ST: Dealer Phne: ( ) Fax: ( ) ZIP: SUBMITTING F: Qute Order a Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price 1. FRAME STYLE Designed in cnjunctin with Baby Jgger allwing their patented quick fld technlgy which allws ne t fld a base unit after remving the seat in ne simple step and with a secure fld latch fr easy strage. Each unit includes: 199BS7 Date: Dealer Acct #: Dealer: Dealer Address: s 12" rear tires & 7" frnt casters s Frnt caster suspensin & swivel lcks s 75 lbs Weight Capcity Vyage Fr Advanced Seating Dealer Cntact: Dealer City: 199BS8 199BS14 E1232 E1234 Vyage fr Mderate Seating 199BS9 E1232 E1234 Frame Style Vyage fr Advanced Seating with Tilt - Includes Seating Vyage fr Mderate Seating with Tilt - Seating nt included in base price Zippie Vyage January 2019 EIZ16 s Quick release frnt and rear wheels s Adjustable seating Shell s Canpy w/ breathable windw/mesh pckets $2,445 $2,205 $2,445 $2,205 199BS10 199BS11 199BS13 Attentin: Address: Address: Ship T City: ST: ZIP: Cnfirm Via: Fax Email Ship T Phne: ( ) Fax: ( ) Mark Fr: s Hand perated Wheel Lck Vyage fr Mderate Seating with Tilt - Includes Seating PO#: Ship T: The HCPCS CODES prvided are based n cde verificatin thrugh PDAC r ur interpretatin f the cde definitins. The use f HCPCS CODES des nt ensure cverage r payment. Fr cverage infrmatin, verify the apprpriate payer's cverage plicy. Vyage fr Advanced Seating with Tilt - Seating nt included in base price s Telescping strller handle 199BS12 199KJ11 Bster Base Optins with seating s 45 Tilt s Fwd & Rwd facing seating capability s Under carriage strage (may be limited when sme ptins chsen) Vyage Bster Base with Tilt and Advanced Seating Vyage Bster Base with Tilt and Mderate Seating JCM Bster Base with Tilt and Advanced Seating JCM Bster Base with Tilt and Mderate Seating Transit Transit Optin $2,765 $2,765 $3,895 $3,895 $250 Fr Mderate Seating See page 2 Fr Advanced Seating See pages 3 and 4 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 1
199KM01 199KM02 Sectin A. Mderate Seating E1014 Recline Feature (required) $350 2. SIZE/SEATING - MODERATE SEATING Chse sectin A (when rdering base which includes seating) r B (when rdering base that des nt include seating in the base price) Mderate Seating is set up in the medium cnfiguratin listed in the matrix n page 7. 199KM03 199KM04 Sectin B. E2292 Mderate Seating E1014 Recline Feature (required) $350 Chse Uphlstery Clr (includes inner cvers and crssver canpy) 199KN01 Blue 199KN02 Red 199KN03 Beige 199KN04 Grey Chse Uphlstery Clr (includes inner cvers and crssver canpy) 199KN05 Blue 199KN06 Red 199KN07 Beige 199KN08 Grey 199KO01 199KO02 Psitining - Laterals (Optinal) Laterals Small - Pair $150 Laterals Large - Pair $150 199KO03 199KO04 Psitining - Laterals (Optinal) Laterals Small - Pair $200 Laterals Large - Pair $200 199KP01 199KP03 Psitining - Hip Guides (Optinal) Hip Guides - Pair Infant Insert - Pair (Hip Guides Reqd.) $125 199KP02 199KP04 Psitining - Hip Guides (Optinal) Hip Guides - Pair Infant Insert - Pair (Hip Guides Reqd.) Head Supprts (Optinal) 199VJ01 E0955 Head Supprts Small - Pair (Recmmended) $150 199VJ02 E0955 Head Supprts Large - Pair $150 199VJ03 199VJ04 E0955 E0955 Head Supprts (Optinal) Head Supprts Small - Pair (Recmmended) $160 Head Supprts Large - Pair $160 199KQ01 199KQ02 Psitining - Medial Supprt (Optinal) E0957 Medial Supprt - Tall $135 E0957 Medial Supprt - Cntur $140 Psitining - Medial Supprt (Optinal) 199KQ03 E0957 Medial Supprt - Tall $155 199KQ04 E0957 Medial Supprt - Cntur $160 199KR01 Grab Bar (Optinal) Grab Bar $135 199KR02 Grab Bar (Optinal) Grab Bar $145 3. WHEELS AND CASTERS Standard with Quick release rear and frnt wheels, and frnt wheel suspensin with caster swivel lcks 199WQ07 12" Pneumatic w/ Airless Inserts with 7" casters STD 4. FOOTREST 199F329 K0040 Angle Adj. Ftrest (Required) $155 5. POSITIONING AND TRUNK SUPPTS JAY Anterir Pelvic Belts - Standard 2 Pint Belt - Push Buttn 1" 199ZZ10 199ZZ11 N Pad (APB5110) 4.5" Pad (APB5115) 199ZZ12 5.5" Pad (APB5116) Standard 2 Pint Belt - Push Buttn 1 1/2" 199ZZ14 N Pad (APB7210) 199ZZ15 7.5" Pad (APB7212) V-Cntur Pelvic 4 Pint Belt - Push Buttn Varies 199ZZ24 199ZZ23 SM Pad - 1" Push Buttn (APB3716) Med Pad - 1-1/2" Push Buttn (APB3727) $40 $91 $91 $40 $86 $170 $170 Anterir Trunk Supprt - Style 199JY01 Classic Dynamic (ATS8100 Series) $152 199JY02 Classic Structure (ATS8300 Series) $152 199JY06 199JY05 JAY Anterir Trunk Supprts - Structure Classic nt available with Early Interventin Size Center Opening Dynamic (ATS8800 Series) Center Opening Structure (ATS9400 Series) Anterir Trunk Supprt - Size 199JZ05 Early Interventin 199JZ06 Xtra Small 199JZ01 Small $152 $152 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 2
Chse Depth (Based n 1" T-Back) 199SD78 Shrt 5" - 8" Depth 199SD79 Medium 7" - 10" Depth 199SD80 Lng 9" - 13" Depth 199CU28 199CU41 199CU42 199CU43 199CU39 199CU44 E2292 E2292 Planar Seat withut Hip Blcks Planar Seat w/ Hip Blck - Pair Cntured Wedge Seat Cntured Anti-Thrust (Ledge) Seat 2. SIZE/SEATING - ADVAED SEATING Chse sectin A (when rdering base which includes seating) r B (when rdering base that des nt include seating in the base price) Cushin includes: - Cntured Medium Density Fam - 6" t 13" Hip Width - 3" Lateral Hip Blcks (Pr) (Hip Blcks Nt avail. n Planar w/ Hip Blck cushin) - Slight Medial Thigh Cntur - Fixed Ischial Ledge -Built in Depth Grwth - Remvable Neprene Cver $265 $265 199ST65 Chse Fam 199FM1 199FM2 199FM3 Chse Depth (Based n 1" T-Back) 199SD78 Shrt 5" - 8" 199SD79 Medium 7" - 10" 199SD80 Lng 9" - 13" (4" grwth) Chse Fam Adjustable Cntur Seat Sft Fam Medium/Sft Fam Medium Fam Sectin B. (Seat ptins when rdering base that des nt include seating in base price.) - ADVAED SEATING Cushin includes: - Cntured Medium Density Fam - 6" t 13" Hip Width - 3" Lateral Hip Blcks (Pr) (Hip Blcks N/A n Planar w/ Hip Blck cushin) - Slight Medial Thigh Cntur - Fixed Ischial Ledge -Built in Depth Grwth - Remvable Neprene Cver E2292 Sectin A. (Seat ptins when rdering base which includes seating) - ADVAED SEATING Planar Seat withut Hip Blcks Planar Seat w/ Hip Blcks Pair $265 199ST60 ADJUSTABLE CONTOUR SEAT includes: -Adjustable Pre-Ischial