tinnitus Balance-Noise Block-QuickSync -
WhistleBlock - WaterResistant - Datalogging -Roger 18 Integrated
Receiver- Roger Ready- Cros B Compatibility - T-Coil/Roger MyLink-
Roger (ComPilotII/Roger X) - Size13 Battery. Moderate/Severe
hearing loss
Digital Power BTE 16 Channels/4 programs - Includes
SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind Block-
Speech in 360- Speech in Loud Noise- DuoPhone- Real Ear Sound-
Flex Control- Tinnitus Balance-Noise Block-QuickSync -
WhistleBlock - WaterResistant - Datalogging -Roger 18 Integrated
Receiver- Roger Ready- Cros B Compatibility - T-Coil/Roger MyLink-
Roger (ComPilotII/Roger X) - Size 13 Battery. Moderate/Severe
hearing loss
Digital BTE 16 Channels/4 Programs - Includes SoundRecover2-
Music- QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance
Noise Generator - Flex Control- Real Ear Sound- DuoPhone- Speech
in Loud Noise -Speech in 360- Sound Relax-WindBlock-
WaterResistant - Datalogging - Cros/B Compatibility- T-
Coil/Roger/MyLink-Roger 18 Integrated Receiver-
Roger(ComPilotii/Roger X) - Size 312 Battery. Moderate/Severe
hearing loss
Digital Super Power BTE 12 Channels/3 Programs - Includes
SoundRecover2-Auto Sense OS- DuoPhone-Real Ear Sound-Flex
Control- T Coil-/Roger MyLink- Roger Ready- Roger Integrated
Receiver -QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance-
WaterResistant - Datalogging - FM/DAI - CrosB compatibility - Size
13 Battery. Moderate/Severe hearing loss
Digital Power BTE 12 Channels/3 Programs- Includes
SoundRecover2-Auto Sense OS- DuoPhone-Real Ear Sound-Flex
Control- T Coil-/Roger MyLink- Roger Ready- Roger 18 Integrated
Receiver -QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance-
WaterResistant - Datalogging- CrosB compatibility - Size 13 Battery.
Moderate/Severe hearing loss
Digital BTE 12 Channels/3 Programs - Includes SoundRecover2-
Auto Sense OS- DuoPhone-Real Ear Sound-Flex Control- T Coil-
/Roger MyLink-QuickSync - WhistleBlock - NoiseBlock - Tinnitus
Balance- WaterResistant - Datalogging - CrosB compatibility - Size
312 Battery. Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 6 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Bolero B30 -SP70db Max Gain - 133
Max Output Phonak 050-0370-01V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Audeo B70 RIC -1046db Max Gain - 124
Max OutputPhonak 050-0348-01
V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Audeo B70 RIC-31246 dB Max gain /130
dB Max output Phonak 050-00352-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Audeo B70 RIC-312T 46 dB Max Gain/130
dB Max Output Phonak 050-0356-01V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Audeo B70 RIC-1346 dB Max Gain/130
dB Max OutputPhonak 050-03560-01
V5257 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5261 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Audeo B50 RIC-1046 dB Max Gain/124
dB Max OutputPhonak 050-0347-01
V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Audeo B50 RIC-31246 dB Max Gain/130
Max OutputPhonak 050-0351-01
V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Audeo B50-312 T46 dB Max Gain/130
dB Max OutputPhonak 050-0355-01
V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Audeo B50-1346 dB Max Gain/130
dB Max OutputPhonak 050-0359-01
V5257 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5261 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Digital Super Power BTE 8 Channels/2 Programs- Includes
AutoSense OS- Tinnitus Balance- Sound Recover2- Noise Block-
Quick Sync- Whistle Block- Cros B Compatible- T Coil/Roger MyLink-
Roger 18 Integrated Receiver-WaterResistant - Datalogging - Size
13 Battery. Moderate/Severe hearing loss
Digital RIC - programmable 16 channels/4 Programs. Includes
SoundRecover2 - Sound Relax- Wind Block- Speech in Loud Noise-
Real Ear Sound-Speech in 360 - Speech in Loud Noise - DuoPhone -
QuickSync - WhistleBlock - NoiseBlock - Flex Control - Tinnitus
Balance- WindBlock- Datalogging - Cros B/BiCros compatibility -
Roger 18 Integrated Receiver-Roger Ready-T Coil - Size 13 Battery.
Moderate/Severe hearing loss
Digital RIC - programmable 12 channels/3 Programs. Includes
SoundRecover2 - DuoPhone - Tinnitus Balance-QuickSync -
WhistleBlock - NoiseBlock - Flex Control-Tinnitus Balance-Real Ear
Sound- Datalogging - CrosB /BiCros compatibility-T Coil-Roger
(ComPilot II/Roger X) Size 10a Battery. Mild-Moderate/Severe
hearing loss
Digital RIC - programmable 12 channels/4 Programs. Includes
SoundRecover2 - DuoPhone-QuickSync - WhistleBlock - NoiseBlock -
Flex Control- Tinnitus Balance- Real Ear Sound-Datalogging- Cros
B/BiCros compatibility-Roger(Com Pilot II/Roger X) - Size 312
Battery. Moderate/Severe hearing loss
Digital RIC - programmable 12 channels/ 4 Programs. Includes
SoundRecover2 - DuoPhone-QuickSync - WhistleBlock - NoiseBlock -
Flex Control - Tinnitus Balance - Datalogging -Tcoil Roger MyLink-
Cros B/BiCros compatibility - Size 312 Battery. Moderate/Severe
hearing loss
Digital RIC - programmable 12 channels/4 Programs. Includes
SoundRecover2 -Real Ear Sound- DuoPhone - UltraZoom Advanced-
QuickSync - WhistleBlock - NoiseBlock - Flex Control - Tinnitus
Balance - Datalogging- Cros B/BiCros compatibility-Roger/MyLink-
Roger Integrated Receiver 18-Roger Ready - Size 13 Battery.
Moderate/Severe hearing loss
Digital RIC - programmable 16 channels/4 Programs. Includes
SoundRecover2 - Speech in 360 - Speech in Loud Noise -
DuoPhone-QuickSync - WhistleBlock - NoiseBlock - Flex Control -
Tinnitus Balance- WindBlock-Sound Relax-Real Ear Sound
Datalogging - Cros B/BiCros compatibility - Size 312 Battery.
Moderate/Severe hearing loss
Digital RIC - programmable 16 channels/4 Programs. Includes
SoundRecover2 - Speech in 360 - Speech in Loud Noise -Real Ear
Sound- DuoPhone -QuickSync - WhistleBlock - NoiseBlock - Flex
Control - Tinnitus Balance- WindBlock- Sound Relax-Datalogging -
Telecoil- CrosB/BiCros compatibility - Size 312 Battery.
