Account # Dealer Name Contact Phone Date Fax E-Mail PO Number Ship to Address City State Zip *HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Power Base Part Number HCPCS MSRP Group 2 Power Base, with 2 pole 240W motors, 300lbs weight capacity Group 2 Power base, single power 30200589 K0835 $6,499 Shroud Color Part Number HCPCS MSRP White 30500732 - No Charge Candy Apple Red 30500733 - No Charge Blue 30500734 - No Charge Power Tilt Seating Part Number HCPCS MSRP Deluxe seat power tilt / angle-adjustable back, seat width & depth-adjustable 32200531 E1002 $4,999 Electronics Part Number HCPCS MSRP Drive only VR2 Through toggle box (special order only) Through VR2 on power tilt- one actuator Through VR2 on power tilt with power AFP- two actuators P3230001-NI E2310 $1,100 33500524-NI E2311 $2,895 Joystick Mounting Brackets Part Number HCPCS MSRP Swing-away mounting bracket (Right) 39922019-NI E1028 $250 Swing-away mounting bracket (Left) 39922020-NI E1028 $250 Inline joystick (Special Order) 1 RevA1
Dimensions for Seating Width measured in 1" Increments 16.5 17.5 18.5 19.5 Width Depth 16 17 16 17 18 19 Depth measured in 1" 18 19 20 21 Increments 20 21 22 22 Standard Cushions Part Number HCPCS MSRP Omit seat cushion N/A N/A N/A W16 x D20 cushion 43780125 N/A $129 W18 x D20 cushion 43780111 N/A $129 W20 x D20 cushion 43780126 N/A $129 W22 x D20 cushion 43780191 N/A $129 Protekt foam, 18"x18"x3", 250 lbs cap 71003 E2601 $139 Protekt foam, 20"x18"x3", 250 lbs cap 71008 E2601 $139 Protekt foam, 22"x18"x3", 400 lbs cap 71005 E2602 $159 Protekt foam, 22"x20"x3", 400 lbs cap 71020 E2602 $159 Protekt gel, 18"x18"x3", 275 lbs cap 74003 E2603 $199 Protekt gel, 20"x18"x3", 275 lbs cap 74014 E2603 $199 Protekt gel, 22"x18"x3", 500 lbs cap 74005 E2604 $219 Protekt gel, 22"x20"x3", 500 lbs cap 74019 E2604 $219 Please Note that the Merits backrest is only compatible with the Merits headrest Standard Backrests Part Number HCPCS MSRP Omit backrest 16"W backrest with cover cloth 43780127/4378012 N/A No Charge 18"W backrest with cover cloth 43780112/4378011 N/A No Charge 20"W backrest with cover cloth 43780128/4378013 N/A No Charge 22"W backrest with cover cloth 43780193/43780194 N/A No Charge Adapter for comfort company backrest (not for use with Avid backrest or 399002210 N/A No Charge Angle-adjustable back 90 degrees 95 degrees 100 degrees 105 degrees 110 degrees Armrest Options Part Number HCPCS MSRP Height-adjustable, cantilever armrests Gel Ovations Arm Accessories Part Number HCPCS MSRP Arm pad 3.5" width 12" 312G N/A $145.00 Arm pad 3.5" width 14" 314G N/A $175.00 2" X 10" Gel Arm pad Right Left 210G N/A $99.00 2" X 12" Gel Arm pad Right Left 212G N/A $115.00 2" X 14" Gel Arm pad Right Left 214G N/A $130.00 Gel Ovations Arm Troughs Part Number HCPCS MSRP First Trough Side - 10"L x 2"W Right Left FTS10 N/A $100.00 First Trough Side - 12"L X 2"W Right Left FTS12 N/A $105.00 First Trough Side - 14"L X 2"W Right Left FTS14 N/A $115.00 Second Trough Side - 10"L X 2"W Right Left STS10 N/A $100.00 Second Trough Side - 12"L X 2"W Right Left STS12 N/A $105.00 Second Trough Side - 14"L X 2"W Right Left STS14 N/A $115.00 2
