a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Ship T: Attentin: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: PO#: ZIP: Kids Quickie 2 SE Nvember 2012 Ship T City: ST: Fax Email Ship T Phne: ( ) Fax: ( ) 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. Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price EIZ10 Dealer City: Address: ADDITIONAL SHIPPING INFORMATION ZIP: KIDS QUICKIE 2 SE (with seat rails) 142WM07 E1236 Kids Quickie 2 SE $1,775.00 K0005 cding still applies fr EIZ10 with certain sizes FRAMES Standard Frame - 250 lbs. Maximum User Weight Frame Type Frame Width 142RS1 Rear Side Straight Transit System Incl. Stabilizer Bar. N/A with padded swing-away armrests r strller handles. 142TO1 Transit System $315.00 Frame Clr 142C2 Black 142C10 Black Opal 142C38 Blue Opal 142C36 Candy Blue 142C14 Candy Purple 142C35 Candy Red 142C128 Cpper 142C6 Frest Green 142C127 Fuchsia 142C126 Glw 142C116 Matte Black 142C117 Matte Green 142C4 Midnight Purple 142C5 Pearl Pink 142C103 Rt Beer 142C114 Sparkle Silver 142C113 Titanium Clr Paint 142C11 Txic Green 142C8 Yellw 142W2 11" (By Uphlstery) 142W3 142W4 142W5 142W6 142W7 12" 13" 14" 15" 16" 142W8 17" 142W9 18" Frame Length 142FL1 Kids 142FL9 Regular 142FL18 Lng Seat Rail Length (Sling Nt Included) 142SN05 10" 142SN06 11" 142SN07 12" 142SN08 13" 142SN09 14" 142SN10 15" 142SN11 16" 142SN12 17" 142SN13 18" Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. 931164 REV.G Page 1
SEATING Seat Uphlstery 142SL1 Sling 142BU1 Standard 142CU1 2" Cushin $95.00 142BU8 Adjustable Uphlstery $150.00 142SL16 Omit Sling, Include Rails 142BP2 Omit Uphlstery Seat Backrest Optins Standard With Push Handles 142PB3 Push Handle 8 (Med r Tall Only) $25.00 142B1 Lw (8.5" - 12") 142PBP2 Omit Push Handle - Straight 142B5 Medium (12" - 15.5") JAY Cushins (Optinal) 142B9 Tall (15.5" - 19") 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 JAY Bundled Cushin 142JC20 Cushin Name r Part # Price List Width: Depth: ARMRESTS 142AA16 Padded Swing Away Adult Nt avail. w/amputee axle plate r transit 142AA9 E0973 Ht Adj. Kids $260.00 142AM1 Desk Length (10") 142AA19 Padded Swing-Away Medium Nt avail. w/amputee axle plate r transit 142AM2 Full Length (14") 142AA8 E0973 Ht/Length Adj. Adult $260.00 142AA17 Padded Swing -Away Kids Nt avail. w/amputee axle plate r transit 142AM1 Desk Length (10") 142AM2 Full Length (14") 142AA6 E0973 Flip Back Height Adjustable (Nt avail. w/ Kids Frame) 142AA14 Omit Armrest 142AM1 Desk Length (10") 142AM2 Full Length (14") 142AM9 Fam Shrt 142AM10 Fam Lng Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. 931164 REV.G Page 2
Hanger Extensin Tube (Required fr Optin 1) Ftplate 1424H14 Impact Guard 142E15 Lng ELR (ELR nly) 142E16 142f3 142H1 142H2 142F48 142A54 k0038 Extra Leg Strap $30.00 142IG2 E0990 60 Swing-Away Hanger Elevating Hanger (Only avail. w/ alum. Ftplates r angle adj. Available n 14"-18" frame widths. N/A w/ lcking angle adj. ftplates r shrt ext. tubes.) Platfrm Flip Up Ftplate (n/a with shrt ext. tubes. Only avail. With 60 70 and 70 V) Neprene (Only avail. With 60 70 and 70 V) $295.00 142E4 Medium (see matrix fr length) 142E5 Lng (see matrix fr length) 142E12 Shrt ELR (ELR nly) 142F4 142F61 142F5 Ftrest Optins $190.00 142HL9 E0951 Heel Lps $50.00 142A110 K0037 E0952 High Munt NA elevating leg rests. Only avail. w/ adult r kids angle adj. ftplates. Kids Angle Adj. Ftplate Lcking Angle Adjustable. (Nt avail. Belw 15" W - Requires Heel Lps) $185.00 Adult Angle Adj. Ftplate (12"-16"w) $185.00 Aluminum Ftplate Available w/ ELRs Te Lps $190.00 142HL8 K0038 Leg Straps $35.00 FOOTRESTS Chse 1 r 2 1. Hanger Type (Munt With Extensin Tube) 2. Hanger Type (Direct Munt 70 Swing-Away Hanger 142E1 Shrt (see matrix fr length) 142F1 Cmpsite Ftplate (12"-16"w) $40.00 CHOOSE 1 OR 2 Hanger 142H7 142H8 142H6 142H23 Extensins (Optinal) 1.42E23 142E24 Ftplate Type 1.42E23 142E24 142F62 E0990 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) 90 Swing Away Hangers (avail. On 12"-16" widths, nt avail. w/8" casters) 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) 90 Ftbard (Only avail. Up t 16" Width, and 70 80 90 direct munt) $280.00 $175.00 $175.00 $280.