Ledge - Adjustable 1" High Fam Wedges fr: Lateral Hip and Thigh Supprt Medial Knee and Thigh Supprt - 3" Seat Depth Grwth Kit - Remvable Neprene Cver ADJUSTABLE CONTOUR SEAT includes: -Adjustable Pre-Ischial Ledge - Adjustable 1" High Fam Wedges fr: Lateral Hip and Thigh Supprt Medial Knee and Thigh Supprt - 3" Seat Depth Grwth Kit - Remvable Neprene Cver Adjustable Cntur Seat $320 $420 199CU37 Cntured Wedge Seat 199FM1 Sft Fam 199FM2 Medium/Sft Fam 199CU38 Cntured Anti-Thrust (Ledge) Seat 199FM3 Medium Fam Chse Depth (Based n 1" T-Back) Chse Depth (Based n 1" T-Back) 199SD78 199SD79 199SD80 Shrt 5" - 8" Depth Medium 7" - 10" Depth Lng 9" - 13" Depth Lateral Hip Supprt (Adjusts frm 7-1/2" t 11" width) Only available with Planar seat withut Hip Blcks and Adj. Cntur seat. 199KH12 E0957 Small (3"Hx 2-1/2"Wx 4-1/2"L) $125 199KC6 SM (4"x 4", 3/8" thick) Right 199KH13 E0957 Large ( 3-3/4"Hx 4"Wx 6"L) $125 199KC4 SM (4"x 4", 3/8" thick) Left 199HE77 E1028 Hardware Medial Supprt Brkt 199KC5 LG (5-3/8"x 4-3/4", 1/2" thick) Right 199KC3 LG (5-3/8"x 4-3/4", 1/2" thick) Left 199KF6 199KF4 199KF5 199KF3 Lateral Thigh Supprt (Adjusts frm 3-1/2" t 11" width) Only available with Planar seat withut Hip Blcks and Adj. Cntur seat. E0953 SM (4"x 4", 3/8" thick) Right E0953 SM (4"x 4", 3/8" thick) Left E0953 LG (5-3/8"x 4-3/4", 1/2" thick) Right E0953 LG (5-3/8"x 4-3/4", 1/2" thick) Left LOWER BODY SUPPTS - ADVAED SEATING 199SD78 199SD79 199SD80 Shrt 5" - 8" Medium 7" - 10" Lng 9" - 13" Medial Supprt Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 3
3. WHEELS AND CASTERS Standard with Quick release rear and frnt wheels, and frnt wheel suspensin with caster swivel lcks 199WQ07 12" Rear Wheels - Pneumatic w/ Airless Inserts 7" casters STD 4. FOOTREST 199F312 K0040 Angle Adj. Ftrest (Required) $155 Ftrest adjustment range 1-1/2" - 12", Shrt Range, the ftplate will be inverted. Chse desired setting, if nt chsen Lng Range is default. 199F313 K0037 Preset in shrt range 1-1/2"-4" 199F314 Preset in lng range 4-1/2" - 12" 5. BACKREST - ADVAED SEATING ONLY BACKREST SHELL BACKREST OPTION 199BT111 Shrt 7" t 13" Height 199KJ9 E1014 Recline Feature ( 90-135 range) $350 Desired Backrest Height Setting (Bld indicates default, when nt picked ) 7" 8" 9" 10" 11" 12" 13" 199BT112 Tall 10" t 17" Height Desired Backrest Height Setting (Bld indicates default, when nt picked ) 10" 11" 12" 13" 14" 15" 16" 17" Sectin A. (Seat ptins when rdering base which includes seating) - ADVAED SEATING " T " Back 1" Thick " T " Back 2-1/2" Thick 199BT35 E2291 Shrt 8" t 10" 199BT28 199BT29 E2291 Medium 10" t 12" E2291 199BT56 E2291 Tall 12" t 14" Extra Tall 14" t 16" (N/A w/ Shrt Backrest Shell) BACK/SEATING OPTIONS Chse sectin A (when rdering base which includes seating) r B (when rdering base that des nt include seating in the base price) 2.5" "T" Back is used fr seat depths as small as 3.5". Backrest has remvable fam fr additinal depth grwth withut adjusting seat pan. 199BT115 199BT116 199BT117 199BT118 E2291 Shrt 8" t 10" E2291 Medium 10" t 12" E2291 Tall 12" t 14" E2291 Extra Tall 14" t 16" (N/A w/ Shrt