Moderate/Severe hearing loss
Digital RIC - programmable 16 channels/4 programs. Includes
SoundRecover2 - Wind Block- Sound Relax-Speech in 360 - Speech
in Loud Noise - DuoPhone -QuickSync - WhistleBlock - NoiseBlock -
Flex Control - Tinnitus Balance-Sound Relax-Real Ear Sound -
Datalogging- Cros B/BiCros compatibility - Size 10a Battery. Mild-
Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 7 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Audeo B30-10
46 Max Gain/ 130 dB
Max Output Phonak 050-0346-01
V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Audeo B30 31246 dB Max Gain/130
dB Max OutputPhonak 050-0350-01
V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Audeo B30-312 T46 dB Max Gain/130
dB Max OutputPhonak 050-0354-01
V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Audeo B30-1346 dB/130 dB
Phonak 050-0358-01V5257 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5261 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
CROS B R- Rechargeable 70 level60 dB Max Gain -122
Output Phonak 050-0601-01.70V5181 $2,478.00 53.855% $1,143.47 $110.00 12 24
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to a rechargeable Audeo B Rechargeable
battery
CROS B R- Rechargeable 70 level (BiCROS)60 dB Max Gain -122
Output Phonak 050-0601-01.70V5221 $2,478.00 53.855% $1,143.47 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to a rechargeable Audeo B Rechargeable
battery
CROS B R- Rechargeable 50 level60 dB Max Gain -122
Output Phonak 050-0601-01.50V5181 $1,928.00 56.977% $829.48 $110.00 12 24
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to a rechargeable Audeo B Rechargeable
battery
CROS B R- Rechargeable 50 level (BiCROS)60 dB Max Gain -122
Output Phonak 050-0601-01.50V5221 $1,928.00 56.977% $829.48 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to a rechargeable Audeo B Rechargeable
battery
CROS B 312- 30 level (excludes all rechargeable BTE/RIC)60 dB Max Gain -122
Output Phonak 050-0274-01.30V5181 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
CROS B 312- 30 level (excludes all rechargeable BTE/RIC) (BiCROS)60 dB Max Gain -122
Output Phonak 050-0274-01.30V5221 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
CROS B 13- 30 level (excludes all rechargeable BTE/RIC)63 dB Max Gain -122
OutputPhonak 050-0275-01.30
V5181 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
CROS B 13- 30 level (excludes all rechargeable BTE/RIC) (BiCROS)63 dB Max Gain -122
OutputPhonak 050-0275-01.30
V5221 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Digital RIC - programmable 8 channels/2 Programs. Includes
SoundRecover2 -QuickSync - WhistleBlock - NoiseBlock- Tinnitus
Balance - Datalogging -Cros B/BiCros compatibility-Roger (ComPilot
II/Roger X) - Size 10 Battery. Mild-Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/2 Programs. Includes Sound
Recover2-QuickSync - WhistleBlock - NoiseBlock - Tinnitus Balance -
Datalogging - Cros B/BiCros compatibility -Roger (ComPilot II/Roger
X) - Size 312 Battery. Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/2 Programs. Includes
SoundRecover2 -QuickSync - WhistleBlock - NoiseBlock - Tinnitus
Balance- T-Coil/ Roger MyLink- Roger (ComPilot II/Roger X-
Datalogging- Cros B/BiCros compatibility- Size 312 Battery.
Moderate/Severe hearing loss
Digital RIC - programmable 8 channels/2 Programs. Includes
SoundRecover2-QuickSync - WhistleBlock - NoiseBlock - Tinnitus
Balance - Datalogging- CrosB/BiCros compatibility -T Coil/Roger
MyLink-Roger (ComPilotII/RogerX) - Size 13 Battery.
Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 8 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
CROS B 312 - 50 level (excludes all rechargeable BTE/RIC) Phonak 050-0274-01.50V5181 $1,588.00 51.889% $764.00 $110.00 12 24
60db Max Gain - 122
CROS B 312 - 50 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0274-01.50V5221 $1,588.00 51.889% $764.00 $110.00 12 24
60db Max Gain - 122
CROS B 13 - 50 level (excludes all rechargeable BTE/RIC) Phonak 050-0275-01.50V5181 $1,588.00 51.889% $764.00 $110.00 12 24
63db Max Gain - 133
Max Output
CROS B 13 - 50 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0275-01.50V5221 $1,588.00 51.889% $764.00 $110.00 12 24
63db Max Gain - 133
Max Output
CROS B 312 - 70 level (excludes all rechargeable BTE/RIC) Phonak 050-0274-01.70V5181 $2,148.00 49.814% $1,078.00 $110.00 12 24
60db Max Gain - 122
Max Output
CROS B 312 - 70 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0274-01.70V5221 $2,148.00 49.814% $1,078.00 $110.00 12 24
60db Max Gain - 122
Max Output
CROS B 13 - 70 level (excludes all rechargeable BTE/RIC) Phonak 050-0275.01.70
V5181 $2,148.00 49.814% $1,078.00 $110.00 12 24
63db Max Gain - 133
Max Output
CROS B 13 - 70 level (excludes all rechargeable BTE/RIC) (BiCROS) Phonak 050-0275.01.70
V5221 $2,148.00 49.814% $1,078.00 $110.00 12 24
63db Max Gain - 133
Max Output
Bolero V70- M 31261db Max Gain - 133
Max OutputPhonak 050-0283-01
V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Bolero V70 - P65db Max Gain - 133
Max OutputPhonak 050-0291-01
V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Bolero V70-SP70db Max Gain - 133
Max OutputPhonak 050-0295-01
V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Digital BTE, AutoSense OS, Speech in 360, Speech in Loud Noise,
Wind Block, SoundRelax, SNR-Boost, FlexControl, Flex Volume,
DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock, Quick Sync,
SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom
Advanced, 16 channels, WCP compatible, size 312 battery, Roger
compatible, telecoil
Digital BTE, Power, AutoSense OS, Speech in 360, Speech in Loud
Noise, Wind Block, SoundRelax, SNR-Boost, FlexControl, Flex
Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,
Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,
UltraZoom Advanced, 16 channels, WCP compatible, size 13
battery, Roger compatible, telecoil
Digital BTE, Super Power,AutoSense OS, Speech in 360, Speech in
Loud Noise, Wind Block, SoundRelax, SNR-Boost, FlexControl, Flex
Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,
Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,
UltraZoom Advanced, 16 channels, WCP compatible, size 13
battery, Roger compatible, telecoil
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Audeo &
Bolero
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 9 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Bolero V50 - M63db Max Gain - 133
Max OutputPhonak 050-0282-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Bolero V50 - P65db Max Gain - 133
Max Output Phonak 050-0290-01V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Bolero V50 - SP70db Max Gain - 133
Max OutputPhonak 050-0294-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Bolero V30 - M63db Max Gain - 133
Max Output Phonak 050-0281-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
Bolero V30 - P65db Max Gain - 133
Max Output Phonak 050-0289-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
Bolero V30 - SP70db Max Gain - 133
Max Output Phonak 050-0293-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
Sky V70 - M63db Max Gain - 133
Max OutputPhonak 050-0328-01
V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Sky V-70 P82db Max Gain - 142
Max Output Phonak 050-0332-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Sky V-70 RIC65db Max Gain - 133
Max Output Phonak 050-0344-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Pediatric Digital BTE - programmable 16 channels/7 programs.
Includes SoundRecover2 -DuoPhone- UltraZoom Advanced-
QuickSync Indicator Light-TamperProof Battery Door-Tamper Proof
mini ear hook - WhistleBlock - NoiseBlock - Flex Control - Zoom
Control - UserPreference -Duo Phone- WindBlock-Sound Relax-
Roger Ready-WaterResistant - Datalogging - FM/DAI - Cros/BiCros
compatibility - T-Coil -RogerMy Link- Size 312 Battery.
