NUTEC ITEMIZED. Custom Configured Seating. Order form and Price List. USA Fax HCPCS Code: E2609 & E2617.

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1 ccount Information ate ill To Phone Number ccount Number Fax Number NUT ITMIZ ustom onfigured Seating Order form and Price List ffective ate 05/01/2017 mail ddress uyer P.O. Number Patient Name Ship To Name ll specifications and pricing are subject to change without notice Otto ock Healthare LP _1I 05/01/2017 ddress ity State/Zip ode Phone Number Please complete this form and return to Ottobock by fax OR click the button to send via . Order Quote Only Notes: HPS ode: 2609 & 2617 US Page 1/9

2 Seating Specifications Insert imensions ack Width Lateral Width (hest Width) Hip Width Seat Width ack Height F Lateral Height F G Seat epth H Total Seat epth H G (dd 1" 3" to G for growth) Seating Upholstery Upholstery olor Options (choose Seating System Upholstery) ontact Surface color ccent Fabric color Lettering lock Script ontact Surface Fabrics ccent Vinyl Fabrics 194 lack artex 169 Red 226 Marina lue 253 Sparkle Red 194R Reversed lack artex 227 Raspberry 225 Grape 255 Sparkle lue 195 lack arlexx 223 Light Pink 224 ark Purple 257 Sparkle lue-green 201 lack Neoprene 293 Laser Pink 158 lack 259 Sparkle Green 390 right Yellow 151 arbon 258 Sparkle Purple 135 Forest Green 154 Light Gray 256 Sparkle harcoal 167 Teal 162 ark Gray *See fabric swatch for additional upholstery options mbroidered Name Thread color Wheelchair escription Model Seat Width Seat epth ack Height Tubing Shape Round Square Rectangular Tubing iameters Seat 3/4" 7/8" 1" Other Top of ack 3/4" 7/8" 1" Other ottom of ack 7/8" 1" 1 1/8" Other lient Measurements in inches HH Head Height SH Shoulder Height US User Seat epth LL Leg Length hest epth W hest Width HW Hip Width H xilla Height H lbow Height SW Shoulder Width HW Head Width H Head ircumference US Page 2/9

3 Solid Seat Modifications [2609] Note: Please include ase Material Thickness in all thickness measurements. Standard Seat Rear is 2" overall (1 1/2 Foam). Seat onstruction (Must hoose One): Full Width etween Seat Rails etween Seat Rails/Full Width Foam 47049= Rectangular Seat nti-thrust Seat TSM $224 symmetrical S $80 Seat epth Left Side Long F Wedge Seat WSF $71 I Seat ISM $130 F symmetrical S $80 Seat epth Right Side Long ontoured Seat SM $237 F Split Seat LSS $386 ustom rawing G K G H I H J L H J K L dditional Seat Modifications 47049=TSM dj. epth nti-thrust (fill in nti-thrust "" " to ") $ =TSM dj. epth ontoured nti-thrust (fill in nti-thrust "" " to ") $ =IMTS uilt in Medial Thigh Support $ =ILS uilt in Lateral Supports $ =WFSM Waterfall Front Seat $ =GSM Grid Seat $ =POM Pelvic Obliquity $ =NOTH Notch for ack Posts No harge 47049=S Separate ase and ushion No harge US Page 3/9

4 Solid ack Measurement Modifications [2617] Note: Please include ase Material Thickness in all thickness measurements. Standard ack Thickness is 1 1/2" overall (1" Foam) (unless specified). ack onstruction (Must hoose One): Full Width etween ack Posts etween ack Posts/Full Width Foam 47049= Rectangular ack I ack IM $130 T ack TM $130 iangular ack M $327 urved ack NTurve $130 (wood) urved by Foam F $130 Rotational RM $419 Scapular ut Outs SRO $104 Lumbar Support LRF $130 ustom rawing Hardware LRH $293 dditional ack Modifications 47049=OM ontoured ack $ =LM Lateral ontrol ack $ =GM Grid ack $ =WF Wedge ut ack Foam $ =SPRO Spinal Relief ut Out $ =SRGI Spinal Relief Gel Insert $ =RF ynamic xtension Relief $ =IRF Independent ynamic xtension Relief $291 US Page 4/9

