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Abraham Matthews
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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: Catalyst 5Ti K0005 $ lb weight capacity Ship To: Address: City: State: Zip: Phone: /Fax: Effective 05/29/2018 Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth Seat Width Seat Depth Price N/C N/C N/C N/C N/C $195 $395 $495 $495 HCPCS E2201 E2201 E N/C q q q q q q q q q 15 N/C q q q q q q q q q 16 N/C q q q q q q q q q 17 N/C q q q q q q q q q 18 N/C q q q q q q q q q 19 $195 q q q q q q q q q $ E2203 q q q q q q q q q Heavy Duty Option q 350 lb Weight Capacity $500 Requires minimum 6 caster height Transit Option q Transit System K0108 $320 Not available with Removable Seat Pan or Heavy Duty Option Cross Brace q Aluminum q Titanium $495 Not available with 21 and 22 Seat Widths Wheelchair Drive Ready Chair will ship from Ki Mobility with adaption kit installed for selected Alber system. Order system separately from Alber USA. Select Rear Seat Height (full profile selections only) in drive wheel size on Rear Seat Height chart (page 5). Requires Rear Anti-Tips. Not available with Spinergy wheels. q e-motion Ready N/C q twion Ready N/C Backrest Back Post / Height Range / Back Height Select Back Height in row corresponding to desired Back Post and Height Range Back Post Standard Price N/C Height Range Back Height Short q 8.5 q 9.5 q 10.5 q 11.5 Medium q 12.5 q 13.5 q 14.5 q 15.5 Tall q 16.5 q 17.5 q 18.5 q 19.5 Standard Back Post Select option below only if a Standard Back Post option is selected on chart at left q Straight without Push Handle N/C q Straight with Push Handle $50 q 8º Bend with Push Handle $80 Not available with Short Back Height Range q Straight with Fold Down Push Handle $125 Not available with Heavy Duty option Angle Adjustable w/ Push Handle $185 Short q 14 q 15 q 16 Medium q 16 q 17 q 18 Tall q 18 q 19 q 20 Push Handle Options Not available with Straight Back Post with Fold Down Push Handle or Heavy Duty Option q Low Profile Push Handle $65 2 shorter than standard push handles 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 without notice Page 1 of 11

2 Backrest continued Back Upholstery Select option below only if Standard or Angle Adjustable Back Post option is selected on chart on previous page q Standard Not available with Short or Medium Back Height Ranges on Seat Widths q Tension Adjustable E2611 $245 q Omit Back Upholstery - $10 Footrest Hanger / Front Frame Bend q 70º N/C q 80º N/C Not available with 7 or 8 Casters q Pro Elevating Leg Rests (PRO ELR) E0990 $295 q Omit Hangers - $20 Military Patch Attached only if ordered with Tension Adjustable Back Upholstery US Military Service Patch $90 q Army q Navy q Marines q Air Force q Coast Guard q US Purple Heart Patch $90 Purple Heart with Military Service Patch Combo $145 q Army q Navy q Marines q Air Force q Coast Guard Footplate q Composite N/C Not available with PRO ELR q Composite Angle Adjustable K0040 $185 Not available with 14 Seat Width q Aluminum Angle Adjustable K0040 $185 q One Piece Flip Up Angle Adjustable K0040 $190 Not available with PRO ELR 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 Hangers and Fixed Front Frame measurements are based on 70º Hanger / Front Frame Bend. Footrest Extension Seat to Footrest Length Extension Tube Hangers (60º, 70º, 80º) PRO ELR Low Pivot PRO ELR High Pivot Fixed Front Frame (70º, 80º) 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 Short q Long q Short q Long q Short 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 Hanger Release If no selection is made Classic Hanger Release will be used q Classic q 4-Way - In line N/C See reference A to the right. Not available with PRO ELR. q 4-Way - Out N/C See reference B to the right A B 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 without notice Page 2 of 11

