This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Frame Depth. Range. Short. Medium.

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1 This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Phone (800) Fax (715) Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: Focus CR E1161 $ lb weight capacity. Tilt range: -5º anterior to 50º posterior. Frame Width Frame Width Range / Frame Width Select Frame Width in desired Frame Width Range Frame Width Frame Width Range Small Medium Large Seating Setup Make one selection from either Option 1 at right or Option 2 below based on desired seating setup OPTION 2: Setup By Frame Depth Select Frame Depth in desired Frame Depth Range Frame Depth Frame Depth Range Short Medium Long q 14 q 15 q 16 q 17 q 18 N/C N/C N/C N/C N/C q 16 q 17 q 18 q 19 q 20 N/C N/C N/C N/C $470 E2201 q 18 q 19 q 20 q 21 q 22 N/C N/C $470 $470 $470 E2201 E2201 E2201 q 14 q 15 q 16 q 17 q 18 N/C N/C N/C N/C N/C q 16 q 17 q 18 q 19 q 20 N/C N/C N/C N/C $605 E2203 q 18 q 19 q 20 q 21 q 22 N/C N/C $605 $605 $1025 E2203 E2203 E2204 Ship To: Address: City: State: Zip: Phone: /Fax: Effective 08/13/2018 OPTION 1: Setup By Ki Mobility Select Seat Depth corresponding to desired Frame Depth Range row and Backrest Offset column. Note: All Seat Depths in a column and in the same frame depth range are achievable future adjustment. Frame Depth Range Short Medium Long Backrest Offset A -2-1 Flush Seat Depth q 16 q 15 q 14 q 17 q 16 q 15 q 14 q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14 q 20 1 q 19 q 18 q 17 q 16 q 15 q 14 q 18 q 17 q 16 q 15 q 14 q 19 q 18 q 17 q 16 q 15 q 14 q 20 1 q 19 q 18 q 17 q 16 q 15 q 14 q 21 1 q 20 1 q 19 q 18 q 17 q 16 q 15 q 22 2 q 21 1 q 20 1 q 19 q 18 q 17 q 16 q 20 1 q 19 q 18 q 17 q 16 q 15 q 14 q 21 1 q 20 1 q 19 q 18 q 17 q 16 q 15 q 22 2 q 21 1 q 20 1 q 19 q 18 q 17 q 16 q 22 2 q 21 1 q 20 1 q 19 q 18 q 17 q 22 2 q 21 1 q 20 1 q 19 q 18 1 Price is $605 E Price is $1025 E2204 A Back Canes 2 Rearward Flush 2 Forward 4 Forward Front of Chair HCPCS codes provided are based on code verification by the PDAC or our interpretation of the code definitions. Proper use of HCPCS codes does not ensure coverage or payment. For coverage information, verify the appropriate payer s coverage policy. DCN Pricing and specifications subject to change out notice Page 1 of 11

2 Frame Options Heavy Duty Option q 400 lb Weight Capacity $425 Available only Long Frame Depth Range and 8 x 2 or 6 x 2 Casters Transit Option q Transit System K0108 $320 Tilt Mechanism Hand q Hand Tilt - Right N/C q Hand Tilt - Left N/C q Hand Tilt - Dual N/C Foot q Foot Tilt - Right N/C q Foot Tilt - Left N/C Backrest Offset Hanger Option q Offset Hanger $30 Tilt Stop included. No anterior tilt. Vent and Battery Tray Not available on 14 or 15 Frame Widths, Foot Tilt Mechanism, Attendant Foot Lock or 5 casters. Requires minimum 16 Seat Height. q Vent Tray E1029 $250 Requires Anti-Tip q Battery Box Holder E1029 $250 Available only Dual Hand Tilt q Vent Tray and Battery Box Holder E1029 New! $500 Requires Anti-Tip. Available only Dual Hand Tilt. Power Tilt Not available Vent Tray, Battery Box Holder or Heavy Duty Option. Includes anterior and posterior tilt stops. q Power Tilt - Right $1995 q Power Tilt - Left $1995 Power Tilt Options Power Tilt selection required. Sent as accessory, replaces Toggle Switch. q Pendant