5 Finishing Options -ST 47049=SOL 2609 Incontinence Liners - Spray-on (ir permeable) $ =I 2609 Incontinence Liners - Sew on (zippered) $ =RS 2609 overs- Removable, secondary (top of cover is replaceable) $ =M 2609 overs- xtra over Modification (omplete cover - requires hardware removal for replacement) 47049=FM 2609 overs- 3 imensional Spacer Fabric $ =H 2609 Heavy uty onstruction (3/4" base, extra mounting hardware as needed) $114 Foams - Standard Foam is 1 1/2" High ensity in Seat (#'s from foam samples) 47049=SFSM 2609 Sunmate, per inch Soft (#4) (#5) $ =SFTF 2609 T-Foam, per inch xtra Soft ( #10) Soft (#11) (#12) Firm (#13) 47049=PF Pudgee, per inch (#6) $ =PF Pudgee, 2 inch (#7) $ =GLS 2609 ction Gel Insert (#14) $ =FIPS 2609 Foam in Place (1 unit SSM) $ =SF 2609 dditional Standard Foam per 1/2" (#2) $16 $77 $87 ustom Seat Foam Please indicate foam type by #s from Foam Samples. Specify foam thickness for each layer. 1/2" Wood (Top) (Middle) (ottom) Finishing Options -K 47049=SOL 2617 Incontinence Liners - Spray-on (ir permeable) $ =I 2617 Incontinence Liners - Sew on (zippered) $ =RS 2617 overs- Removable, secondary (top of cover is replaceable) $ =M 2617 overs- xtra over Modification (omplete cover - requires hardware removal for replacement) $ =FM 2617 overs- 3 imensional Spacer Fabric $ =H 2617 Heavy uty onstruction (3/4" base, extra mounting hardware as needed) $114 Foams - Standard Foam is 1" High ensity in ackrest (#'s from foam samples) 47049=SFSM 2617 Sunmate, per inch Soft (#4) (#5) $ =SFTF 2617 T-Foam, per inch xtra Soft ( #10) Soft (#11) (#12) Firm (#13) 47049=PF Pudgee, per inch (#6) $ =PF Pudgee, 2 inch (#7) $ =GLS 2617 ction Gel Insert (#14) $ =FIP 2617 Foam in Place (1 unit SSM) $ =SF 2617 dditional Standard Foam per 1/2" (#2) $16 $87 ustom Seat Foam Please indicate foam type by #s from Foam Samples. Specify foam thickness for each layer. 1/2" Wood (Top) (Middle) (ottom) US Page 5/9

6 Seating Packages (Includes hinged seat and/or back with all mounting hardware) 47049=SS Seat/ack with Knob Hardware - 14" and smaller $1, =SS100-S 2609 Seat with Knob Hardware - 14" and smaller $ =SS ack with Knob Hardware - 14" and smaller $ =SS Seat/ack with Knob Hardware - 15" and r $1, =SS101-S 2609 Seat with Knob Hardware - 15" and r $ =SS ack with Knob Hardware - 15" and r $ =SS Seat/ack with djustable rop Hook Hardware - 14" and smaller $1, =SS Seat/ack with djustable rop Hook Hardware - 15" and r $1, =SS ack with Knob Hardware and Velcro Seat - 14" and smaller $ =SS ack with Knob Hardware and Velcro Seat - 15" and r $1, =SS Mini Seat/ack with Mini Knob Hardware 10"-12" wide $1, =SS107-S 2609 Mini Seat with Mini Knob Hardware 10"-12" wide $ =SS Mini ack with Mini Knob Hardware 10"-12" wide $ =SS Planar Seat and ack 1" clips $743 Solid Seats with Hardware (4 point attachment) 47049=SFH Solid Seat with Flush Mount rop Hooks $ =SFH Solid Seat with 1" rop Hooks $ =SFH Solid Seat with 2" rop Hooks $ =SH Solid Seat with djustable rop Hooks $ =SKR Solid Seat with Knob Release Hardware - 2 pair $ =VL L Versa Lock lips in Lieu of Horseshoe lips - 1 pair $ =VL L Versa Lock lips in Lieu of Horseshoe lips - 2 pair $149 Solid Seats without Hardware 47049=SSI Solid Seat Insert (comes standard with hook and loop) $ =SSI Solid Seat Insert with T-Nuts $233 rop ases 47049=F100 Plastic ase with Flush Mount rop Hooks $ =F101 Plastic ase with 1" rop Hooks $ =F102 Plastic ase with 2" rop Hooks $ =100 Plastic ase with djustable rop Hooks $337 Solid acks with Hardware (4 point attachment) 47049=NTFH Solid ack with Flush Mount rop Hooks $ =FH Solid ack with 1" rop Hooks $ =FH Solid ack with 2" rop Hooks $ =H Solid ack with djustable rop Hooks $ =KR Solid ack with Knob Release Hardware - 2 pair $ =VL L Versa Lock lips in Lieu of Horseshoe lips - 1 pair $ =VL L Versa Lock lips in Lieu of Horseshoe lips - 2 pair $149 Solid acks without Hardware 47049=SI Solid ack Insert (comes standard with hook and loop) $ =SI Solid ack Insert with T-Nuts $258 Seat to ack racket 47149=STHF Flush Hinge $ =STH15 1 1/2" Offset Hinge $ =STH30 3" Offset Hinge $118 US Page 6/9

