a Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: ZIP: SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price KIDS QUICKIE 2 SE K0005 cding still applies fr EIZ10 with certain sizes - Standard Frame - 250 lbs. Maximum User Weight - Uses Rear Side Frame Depth Adj. & Depth Adj. Back 142WM07 E1236 Kids Quickie 2 SE w/ Seating $2,395 142WM08 E1238 Kids Quickie 2 SE w/ Seating $2,525 Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Mark Fr: Select - Frame Type 142RS1 Kids Quickie 2 SE January 2018 EIZ10 Attentin: 142FT54 142FT55 Address: Address: Ship T City: 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. Nte: HCPCS Cdes shwn as submitted. Sme sizes fit ther HCPC cdes i.e. 15"-16" widths = K0005 Rear Side Straight Transit System Incl. Stabilizer Bar, must rder Push Handle. N/A with padded swing-away armrests r strller handles. 142TO1 K0108 Transit System $315.00 PO#: Ship T: Select - Frame Type ST: Crss Brace with Seat Rails Crss Brace w/ Seat Rails Frame Length ZIP: 142FL1 Kids (12"-14") 142FL9 Regular (13"-16") 142FL18 Lng (15"-18") 142W2 142W3 142W4 142W5 12" 13" 14" 142W37 15" $250 142W40 16" $250 142W38 17" $250 142W39 Frame Width 11" (By Uphlstery) 18" $250 Standard Clrs 142C140 Aztec Gld 142C2 Black (N/A as base w/ Zebra) 142C141 Black Cherry 142C10 Black Opal 142C38 Blue Opal 142C36 Candy Blue 142C14 Candy Purple 142C35 Candy Red 142C142 Electric Blue 142C143 Evergreen 142C126 142C144 Glw Green Apple 142C147 Ht Sparkle Pink 142C148 Mauve Pink 142C103 Rtbeer 142C114 Sparkle Silver FRAME COLOR Seat Rail Depth (Sling Nt Included) 142SN05 10" 142SN06 11" 142SN07 12" 142SN08 13" 142SN09 14" 142SN10 15" $250 142SN11 142SN12 142SN13 18" 142C145 142C113 142C8 142C151 142C152 Standard Clrs - Cnt. $250 17" $250 Sunrise Orange Standard Matte Clrs 142C116 Matte Black 142C150 142C149 Yellw Matte Black Cherry Matte Electric Blue Matte Evergreen 142C43 Mssy Oak Camuflage 142C42 Stars and Stripes 142C108 16" Titanium Clr Paint Matte Purple Custm Clrs Zebra (Chse base clr abve: White Std, N/A Black) $250 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 1
SEATING 142SL1 142SL16 JAY Cushins (Optinal) T rder any JAY cushins n-chair, please see the JAY price list. Cushin name r part number must be filled ut with desired width and depth 142JC20 JAY Bundled Cushin Cushin Name r Part # Width (in.): Sling Seat Depth (in.): Omit Sling, Include Rails Price List FRAME DEPTH Width (in.): Cushin 142CU1 K0669 2" Cushin $120 142JB02 JAY Backs (Optinal) Ordering JAY backs n-chair, please see the JAY price list. Requires part # JAY Bundled Backrest Backrest Name r Part # Height (in.): Price List Frame Depth - With Seat Rails 142BL14 1" ffset frm seat rail 142BL15 2" ffset frm seat rail BACKREST Frame Depth - Withut Seat Rails 142FD1 10" 142FD2 11" 142FD3 12" 142FD4 13" 142FD5 14" 142FD6 15" 142FD7 16" 142FD8 17" 142FD9 18" 142FD10 19" 142FD11 20" 142B1 142B5 142B9 Back Height Standard With Push Handles Lw (8.5" - 12") Medium (12" - 15.5") Tall (15.5" - 19") 142BP27 142BP28 142BP29 142BP33 Strller Handles Depth Adjustable Standard Depth Adjustable Med Depth Adjustable Tall Swing Away Adjustable $100 142BU1 142BU8 142BP2 Standard Uphlstery Adjustable Uphlstery Omit Uphlstery $150 Extensin Remvable $100 Backrest Optins 142BP1 142BP3 142BP2 Push Handle Push Handle 8 (Med r Tall Only) Omit Push Handle - Straight N/A w/ transit $25 ARMRESTS 142AA8 142AA9 142AA14 Armrest Height Adj. Adult $285.00 Height Adj. Kids $285.00 Omit Armrest 142AA16 142AA19 142AA17 142AA6 Armrest Padded Swing Away Adult N/A w/amputee axle plate r transit Padded Swing Away Medium N/A w/amputee axle plate r transit Padded Swing Away Kids N/A w/amputee axle plate r transit Flip Back Height Adjustable (N/A w/ Kids Frame).00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 2