Control New! N/C q Interface for Adaptive Switching $275 Back Post / Height Range / Back Height Select Back Height in row corresponding to desired Back Post and Height Range Back Post Price Height Back Height Range Stroller Handle Short q 20 Back Post N/C (Folding) Tall q 24 Fixed Height Short q 22 Adjustable Handle 2 N/C (Folding) Tall q 26 Adjustable Height Adjustable Handle $25 (Folding) Reclining Back Short q 22 Adjustable Handle 1, 2 $885 (Non-folding) Tall q 26 1 Not available O2 Holder 2 Not available Seating Dynamics Rocker Back Stroller Handle Back Post Option Available only Stroller Handle Back Post q Removable Stroller Handle Extension $75 Other Backrest Options q Non Folding Back N/C Standard Reclining Back and Seating Dynamics Rocker Back q Seating Dynamics Rocker Back K0108 $1995 Not available Angle Adjustable Locking Extendable Flip Up Armrests, Heavy Duty Option or Reclining Backrest. Available only Non Folding Back. q Adjustable Height Rigidizer Bar $75 Short 1, 2 q 18 q 19 q 20 q 21 q 22 q 23 q 24 q 25 Tall q 20 2 q 21 2 q 22 2 q 23 q 24 q 25 q 26 q 27 Reclining Backrest Options Select options below if Reclining Back is selected on chart above Recline Angle: q 0º - 65º E1225 q 10º - 75º E1225 q 20º - 85º E1226 Gas Spring: q Standard Spring q Heavy Duty Spring DCN Pricing and specifications subject to change out notice Page 2 of 11

3 Footrest Hanger / Front Frame Bend q 60º N/C Available only Extension Tube Hangers q 70º N/C q 80º N/C Not available 7 or 8 Casters q 90º N/C Available only Front Mount Hangers. Not available 7 or 8 Casters. q Pro Elevating Leg Rests (PRO ELR) E0990 $295 q Omit Hangers - $20 Footplate q Composite N/C Not available Front Mount Hangers or PRO ELR q Composite Angle Adjustable K0040 $185 Not available Front Mount Hangers or 14 Seat Width out Offset Hangers q Aluminum Angle Adjustable K0040 $190 q One Piece Flip Up Angle Adjustable K0040 $190 Not available Front Mount Hangers, PRO ELR or 21 or 22 Seat Widths in combination Offset Hangers Footrest / Extension / Seat to Footrest Length Select Seat to Footrest Length in row corresponding to desired Footrest and Extension. Footrest Length of at least 2.5 shorter than Front Seat Height recommended. Extension Tube Hanger measurements based on 70º Hanger Bend. Footrest Extension Seat to Footrest Length Extension Short q 10 q 10.5 q 11 q 11.5 q 12 q 12.5 q 13 q 13.5 Tube Medium Hangers q 11.5 q 12 q 12.5 q 13 q 13.5 q 14 q 14.5 q 15 q 15.5 (60º, 70º, 80º) Long q 14 q 14.5 q 15 q 15.5 q 16 q 16.5 q 17 q 17.5 q 18 Front Mount Hangers 1 PRO ELR Low Pivot Short (70º, 80º, 90º) Medium (70º, 80º, 90º) Long (70º, 80º) Standard Selections Requires 3 Extension q 5 q 5.5 q 6 q 6.5 q 8.5 q 9 q 9.5 q 7 q 7.5 q 8 q 10 q 10.5 q 11 q 5 q 5.5 q 6 q 6.5 q 7 q 7.5 q 10.5 q 11 q 11.5 q 8 q 8.5 q 9 q 9.5 q 10 q 12 q 12.5 q 13 q 5 q 5.5 q 6 q 6.5 q 7 q 7.5 q 8 q 8.5 q 12.5 q 13 q 13.5 q 9 q 9.5 q 10 q 10.5 q 11 q 11.5 q 12 q 14 q 14.5 q 15 Short q Long q PRO ELR Short q High Pivot Long q Available only Aluminum Angle Adjustable Footplates. See Minimum Front Seat Height chart below. Minimum Front Seat Height Front Mount Hangers Hanger Length Short Medium Long Hanger Bend 70º 80/90º 70º 80/90º 70º 80º Minimum Front Seat Height Standard Selection Minimum Front Seat Height 3 Extension Heel Loop Not available One Piece Flip Up Angle Adjustable Footplate q Heel Loops