7 Thoracic and Lateral Support Lateral Hip/Thigh Supports [ ] 47149= Lateral Thoracic Supports [ ] 47149= ustom Pad Thickness Note: Standard Pad Thickness is 1." Hardware Fixed racket LHS-F $317 Quick Release racket LHS-QR $594 Offset Inch 1" 2" Medial Thigh Support (Hip bductor) 47149= [ ] Flat Pad ustom urved Pad H 3 x 4 4 x 5 5 x 6 x ustom Pad Thickness Note: Standard Pad Thickness is approximately 3/4" Hardware Fixed rackets LTS-F $317 Summer Winter rackets LTS-SW $569 Push utton Swingaway rackets LTS-P $617 Summer Winter Swingaway rackets LTS-SWP $685 Lift to Release Swingaway LTS-S $538 Offset Inch 1" 2" ustom WF x WR x x H 3 x _1 1/2_ x _3 1/2_ x 3 3 1/2_ x _2 1/2_ x 4 x 3 1/2 4 x 3 x _4 1/2_ x 4 x x x Hardware Flip own racket -F $503 Slide Out racket -SO $323 rop In racket -I $507 Quick Release Flip Under -FQR $530 Tracks [K0108] 47049= 11" ouble NT-TRK-11 $72 11" Single NT-TRK-11S $71 13" ouble NT-TRK-13 $77 15" ouble NT-TRK-15 $79 3" ouble NT-TRK-3 $64 3" Single NT-TRK-3S $60 5" ouble NT-TRK-5 $66 5" Single NT-TRK-5S $65 7" ouble NT-TRK-7 $68 7" Single NT-TRK-7S $67 9" ouble NT-TRK-9 $70 9" Single NT-TRK-9S $69 Lateral Knee Supports 47149= Lateral Knee Supports [ ] $226 (lamp on to footrest hanger) Pad Size 3" Round 4" Round ustom x Tubing iameter 7/8" NT-LKS78 1" NT-LKS88 racket Height Short Tall rm Rest (Hip Support Mount) 41149= Fixed Height R-FH $317 djustable Height R-H $536 US Page 7/9