3 Footrest continued Heel Loop q Heel Loops E0951 $30 Not available with One Piece Flip Up Angle Adjustable Footplate q Adjustable Heel Loops E0951 New! $50 Not available with One Piece Flip Up Angle Adjustable Footplate q Omit Heel Loops N/C Front Seat Height and Casters Calf Strap q Velcro Adjustable K0038 $35 q Padded Velcro Adjustable K0038 $68 q Bodypoint Padded AeroMesh K0038 $102 Caster Size / Front Frame Type / Front Seat Height Select Front Seat Height in row corresponding to desired caster size Caster Front Seat Height Size 4 q 15 1 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 16 q 16.5 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q 20.5 q 21 7 q 18 q 18.5 q 19 q 19.5 q 20 q 20.5 q 21 8 q 19 q 19.5 q 20 q 20.5 q 21 1 Not availale with 4 x 1 Poly Caster Caster Type q.75 Rollerblade N/C Not available with 5, 6, 7 and 8 Caster Sizes q.75 Lighted Rollerblade $70 Not available with 5, 6, 7 and 8 Caster Sizes q 1 Poly N/C q 1 Poly Aluminum $160 Not available with 6, 7 and 8 Caster Sizes 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 1.5 Soft Roll Aluminum $175 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 Caster Housing q Standard N/C q Performance $35 Wheel Locks Wheel Lock q Push to Lock q Push to Lock Flush Mount N/C q Pull to Lock N/C q Low Profile Scissor Lock $45 Not available with Low Poly, Full Poly or Sentinel Solid tires q Short Thro Scissor Lock $110 q Omit Wheel Locks N/C Maximum Seat Dump Reference (Front Seat Height minus Rear Seat Height) Seat Depth Maximum Dump Standard Caster Housing Maximum Dump Performance Caster Housing Depending on configuration, chairs with Fixed Front Frame Type may achieve up to an additional.75 Fork Stem q Best Fit Ki Mobility will pick optimal Fork Stem based on Caster Size and Front Seat Height q Standard Fork Stem N/C q 3/4 Longer Fork Stem N/C q Longer Fork Stem N/C Fork Options q Frog Legs Ultra-Sport Fork - Black $425 Available only with 4, 5 or 6 casters. Not available with Caster Pin Locks, Heavy Duty Option, 2 Poly caster or 2 Pneumatic w/ Foam Insert caster. End User Weight Required: lbs q Frog Legs PHASE 2 Carbon Fork $425 Lightweight shock absorbing fork. Available only with 4, 5 or 6 casters. Not available with Caster Pin Locks, Heavy Duty Option, 2 Poly caster or 2 Pneumatic w/ Foam Insert caster. q Caster Pin Locks K0073 $195 Not available with Performance Caster Housing, Longer Fork Stem or Frog Legs Fork 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 with Airless Insert Rear Tire Types DCN Pricing and specifications subject to change without notice Page 3 of 11

4 Rear Seat Height and Wheels Wheel Size / Tire Profile / Rear Seat Height Select Rear Seat Height in row corresponding to Wheel Size and Tire Profile. 14 Seat Depth not available with 24, 25 or 26 Rear Wheels. m Requires curved axle plate q Any axle plate can be used (Curved, Standard, Amputee, One Arm Drive) Wheel Size Tire Profile Rear Seat Height Low m 11.5 q 12 1 m 12.5 q 13 1 m 13.5 q 14 m 14.5 q 15 m 15.5 m Full m 12 q m 13 q m 14 q 14.5 m 15 q 15.5 m 16 m Low m 12.5 q 13 1 m 13.5 q 14 1 m 14.5 q 15 m 15.5 q 16 m 16.5 m 17 Full m 13 q m 14 q m 15 q 15.5 m 16 q 16.5 m 17 m 17.5 Low m 13.5 q 14 1 m 14.5 q 15 1 m 15.5 q 16 m 16.5 q 17 m 17.5 m 18 Full m 14 q m 15 q m 16 q 16.5 m 17 q 17.5 m 18 m Low m 14 q m 15 q m 16 q 16.5 m 17 q 17.5 m 18 m Low m 14.5 q 15 1 m 15.5 q 16 1 m 16.5 q 17 m 17.5 q 18 m 18.5 m 19 Full m 15 q m 16 q m 17 q 17.5 m 18 q 18.5 m 19 m Not available with Amputee Axle Plate One Arm Drive q One Arm Drive E0958 $1095 Available only with 24 Mag wheels. Not available with 14 Rear Seat Height in combination with 24 rear wheel or 4 camber. 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 Plate No selection needed with One Arm Drive q Standard m Curved $85 q Amputee $175 Not available with Swing Away Armrests or Wheelchair Drive Ready Option Rear Tire Type Full Profile q Street Pneumatic 1 3/8 E2211, E2212 Not available on 25 rear wheel q Full Poly 1 3/8 E2218 $95 Not available on Superlight or 25 rear wheel q Pneumatic with Airless Insert 1 3/8 E2211, E2213 $125 Not available on Superlight or 25 rear wheel q Schwalbe HS /8 E2211, E2212 $125 Available only on 24 rear wheel. Not available on Mag wheels. q Euro Trek Knobby 1 3/8 E2211, E2212 $95 Available only on 24 rear wheel Rear Wheel Type q 24 Spoke N/C q Spoke (20, 22, 25 or 26 ) $200 q Mag $50 Not available in 25 or 26 rear wheels q Superlight Spoke $295 Available only in 24 and 25 rear wheels. Not available with Heavy Duty Option. q Spinergy Spox $795 Not available in 20 rear wheel Color: q Black q Red q White q Blue q Yellow Handrim: q Short Tab q Long Tab Available only with Aluminum Anodized and Plastic Coated Handrims q Spinergy LX $995 Not available in 20 rear wheel Color: q Black q Red q White q Blue q Yellow q Pink q Green q Orange Handrim: q Short Tab q Long Tab Available only with Aluminum Anodized and Plastic Coated Handrims Low Profile q Low Poly 1 E2218 $75 Not available on Superlight, 25 or 26 rear wheels q Sentinel Solid Tire 1 E2218 $95 Not available on Superlight wheels or 20 and 22 Mag wheels q High Pressure 1 E2211, E2212 $95 Not available on Mag wheels q Schwalbe One 1 E2211, E2212 $125 Not available on Mag, 20, 22 or 26 rear wheels q Schwalbe Marathon Plus Evolution 1 E2211, E2212 $125 Not available on Mag, 20 or 22 rear wheels DCN Pricing and specifications subject to change without notice Page 4 of 11