Backrest Shell) Sectin B. (Seat ptins when rdering base that des nt include seating in base price.) - ADVAED SEATING " T " Back 1" Thick " T " Back 2-1/2" Thick 199BT103 E2291 Shrt 8" t 10" $305 199BT104 E2291 Medium 10" t 12" $305 199BT105 E2291 Tall 12" t 14" $305 199BT107 E2291 Shrt 8" t 10" Extra Tall 14" t 16" 199BT108 E2291 Medium 10" t 12" 199BT106 E2291 $305 (N/A w/ Shrt Backrest Shell) 199BT109 E2291 Tall 12" t 14" 199BT110 E2291 Extra Tall 14" t 16" (N/A w/ Shrt Backrest Shell) 2-1/2" "T" Back is used fr seat depths as small as 3-1/2", backrest has remvable fam fr additinal depth grwth withut adjusting seat pan. Head Supprts - ADVAED SEATING ONLY Hardware allws the headrest t be flush munted t backrest when abve shell. When chsing a Headrest ptin, Hardware Bracket must be chsen, Hardware available individually as well. Headrest Ht. Adj. Range based n Backrest shell hgt chsen in Sec. 5. i.e. Shrt Height adj.9" - 19.5" & Tall Height Adj. 13" - 23-1/2" frm seat pan. 199HE40 199HE41 199HE42 199HE43 199HE29 E0955 Whitmyer 8" Plush E0955 Whitmyer 10" Plush E0955 Whitmyer SM Cntur Cradle E0955 Whitmyer Med Cntur Cradle E0955 Whitmyer Sm Adjust-A-Plush $270 199HQ6 199HE31 E1028 Whitmyer DFS (Frehead Strap) Squared fr Single pad, must rder Whitmyer headrest Hardware Bracket Only (can be chsen w/ headrest) $120 $105 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 4
POSITIONING AND TRUNK SUPPTS - ADVAED SEATING ONLY Fr the supprts, Vyage will be set up at factry. Insert dimensins n last page spec. drawing. (Nt required, will default t std. settings) Lateral Trunk Supprt Laterals height adj. range based n Backrest Shell Height chsen in Sec. 5. i.e. Shrt Height Lats adj. 3" - 12", Tall height lats adj. 3" - 17" Fixed Laterals (Adjustable 1"-10" widths) 199KE24 Fixed Angle Adjustable - Right 199KE25 Fixed Angle Adjustable - Left 199KD15 199KD19 199KD13 199KD17 Large Straight Pad 3" x 6" - Right Large Straight Pad 3" x 6" - Left Small Straight Pad 2" x 6" - Right Small Straight Pad 2" x 6" - Left Swing Away Laterals (Adjustable 1"-8" widths) 199KE41 Swing Away Bracket Adj. - Right 199KE42 Swing Away Bracket Adj. - Left 199KD15 Large Straight Pad 3" x 6" - Right 199KD19 Large Straight Pad 3" x 6" - Left 199KD16 Large Curved Pad 3" x 6" - Right 199KD20 Large Curved Pad 3" x 6" - Left 199KD13 Small Straight Pad 2" x 6" - Right 199KD17 Small Straight Pad 2" x 6" - Left 199KD14 Small Curved Pad 2" x 6" - Right 199KD18 Small Curved Pad 2" x 6" - Left 6. KEY OPTIONS 199A827 199A828 199A829 199SS2 199KI1 199KI4 199KI5 199SS1 JAY Anterir Trunk Supprt JAY Cntur Dynamic EI Pad JAY Cntur Dynamic XSmall Pad $152 JAY Cntur Dynamic Small Pad $152 Anterir Trunk H Strap Supprt Anterir Trunk Butterfly Supprt (Adj. listed belw) Dimensins are seat t shulder height. 