Ministry of Health and Long-Term Care Assistive Devices ... · PDF fileMobility Devices Product Manual Effective ... 2017 Assistive Devices Program Ministry of Health and Long-Term

Mobility DevicesProduct Manual

Effective Date : May 01, 2018

Assistive Devices ProgramMinistry of Health and Long-Term Care

Printed Date: May 1, 2018 Page: 1 of 89

Ministry of Health and Long-Term Care

Assistive Devices ProgramProduct Manual

Mobility Devices Effective From: May 01, 2018

Ambulation AidsDevice Type Manufacturer Device Device Code Max

Allowed Qty.

Approved Price

Adult Wheeled Walker Type 1 Airway Surgical Top Release 5051/5051-J MW1AR0005 1 $82.00Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, two or four small wheels (less than 6" diameter) and braking system (if available). See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Drive Medical 10263KDR Travel Folding Walker

AA0000560 1 $82.00

Deluxe Folding Wheeled Walker MW1GM0010 1 $82.00

One Button Or Dual Trigger Release

MW1D50005 1 $82.00

Guardian Red Dot Extra Wide G07767 MW1GU0020 1 $82.00

Red Dot G07756 MW1GU0035 1 $82.00

Red Dot Standard G07755 & G07756

MW1GU0015 1 $82.00

Invacare Adult MW1IN0010 1 $82.00

Lumex Dual Release Adult/Junior MW1LU0020 1 $82.00

Lightweight Adult/Junior MW1LU0010 1 $82.00

Rubbermaid Deluxe MW1C60010 1 $82.00

Sunrise Medical Breezy Everyday Folding Walking Frame with wheels

AA0001152 1 $82.00

Adult Wheeled Walker Type 2Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, four small wheels (less than 6" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Airway Surgical 5314 MW2AR0010 1 $324.00

Drive Medical Airgo Adventure 6 MW2GM0040 1 $324.00

Airgo Excursion 6 X20 AA0001355 1 $324.00

Airgo Ultra Light MW2GM0050 1 $324.00

Duet 795b Rollator MW2D00010 1 $324.00

Go-Lite Deluxe MW2D50005 1 $324.00

Evolution Medical Challenger Grande MW2EV0025 1 $324.00

Challenger Mini MW2EV0010 1 $324.00

Sprite & Sprite Mini MW2EV0005 1 $324.00

Sprite Grande MW2EV0020 1 $324.00

Xpresso Companion Two AA0001309 1 $324.00

Xpresso Trillium Two AA0001306 1 $324.00

Human Care Canada Inc.

Nexus 1 (Cable Brake) MW2DG0050 1 $324.00

Invacare Rollite 65100 MW2IN0050 1 $324.00

MEDLINE INDUSTRIES INC.

Translator AA0000459 1 $324.00

Nighthawk Ats 902 Handi Lite MW2NM0005 1 $324.00

Ats 903 Handi Lite MW2NM0010 1 $324.00

Ats 904 Handi Lite MW2NM0015 1 $324.00

Ovation Compact 807-6 MW2NM1005 1 $324.00

Parsons Adl 4200 Dx MW2DG0010 1 $324.00

4200 Lx MW2DG0005 1 $324.00

Page: 2 of 89





Allowed Qty.

Approved Price

Adult Wheeled Walker Type 2 Prode3 ProDe3 Victr/ 17,19 21 inches AA0000320 1 $324.00Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, four small wheels (less than 6" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Sunburst Medical Freedom Plus MW22S0005 1 $324.00

Freedom Plus Short MW22S0010 1 $324.00

Adult Wheeled Walker Type 3Walker type most suitable for active use on most terrains. ADP price includes frame,four large wheels (6"/8" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Access Vital As Active MW3V80005 1 $417.00

Breeze MW3V80010 1 $417.00

Airway Surgical 5305 Adult Type 3 Walker AA0000315 1 $417.00

5307 Rollator AA0000460 1 $417.00

Amg Medical Airgo Vista V20 AA0001338 1 $417.00

Dolomite Alpha Advanced MW3DO1085 1 $417.00

Alpha Basic MW3DO1080 1 $417.00

Jazz MW3DO2000 1 $417.00

Opal Futura Symphony MW3DO1055 1 $417.00

Opal Legacy MW3DO1040 1 $417.00

Opal Maxi / Maxi+ MW3DO1035 1 $417.00

Soprano MW3DO1095 1 $417.00

Drive Medical AIRGO EXCURSION XWD AA0000124 1 $417.00

Airgo Adventure 8 MW3GM0060 1 $417.00

Airgo Comfort Plus Xwd MW3GM0055 1 $417.00

Airgo Comfort-Plus MW3GM0050 1 $417.00

Airgo Duo MW3GM0040 1 $417.00

Airgo Excursion MW3GM0065 1 $417.00

Airgo Fusion Rollator AA0000694 1 $417.00

Airgo Navigator MW3GM0015 1 $417.00

Diamond 740r Rollator MW3D50010 1 $417.00

Nitro AA0001036 1 $417.00

Nitro HD Rollator AA0001238 1 $417.00

Nitro Hemi AA0001193 1 $417.00

Nitro Tall AA0001194 1 $417.00

Enkatsu Solutions Prima Rollator MW3EH0005 1 $417.00

Evolution Medical Challenger Low Wide MW3EV0035 1 $417.00

Challenger Wide MW3EV0030 1 $417.00

Evolution Dx, Ldx, Wdx, Lwdx MW3EV0005 1 $417.00

Horizon Dx, Wdx, Lwdx, Tdx MW3EV0010 1 $417.00

Piper Dx, Mdx, Smdx, Tdx MW3EV0020 1 $417.00

Xpresso Companion AA0001308 1 $417.00

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Allowed Qty.

Approved Price

Adult Wheeled Walker Type 3 Evolution Medical Xpresso Trillium AA0001307 1 $417.00Walker type most suitable for active use on most terrains. ADP price includes frame,four large wheels (6"/8" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required.

Xpresso Wide & Low Wide AA0001283 1 $417.00

Xpresso Zero, Zero Mini & Zero Tall

AA0001282 1 $417.00

Xpresso, Xpresso Lite MW3EV0040 1 $417.00

GF HEALTH PRODUCTS

HYBRID LX Rollator AA0000453 1 $417.00

Human Care Canada Inc.

Nexus Ii (Cable Brake) MW3DG0040 1 $417.00

Nexus Iii (Cable Free Braking System)

MW3DG0045 1 $417.00

Nighthawk Ats 906 0vation MW3NM0015 1 $417.00



Parsons Adl 4200swx MW3DG0035 1 $417.00

4200wx MW3DG0030 1 $417.00

Prode3 ProDe3 Aurora 19/21/23 inches AA0000321 1 $417.00

ProDe3 Balius/21 wide AA0000319 1 $417.00

Sunburst Medical Freedom All Terrain MW32S0010 1 $417.00

Freedom Xl MW32S0015 1 $417.00

Freedom Xls MW32S0005 1 $417.00

Mirage 4900 MW32S0030 1 $417.00

Mirage 4925 MW32S0040 1 $417.00

Mirage 4950 MW32S0035 1 $417.00

Shopper 4700 MW32S0020 1 $417.00

Titan MW32S0050 1 $417.00

Sunrise Medical Gemino AA0001082 1 $417.00

Gemino 60 AA0001236 1 $417.00

Topro Olympos MW3TV0020 1 $417.00

Troja MW3TV0010 1 $417.00

Triumph Mobility Inc Escape AA0001084 1 $417.00

Wheelzahead USA, LLC

Wheelzahead Track III Rollator AA0001235 1 $417.00

Forearm Crutches1 Pair of Forearm Crutches from the following manufacturers may be billed under this code.

Approved ADP Manufacturers Only

Forearm Crutches MKZND0005 1 $121.00

Paediatric Specific Walking FrameADP price includes frame, four wheels, hand grips (including arm supports), and built in sitting support (e.g. sling/saddle seat). See Ambulation Aids Options Chart for adolescent

Can-Dan Rehatec Buddy Roamer AA0001101 1 $2,578.00

Meywalk 3, Meywalk 4 MW6CD0045 1 $2,578.00

Meywalk, Medium & Large MW6CD0040 1 $2,578.00

Page: 4 of 89





Allowed Qty.

Approved Price

sizes. Can-Dan Rehatec Mini-Meywalk MW6CD0050 1 $2,578.00

Hoggi Flux Gait Trainer MW6K20005 1 $2,578.00

Ormesa Dynamico MW6R80055 1 $2,578.00

Grillo MW6OA0005 1 $2,578.00

Prime Engineering Kidwalk MW62P0005 1 $2,578.00

Rifton Equipment Pacer Gait Trainer MW6RF0005 1 $2,578.00

Snug Seat Inc. Bronco,Sizes 0,1,2 MW6R80060 1 $2,578.00

Crocodile Reverse Walker MW6R80070 1 $2,578.00

Gator MW6R80005 1 $2,578.00

Mustang Gait Trainer AA0000693 1 $2,578.00

Pony,Size 0 MW6R80040 1 $2,578.00

Pony,Size 1 MW6R80045 1 $2,578.00

Pony,Size 2 MW6R80050 1 $2,578.00

Pony,Size 3 MW6R80052 1 $2,578.00

Paediatric Specific Wheeled Walker Type 1Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, two or four small wheels, and braking system (if available). See Ambulation Aids Options Chart for adolescent sizes.

Drive Medical Nimbo KA1200N AA0000110 1 $220.00

Nimbo KA2200N AA0000111 1 $220.00

Nimbo KA3200N AA0000112 1 $220.00

Nimbo KA4200N AA0000105 1 $220.00

Guardian Strider Tweener G07783 MW4GU0035 1 $220.00

Strider Tyke G07782 MW4GU0030 1 $220.00

Tyke G07751 MW4GU0010 1 $220.00

Kaye Adolescent 2 Wheels MW4KY0065 1 $220.00

Adolescent 4 Wheels MW4KY0070 1 $220.00

Adolescent 4 Wheels/Swivel MW4KY0075 1 $220.00

Child 2 Wheels MW4KY0020 1 $220.00

Child 4 Wheels MW4KY0025 1 $220.00

Child 4 Wheels/Swivel MW4KY0030 1 $220.00

Child Small 2 Wheels MW4KY0005 1 $220.00

Child Small 4 Wheels MW4KY0010 1 $220.00

Child Small 4 Wheels/Swivel MW4KY0015 1 $220.00

Pre-Adolescent 2 Wheels MW4KY0050 1 $220.00

Pre-Adolescent 4 Wheels MW4KY0055 1 $220.00

Pre-Adolescent 4 Wheels/Swivel MW4KY0060 1 $220.00

Youth 2 Wheels MW4KY0035 1 $220.00

Youth 4 Wheels MW4KY0040 1 $220.00

Youth 4 Wheels/Swivel MW4KY0045 1 $220.00

Page: 5 of 89





Allowed Qty.

Approved Price

Paediatric Specific Wheeled Walker Type 2Walker type most suitable for active use on most terrains. ADP price includes all components and options.

Sunrise Medical Gemino S AA0001303 1 $417.00

Paediatric Standing Frame Type 1ADP price includes frame, positioning straps, trunk, pelvic, knee and foot supports, and tray. See Ambulation Aids Options Chart for adolescent sizes.

Otto Bock Leckey Totstander AA0001369 1 $1,219.00

Vertical Stander MS1HY0005 1 $1,219.00

Prime Engineering Up-Right Stander MS12P0015 1 $1,219.00

Paediatric Standing Frame Type 2ADP price includes frame, positioning straps, trunk, pelvic, knee and foot supports, and tray. See Ambulation Aids Options Chart for adolescent sizes.

Altimate Medical Easy Stand 5000&7000 Magician

MS2HC0005 1 $3,285.00

Easy Stand Bantam MS2HC0015 1 $3,285.00

Easy Stand Evolv MS2HC0010 1 $3,285.00

Easystand Zing AA0001304 1 $3,285.00

Ormesa Dondolino, Size 1 MS2OA0010 1 $3,285.00

Dondolino, Size 2 MS2OA0015 1 $3,285.00

Dondolino, Size 3 MS2OA0020 1 $3,285.00

Mini Standy MS2OA0030 1 $3,285.00

Standy MS2OA0035 1 $3,285.00

Otto Bock Leckey Horizon Stander AA0001371 1 $3,285.00

Leckey Freestander AA0001368 1 $3,285.00

Leckey Mygo Stander AA0000692 1 $3,285.00

Leckey Pronestander AA0001370 1 $3,285.00

Squiggle Stander AA0000700 1 $3,285.00

Prime Engineering Kidstand & Grandstand 111 MS22P0010 1 $3,285.00

Superstand,Small & Youth MS22P0005 1 $3,285.00

Symmetry Standing Frame MS22P0015 1 $3,285.00

Snug Seat Inc. Buffalo/ Caribou, all sizes MS2R80005 1 $3,285.00

Gazelle,Size 1 MS2R80020 1 $3,285.00

Gazelle,Size 2 MS2R80025 1 $3,285.00

Gazelle,Size 3 MS2R80030 1 $3,285.00

Synetik ErgoCare Baby,Kid & Junior MS2JP0010 1 $3,285.00

Page: 6 of 89




Ambulation AidsOPTIONS:

Device Type Manufacturer Device Device Code Max Allowed

Qty.

Approved Price

AA - Custom Modifications MOCM 1 The MOCM code may be used when custom modifications are required to an ADP listed ambulation aid or paediatric stander, and there is no ADP code with assigned funding available. The following documentation must be submitted: 1. Authorizer must provide clinical rationale to support the request. 2. Vendor must provide a breakdown of the cost of labour (not to exceed $40.00/hour), and parts.

Adolescent Size Paediatric Specific Walker

AA5 1 $100.00

Additional funding for adolescent sized paediatric walkers. Authorizer must document clinical requirements. Selected device must meet size requirements.

Adolescent Size Paediatric Standing Frame

AA7 1 $300.00

Additional funding for adolescent sized paediatric standing frames (device type ms1 & ms2). Authorizer must document clinical requirements. Selected device must meet size requirements.

Adolescent Size Paediatric Walking Frame

AA6 1 $200.00

Additional funding for adolescent sized paediatric walking frames (device type mw6). Authorizer must document clinical requirements. Selected device must meet size requirements.

