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1 This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: Rogue XPe K0005, E1235 $2415 Rogue Width Growable Frame. Price does not include one time free growth kit. 200 lb weight capacity. Maximum Seat Width of 18. Ship To: Address: City: State: Zip: Phone: /Fax: Effective 02/22/2019 Frame Seat Width / Seat Depth Select box corresponding to desired Seat Width and Depth. See references A and B on page 8. Seat Depth Seat Width Price N/C N/C N/C N/C N/C N/C N/C N/C N/C 10 N/C q q q q q q q q q 11 N/C q q q q q q q q q 12 N/C q q q q q q q q q 13 N/C q q q q q q q q q 14 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 N/C q q q q q q q q q 20 N/C E2203 q q q q q q q q q Transit Option Cannot be retrofitted q Transit System K0108 $320 Seat Option q Standard Seat Sling N/C q Solid Seat Pan E2231 $245 q Omit Seat N/C Sling Position In Performance Position (0 ), sling is at front of frame. The 1 or 2 sling position extends the frame in front of the sling by that amount. See reference C on page 8. q 0 (Performance) N/C q 1 N/C q 2 (Classic) N/C Adjustable Depth Adds the capability to grow seat in depth. Seat depth plus Adjustable Depth cannot exceed q No Rear Adjustment N/C q 1/2 N/C q 1 N/C q 2 N/C q 3 N/C Front Frame Bend Angle between front seat tube and ground. See reference D on page 8. q 90º $150 q 85º N/C q 80º N/C q 75º N/C q 70º N/C 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 15

2 Backrest Back Post / Height Range / Back Height Select Back Height in row corresponding to desired Back Post and Height Range Back Post Height Range Back Height Height Adjustable (Standard or 1 Inward Offset) Fixed Height (Straight or 1 Inward Offset) Fixed Height 2 Offset Stroller Handle Stroller Handles are removable and height adjustable q Ergo Stroller Handle $185 q Single Stroller Handle $165 q Double Stroller Handle $330 Not available with Push Handles or 10 Seat Width Back Upholstery Ex. Short 1 q 9 q 10 q 11 q 12 Short q 11 1 q 12 q 13 q 14 Medium q 13 q 14 q 15 q 16 Tall q 15 q 16 q 17 q 18 q 9 1 q 10 1 q 11 1 q 12 q 13 q 14 q 15 q 16 q 17 q 18 q 11 1 q 12 1 q 13 1 q 14 1 q 15 q 16 q 17 1 Not available with Fold Down Push Handle Available only with Height Adjustable Back Posts q Padded Velcro Adjustable Std q Tension Adjustable E2611 $295 q Omit Back Upholstery -$10 Height Adjustable Back Post Option Selection required with Height Adjustable Back Post. Each Offset Back Post is offset 1/2 creating 1 overall offset. q Standard N/C q 1 Inward Offset N/C Fixed Height Back Post Option Selection required with Fixed Height Back Post. Uses 1 tubes compatible with after-market backs. Not available with back upholstery. 2 Inward or Outward Offset Back Posts are offset 1 creating 2 overall offset. 1 Offset Back Post is offset 1/2 creating 1 overall offset. q Straight N/C q 1 Inward Offset N/C q 2 Inward Offset $95 q 2 Outward Offset $95 Not available with Swing Away Armrests Push Handle q Omit Push Handle N/C q Standard Push Handle $15 q Low Profile Push Handle $135 2 shorter than standard push handles q Fold Down Push Handle $100 Not available on Height Adjustable Back Posts with 9-11 Back Heights or Offset Back Posts with Back Heights q Bolt-On Push Handle $175 Handles will be 1-2 above back height Spinergy Backrest Release Cable Color Select desired color. If no selection is made, black will be used. q Black q Red q White q Blue q Yellow q Orange q Green q Pink Seat Back Angle Standard is 90º (perpendicular to floor). Minus (-º) closes back angle. Plus (+º) opens back angle. q Std q +2º q +4º q +6º q +8º q +10º q -2º q -4º q -6º q -8º q -10º DCN Pricing and specifications subject to change without notice Page 2 of 15