199KI2 199KI3 $165 Small Butterfly Pad (12" - 14") $110 Medium Butterfly Pad (14" - 16") $110 Large Butterfly Pad (>16") $110 Only available with Butterfly Supprt XX Small H Strap 5 Pint XX Small Butterfly Pad (< 10") X Small Butterfly Pad (10" - 12") Trunk Supprt Optins Shulder Strap Pads $152 $110 $110 $25 199A68 199A69 199A79 199A80 6" Lng She Hlders - Pair $120 18" Ft straps with Cvers - Pair Tray Munt adjusts frm 4-1/2"-7-1/2" with 1" tall cushin 199A91 199A92 E0952 E0951 E0952 E0951 8" Lng She Hlders - Pair Ft Straps E0952 16" Ft Straps with Cvers - Pair E0952 Upper Extremity Supprt Tray (Angle Adjustable Hardware Included) E0950 E0950 She Hlders Light Grey Clear Ply $120 $35 $35 $145 $165 Pelvic Psitining Belt (Advanced Seating nly) Must use when rdering Anterir Trunk Supprts. 199A14 1" Padded $45 199A15 1-1/2" Padded $45 199A263 199A256 1" Padded Aut Style (Dual Pull) 1-1/2" Padded Aut Style $55 $55 199A830 JAY Medial 4-Pint Belt XS Pad $95 199A831 JAY Medial 4-Pint Belt Sml Pad $95 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 5
199LF1 199LF11 E1029 E1029 199LF2 E1029 199LF3 E1029 199LF4 E1029 6. KEY OPTIONS Cnt. Accessries Accessries Cnt. Dvetail Vertical Frame Munted 199A74 K0105 IV Supprt Ple $145 Hardware fr LTV ventilatrs (limit 15lbs & includes 1 Utility hk) 199A713 E2208 O2 Tank Hlder Dvetail Vertical Frame Munted Hardware fr Trilgy ventilatrs (limit 15lbs & includes 1 Utility hk) (Only includes female dvetail munt) Battery and Vent/Utility Underframe Tray (limit 50lbs, ideal fr U1 r Grp 22 Batteries & includes 1 Utility hk) Frnt Munt Utility platfrm (limit 50lbs) Rear Add n Accessry platfrm (limit 45lbs r ne Grp 24 battery & includes 1 Utility hk. Must be remved r flded befre flding base) Belw accessries nt available with Bster Base $410 199A714 199LF5 199LF7 199A462 K0105 E2208 IV/O2 Cmbinatin $245 Cup Hlder/ Bttle/Feeding Utility Hk (i.e.suctin canister) Rain Cape $45 $25 Flr Sitter/ Feeder Base 199A083 Flding Bster Base(Ht. Adj.) $1,395 199A082 JCM Flding Bster Base(Ht. Adj.) $2,595 Frnt Munt Utility Platfrm Cup Hlder Utility Hk IV Supprt Ple Upper Extremity Supprt Tray Flding Bster Base JCM Flding Bster Base O2 Tank Hlder Battery and Vent/Utility Underframe Tray Dvetail Vertical Vent Munt (LTV/Trilgy) Rear Add On Accessry Platfrm 7. COLS - ADVAED SEATING ONLY Clr Optins - Slid Custm Optin (Only available with Prints) Slid Clrs Custm Clr Selectin: Chse & 199CL9 Purple 199C001 Enter frm Slid Clr Optins: 199CL20 Pink Srbet 199CL11 Green Canpy Pattern 199CL12 Navy Blue 199UF01 Crss Over 199CL13 Orange 199UF02 Center Stripe 199CL17 199CL16 199CL18 Turquise Black Burgundy Clr Optins - Print (Std. Trim listed behind each print) 199CL19 199CL14 199CL15 Lepard (Std. w/ Black Trim) Butterflies (Std. w/ Purple Trim) Red Race Flags (Std. w/ Red Trim) Crss Over Center Stripe Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 6
Desired Set Up Specificatins (Nt Required) (All units are in inches) Child's Name Age: Diagnsis: Height: Weight: 1. Tp f Head t Seat: 7. Width f Head: 2. Tp f Shulder t Seat*: 8. Shulder Width: 3. Under Arm t Seat: 9. Chest Width: 4. Trunk Depth: 10. Hip Width: 5. Actual Sitting Depth*: 11. Left Lwer Leg Length*: 6. Ft Length: 12. Right Lwer Leg Length*: * Critical Dimensins Mderate Seating Set-up Guide Sunrise Medical (US) LLC 2842 Business Park Ave. Fresn, CA 93727 USA Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 7