E0951 $30 q Adjustable Heel Loops E0951 $50 q Omit Heel Loops N/C Calf Strap q Velcro Adjustable K0038 $35 q Padded Velcro Adjustable K0038 $68 q Bodypoint Padded AeroMesh K0038 $102 3 Extension Available only Front Mount Hangers. Provided as parts. q 3 Extension for Front Mount Hanger N/C Residual Limb Support Residual Limb Support E1020 q Left $395 q Right $395 q Omit Left Hanger - $10 q Omit Right Hanger - $10 Cover q Smooth q Air Mesh q Smooth q Air Mesh Pad Size q 5 x 8 q 9 x 14 q 5 x 8 q 9 x 14 q 7 x 10 q 11 x 10 q 7 x 10 q 11 x 10 q 9 x 10 q 11 x 14 q 9 x 10 q 11 x 14 DCN Pricing and specifications subject to change out notice Page 3 of 11

4 Footrest continued Hanger Release If no selection is made Classic Hanger Release will be used q Classic Std q 4-Way - In line N/C See reference A to the right. Not available PRO ELR. q 4-Way - Out N/C See reference B to the right Seat Height, Casters and Rear Wheels A B Seat Height / Caster Size / Rear Wheel Size Select Seat Height corresponding to desired Rear Wheel and Caster Size. SoftWheel available only in 24 and 25 rear wheels. Rear Caster Size Rear Caster Size Wheel x x 2 Wheel x x 2 Size Seat Height Size Seat Height 12 3 Pneumatic or Pneumatic Airless Insert Tire 12 3 Full Poly Tire 16 4 Pneumatic, Pneumatic Airless Insert or Full Poly Tire 16 4 Low Poly Tire q 13.5 q 14 q 14.5 q 14.5 q 14.5 q 17 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 19 q 19 q 19 q 19 q 19 q 19 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 16.5 q 16.5 q 16.5 q 17 q 17 q 17 q 17 q 17 q 17 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 19 q 19 q 19 q 19 q 13 q 13.5 q 14 q 14 q 14 q 14.5 q 14.5 q 14.5 q 15 q 15 q 15 q 15 q 15.5 q 15.5 q 15.5 q 15.5 q 16 q 16 q 16 q 16 q 16 q 16 q q 16.5 q q q q 19 q 19 q 19 q 19 2 q 19 q 19 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 20 q 20 q 20 q 20 q 20 q 20 q 20.5 q 20.5 q 20.5 q 20.5 q 20.5 q 20.5 q 13 q 13.5 q 14 q 14 q 14 q 14.5 q 14.5 q 14.5 q 15 q 15 q 15 q 15 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 19 q 19 q 19 q 19 q 19 q 19 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 20 q 20 q 20 q 20 q 20 q 20 q 20.5 q 20.5 q Drum Brake q 13.5 q 14 q 14 q 14 q 14.5 q 14.5 q 14.5 q 15 q 15 q 15 q 15 q 15.5 q 15.5 q 15.5 q 15.5 q 16 q 16 q 16 q 16 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 19 q 19 q 19 q 19 q 19 q 19 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 20 q 20 q 20 q 20 q 20 q 20 q 20.5 q 20.5 q 20.5 q 20.5 q 20.5 q 20.5 q 15 q 15 q 15 q 15 q 15.5 q 15.5 q 15.5 q 15.5 q 16 q 16 q 16 q 16 q 16 q 16 q 16.5 q 16.5 q 16.5 q 16.5 q 16.5 q 16.5 q 17 q 17 q 17 q 17 q 17 q 17 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q q q q q 16 q 16 q 16 q 16 q 16 q 16.5 q 16.5 q 16.5 q 16.5 q 16.5 q 16.5 q 17 q 17 q 17 q 17 q 17 q 17 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 19 q 19 q 19 q 19 q 19 q 19 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 16.5 q q q 17 q 17 q 17 q 17 q 17 q 17 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 17.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 18.5 q 19 q 19 q 19 q 19 q 19 q 19 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 19.5 q 20 q 20 q 20 q 20 q 20 q Available only Full Poly tire 2 Not available Full Poly tire 3 Not available Vent and Battery Tray combination 4 Seat heights higher than rear wheel are not available Vent and Battery Tray combination DCN Pricing and specifications subject to change out notice Page 4 of 11