Extra Wide Adult Wheeled Walker AA8 1 $100.00Extra wide adult wheeled walker (greater than 18" between push handles) due to client stature. Client weight less than 275lbs. Authorizer must document client's requirements.

Forearm Attachments AA1 2 $200.00Forearm attachments for wheeled walkers. Authorizer must provide clinical rationale to support request (maximum 2).

Heavy Duty Package Client Weight 275-350 lbs

AA2 1 $100.00

Heavy duty package for wheeled walkers, client weight 275-350 lbs. Authorizer must document client weight. Selected device must meet weight requirements.

Heavy Duty Package Client Weight 350-400 lbs

AA3 1 $150.00

Page: 7 of 89




Ambulation AidsOPTIONS:


Qty.

Approved Price

Heavy duty package for wheeled walkers, client weight 350-400 lbs. Authorizer must document client weight. Selected device must meet weight requirements.

Heavy Duty Package Client Weight Exceeded 400 lbs

AA4 1 $200.00

Heavy duty package for wheeled walkers, client weight exceeds 400lbs. Authorizer must document client weight. Selected device must meet weight requirements.

Unilateral Hand Brake AA9 1 $100.00Unilateral hand brake. allows locking/braking of both brakes using one hand. Authorizer must document clinical requirements. (max 1)

Page: 8 of 89




SeatingDevice Type Manufacturer Device Device Code Max

Allowed Qty.

Approved Price

Back Support Action Products Twister Cb Back 15"-16" Width X 11"-16" Height

SEBAN0005 1 $388.00

Twister Cb Back 15"-16" Width X 17"-21" Height

SEBAN0025 1 $388.00


SEBAN0010 1 $388.00


SEBAN0030 1 $388.00


SEBAN0015 1 $457.00


SEBAN0035 1 $457.00


SEBAN0020 1 $457.00


SEBAN0040 1 $457.00

Adaptive Engineering Lab

DROP-IN R-BACK CURVED - SUN-MATE OR PUDGEE FOAM

SEBE10035 1 $201.00

Drop-In R-Back Curved With 1.5" Poly Foam

SEBE10030 1 $192.00

Drop-In R-Back Curved With Sun-Mate Or Pudgee Foam

SEBE10040 1 $230.00

Drop-In R-Back With 1" Poly Foam SEBE10005 1 $153.00

Drop-In R-Back With 1.5" Poly Foam SEBE10010 1 $168.00

Drop-In R-Back With Sun-Mate Or Pudgee Foam

SEBE10020 1 $168.00

Drop-In T-Back Curved - Sun-Mate Or Pudgee Foam

SEBE10075 1 $249.00

Drop-In T-Back Curved With Sun-Mate Or Pudgee Foam

SEBE10080 1 $219.00

Drop-In T-Back With Sun-Mate Or Pudgee Foam

SEBE10060 1 $216.00

Adaptive Equipment Systems (Aes)

Adjustable Bi-Angular Solid Back Insert, Includes T-Nuts & Adjustment Brackets.

SEB2L1025 1 $378.00

I Or T Or Curved Syle Solid Back Insert, Includes T-Nuts.

SEB2L1015 1 $236.00

Oversize Upcharge For Backs Over 2o" But Less Than 28".

SEB2L1040 1 $69.00

Quick-Fit Contour/Bi-Angular Solid Back Insert, Incudes T-Nuts.

SEB2L1030 1 $519.00

Sculptured Solid Back Insert, Includes T-Nuts.

SEB2L1035 1 $862.00

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Allowed Qty.

Approved Price

Back Support Adaptive Equipment Systems (Aes)

Sculpturefit Back W/Attaching Hardware, Custom.

SEB2L0015 1 $1,066.00

Solid Back Insert Package W/Universal Hardware Or E-Z Mount Mount Hardware & Rotating Hold Downs.

SEB2L0005 1 $555.00

Solid Back Insert Package, Li'L Kiddos, 14" Wide Or Less.

SEB2L0020 1 $632.00

Solid Back Insert Package, Li'L Kiddos, Contoured, 14" Wide.

SEB2L0025 1 $775.00

Solid Back Insert, Includes T-Nuts, Li'L Kiddos, 14" Wide Or Less.

SEB2L1010 1 $213.00

Solid Back Insert, Includes T-Nuts. SEB2L1005 1 $158.00

Solid Back W/Drop Hooks & Fixed Hold Downs.

SEB2L0010 1 $230.00

Advanced Mobility

Contoured Back SEBAO0040 1 $259.00

Deep "U" Back SEBAO0035 1 $293.00

Ez Back Basic SEBAO0060 1 $304.00

Ez Back System Complete SEBAO0055 1 $354.00

Pro Back Support SEBAO0065 1 $449.00

U Form Deep Contour Back Support SEBAO0050 1 $744.00

Amysystems Contour Back Support For Heavy Duty SEB4P0020 1 $825.00

Contour Back Support, Non-Standard Sizes

SEB4P0015 1 $524.00

Contour Back Support, Standard Sizes SEB4P0010 1 $442.00

Blake Medical Silverback Max 16/18/20" wide SE0001109 1 $872.00

Silverback Prime 16/18/20" wide SE0001108 1 $742.00

Body Ryzm Life Sciences / Perspectis, Inc.

JazzRX SE0001205 1 $63.00

Broda Back Pad SEBB-0010 1 $58.00

Custom Fabricated

Back With Permanent Lateral Supports, Vinyl Cover, Without Mounting Hardware

SEBCF114L 1 $561.00

Complex Indirect Molded Back, Without Cover And Mounting Hardware

SEBCF118L 1 $1,259.00

Complex Molded Back (Foam In Place), Without Cover And Mounting Hardware

SEBCF117L 1 $1,122.00

Contoured Back (Foam On Rigid Base), Minimal Trunk Support, Vinyl Cover, Without Mounting Hardware

SEBCF112L 1 $431.00

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Allowed Qty.

Approved Price

Back Support Custom Fabricated

Custom Contoured Back, Moderate Trunk Support, Vinyl Cover, Without Mounting Hardware

SEBCF113L 1 $673.00

Custom Shaped Sculptured Back, Includes Cover, Without Mounting Hardware

SEBCF115L 1 $819.00

Flat Back/Planar Design, Vinyl Cover Without Mounting Hardware

SEBCF110L 1 $259.00

Simple Molded Back (Foam In Place), Without Cover And Mounting Hardware

SEBCF116L 1 $810.00

Dynamic Health Care Solutions

Armadillo Back Support 14" - 24" SE0001130 1 $687.00

Armadillo Back Support with Vicair Technology Cushion

SE0001280 1 $893.00

Classic Deep Pelvic Back 22" SE0001495 1 $566.00

Classic Deep Pelvic Back Support SE0000341 1 $579.00

Classic Pelvic Back 22" SE0001494 1 $497.00

Classic Pelvic Back Support SE0000340 1 $496.00

Cushion Size 14" - 21" SEBD30005 1 $475.00

Cushion Sizes 14" - 21" SEBD30015 1 $579.00

NXT ACT Back, Cushion Size 14"- 21" SEBD30010 1 $496.00

NXT HA SC 22" SE0000334 1 $496.00

NXT SC BACK 12" TO 20" SE0000339 1 $475.00

NXT VC BACK SE0000120 1 $756.00

Nxt Carbon Fiber FHAC Back, FM SE0001221 1 $756.00

Optima Carbon Deep Thoracic Back Support

SE0001281 1 $824.00

Optima Carbon Thoracic Back Support SE0001222 1 $756.00

Optima Deep Thoracic Back Support SE0001219 1 $545.00

Optima Deep Thoracic Back Support 22"

SE0001216 1 $566.00

Optima Deep Thoracic Back Support 23" - 29"

SE0001348 1 $566.00

Optima Thoracic Back Support SE0001217 1 $476.00

Optima Thoracic Back Support 22" SE0001215 1 $497.00

Optima Thoracic Back Support 23" - 29" SE0001347 1 $497.00

UFit Customizable Pelvic Back Support 14" - 20"

SE0001343 1 $618.00

UFit Customizable Pelvic Back Support 22" - 24"

SE0001344 1 $687.00

UFit Deep Customizable Pelvic Back SE0001345 1 $687.00

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Allowed Qty.

Approved Price

Back Support Dynamic Health Care Solutions

Support 14" - 20" Wide

UFit Deep Customizable Pelvic Back Support 22" - 24" Wide

SE0001346 1 $825.00

UFit II Back 14" - 20" SE0001490 1 $652.00

UFit II Back 22" SE0001491 1 $687.00

UFit II Deep Back 14" - 20" SE0001492 1 $721.00

UFit II Deep Back 22" SE0001493 1 $825.00

Xtend Deep Height Adjustable Back Support 16" - 20"

SE0000336 1 $475.00

Xtend Deep Height Adjustable Back Support 22" -24"

SE0000338 1 $496.00

Xtend Height Adjustable Back Support 16" - 20"

SE0000335 1 $475.00

Xtend Height Adjustable Back Support 22 " - 24"

SE0001182 1 $497.00

Xtend Kids Height Adjustable Back Support 10" - 14"

SE0001129 1 $476.00

Xtend Low Deep Height Adjustable Back Support 12" - 20"

SE0001328 1 $475.00

Xtend Low Deep Height Adjustable Back Support 22" - 24"

SE0001329 1 $496.00

Xtend Low Height Adjustable Back Support 12" - 20"

SE0001326 1 $475.00

Xtend Low Height Adjustable Back Support 22" - 24"

SE0001327 1 $497.00

nxt HA SC Back 16" to 20" SE0000337 1 $475.00

Future Mobility Custom Lunar Back SE0000684 1 $656.00

Custom Lunar Back HD SE0000685 1 $1,242.00

Full Back - Sizes From 14" To 22" - Lateral

SEBFM3040 1 $549.00

Full Back - Sizes From 14" To 22" - Ultra Lateral

SEBFM3050 1 $590.00

Full Back - Sizes From 18" To 24" No Lateral

SEBFM3020 1 $507.00

Full Back Style Heavy Duty SEBFM3060 1 $725.00

Low Back - Sizes From 14" To 22" - Lateral

SEBFM3035 1 $483.00

Low Back - Sizes From 16" To 20" - No Lateral

SEBFM3010 1 $431.00

Lunar Slim Back SE0001243 1 $431.00

Lunar Slim Back (Bariatric) SE0001244 1 $690.00

Mid Back - Sizes From 14" To 22" - SEBFM3030 1 $531.00

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Allowed Qty.

Approved Price

Back Support Future Mobility Lateral

Mid Back - Sizes From 14" To 22" - Ultra Lateral

SEBFM3045 1 $573.00

Mid Back - Sizes From 16" To 20" - No Lateral

SEBFM3015 1 $490.00

Mid Back Style Heavy Duty SEBFM3055 1 $690.00

Orion Back SEBFM3005 1 $400.00

Prism Air Back - Custom Sizes SEBFM0045 1 $742.00

Prism Air Back - Non Standard Sizes SEBFM0040 1 $656.00

Prism Air Back Fits 16,18,20" Wide W/C

SEBFM0035 1 $552.00

Prism Bariatric Air Back 21x16 Though 24x20

SEBFM2025 1 $828.00

Prism Bariatric Air Back- Custom Size SEBFM2030 1 $914.00

Prism Bariatric Basic Back - Custom Size

SEBFM2010 1 $742.00

Prism Bariatric Basic Back 21x16 Through 42x20

SEBFM2005 1 $690.00

Prism Bariatric Ultra Back 21x16 Through 24x20

SEBFM2015 1 $697.00

Prism Bariatric Ultra Back- Custom Size SEBFM2020 1 $794.00

Prism Basic Back - Custom Sizes SEBFM0015 1 $569.00

Prism Basic Back - Non Standard Sizes SEBFM0010 1 $518.00

Prism Basic Back Fits 16,18,20" Wide W/C

SEBFM0005 1 $424.00

Prism Max Back - Upcharge SEBFM0150 1 $86.00

Prism Phantom Back 12-18" Width X 7" Height

SEBFM0070 1 $275.00

Prism Super Back For Kids - Custom Sizes

SEBFM0090 1 $569.00

Prism Super Back For Kids - Non Standard Sizes

SEBFM0085 1 $493.00

Prism Super Back For Kids Fits 10, 12, 14 And 16" Wide W/C

SEBFM0080 1 $431.00

Prism Truefitt Back - Bariatric Sizes SEBFM0060 1 $863.00

Prism Truefitt Back - Custom Sizes SEBFM0065 1 $707.00

Prism Truefitt Back - Non Standard Sizes

SEBFM0055 1 $638.00

Prism Truefitt Back Fits 16,18,20" Wide W/C

SEBFM0050 1 $604.00

Prism Ultra Back - Custom Sizes SEBFM0030 1 $697.00

Page: 13 of 89





Allowed Qty.

Approved Price

Back Support Future Mobility Prism Ultra Back - Non Standard Sizes SEBFM0025 1 $621.00

Prism Ultra Back Fits 16,18,20" Wide W/C

SEBFM0020 1 $535.00

Hoggi Back Cushion Shaped SE0000469 1 $272.00

Back Cushion trough Shaped SE0000466 1 $322.00

Xps Adaptive Back Cushion SEBK20050 1 $259.00

Innovators 1993 Inc

K Special Back-Custom SEBI30020 1 $152.00

K Special Back-Standard SEBI30010 1 $130.00

K-Combo Back SEBI30060 1 $173.00

K-Combo Back Custom SEBI30065 1 $191.00

Key-Hole Back SEBI30030 1 $152.00

Key-Hole Back Custom SEBI30040 1 $169.00

Key-Hole Back Custom Adjustable Top SEBI30045 1 $169.00

Invacare Contour U Back Includes All Modifications & Vacuum/Vinyl Upholstery

SEBNS1030 1 $1,156.00

Curved Back Fits 10" To 20" Wide W/C SEBNS0030 1 $432.00

Curved Back Pneumatic Fits 10" To 20" Wide W/C

SEBNS0040 1 $474.00

Curved Back Pneumatic Special Size & Modifications

SEBNS0045 1 $562.00

Curved Back Special Size & Modifications

SEBNS0035 1 $519.00

Naked Contour U Back, Includes All Modifications & Vacuum/Moisture Proof Coating/Removable Cover & Cover Pattern.

