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Brendan Tyler
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1 This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Effective 05/14/2018 Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: q Catalyst 4 K0004 $ Lowest Front Seat Height 250 lb weight capacity q Catalyst 4 Super Low K0004 $ Lowest Front Seat Height 250 lb weight capacity Ship To: Address: City: State: Zip: Phone: /Fax: 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. Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth Seat Width Heavy Duty Option q 350 lb Weight Capacity $500 Requires minimum 6 caster height Seat Depth Price $420 $495 $100 N/C N/C HCPCS E2201 E N/C q q q q q 18 N/C q q q q q 20 $450 E2203 q q q q q Backrest Back Post / Height Range / Back Height Select Back Height in row corresponding to desired Back Post Back Post Price Back Height Standard N/C q 16.5 q 17.5 q 18.5 q 19.5 Angle Adjustable w/ Push Handle $185 q 16 q 17 q 18 Back Upholstery q Standard q Tension Adjustable E2611 $245 q Omit Back Upholstery - $10 Military Patch Attached only if ordered with Tension Adjustable Back Upholstery q US Military Service Patch $90 q Army q Navy q Marines q Air Force q Coast Guard q US Purple Heart Patch $90 q Purple Heart with Military Service Patch Combo $145 q Army q Navy q Marines q Air Force q Coast Guard DCN Pricing and specifications subject to change without notice Page 1 of 10

2 Footrest Hanger Bend q 60º N/C q 70º N/C q Elevating Leg Rests (ELR) E0990 $295 q Pro Elevating Leg Rests (PRO ELR) E0990 $350 q Omit Hangers N/C Footplate q Composite N/C Not available with PRO ELR q Composite Angle Adjustable K0040 $185 Not available with ELR or 14 Seat Width q Aluminum Angle Adjustable K0040 $185 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 are based on 70º Hanger / Front Frame Bend. Footrest Extension Seat to Footrest Length Extension Tube Hangers (60º, 70º) Short q 11 q 11.5 q 12 q 12.5 q 13 q 13.5 q 14 q 14.5 q 15 Medium q 13 q 13.5 q 14 q 14.5 q 15 q 15.5 q 16 q 16.5 q 17 Long q 15.5 q 16 q 16.5 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 Elevating Leg Rests (ELR) Extended Length ELR PRO ELR Low Pivot PRO ELR High Pivot Short q 12 q 13 q 14 q 15 q 16 Long q 13 q 14 q 15 q 16 q 17 q 18 Short q 18 q 19 q 20 q 21 q 22 Long q 18 q 19 q 20 q 21 q 22 q 23 q 24 Short q Long q Short q Long q Heel Loop q Heel Loops E0951 $30 q Adjustable Heel Loops E0951 New! $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 Residual Limb Support q Residual Limb Support E1020 q Left $395 q Right $395 q Omit Left Hanger N/C q Omit Right Hanger N/C 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 without notice Page 2 of 10

3 Front Seat Height and Casters Caster Size / Front Frame Type / Front Seat Height Select Front Seat Height in row corresponding to desired caster size. Note: Selections in first three Front Seat Height columns require Catalyst 4 Super Low. Caster Front Seat Height Size Uses Super Low Front Frame 4 q q 14 q 14.5 q 15 2 q 15.5 q 16 q 16.5 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 5 q 14.5 q 15 q 15.5 q 16 q 16.5 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q q 15.5 q 16 q 16.5 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q 20.5 q 21 7 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q 20.5 q 21 8 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q 20.5 q 21 Selection for Catalyst 4 Super Low is part of base frame selection on page 1 1 Front Seat Height not available with 4 x 1 Poly Caster 2 Super Low Front Frame required when using 4 x 1 Poly Caster Caster Type q 1 Poly N/C q 1 Pneumatic $80 Not available with 4, 5 and 7 Caster Sizes q 1.5 Poly $50 Not available with 7 and 8 Caster Sizes q 2 Poly $70 Not available with 4, 5, 7 and 8 Caster Sizes q 2 Pneumatic w/ Foam Insert $225 Not available with 4, 5, 6 and 7 Caster Sizes Rear Seat Height and Wheels Maximum Seat Dump Reference (Front Seat Height minus Rear Seat Height) Seat Depth Maximum Dump Fork Stem q Standard Fork Stem q 3/4 Longer Fork Stem $35 q Longer Fork Stem $35 Wheel Size / Tire Profile / Rear Seat Height Select Rear Seat Height in row corresponding to desired Wheel Size and Tire Profile Wheel Size Tire Profile Rear Seat Height Low q q 13.5 q 14.5 q 15.5 q 16.5 Full q 13 1 q 14 q 15 q 16 q 17 Low q q 14.5 q 15.5 q 16.5 q 17.5 Full q 14 1 q 15 q 16 q 17 q 18 Low q q 15.5 q 16.5 q 17.5 q 18.5 Full q 15 1 q 16 q 17 q 18 q 19 1 Not available with Flip Back Armrests Rear Wheel Type q Assembled 24 Six-Spoke Mag with Treaded Tire and Composite Handrim - $25 No substitutions available. Do not select Rear Tire Type or Handrim. Measures as Full Tire. q Spoke $50 q Mag N/C Rear Tire Type Low Profile q Low Poly 1 E2218 Full Profile q Full Poly 1 3/8 E2218 $30 q Street Pneumatic 1 3/8 E2211, E2212 $80 q Pneumatic with Airless Insert 1 3/8 E2211, E2213 $200 Handrim Standard Handrims q Aluminum Anodized q Plastic Coated $95 q Projection (8 Vertical Projections) $295 Available on 22 and 24 Spoke wheels and 24 Mag wheels with full tires q Omit Handrim N/C Handrim Option q 3M Micro Grip $65 Not available on Plastic Coated or Projection Handrims Natural Fit Handrims Not available on 20 rear wheel or 22 Mag wheels. Not recommended with 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 DCN Pricing and specifications subject to change without notice Page 3 of 10

