Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax:( ) Mark Fr: ZIP: SUBMITTING F: Qute Order 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. 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: s Hand perated Wheel Lck s Quick release frnt and rear wheels Vyage fr Advanced Seating with 199BS7 E1232 Tilt - Includes Seating Vyage fr Advanced Seating with 199BS8 E1234 Tilt - Seating nt included in base price Vyage fr Mderate Seating Zippie Vyage January 2018 EIZ16 s Telescping strller handle 199BS12 199KJ11 Address: Address: Ship T City: Cnfirm Via: Fax Email Ship T Phne: ( ) Fax:( ) s 12" rear tires & 7" frnt casters s Frnt caster suspensin & swivel lcks s 75 lbs Weight Capcity Vyage Fr Advanced Seating 199BS9 199BS14 Frame Style E1232 Vyage fr Mderate Seating with Tilt - Includes Seating E1234 Vyage fr Mderate Seating with Tilt - Seating nt included in base price s Adjustable seating Shell $2,445 199BS11 PO#: Ship T: Attentin: s 45 Tilt ST: Vyage Bster Base with Tilt and Advanced Seating ZIP: s Fwd & Rwd facing seating capability s Under carriage strage s Canpy w/ breathable windw/mesh pckets (may be limited when sme ptins chsen) Bster Base Optins with seating $2,445 $2,205 $2,205 199BS10 199BS13 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 K0108 Transit Optin $2,765 $2,765 $3,895 $3,895 $250 Fr Mderate Seating See page 2 Fr Adv anced 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
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. Sectin A. Sectin B. 199KM01 Mderate Seating 199KM03 E2292 Mderate Seating 199KM02 E1014 Recline Feature (required) $325 199KM04 E1014 Recline Feature (required) $325 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 $125 Laterals Large - Pair $125 199KO03 199KO04 Psitining - Laterals (Optinal) Laterals Small - Pair $175 Laterals Large - Pair $175 Psitining - Hip Guides (Optinal) 199KP01 Hip Guides - Pair $125 Psitining - Hip Guides (Optinal) 199KP02 Hip Guides - Pair Infant Insert - Pair Infant Insert - Pair 199KP03 $125 199KP04 (Hip Guides Reqd.) (Hip Guides Reqd.) $175 $175 Head Supprts (Optinal) Head Supprts Small - Pair 199VJ01 E0955 $125 (Recmmended) 199VJ02 E0955 Head Supprts Large - Pair $125 199VJ03 199VJ04 Head Supprts (Optinal) Head Supprts Small - Pair E0955 $135 (Recmmended) E0955 Head Supprts Large - Pair $135 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 K0108 Grab Bar (Optinal) Grab Bar $110 199KR02 K0108 Grab Bar (Optinal) Grab Bar $120 3. W HEELS 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 199F329 K0040 Angle Adj. Ftrest (Required) $155 4. FOOTREST 5. POSITIONING AND TRUNK SUPPTS JAY Anterir Pelvic Belts - E0978 Standard 2 Pint Belt - Push Buttn 1" 199ZZ10 199ZZ11 E0978 E0978 N Pad (APB5110) 4.5" Pad (APB5115) 199ZZ12 E0978 5.5" Pad (APB5116) Standard 2 Pint Belt - Push Buttn 1 1/2" 199ZZ14 E0978 N Pad (APB7210) 199ZZ15 E0978 7.5" Pad (APB7212) V-Cntur Pelvic 4 Pint Belt - Push Buttn Varies SM Pad - 1" Push Buttn 199ZZ24 E0978 (APB3716) Med Pad - 1-1/2" Push Buttn 199ZZ23 E0978 (APB3727) $40 $91 $91 $40 $86 $170 $170 JAY Anterir Trunk Supprts - Structure Classic nt available with Early Interventin Size Anterir Trunk Supprt - Style 199JY01 Classic Dynamic (ATS8100 Series) $152 199JY02 Classic Structure (ATS8300 Series) $152 199JY06 Center Opening Dynamic (ATS8800 Series) $152 199JY05 Center Opening Structure (ATS9400 Series) $152 Anterir Trunk Supprt - Size 199JZ05 Early Interventin 199JZ06 Xtra Small 199JZ01 Small Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 2