Hanger 1. Hanger Type (Munt With Extensin Tube) 142H1 142H2 60 Swing Away Hanger 70 Swing Away Hanger Elevating Hanger (Only avail. w/ alum. Ftplates r angle adj. Available n 14"- 142H14 E0990 18" frame widths. N/A w/ lcking angle adj. ftplates r shrt ext. tubes.) Extensin Tube (Required fr Optin 1) Ftplate 142E1 142E2 142E5 142E12 142E15 142E16 142F4 142f3 Shrt (see matrix fr length) Medium (see matrix fr length) 142F1 E0951 Cmpsite Ftplate (12"-16"w) 142F48 Adult Angle Adj. Ftplate (12"-16"w) Lng (see matrix fr length) Shrt ELR (ELR nly) Lng ELR (ELR nly) High Munt (N/A elevating leg rests. Only avail. w/ adult r kids angle adj. ftplates.) Kids Angle Adj. Ftplate Platfrm Flip Up Ftplate (N/A with shrt ext. tubes. Only avail. with 60 r 70 ) $190 FOOTRESTS Chse 1 r 2 CHOOSE 1 OR 2 Hanger 142H7 90 Swing Away ELR(avail. n 12"-16" 142H23 E0990 widths, N/A w/8" casters) Extensins (Optinal) 142H8 142H6 142E23 142E24 Ftplate Type 142F9 142F8 2. Hanger Type (Direct Munt) 70 Swing Away Hangers Frnt Munt (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 80 Swing Away Hangers Frnt Munt (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 90 Swing Away Hangers (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 2" Extensins (N/A w/90 hangers & elevating leg rests) 4" Extensins (N/A w/90 hangers & elevating leg rests) Kids Angle Adjustable Ftplate (10" - 16" W) Adult Angle Adjustable Ftplate (Available n 12" - 16" W) 142F61 142F5 Ftrest Optins 142HL9 142HL8 142A54 Impact Guard 142IG2 E0951 Lcking Angle Adjustable. (N/A Belw 15" W - Requires Heel Lps) Aluminum Ftplate Available w/ ELRs Heel Lps K0038 Leg Straps $35 K0038 Extra Leg Strap Neprene (Only avail. with 60 r 70 ) $190 $50 $30 CASTERS 142CW3 142CW31 142CW5 142CW7 E2219 142CW6 142CW34 142CW21 142CW32 E2214 E2215 Caster Wheels 4" Plyurethane 4" Micr-Lighted 5" Lw Prfile Plyurethane E2214 6" Pneumatic (Requires selectin f 142CW33 $75 E2215 Caster Tire Tube/Insert) 142CW35 E2219 5" x 1.5" Semi-Pneumatic (Only avail. fr use in bttm frk hles) 6" Plyurethane 8" Plyurethane (N/A w/ elevating leg rests r w/kids frame length.) E2219 5" Sft Rll Semi-Pneumatic $90 6" x 1.5" Semi-Pneumatic (nly avail. fr use in bttm frk hles) 8" Pneumatic (N/A w/ elevating leg rests. N/A w/kids frame length. Requires selectin f Caster Tire Tube/Insert) $70 142CW39 142CW36 142CW12 142CZ2 142CZ1 E2214 E2215 Caster Wheels - Cntinued Omit Caster Wheels Caster Tire Tube/Insert Requires a selectin f 6", 8" r 8" x 2" Pneumatic Tire. K0064 8" x 1.5" Semi-Pneumatic (nly avail. fr use in bttm frk hles) 8" x 2" Pneumatic (N/A w/ 90 elevating leg rests. N/A w/kids frame length. Requires selectin f Caster Tire Tube/Insert) Airless Insert (Only avail. With 8"x2" Pneumatic) Caster Tube (all sizes) Caster Optins $145 $65 $20 142CS5 3/4" Lnger Frk Stem Blt 142CS10 1-1/2" Lnger Frk Stem Blt 142CS3 K0073 Caster Pin Lcks $195 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 3
AXLE AND WHEELS Axle Plate Rear Wheel Tire Tube/Insert 142AL2 Standard Adjustable Requires a selectin f Pneumatic 142AL71 E0959 Amputee Adjustable 142RZ2 E2213 Pneumatic Airless Insert $80 Axle 142RT1 Pneumatic Tube 142AX1 Quick Release 142AX11 Quad Quick Release $125 Hand Rim 142HR1 Aluminum Andized Anti-Tip 142HR4 Plastic Cated $95 142AT1 E0971 Rear Anti-Tip $140 142HR7 Omit Rear Wheel Type Wheel Lck 142RW3 20" Mag 142WL1 High Munt Push 142RW74 20" Lite Spke 142WL2 High Munt Pull 142RW8 22" Mag 142RW75 22" Lite Spke Extensin Handle 142RW1 24" Mag 142EH1 E0961 6" Pair $75 142RW54 24" Spke $100 Grade Aid Rear Wheel Tire Requires a selectin f Rear Wheel Tire/Insert 142RT1 Pneumatic (Requires the selectin f Rear Wheel Tire/Insert) 142GA1 E0974 Grade Aid $150 142RT29 Full Plyurethane (avail w/mag nly) $50 142RT4 Lw Plyurethane (avail w/24" Mag nly) $50 ACCESSORIES Backpack Spke Guard 142A1 Utility Pack - Black $65 142A24 K0065 Clear $115 142A2 Kids Black Backpack - Zippie $60 142A23 K0065 Black $115 142A8 Seat Puch Black $50 Miscellaneus 142A49 E2207 Crutch Hlder $195 142A83 Tl Kit $45 142A54 K0038 Extra Leg Strap $30 Psitining Belt 142A141 E0978 Belt 1.5" Aut Buckle w/clamps $70 Upper Extremity Supprt Tray 142A117 E0978 Belt 2" Aircraft Buckle w/clamps $110 142A29 E0950 X-Small (Suggested 10"-12") 142A118 E0978 Belt 2" Aircraft Buckle w/clamps $120 142A30 E0950 Small (Suggested 13"-14") 142A112 E0978 1" Dual Pull Side Squeeze Pad w /Clmp 142A31 E0950 Medium (Suggested 15"-17") 142A814 E0978 1" Cmfrt Fit APB5116 $120 142A31 E0950 Large (Suggested 18"-20") 142SR2 142SR3 142SG4 142SG3 Strller Handles Regular Strller Handles Plastic Kids Plastic Regular $125 Tall Strller Handles $125 Side Guard Nt available with height adj. flip back armrest K0108 K0108 $140 $140 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 4
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 5