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. 931164 REV.G Page 3
CASTERS Caster Wheels Caster Wheels - Cntinued 142CW3 142CW31 4" Plyurethane 4" Micr Lighted $65.00 $70.00 142CW39 8" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 142CW5 142CW7 5" Lw Prfile Plyurethane 5" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 142CW36 8" x 2" Pneumatic (Nt avail. w/ 90 elevating leg rests. Nt avail. w/kids frame length. Requires selectin f Caster Tire Tube/Insert) $125.00 142CW6 5" Sft Rll Semi Pneumatic 142CW33 142CW35 142CW21 6" Pneumatic (Requires selectin f Caster Tire Tube/Insert) 6" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 8" Pneumatic (Nt avail. w/ 90 elevating leg rests. Nt avail. w/kids frame length. Requires selectin f Caster Tire Tube/Insert) 142CW34 6" Plyurethane 142CZ2 K0064 142OM Omit Caster Wheels 142CZ1 Caster Tire Tube/Insert Requires a selectin f 6", 8" r 8"x2" Pneumatic Tire. Airless Insert (Only avail. With 8"x2" Pneumatic) Caster Tube (all sizes) $65.00 $20.00 142CW32 8" Plyurethane (Nt avail. w/ 90 elevating leg rests r w/kids frame length.) Caster Optins 142CS5 3/4" Lnger Frk Stem Blt 142CS10 1-1/2" Lnger Frk Stem Blt 142CS3 K0073 Caster Pin Lcks $195.00 AXLE AND WHEELS Axle Plate 142AL2 Standard Adjustable 142AL6 E0959 Amputee Adjustable Axle 142AX1 Quick Release 142AX11 Quad Quick Release $90.00 142AX30 Omit Anti-Tip 142AT6 E0971 Rear Anti-Tip $135.00 Rear Wheel Type 142RW3 20" Mag 142RW74 20" Spke 142RW8 22" Mag 142RW75 22" Spke 142RW1 24" Mag 142RW54 24" Spke $100.00 142RT1 E2211 E2212 Rear Wheel Tire Tube/Insert Requires a selectin f Pneumatic 142RZ2 E2213 Pneumatic Airless Insert $80.00 Pneumatic Tube Hand Rim 142HR1 Aluminum Andized 142HR4 Plastic Cated $95.00 142HR7 Omit Wheel Lck 142WL1 High Munt Push 142WL2 High Munt Pull Extensin Handle 142EH1 E0961 6" Pair 142RT1 E2211 E2212 Rear Wheel Tire Pneumatic (Requires the selectin f Rear Wheel Tire/Insert) 142RT3 Full Plyurethane (avail w/mag nly) $50.00 142RT4 Full Plyurethane (avail w/24" Mag nly) $50.00 Grade Aid Requires a selectin f Rear Wheel Tire/Insert 142GA1 E0974 Grade Aid $150.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. 931164 REV.G Page 4
ACCESSORIES Backpack 142A1 Utility Pack - Black 142A2 Kids Black Backpack - Zippie $50.00 Spke Guard 142A23 K0065 Black $115.00 142A24 K0065 Clear $115.00 Seat Puch 142A8 Black $45.00 Crutch Hlder 142A49 E2207 Crutch Hlder $195.00 Miscellaneus 142A83 Tl Kit $45.00 Psitining Belt 142A141 E0978 Belt 1.5" Aut Buckle w/clamps $70.00 142A117 E0978 Belt 2" Aircraft Buckle w/clamps $110.00 142A118 142A112 142A814 K0108 E0978 E0978 Belt 2" Aircraft Buckle w/clamps 1" Dual Pull Side Squeeze Pad w /Clmp 1" Cmfrt Fit APB5116 $120.00 $120.00 Strller Handles 142SR2 Regular Strller Handles $125.00 142SR3 Tall Strller Handles $125.00 Upper Extremity Supprt Tray 142A29 E0950 X-Small (Suggested 10"-12") 142A30 E0950 Small (Suggested 13"-14") 142A31 E0950 Medium (Suggested 15"-17") 142A32 E0950 Large (Suggested 18"-20") Side Guard Nt available with height adj. flip back armrests 142SG4 K0108 Plastic Kids $125.00 142SG3 K0108 Plastic Regular $125.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. 931164 REV.G Page 5