Moderate/Severe hearing loss
Pediatric Digital Super Power BTE - programmable 16 channels/7
programs. Includes SoundRecover2 - DuoPhone-Roger Ready-
Indicator Light-Tamper Proof Battery Door-Tamper Proof Ear Hook-
UltraZoom Advanced-QuickSync - WhistleBlock - NoiseBlock - Flex
Control - UserPreference - Tinnitus Balance- WindBlock-Sound
Relax- WaterResistant - Datalogging - DuoPhone - FM/DAI -
Cros/BiCros compatibility - T-Coil -Roger My Link - Size 13 Battery.
Moderate/Severe hearing loss
Pediatric Digital RIC - programmable 16 channels/7 programs.
Includes SoundRecover2 - UltraZoom Advanced-QuickSync -
WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -
UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-
Coil - Size 13 Battery. Moderate/Severe hearing loss
Digital BTE, Super Power, AutoSense OS, SNR-Boost, FlexControl,
Flex Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,
Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,
UltraZoom Standard, 12 channels, WCP compatible, size 13 battery,
telecoil, Roger compatible
Digital BTE,AutoSense OS, SNR-Boost, FlexControl, Flex Volume,
DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock, Quick Sync,
SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom
Standard, 12 channels, WCP compatible, size 312 battery, telecoil,
Roger compatible
Digital BTE, Power, AutoSense OS, SNR-Boost, FlexControl, Flex
Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,
Quick Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,
UltraZoom Standard, 12 channels, WCP compatible, size 13 battery,
telecoil, Roger compatible
Digital BTE, AutoSense OS, WhistleBlock, NoiseBlock, Quick Sync,
SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom
Essential, 8 channels, WCP compatible, size 312 battery, Roger
compatible, telecoil
Digital BTE, AutoSense OS, WhistleBlock, NoiseBlock, Quick Sync,
SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom
Essential, 8 channels, WCP compatible, size 13 battery, Roger
compatible, telecoil
Digital BTE, AutoSense OS, WhistleBlock, NoiseBlock, Quick Sync,
SoundRecover, Tinnitus Balance, auto Acclimatization, UltraZoom
Essential, 8 channels, WCP compatible, size 13 battery, Roger
compatible, telecoil
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 10 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Sky V70 - SP 63db Max Gain - 133
Max OutputPhonak 050-0336-01
V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Sky V-70 UP82db Max Gain - 142
Max Output Phonak 050-0340-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Sky V-50 SP75db Max Gain - 140
Max OutputPhonak 050-0335-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Sky V-50 RIC65db Max Gain - 133
Max OutputPhonak 050-0343-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Sky V50 - M63db Max Gain - 133
Max Output Phonak 050-0327-01V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Sky V50 - P
63db Max Gain - 133
Max Output Phonak 050-0331-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Sky V50-UP82db Max Gain - 133
Max Output050-0339-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Naida V-70 SP75db Max Gain - 140
Max Output Phonak 050-0244-01V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12
Pediatric Digital BTE - programmable 16 channels/7 programs.
Includes SoundRecover2 - UltraZoom Advanced-QuickSync -
WhistleBlock - NoiseBlock - Flex Control - Zoom Control -
UserPreference - Tinnitus Balance-Duo Phone- WindBlock-Sound
Relax- WaterResistant - Datalogging - FM/DAI - Cros/BiCros
compatibility - T-Coil -RogerMy Link-Indicator Light-Tamperproof
Battery Door-Tamperproof Mini ear hook-Size 13 Battery.
Moderate/Severe hearing loss
Pediatric Digital Super Power BTE - programmable 16 channels/7
programs. Includes SoundRecover2 - UltraZoom Advanced-
QuickSync - WhistleBlock - NoiseBlock - Flex Control -
UserPreference - Tinnitus Balance- WindBlock-Sound Relax-
WaterResistant - Datalogging - DuoPhone - FM/DAI - Cros/BiCros
compatibility - T-Coil -Roger My Link-Size 675 Battery.
Moderate/Severe hearing loss
Pediatric Digital Super Power BTE - programmable 12 channels/4
programs. Includes SoundRecover2 - UltraZoom -QuickSync -
DuoPhone-Flex Control-WhistleBlock - NoiseBlock - Tinnitus Balance
WaterResistant - Datalogging - EasyPhone - FM/DAI - Cros/BiCros
compatibility - Size 13 Battery. Moderate/Severe hearing loss
Pediatric Digital RIC - programmable 12 channels/4 programs.
Includes SoundRecover2 - UltraZoom Advanced-QuickSync -
WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -
UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility - T-
Coil - Size 13 Battery. Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 12 channels/4 programs.
Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -
NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -
EasyPhone - FM/DAI - Cros/BiCros compatibility - Size 312 Battery.
Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 12 channels/4 programs.
Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -
NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -
EasyPhone - FM/DAI - Cros/BiCros compatibility - Size 13 Battery.
Moderate/Severe hearing loss
Pediatric Digital BTE - programmable 12 channels/4 programs.
Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -
NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -
EasyPhone - FM/DAI - Cros/BiCros compatibility - Size 675 Battery.
Moderate/Severe hearing loss
Digital Super Power BTE - programmable 16 channels/7 programs.
Includes SoundRecover2 - UltraZoom Advanced-QuickSync -
WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -
UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility -
Size 13 Battery. Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 11 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
Naida V-70 UP82db Max Gain - 142
Max OutputPhonak 050-0248-01
V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Naida V-70 RIC65db Max Gain - 133
Max Output Phonak 050-0267-01
V5257 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5261 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Naida V-50 UP82db Max Gain - 142
Max OutputPhonak 050-0247-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Naida V-50 SP75db Max Gain - 140
Max OutputPhonak 050-0243-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Naida V-50 RIC
65db Max Gain - 133
Max Output Phonak 050-0266-01
V5257 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5261 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Naida V-30 UP82db Max Gain - 142
Max OutputPhonak 050-0246-01
V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
Naida V-30 SP75db Max Gain - 140
Max Output Phonak 050-0242-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
Naida V-30 RIC Phonak 050-0265-01V5257 Monaural $629.00 52.464% $299.00 $129.00 12 36
65db Max Gain - 133
Max Output
V5261 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
CROS II 312 - BTE Venture Package 30 level Phonak 050-0228-01.30V5181 $1,378.00 50.798% $678.00 $110.00 12 24
60db Max Gain - 122 Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Digital BTE - programmable 12 channels/4 programs. Includes
SoundRecover - UltraZoom Advanced-QuickSync - WhistleBlock -
NoiseBlock - Flex Volume - Zoom Control - UserPreference - Tinnitus
Balance- WindBlock WaterResistant - Datalogging - EasyPhone -
FM/DAI - Cros/BiCros compatibility - T-Coil - Size 13 Battery.
Moderate/Severe hearing loss
Digital Super Power BTE - programmable 8 channels/3 programs.
Includes SoundRecover2 -everyday automatic -QuickSync -
WhistleBlock - Tinnitus Balance -WaterResistant - Datalogging -
Cros/BiCros compatibility - Size 675 Battery. Moderate/Severe
hearing loss
Digital Super Power BTE - programmable 8 channels/3 programs.