SEBNS1035 1 $1,375.00

Personal Back Bariatric Builder Size SEBNS0058 1 $657.00

Personal Back Fits 16", 18", 20" Wide W/C

SEBNS0052 1 $444.00

Personal Back Plus - Bariatric Builder Size

SEBNS0088 1 $771.00

Personal Back Plus - Fits 16", 18", 20" Wide W/C

SEBNS0062 1 $558.00

Silhoutte Back Support SEBNS1020 1 $545.00

Invacare - Matrx Seating

Deep Heavy Duty Posture Back, All Sizes

SEB1M0020 1 $922.00

Deep Posture Back, All Sizes SEB1M0015 1 $681.00

Genera Back SEB1M0050 1 $382.00

Heavy Duty Posture Back Fits W/C 20"-25" Width & 16"-20" Height

SEB1M0010 1 $801.00

Page: 14 of 89





Allowed Qty.

Approved Price

Back Support Invacare - Matrx Seating

Matrx Elite HD, greater than 24" SE0001052 1 $1,113.00

Matrx Elite HD, up to 24" SE0001051 1 $703.00

Matrx Elite TR - Adult SE0001214 1 $596.00

Matrx High Back Fits W/C 16" - 21" Width & 20" - 30" Height

SEB1M1005 1 $560.00

Matrx MX1 Superlite, 12" SE0001054 1 $785.00



Matrx Mini - Paediatric SE0001213 1 $583.00

PB Elite Deep All Sizes SEB1M0026 1 $618.00

PB Extra Wide Deep Heavy Duty Backs From 16 To 20 Inches

SEB1M0040 1 $1,239.00

PB Extra Wide Heavy Duty Backs Sizes 16 To 20 Inches

SEB1M0035 1 $1,133.00

PB Posture Back Elite, Posture Back Elite Full Back, All Sizes

SEB1M0025 1 $584.00

Posture Back Fits W/C 13"-20" Width & 12"-20"Height

SEB1M0005 1 $560.00

Trx Rehab Back, Fits W/C 18" - 25" Width

SEB1M1050 1 $204.00

Jay Medical Foam Back SEBJA5040 1 $99.00

J2 Deep Contour Back 14w-19w, Includes Mounting Hardware, Cover, Lumbar Supports & Lateral Wedges

SEBJA7000 1 $523.00

J2 Deep Contour Back 20wx20h, Includes Mounting Hardware, Cover, Lumbar Supports & Lateral Wedges

SEBJA7005 1 $557.00

J3 Lower Thoracic Back, All Sizes SEBJA0900 1 $380.00

J3 Mid Thoracic Back, All Sizes SEBJA0905 1 $511.00

J3 Shoulder Height Back, All Sizes SEBJA0915 1 $618.00

J3 Upper Thoracic Back, All Sizes SEBJA0910 1 $600.00

JAY 2 Plus 20-23", 23-26" J2 Back Assembly For 0 Or 8 Degree Backposts

SEBJA0300 1 $982.00

JAY Zip Back All Sizes SE0000640 1 $587.00

Jay 2 Back Includes Mounting Hardware (""K"" Or ""G"" Type), Cover & Lumbar Supports (14""-19"")

SEBJA0100 1 $501.00

Jay 2 Back Includes Mounting Hardware, Cover & Lumbar Supports (12"/13")

SEBJA0105 1 $501.00

Page: 15 of 89





Allowed Qty.

Approved Price

Back Support Jay Medical Jay 2 Back- Includes Mounting Hardware (""K"" Or ""G"" Type), Cover & Lumbar Supports (20"")

SEBJA0110 1 $560.00

Jay 2 Plus 20-23", 23-26" Back Assembly For 0 To 8 Degree Backposts, With Headrest Mounting Kit

SEBJA0310 1 $1,052.00

Jay 2 Tall Back- Includes Mounting Hardware, Cover & Lumbar Supports (20")

SEBJA0130 1 $662.00

Jay 2 Tall Back- Includes Mounting Hardware, Cover & Lumbar Supports (14"/16"/17"/18")

SEBJA0120 1 $574.00

Jay Active Back 18"-14" Quick Release Mount

SEBJA1010 1 $364.00

Jay Active Back 18"-14" Rigid Mount SEBJA1015 1 $337.00

Jay Active Back 18"/16" Tall Quick Release Mount

SEBJA1012 1 $396.00

Jay Active Back 20" Tall SEBJA1014 1 $464.00

Jay Active Back With Permanent Mount (Large)

SEBJA1019 1 $432.00

Jay Basic Back, Fixed Clamp Style, All Sizes

SEBJA2025 1 $350.00

Jay Basic Back, Fixed Strap Style, All Sizes

SEBJA2020 1 $322.00

Jay Care Back 15-18" Wide SEBJA5000 1 $440.00

Jay Care Back 19-20" Plus Width SEBJA5010 1 $527.00

Jay Care Back Foam Large Size SEBJA5045 1 $136.00

Jay Care Back Shell Large Size SEBJA5055 1 $282.00

Jay Encompass Back SEBJA8200 1 $311.00

Jay Fit Back Adjustable Contour Back For 10" Or 12" Frame Width, Various Back Heights

SEBJA4005 1 $290.00

Jay Fit Back Adjustable Contour Back For 14" Or 16" Frame Width, Various Back Heights

SEBJA4010 1 $328.00

Jay Fit Back Adjustable Contour Back For 18" Frame Width, Various Back Heights

SEBJA4015 1 $366.00

Jay Focus Point Back, All Sizes SEBJA8100 1 $540.00

Jay Modual Back Custom Contoured Insert 18"/16"/14"

SEBJA3050 1 $602.00

Jay Modual Back Custom Contoured Insert 20"

SEBJA3055 1 $695.00

Page: 16 of 89





Allowed Qty.

Approved Price

Back Support Jay Medical Jay Modual Back Standard Insert 18"/16"/14"

SEBJA3005 1 $359.00

Jay Modual Back Standard Insert 20" SEBJA3010 1 $469.00

Jay Modular Back Adjustable Aluminum Shell 20"

SEBJA3002 1 $640.00

Jay Modular Back Adjustable Aluminum Shell (18",16",14")

SEBJA3000 1 $552.00

Jay Union Back Standard with 4 point hardware

SE0000644 1 $620.00

Jay Union Back Standard with standard hardware

SE0000643 1 $586.00

Jay Union Back Tall with 4 point Hardware

SE0000646 1 $703.00

Jay Union Back Tall with Standard Hardware

SE0000645 1 $668.00

Kid Kart I-Back Cushion Tlc SEBKT2015 1 $101.00

Xpress T-Back 1" Short, Regular, Or Tall

SEBKT2025 1 $112.00

Xpress T-Back 2.5" Short, Regular, Or Tall

SEBKT2030 1 $112.00

Lpa Medical Inc. Adjustable Tension Back SEBO12010 1 $172.00

Contour Back Cushion SEBO12005 1 $93.00

Maple Leaf Wheelchair

Contour Padded Personal Back SEBWM0005 1 $248.00

ML Deep SE0001085 1 $419.00

ML Kyphothic SE0001089 1 $574.00

ML Mid SE0001086 1 $483.00

ML Shallow SE0001087 1 $375.00

ML Shape SE0001088 1 $566.00

ML Slim Custom SE0001337 1 $600.00

ML Slim Short SE0001336 1 $525.00

ML Slim Standard SE0001334 1 $500.00

ML Slim Tall SE0001335 1 $525.00

The Fusion Essential (Bariatric) SE0001364 1 $833.00

The Fusion Essential (Non-Standard, All Sizes)

SE0001363 1 $764.00

The Fusion Essential (Standard, All Sizes)

SE0001362 1 $695.00

The Fusion1 (Bariatric) SE0001361 1 $633.00

The Fusion1 (Non-Standard, All Sizes) SE0001360 1 $564.00

The Fusion1 (Standard, All Sizes) SE0001359 1 $495.00

Page: 17 of 89





Allowed Qty.

Approved Price

Back Support Motion Concepts MX1 Dual Mount 14-18 wide x 9 hgh SE0000135 1 $825.00

MX1 Dual Mount 14-18 x 16 high SE0000137 1 $960.00

MX1 Dual mount 14-18 wide x 12 high SE0000136 1 $894.00

MX1 Mono Mount 14-18 wide x 16 high SE0000134 1 $928.00

MX1 Mono Mount 14-18 wide x 9 high SE0000132 1 $790.00

MX1 Mono mount 14-18 wide x 12 high SE0000133 1 $859.00

MX1 Quick Release Dual Mount 14-18 wide x 16 high

SE0000140 1 $980.00

MX1 Quick Release Dual Mount 14-18 x 12 high

SE0000139 1 $911.00

MX1 Quick Release Dual Mount 14-18 x 9 high

SE0000138 1 $842.00

Matrx MX2 Back (14" x 12 ", 15" x 12", 16" x 12", 17" x 12", 18" x 12") with fixed mounting or quick release hardware

SE0001462 1 $825.00


SE0001463 1 $859.00


SE0001460 1 $756.00


SE0001461 1 $790.00

Trx Contour Back, For Trx Systems, 16, 18, 22" Wide Wheelchairs, Height Adjustable 18-26"

SEBZG0005 1 $237.00

Trx Onyx Contour Back & Trx Single Post Cloth Contour Back, For Trx Systems

SEBZG0020 1 $318.00

Trx Single Post Onyx Contour Back For Trx Systems

SEBZG0025 1 $318.00

Nighthawk Key-Hole Back SEBNM0050 1 $197.00

Relaxed Back High SEBNM0010 1 $159.00

Relaxed Back High With Flap SEBNM0020 1 $168.00

Relaxed Back Low SEBNM0005 1 $159.00

Orthofab High Profile Contoured 14-20"Width, 16-20" Height

SEBOF2005 1 $367.00

High Profile Contoured Non Standard Sizes

SEBOF2010 1 $407.00

High Profile Tall Contoured 14-20" Width, 18-22" Height

SEBOF2015 1 $345.00

Page: 18 of 89





Allowed Qty.

Approved Price

Back Support Orthofab High Profile Tall Contoured Non Standard Sizes & Options

SEBOF2020 1 $407.00

Low Profile Contoured 14-20" Width, 16-20" Height

SEBOF2025 1 $345.00

Low Profile Contoured Non Standard Sizes

SEBOF2030 1 $407.00

Modular Mild Or Deep Contour 14-20" Width & 16,18,20" Height

SEBOF1005 1 $449.00

Modular Mild Or Deep Contour Non Standard Sizes

SEBOF1010 1 $497.00

Otto Bock Back System 1, 15" To 17" & 18" To 20"

SEBOB9555 1 $342.00

Back System 2, 15" To 17" & 18" To 20"

SEBOB9600 1 $438.00

Back System 3, 15" To 17" & 18" To 20"

SEBOB9605 1 $523.00

Back System 4, 15" - 20" Sizes SEBOB9610 1 $684.00

Back-Finished With Spray Coating,Cover,Sewing Pattern

SEBOB9650 1 $1,710.00

Back-Itemized Cushion (Unfinished) SEBOB9655 1 $1,253.00

OBSS Ortho-Shape Back (All Sizes) SE0001375 1 $2,539.00

Performance Health Products

V-Trak Ax-Sb Back Support Connisting Of 1 Insert, All Sizes

SEBP00015 1 $555.00

V-Trak Ax-Sb Back Support Consisting Of 2 Inserts, All Sizes

SEBP00020 1 $876.00

V-Trak Ax-Sb Back Support Consisting Of 3 Inserts, All Sizes

SEBP00025 1 $1,152.00

V-Trak Axh Back Support, All Sizes SEBP00010 1 $752.00

V-Trak Axs Back Support, All Sizes SEBP00005 1 $673.00

Permobil Ergo Back - Fixed - All Sizes SEB1P0005 1 $692.00

Ergo Back - Recline - All Sizes SEB1P0010 1 $692.00

ROHO Agility Carbon Back System with Air Only (items greater than 10¿ high)

SE0001373 1 $1,208.00

ROHO Agility Carbon Back System with Air Only (items up to 10¿ high)

SE0001372 1 $966.00

Rectangular Back - All Sizes SEB1P0015 1 $1,052.00

Physipro HP2 Back Support, all models, all sizes SE0001071 1 $480.00

Premium Back Support, all sizes SE0001072 1 $480.00

Positech Innovation Inc.

BACKUS (oversize) with detachable/waterproof foam cushion backrest (all sizes) including laterals and standard or swing-away anchors

SE0001437 1 $1,550.00

Page: 19 of 89





Allowed Qty.

Approved Price

Back Support Positech Innovation Inc.

BACKUS with detachable/waterproof foam cushion backrest (all sizes) including laterals and standard or swing-away anchors

SE0001436 1 $1,425.00

CURVUS (oversize) with detachable/waterproof foam cushion backrest (all sizes) including laterals and standard or swing-away anchors

SE0001439 1 $1,675.00

CURVUS with detachable waterproof foam cushion backrest (all sizes) including laterals and standard or swing-away anchors

SE0001438 1 $1,550.00

FLEXUS (complete system, one-size-fits-all) with height adjustable foam cushion backrest including laterals and standard or swing-away anchors

SE0001440 1 $2,800.00

Power Plus Mobility

Relax Form Fit SEBWM0026 1 $707.00

Relax Full Fit SEBWM0010 1 $524.00

Relax Full Fit (custom) SEBWM0015 1 $621.00

Relax Gentle Fit SEBWM0020 1 $469.00

Relax Gentle Fit (Custom) SEBWM0025 1 $524.00

Relax Snug Fit SEBWM0027 1 $604.00

Relax Spiral Fit SEBWM0030 1 $718.00

Upcharge For Custom Height SEBWM0040 1 $152.00

Upcharge For Custom Width SEBWM0035 1 $152.00

Precision Rehab Manufacturing

Back Sewn Cover Waterproof Foam, Includes Labour For Digitizing Or Plastering

SEBWB0010 1 $1,476.00

Back Vacuum Formed, Includes Labour For Digitizing Or Plastering

SEBWB0005 1 $1,241.00

Base Cushion Back, Includes All Modifications & Labour For Digitizing Or Plastering

SEBWB0015 1 $1,793.00

Precision - Fit Back Cushion Upcharge, Extra Wide Or Extra Tall, 20" - 24"

SEBWB0022 1 $207.00

Precision - Fit Back Cushion, Subtle, Moderate Or Aggresive Positioning. Includes Hinged Or Fixed Laterals And Cover.