5 Seat Height, Casters and Rear Wheels continued Caster Type q 1 Poly N/C q 1 Poly Aluminum $110 Not available 6, 7 or 8 Caster Sizes q 1 Pneumatic $110 Not available 5 and 7 Caster Sizes q 1.5 Poly $50 Not available 7 and 8 Caster Sizes q 1.5 Soft Roll Aluminum $175 Not available 7 and 8 Caster Sizes q 2 Poly $50 Not available 5, 7 or 8 Caster Sizes q 2 Pneumatic w/ Foam Insert $225 Not available 5, 6 or 7 Caster Sizes One Arm Drive q One Arm Drive E0958 $1295 Available only 24 Mag wheels. Not available Vent Tray, Battery Box Holder or Self Propel Axle Plate. Standard Handrim will be Aluminum Anodized. Axle not quick release. Drive Handrim Side: q Left q Right Drive Handrim Type: q Aluminum N/C q Poly Coated $200 Axle No selection needed One Arm Drive or Drum Brake. Same axles will be used if SoftWheels are ordered as an additional set of wheels. q Fixed N/C Not available SoftWheel q Quick Release N/C Self Propel Axle Plate q Self Propel Axle Plate $95 Not available Vent Tray or 12 or 16 rear wheels Rear Wheel Type q Mag N/C q 24 Spoke $200 q Omit N/C Add SoftWheel Available only in 24 rear wheel. Not available Heavy Duty Option. Same wheel size will be used if SoftWheels are ordered as an additional set of wheels. Selection required in Seat Height / Caster Size / Rear Wheel Size chart on page 4. q Aluminum SoftWheel $2750 q Stage 1 (85 lbs - 99 lbs) q Stage 2 (100 lbs lbs) q Stage 3 (131 lbs lbs) q Stage 4 (159 lbs lbs) q Stage 5 (186 lbs lbs) q Stage 6 (219 lbs lbs) q Magnesium SoftWheel $3000 q Stage 1 (85 lbs - 99 lbs) q Stage 2 (100 lbs lbs) q Stage 3 (131 lbs lbs) q Stage 4 (159 lbs lbs) q Stage 5 (186 lbs lbs) q Stage 6 (219 lbs lbs) SoftWheel Handrim Select handrim below for SoftWheel Standard Handrims q Aluminum Anodized N/C q Plastic Coated N/C Natural Fit Handrims Available only in 24 rear wheel. Not available thumb grip. q Natural Fit Standard $345 q Natural Fit LT $345 Rear Tire Type Same tire will be used if SoftWheels are ordered as an additional set of wheels q Full Poly E2218 N/C q Low Poly E2218 N/C Available only 16 rear wheel q Pneumatic E2211, E2212 N/C q Pneumatic Airless Insert E2211, E2213 $85 Handrim Handrims not available on 12 or 16 rear wheels. No selection needed One Arm Drive or SoftWheel. Standard Handrims q Aluminum Anodized Std q Plastic Coated $95 q Projection (8 Vertical Projections) $295 Available on 24 rear wheel q Rib Grips $850 Available only on 24 Spoke wheels. Option has an extended lead time. Color: q Black q Blue q Orange q Pink q Red q Omit Handrims N/C Handrim Option Natural Fit Handrims Not available on 20 rear wheel or 22 Mag wheels. Not recommended Mag wheels. q Natural Fit LT Regular Grip $445 q Natural Fit Standard Regular Grip $445 q Natural Fit LT Super Grip $495 q Natural Fit Standard Super Grip $495 q Natural Fit LT Omit Grip $345 q Natural Fit Standard Omit Grip $345 Not available on Plastic Coated or Projection Handrims q 3M Micro Grip $65 Available only on Aluminum Anodized handrims DCN Pricing and specifications subject to change out notice Page 5 of 11