Includes SoundRecover2 -everyday automatic -QuickSync -
WhistleBlock - Tinnitus Balance -WaterResistant - Datalogging -
Cros/BiCros compatibility - Size 13 Battery. Moderate/Severe
hearing loss
Digital BTE - programmable 8 channels/3 programs. Includes
SoundRecover - UltraZoom Advanced-QuickSync - WhistleBlock -
NoiseBlock - Flex Volume - Zoom Control - UserPreference - Tinnitus
Balance- WindBlock WaterResistant - Datalogging - EasyPhone -
FM/DAI - Cros/BiCros compatibility - T-Coil - Size 13 Battery.
Moderate/Severe hearing loss
Digital Super Power BTE - programmable 16 channels/7 programs.
Includes SoundRecover - UltraZoom Advanced-QuickSync -
WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -
UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - EasyPhone - FM/DAI - Cros/BiCros compatibility - T-
Coil - Size 675 Battery. Moderate/Severe hearing loss
Digital BTE - programmable 16 channels/7 programs. Includes
SoundRecover2 - UltraZoom Advanced-QuickSync - WhistleBlock -
NoiseBlock - Flex Volume - Zoom Control - UserPreference - Tinnitus
Balance- WindBlock WaterResistant - Datalogging - EasyPhone -
FM/DAI - Cros/BiCros compatibility - T-Coil - Size13 Battery.
Moderate/Severe hearing loss
Digital Super Power BTE - programmable 12 channels/4 programs.
Includes SoundRecover2 - UltraZoom Advanced-QuickSync -
WhistleBlock - NoiseBlock - Flex Volume - Zoom Control -
UserPreference - Tinnitus Balance- WindBlock WaterResistant -
Datalogging - DuoPhone - FM/DAI - Cros/BiCros compatibility - T-
Coil -Size 675 Battery. Moderate/Severe hearing loss
Digital Super Power BTE - programmable 12 channels/4 programs.
Includes SoundRecover2 - UltraZoom -QuickSync - WhistleBlock -
NoiseBlock - Tinnitus Balance WaterResistant - Datalogging -
DuoPhone - FM/DAI - Cros/BiCros compatibility - Size 13 Battery.
Moderate/Severe hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 12 of 25
Price Schedule
DESCRIPTION & FEATURES (See below) db RANGEMANUFA
CTURER
MODEL NUMBER (19
Characters or less)HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT PERCENT
DISCOUNT OFF LIST
PRICE
EQUIPMENT TOTAL
PRICE
FIXED NON -
WARRANTY REPAIR
PRICE
NON - WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY REPAIR PERIOD
(MONTHS)
CROS II 312 - BTE Venture Package 30 level (BiCROS) Phonak 050-0228-01.30
V5221 $1,378.00 50.798% $678.00 $110.00 12 24
60db Max Gain - 122
CROS II 13 - BTE Venture Package 30 level Phonak 050-0229.01.30V5181 $1,378.00 50.798% $678.00 $110.00 12 24
63db Max Gain - 133
Max Output
CROS II 13 - BTE Venture Package 30 level (BiCROS) Phonak 050-0229.01.30V5221 $1,378.00 50.798% $678.00 $110.00 12 24
63db Max Gain - 133
Max Output
CROS II 312 - BTE Venture Package 50 level Phonak 050-0228-01.50V5181 $1,548.00 50.646% $764.00 $110.00 12 24
60db Max Gain - 122
Max Output
CROS II 312 - BTE Venture Package 50 level (BiCROS) Phonak 050-0228-01.50V5221 $1,548.00 50.646% $764.00 $110.00 12 24
60db Max Gain - 122
Max Output
CROS II 13 - BTE Venture Package 50 level Phonak 050-0229-01.50V5181 $1,548.00 50.646% $764.00 $110.00 12 24
63db Max Gain - 133
Max Output
CROS II 13 - BTE Venture Package 50 level (BiCROS) Phonak 050-0229-01.50V5221 $1,548.00 50.646% $764.00 $110.00 12 24
63db Max Gain - 133
Max Output
CROS II 312 - BTE Venture Package 70 level Phonak 050-0228-01.70V5181 $2,098.00 48.618% $1,078.00 $110.00 12 24
60db Max Gain - 122
CROS II 312 - BTE Venture Package 70 level (BiCROS) Phonak 050-0228-01.70V5221 $2,098.00 48.618% $1,078.00 $110.00 12 24
60db Max Gain - 122
CROS II 13 - BTE Venture Package 70 level Phonak 050-0229-01.70V5181 $2,098.00 48.618% $1,078.00 $110.00 12 24
63db Max Gain - 133
CROS II 13 - BTE Venture Package 70 level (BiCROS) Phonak 050-0229-01.70V5221 $2,098.00 48.618% $1,078.00 $110.00 12 24
63db Max Gain - 133 Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Audéo V and Bolero
V
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 13 of 25
Price Schedule
IN THE EAR TYPES – Prices shall be for a single hearing aid or two hearing aids and case. List model number for the full range of instruments. Include all features. Indicate Class D power or Class B power.
FULL SHELL CONCHA MODEL DESCRIPTION &
FEATURES (See below)db RANGE MANUFACTURER
MODEL
NUMBER (19
Characters or
less)
HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY
REPAIR PERIOD
(MONTHS)
Virto B70-13 Phonak 063-0237-01 V5256 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5260 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Virto B50 - 13 Phonak 063-0238-01 V5256 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5260 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
70db Max Gain -
130 Max Output
Virto B30-13 Phonak 063-0239-01 V5256 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5260 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Virto V70-13 Phonak 063-0147-01 V5256 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5260 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Virto V50-13 Phonak 063-0154-01 V5256 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5260 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Virto V30-13 Phonak 063-0158-01 V5256 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5260 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
CROS II 13 -Venture ITE Package 70 level Phonak 063-0099-01.70 V5171 $2,098.00 48.618% $1,078.00 $110.00 12 24
CROS II 13 -Venture ITE Package 70 level (BiCROS) Phonak 063-0099-01.70 V5211 $2,098.00 48.618% $1,078.00 $110.00 12 24
CROS II 13 -Venture ITE Package 50 level Phonak 063-0099-01.50 V5171 $1,548.00 50.646% $764.00 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Digital Power Full shell 16 Channels/4 programs - Includes
SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind
Block- Speech in 360- Speech in Loud Noise- DuoPhone- Real
Ear Sound- Flex Control- Tinnitus Balance-Noise Block-
QuickSync - WhistleBlock - WaterResistant - Datalogging-
Cros B Compatibility -Size13 Battery. Moderate/Severe hearing
loss
70db Max Gain -
130 Max Output
Digital Full shell- programmable 12 channels/3 Programs.