199CU42 E2294 Cntured Wedge Seat 199CU43 E2294 Cntured Anti-Thrust (Ledge) Seat Chse Depth (Based n 1" T-Back) 199SD78 Shrt 5" - 8" Depth 199SD79 Medium 7" - 10" Depth 199SD80 Lng 9" - 13" Depth 199CU44 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 199CU28 Planar Seat withut Hip Blcks 199CU41 E2292 E2292 Sectin A. (Seat ptins when rdering base which includes seating) - ADVAED SEATING Planar Seat w/ Hip Blck - Pair Planar Seat w/ Hip Blcks Pair 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) 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 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 199CU39 E2292 Planar Seat withut Hip Blcks 2. SIZE/SEATING - ADVAED SEATING $335 Chse Fam E2294 Sft Fam Medium/Sft Fam Medium Fam 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 E2294 Adjustable Cntur Seat Adjustable Cntur Seat $320 $420 199CU37 E2294 Cntured Wedge Seat $335 199FM1 Sft Fam 199CU38 Chse Depth (Based n 1" T-Back) 199SD78 Shrt 5" - 8" Depth 199SD79 Medium 7" - 10" Depth 199SD80 Lng 9" - 13" Depth Only available with Planar seat withut Hip Blcks and Adj. Cntur seat. 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 199KC5 199KC3 E2294 Cntured Anti-Thrust (Ledge) Seat Lateral Hip Supprt (Adjusts frm 7-1/2" t 11" width) LG (5-3/8"x 4-3/4", 1/2" thick) Right LG (5-3/8"x 4-3/4", 1/2" thick) Left Lateral Thigh Supprt (Adjusts frm 3-1/2" t 11" width) $335 Only available with Planar seat withut Hip Blcks and Adj. Cntur seat. 199KF6 SM (4"x 4", 3/8" thick) Right 199KF4 SM (4"x 4", 3/8" thick) Left 199KF5 LG (5-3/8"x 4-3/4", 1/2" thick) Right 199KF3 LG (5-3/8"x 4-3/4", 1/2" thick) Left 199FM2 199FM3 199KH12 Medium/Sft Fam Medium Fam Chse Depth (Based n 1" T-Back) 199SD78 Shrt 5" - 8" 199SD79 Medium 7" - 10" 199SD80 Lng 9" - 13" LOW ER BODY SUPPTS - ADVAED SEATING 199HE77 Medial Supprt E0957 Small (3"Hx 2-1/2"Wx 4-1/2"L) $125 E1028 Hardware Medial Supprt Brkt Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 3
3. W HEELS 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 199F312 K0040 Angle Adj. Ftrest (Required) $155 4. FOOTREST 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) 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" $325 199BT29 E2291 Tall 12" t 14" 199BT115 E2291 Shrt 8" t 10" Extra Tall 14" t 16" 199BT116 E2291 Medium 10" t 12" 199BT56 E2291 (N/A w/ Shrt Backrest Shell) 199BT117 E2291 Tall 12" t 14" Extra Tall 14" t 16" 199BT118 E2291 (N/A w/ Shrt Backrest Shell) Sectin B. (Seat ptins when rdering base that des nt include seating in base price.) - 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) 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 E2291 Medium 10" t 12" BACK/SEATING OPTIONS " T " Back 1" Thick " T " Back 2-1/2" Thick 199BT103 E2291 Shrt 8" t 10" $305 2-1/2" "T" Back is used fr seat depths as small as 3-1/2", backrest has 199BT104 E2291 Medium 10" t 12" $305 remvable fam fr additinal depth grwth withut adjusting seat pan. 199BT105 E2291 Tall 12" t 14" $305 199BT107 E2291 Shrt 8" t 10" $375 Extra Tall 14" t 16" 199BT108 E2291 Medium 10" t 12" $375 199BT106 E2291 $305 (N/A w/ Shrt Backrest Shell) 199BT109 