3 Front Seat Height and Casters Caster Size / Footrest Taper / Front Seat Height Select Front Seat Height in row corresponding to Footrest Taper and Caster Size. 6 casters not available with 85º and 90º Front Frame Bend. Footrest Taper indicates bend of front frame creating footrest width. Taper is measured from outside of seat frame to outside of front tube. Taper is not available with 70º Front Frame Bend. See reference E on page 8. Front Seat Height is measured from floor to top of seat tube at front of seat sling. Adjustable up or down by 1/2. See reference F on page 8. Footrest Taper Straight Caster Front Seat Height Size 3 q 13.5 q 14 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 14 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 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 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 16.5 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q Taper 4 q 17 q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q q 17.5 q 18 q 18.5 q 19 q 19.5 q 20 q q 18 q 18.5 q 19 q 19.5 q 20 q 20.5 Caster Type q.75 Rollerblade N/C Available only with 3 and 4 Caster Sizes q.75 Lighted Rollerblade $70 Not available with 6 Caster Size q 1 Poly N/C Not available with 3 Caster Size q 1 Poly Aluminum $110 Available only with 4 and 5 Caster Sizes q 1 Pneumatic $85 Available only with 6 Caster Size q 1.5 Poly $50 Not available with 3 Caster Size q 1.5 Soft Roll Aluminum $175 Footrest Footplate q Tubular Open Footplate Std Not available with footrest widths less than 9.5. See Reference G on page 8. q Tubular Footplate with ABS Cover $30 Not available with footrest widths less than 9.5. See Reference G on page 8. q Aluminum Angle Adjustable K0040 $95 q Aluminum Angle Adjustable with Riser K0040, K0037 $165 q High Mount Aluminum Angle Adjustable K0040, K0037 $165 q Angle Adjustable Flip Under K0040, K0037 $185 Not available with footrest widths less than 9.5. See Reference G on page 8. q High Mount Angle Adjustable Flip Under K0040, K0037 $270 Not available w/footrest widths greater than See Reference G on page 8. Fork Options q Standard Fork Std q Single Sided Fork $125 q Frog Legs Ultra-Sport Fork - Black E1015 $425 Not included in Colored Anodizing Package End User Weight Required: lbs q Frog Legs PHASE 2 Carbon Fork $425 Lightweight shock absorbing fork. Not included in Colored Anodizing Package. Seat to Footrest Length Measured from front edge of seat sling to top, rear of footrest. Footrest length at least 2.5 shorter than Front Seat Height recommended. See reference H on page 8. q 8 q 8.5 q 9 q 9.5 q 10 q 10.5 q 11 q 11.5 q 12 q 12.5 q 13 q 13.5 q 14 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 Footrest Protector q Footrest Protector N/C Not available with Angle Adjustable Flip Under, High Mount Angle Adjustable Flip Under or High Mount Aluminum Angle Adjustable Footplates DCN Pricing and specifications subject to change without notice Page 3 of 15

4 Rear Seat Height and Wheels Wheel Size / Rear Seat Height Select Rear Seat Height in row corresponding to desired Wheel Size. For proper setup, selection is required when omitting rear wheels. Measured from floor to top of seat tube at front of back post. Rear Seat Height is custom to needs. See reference I on page 8. Wheel Rear Seat Height Size 18 q q 12 q 12.5 q 13 q 13.5 q 14 q 14.5 q 15 q 15.5 q 16 q 16.5 q 17 q 17.5 q 18 q 18.5 q q q 13 q 13.5 q 14 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 q q 14 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 q 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 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 1 Available only with Low Profile tires One Arm Drive One Arm Drive E0958 $1495 Available only with 24 Mag wheel. Not available with 10 Seat Width. Axle not quick release. Standard Handrim will be Aluminum Anodized. Drive Handrim Side: q Left q Right Drive Handrim Type: q Aluminum N/C q Poly Coated $200 Rear Wheel Type q Spoke N/C q MAXX Performance Spoke New! $99 Available only in 22 or 24 wheel sizes q Mag (Black) $50 Not available in 18 or 25 wheel sizes Colored Mag $100 Available only in 20 and 22 wheel sizes Color: q Florescent Red q White q Blue q Pink q Superlight Spoke $315 Available only in 24 and 25 wheel sizes. 25 wheel size available only with Superlight and Plastic Coated Handrims. New! Handrim: q Short Tab q Long Tab Spinergy Spox $820 Not available in 18 wheel size 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 Spinergy LX $1025 Not available in 18 or 20 wheel sizes Color: q Black q Red q White q Blue q Yellow q Pink q Green q Orange q Purple New! Handrim: q Short Tab q Long Tab Available only with Aluminum Anodized and Plastic Coated Handrims q Omit Rear Wheels N/C Rear Tire Type Full Profile q Street Pneumatic 1 3/8 E2211, E2212 Std Not available on 25 wheel size q Full Poly 1 3/8 E2218 $95 Not available on Superlight wheel or 25 wheel size q Pneumatic with Airless Insert 1 3/8 E2211, E2213 $80 Not available on Superlight wheel or 25 wheel size q Schwalbe HS /8 E2211, E2212 $125 Available only on 24 wheel size. Not available on Mag wheel. q Euro Trek Knobby 1 3/8 E2211, E2212 $95 Available only on 24 wheel size q Mountain 2 Black E2211, E2212 $95 Available only on 22, 24 and 25 Spoke and Spinergy wheels Low Profile q Low Poly 1 E2218 $75 Not available on Superlight wheel or 25 wheel size q Sentinel Solid Tire 1 E2218 $95 Not available on Superlight wheel, 18 wheel size or 20 and 22 Mag wheels q High Pressure 1 E2211, E2212 $95 Not available on Mag wheel or 18 wheel size q Schwalbe One 1 E2211, E2212 $125 Available only on 24 and 25 wheel sizes. Not available on Mag wheel. q Schwalbe Marathon Plus Evolution 1 E2211, E2212 $135 Available only on 24 and 25 wheel sizes. Not available on Mag wheel. DCN Pricing and specifications subject to change without notice Page 4 of 15

