Client: P.O.#: AT MSRP List AP3 AP4 GAP GAPS 1386/87 FUA PT0031 3 x 12 Desk Length Leatherette 4 x 16 Tapered Leatherette Standard Height Adjustable, Removable Armrest Flip-Up Armrest Left $37.50/ea. $164.00/ea. $164.00/ea. $565.00 $615.00 K0020 K0020 K0106 K0106 Non-Powered 1347 1548 1355 1371 AMP Center Mount, Fixed, One Piece, Height Adj. Center Mount, Flip-Up, Angle Adj., One Piece, Height Adj. Center Mount, Flip-Up, Angle Adj., Two Piece, Height Adj. Side Mount, Flip-Up, Two Piece, Height Adj. Amp Support Non-Powered Legrest Options CS SP102M/SP102L Calf Strap (side mount only) Calf Strap (side mount only) BODYPOINT Aeromesh M-36 HL Heel Loops 1550 Center Mount Calf Pads SMCP Side Mount Calf Pads 827A Foot Straps Special Request: Powered or L-40 $150.00 $160.00 $160.00 $351.00/ea $90.00 $90.00 $95.00 $430.00 $460.00 $68.00 5 / Powered Legrest Options SMCP Calf Pads for Side Mount Legrest w/breathable fabric $230.00 827 / / 5. 5. 5. Foot Straps $68.00 K0040 K0037 K0037 K0037 K0038 K0038 E0951 E0995 HEADREST MPS Rehab HD-MF MPS Headrest LATERAL SUPPORTS MPS Comfort Company Moldable Headrest Pad Removable Multi-Axis Headrest Hardware $.00.00 5. L -L/RS4W4T Comfort Company Single Lateral Pad Rigid, 5 W x 4 T, Stretch-Air Cover Right Left circle xs,s,m,l $53.00/ea LT1-SA omfort Company Single Swingaway Lateral Hardware Right Left $4. /ea E08955 E1028 E1028 E0956 Rehab LT1-SA Comfort Company Single Swingaway Lateral Hardware Right Left $263/ea E1028 LT1-RGD Comfort Company Single Rigid Lateral Hardware Right Left $79.00/ea E0956 LT1-L/RS4W4T Comfort Company Single Lateral Pad Rigid, 5 W x 4 T, Stretch-Air Cover Right Left circle xs,s,m,l $53.00/ea E0956 CHEST HARNESS 1401 Loop Style Positioning Chest Strap $105.00 E0960 SH103M Chest Strap BODYPOINT Monoflex, Rear-Pull M $110.00 E0960 BUTTERFLY STYLE: PBH Padded Butterfly Positioning Chest Strap $143.00 E0960 SH331L-B1 BODYPOINT Stayflex, Narrow Front-Pull L without zipper $168.00 E0960 Pg. 3
CHOOSE JOYSTICK TYPE: DXREM420 Standard Joystick Module. No LCD Display and No Mono Jacks E2323 DX2 Color LCD Display w/mono Jack Ports for External Switches $380.00 E2323 CHOOSE JOYSTICK HANDLE TYPE: Cone-Shaped - Standard BodyPoint U Shaped w/flex Shaft 3 4 $143.00 E2323 BodyPoint Rubber Grip Handle 3 $134.00 E2323 BodyPoint Mushroom Head Rubber Grip Handle 2 2.5 $134.00 E2323 $134.00 E2323 CHOOSE JOYSTICK MOUNT: 4 Left - Adjustable Depth 4 Right- Adjustable Depth Swingaway Joystick Left 5 Right 5 $480.00 E2323 Midline Mount Armrest Right Armrest Call for Quote E1028 JOYSTICK ACCESSORIES: JSLK Joystick Lock- Electronically locks chair from driving $175.00 RVAL Reverse Alarm $175.00 ALTERNATIVE DRIVE SYSTEMS: Head Array Chin Control ASL Stealth Switch-It Stealth Bibmount (Mini) Call for Quote ENVIRONMENTAL CONTROLS: iportal Control Unit - Integrates Apple Devices (iphone, ipod, ipad) into Dynamic $950.00 iportacc iportal with Computer Mouse Accessibility. Allows user to operate any computer through sip and puff, head array, or joystick through Blue Tooth connection $1,600.00 HIP GUIDES 1509 Hip Guides $300.00 KNEE ADDUCTORS Knee Adductors; Multi-Axis; Removable with 4.5x6 Pad $3 0.00 1608 1608XL ABSB EB205L-B1/HW312-KIT WC19 Push Button Style Seat Pos. Strap - 64 Push Button Style Seat Pos. Strap - 80 Airline Buckle Seat Pos. Strap BODYPOINT Evoflex Pelvic Stabilizer L And Mounting Bracket Kit $12.00 $14.00 Transit Hooks (WC 19 Compliant) with Lap Belt $1250.00 1330 1872 1342 1337 2171 RDC V6 Seating Systems below include: Either a MPS Seat/Seat Cushion, MPS Seat Back w/ Solid Seat Pan, or Rehab Seat (see pg. 1 for a description of each style), and height adjustable armrest. (No charge if ordered w/ Power Tilt or Recline) V6 MPS Seating System or Rehab Seating w/ No Power Seating Options V6 w/ 50 Power TIS* V6 Rehab Seating System w/ 135 Integrated Shear Reduction (ISR) Power Recline* V6 MPS Seating System w/ 135 Power Recline* V6 w/ 12 Seat Elevator* - 300 lb. Capacity Reduced Drive Capability TIS Seat Elevator (Option for driving while elevated and/or tilted) *Must be ordered with upgraded elecronics SFCK or MFCK depending on number of options selected $2,780.00 $4,995.00 $4,968.00 $3,495.00 $4,495.00 $700.00/ea. K0108 E1002 E1004 E1003 E2300 K0108
