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This form must be opened in dobe crobat. The Submit Form button will not work from most browser windows. Company: ccount Number: Date: Quote PO Number: RTS: Ship To: ddress: City: State: Zip: Phone: Marked For: Email/Fax: Effective 04/08/2019 xiom ack xiom Posterior ack (P) 8 10 12 12 20 22 Retail (Each) $555 $555 $555 $555 $555 $791 HCPC E2613 E2613 E2613 E2613 E2613 E2614 Part Number XP1208 XP1408 XP1608 XP1808 XP2008 Part Number XP1410 XP1610 XP1810 XP2010 XP2210 Part Number XP1212 XP1412 XP1612 XP1812 XP2012 Part Number XP1414 XP1614 XP1814 XP2014 XP2214 Part Number XP1216 XP1416 XP1616 XP1816 XP2016 Part Number XP1418 XP1618 XP1818 XP2018 XP2218 Gloss Finish Gloss Finish Matte Finish Matte Finish 4.1 4.1 xiom Posterior ack Measurement Reference ack Depth 8 10 6.5 10 12 8.5 12 10.5 8.5 9.5 2.25 20 10.5 xiom Posterior ack - xiom Posterior ack - HCPCS codes provided are based on code verification by the PDC 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. DCN0419.0 Pricing and specifications subject to change without notice Page 1 of 7

xiom ack continued xiom Posterior Lateral ack (PL) 12 20 22 Retail (Each) $636 $636 $636 $636 $636 $862 HCPC E2615 E2615 E2615 E2615 E2615 E2616 Part Number XPL1208 XPL1408 XPL1608 XPL1808 XPL2008 8 Part Number XPL1410 XPL1610 XPL1810 XPL2010 XPL2210 10 Part Number XPL1212 XPL1412 XPL1612 XPL1812 XPL2012 12 Part Number XPL1414 XPL1614 XPL1814 XPL2014 XPL2214 Part Number XPL1216 XPL1416 XPL1616 XPL1816 XPL2016 Part Number XPL1418 XPL1618 XPL1818 XPL2018 XPL2218 Part Number XPL1220 XPL1420 XPL1620 XPL1820 XPL2020 20 Part Number XPL1422 XPL1622 XPL1822 XPL2022 XPL2222 22 Gloss Finish Gloss Finish Matte Finish Matte Finish xiom Posterior Lateral ack Measurement Reference ack Depth 8 10 6.5 10 12 8.5 12 10.5 8.5 9.5 20 10.5 3.65 xiom Posterior Lateral ack - xiom Posterior Lateral ack - xiom Posterior Lateral ack - 20 22 11.5 22 24 12.5 DCN0419.0 Pricing and specifications subject to change without notice Page 2 of 7

xiom ack continued xiom Lateral ack (L) 12 20 22 Retail (Each) $735 $735 $735 $735 $735 $813 HCPC E2620 E2620 E2620 E2620 E2620 E2621 Part Number XL1208 XL1408 XL1608 XL1808 XL2008 8 Part Number XL1410 XL1610 XL1810 XL2010 XL2210 10 Part Number XL1212 XL1412 XL1612 XL1812 XL2012 12 Part Number XL1414 XL1614 XL1814 XL2014 XL2214 Part Number XL1216 XL1416 XL1616 XL1816 XL2016 Part Number XL1418 XL1618 XL1818 XL2018 XL2218 Part Number XL1220 XL1420 XL1620 XL1820 XL2020 20 Part Number XL1422 XL1622 XL1822 XL2022 XL2222 22 Gloss Finish Gloss Finish Matte Finish Matte Finish xiom Lateral ack Measurement Reference ack Depth 8 10 6.5 10 12 8.5 12 10.5 8.5 9.5 20 10.5 3.65 xiom Lateral ack - xiom Lateral ack - xiom Lateral ack - 20 22 11.5 22 24 12.5 DCN0419.0 Pricing and specifications subject to change without notice Page 3 of 7

xiom ack continued xiom Deep Lateral ack (DL) 20 22 12 20 22 Retail (Each) $735 $735 $735 $735 $735 $813 HCPC E2620 E2620 E2620 E2620 E2620 E2621 Part Number XDL1214 XDL1414 XDL1614 XDL1814 XDL2014 XDL2214 Part Number XDL1416 XDL1616 XDL1816 XDL2016 Part Number XDL1218 XDL1418 XDL1618 XDL1818 XDL2018 XDL2218 Part Number XDL1220 XDL1420 XDL1620 XDL1820 XDL2020 Part Number XDL1422 XDL1622 XDL1822 XDL2022 XDL2222 Gloss Finish Gloss Finish Matte Finish Matte Finish 7.75 7.75 xiom Deep Lateral ack Measurement Reference ack 1 12 20 22 Depth 8.25 8.25 8.25 8.25 8.25 8.25 9.25 9.25 9.25 9.25 9.25 9.25 20 10.25 10.25 10.25 10.25 10.25 10.25 6 20 22 9.5 9.75 10 10.25 10.25 10.5 22 24 10.75 11 11.25 11.5 11.5 11.75 1 Measurement based on back width xiom Deep Lateral ack - xiom Deep Lateral ack - DCN0419.0 Pricing and specifications subject to change without notice Page 4 of 7