SEBWB0020 1 $930.00

Pride Mobility Products

Synergy Standard Back Support, up to 20". For additional sizing see SEBND0015.

SE0000971 1 $311.00

Synergy Tru Comfort Back Standard, SEBX10025 1 $518.00

Page: 20 of 89





Allowed Qty.

Approved Price

Back Support Pride Mobility Products

Reclining Or Tilt And Recline Back Greater Than 20" Wide

Synergy Tru-Comfort Back Synergy Tru Comfort Back Standard, Reclining Or Tilt And Recline Back Up To 20" Wide

SEBX10020 1 $480.00

Quickie BREEZY RELAX2 COMFORT BACK ANATOMICAL SHAPE

SE0000117 1 $1,722.00

Contour Back - Tilt Fx SEBQU0400 1 $359.00

Ride Designs Corbac Adjustable Contour Back Support, All Sizes

SEBR40005 1 $338.00

Ride Custom Back Support SEBR40010 1 $2,254.00

Ride Decaf, all sizes SE0001045 1 $542.00

Ride Java Back 12", 14", 15", 18" SE0001242 1 $542.00

Ride Java Back Grande SE0001144 1 $561.00

Ride Java Back Grande Deep SE0001145 1 $638.00

Ride Java Back Regular/Tall Deep SE0001143 1 $618.00

Roho Agility Back - Custom Design - All Variation

SE0001167 1 $1,439.00

Agility Back Support SE0000970 1 $636.00

Agility Max Contour Back - all sizes SE0001118 1 $822.00

Low Back (10" Height) All Standard Sizes 14" - 18"

SEBRO3010 1 $1,031.00

Lumbar Support Cushion (Made To Order)

SEBRO2015 1 $341.00

Recliner Wheelchair Cushion Made To Order (One Piece Back & Seat- 2 Sections,2 Valves)

SEBRO2005 1 $1,035.00

Recliner Wheelchair Cushion-Custom (More Than 2 Sections And/Or 2 Halves)

SEBRO2010 1 $1,208.00

Standard Back (16" Height) All Standard Sizes 14" - 18"

SEBRO3005 1 $1,289.00

Starkey - Viennatone

Butterfly Back System SEBV10005 1 $293.00

Stealth Products ADI - AL and AFT Backrest - Active Contour, all sizes

SE0001290 1 $595.00

ADI - AL and AFT Backrest - Deep, Contour, all sizes

SE0001291 1 $658.00

ADI - AL and AFT Backrest - Extra Deep contour, all sizes

SE0001292 1 $721.00

ADI - CF Backrest - Active Contour, all SE0001293 1 $774.00

Page: 21 of 89





Allowed Qty.

Approved Price

Back Support Stealth Products sizes

ADI - CF Backrest - Deep Contour, all sizes

SE0001294 1 $838.00

Sunrise Medical Back Cushion 16x20,18x20, 20x20 SEBM90005 1 $169.00

Backrest "Plush", Deep Or Active Contour

SEBM90020 1 $459.00

Lateral Support Backrest 16x20,18x20 SEBM90010 1 $297.00

Mid Thoracic Posterior Deep Jay 3 Back - Sizes 12 Height To 26 Width Sizes 15 Height To 26 Width

SEBJA8205 1 $1,052.00

Sedeo Pro-Comfort Backrest 16"w to 18"w x 20"h

SE0000655 1 $518.00

Sedeo Pro-Comfort Backrest 20"w x 20"h

SE0000656 1 $552.00

Sedeo Pro-comfort Backrest 22"w x 20" h

SE0000657 1 $587.00

Sedeo Pro-deep Backrest 16"w to 18"w x to 20"h

SE0000658 1 $587.00

Sedeo Pro-deep Backrest 20"w x 20"h SE0000659 1 $620.00

Sedeo Pro-deep Backrest, Active cut 16"w to 18"w x 20"h

SE0000661 1 $587.00

Sedeo Pro-deep Backrest, Active cut 20" w x 20"h

SE0000662 1 $620.00

Sedeo Pro-deep Backrest, Active cut 22"w x 20" h

SE0000663 1 $656.00

Sedeo Pro-deep backrest 22"w x 20 h SE0000660 1 $656.00

Shoulder Height Posterior Deep Jay 3 Back

SEBJA8215 1 $1,221.00

Smartsit Comfort Back - All Sizes SEBM90100 1 $549.00

Upper Thoracic Posterior Deep Jay 3 Back - Sizes 18 Height To 24 Width

SEBJA8210 1 $1,121.00

Supracor Stimulite Lumbar Support SEBRR0010 1 $110.00

The Comfort Company

Acta Relief Back - All Variations SE0001168 1 $877.00

Acta-Back, All Variations, All Sizes SEB7C0010 1 $650.00

Acta-Back, All Variations, Custom Sizes SEB7C0015 1 $1,155.00

Incrediback, Modable, Tall, Deep, Tall-Deep, Custom Sizes

SEB7C0025 1 $1,311.00

Incrediback, Moldable, Tall, Deep, Tall-Deep, All Sizes

SEB7C0020 1 $644.00

Toronto Orthopedic Ltd.

Tops Back Cushion (10" & 12" Width) SEBTP0005 1 $212.00

Page: 22 of 89





Allowed Qty.

Approved Price

Back Support Varilite Medical Products

Evolution Back - Regular SEBVP0050 1 $674.00

Evolution Back - Regular Bariatric SEBVP0055 1 $942.00

Evolution Back - Tall SEBVP0060 1 $746.00

Evolution Deep Back - All Sizes SEBVP0070 1 $978.00

Icon Back - Bariatric SEBVP0120 1 $965.00

Icon Back - Deep SEBVP0115 1 $884.00

Icon Back - Low SEBVP0100 1 $618.00

Icon Back - Tall SEBVP1110 1 $724.00

Icon Back -Mid SEBVP0105 1 $643.00

Junior Backs SE0001147 1 $643.00

Talon Back - All Sizes SEBVP0080 1 $479.00

Vision Wheelchair Seating Systems Inc.

Viscount Tall Back Support For 16' Or 18" W/C

SEBVC0030 1 $1,036.00

Viscount Tall Back Support, Custom Sizes

SEBVC0035 1 $1,308.00

Viva Contoured Postural Back 14"-16" W/C Or 16"-18" W/C

SEBVC0015 1 $198.00

Complete Assembly Adaptive Engineering Lab

Contoured Seat System (Includes Seat, Back, Support Pads, Hardware)

SECE10020 1 $1,057.00


Basis Contoured Seat & Back Including Connecting Hinge (Select Type). Does Not Include Mounting Hardware.

SEC2L0010 1 $742.00

Basis Contoured Seat & Back Including Connecting Hinge Package. Li'L Kiddos,14" Wide Or Less. Does Not Include Mounting Hardware.

SEC2L0020 1 $897.00

Basis Seat & Back Including Connecting Hinge (Select Type). Does Not Include Mounting Hardware.

SEC2L0005 1 $511.00

Basis Seat & Back Including Connecting Hinge Package. Li'L Kiddos,14" Wide Or Less. Does Not Include Mounting Hardware.

SEC2L0015 1 $595.00

Amysystems Bariatric Power Recline With Integrated Shear Reduction (Isr)

SEC4P0065 1 $6,999.00

Broda Hsp Padding Package (Includes Short Wing Cover, Extended Shoulder Bolsters, Full Extension Foot Pad, F-2 Foot Rest, Thigh Belt)

SECB-0005 1 $486.00

Custom Modify Or Refurbish Existing Custom SEMCF900L 1 $431.00

Page: 23 of 89





Allowed Qty.

Approved Price

Complete Assembly Fabricated Seating System. Includes Parts,Hardware,Labour Changes To Head Rest,Back Support,Seat, & Footrest Etc.

Hoggi Adjustible Height Back System Planar Back Cushion

SE0000467 1 $272.00

Bingo Ius Or Xps Seat Frame Size 1 SECK20005 1 $1,352.00

Bingo Ius Or Xps Seat Frame Size 2 SECK20010 1 $1,373.00

Configurable Adjustible Height I Back System

SE0000468 1 $272.00

Ius Adaptive Seat And Back Cushions With Airflex

SECK20105 1 $607.00

Ius Adaptive Seat And Back Cushions - Breathable

SECK20100 1 $224.00

Invacare Kinesthetic Seating System Fits 10" To 14" Wide W/C, (Includes Basic Headrest, Lateral Supports, Padded Lap Belt, Ulti-Mate Base, Curved Back & Growth Bracket)

SECNS0005 1 $1,131.00

Kinesthetic Seating System Fits 16" To 20" Wide W/C, (Includes Basic Headrest, Lateral Supports, Padded Lap Belt, Ulti-Mate Base & Curved Back)

SECNS0010 1 $1,131.00

Kid Kart Tlc Shell Assembly With Contour Seating

SECKT2010 1 $990.00

Tlc Shell Assembly With Planar Seating SECKT2005 1 $790.00

Xpress Adjustable Contour Seating Package

SECKT3005 1 $773.00

Xpress Shell Assembly With Contour Seating

SECKT3015 1 $773.00

Xpress Shell Assembly With Planar Seating

SECKT3010 1 $555.00

Otto Bock Kimba Spring Multifunctional Seating Unit - Size 1 Includes Elevating Legrests, Flip-Up Footrest, Laterals, Adjustable Hip Pads & Padding.

SECOB3005 1 $1,308.00

Kimba Spring Multifunctional Seating Unit - Size 2 Includes Elevating Legrests, Flip-Up Footrest, Laterals, Adjustable Hip Pads & Padding.

SECOB3010 1 $1,377.00

Kimba Spring Plus Adjustable Seating System - Size 1 Includes Armrests, Elevating Legrests,

SECOB4005 1 $1,256.00

Page: 24 of 89





Allowed Qty.

Approved Price

Complete Assembly Otto Bock Adjustable Footplates & Recline.

Kimba Spring Plus Adjustable Seating System - Size 2 Includes Armrests, Elevating Legrests, Adjustable Footplates & Recline.

SECOB4010 1 $1,415.00

Kimbo Neo Basic Seat - Size 1 - Includes Elevating Legrests, Flip-Up Footrest, Laterals, Adjustable Hip Pads & Padding.

SE0001158 1 $1,394.00

Mygo Seat Shell Size 1 Includes Seat Shell And Cushions

SECOB4015 1 $1,559.00

Mygo Seat Shell Size 2 Includes Seat Shell Cushions And Shoulder Support

SECOB4020 1 $1,793.00

OBSS Ortho-Shape SE0001046 1 $3,723.00

OBSS Ortho-Shape, greater than 20" wide and/or deep

SE0001047 1 $4,033.00

OBSS Ortho-Shape, including additional liner for growth

SE0001048 1 $3,964.00

Squiggle Seating System SE0000701 1 $1,477.00

Spenco Silicore Wheelchair Seat With Back and Sides

SECSO0010 1 $105.00

THOMASHILFEN EasyS or EasyS Modular SE0001026 1 $1,377.00

Thevo Twist SE0001025 1 $1,477.00


Tops Seating System Includes Butterfly Chest Strap, Combination Head/Neckrest Tilt Tray, Stroller Interface, Back And Seat

SECTP0005 1 $1,347.00

Headrest/Neckrest Adaptive Engineering Lab

Curved Headrest SEHE10015 1 $88.00

Tri-Pad Headrest SEHE10005 1 $272.00


Curved Hr Pad Or Contoured Hr Pad Or Bell Curved Hr Pad, Cobra Headrest Bracket, Flip-Down.

SEH2L0035 1 $455.00

Curved Hr Pad Or Contoured Hr Pad Or Bell Curved Hr Pad, Cobra Headrest Bracket.

SEH2L0030 1 $381.00

Lateral-Posterior Head Support, Adjustable Depth Bracket, 6-1/2"W X 7"H.

SEH2L0015 1 $355.00

Lateral-Posterior Head Support, Adjustable Depth Bracket, Hinged.

SEH2L0005 1 $388.00

Page: 25 of 89





Allowed Qty.

Approved Price

Headrest/Neckrest Adaptive Equipment Systems (Aes)

Lateral-Posterior Head Support, Adjustable Depth Bracket, Paediatric 4" X 4" Or 5"X 5" Or 6"X 6".

SEH2L0010 1 $337.00

Lateral-Posterior Head Support, Cobra Headrest Bracket, 5" X 5"Or 6" X 6" Or 7" X 7"Or 8" X 8".

SEH2L0020 1 $464.00

Lateral-Posterior Head Support, Cobra Style Headrest Bracket, Flip-Down 5" X 5"Or 6"X6" Or 7"X7" Or 8" X8".

SEH2L0025 1 $536.00

Advanced Mobility

Custom Headrest SEHAO0015 1 $173.00

Deep "U" Headrest SEHAO0020 1 $135.00

Large Padded Headrest SEHAO0025 1 $100.00

Macintosh Oxbow Headrest SEHAO0010 1 $173.00

So Soft Oval Headrest SEHAO0030 1 $135.00

Standard Curved Padded Headrest SEHAO0005 1 $100.00

Amysystems Curved Headrest, All Sizes SEH4P0010 1 $161.00

Broda Neckrest Cushion SEHB-0010 1 $41.00

Custom Fabricated

Adjustable Headrest With Neckrest, Vinyl Cover, Without Hardware

SEHCF080L 1 $362.00

Complex Headrest/Contoured Or Molded, Vinyl Cover, Without Hardware

SEHCF060L 1 $267.00

Contoured Headrest/Curved Surface, Vinyl Cover, Without Hardware

SEHCF050L 1 $173.00

Flat Headrest/Planar Head Support, Vinyl Cover, Without Hardware

SEHCF040L 1 $108.00

Head Or Neckrest Incorporated With Mobility Switches, Vinyl Cover, Without Hardware

SEHCF090L 1 $267.00

Neckrest With Vinyl Cover, Without Hardware

SEHCF070L 1 $164.00

Daher Specialty Foam Products

Combination Headrest SEHDH0010 1 $50.00

Full Support Headrest SEHDH0015 1 $66.00

Large Headrest SEHDH0005 1 $50.00


MultiFit Headrest SE0001131 1 $155.00

Future Mobility Large Headrest With Multi-Axial Hardware

SEHFM0015 1 $245.00

Large Padded Headrest SEHFM0005 1 $190.00

Page: 26 of 89





Allowed Qty.

Approved Price

Headrest/Neckrest Future Mobility Small Headrest With Multi-Axial Hardware

SEHFM0020 1 $242.00

Small Padded Headrest SEHFM0010 1 $186.00

Hoggi Ius Headrest SEHK20005 1 $248.00

Invacare Basic Headrest - Adult SEHNS1010 1 $191.00

Basic Headrest - Child SEHNS1005 1 $191.00

Curved Adjustable Headrest System SEHNS1030 1 $284.00

Large Adjustable Headrest System SEHNS1020 1 $305.00

Small Adjustable Headrest System SEHNS1015 1 $305.00

Two Step Adjustable Headrest System SEHNS1025 1 $284.00

Invacare - Matrx Seating

Matrx Elan 4 Point Headrest Pad (w/ Infection Control) with removable cover

SE0001325 1 $473.00

Matrx Elan 4 Point Headrest Pad with standard removable cover

SE0001324 1 $448.00

Matrx Elan Occipital Headrest Pad w/ removable Infection Control cover 9" x 7" or 12" x 8"

SE0001323 1 $366.00

Matrx Elan Occipital Headrest Pad with removable cover - 9" x 7" or 12" x 8"

SE0001322 1 $341.00

Matrx Elan Standard Headrest Pad with removable Infection Control cover - 6" x 3.5", 10" x 5" or 14" x 5"

SE0001321 1 $335.00

Matrx Elan Standard Headrest Pad with removable cover - 6" x 3.5", 10" x 5" or 14" x 5"

SE0001320 1 $310.00

Jay Medical Four Pad Headrest - Junior SEHJA0016 1 $254.00

Four Pad Rotational Headrest - Junior SEHJA0018 1 $380.00

Four Pad Rotational Headrest - Standard

SEHJA0017 1 $380.00

Full Width Headrest SEHJA0020 1 $127.00

Single Pad Headrest - Large SEHJA0006 1 $72.00

Single Pad Headrest - Small SEHJA0005 1 $72.00

Three Pad Headrest - Large SEHJA0011 1 $181.00

Three Pad Headrest - Large Junior SEHJA0013 1 $181.00

Three Pad Headrest - Small SEHJA0010 1 $181.00

Three Pad Headrest - Small Junior SEHJA0012 1 $181.00

Three Pad Rotational Headrest - Large SEHJA0027 1 $304.00

Three Pad Rotational Headrest - Large Junior

SEHJA0029 1 $304.00

Three Pad Rotational Headrest - Small SEHJA0026 1 $304.00

Three Pad Rotational Headrest - Small SEHJA0028 1 $304.00

Page: 27 of 89





Allowed Qty.

Approved Price

Headrest/Neckrest Jay Medical Junior

Kid Kart Xpress Micro Adjustable Head Support SEHKT3010 1 $211.00

Xpress Planar Head Support SEHKT3015 1 $138.00

Xpress Tri-Wing Adjustable Head Support

SEHKT3005 1 $107.00

Lpa Medical Inc. Cervical Support SEHO12005 1 $36.00

Contour Headrest SEHO12010 1 $86.00


ML Contour SE0001133 1 $179.00

Metalcraft Industries

Contoured Headrest With Mounting Hardware Small, Large, Xlarge

SEHNG0005 1 $260.00

Occipital Ring With Mounting Hardware Small & Large Child Or Adult

SEHNG0015 1 $298.00

Occipital Ring, Add-On, With Mounting Hardware Small & Large Child Or Adult

SEHNG0020 1 $260.00

Motion Concepts Onyx Auto Style Headrest SEHZG0005 1 $161.00

Orthofab Padded Contour Support Without Mounting Hardware, Small, Medium, Or Large

SEHOF1005 1 $91.00

Otto Bock Adjustable Wing Headrest (Size 1 & 2) SEHOB6020 1 $485.00

Contoured Headrest (Size 1 & 2) SEHOB6010 1 $138.00

Fixed Wing Headrest (Size 1 & 2) SEHOB6015 1 $342.00

Headrest - Combination SEHOB0010 1 $72.00

Headrest - Large/Small SEHOB0100 1 $72.00

Headrest - Lateral Control SEHOB0050 1 $117.00

Headrest Support (Size 1 & 2) SEHOB6005 1 $247.00

Neckrest - All Sizes SEHOB0250 1 $82.00

Soft Headrest - Large/Small SEHOB0110 1 $104.00

X-Style Headrest/Neckrest Combination, Adult & Paediatric Sizes.

SEHOB0015 1 $108.00

Performance Health Products

V-Trak Headrest, All Sizes, All Configurations

SEHP00005 1 $311.00

Permobil Headrest - For Ergo Back SEH1P0005 1 $405.00

Physipro Headrest SE0001073 1 $147.00


SUMMUS (all sizes) including hardware (support holder and fastener)

SE0001446 1 $500.00

Power Plus Mobility

Contour Headrest Including Brackets SEHWM0005 1 $221.00

Page: 28 of 89





Allowed Qty.

Approved Price

Headrest/Neckrest Precision Rehab Manufacturing

Headreast - Large (14") Or Small (10") Pad

SEHWB0010 1 $104.00


TRU-Comfort 2 Including Mounting Hardware

SE0001153 1 $243.00

Stealth Products Stealth Combo Headrest With Multi Axis Hardware, Large & Small Sizes

SEHNS2050 1 $462.00

Stealth Comfort Plus Large 14" Comfort Pad Only (With Ring)

SEHNS3015 1 $142.00

Stealth Comfort Plus Medium 10" Comfort Pad Only (With Ring)

SEHNS3025 1 $142.00

Stealth Comfort Plus, Large 14" Pad /Multi Axis Hardware

SEHNS3020 1 $292.00

Stealth Comfort Plus, Large 14" Pad/Standard Hardware

SEHNS3005 1 $242.00

Stealth Comfort Plus, Medium 10" Pad/Multi Axis Hardware

SEHNS3030 1 $292.00

Stealth Comfort Plus, Medium 10" Pad/Standard Hardware

SEHNS3010 1 $242.00

Stealth Comfort Plus, Swingaway Both Sides, Standard Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3060 1 $426.00

Stealth Comfort Plus, Swingaway Left Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3070 1 $323.00

Stealth Comfort Plus, Swingaway Right Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3065 1 $323.00

Stealth I2i Headrest System - All Sizes SEHNS2060 1 $709.00

Stealth Occipital/Sub Occipital & Laterals, Adult & Paediatric Sizes (Specify Swingaway)

SEHNS2005 1 $977.00

Stealth Otto Bock Style, Swing Away Both Sides, Standard Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3075 1 $480.00

Stealth Otto Bock Style, Swingaway Left Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3085 1 $367.00

Stealth Otto Bock Style, Swingaway Right Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS3080 1 $367.00

Stealth Ultra Channel With Ring, Large & Small Sizes

SEHNS2020 1 $558.00

Stealth Ultra Large Combo With Large Sub Occipital

SEHNS2007 1 $885.00

Page: 29 of 89





Allowed Qty.

Approved Price

Headrest/Neckrest Stealth Products Stealth Ultra Occipital & Laterals, Small & Large Sizes (Specify Swingaway)

SEHNS2015 1 $693.00

Stealth Ultra Occipital Large/Small SEHNS2030 1 $285.00

Stealth Ultra Small & Occipital/Sub Occipital

SEHNS2010 1 $568.00

Stealth Ultra Small Combo With Large Sub Occipital

SEHNS2009 1 $885.00

Stealth Ultra Sub Occipital Large/Small SEHNS2025 1 $285.00

Stealth Ultra Swing Both Sides, Standard Lateral Pad/Spot Pad/Long Lateral Pad

SEHNS2035 1 $409.00

Stealth Ultra Swingaway Standard & Long Lateral Pad, Or Spot Pad

SEHNS2045 2 $323.00

Stealth Ultra-Ac Adjustable Channel SEHNS2040 1 $270.00

Sunrise Medical Emineo Advanced Headrest SEHM90105 1 $311.00

Emineo Basic Headrest SEHM90100 1 $204.00

Large Headrest SEHM90015 1 $128.00

Lateral Support Headrest SEHM90010 1 $121.00

Offset Headrest Large SEHM90030 1 $183.00

Offset Headrest Lateral SEHM90025 1 $176.00

Offset Headrest Small SEHM90020 1 $169.00

Sedeo Pro Flexible Headrest Pad SE0000665 1 $93.00

Sedeo Pro Large Headrest Pad SE0000666 1 $100.00

Sedeo Pro small headrest pad SE0000664 1 $69.00

Small Headrest Assesmbly SEHM90005 1 $114.00

The Comfort Company

Headrest - Moldable, Includes Cover SEH7C0015 1 $188.00


Vector Head N Neck Support, 11"W X 8"D Pad

SEHVC0005 1 $200.00

Vector Head N Neck Support, Custom Pad

SEHVC0010 1 $283.00

Whitmyer Biomechanix

10" Plush Occipital Pad & Single Sub-Occipital Pad With Linx Vertical/Horizontal Mount

SEHWH7005 1 $361.00

10" Plush Occipital Pad & Single Sub-Occipital Pad With Onyx Vertical/Horizontal Mount

SEHWH7020 1 $339.00

10" Plush Occipital Pad & Single Sub-Occipital Pad With Pro Verticial/Horizontal Mount

SEHWH7035 1 $371.00

Page: 30 of 89





Allowed Qty.

Approved Price

Headrest/Neckrest Whitmyer Biomechanix

14" Plush Pad With Linx Vertical/Horizontal Mount

SEHWH5010 1 $197.00

14" Plush Pad With Onyx Vertical/Horizontal Mount

SEHWH5030 1 $197.00

14" Plush Pad With Pro Vertical/Horizontal Mount

SEHWH5040 1 $210.00

19" Plush Pad With Link Vertical/Horizontal Mount

SEHWH5015 1 $288.00

19" Plush Pad With Onyx Vertical/Horizontal Mount

SEHWH5032 1 $260.00

19" Plush Pad With Pro Vertical/Horizontal Mount

SEHWH5045 1 $292.00

4"X6" Occipital Pad & Single Sub-Occipital Pad With Onyx Vertical/Horizontal Mount

SEHWH7025 1 $288.00

4"X6" Occipital Pad & Single Sub-Occipital Pad With Pro Vertical/Horizontal Mount

SEHWH7040 1 $320.00

4"X6"Occipital Pad & Single Sub-Occipital Pad With Lynx Vertical/Horizontal Mount

SEHWH7010 1 $316.00

4"X6"Occipital Pad With Size 1/2 Sub-Occipital Pads With Lynx Vertical/Horizontal Mount

SEHWH7050 1 $380.00

4"X6"Occipital Pad With Size 1/2 Sub-Occipital Pads With Onyx Vertical/Horizontal Mount

SEHWH7065 1 $297.00

4"X6"Occipital Pad With Size 1/2 Sub-Occipital Pads With Pro Vertical/Horizontal Mount

SEHWH7080 1 $416.00

8" Or 10" Plush Pad With Lightweight Vertical/Horizontal Mount

SEHWH5020 1 $188.00

8" Or 10" Plush Pad With Linx Vertical/Horizontal Mount

SEHWH5005 1 $188.00

8" Or 10" Plush Pad With Onyx Vertical/Horizontal Mount

SEHWH5025 1 $188.00

8" Or 10" Plush Pad With Pro Vertical/Horizontal Mount

SEHWH5035 1 $202.00

8"/10" Plush Occipital Pad With Size 1 Sub-Occipital Pads With Pro Vertical/Horizontal Mount

SEHWH7085 1 $467.00

8"/10" Plush Occipital Pad With Size 1sub-Occipital Pads With Lynx Vertical/Horizontal Mount

SEHWH7055 1 $430.00

8"/10" Plush Occipital Pad With Size 1sub-Occipital Pads

SEHWH7070 1 $453.00

Page: 31 of 89





Allowed Qty.

Approved Price


With Onyx Vertical/Horizontal Mount

Adjust-A-Plush Headrest System SEHWH7260 1 $235.00

Bilateral Lfc With Pads And Interface Plate For Plush & Contoured Cradle Systems

SEHWH7235 1 $398.00

Heads Up Pad All Sizes - Add On Occipital Pads Optional

SE0001099 1 $207.00

Large Pad With Lightweight Vertical/Horizontal Mount

SEHWH5075 1 $142.00

Large Pad With Linx Vertical/Horizontal Mount

SEHWH5060 1 $142.00

Large Pad With Onyx Vertical/Horizontal Mount

SEHWH5090 1 $183.00

Large Pad With Pro Vertical/Horizontal Mount

SEHWH5110 1 $197.00

Lateral Facial Component With Pad SEHWH7250 2 $183.00

Medium Pad With Lightweight Vertical/Horizontal Mount, LWS-CCS3

SEHWH5070 1 $133.00

Medium Pad With Lightweight Vertical/Horizontal Mount, ONYX-CCS3

SEHWH5085 1 $174.00

Medium Pad With Linx Vertical/Horizontal Mount

SEHWH5055 1 $133.00

Medium Pad With Pro Vertical/Horizontal Mount

SEHWH5105 1 $151.00

Occipital Pad With Size 3/4 Sub-Occipital Pads 1"X4",4"X6",1"X4" With Lynx Vertical/Horizontal Mount

SEHWH7105 1 $380.00

Occipital Pad With Size 3/4 Sub-Occipital Pads 1"X4",4"X6",1"X4" With Onyx Vertical/Horizontal Mount

SEHWH7115 1 $393.00

Occipital Pad With Size 3/4 Sub-Occipital Pads 1"X4",4"X6",1"X4" With Pro Vertical/Horizontal Mount

SEHWH7125 1 $416.00

Single Pad Dynamic Forehead Strap System All Sizes

SEHWH7200 1 $252.00

Single Pad Static Forehead Strap System All Sizes

SEHWH7205 1 $266.00

Small Pad With Lightweight Vertical/Horizontal Mount

SEHWH5065 1 $123.00

Small Pad With Linx Vertical/Horizontal Mount

SEHWH5050 1 $123.00

Small Pad With Onyx SEHWH5080 1 $165.00

Page: 32 of 89





Allowed Qty.

Approved Price


Vertical/Horizontal Mount

Small Pad With Pro Vertical/Horizontal Mount

SEHWH5095 1 $142.00

T-Bar Occipital Pads & Single Sub-Occipital Pad 2.25"X7" & 2.25"X5" With Linx Vertical/Horizontal Mount

SEHWH7015 1 $562.00

T-Bar Occipital Pads & Single Sub-Occipital Pad 2.25"X7" & 2.25"X5" With Onyx Vertical/Horizontal Mount

SEHWH7030 1 $535.00

T-Bar Occipital Pads & Single Sub-Occipital Pad 2.25"X7" & 2.25"X5" With Pro Vertical/Horizontal Mount

SEHWH7045 1 $572.00

T-Bar Occipital Pads With Size 1 Sub-Occipital Pads 2.25"X7" With Pro Vertical/Horizontal Mount

SEHWH7090 1 $636.00

T-Bar Occipital Pads With Size 1sub-Occipital Pads 2.25"X7" With Linx Vertical/Horizontal Mount

SEHWH7060 1 $599.00

T-Bar Occipital Pads With Size 1sub-Occipital Pads 2.25"X7" With Onyx Vertical/Horizontal Mount

SEHWH7075 1 $612.00

T-Bar Occipital Pads With Size 3 Single Sub-Occipital Pads 2.25"X5" With Linx Vertical/Horizontal Mount

SEHWH7110 1 $599.00

T-Bar Occipital Pads With Size 3 Single Sub-Occipital Pads 2.25"X5" With Onyx Vertical/Horizontal Mount

SEHWH7120 1 $612.00

T-Bar Occipital Pads With Size 3 Single Sub-Occipital Pads 2.25"X5" With Pro Vertical/Horizontal Mount

SEHWH7130 1 $636.00

Unilateral Lfc With Pads And Interface Plate For Plush & Contoured Cradle Systems

SEHWH7230 1 $216.00

Seat Cushion 5 Minds Mobility Inc.

ACe Comfort II Cushion 14¿x14¿, 14¿x16¿

SE0001428 1 $590.00

ACe Comfort II Cushion 16¿x16¿, 16¿x18¿, 18¿x16¿, 18¿x18¿

SE0001429 1 $604.00

ACe Comfort II Cushion 16¿x20¿, 18¿x20¿, 20¿x16¿, 20¿x18¿

SE0001430 1 $618.00

Page: 33 of 89





Allowed Qty.

Approved Price


ACe Comfort II Cushion 20¿x20¿ SE0001431 1 $631.00

ACe Comfort II Cushion 22¿x16¿,22¿x18¿

SE0001432 1 $645.00

ACe Comfort II Cushion 22¿x20¿ SE0001433 1 $652.00

ACe Comfort and ACe Contour Cushions

SE0001264 1 $376.00

ACe Complete Cushion 16¿x16¿, 16¿x18¿, 18¿x16¿, 18¿x18¿

SE0001349 1 $790.00

ACe Complete Cushion 16¿x20¿, 18¿x20¿, 20¿x16¿, 20¿x18¿

SE0001350 1 $804.00

ACe Complete Cushion 20¿x20¿ SE0001351 1 $818.00

ACe Complete Cushion Dual Valve (Bariatric) 22" x 16", 22" x 18"

SE0001410 1 $838.00

ACe Complete Cushion Dual Valve (Bariatric) 22" x 20", 24" x 16", 24" x 18"

SE0001411 1 $845.00

ACe Complete Cushion Dual Valve (Bariatric) 24" x 20"

SE0001412 1 $852.00

ACe Complete Cushion Dual Valve (Paediatric) 12¿x10¿, 12¿x12¿, 12"x14¿

SE0001408 1 $776.00

ACe Complete Cushion Dual Valve (Paediatric) 14¿x10¿, 14¿x12¿, 14"x14¿

SE0001409 1 $783.00

ACe Complete Cushion Single Valve (Bariatric) 22" x 16", 22" x 18"

SE0001405 1 $825.00

ACe Complete Cushion Single Valve (Bariatric) 22" x 20", 24" x 16", 24" x 18"

SE0001406 1 $831.00

ACe Complete Cushion Single Valve (Bariatric) 24" x 20"

SE0001407 1 $838.00

ACe Complete Cushion Single Valve (Paediatric) 12¿x10¿, 12¿x12¿, 12"x14¿

SE0001403 1 $762.00

ACe Complete Cushion Single Valve (Paediatric) 14¿x10¿, 14¿x12¿, 14"x14¿

SE0001404 1 $769.00

ACe Complete Dual Valve Cushion 16¿x16¿, 16¿x18¿, 18¿x16¿, 18¿x18¿

SE0001413 1 $804.00

ACe Complete Dual Valve Cushion 16¿x20¿, 18¿x20¿, 20¿x16¿, 20¿x18¿

SE0001414 1 $818.00

ACe Complete Dual Valve Cushion 20¿x20"

SE0001415 1 $825.00

ACe Contour VF Modular Cushion (Bariatric) 22¿x16¿, 22¿x18"

SE0001423 1 $624.00

ACe Contour VF Modular Cushion SE0001424 1 $631.00

Page: 34 of 89





Allowed Qty.

Approved Price


(Bariatric) 22¿x20¿

ACe Contour VF Modular Cushion (Bariatric) 24¿x16¿, 24¿x18¿

SE0001425 1 $638.00

ACe Contour VF Modular Cushion (Bariatric) 24¿x20¿, 20¿x22¿, 22¿x22¿

SE0001426 1 $645.00

ACe Contour VF Modular Cushion (Bariatric) 24¿x22¿

SE0001427 1 $652.00

ACe Contour VF Modular Cushion (Paediatric) 10¿x10¿

SE0001417 1 $542.00

ACe Contour VF Modular Cushion (Paediatric) 10¿x12¿, 12¿x10¿

SE0001418 1 $549.00

ACe Contour VF Modular Cushion (Paediatric) 12¿x12"

SE0001419 1 $555.00

ACe Contour VF Modular Cushion (Paediatric) 12¿x14¿, 14¿x10¿

SE0001420 1 $562.00


SE0001421 1 $569.00


SE0001422 1 $576.00


SE0001416 1 $535.00

ACe Contour VF Modular Cushion 16¿x16¿, 16¿x18¿, 18¿x16¿, 18¿x18¿

SE0001352 1 $583.00

ACe Contour VF Modular Cushion 16¿x20¿, 18¿x20¿, 20¿x16¿, 20¿x18¿

SE0001353 1 $597.00

ACe Contour VF Modular Cushion 20¿x20¿

SE0001354 1 $611.00

Action Products ACTION XACT LP2 SE0000329 1 $598.00

Action Xact LP2 SIZES XP: WIDTH: 16"/18"/20"/22" DEPTH: 16"/18"/20"

SE0000570 1 $599.00

Action Xact LP2 XP: SIZES: XP 1818 TO 22X20

SE0000571 1 $686.00

Centurian Cushion 16x16,16x81,18x16,18x18

SESAN2205 1 $229.00

Centurian Cushion 18x20,20x18,20x20 SESAN2210 1 $404.00

Centurian Cushion Large Custom Sizes SESAN2225 1 $423.00

Centurian Cushion Small Custom Sizes SESAN2215 1 $347.00

Centurian Cushion Xlarge Custom Sizes

SESAN2230 1 $539.00

Commuter Cushion 16x16,16x18,18x16,18x18

SESAN4405 1 $207.00

Commuter Cushion 18x20,20x18,20x20 SESAN4410 1 $404.00

Commuter Cushion Large Custom SESAN4425 1 $396.00

Page: 35 of 89





Allowed Qty.

Approved Price

Seat Cushion Action Products Sizes

Commuter Cushion Medium Custom Sizes

SESAN4420 1 $351.00

Commuter Cushion Small Sizes SESAN4415 1 $319.00

Pilot Cushion 16x16,16x18,18x16,18x18

SESAN3305 1 $267.00

Pilot Cushion 18x20,20x18,20x20 SESAN3310 1 $372.00

Pilot Cushion Large Custom Sizes SESAN3325 1 $481.00

Pilot Cushion Medium Custom Sizes SESAN3320 1 $416.00

Pilot Cushion Small Custom Sizes SESAN3315 1 $361.00

Pilot Cushion Xlarge Sizes SESAN3330 1 $558.00

Pilot Cushion Xxxlarge Custom Sizes SESAN3340 1 $790.00

Professional Cushion 16x16,16x18,18x16,18x18

SESAN1105 1 $354.00

Professional Cushion 18x20,20x18,20x20

SESAN1115 1 $574.00

Professional Cushion Large Custom Sizes

SESAN1130 1 $602.00

Professional Cushion Medium Custom Sizes

SESAN1125 1 $515.00

Shear Smart Pad 16x16,16x18,18x16,18x18

SESAN5505 1 $181.00

Shear Smart Pad 18x20, 20x18, 20x20 SESAN5510 1 $216.00

Xact Classic Cushion 10x10,16x14,17x17,16x20,18x20,20x20

SESAN9905 1 $599.00

Xact Classic Cushion 16x16,16x18,18x16,18x18

SESAN9910 1 $513.00

Xact Individual Cushion All Custom Sizes

SESAN9915 1 $1,031.00

Xact Individual Cushion Custom Sizes SESAN9920 1 $1,031.00

Xact Integrated Cushion With Drop Seat 16x20,18x20, 20x20

SESAN9010 1 $647.00

Xact Integrated Drop Base Sizes 10x10 To 18x18

SESAN9005 1 $599.00

Xact Lite Cushion 16x16 - 18x18 SESAN9015 1 $367.00

Xact Lite Cushion 18x20 - 20x20 SESAN9020 1 $427.00

Xact Soft Foam Cushion 16x16, 16x18, 18x16, 18x18

SESAN9980 1 $513.00

Xact Soft Foam Cushion 16x20,18x20, 20x16, 20x18, 20x20

SESAN9985 1 $647.00

Xact Soft Foam Cushion With Integrated Drop Seat, All Sizes

SESAN9990 1 $729.00

Page: 36 of 89





Allowed Qty.

Approved Price

Seat Cushion Adaptive Engineering Lab

Drop-In Seat With 1.5" Sun-Mate Or Pudgee Foam

SESE10030 1 $184.00

Drop-In Seat With Contour One Foam SESE10035 1 $261.00

Drop-In Seat With Poly Foam SESE10020 1 $167.00

Full-Width Seat With 1.5" Sun-Mate Or Pudgee Foam

SESE10065 1 $324.00

Full-Width Seat With 1.5" Un-Mate Or T-Foam

SESE10055 1 $184.00

Full-Width Seat With Contour-One Foam

SESE10070 1 $261.00


Full Width Solid Seat Package With J Or Flush Or Drop Hooks & Hold Downs.

SES2L0010 1 $559.00

Offset, T Style, I Style, Anti-Thrust Or Medial Thigh Support Solid Seat Insert, Includes T-Nuts.

SES2L1015 1 $232.00

Oversize Upcharge For Seats Over 2o" But Less Than 28".

SES2L1035 1 $69.00

Quick Fit Anti-Thrust Or Contour Solid Seat Insert, Includes T-Nuts.

SES2L1020 1 $423.00

Quick-Fit Contoured, Adjustable Split, Or Foam Form Solid Seat Insert, Incudes T-Nuts.

SES2L1030 1 $491.00

Sculptured Solid Set Insert, Includes T-Nuts, Custom.

SES2L1025 1 $862.00

Sculpturefit Seat Package 2/Attaching Hardware, Custom.

SES2L0015 1 $1,066.00

Solid Seat Insert Package, Li'L Kiddos, 14" Wide Or Less.

SES2L0020 1 $548.00

Solid Seat Insert Package, Li'L Kiddos, Contoured, 14" Wide Or Less.

SES2L0025 1 $708.00

Solid Seat Insert, Includes T-Nuts, Li'L Kiddos, 14" Wide Or Less.

SES2L1010 1 $213.00

Solid Seat Insert, Includes T-Nuts. SES2L1005 1 $158.00

Solid Seat Package W/Universal Or E-Z Mount Hardware.

SES2L0005 1 $467.00

Advanced Mobility

All Star Cushion Custom Sizes Includes Cover

SESAO0080 1 $503.00

All Star Cushion Includes Cover And Sizes 16x16 16x18 16x18 17x17 18x16 18x18

SESAO0085 1 $445.00

Page: 37 of 89





Allowed Qty.

Approved Price

Seat Cushion Advanced Mobility

All Star Drop Base, Includes Cover, Base, 4 Drop Hooks

SESAO0090 1 $496.00

Comfort Contoured Cushion SESAO0030 1 $121.00

Gel Flotation Pad SESAO0110 1 $279.00

Pro Custom Cushion With Built In Drop Base

SESAO0070 1 $530.00

Pro-Custom Cushion With Covers SESAO0075 1 $486.00

Superstar Cushion Includes Cover 16x16, 16x18, 18x16, 18x18

SESAO0100 1 $518.00

Superstar Drop Base, Size 17x17, Includes Cover, Base, 4 Drop Hooks

SESAO0105 1 $604.00

Upcharge For Custom Sizes Other Than 17x17

SESAO0115 1 $68.00

Amoena Medizin Amovida Motion AV400 SE0000959 1 $189.00

Amovida Motion Comfort + AV500 SE0000960 1 $229.00

Amysystems CG Air Deluxe 10 x 10 - 20 x 20 (includes 3D mesh or incontinence covers)

SE0001384 1 $635.00

CG Air Deluxe 10 x 10 - 20 x 20 (includes standard covers)

SE0001383 1 $568.00

CG Air Deluxe 22" - 24" wide (including 3D mesh or incontinence covers)

SE0001386 1 $664.00

CG Air Deluxe 22" - 24" wide (including standard covers)

SE0001385 1 $635.00

CG Air Deluxe 26"+ wide (includes 3D mesh or incontinence covers)

SE0001388 1 $733.00

CG Air Deluxe 26"+ wide (including standard covers)

SE0001387 1 $704.00

CG Air Single or Dual Valve 10 x 10 - 20 x 20 (includes 3D mesh or incontinence covers 2", 3", 4" high)

SE0001378 1 $511.00

CG Air Single or Dual Valve 10 x 10 - 20 x 20 (includes standard covers 2", 3", 4" high)

SE0001377 1 $435.00

CG Air Single or Dual Valve 22" - 24" wide (includes 3D mesh or incontinence covers 2", 3", 4" high)

SE0001380 1 $664.00

CG Air Single or Dual Valve 22" - 24" wide (includes standard covers 2", 3", 4" high)

SE0001379 1 $664.00

CG Air Single or Dual Valve 26"+ (includes standard covers 2", 3", 4" high)

SE0001381 1 $704.00

Page: 38 of 89





Allowed Qty.