8 Headrest Support [ ] 47149= Multi-xis Offset HR-MRKT $295 Rock-n-Lock HR-RNLRKT-4 $431 RLRKT-M-4 $506 (Multi-xis Mod.) RLRKT-4M $631 (ynamic Mod.) L-racket HR-LRKT $112 Flip own Rock-n-Lock HR-FRKT-4 $489 HR-FRKT-M-4 $404 (Multi-xis Mod.) FRLRKT-4M $569 (ynamic Mod.) epth djustable HR-RKT $305 oncave HR-P $198 Size S M L Lateral ontrol HR-LP $252 Size S M L 3-Pad Fixed HR-3PP $275 Hinged HR-3PHP $351 Size S M L Komfi Fit HR-KFP $238 One Size Only djustable oncave HR-P $301 Size M L elled HR-LP $282 One Size Only Foot Supports [K0108] 47149= Pelvic 47149= Positioning elts [0978] Footboxes Mounting Options Hip elt Padded olt to Footplate Miniature 1" P-PH-M $45 olt to Solid Seat (fixed angle) Pediatric 1½" x 44" P-PH-P $45 Other dult 2" x 48" P-PH- $54 ouble Leg Footbox $518 W H F-LS _11_ x _8_ x _7_ F-LM _13_ x _10_ x _9_ F-LL _15_ x _12_ x _11_ ustom F-L x x Single Leg Footbox $603 W H F-SLS _5_ x _8_ x _7_ F-SLM _6_ x _10_ x _9_ F-SLL _7_ x _12_ x _11_ ustom F-SL x x Foot Supports with Padded Straps $230 FSS FSM FSL xtra FSXL nkle Holders $141 H-S H-M H-L xtra H-XL enter Pull - 2 Point Padded $112 xtra P-PHXS-P P-PHS-P P-PHM-P P-PHL-P xtra P-PHXL-P enter Pull - 4 Point Padded $137 xtra P-4PXS-P P-4PS-P P-4PM-P P-4PL-P ouble Rear Pull - 2 Point Padded $122 xtra P-PHXS-P P-PHS-P P-PHM-P P-PHL-P xtra P-PHXL-P ouble Rear Pull 4 Point Padded $156 P-4PS-P P-4PM-P P-4PL-P hest elts [0960] 47149= Static H-elt $156 P-HS P-HM P-HL ynamic H-elt $188 P-HS P-HM P-HL Static ack Pack Straps $130 P-PSS P-PSM P-PSL ynamic ack Pack Straps $163 P-PSS P-PSM P-PSL Static utterfly hest elt $171 xtra P-FXS P-FS P-FM P-FL ynamic utterfly hest elt $201 xtra P-FXS P-FS P-FM P-FL Strap Risers [K0108] 1" w/fastners SR-1 $67 2" w/fastners SR-2 $67 US Page 8/9

9 Wheelchair Trays (must fill in tray measurement form below) 47149=NT NUT Wheelchair Tray Please specify tray material: 1/4" lear crylic 1/4" S 3/8" Wood 3/8" Polycarbonate 47149=NT Full Padded Tray - 1/2' Wood & 1" Foam $ =TM-RIM 0950 dd 1/2" PV Rim to Tray $56 Tray Hardware 47149=TM-SR K0108 Standard Tray Rails $ =TM-TR K0108 Tubular Tray Rails $ =TM-LR K0108 am Lock Tray Rails $ =TM-T K0108 Tray lamps - Toggle $ =TM-TTK K0108 Toggle lamp Kit w/ Width djustable Support Rail $ =TRYTRKS K0108 Tray Tracks - For Mounting Tray Rails $64 Tray ccessories 47149=TM-RS K0108 Tray Retaning Strap $ =TM-SPP K0108 Shoulder Protection Pads - Tray Mount $ =TM-P K0108 lbow Pads - Tray Mount - Velcro On $ =TM-FP K0108 Tray Pad- Full Size - Velcro On $ =TM-HP K0108 Tray Pad- Half Size - Velcro On $ =TM-PO K0108 Powerdrive ut Out (indicate location on tray measurement form below) $36 Tray Measurement Form $159 Outside to Outside of rmrests Miscellaneous Items 47149=NT-O2H K0108 Oxygen Tank Holder- Frame Mount w/ lamps for ylinder $ =NT-LTVM-78 /-88 K0108 LTV Ventilator Mount - lamp on (fits 7/8 or 1" tubing) $ =NT-LTVM-S K0108 LTV Ventilator Mount - olt on $ =NT-IVP48 K0108 IV Pole lamp on 48" $431 mputee Support 47149=KS mputee Support - Multiarticular (fits 7/8 or 1" tubing) $ =KS mputee Support - ent Tube (fits 7/8 or 1" tubing) $ =KS-STRP K0108 Positioning Strap for mputee Support $31 US Page 9/9