xiom ack ccessories Headrest and Hardware Fill uantity needed in the box corresponding with the headrest and hardware combination in chart below. vailable only on or backs. CP450 CP250 CP150 P250 P350 P450 TCP205 TCP105 HMO400 HMO475-1 TW480-1 Hardware Standard Straight ack Mount Hardware with 1 all Multi xis Removable Hardware w/1 Horizontal ar Headrest Hardware with 1 all HMO400 HMO475-1 TW480-1 Description Item Code HCPC Kio Code Retail (Each) Kio Code Retail (Each) Kio Code Retail (Each) Comfort Plus Headrest 8 CP450 E0955 HDR001 $277 HDR009 $313 HDR017 $388 Comfort Plus Headrest 10 CP250 E0955 HDR002 $277 HDR010 $313 HDR018 $388 Headrest Pad Comfort Plus Headrest CP150 E0955 HDR003 $277 HDR011 $313 HDR019 $388 Small ll Positioning Headrest Pad and Ring Only Medium ll Positioning Headrest Pad and Ring Only Large ll Positioning Headrest Pad and Ring Only P250 E0955 HDR004 $277 HDR012 $313 HDR020 $388 P350 E0955 HDR005 $277 HDR013 $313 HDR021 $388 P450 E0955 HDR006 $277 HDR014 $313 HDR022 $388 Tri-Comfort Plus Headrest TCP205 E0955 HDR007 $288 HDR015 $324 HDR023 $399 Tri-Comfort Plus Headrest 19 TCP105 E0955 HDR008 $288 HDR016 $324 HDR024 $399 Universal Mounting Hardware For use with other manufacturer headrests Description Item Code HCPC Retail (Each) Universal Mounting Plate UMP K0108 $40 DCN0419.0 Pricing and specifications subject to change without notice Page 5 of 7

xiom ack ccessories continued Lateral Support Sold in pairs Description Item Code HCPC Retail (Each) Laterals for Posterior ack 3 x 4 Lateral Pads with Fixed Mounting Hardware for xiom Posterior ack 4 x 5 Lateral Pads with Fixed Mounting Hardware for xiom Posterior ack 3 x 4 Lateral Pads with Swing way Mounting Hardware for xiom Posterior ack 4 x 5 Lateral Pads with Swing way Mounting Hardware for xiom Posterior ack Laterals for Posterior Lateral ack and Lateral ack 3 x 4 Lateral Pads with Fixed Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks 4 x 5 Lateral Pads with Fixed Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks 3 x 4 Lateral Pads with Swing way Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks 4 x 5 Lateral Pads with Swing way Mounting Hardware for xiom Posterior Lateral and xiom Lateral acks LF3x4P E0956 $305 LF4x5P E0956 $305 LS3x4P E0956, E1028 $650 LS4x5P E0956, E1028 $650 LF3x4L E0956 $305 LF4x5L E0956 $305 LS3x4L E0956, E1028 $650 LS4x5L E0956, E1028 $650 Lumbar Pads vailable only with xiom Lateral ack and xiom Deep Lateral ack Description Item Code HCPC Retail (Each) Lumbar Pad 12 L12 K0108 $48 Lumbar Pad L14 K0108 $48 Lumbar Pad L16 K0108 $48 Lumbar Pad L18 K0108 $48 Lumbar Pad 20 L20 K0108 $48 Lumbar Pad 22 L22 K0108 $48 Privacy Flap Description Item Code HCPC Retail (Each) Privacy Flap 12 PF12 K0108 $45 Privacy Flap PF14 K0108 $45 Privacy Flap PF16 K0108 $45 Privacy Flap PF18 K0108 $45 Privacy Flap 20 PF20 K0108 $45 Privacy Flap 22 PF22 K0108 $45 DCN0419.0 Pricing and specifications subject to change without notice Page 6 of 7

xiom ack ccessories continued Therafin Posture Support Description Item Code HCPC Retail (Each) Small Static Therafit 2-Piece Chest Strap with H & L dj and 1 Safety Strap 60153T E0960 $144 Medium Static Therafit 2-Piece Chest Strap with H & L dj and 1 Safety Strap 60154T E0960 $144 Large Static Therafit 2-Piece Chest Strap with H & L dj and 1 Safety Strap 60155T E0960 $144 Small Dynamic Therafit Chest Strap with Dual D-Ring djustment 60110T E0960 $113 Medium Dynamic Therafit Chest Strap with Dual D-Ring djustment 60111T E0960 $113 Large Dynamic Therafit Chest Strap with Dual D-Ring djustment 60112T E0960 $113 Small Dynamic Therafit Comfortfit Full Vest 30589T E0960 $167 Medum Dynamic Therafit Comfortfit Full Vest 30590T E0960 $167 Large Dynamic Therafit Comfortfit Full Vest 30591T E0960 $167 XLarge Dynamic Therafit Comfortfit Full Vest 30592T E0960 $167 XXLarge Dynamic Therafit Comfortfit Full Vest 30593T E0960 $167 Small Dynamic Therafit Comfortfit Trim Vest 30618T E0960 $169 Medum Dynamic Therafit Comfortfit Trim Vest 30619T E0960 $169 Large Dynamic Therafit Comfortfit Trim Vest 30620T E0960 $169 XLarge Dynamic Therafit Comfortfit Trim Vest 30621T E0960 $169 XXLarge Dynamic Therafit Comfortfit Trim Vest 30622T E0960 $169 xiom ack Modifications Extended lead times will apply xiom ack Modifications Description Item Code HCPC Retail (Each) Modification for 4 Point Harness XM4PT K0108 N/C Modification for 2 Point Chest Strap XM2PT K0108 N/C Modification for Shoulder Guides Includes shoulder guides XMSG K0108 $50 DCN0419.0 Pricing and specifications subject to change without notice Page 7 of 7

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