5 Rear Seat Height and Wheels continued Handrim No selection needed with One Arm Drive Standard Handrims q Aluminum Anodized Std q Superlight Aluminum Anodized $50 Available only on 24 and 25 wheel sizes. Not available with standard Spoke wheel or Mag wheel. q Plastic Coated $95 q Projection (8 Vertical Projections) $315 Available only with full profile tires. Available only with Spoke wheel sizes or Mag wheel q Spinergy Flex Rim $600 Available only on 24 and 25 Spinergy LX wheels q Omit Handrim N/C Natural Fit Handrims Not available on 18 or 20 wheel sizes or 22 Mag wheel. Not recommended with Mag wheel. 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 Handrim Option q 3M Micro Grip $65 Not available on Plastic Coated or Projection Handrims Axle q Quick Release Std q Quad Quick Release $175 Not available with Mag or Spinergy wheels 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 4). Requires Rear Anti-Tips. Not available with 5th Wheel or Spinergy wheels. q e-motion Ready N/C q twion Ready N/C Camber Selection: q 0º q 3º Rear Wheel Camber No selection needed with One Arm Drive q 0º q 2º q 4º q 6º q 8º Rear Wheel Spacing 1.5 minimum Rear Wheel Spacing with Height Adjustable Armrest. 1 minimum Rear Wheel Spacing with 0º Rear Wheel Camber. See reference K on page 8. No selection needed with One Arm Drive or Wheelchair Drive Ready options. q.75 q 1 q 1.25 q 1.5 q 1.75 Center of Gravity Preset Measured from front of back post to center of rear axle. 0 indicates axle will be directly under back post. 2 minimum Center of Gravity with 5th Wheel and One Arm Drive. See reference J on page 8. Amputee Positions q -1.5 q q -1 q -.75 q -.5 q -.25 q 0 q.25 Standard Positions q.5 q.75 q 1 q 1.25 q 1.5 q 1.75 q 2 q 2.25 q 2.5 q 2.75 q 3 q 3.25 q 3.5 q 3.75 q 4 q 4.25 Wheel Locks Wheel Lock q Push to Lock Std q Push to Lock Flush Mount N/C q Pull to Lock N/C q Under Seat Scissor Lock $35 q Low Profile Scissor Lock $45 Not available with Low Poly, Full Poly or Sentinel Solid tires q Short Thro Scissor Lock $125 q Omit Wheel Locks N/C Wheel Lock Options q Extension Handles E0961 $70 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 tires DCN Pricing and specifications subject to change without notice Page 5 of 15