E2291 Tall 12" t 14" $375 199BT110 Extra Tall 14" t 16" E2291 (N/A w/ Shrt Backrest Shell) $375 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 E0955 Whitmyer 8" Plush 199HE41 E0955 Whitmyer 10" Plush 199HQ6 199HE42 E0955 Whitmyer SM Cntur Cradle 199HE43 E0955 Whitmyer Med Cntur Cradle 199HE29 E0955 Whitmyer Sm Adjust-A-Plush $270 199HE31 Head Supprts - ADVAED SEATING ONLY 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. Whitmyer DFS (Frehead Strap) K0108 Squared fr Single pad, must rder Whitmyer headrest Hardware Bracket Only E1028 (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
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 199KD15 199KD19 199KD13 199KD17 Fixed Angle Adjustable - Left Swing Away Laterals (Adjustable 1"-8" widths) 199KE41 Swing Away Bracket Adj. - Right 199KI1 XX Small Butterfly Pad (< 10") $110 199KE42 Swing Away Bracket Adj. - Left 199KI2 X Small Butterfly Pad (10" - 12") $110 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 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 JAY Anterir Trunk Supprt Laterals height adj. range based n Backrest Shell Height chsen in Sec. 5. 199A827 JAY Cntur Dynamic EI Pad $152 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 6. KEY OPTIONS 199A828 199A829 JAY Cntur Dynamic Small Pad $152 199SS2 Anterir Trunk H Strap Supprt XX Small H Strap 5 Pint Anterir Trunk Butterfly Supprt (Adj. listed belw) Dimensins are seat t shulder height. 199KI3 Small Butterfly Pad (12" - 14") $110 199KI4 199KI5 JAY Cntur Dynamic XSmall Pad $152 Trunk Supprt Optins Only available with Butterfly Supprt 199SS1 Shulder Strap Pads $165 Medium Butterfly Pad (14" - 16") $110 Large Butterfly Pad (>16") $110 $25 199A68 199A69 199A79 199A80 E0952 E0951 E0952 E0951 She Hlders 8" Lng She Hlders - Pair Ft Straps $120 Upper Extremity Supprt Tray (Angle Adjustable Hardware Included) 199A91 E0952 16" Ft Straps with Cvers - Pair $35 E0952 Tray Munt adjusts frm 4-1/2"-7-1/2" with 1" tall cushin 199A92 E0950 E0950 6" Lng She Hlders - Pair $120 18" Ft straps with Cvers - Pair Light Grey Clear Ply $35 $145 $165 Pelvic Psitining Belt (Advanced Seating nly) Must use when rdering Anterir Trunk Supprts. 199A14 E0978 1" Padded $45 199A15 E0978 1-1/2" Padded $45 199A263 E0978 1" Padded Aut Style (Dual Pull) $55 199A256 E0978 1-1/2" Padded Aut Style $55 199A830 E0978 JAY Medial 4-Pint Belt XS Pad $95 199A831 E0978 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 199LF2 199LF3 199LF4 Accessries Dvetail Vertical Frame Munted Hardware fr LTV ventilatrs (limit 15lbs & includes 1 Utility hk) 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 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) 6. KEY OPTIONS Cnt. Belw accessries nt available with Bster Base $340 $340 $400 $355 $135 Accessries Cnt. 199A74 K0105 IV Supprt Ple $145 199A713 199A714 199LF5 199LF7 199A462 E2208 O2 Tank Hlder $175 K0105 E2208 IV/O2 Cmbinatin $245 Cup Hlder/ Bttle/Feeding $45 Utility Hk (i.e.suctin canister) $25 Rain Cape $175 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 7. COLS - ADVAED SEATING ONLY Dvetail Vertical Vent Munt (LTV/Trilgy) Rear Add On Accessry Platfrm 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 Ov er 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. Lef t 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