Approved Price

Seat Cushion Amysystems CG Air Single or Dual Valve 26"+ wide (includes 3D mesh or incontinence covers 2", 3", 4" high)

SE0001382 1 $733.00

Contour Seat Cushion For Heavy Duty SES4P0020 1 $618.00

Contour Seat Cushion, Non-Standard Sizes

SES4P0015 1 $524.00

Contour Seat Cushion, Standard Sizes SES4P0010 1 $442.00

Bioform Reha Foundation Cushion - All Sizes SESZB0005 1 $417.00

Blake Medical Geomatrix Bronze SESG00005 1 $368.00

Geomatrix Gold, Gold+ SESG00015 1 $529.00

Geomatrix Gold, Gold+ Custom Sizes SESG00020 1 $621.00

Geomatrix Hybrid Or Hybrid Deep SESG00030 1 $562.00

Geomatrix Platinum SESG00025 1 $752.00

Geomatrix Silver SESG00010 1 $483.00

Zentury, all sizes SE0000996 1 $242.00

Body Ryzm Life Sciences / Perspectis, Inc.

SambaMD SE0001204 1 $149.00

Broda Seat Pad SESB-0010 1 $53.00

Clearview Healthcare Products

Debbonair Dynamics/Cushionair Cushion - Greater Than 20" Width Or Depth

SESGC0015 1 $583.00

Debbonair Dynamics/Cushionair Cushion - Standard Sizes

SESGC0005 1 $471.00

Debbonair Dynamics/Cushionair Cushion - Up To 20" Width Or Depth

SESGC0010 1 $503.00

Custom Fabricated

Complex Indirect Molded Seat, Without Cover & Mounting Hardware

SESCF105L 1 $1,259.00

Contoured Seat, Includes Cover, Without Hardware

SESCF103L 1 $518.00

Flat Seat/Rigid Base, Includes Cover, Without Hardware

SESCF101L 1 $259.00

Sculptured Seat, Includes Cover, Without Hardware

SESCF104L 1 $621.00

Wedged Seat (Thigh Bar), Includes Cover, Without Hardware

SESCF102L 1 $388.00


Nxt BioFit Cushion, all sizes SE0001037 1 $411.00

Nxt KulFit Cushion, all sizes SE0001039 1 $376.00

Nxt NuFit Cushion, all sizes SE0001038 1 $376.00

Page: 39 of 89





Allowed Qty.

Approved Price

Seat Cushion Dynamic Health Care Solutions

nxt BioFit Cushion (20", 22" and 24" x 22")

SE0001434 1 $431.00

Future Mobility Prism Elite Cushion 16x16-20x20 SESFM0060 1 $259.00

Prism Elite Cushion Custom Sizes SESFM0065 1 $293.00

Prism Ideal Cushion All Sizes SESFM0050 1 $159.00

Prism Supreme Air Cushion 18x18 Through 20x20

SESFM0030 1 $500.00

Prism Supreme Air Cushion 18x19 Through 20x19

SESFM0035 1 $518.00

Prism Supreme Air Cushion Custom Sizes

SESFM0040 1 $542.00

Prism Supreme Cushion 14x14 Through 18x20

SESFM0015 1 $397.00

Prism Supreme Cushion 15x16 Through 20x20

SESFM0020 1 $414.00

Prism Supreme Cushion Custom Sizes SESFM0025 1 $473.00

Prism Supreme Gel Cushion 14x14 Through 18x20

SESFM0110 1 $466.00

Prism Supreme Gel Cushion 15x16 Through 20x20

SESFM0115 1 $483.00

Prism Supreme Gel Cushion Custom Sizes

SESFM0120 1 $535.00

Prism Supreme Heavy Duty Cushion SESFM0125 1 $552.00

Prism Supreme Ii Plus Cushion 14x14 Through 18x20

SESFM0070 1 $397.00

Prism Supreme Ii Plus Cushion 15x16 Through 20x20

SESFM0075 1 $414.00

Prism Supreme Ii Plus Cushion Custom Sizes

SESFM0080 1 $473.00

Serene Champion SE0001226 1 $311.00

Serene Paramount SE0001227 1 $311.00

Serene Paramount Gel SE0001229 1 $362.00

Serene Paramount Visco SE0001228 1 $342.00

Serene Prime SE0001225 1 $97.00

Super Cushion For Kids 10x10 Through 16x16

SESFM0090 1 $397.00

Super Cushion For Kids 10x12 Through 16x12

SESFM0095 1 $414.00

Super Cushion For Kids Custom Sizes SESFM0100 1 $473.00

Hoggi Non Standard Seat Width SE0000464 1 $200.00

Standard Seat Width SE0000463 1 $132.00

Page: 40 of 89





Allowed Qty.

Approved Price

Seat Cushion Hoggi Swingbo Plus Seat Cushion SE0000465 1 $174.00

Xps Adaptive Seat Cushion SESK20050 1 $269.00

Invacare Absolute Fits 16" To 20" Wide W/C SESNS0005 1 $74.00

Airflo Cushion Custom Sizes SESNS2015 1 $558.00

Airflo Cushion Fits 14 To 18" Wide W/C SESNS2005 1 $489.00

Airflo Cushion Fits 20" To 22" Wide W/C

SESNS2010 1 $495.00

Comfort -Mate Extra - Special Size Modifications

SESNS0039 1 $143.00

Comfort-Mate Extra - Fits 14" To 22" Wide W/C

SESNS0037 1 $143.00

Contour U Seat Includes All Modifications & Vacuum/Vinyl Upholstery

SESNS0075 1 $1,156.00

Invacare Matrx Flovair Cushion - Gentle/Max Contour

SE0000967 1 $449.00

Invacare Matrx Stabilite Cushion SE0000966 1 $317.00

MATRX PS POSTURE SEAT Pediatric Sizes 1010/1012/1014

SE0000131 1 $638.00

Naked Contour U Seat, Includes All Modifications & Vacuum/Moisture Proof Coating/Removable Cover & Cover Pattern.

SESNS0080 1 $1,375.00

Silhouette Seat Cushion SESNS0070 1 $545.00

Single Density Cushion, Non Standard Size

SESNS0015 1 $91.00

Ulti-mate Base Fits 10" To 14" Wide W/C

SESNS1040 1 $416.00

Ulti-mate Base Special Adult Size & Modifications

SESNS1035 1 $578.00

Ulti-mate Base Special Junior Size & Modifications

SESNS1045 1 $578.00

Ulti-mate Cushion Fits 10" To 14" Wide W/C

SESNS0050 1 $302.00

Ulti-mate Cushion Fits 16" To 20" Wide W/C

SESNS0040 1 $373.00

Ulti-mate Cushion Special Adult Size & Modifications

SESNS0045 1 $458.00

Ulti-mate Cushion Special Junior Size & Modifications

SESNS0055 1 $387.00

Ulti-mate Fits 16" To 20" Wide W/C SESNS1030 1 $456.00

Invacare - Matrx Flo-Tech Cushion Fits W/C 16" - 19" SES1M0030 1 $551.00

Page: 41 of 89





Allowed Qty.

Approved Price

Seat Cushion Seating Width & 16" - 21" Depth

Flo-Tech Cushion Fits W/C 20" - 24 Width & 20" - 22" Depth

SES1M0040 1 $744.00

Flo-Tech Cushion Fits W/C 20" Width & 16" - 18" Depth

SES1M0035 1 $632.00

Kidabra Base Fits W/C 12"-14" Width & 12"-15" Depth

SES1M2005 1 $584.00

Kidabra Fits W/C 11"-14" Width & 12"-15" Depth

SES1M0015 1 $439.00

Matrx Libra - Heavy Duty SE0001237 1 $707.00

Matrx Libra - Standard SE0001212 1 $514.00

Matrx Posture Seat (PS Cushion) 23x30 Width To 21x30 Deep

SES1M0066 1 $687.00

Matrx Posture Seat(PS Cushion), All Sizes

SES1M0060 1 $383.00

Matrx Vi Base Fits W/C 16"-20" Width & 16"-19" Depth

SES1M1005 1 $584.00

Matrx Vi Cushion Bariatric Sizes, Client Weight Exceeds 300lbs

SES1M0011 1 $640.00

Matrx Vi Cushion Fits W/C 14"-18" Width & 15"-21" Depth

SES1M0005 1 $475.00

Matrx Vi Wide Cushion Fits W/C 19"-22" Width & 16"-21" Depth

SES1M0010 1 $519.00

Matrx Wide Cushion Fits W/C 20" Width & 16"-19" Depth

SES1M1010 1 $616.00

PS Cushion with Visco Foam Upgrade All Sizes

SES1M0070 1 $452.00

Posture Seat (PS Cushion) 11-12 Inches Wide To 20-21 Inches Deep

SES1M0065 1 $382.00

Jay Medical J-Gel Base SESJA6830 1 $186.00

J-Gel Cushion 16" & 18" Deep SESJA0700 1 $370.00

J-Gel Cushion 20" Deep SESJA0705 1 $370.00

J2 Base Large Sizes SESJA6810 1 $226.00

J2 Base Standard Sizes SESJA6800 1 $179.00

J2 Plus Cushion Foam Base SESJA6835 1 $143.00

J2 Plus Cushion, Ae Cover With Custom Foam Kit

SESJA0755 1 $595.00

J2 Plus Cushion, Ae Cover With Fluid Pad

SESJA0760 1 $745.00

J2 Plus Cushion, Ae Cover With Foam Kit

SESJA0750 1 $566.00

Page: 42 of 89





Allowed Qty.

Approved Price

Seat Cushion Jay Medical J2 Plus Cushion, Ls Inc. Cover With Custom Foam Kit

SESJA0770 1 $597.00

J2 Plus Cushion, Ls Inc. Cover With Fluid Pad

SESJA0775 1 $745.00

J2 Plus Cushion, Ls Inc. Cover With Foam Kit

SESJA0765 1 $609.00

J3 Cushion SESJA0800 1 $604.00

Jay 2 17x17 SESJA0485 1 $471.00

Jay 2 17x17 With Incontinent Cover SESJA0462 1 $474.00

Jay 2 17x17 With Air Exchange Cover SESJA0442 1 $481.00

Jay 2 18x20, 15.5x20 With Air Exchange Cover

SESJA0450 1 $552.00

Jay 2 18x20, 15.5x20 With Incontinent Cover

SESJA0470 1 $543.00

Jay 2 20x16 SESJA0480 1 $543.00

Jay 2 20x16, 20x18 With Air Exchange Cover

SESJA0441 1 $552.00

Jay 2 20x16, 20x18 With Incontinent Cover

SESJA0461 1 $543.00

Jay 2 20x18 SESJA0490 1 $533.00





Jay 2 Cushion 14x16 With Standard Cover

SESJA0425 1 $471.00

Jay 2 Cushion 15.5x 16, 15.5 X 18 With Standard Cover

SESJA0420 1 $471.00

Jay 2 Cushion 18x16, 18x18 With Standard Cover

SESJA0400 1 $471.00


SESJA0405 1 $618.00


SESJA0415 1 $685.00

Jay 2 Cushion18x20, 15.5x20 With Standard Cover

SESJA0410 1 $543.00

Jay 2 Deep Contour 20x16, 20x18, 16x20, 18x20

SESJA0505 1 $535.00

Jay 2 Deep Contour 20x20, 22x16, 22x18

SESJA0507 1 $619.00

Jay 2 Deep Contour 24x18 SESJA0510 1 $654.00

Jay 2 Deep Contour Standard Sizes SESJA0500 1 $492.00

Page: 43 of 89





Allowed Qty.

Approved Price

Seat Cushion Jay Medical Jay 2 Deep Contourn with Solid Drop Seat 20x16, 20x18, 16x20, 18x20, Solid Drop Seat Attached

SESJA0605 1 $574.00

Jay 2 Deep Contourn with Solid Drop Seat 20x20, 22x16, 22x18, Solid Drop Seat Attached

SESJA0610 1 $629.00

Jay 2 Deep Contourn with Solid Drop Seat Standard Sizes With Solid Drop Seat

SESJA0600 1 $516.00

Jay 2 Standard Sizes With Air Exchange Cover

SESJA0440 1 $481.00

Jay 2 Standard Sizes With Incontinent Cover

SESJA0460 1 $474.00

Jay 3 Air Cushion - Dual Valve SESJA9910 1 $618.00

Jay 3 Air Cushion - Single Valve SESJA9905 1 $607.00

Jay 3 Air Cushion -Width X Depth Greater Than 21 Inches

SESJA9915 1 $752.00

Jay 3 Air Cushion- Dual Valve -Width X Depth .gt.21 Inches

SESJA9920 1 $762.00

Jay Active Cushion 18x16, 16x16, 14x16

SESJA2010 1 $523.00

Jay Active Cushion 18x18, 16x18 SESJA2100 1 $523.00

Jay Active Cushion 20x18, 18x20, 16x20, With Adductor Wedges

SESJA2200 1 $574.00

Jay Active Foam Base 20" Deep SESJA6325 1 $226.00

Jay Basic Pro Cushion SE0001016 1 $121.00

Jay Care Cushion 18x16, 18x8, 16x16, 16x18

SESJA5500 1 $350.00

Jay Combi Base 18x16 To 15.5x20 SESJA6400 1 $37.00

Jay Combi Base 20x18 SESJA6500 1 $71.00

Jay Combi Cushion 14x14/12x12 With Back Support

SESJA3200 1 $194.00

Jay Combi Cushion 18x16 To 15.5x20 SESJA3010 1 $194.00

Jay Combi Cushion 20x18 With Back Support

SESJA3100 1 $183.00

Jay Combi With Lumbar Support 14x14, 12x12

SESJA3326 1 $153.00

Jay Combi With Lumbar Support 18x20, 16x20

SESJA3317 1 $179.00

Jay Combi With Lumbar Support 20x18 SESJA3316 1 $179.00

Jay Combi With Lumbar Support, Narrow Adult Soft 15.5x16

SESJA3320 1 $183.00

Page: 44 of 89





Allowed Qty.