6 Armrests Armrest Please select Arm Pad option q Height Adjustable T-Arm ( ) E0973 $340 Not available with Seat Depths less than minimum Rear Wheel Spacing q Height Adjustable T-Arm Low ( ) E0973 $340 Not available with Seat Depths less than minimum Rear Wheel Spacing q Angle Adjustable Locking Extendable Flip Up E0973 $265 Requires Fixed Height Backrest. Not available with backrest heights less than 12. 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 Not available with Angle Adjustable Locking Extendable Flip Up Armrest Foam Grip N/C q Desk q Full Available only with Angle Adjustable Locking Extendable Flip Up Armrest Armrest continued q Short Swing Away (7-9 ) E0973 $195 Not available with Arm Pads or Outward Offset Back Posts. If selection is not available with rear wheel and rear seat height configuration, then Tall Swing Away armrest will be used. q Tall Swing Away ( ) E0973 $195 Not available with Arm Pads or Outward Offset Back Posts q Short Swing Away with Side Guard (7-9 ) E0973 $285 Includes Composite Side Guard with Direct Mount Receiver. Not available with Arm Pads or Outward Offset Back Posts. If selection is not available with rear wheel and rear seat height configuration, then Tall Swing Away with Side Guard armrest will be used. q Tall Swing Away with Side Guard ( ) E0973 $285 Includes Composite Side Guard with Direct Mount Receiver. Not available with Arm Pads or Outward Offset Back Posts. q Omit Armrests N/C Side Guards Not available with T-Arms or Swing Away with Side Guard Armrests Direct Mount q Composite Side Guards K0108 $ minimum Seat Depth Aluminum Adjustable Fender with Foam Pad K0108 Not available with Adjustable Depth greater than 1/2 q Black Matte $275 q Match Frame Color $325 Not available with Hydrographics q Carbon Fiber Adjustable Fender K0108 $485 Not available with Adjustable Depth greater than 1/2 Clamp-On Mount q Composite Side Guards K0108 $ minimum Seat Depth q Composite Side Guards - Pediatric K0108 $140 Aluminum Adjustable Fender with Foam Pad K0108 q Black Matte $305 q Match Frame Color $355 Not available with Hydrographics q Carbon Fiber Adjustable Fender K0108 $515 Fabric Side Guard Not available when omitting Back Upholstery q Fabric Side Guards K0108 $85 Accessories 5th Wheel Rotating removable rear caster. Not available with Anti-Tips or 25 rear wheel. q Standard 5th Wheel E0971 $210 Dynamic 5th Wheel K0108 $210 Elastomer: q Soft q Firm Both elastomers are included; the selected elastomer will be installed Anti-Tip Not available with 5th wheel q Rear Anti-Tips E0971 $140 Calf Strap q Velcro Adjustable K0038 $35 q Padded Velcro Adjustable K0038 $68 q Bodypoint Padded AeroMesh K0038 $102 Belt Mounting Kit q Ki Mobility Belt Mounting Clamp $35 q Bodypoint Belt Mounting Bracket Kit $105 Positioning Belt q 1 Auto Buckle E0978 $70 q 1 Padded Auto Buckle E0978 $155 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 ) DCN Pricing and specifications subject to change without notice Page 6 of 15

7 Accessories continued Spoke Guards q Clear Spoke Guards K0065 $115 Not available with Mag wheel q Black Spoke Guards K0065 $115 Not available with 18 or 20 wheel sizes or Mag wheel Designer Spoke Guards K0065 $200 Available only with 20 and 22 wheel sizes. Not available with Mag wheel. Design: q Blue Monster q Fairy Garden q Havin a Hoot q Robo Fun q Rockin Reptiles q Super Puppies q Tutu Cute q Tuxedo Time Color Other Accessories q Tool Kit $45 q Removable Underseat Pouch $50 q Pediatric Ki Mobility Backpack $65 q Ki Mobility Backpack $65 Best fit on chairs more than 10 wide q Luggage Carrier $85 q Black Neoprene Impact Guards $85 q Under Chair Carrier and Removable Bag $85 Not available with Seat Widths less than 14 q Cane and Crutch Holder $195 Frame and Accent Select desired frame and accent colors. Accent color is used on backrest rigidizer bar; if no accent color is selected, frame color will be used. Gloss Finish Frame Accent Matte Finish Frame Accent Black N/C q q Army Green N/C q q Blue Skies N/C q q Charcoal Gray N/C q q Bubblegum Pink N/C q q Emerald Green N/C q q Candy Blue N/C q q Iridescent Burgundy N/C q q Candy Purple N/C q q Iridescent Navy N/C q q Candy Red N/C q q Retro Red N/C q q Copper N/C q q Royal Blue N/C q q Granny Smith N/C q q Shadow Black N/C q q Metallic Fuchsia New! N/C q q Smooth White N/C q q Metallic Orange N/C Silver N/C q q q q Colored Anodizing Package Teal N/C Yellow N/C q q Hydrographics Visit for current Hydrographic options. Available on frame only; please choose accent color above. Note selection below. q $695 Not available with Transit Option q q Select desired color. If no selection is made, black will be used. Included in Colored Anodizing Package: Backrest plates, release cable housings, camber tube, towers, CG clamps, side guard receivers, RP tuning housing, front caster forks (standard or Single Sided) and Dynamic 5th Wheel split clamp. Camber tube not included if Wheelchair Drive Ready is selected. q Black N/C q Blue $165 q Bright Green $165 q Orange $165 q Pewter $165 q Pink $165 q Purple $165 q Red $165 q Gold $165 DCN Pricing and specifications subject to change without notice Page 7 of 15