Includes SoundRecover2-Real Ear Sound- DuoPhone-
QuickSync - WhistleBlock - NoiseBlock - Flex Control- Tinnitus
Balance-Cros B Compatible-Datalogging- Moderate/Severe
hearing loss
Digital Full shell 8 Channels/2 Programs- Includes AutoSense
OS- Tinnitus Balance- Sound Recover2- Noise Block- Quick
Sync- Whistle Block- Cros B Compatible -WaterResistant -
Datalogging - Size 312 Battery. Moderate/Severe hearing loss
70db Max Gain -
130 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
70db Max Gain -
130 Max Output
Digital ITE, Programmable 16 channels/7 programs,AutoSense
OS, WhistleBlock, NoiseBlock, Sound Relax, Duo Phone, Flex
Control, Quick Sync, SoundRecover, Tinnitus Balance, auto
Acclimatization, UltraZoom Essential, 16 channels, WCP
compatible, size 13 battery, Roger compatible, telecoil
70db Max Gain -
130 Max Output
Digital ITE, 12 channels/4 programs,AutoSense OS, SNR-
Boost, FlexControl, Flex Volume, DuoPhone, Real Ear Sound,
WhistleBlock, NoiseBlock, Quick Sync, SoundRecover,
Tinnitus Balance, auto Acclimatization, UltraZoom Standard,
12 channels, WCP compatible, size 13 battery, telecoil, Roger
compatible
70db Max Gain -
130 Max Output
Digital ITE AutoSense OS, WhistleBlock, NoiseBlock, Quick
Sync, SoundRecover, Tinnitus Balance, auto Acclimatization,
UltraZoom Essential, 8 channels, WCP compatible, size 13
battery, Roger compatible, telecoil
70db Max Gain -
130 Max Output
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 14 of 25
Price Schedule
FULL SHELL CONCHA MODEL DESCRIPTION &
FEATURES (See below)db RANGE MANUFACTURER
MODEL
NUMBER (19
Characters or
less)
HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY
REPAIR PERIOD
(MONTHS)
CROS II 13 -Venture ITE Package 50 level (BiCROS) Phonak 063-0099-01.50 V5211 $1,548.00 50.646% $764.00 $110.00 12 24
CROS II 13 -Venture ITE Package 30 level Phonak 063-0099-01.30 V5171 $1,378.00 50.798% $678.00 $110.00 12 24
CROS II 13 -Venture ITE Package 30 level (BiCROS) Phonak 063-0099-01.30 V5211 $1,378.00 50.798% $678.00 $110.00 12 24
CROS B Custom 13- 30 level Belong VirtoPhonak
063-0247-01.30 V5171 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Virto
63 dB Max Gain -
122 Output
CROS B Custom 13- 30 level Belong Virto (BiCROS)
Phonak
063-0247-01.30 V5211 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Virto
63 dB Max Gain -
122 Output
CROS B Custom 13 - 50 level Belong Virto Phonak 063-0247-01.50 V5171 $1,588.00 51.889% $764.00 $110.00 12 24
CROS B Custom 13 - 50 level Belong Virto (BiCROS) Phonak 063-0247-01.50 V5211 $1,588.00 51.889% $764.00 $110.00 12 24
CROS B Custom 13 - 70 level Belong Virto Phonak 063-0247-01.70 V5171 $2,148.00 49.814% $1,078.00 $110.00 12 24
CROS B Custom 13 - 70 level Belong Virto (BiCROS) Phonak 063-0247-01.70 V5211 $2,148.00 49.814% $1,078.00 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Virto
63db Max Gain -
133 Max Output
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Virto
63db Max Gain -
133 Max Output
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Virto
63db Max Gain -
133 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Belong Virto
63db Max Gain -
133 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 15 of 25
Price Schedule
IN THE EAR TYPES – Prices shall be for a single hearing aid, or two hearing aids and case. List model number for the full range of instruments. Include all features. Indicate Class D power or Class B power.
HALF SHELL CONCHA DESCRIPTION & FEATURES
(See below)db RANGE
MANUFACT
URER
MODEL NUMBER
(19 Characters or
less)
HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT OFF
LIST PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY
REPAIR PERIOD
(MONTHS)
Virto B70 312
65dB 122 Max
OutputPhonak 063-0024-01
V5256 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5260 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
Virto B50 312
70db Max Gain -
130 Max OutputPhonak 063-0234-01
V5256 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5260 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
Virto B30 312Phonak 063-0235-01
V5256 Monaural $649.00 53.929% $299.00 $129.00 12 36
70db Max Gain -
130 Max Output V5260 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
Virto V30-312 Phonak 063-0157-01 V5256 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5260 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
Virto V50-312 Phonak 063-0153-01 V5256 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5260 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Virto V70-312 Phonak 063-0146-01 V5256 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5260 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Digital Power Half Shell 16 Channels/4 programs - Includes
SoundRecover2 - Sound Relax-Auto Sense OS- Music- Wind
Block- Speech in 360- Speech in Loud Noise- DuoPhone- Real
Ear Sound- Flex Control- Tinnitus Balance-Noise Block-
QuickSync - WhistleBlock - WaterResistant - Datalogging- Cros
B Compatibility - Size 312 Battery. Moderate/Severe hearing loss
Digital Half shell- programmable 12 channels/3 Programs.
Includes SoundRecover2-Real Ear Sound- DuoPhone-
QuickSync - WhistleBlock - NoiseBlock - Flex Control- Tinnitus
Balance-Cros B Compatible-Datalogging- Moderate/Severe
hearing loss
Digital Half shell 8 Channels/2 Programs- Includes AutoSense
OS- Tinnitus Balance- Sound Recover2- Noise Block- Quick
Sync- Whistle Block- Cros B Compatible -WaterResistant -
Datalogging - Wind/Weather Protection - Size 312 Battery.
Moderate/Severe hearing loss
Digital Half Shell,AutoSense OS, WhistleBlock, NoiseBlock,
Quick Sync, SoundRecover, Tinnitus Balance, auto
Acclimatization, UltraZoom Essential, 8 channels, WCP
compatible, size 312 battery, Roger compatible, telecoil
60db Max Gain -
122 Max Output
Digital Half Shell, AutoSense OS, SNR-Boost, FlexControl, Flex
Volume, DuoPhone, Real Ear Sound, WhistleBlock, NoiseBlock,
Quick Sync, SoundRecover, Tinnitus Balance, auto
Acclimatization, UltraZoom Standard, 12 channels, WCP
compatible, size 312 battery, telecoil, Roger compatible
60db Max Gain -
122 Max Output
Digital Half Shell,AutoSense OS, WhistleBlock, NoiseBlock,
Quick Sync, SoundRecover, Tinnitus Balance, auto
Acclimatization, UltraZoom Essential, 8 channels, WCP
compatible, size 312 battery, Roger compatible, telecoil
60db Max Gain -
122 Max Output
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 16 of 25
Price Schedule
HALF SHELL CONCHA DESCRIPTION & FEATURES
(See below)db RANGE
MANUFACT
URER
MODEL NUMBER
(19 Characters or
less)
HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT OFF
LIST PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR PERIOD
(MONTHS)
WARRANTY
REPAIR PERIOD
(MONTHS)
CROS II 312 -Venture ITE Package 70 level Phonak 063-0098-01.70 V5171 $2,098.00 48.618% $1,078.00 $110.00 12 24
CROS II 312 -Venture ITE Package 70 level (BiCROS) Phonak 063-0098-01.70 V5211 $2,098.00 48.618% $1,078.00 $110.00 12 24
CROS II 312 -Venture ITE Package 50 level Phonak 063-0098-01.50 V5171 $1,548.00 50.646% $764.00 $110.00 12 24
CROS II 312 -Venture ITE Package 50 level (BiCROS) Phonak 063-0098-01.50 V5211 $1,548.00 50.646% $764.00 $110.00 12 24
CROS II 312 -Venture ITE Package 30 level Phonak 063-0098-01.30 V5171 $1,378.00 50.798% $678.00 $110.00 12 24
CROS II 312 -Venture ITE Package 30 level (BiCROS) Phonak 063-0098-01.30 V5211 $1,378.00 50.798% $678.00 $110.00 12 24
CROS B Custom 312- 30 level Virto Belong Phonak 063-0246-01.30 V5171 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Virto Belong
63 dB Max Gain -
122 Output
CROS B Custom 312- 30 level Virto Belong (BiCROS) Phonak 063-0246-01.30 V5211 $1,398.00 51.502% $678.00 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Virto Belong
63 dB Max Gain -
122 Output
CROS B Custom 312 - 50 level Virto Belong Phonak 063-0246-01.50 V5171 $1,588.00 51.889% $764.00 $110.00 12 24
CROS B Custom 312 - 50 level Virto Belong (BiCROS) Phonak 063-0246-01.50 V5211 $1,588.00 51.889% $764.00 $110.00 12 24
CROS B Custom 312 -70 Virto Belong Phonak 063-0246-01.70 V5171 $2,148.00 49.814% $1,078.00 $110.00 12 24
CROS B Custom 312 -70 Virto Belong (BiCROS) Phonak 063-0246-01.70 V5211 $2,148.00 49.814% $1,078.00 $110.00 12 24
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Virto Belong
63db Max Gain -
133 Max Output
Designed for those with Bilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Virto Belong
63db Max Gain -
133 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Virto Belong
63db Max Gain -
133 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to any model of Phonak Virto Belong
63db Max Gain -
133 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Designed for those with Unilateral hearing loss. Transfers the
microphone input signal to Phonak Virto V hearing aids
70db Max Gain -
130 Max Output
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 17 of 25
Price Schedule
IN THE EAR TYPES – Prices shall be for a single hearing aid or two hearing aids and case. List model number for the full range of instruments. Include all features. Indicate Class D power or Class B power.
LOW PROFILE DESCRIPTION &
FEATURES (See below)db RANGE
MANUFACTUR
ER
MODEL
NUMBER (19
Characters or
less)
HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY
REPAIR PERIOD
(MONTHS)
Virto B70 - Low Profile MC Phonak 063-0217-01 V5256 Monaural $1,399.00 50.036% $699.00 $129.00 12 36
V5260 Binaural $2,798.00 50.036% $1,398.00 $258.00 12 36
60db Max Gain -
122 Max Output
Virto B50 - Low Profile MC Phonak 063-0218-01 V5256 Monaural $839.00 54.112% $385.00 $129.00 12 36
V5260 Binaural $1,678.00 54.112% $770.00 $258.00 12 36
60db Max Gain -
122 Max Output
Virto B30-10 Low Profile MC Phonak 063-0219-01 V5256 Monaural $649.00 53.929% $299.00 $129.00 12 36
V5260 Binaural $1,298.00 53.929% $598.00 $258.00 12 36
60db Max Gain -
122 Max Output
Digital ITE - programmable 16
channels/7 programs. Includes
SoundRecover2 -Speech in 360-Sound
Relax-Wind Block-Flex Control-Tinnitus
Balance Noise Generator- UltraZoom
Advanced-WhistleBlock - NoiseBlock -
Quick Sync - Zoom Control -
UserPreference - Tinnitus Balance-
WindBlock WaterResistant - Datalogging-
Size10 Battery. Mild/Moderate hearing
loss
Digital ITE - programmable 12
channels/4 programs. Includes
SoundRecover2 - Sound Relax-Real Ear
Sound-Flex Control-Tinnitus Balance
Generator-Noise Block-Quick Sync-
Whistle Block-UltraZoom Advanced-
WhistleBlock - NoiseBlock - Flex Volume
- Zoom Control - UserPreference -
Tinnitus Balance- WindBlock
WaterResistant - Datalogging- Size10
Battery. Mild/Moderate hearing loss
Digital ITE - programmable 8
channels/4 programs. Includes
SoundRecover2 - Sound Relax-Flex
Control-Tinnitus Balance Generator-
Quick Sync-WhistleBlock -
NoiseBlock- UserPreference -
Tinnitus Balance- WindBlock
WaterResistant - Datalogging-
Size10 Battery. Mild/Moderate
hearing loss
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 18 of 25
Price Schedule
LOW PROFILE DESCRIPTION &
FEATURES (See below)db RANGE
MANUFACTUR
ER
MODEL
NUMBER (19
Characters or
less)
HCPCS CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY
REPAIR PERIOD
(MONTHS)
Virto V70 - Low Profile MC Phonak 063-0145-01V5256 Monaural $1,349.00 48.184% $699.00 $129.00 12 36
V5260 Binaural $2,698.00 48.184% $1,398.00 $258.00 12 36
Virto V50 - Low Profile MC Phonak 063-0152-01 V5256 Monaural $799.00 51.815% $385.00 $129.00 12 36
V5260 Binaural $1,598.00 51.815% $770.00 $258.00 12 36
Virto V30 - Low Profile MC Phonak 063-0177-01 V5256 Monaural $629.00 52.464% $299.00 $129.00 12 36
V5260 Binaural $1,258.00 52.464% $598.00 $258.00 12 36
60db Max Gain -
122 Max Output
60db Max Gain -
122 Max Output
Digital ITE - programmable 8 channels/4
programs. Includes SoundRecover - Flex
Control-Tinnitus Balance Generator-
Noise Block-Quick Sync-WhistleBlock -
NoiseBlock- UserPreference - Tinnitus
Balance- WindBlock WaterResistant -
Datalogging- Size10 Battery.
Mild/Moderate hearing loss
Digital ITE - programmable 16
channels/7 programs. Includes
SoundRecover2 -Speech in 360-Sound
Relax-Wind Block-Flex Control-Tinnitus
Balance Noise Generator- UltraZoom
Advanced-WhistleBlock - NoiseBlock -
Quick Sync - Zoom Control -
UserPreference - Tinnitus Balance-
WindBlock WaterResistant - Datalogging-
Size10 Battery. Mild/Moderate hearing
loss
Digital ITE - programmable 16
channels/7 programs. Includes
SoundRecover -Wind Block-Flex Control-
Tinnitus Balance Noise Generator-
UltraZoom Advanced-WhistleBlock -
NoiseBlock - DuoPhone-Quick Sync -
Zoom Control - UserPreference - Tinnitus
Balance- WindBlock WaterResistant -
Datalogging- Size10 Battery.
Mild/Moderate hearing loss
60db Max Gain -
122 Max Output
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 19 of 25
Price Schedule
Personal Frequency Modulations (FM) Systems – Prices shall be for either a single instrument or complete FM system with antenna type built into the microphone cords, which may be powered by disposable alkaline
batteries or rechargeable batteries.
PFM (FM) Systems DESCRIPTION & FEATURES (See
below)
db
RANGE
MANUFAC
TURER
MODEL NUMBER (19
Characters or less)
HCPCS
CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY REPAIR
PERIOD (MONTHS)
Roger Adult Monaural Phonak FM_ADULT_MON V5281
Kit contains 1 Roger Transmitter/Microphone and 1
Roger Receiver N/A As indicated by components per Cheryl
Roger Pediatric Monaural Phonak FM_PED_MON V5281
Kit contains 1 Roger Pediatric Transmitter/Microphone
and 1 Roger Receiver N/A
Roger Adult Binaural Phonak FM_ADULT_BIN V5282
Kit contains 1 Roger Transmitter/Microphone and 2
Roger Receivers N/A
Roger Pediatric Binaural Phonak FM_PED_BIN V5282
Kit contains 1 Roger Pediatric Transmitter/Microphone
and 2 Roger Receivers N/A
Roger Select IN Phonak 056-3002-P5011 V5288 $1,399.00 35.000% $909.35 $110.00 12 24
Roger Select IN is a wireless microphone that when
placed on the table can automatically selects who is
talking and seamlessly switches from one talker to
another. It can also transmit multimedia and Bluetooth
phone calls. Compatible with Roger Direct N/A
Roger Table Microphone II IN Phonak 056-4002-P5011 V5288 $1,799.00 35.000% $1,169.35 $110.00 12 24
Wireless microphone especially designed for meetings.
Simply place them on the meeting table and speech is
clearly and wirelessly transmitted to your receivers.
Compatible with Roger Direct N/A
Roger Pen IN Phonak 056-3003-P90008 V5288 $1,349.00 35.000% $876.85 $110.00 12 24
N/A `
As indicated by components per Cheryl
As indicated by components per Cheryl
As indicated by components per Cheryl
Roger technology is an adaptive digital wireless
transmission technology. Roger Pen features adaptive
wireless transmission, fully automated settings,
wideband audio Bluetooth for cell phone use, TV
connectivity and an audio input for listening to
multimedia. Compatible with Roger DIrect
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 20 of 25
Price Schedule
PFM (FM) Systems DESCRIPTION & FEATURES (See
below)
db
RANGE
MANUFAC
TURER
MODEL NUMBER (19
Characters or less)
HCPCS
CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY REPAIR
PERIOD (MONTHS)
Roger Select Phonak 052-3477-000XX V5288 $900.00 35.000% $585.00 $110.00 12 12
Roger Select is a wireless microphone that when placed
on the table can automatically selects who is talking and
seamlessly switches from one talker to another. It can
also transmit multimedia and Bluetooth phone calls.
Compatible with Roger 02 and 03 receivers. N/A
Roger Table Microphone II Phonak 052-4125-000P5 V5288 $1,300.00 35.000% $845.00 $110.00 12 12
Wireless microphone especially designed for meetings.
Simply place them on the meeting table and speech is
clearly and wirelessly transmitted to your receivers.
Compatible with Roger 02 and 03 receivers. N/A
TV Connector D Phonak 076-3006-0611 V5286 $199.00 25.000% $149.25 $110.00 12 12
Interface allows you to stream the TV signal directly to
your Audeo M hearing instruments N/A
Roger Easy Pen-Transmitter Phonak 052-3285-000XX V5288 $775.00 35.000% $503.75 $110.00 12 12
N/A
Roger Pen-Transmitter Phonak 052-3191-000XX V5288 $825.00 35.000% $536.25 $110.00 12 12
N/A
Roger Clip-On Mic-TransmitterPhonak
052-3294V5288 $640.00 35.000% $416.00 $110.00 12 12
N/A
Roger technology is an adaptive digital wireless
transmission technology. Roger Easy Pen features
adaptive wireless transmission, fully automated settings,
wideband audio for TV connectivity and an audio input
for listening to multimedia. Kit includes: Power supply
and docking station. Compatible with Roger 02 and 03
receivers
Roger technology is an adaptive digital wireless
transmission technology. Roger Pen features adaptive
wireless transmission, fully automated settings,
wideband audio Bluetooth for cell phone use, TV
connectivity and an audio input for listening to
multimedia. Kit includes: Power supply and docking
station. Compatible with Roger 02 and 03 receivers
Roger technology is an adaptive digital wireless
transmission technology. Roger Clip-On Mic is a
discreet, shirt-worm microphone that uses adaptive
wireless transmission. Features an audio input for
listening to multimedia and TV connectivity. Kit includes:
Power supply and docking station. Compatible with
Roger 02 and 03 receivers
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 21 of 25
Price Schedule
PFM (FM) Systems DESCRIPTION & FEATURES (See
below)
db
RANGE
MANUFAC
TURER
MODEL NUMBER (19
Characters or less)
HCPCS
CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY REPAIR
PERIOD (MONTHS)
Roger Touchscreen MicrophonePhonak
052-3297V5288 $995.00 35.000% $646.75 $110.00 12 12
Simple and intuitive microphone for the teacher to wear
around the neck or place on a table to pick up speech
from a group of students. Compatible with Roger 02
receivers N/A
Roger Pass-Around MicrophonePhonak
052-3261V5288 $550.00 35.000% $357.50 $110.00 12 24
N/A
Roger MyLink (02)-Pediatric-Receiver Phonak 052-0502 V5283 $699.00 35.000% $454.35 $110.00 12 24
N/A
Roger MyLink (02)-Pediatric Receiver (short loop) Phonak 052-0501 V5283 $699.00 35.000% $454.35 $110.00 12 24
N/A
Roger MyLink (03) Adult Receiver (includes charger) Phonak 052-0510 V5283 $600.00 35.000% $390.00 $110.00 12 24
N/A
Roger Technology.Universal Roger receiver that works
with any hearing aid or cochlear implant that features a
telecoil. Headphone output for listeners with normal
hearing. Includes power supply and 30 inch neckloop.
Compatible with Roger inspiro, Roger Pen, Roger
TableMic, Roger Clip-On Mic and Roger SoundField.
Roger Technology.Universal Roger receiver that works
with any hearing aid or cochlear implant that features a
telecoil. Headphone output for listeners with normal
hearing. Includes power supply and 22 inch neckloop.
Compatible with Roger inspiro, Roger Pen, Roger
TableMic, Roger Clip-On Mic and Roger SoundField.
Roger Technology.Universal Roger receiver that works
with any hearing aid or cochlear implant that features a
telecoil. Headphone output for listeners with normal
hearing. Includes power supply and 30 inch neckloop.
Compatible with Roger Pen, Roger TableMic, and Roger
Clip-On Mic.