Accessories Part Number HCPCS MSRP Swing-away trunk support bracket (R&L, for one unit) 39900179 E1028 $499 Sta-Rite articulating regular lateral supprt hardware- Left EACH SRRLHL - $245 Sta-Rite articulating regular lateral supprt hardware- Right EACH SRRLHR - $245 Trunk support pad- L 6"x4"x1" (2pc/ pack) 39900191 E0956 $79 Trunk support pad- M 5"x4" x1" (2pc/ pack) 39900177 E0956 $79 Trunk support pad- S 5"x 3"x1" (2pc/ pack) 39900178 E0956 $79 Swing-away abductor bracket 39900176 E1028 $149 Abductor pad- M: 6"x4"x3" 39900174 E0957 $54 Abductor pad- S: 4"x3.5"x3" 39900175 E0957 $52 Headrest Part Number HCPCS MSRP Omit headrest Headrest 9" 39906011 E0955 $150 Swing-away headrest mount 32100238-NI E1028 $99 Footplate and Legrest Options Part Number HCPCS MSRP Standard center footplate with calf pads 33300446 N/A No Charge Manual elevating legrest, gooseneck mount PAIR 39904M10 E0990 $179 Power articulating foot platform 33300418 E1012 $2,398 Gel Ovations Footplate and Legrest Part Number HCPCS MSRP Single piece footplate gel foot protector cover GFPCS N/A $150 Gel and foam calf pad 8" X 6" X 1.5" PAIR GCP N/A $245 Sta-Rite swing-away removable residual Right Left SRSSF E1020 $350 limb support 6" X 7.5 DSSP flat Sta-Rite swing-down residual limb support bracket SRSSFHO E1028 $250 Gel Ovations Residual Limb Support Part Number HCPCS MSRP Universal elbow stop bracket and flat pad 3"x4" Right Left UESF1 E229 $45.00 Batteries Part Number HCPCS MSRP 12V, 34 Ah, U1, AGM, BWG (x2) SCPU1 E2365 $158 ea. 12V, 55 Ah, 22NF, AGM, BWG (x2) BW12550-IT E2361 $255 ea. 12V, 55 Ah, 22NF, Gel, MK (x2) M22NF E2361 $295 ea. *When ordering the version with power tilt seating, we recommend using 22NF batteries* 3
Vision Ultra-standard Captain Seat Pan Seat Power Base Part Number HCPCS MSRP Group 2 Power base, pan seat Group 2 Power base, captain seat Group 2 Power Base, with 2 pole 240W motors, 300lbs weight capacity 30200589 K0822 $6,499 30200589 K0823 $6,499 Captain Seat Part Number HCPCS MSRP 18"W x 18"-20" x 20"H depth-adjustable 32100242 N/A No Charge 20"W x 18"-20" x 20"H depth-adjustable 32100264 N/A No Charge 22"W x 20"-22" x 20"H depth-adjustable 32100265 N/A $450 (Only for Captain Seating) 20 21 22 23 Pan Seat Part Number HCPCS MSRP 18"W x 18"-20" x 20"H depth-adjustable 32200535 N/A No Charge 20"W x 18"-20" x 20"H depth-adjustable 32100269 N/A No Charge 22"W x 20"-22" x 20"H depth-adjustable 32100270 N/A $450 (Only for Pan Seating) 16.5 17.5 18.5 19.5 Standard Cushions (Only for Pan Seating) Part Number HCPCS MSRP Protekt foam, 18"x18"x3", 250 lbs cap 71003 E2601 $139 Protekt foam, 20"x18"x3", 250 lbs cap 71008 E2601 $139 Protekt foam, 22"x18"x3", 400 lbs cap 71005 E2602 $159 Protekt foam, 22"x20"x3", 400 lbs cap 71020 E2602 $159 Protekt gel, 18"x18"x3", 275 lbs cap 74003 E2603 $199 Protekt gel, 20"x18"x3", 275 lbs cap 74014 E2603 $199 Protekt gel, 22"x18"x3", 500 lbs cap 74005 E2604 $219 Protekt gel, 22"x20"x3", 500 lbs cap 74019 E2604 $219 http://www.meritsusa.com 4
Vision Ultra-standard Joystick Mounting Brackets Part Number HCPCS MSRP Swing-away mounting bracket (Right) 39922019-NI E1028 $250 Swing-away mounting bracket (Left) 39922020-NI E1028 $250 Inline joystick (Special Order) - - No Charge Armrest Options Part Number HCPCS MSRP Height-adjustable, detachable armrest (Captain seat and pan seat) Right Left 31000353/31000352 E0973 $150 Foot platform and Legrest Options Part Number HCPCS MSRP Center mount foot platform 33300422 N/A No Charge Seat pan to foot platform length 10.5"-12.5" (not including cushion) Center mount foot platform - long (special order) 33300422-L N/A No Charge Seat pan to foot platform length > 12.5" (not including cushion) Non-powered elevating legrests PAIR 33401229 K0195 $360 Batteries Part Number HCPCS MSRP 12V, 34 Ah, U1, AGM, BWG (x2) SCPU1 E2365 $158 ea. 12V, 55 Ah, 22NF, AGM, BWG (x2) BW12550-IT E2361 $255 ea. 12V, 55 Ah, 22NF, Gel, MK (x2) M22NF E2361 $295 ea. Shroud Color Part Number HCPCS MSRP White 30500732 - No Charge Candy Apple Red 30500733 - No Charge Blue 30500734 - No Charge http://www.meritsusa.com 5 RevA1