References A. Seat Width See Diagram 1 Measured from outside of frame tube on one side to outside of frame tube on other side. B.

Sling Position See Diagram 2 In Performance Position (0 ), sling is at front of frame to keep chair shorter and more maneuverable.

Front Frame Bend See Diagram 3 Angle between front seat tube and ground. E. Footrest Taper See Diagram 1 Indicates bend of front frame creating footrest.

8 References A. Seat Width See Diagram 1 Measured from outside of frame tube on one side to outside of frame tube on other side. B. Seat Depth See Diagram 3 Measured from front of back posts to front edge of seat sling. Seat sling starts at beginning of bend at front of frame. C. Sling Position See Diagram 2 In Performance Position (0 ), sling is at front of frame to keep chair shorter and more maneuverable. The 1 or 2 seat sling position extends the frame in front of the sling by that amount. Adding more frame can improve stability and provide support to aid in transfers. Diagram 1 K F A G E D. Front Frame Bend See Diagram 3 Angle between front seat tube and ground. E. Footrest Taper See Diagram 1 Indicates bend of front frame creating footrest. Taper is measured from outside of seat frame to outside of front tube. F. Front Seat Height See Diagram 1 Measured from floor to top of seat tube at front of seat sling. G. Footrest Width See Diagram 1 Measured from inside of front tube to inside of front tube on other side. Footrest width is listed below for each seat width and taper. Seat Width Straight 1 Taper Outside Measurement 2 Narrower than Seat Width Narrower than Seat Width Diagram 2 C H. Seat to Footrest Length See Diagram 3 Measured from front edge of seat sling to top rear of footrest. Footrest length of at least 2.5 shorter than front seat height recommended. I. Rear Seat Height See Diagram 3 Measured from floor to top of seat tube at front of back post. Rear seat height is custom to needs. Diagram 3 B J. Center of Gravity Preset See Diagram 3 Measured from front of back post to center of rear axle. 0 indicates axle will be directly under back post. H J I K. Rear Wheel Spacing See Diagram 1 Measured from outside of seat back to inside of rear tire. Adjustable out.5 from setting. D DCN Pricing and specifications subject to change without notice Page 8 of 15

9 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 9 of 15

10 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 On Demand On Demand products are ordered with an extended lead time 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 10 of 15

11 Elite Deep Back HCPCS Code: E2620 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 On Demand On Demand 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 11 of 15

12 MX2 Back HCPCS Code: E2615 Weight Capacity: 250 lbs. The MX2 Back is On Demand only. On Demand products are ordered with an extended lead time. 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 12 of 15

13 Mini Back Comes standard with Kidabra cover. Weight Capacity: 150 lbs. Quick Ship Quick Ship products are stocked q Matrx Mini Back 10 x 07 - MINI1007 $625 q Matrx Mini Back 10 x 10 - MINI1010 $625 q Matrx Mini Back 10 x 12 - MINI1012 $625 q Matrx Mini Back 10 x 14 - MINI1014 $625 q Matrx Mini Back 12 x 07 - MINI1207 $625 q Matrx Mini Back 12 x 10 - MINI1210 $625 q Matrx Mini Back 12 x 12 - MINI1212 $625 q Matrx Mini Back 12 x 14 - MINI1214 $625 q Matrx Mini Back 14 x 07 - MINI1407 $625 q Matrx Mini Back 14 x 10 - MINI1410 $625 q Matrx Mini Back 14 x 12 - MINI1412 $625 q Matrx Mini Back 14 x 14 - MINI1414 $625 Kid*ab*ra Cushion Weight Capacity: 150 lbs. HCPCS Code: E2615 On Demand On Demand products are ordered with an extended lead time q Matrx Mini Back 11 x 07 - MINI1107 $625 q Matrx Mini Back 11 x 10 - MINI1110 $625 q Matrx Mini Back 11 x 12 - MINI1112 $625 q Matrx Mini Back 11 x 14 - MINI1114 $625 q Matrx Mini Back 13 x 07 - MINI1307 $625 q Matrx Mini Back 13 x 10 - MINI1310 $625 q Matrx Mini Back 13 x 12 - MINI1312 $625 q Matrx Mini Back 13 x 14 - MINI1314 $625 HCPCS Code: E2607 Quick Ship Quick Ship products are stocked q Matrx Kid*ab*ra Cushion 12 x 12 - KA1212-VI $425 q Matrx Kid*ab*ra Cushion 12 x 14 - KA1214-VI $425 q Matrx Kid*ab*ra Cushion 14 x 12 - KA1412-VI $425 DCN Pricing and specifications subject to change without notice Page 13 of 15

