Background: Direct-to-consumer (DTC) hearing devices, including over-the-counter (OTC) hearing aids and personal sound amplification products (PSAPs), are expanding access to hearing care. However, uncertainty remains regarding their ability to provide appropriate amplification relative to prescriptive targets. This study compared real-ear insertion gain (REIG), with a focus on the effects of device category and tuning on prescriptive target matching. Methods: A cross-sectional secondary analysis of REIG data from HearAdvisor (hearadvisor.com) was conducted on 93 consumer and prescription hearing devices (186 conditions: initial and tuned fit). Devices were categorized as PSAP (n=9), OTC preset (OTC-PS; n=24), OTC self-fitting (OTC-SF; n=35), and prescription (Rx) hearing aids (n=25). REIG was evaluated relative to NAL-NL2 prescriptive targets across key speech frequencies (500-4000 Hz) at three input levels: 55, 65, and 75 dB SPL. Root mean square error (RMSE) was calculated at all three input levels; the 65 dB SPL condition (representing average conversational speech) was the primary metric. Group differences were assessed using Kruskal–Wallis with Bonferroni-corrected pairwise Mann-Whitney U post-hoc comparisons. Results: Significant group differences were observed at the initial fit (65 dB SPL) across all frequencies (all p≤0.019), with a clear performance gradient: PSAP (RMSE: 13.8 dB) > OTC-PS (9.2 dB) > OTC-SF (6.5 dB) > Rx (5.3 dB). At 2000 Hz, PSAPs differed significantly from OTC-SF (p_adj=0.031) and Rx 1 IHCON 2026 devices (p_adj=0.012), with more pronounced differences at higher frequencies (3150–4000 Hz; p_adj≤0.031). Initial fit adequacy was low, with few devices achieving ±5 dB across all frequencies (PSAP: 0%, OTC-PS: 17%, OTC-SF: 14%, Rx: 12%). Following tuning, group differences were no longer significant at low frequencies (p>0.05) but persisted at high frequencies (2000–4000 Hz; p≤0.0079). Performance improved, reflected by reduced RMSE: PSAP (12.3 dB) > OTC-PS (9.1 dB) > OTC-SF (4.9 dB) > Rx (0.7 dB). At 2000 Hz, OTC-SF differed from PSAP (p_adj=0.046). At higher frequencies, Rx devices consistently outperformed all other categories (p_adj≤0.002), with additional differences between OTC-PS, OTC-SF, and PSAP (p_adj≤0.004). Fit adequacy improved to 11% (PSAP), 25% (OTC-PS), 51% (OTC-SF), and 100% (Rx). Conclusions: Device category strongly predicts fitting accuracy, with a clear performance hierarchy: Rx > OTC-SF > OTC-PS > PSAP. However, tunability, particularly in Rx devices, is the primary driver of achieving prescriptive targets. These findings highlight that while DTC devices increase access, performance is strongly influenced by both device category and fitting capability. Whether proximity to prescriptive targets translates to improved self-reported benefit remains to be established.