4 Axles Axle Bracket q Offset Axle Bracket q Reverse Mount Offset Axle Bracket N/C Not available with Swing Away Armrests Wheel Locks Wheel Lock q Push to Lock q Push to Lock Flush Mount N/C q Pull to Lock N/C q Omit Wheel Locks N/C Armrests Armrest Please select Arm Pad option q Height Adjustable T-Arm ( ) E0973 $265 q Height Adjustable T-Arm Low ( ) E0973 $265 q Height Adjustable Flip Back T-Arm ( ) E0973 New! _ $275 q Flip Back (10.5 ) N/C Not available with Angle Adjustable Back Posts Accessories Removable Side Guard q Composite Side Guards K0108 $140 Not available with T-Arm or Flip Back Armrests Anti-Tip q Rear Anti-Tips E0971 $140 Positioning Belt q Auto Buckle E0978 $70 q Padded Auto Buckle E0978 $155 q 2 Airline Buckle E0978 $110 q Bodypoint Evoflex - Pelvic Stabilizer E0978 $183 Size: q Small (16-24 ) q Medium (19-29 ) q Large (25-37 ) q Bodypoint Belt Mounting Kit $105 Style: q Bracket q Band Clamp 1 Frame Color Axle q Fixed Axle q Quick Release Axle $95 Wheel Lock Options q Extension Handles E0961 $67 Available only with Push to Lock or Pull to Lock Wheel Locks q Grade Aids E0974 $150 Available only with Push to Lock Wheel Locks and Pneumatic or Pneumatic w/ Airless Insert Rear Tire Types Arm Pad Not available with Swing Away Armrests Standard Arm Pad N/C q Desk q Full Waterfall Arm Pad $25 q Desk q Full Available only with Height Adjustable T-Arms Armrest continued q Swing Away ( ) E0973 $195 Not available with Angle Adjustable Back Posts or Arm Pads q Omit Armrests N/C Other Accessories q Tool Kit $45 q Removable Underseat Pouch $50 q Ki Mobility Backpack $65 q Black Neoprene Impact Guards $85 q Clear Spoke Guards K0065 $115 Not available with Mag wheels q Black Spoke Guards K0065 $115 Not available with 20 rear wheel or Mag wheels q Cane and Crutch Holder $195 q IV Pole $265 Straight Back Canes will be used when this option is selected O 2 Holder q O 2 Holder E2208 $295 q Right Side q Left Side 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 Gloss Finish q Black N/C DCN Pricing and specifications subject to change without notice Page 4 of 10

5 Catalyst Front Seat Height Matrix 4 Caster 5 Caster 6 Caster 7 Caster 8 Caster FSH Super Low Stem Fork FSH Super Low Stem Fork FSH Super Low Stem Fork FSH Super Low Stem Fork FSH Super Low Stem Fork / / / n/a 3/4 4 3/ / / /4 5 3/ n/a n/a / n/a / n/a 8 x 2 caster not available with 6 fork 3/ / n/a / / n/a x 2 caster not available with 5 fork Front Seat Height not available with 4 x 1 Poly Caster 2 Not available with 4 x 1 Poly, 4 x 1.5 Poly or 4 x 1.5 Soft Roll Aluminum Seat heights with FSH heading available with Standard Front Frame. Seat heights with Super Low heading available with Super Low Front Frame. Actual seat height may vary depending upon configuration. DCN Pricing and specifications subject to change without notice Page 5 of 10

6 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 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 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 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 without notice Page 6 of 10

7 Elite Back 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 STEP 2: Choose Back Hardware (Selection Required) Back Hardware q Easy Set Hardware - PBMH N/C Not available with 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 products are ordered with an extended lead time 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 DCN Pricing and specifications subject to change without notice Page 7 of 10

8 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 HCPCS Code: E2620 products are ordered with an extended lead time 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 STEP 2: Choose Back Hardware (Selection Required) Back Hardware q Easy Set Hardware - PBMH N/C Not available with 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 without notice Page 8 of 10