14 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 Only for Swing Away Lateral Medium 3.75 H x 5.75 L - EPAD-M q Quantity 1 $110 q Quantity 2 $220 Pad Only for Swing Away Lateral Large 4.25 H x 6.5 L - EPAD-L q Quantity 1 $110 q Quantity 2 $220 Hardware Options On Demand On Demand 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 On Demand On Demand products are ordered with an extended lead time q Elite Lateral Fixed Hardware with Standard Pad 5 H x 7.5 L (Left) PBLS-L $110 q Elite Lateral Fixed Hardware with Standard Pad 5 H x 7.5 L (Right) PBLS-R $110 q Elite Lateral Fixed Hardware with Small Pad 3 H x 5.5 L (Left) PBSS-L $110 q Elite Lateral Fixed Hardware with Small Pad 3 H x 5.5 L (Right) PBSS-R $110 q Elite Lateral Fixed Hardware with Offset Pad 5 H x 7.5 L (Left) PBOL-L $110 q Elite Lateral Fixed Hardware with 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 On Demand On Demand 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 14 of 15

15 Comfort Company Curve Cushion Weight capacity for cushions 13 wide and under: 100 lbs. Weight capacity for 14 wide cushions: 150 lbs. HCPCS Code: E2601 Quick Ship Quick Ship products are stocked q Comfort Company Curve Cushion 10 x 10 - CU-FV-1010 $99 q Comfort Company Curve Cushion 10 x 11 - CU-FV-1011 $99 q Comfort Company Curve Cushion 10 x 12 - CU-FV-1012 $99 q Comfort Company Curve Cushion 10 x 13 - CU-FV-1013 $99 q Comfort Company Curve Cushion 11 x 10 - CU-FV-1110 $99 q Comfort Company Curve Cushion 11 x 11 - CU-FV-1111 $99 q Comfort Company Curve Cushion 11 x 12 - CU-FV-1112 $99 q Comfort Company Curve Cushion 11 x 14 - CU-FV-1114 $99 q Comfort Company Curve Cushion 12 x 10 - CU-FV-1210 $99 q Comfort Company Curve Cushion 12 x 11 - CU-FV-1211 $99 q Comfort Company Curve Cushion 12 x 12 - CU-FV-1212 $99 q Comfort Company Curve Cushion 12 x 13 - CU-FV-1213 $99 q Comfort Company Curve Cushion 12 x 14 - CU-FV-1214 $99 q Comfort Company Curve Cushion 13 x 10 - CU-FV-1310 $99 q Comfort Company Curve Cushion 13 x 11 - CU-FV-1311 $99 q Comfort Company Curve Cushion 13 x 12 - CU-FV-1312 $99 q Comfort Company Curve Cushion 13 x 13 - CU-FV-1313 $99 q Comfort Company Curve Cushion 13 x 14 - CU-FV-1314 $99 q Comfort Company Curve Cushion 14 x 11 - CU-FV-1411 $99 q Comfort Company Curve Cushion 14 x 12 - CU-FV-1412 $99 q Comfort Company Curve Cushion 14 x 13 - CU-FV-1413 $99 On Demand On Demand products are ordered with an extended lead time q Comfort Company Curve Cushion 10 x 14 - CU-FV-1014 $99 q Comfort Company Curve Cushion 11 x 13 - CU-FV-1113 $99 q Comfort Company Curve Cushion 14 x 10 - CU-FV-1410 $99 DCN Pricing and specifications subject to change without notice Page 15 of 15

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

This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Canada Company: Account Number: Date: q Quote q PO Number: RTS: Marked For: Rogue XP $3705 Rogue