6 Wheel Locks Wheel Lock q Push to Lock N/C q Pull to Lock N/C Not available 12 or 16 Full Poly tires q Attendant Foot Lock $75 q Drum Brake E2228 $1200 Not available Hand Tilt Mechanism, Reclining Backrest or 16 Low Poly tire. Axle is Quick Release. q Omit Wheel Locks N/C Armrests Armrest Please select Arm Pad option q Height Adjustable T-Arm (8-13 ) E0973 $265 Not available Heavy Duty option q Height Adjustable T-Arm Low ( ) E0973 $265 Not available Heavy Duty option q Height Adj. Dual Post Flip Back ( ) E0973 $275 q Angle Adjustable Locking Extendable Flip Up E0973 $265 Not available Seating Dynamics Rocker Back or Heavy Duty option. Minimum armrest height Reclining Backrest is 12. q Omit Armrests N/C Accessories Removable Side Guard q Composite Side Guards K0108 $140 Not available T-Arm or Dual Post Flip Back Armrests Anti-Tip q Rear Anti-Tips E0971 $140 Required Reclining Backrest or Vent Tray Positioning Belt q 1 1/2 Auto Buckle E0978 $70 q 1 1/2 Padded Auto Buckle E0978 $155 q 2 Airline Buckle E0978 $110 Bodypoint Evoflex - Pelvic Stabilizer E0978 $183 Size: q Small (16-24 ) q Medium (19-29 ) q Large (25-37 ) Belt Mounting Kit q Ki Mobility Belt Mounting Brackets $50 q Bodypoint 1 Band Clamp Belt Mounting Kit $105 Frame Color Wheel Lock continued q Combination Attendant Foot Lock $145 Available only 12 or 16 rear wheels. Includes Extension Handles. Push to Lock only. Dual - Drum Brake $1270 Not available Hand Tilt Mechanism, Reclining Backrest or 16 Low Poly tire. Axle is Quick Release. q Push to Lock q Pull to Lock Wheel Lock Options q Extension Handles E0961 $70 Available only Push to Lock or Pull to Lock Wheel Locks. Arm Pad Standard Arm Pad N/C q Desk q Full Waterfall Arm Pad $25 q Desk q Full Not available Angle Adjustable Locking Extendable Flip Up Armrests Foam Grip N/C q Desk q Full Available only Angle Adjustable Locking Extendable Flip Up Armrest Seat Pan q Growing Adjustable Aluminum Seat Pan E2231 $200 O 2 Holder q O 2 Holder E2208 $170 Not available Reclining Backrest or Rocker Back Other Accessories q Tool Kit $55 q Removable Underseat Pouch $50 q Ki Mobility Backpack $65 q Black Neoprene Impact Guards $85 q Clear Spoke Guards K0065 $115 Available only Spoke wheels q Black Spoke Guards K0065 $115 Available only Spoke wheels q Tilt Stop (Pair) K0108 $30 Included Offset Hangers q IV Pole $265 Gloss Finish q Black N/C q Blue Skies N/C q Bubblegum Pink N/C q Candy Blue N/C q Candy Purple N/C q Candy Red N/C q Copper N/C q Fuchsia N/C q Granny Smith N/C q Metallic Orange N/C q Yellow N/C Matte Finish q Army Green N/C q Charcoal Gray N/C q Emerald Green N/C q Iridescent Burgundy N/C q Iridescent Navy N/C q Retro Red N/C q Royal Blue N/C q Shadow Black N/C q Smooth White N/C DCN Pricing and specifications subject to change out notice Page 6 of 11

7 Axiom G, S and P Cushions Select size in chart at right. Weight capacity: 350 lbs. Cushions Under 22 Wide q Axiom G E2601 $120 q Axiom S E2603 $199 q Axiom P E2605 $ Wide Cushions q Axiom G E2602 $199 q Axiom S E2604 $299 q Axiom P E2606 $440 Axiom G, S or P Cushion Quantity: q 1 q 2 If no selection is made, quantity 1 will be selected Axiom SP Cushions Select size in chart at right. Weight capacity: 350 lbs. Cushions Under 22 Wide q Axiom SP - Visco E2607 $410 q Axiom SP - Fluid E2607 $ Wide Cushions q Axiom SP - Visco E2608 $499 q Axiom SP - Fluid E2608 $549 Axiom SP Cushion Quantity: q 1 q 2 If no selection is made, quantity 1 will be selected Axiom Accessories Outer Covers q Axiom G Extra Outer Cover $70 q Axiom S Extra Outer Cover $80 q Axiom P Extra Outer Cover $90 q Axiom SP Extra Visco Outer Cover $100 q Axiom SP Extra Fluid Outer Cover $100 Outer Cover Quantity: q 1 q 2 If no selection is made, quantity 1 will be selected Inner Covers q Axiom SP Extra Visco Inner Cover $100 q Axiom SP Extra Fluid Inner Cover $100 Inner Cover Quantity: q 1 q 2 If no selection is made, quantity 1 will be selected Depth Depth Width q 15 q q q 16 q q q q q q q 17 q q q q q q 18 q q q q q q q 19 q q q 20 q q q q q Width q q q 15 q q q q q 16 q q q q q q q q 17 q q q q q q q q 18 q q q q q q q q q 19 q q q q q q q q 20 q q q q q q q q Solid Seat Insert Select size in chart below. Weight capacity: 350 lbs. Solid Seat Insert $55 Depth Width q 15 q q q 16 q q q q q q q 17 q q q q q q 18 q q q q q q q 19 q q q 20 q q q q q Solid Seat Insert Quantity: q 1 q 2 If no selection is made, quantity 1 will be selected DCN Pricing and specifications subject to change out notice Page 7 of 11

8 Elite Back HCPCS Code: E2620 Weight Capacity: 300 lbs. STEP 1: Choose Back Size Quick Ship Quick Ship products are stocked q Matrx Elite Back 14 x 14 - PBE1414 $625 q Matrx Elite Back 14 x 16 - PBE1416 $625 q Matrx Elite Back 14 x 18 - PBE1418 $625 q Matrx Elite Back 15 x 14 - PBE1514 $625 q Matrx Elite Back 15 x 16 - PBE1516 $625 q Matrx Elite Back 15 x 18 - PBE1518 $625 q Matrx Elite Back 16 x 12 - PBE1612 $625 q Matrx Elite Back 16 x 14 - PBE1614 $625 q Matrx Elite Back 16 x 16 - PBE1616 $625 q Matrx Elite Back 16 x 18 - PBE1618 $625 q Matrx Elite Back 16 x 20 - PBE1620 $625 q Matrx Elite Back 17 x 16 - PBE1716 $625 q Matrx Elite Back 17 x 18 - PBE1718 $625 q Matrx Elite Back 17 x 20 - PBE1720 $625 q Matrx Elite Back 18 x 14 - PBE1814 $625 q Matrx Elite Back 18 x 16 - PBE1816 $625 q Matrx Elite Back 18 x 18 - PBE1818 $625 q Matrx Elite Back 18 x 20 - PBE1820 $625 q Matrx Elite Back 19 x 16 - PBE1916 $625 q Matrx Elite Back 19 x 18 - PBE1918 $625 q Matrx Elite Back 20 x 16 - PBE2016 $625 q Matrx Elite Back 20 x 18 - PBE2018 $625 q Matrx Elite Back 20 x 20 - PBE2020 $625 q Matrx Elite Back 12 x 10 - PBE1210 $625 q Matrx Elite Back 12 x 12 - PBE1212 $625 q Matrx Elite Back 12 x 14 - PBE1214 $625 q Matrx Elite Back 12 x 16 - PBE1216 $625 q Matrx Elite Back 12 x 18 - PBE1218 $625 q Matrx Elite Back 13 x 10 - PBE1310 $625 q Matrx Elite Back 13 x 12 - PBE1312 $625 q Matrx Elite Back 13 x 14 - PBE1314 $625 q Matrx Elite Back 13 x 16 - PBE1316 $625 q Matrx Elite Back 13 x 18 - PBE1318 $625 q Matrx Elite Back 14 x 10 - PBE1410 $625 q Matrx Elite Back 14 x 12 - PBE1412 $625 q Matrx Elite Back 14 x 20 - PBE1420 $625 q Matrx Elite Back 15 x 10 - PBE1510 $625 q Matrx Elite Back 15 x 12 - PBE1512 $625 q Matrx Elite Back 15 x 20 - PBE1520 $625 q Matrx Elite Back 16 x 10 - PBE1610 $625 q Matrx Elite Back 17 x 10 - PBE1710 $625 q Matrx Elite Back 17 x 12 - PBE1712 $625 q Matrx Elite Back 17 x 14 - PBE1714 $625 q Matrx Elite Back 18 x 10 - PBE1810 $625 q Matrx Elite Back 18 x 12 - PBE1812 $625 q Matrx Elite Back 19 x 10 - PBE1910 $625 q Matrx Elite Back 19 x 12 - PBE1912 $625 q Matrx Elite Back 19 x 20 - PBE1920 $625 q Matrx Elite Back 20 x 10 - PBE2010 $625 q Matrx Elite Back 20 x 12 - PBE2012 $625 STEP 2: Choose Back Hardware (Selection Required) Back Hardware q Easy Set Hardware - PBMH N/C Not available Angle Adjustable Locking Flip Up or Tubular Flip Up Armrests, O2 Holder or welded rigidizer bar q Split Mounting Hardware - SMHU N/C DCN Pricing and specifications subject to change out notice Page 8 of 11

9 Elite Deep Back Weight Capacity: 300 lbs. STEP 1: Choose Back Size Quick Ship Quick Ship products are stocked q Matrx Elite Deep Back 14 x 16 - EDB1416 $760 q Matrx Elite Deep Back 14 x 18 - EDB1418 $760 q Matrx Elite Deep Back 15 x 16 - EDB1516 $760 q Matrx Elite Deep Back 15 x 18 - EDB1518 $760 q Matrx Elite Deep Back 16 x 16 - EDB1616 $760 q Matrx Elite Deep Back 16 x 18 - EDB1618 $760 q Matrx Elite Deep Back 16 x 20 - EDB1620 $760 q Matrx Elite Deep Back 17 x 16 - EDB1716 $760 q Matrx Elite Deep Back 17 x 18 - EDB1718 $760 q Matrx Elite Deep Back 17 x 20 - EDB1720 $760 q Matrx Elite Deep Back 18 x 16 - EDB1816 $760 q Matrx Elite Deep Back 18 x 18 - EDB1818 $760 q Matrx Elite Deep Back 18 x 20 - EDB1820 $760 q Matrx Elite Deep Back 19 x 18 - EDB1918 $760 q Matrx Elite Deep Back 19 x 20 - EDB1920 $760 q Matrx Elite Deep Back 20 x 16 - EDB2016 $760 q Matrx Elite Deep Back 20 x 18 - EDB2018 $760 q Matrx Elite Deep Back 20 x 20 - EDB2020 $760 STEP 2: Choose Back Hardware (Selection Required) Back Hardware q Easy Set Hardware - PBMH N/C Not available Angle Adjustable Locking Flip Up or Tubular Flip Up Armrests, O2 Holder or welded rigidizer bar q Split Mounting Hardware - SMHU N/C HCPCS Code: E2620 q Matrx Elite Deep Back 14 x 12 - EDB1412 $760 q Matrx Elite Deep Back 14 x 20 - EDB1420 $760 q Matrx Elite Deep Back 15 x 10 - EDB1510 $760 q Matrx Elite Deep Back 15 x 12 - EDB1512 $760 q Matrx Elite Deep Back 15 x 20 - EDB1520 $760 q Matrx Elite Deep Back 16 x 10 - EDB1610 $760 q Matrx Elite Deep Back 16 x 12 - EDB1612 $760 q Matrx Elite Deep Back 17 x 10 - EDB1710 $760 q Matrx Elite Deep Back 17 x 12 - EDB1712 $760 q Matrx Elite Deep Back 18 x 10 - EDB1810 $760 q Matrx Elite Deep Back 18 x 12 - EDB1812 $760 q Matrx Elite Deep Back 19 x 10 - EDB1910 $760 q Matrx Elite Deep Back 19 x 12 - EDB1912 $760 q Matrx Elite Deep Back 19 x 16 - EDB1916 $760 q Matrx Elite Deep Back 20 x 10 - EDB2010 $760 q Matrx Elite Deep Back 20 x 12 - EDB2012 $760 DCN Pricing and specifications subject to change out notice Page 9 of 11

10 Elite TR Back Weight Capacity: 300 lbs. STEP 1: Choose Back Size Quick Ship Quick Ship products are stocked q Matrx Elite Tilt / Recline Back 15 x 18 - PBE1518-TR $650 q Matrx Elite Tilt / Recline Back 16 x 18 - PBE1618-TR $650 q Matrx Elite Tilt / Recline Back 16 x 20 - PBE1620-TR $650 q Matrx Elite Tilt / Recline Back 17 x 18 - PBE1718-TR $650 q Matrx Elite Tilt / Recline Back 17 x 20 - PBE1720-TR $650 q Matrx Elite Tilt / Recline Back 18 x 18 - PBE1818-TR $650 q Matrx Elite Tilt / Recline Back 18 x 20 - PBE1820-TR $650 q Matrx Elite Tilt / Recline Back 19 x 18 - PBE1918-TR $650 q Matrx Elite Tilt / Recline Back 19 x 20 - PBE1920-TR $650 q Matrx Elite Tilt / Recline Back 20 x 18 - PBE2018-TR $650 q Matrx Elite Tilt / Recline Back 20 x 20 - PBE2020-TR $650 STEP 2: Choose Back Hardware (Selection Required) Back Hardware q Easy Set Hardware - PBMH N/C Not available Angle Adjustable Locking Flip Up or Tubular Flip Up Armrests, O2 Holder or welded rigidizer bar q Split Mounting Hardware - SMHU N/C HCPCS Code: E2620 q Matrx Elite Tilt / Recline Back 15 x 16 - PBE1516-TR $650 q Matrx Elite Tilt / Recline Back 15 x 20 - PBE1520-TR $650 q Matrx Elite Tilt / Recline Back 16 x 16 - PBE1616-TR $650 q Matrx Elite Tilt / Recline Back 17 x 16 - PBE1716-TR $650 q Matrx Elite Tilt / Recline Back 18 x 16 - PBE1816-TR $650 q Matrx Elite Tilt / Recline Back 19 x 16 - PBE1916-TR $650 q Matrx Elite Tilt / Recline Back 20 x 16 - PBE2016-TR $650 DCN Pricing and specifications subject to change out notice Page 10 of 11

11 Matrx Elan Headrest HCPCS Code: Hardware E0128 / Pad E0955 Quick Ship Quick Ship products are stocked q Elan Hardware - MEHW $220 q Elan Mini Hardware - MEMH $220 q Elan Standard Pad 6 W x 3.5 H w/ Std Cover - ESP6 $235 q Elan Standard Pad 10 W x 5 H w/ Std Cover - ESP10 $235 q Elan Standard Pad 14 W x 5 H w/ Std Cover - ESP14 $235 Matrx Elite/Mini Laterals q Elan Standard Pad 6 W x 3.5 H w/ Infection Control Cover - ESP6-IC $235 q Elan Standard Pad 10 W x 5 H w/ Infection Control Cover - ESP10-IC $235 q Elan Standard Pad 14 W x 5 H w/ Infection Control Cover - ESP14-IC $235 q Elan Occipital Pad 9 W x 7 H w/ Std Cover - EOP9 $235 q Elan Occipital Pad 9 W x 7 H w/ Infection Control Cover - EOP9-IC $235 q Elan Occiptal Pad 12 W x 8 H w/ Std Cover - EOP12 $235 q Elan Occipital Pad 12 W x 8 H w/ Infection Control Cover - EOP12-IC $235 q Elan 4 Point Pad 11 W x 10 H w/ Std Cover - E4POINT $325 q Elan 4 Point Pad 11 W x 10 H w/ Infection Control Cover - E4POINT-IC $325 HCPCS Code: Swing Away Hardware, Offset Hardware E1028 / Fixed Hardware, Pad E0956 Quick Ship Quick Ship products are stocked Elite Swing Away Lateral Hardware Only - SAHEB q Quantity 1 $225 q Quantity 2 $450 q Elite Offset Swing Away Lateral Hardware Only (Left) - OSAH-L $225 q Elite Offset Swing Away Lateral Hardware Only (Right) - OSAH-R $225 Pad for Swing Away Lateral Medium 3.75 H x 5.75 L - EPAD-M q Quantity 1 $110 q Quantity 2 $220 Pad for Swing Away Lateral Large 4.25 H x 6.5 L - EPAD-L q Quantity 1 $110 q Quantity 2 $220 Hardware Options q Easy Set Hardware (Pair) - PBMH $225 q Split Mounting Hardware (Pair) - SMH $200 q Heavy Duty Easy Set Hardware (Pair) - HDMH $325 q Extended Range Mounting Hardware (Pair) - ERMH $225 q Fixed Space Saver Mounting Hardware (Pair) - FSSH $200 q Carbon Fiber Fixed Mount Hardware for MX2 Back - IMX2CFH $245 q Quick Release Hardware for MX2 Back - IMX2QRH $270 q Elite Lateral Fixed Standard Pad 5 H x 7.5 L (Left) - PBLS-L $110 q Elite Lateral Fixed Standard Pad 5 H x 7.5 L (Right) - PBLS-R $110 q Elite Lateral Fixed Small Pad 3 H x 5.5 L (Left) - PBSS-L $110 q Elite Lateral Fixed Small Pad 3 H x 5.5 L (Right) - PBSS-R $110 q Elite Lateral Fixed Offset Pad 5 H x 7.5 L (Left) - PBOL-L $110 q Elite Lateral Fixed Offset Pad 5 H x 7.5 L (Right) - PBOL-R $110 Mini Swing-Away Lateral Hardware Only - SAHMINI q Quantity 1 $225 q Quantity 2 $450 Pad for Swing Away Lateral X Small 3.25 H x 4.25 L - EPAD-XS q Quantity 1 $110 q Quantity 2 $220 Pad for Swing Away Lateral Small 3.5 H x 5.25 L - EPAD-S q Quantity 1 $110 q Quantity 2 $220 Other Matrx Products q Chest Harness Interface Kit for Elite Back - CHIEB $95 q Chest Harness Interface Kit for Mini Back - HIMINI $85 q Extended Mounting Pins for Mounting to Backs 2 Wider - EMP $60 q Privacy Flap X Small (Fits 12 to 14 Backs) - PFLAP-XS $40 q Privacy Flap Small (Fits 15 to 16 Backs) - PFLAP-S $40 q Privacy Flap Medium (Fits 17 to 18 Backs) - PFLAP-M $40 q Privacy Flap Large (Fits 19 to 20 Backs) - PFLAP-L $40 q Privacy Flap X Large (Fits 21 to 22 Backs) - PFLAP-XL $40 DCN Pricing and specifications subject to change out notice Page 11 of 11