5 Rear Seat Height and Wheels continued Handrim No selection needed with One Arm Drive Standard Handrims q Aluminum Anodized q Superlight Aluminum Anodized $50 Available only on 24 and 25 Superlight and Spinergy wheels. Not available with Heavy Duty Option. q Plastic Coated $95 q Projection (8 Vertical Projections) $295 Available on 22, 24, 25 and 26 Spoke wheels & 24 Mag wheels w/full tires q Spinergy Flex Rim $600 Available only on 24 and 25 Spinergy LX wheels q Omit Handrim N/C Handrim Option q 3M Micro Grip $65 Not available on Plastic Coated or Projection Handrims Axles Axle No selection needed with Wheelchair Drive Ready Option and One Arm Drive q Quick Release q Quad Quick Release $175 Not available with Mag wheels Armrests Armrest Please select Arm Pad option q Height Adjustable T-Arm ( ) E0973 $375 q Height Adjustable T-Arm Low ( ) E0973 $375 q Height Adjustable Flip Back T-Arm ( ) E0973 $275 q Flip Back (10.5 ) $425 Not available with Seat Depths less than 16 or Angle Adjustable Back Posts Accessories 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 Axle Position Rear Wheel Camber: q 0º q 2º q 4º Center of Gravity: q Rear q Center q Forward 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 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 Bodypoint Evoflex - Pelvic Stabilizer E0978 $183 Size: q Small (16-24 ) q Medium (19-29 ) q Large (25-37 ) Bodypoint Belt Mounting Kit $105 Style: q Bracket q Band Clamp 1 O 2 Holder O 2 Holder E2208 $295 q Right Side q Left Side Seat Pan q Removable Aluminum Seat Pan E2231 $245 Not available with Transit System. Pan depth 1/2 shorter than Seat Depth. Other Accessories q Tool Kit $45 q Removable Underseat Pouch $50 q Pediatric Ki Mobility Backpack New! $50 q Ki Mobility Backpack $65 q Luggage Carrier $85 Not available with PRO ELR or Residual Limb Support 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 Available only with Standard Straight Back Posts DCN Pricing and specifications subject to change without notice Page 5 of 11

6 Catalyst Front Seat Height Matrix 4 Caster 5 Caster 6 Caster 7 Caster 8 Caster FSH Stem Fork FSH Stem Fork FSH Stem Fork FSH Stem Fork FSH Stem Fork / / / /4 4 3/ / / /4 5 3/ / / x 2 caster not available with 6 fork / / / / x 2 caster not available with 5 fork 1 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 Actual seat height may vary depending upon configuration. DCN Pricing and specifications subject to change without 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 without 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 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 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 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 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 9 of 11

10 MX2 Back Weight Capacity: 250 lbs. HCPCS Code: E2615 The MX2 Back is only.. MX2 Back with Fixed Hardware MX2 Back with Quick Release 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 Hardware included 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 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/ 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 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/ 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 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 without notice Page 11 of 11

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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