9 MX2 Back Weight Capacity: 250 lbs. The MX2 Back is only. products are ordered with an extended lead time. MX2 Back with Fixed Hardware Hardware included q Matrx MX2 Back w/ Fixed Hardware 14 x 06 - IMX21406-CFH $795 q Matrx MX2 Back w/ Fixed Hardware 14 x 09 - IMX21409-CFH $835 q Matrx MX2 Back w/ Fixed Hardware 14 x 12 - IMX21412-CFH $875 q Matrx MX2 Back w/ Fixed Hardware 14 x 16 - IMX21416-CFH $915 q Matrx MX2 Back w/ Fixed Hardware 15 x 06 - IMX21506-CFH $795 q Matrx MX2 Back w/ Fixed Hardware 15 x 09 - IMX21509-CFH $835 q Matrx MX2 Back w/ Fixed Hardware 15 x 12 - IMX21512-CFH $875 q Matrx MX2 Back w/ Fixed Hardware 15 x 16 - IMX21516-CFH $915 q Matrx MX2 Back w/ Fixed Hardware 16 x 06 - IMX21606-CFH $795 q Matrx MX2 Back w/ Fixed Hardware 16 x 09 - IMX21609-CFH $835 q Matrx MX2 Back w/ Fixed Hardware 16 x 12 - IMX21612-CFH $875 q Matrx MX2 Back w/ Fixed Hardware 16 x 16 - IMX21616-CFH $915 q Matrx MX2 Back w/ Fixed Hardware 17 x 06 - IMX21706-CFH $795 q Matrx MX2 Back w/ Fixed Hardware 17 x 09 - IMX21709-CFH $835 q Matrx MX2 Back w/ Fixed Hardware 17 x 12 - IMX21712-CFH $875 q Matrx MX2 Back w/ Fixed Hardware 17 x 16 - IMX21716-CFH $915 q Matrx MX2 Back w/ Fixed Hardware 18 x 06 - IMX21806-CFH $795 q Matrx MX2 Back w/ Fixed Hardware 18 x 09 - IMX21809-CFH $835 q Matrx MX2 Back w/ Fixed Hardware 18 x 12 - IMX21812-CFH $875 q Matrx MX2 Back w/ Fixed Hardware 18 x 16 - IMX21816-CFH $915 MX2 Back with Quick Release Hardware Hardware included HCPCS Code: E2615 q Matrx MX2 Back w/ QR Hardware 14 x 06 - IMX21406-QRH $820 q Matrx MX2 Back w/ QR Hardware 14 x 09 - IMX21409-QRH $860 q Matrx MX2 Back w/ QR Hardware 14 x 12 - IMX21412-QRH $900 q Matrx MX2 Back w/ QR Hardware 14 x 16 - IMX21416-QRH $940 q Matrx MX2 Back w/ QR Hardware 15 x 06 - IMX21506-QRH $820 q Matrx MX2 Back w/ QR Hardware 15 x 09 - IMX21509-QRH $860 q Matrx MX2 Back w/ QR Hardware 15 x 12 - IMX21512-QRH $900 q Matrx MX2 Back w/ QR Hardware 15 x 16 - IMX21516-QRH $940 q Matrx MX2 Back w/ QR Hardware 16 x 06 - IMX21606-QRH $820 q Matrx MX2 Back w/ QR Hardware 16 x 09 - IMX21609-QRH $860 q Matrx MX2 Back w/ QR Hardware 16 x 12 - IMX21612-QRH $900 q Matrx MX2 Back w/ QR Hardware 16 x 16 - IMX21616-QRH $940 q Matrx MX2 Back w/ QR Hardware 17 x 06 - IMX21706-QRH $820 q Matrx MX2 Back w/ QR Hardware 17 x 09 - IMX21709-QRH $860 q Matrx MX2 Back w/ QR Hardware 17 x 12 - IMX21712-QRH $900 q Matrx MX2 Back w/ QR Hardware 17 x 16 - IMX21716-QRH $940 q Matrx MX2 Back w/ QR Hardware 18 x 06 - IMX21806-QRH $820 q Matrx MX2 Back w/ QR Hardware 18 x 09 - IMX21809-QRH $860 q Matrx MX2 Back w/ QR Hardware 18 x 12 - IMX21812-QRH $900 q Matrx MX2 Back w/ QR Hardware 18 x 16 - IMX21816-QRH $940 DCN Pricing and specifications subject to change without notice Page 9 of 10

10 Matrx Elan Headrest 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/ Cover - ESP6 $235 q Elan Standard Pad 10 W x 5 H w/ Cover - ESP10 $235 q Elan Standard Pad 14 W x 5 H w/ Cover - ESP14 $235 HCPCS Code: Hardware E0128 / Pad E0955 products are ordered with an extended lead time 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/ 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/ 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/ Cover - E4POINT $325 q Elan 4 Point Pad 11 W x 10 H w/ Infection Control Cover - E4POINT-IC $325 Matrx Elite/Mini Laterals 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 products are ordered with an extended lead time 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 products are ordered with an extended lead time 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 products are ordered with an extended lead time 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 without notice Page 10 of 10

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This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Phone (800) 981-1540 Fax (715) 254-0996 Company: Account Number: Date: q Quote q PO Number: RTS: