HEARING AID DIGITAL ADVANCED - HALF SHELL - LEFT

GENERAL NOTES IF THE BENEFIT GRID SPECIFIES A SPECIALIST, ONLY THAT SPECIALIST IS ACCEPTED. SHOULD "MD" BE INDICATED, THE SERVICE MAY BE PRESCRIBED/RECOMMENDED BY A GENERAL PRACTITIONER OR ANY MEDICAL SPECIALIST. COMMAS APPEARING IN THE "PRESCRIBER REQUIRED" AND "RECOMMENDER REQUIRED" COLUMNS INDICATE OR, EG. "MD", "RN" MEANS "MD" OR "RN". PROVIDER MUST SUPPLY A COPY OF THE MANUFACTURER'S INVOICE. THE DOLLAR LIMIT AND/OR FEE ON THE BENEFIT GRID INCLUDES THE MARK-UP PRE-AUTHORIZATION NOT REQUIRED FOR REPLACEMENT ISSUE UNLESS OTHERWISE INDICATED. SPECIAL NOTES NOTE 28 - MANUFACTURER INVOICE PRICE MUST BE THE LESSER OF: 1) AT LEAST 20% BELOW INDIVIDUAL MANUFACTURER LIST PRICE IF PRICED AT $599.99 OR BELOW OR 2) AT LEAST 25% BELOW INDIVIDUAL MANUFACTURER LIST PRICE IF PRICED AT $600.00 OR ABOVE OR NOTE 32 : ALL HEARING AID REQUESTS (MONAURAL AND BINAURAL) FOR INTERMEDIATE AND ADVANCED LEVEL HEARING AIDS WILL INCLUDE THE CLIENT'S CHOICE OF 3 ACCESSORIES (INCLUDING WIRELESS ACCESSORIES) INCLUDED IN THE BENEFIT GRID PRICE OF THE HEARING AID.