Student microphone that can be passed from one
student to another, allowing the child with a hearing loss
to hear not only the teacher but also classmate
comments. Compatible with Roger 02 receivers
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 22 of 25
Price Schedule
PFM (FM) Systems DESCRIPTION & FEATURES (See
below)
db
RANGE
MANUFAC
TURER
MODEL NUMBER (19
Characters or less)
HCPCS
CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY REPAIR
PERIOD (MONTHS)
Roger X (02) Pediatric Receiver Phonak 052-3113-D02P5 V5284 $926.00 35.000% $601.90 $110.00 12 24
N/A
Roger X (03) Adult Receiver Phonak 052-3215-D03P5 V5284 $740.00 35.000% $481.00 $110.00 12 24
N/A
Roger 14 (02) Pediatric Integrated Receiver Phonak 052-3222-D02XX V5273 $926.00 35.000% $601.90 $110.00 12 24
N/A
Roger 14 (03) Adult Integrated Receiver Phonak 052-3223-D03XX V5273 $740.00 35.000% $481.00 $110.00 12 24
N/A
Roger 17 (02) Pediatric Integrated Receiver Phonak 052-3235-D02XX V5273 $926.00 35.000% $601.90 $110.00 12 24
N/A
Roger 17 (03) Adult Integrated Receiver Phonak 052-3236-D03XX V5273 $740.00 35.000% $481.00 $110.00 12 24
N/A
Roger Technology. Discreet design integrated Roger
receivers for use with Advanced Bionics Naida CI.
Compatible with Roger Pen, Roger TableMic and Roger
Clip-On Mic
Roger Technology. Discreet design integrated Roger
receivers for use with Advanced Bionics Naida CI.
Compatible with Roger inspiro, Roger Pen, Roger
TableMic, Roger Clip-On Mic and Roger SoundField.
Roger Technology. Discreet design integrated Roger
receivers for use with Cochlear's Nucleus 5 and 6.
Compatible with Roger inspiro, Roger Pen, Roger
TableMic, Roger Clip-On Mic and Roger SoundField.
Roger Technology. Discreet design integrated Roger
receivers for use with Cochlear's Nucleus 5 and 6.
Compatible with Roger Pen, Roger TableMic, and Roger
Clip-On Mic
Roger Technology. Miniature universal Roger receiver-
compatible with most BTE hearing aids (with appropriate
audioshoe), cochlear implant speech processor, and
streaming device through the three pin Europlug
connector. Compatible with Roger Pen, Roger
TableMicand Roger Clip-On Mic
Roger Technology. Miniature universal Roger receiver-
compatible with most BTE hearing aids (with appropriate
audioshoe), cochlear implant speech processor, and
streaming device through the three pin Europlug
connector. Compatible with Roger inspiro, Roger Pen,
Roger TableMic, Roger Clip-On Mic and Roger
SoundField.
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 23 of 25
Price Schedule
PFM (FM) Systems DESCRIPTION & FEATURES (See
below)
db
RANGE
MANUFAC
TURER
MODEL NUMBER (19
Characters or less)
HCPCS
CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY REPAIR
PERIOD (MONTHS)
Roger 18 Adult Phonak 052-3236-D03XX V5284 $740.00 35.000% $481.00 $110.00 12 24
Roger Technology. Discreet design integrated Roger
receivers. Compatible with Roger Pen, Roger TableMic
and Roger Clip-On Mic. Compatible with Audeo V-13,
Bolero V-P/SP, Naida V-RIC/SP, Sky V-RIC/P/SP N/A
Roger 18-Pediatric Phonak 052-3281-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24
Roger Technology. Discreet design integrated Roger
receivers. Compatible with Roger inspiro, Roger
SoundField, Roger Pen, Roger TableMic and Roger Clip-
On Mic. Compatible with Audeo V-13, Bolero V-P/SP,
Naida V-RIC/SP, Sky V-RIC/P/SP N/A
Roger 19-Adult Integrated ReceiverPhonak
052-3292-D03XXV5284 $740.00 35.000% $481.00 $110.00 12 24
Roger Technology. Discreet design integrated Roger
receivers. Compatible with Roger Pen, Roger TableMic
and Roger Clip-On Mic. Compatible with Naida V-UP and
Sky V-UP N/A
Roger 19-Pediatric Integrated Receiver Phonak 052-3291-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24
Roger Technology. Discreet design integrated Roger
receivers. Compatible with Roger inspiro, Roger
SoundField, Roger Pen, Roger TableMic and Roger Clip-
On Mic. Compatible with Naida V-UP and Sky V-UP N/A
Roger 20-Pediatric Integrated Receiver Phonak 052-3317-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24
Roger Technology. Discreet design integrated Roger
receivers. Compatible with Roger inspiro, Roger
SoundField, Roger Pen, Roger TableMic and Roger Clip-
On Mic. Compatible with Cochlear Nucleus 7 N/A
Roger 21-Pediatric Integrated Receiver Phonak 052-3469-D02XX V5284 $926.00 35.000% $601.90 $110.00 12 24
Roger Technology. Discreet design integrated Roger
receivers. Compatible with Roger inspiro, Roger
SoundField, Roger Pen, Roger TableMic and Roger Clip-
On Mic. Compatible with MED-EL Sonnet N/A
Roger Focus (02) Receiver Phonak 052-3272-D02XX V5284 $750.00 35.000% $487.50 $110.00 12 24
N/A
Roger Technology. Stand-Alone Roger receiver
designed for those with normal hearing/APD. Compatible
with Roger inspiro, Roger Pen, Roger Clip-On Mic and
Roger SoundField.
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 24 of 25
Price Schedule
PFM (FM) Systems DESCRIPTION & FEATURES (See
below)
db
RANGE
MANUFAC
TURER
MODEL NUMBER (19
Characters or less)
HCPCS
CODE(S)
EQUIPMENT
PUBLISHED
LIST PRICE
EQUIPMENT
PERCENT
DISCOUNT
OFF LIST
PRICE
EQUIPMENT
TOTAL PRICE
FIXED NON -
WARRANTY
REPAIR PRICE
NON -
WARRANTY
REPAIR
PERIOD
(MONTHS)
WARRANTY REPAIR
PERIOD (MONTHS)
Phonak RemoteControl Phonak 076-0065-P5 V5286 $210.00 25.000% $157.50 $110.00 12 12
N/A
Partner Mic Phonak 076-4001-P511 V5286 $399.00 25.000% $299.25 $110.00 12 12
N/A
DECT II cordless Home Phone Phonak 076-0050-P511 V5286 $229.00 25.000% $171.75 $110.00 12 12
N/A
PilotOne II Phonak 076-0019-P5 V5286 $209.00 25.000% $129.35 $110.00 12 12
N/A
RemoteMic II Phonak 076-0039-P509 V5286 $105.00 25.000% $78.75 $110.00 12 12
N/A
ComPilot II (includes power supply)Phonak
076-0023-P520V5286 $259.00 40.060% $194.25 $110.00 12 12
N/A
ComPilot AIR II (includes power supply) Phonak 076-0028-P520 V5286 $299.00 25.000% $224.25 $110.00 12 12
N/A
TV Link II Phonak 076-0040-P520 V5286 $199.00 25.000% $149.25 $110.00 12 12
N/A
Connects Venture hearing aids wirelessly to cell phones
and Bluetooth-enabled music sources
Connects Venture hearing aids wirelessly to cell phones
and Bluetooth-enabled music sources without a neckloop
The interface to TV and other audio sources supporting
digital audio signals
Cordless home phone transmits calls directly and
binaurally to all wireless Phonak hearing instruments -
Venture Compatible
Remote compatibility-Marvel hearing aids
Remote microphone-Marvel hearing aids
Remote compatibility-Venture hearing aids
Wireless microphone for one-on-one conversations over
distance.
Exhibit A - Sonova Phonak - Contract No. 129975 Amendment No. 4 25 of 25