Client: P.O.#: AT MSRP List SFCK MFCK Single Seat Function Control Kit - Function through: Joystick For operation of a single seat function through the wheelchair electronics via the drive controls $1,365.00 E2310 and/or membrane switch. TOG2 Separate Toggle $ 600.00 (add for separate toggle) Multiple Seat Function Control Kit - Function through: Joystick MUST be selected if ordering two or more seat functions. This device is used to operate two or more seat functions through the wheelchair electronics via the drive controls and/or membrane switch. TOG4 Separate Toggle $2,793.00 E2311 $ 600.00 (add for separate toggle) 12 x 12 12 x 14 14 x 12 14 x 14 14 x 16 16 x 16 16 x 18 18 x 16 18 x 18 18 x 20 20 x 18 20 x 20 22 x 18 22 x 20 24 x 18 24 x 20 1360 1520 1519 15 V Standard MPS Seat Back 4 Extra Tall Seat Back All Vinyl Seat Back 4 Extra Tall Seat Back - All Vinyl $395.00 $195.00 $590.00 CU-FN 46G M2-F BK-M BK-R BK-V Curve Cushion - Molded foam w/ medial & lateral thigh supports - size: W x L Elements Cushion - Single layer foam with quadra gel pack - size: W x L M2 Cushion - Quadra gel with pelvic, lateral & medial thigh supports - size: W x L ACTA - Back - with moldable center section and high resiliency wings circle height: 12 14 16 18 20 22 Radius Back - with high resiliency foam circle height: 12 14 16 18 20 22 Visco Back - with high resiliency foam circle height: 12 14 16 18 20 22 $86.00 $86.00 $305.00 $640.00 $636.00 $578.00 E2601 E2601 E2607 E2613 E2611 E2611 1396 Removable Clear Polycarb Table (May not work w/ some options) $525.00 E0980 1605 Waterproof Wheelchair Cover $121.00 K0108 1606 Waterproof Joystick Cover $40.00 K0108 1604 Deluxe Backpack $64.00 K0108 1603 Armrest Bag $26.00 K0108 2304 Full Lighting Kit- 2 headlights, 2 Red Marker Lights w/turn Signals through Joystick $995.00 K0108 1137 Luggage Rack $270.00 K0108 PT0029 Mud Guards (Drive tires only) $315.00 K0108 PT0035 Cane Holder (May not work w/some options) $302.50 PT0052 Cup Holder $100.00 PT0036 Lift Brackets- Used with 4-Point Boom Lift (NOT approved as transport tie downs) $368.00 A02H Articulating Oxygen Holder $800.00 PWB Power Buddy- Includes USB Charging Port and Reading Light $119.95 $. $. $1. LGSVC $1. discounts do not apply Pg. 4
Client: P.O.#: AT MSRP List BAT BCSTD B Group 24 Sealed LA/AGM, Installed (Two Required) $275.00/ea. E2363 Battery Charger $ 5.00/ea. Special Notes: *Please note that the HCPCS codes indicated on this order form are our interpretation of the new codes and how we believe our products should be coded. The individual DMERC S will determine if our interpretation is appropriate and whether or not items will be accepted or denied. IIM cannot guarantee that use of the designated codes will ensure coverage or payment. Contact the insureer to confirm compliance with coding and coverage policy. *Innovation In Motion recommends all wheelchairs be fitted and programmed to the user under the guidance of the healthcare professional, knowledgeable of the particular limitations of the product. *All specifications and dimensions are approximate. *Specifications and prices are subject to change without notification. *Effective IIIQTR201. Pg. 5