Approved Price

Seat Cushion Jay Medical Jay Combi With Lumbar Support, Regular Adult Short 18x16

SESJA3310 1 $183.00

Jay Combi With Lumbar Support, Regular Adult

SESJA3315 1 $183.00

Jay Combi Without Lumbar Support 14x14, 12x12

SESJA3346 1 $154.00

Jay Combi Without Lumbar Support 16x20, 18x20

SESJA3337 1 $154.00

Jay Combi Without Lumbar Support 20x18

SESJA3336 1 $154.00

Jay Combi Without Lumbar Support, Narrow Adult Short 15.5x16

SESJA3340 1 $154.00

Jay Combi Without Lumbar Support, Narrow Adult 15.5x18

SESJA3345 1 $154.00

Jay Combi Without Lumbar Support, Regular Adult Short 18x16

SESJA3330 1 $154.00

Jay Combi Without Lumbar Support, Regular Adult Soft 18x18

SESJA3335 1 $154.00

Jay Cushion 18x16, 15.5x16, 14x16 SESJA0010 1 $528.00

Jay Cushion 18x18, 15.5x18, SESJA0100 1 $528.00

Jay Cushion 18x20, 15.5x20 SESJA0250 1 $585.00

Jay Cushion 20x20, 24x20 SESJA0200 1 $704.00

Jay Cushion Sizes 18x16 To 10x10 With Incontinent Cover

SESJA0350 1 $540.00

Jay Cusion Sizes 18x16 To 10x10 With Air Exchange Cover

SESJA0325 1 $550.00

Jay Duo Cushion 16x16,16x18, 18x16, 18x18 Includes Solid Seat, 2 Covers & Hardware

SESJA8005 1 $354.00

Jay Duo Cushion 17x16, 17x18 Includes Solid Seat, 2 Covers & Hardware

SESJA8017 1 $354.00

Jay Duo Cushion 20x16 Includes Solid Seat, 2 Covers & Hardware

SESJA8015 1 $400.00

Jay Duo Cushion Foam Cushion 16x16, 16x18, 18x16, 18x18

SESJA8040 1 $165.00

Jay Duo Cushion Foam Cushion 17x16, 17x18

SESJA8057 1 $165.00

Jay Duo Cushion Foam Cushion 20x16 SESJA8055 1 $194.00

Page: 45 of 89





Allowed Qty.

Approved Price

Seat Cushion Jay Medical Jay Duo Cushion Foam Cushion 20x18 SESJA8050 1 $194.00

Jay Duo Cushion Large Adult 20x18 Includes Solid Seat, 2 Covers & Hardware

SESJA8010 1 $392.00

Jay Duo Cushion Narrow Pan 16x16, 16x18, 18x16, 18x18 Includes Cushion, 2 Covers & Hardware

SESJA8020 1 $347.00

Jay Duo Cushion Narrow Pan 17x16, 17x18 Includes Solid Seat, 2 Covers & Hardware

SESJA8027 1 $354.00

Jay Duo Cushion Narrow Pan 20x16 Includes Solid Seat, 2 Covers & Hardware

SESJA8025 1 $392.00

Jay Duo Cushion Narrow Pan 20x18 Includes Cushion, 2 Covers & Hardware

SESJA8030 1 $392.00

Jay Easy Cushion With Flat Or Curved Bottom Sizes 14x16 Through 18x18

SESJA9805 1 $387.00

Jay Easy Cushion With Flat Or Curved Bottom Sizes 18x20 Through 20x20

SESJA9810 1 $405.00

Jay Easy Foam Base With Flat Or Curved Bottom Sizes 14x16 Through 18x18

SESJA9815 1 $102.00

Jay Easy Foam Base With Flat Or Curved Bottom Sizes 18x20 Through 20x20

SESJA9820 1 $116.00

Jay Fit Cushion Adjustable Contour Seat For 10" Or 12" Frame Width, Various Seat Depths

SESJA9700 1 $308.00

Jay Fit Cushion Adjustable Contour Seat For 14" Or 16" Frame Width, Various Seat Depths

SESJA9705 1 $343.00

Jay Fit Cushion Adjustable Contour Seat For 18" Frame Width, Various Seat Depths

SESJA9710 1 $381.00

Jay Foam Base 20" Deep SESJA6050 1 $203.00

Jay Fusion Air Single Valve Regular size

SE0000953 1 $604.00

Jay Fusion Air Single Valve width of 22" or more OR Jay Fusion Air Single Valve depth of 22" or more

SE0000954 1 $677.00

Jay Fusion Cushion AIR Dual Valve regular size

SE0000956 1 $614.00

Jay Fusion Cushion AIr Dual Valve SE0000957 1 $688.00

Page: 46 of 89





Allowed Qty.

Approved Price

Seat Cushion Jay Medical width of 22" or more OR Jay Fusion Cushion AIr Dual Valve depth of 22" or more

Jay Fusion Cushion AIr Dual Valve with width AND depth greater than 22"

SE0000958 1 $762.00

Jay Fusion Cushion Air Single Valve with width AND depth greater than 22"

SE0000955 1 $750.00

Jay Fusion Cushion Fluid width and depth of 22" or more

SE0000952 1 $750.00

Jay Fusion Cushion Fluid width of 22" or more OR Jay Fusion Cushion Fluid depth of 22" or more

SE0000951 1 $677.00

Jay Fusion Cushion regular size SE0000950 1 $604.00

Jay GO SE0000350 1 $172.00

Jay GS 10x13,12x15,14x17,16x19,18x20

SESJA5000 1 $512.00

Jay GS Cushion Pressure Relief Pad With Air Exchange Cover

SESJA5010 1 $594.00

Jay GS Cushion Pressure Relief Pad With Incontinent Cover

SESJA5005 1 $605.00

Jay Go - 19X15 to 24X24 SE0000324 1 $193.00

Jay Go Cushion Adult and Paediatric JGO14x14 to 18X24

SE0000323 1 $173.00

Jay ION SE0000348 1 $379.00

Jay Lite Cushion - All Sizes SESJA4200 1 $483.00

Jay Recline Cushion 20x20 SESJA9505 1 $685.00

Jay Recline Cushion 24x20 SESJA9515 1 $725.00

Jay Recline Cushion Large Sizes SESJA9510 1 $594.00

Jay Recline Cushion Standard Sizes SESJA9500 1 $519.00

Jay Recliner Cushion 18/15.5x20 With Incontinent Cover

SESJA1375 1 $607.00

Jay Recliner Cushion 18x16 To 10x10 With Incontinent Cover

SESJA1350 1 $552.00

Jay Recliner Cushion 18x16, 18x18, 15.5x16, 15.5x18, 14x16

SESJA1010 1 $550.00

Jay Recliner Cushion 18x20, 15.5x20 SESJA1100 1 $619.00

Jay Recliner Cushion 20x20 With Incontinent Cover

SESJA1400 1 $690.00

Jay Recliner Cushion 20x20,24x20 With Quadrant Pads

SESJA1200 1 $737.00

Jay Recliner Cushion 24x20 With Incontinent Cover

SESJA1425 1 $723.00

Page: 47 of 89





Allowed Qty.

Approved Price

Seat Cushion Jay Medical Jay Solution With Solid Drop Seat, Sizes 14 X 14 - 18 X 20, Includes Cover

SESJA0370 1 $549.00

Jay Solution With Solid Drop Seat, Sizes 19 X 18 - 20 X 18, Includes Cover

SESJA0375 1 $587.00

Jay Solution, Sizes 14 X 14 -17 X 18, Includes Cover

SESJA0360 1 $413.00

Jay Solution, Sizes 18 X 16 - 20 X 18, Includes Cover

SESJA0365 1 $430.00

Jay Triad Cushion 16x16, 16x18, 18x16,18x18,20x18 With Solid Drop Base

SESJA9120 1 $299.00

Jay Triad Cushion 20x18 SESJA9106 1 $299.00

Jay Triad Cushion 20x18 With Solid Drop Seat

SESJA9125 1 $391.00

Jay Triad Cushion Standard Sizes SESJA9105 1 $299.00

Jay Union Cushion 14X14 TO 18X18 SE0000352 1 $440.00

Jay Union Cushion 18X19 TO 24X24 SE0000353 1 $465.00

Jay Union Cushion with additional cover size 14X14 TO 18X18

SE0000354 1 $475.00

Jay Union Cushion with additional cover size 18X19 TO 24X24

SE0000355 1 $499.00

Jay Xtreme Cushion 14x14 To 18x18 With 2 Covers

SESJA9020 1 $428.00

Jay Xtreme Cushion 16x20, 18x20 With 2 Covers

SESJA9040 1 $366.00

Jay Xtreme Cushion 20x20 With 2 Covers

SESJA9030 1 $563.00

Jay Zip Cushion, All Sizes SESJA5550 1 $411.00

Tlc Contoured Seat Cushion SESKT2010 1 $990.00

Xpress Standard Seat Cushion - Specify Short (900020/1) Or Long (900022/3)

SESKT2020 1 $173.00

Kaji Corporation Exgel OWL Cushion Contour (all sizes) SE0001478 1 $620.00

Exgel OWL Cushion Deep Contour (all sizes)

SE0001479 1 $620.00

Exgel OWL Cushion Deep Contour Slim (all sizes)

SE0001480 1 $638.00

Exgel OWL Cushion High (all sizes) SE0001477 1 $638.00

Exgel OWL Cushion Regular (all sizes) SE0001476 1 $604.00

Ki Mobility Axiom G Cushion 14 x 14 - 20 x 20 SE0001389 1 $135.00

Axiom G Cushion 22 x 18 - 22 x 20 SE0001390 1 $190.00

Page: 48 of 89





Allowed Qty.

Approved Price

Seat Cushion Ki Mobility Axiom P Cushion 14 x 14 - 20 x 20 SE0001391 1 $397.00

Axiom S Cushion 14 x 14 - 20 x 20 SE0001393 1 $186.00

Axiom S Cushion 22 x 18 - 22 x 20 SE0001394 1 $276.00

Axiom SP Cushion Fluid 14 x 14 - 20 x 20

SE0001395 1 $480.00

Axiom SP Cushion Fluid 21 x 18 - 22 x 20

SE0001396 1 $573.00

Axiom SP Cushion Visco 14 x 14 - 20 x 20

SE0001397 1 $442.00

Axiom SP Cushion Visco 21 x 18 - 22 x 20

SE0001398 1 $535.00

Kid Kart Xpress Contour Adjustable Cushion - Specify Short (900312-28) Or Long (900329-36)

SESKT2030 1 $348.00

Xpress Ledge Seat Cushion - Specify Short (900028/9) Or Long (900030/1)

SESKT2026 1 $319.00

Xpress Wedge Seat Cushion - Specify Short (900024/5) Or Long (900026/7)

SESKT2025 1 $66.00

Lpa Medical Inc. Contour Seat Cushion With Perineal Abductor

SESO12005 1 $93.00

Pre-Cure Cushion SESO12010 1 $155.00


ML Bariatric SE0001092 1 $541.00

ML Cozy SE0001090 1 $331.00

ML Extreme Comfort SE0001091 1 $431.00

Nylon/Leatherette 2" Foam Cushion SESWM0001 1 $55.00

Nylon/Leatherette 3" Foam Cushion SESWM0005 1 $62.00

Motion Concepts Trx Onyx Seat 16-19" Width SESZG0005 1 $555.00

Trx Onyx Seat 20-22" Width SESZG0010 1 $599.00

Nighthawk 2" Standard Foam With Cover SESNM2000 1 $82.00

3" Standard Foam With Cover SESNM2010 1 $47.00

Aero Space Cushion, 18x16x3 SESNM9060 1 $208.00

Afg Cushion 16x16, 16x18, 18x16, 18x18

SESNM1010 1 $299.00

Bi-Sunmate Cushion & Base SESNM8070 1 $392.00

Cumfy Plus Cushion With Cover SESNM4000 1 $273.00

Gel Suspension Cushion 16x16,18x16,18x18

SESNM9045 1 $257.00

Gel Suspension Cushion 20x16, 20x18 SESNM9050 1 $216.00

Med Foam 1" Thru 4" With Cover SESNM0010 1 $221.00

Page: 49 of 89





Allowed Qty.

Approved Price

Seat Cushion Nighthawk Superior Cumfy Cushion & Base SESNM8000 1 $474.00

Superior Cushion With Cover SESNM2050 1 $372.00

Upcharge For Custom Sized Or Oversized Cushions

SESNM0000 1 $42.00

Orthofab Cushion With Contour Add Ons 15-18" Width & 15-20" Depth

SESOF1005 1 $279.00

Cushion With Contour Add Ons Non Standard Sizes & Options

SESOF1010 1 $331.00

Cushion With Visco Foam Insert & Contour Add Ons 14-20" Width & 15-20" Depth

SESOF1025 1 $317.00

Cushion With Visco Foam Insert & Contour Add Ons Non Standard Sizes & Options

SESOF1030 1 $386.00

Otto Bock Aerial Cushion 15"x16" to 20"x18" SE0000691 1 $480.00

All Sizes SESOB704L 1 $383.00

Aquos Cushion 15"x18" to 20"x18" SE0000690 1 $359.00

Comfort Custom Sizes SESOB8045 1 $699.00

Seat Finished With Spray Coating,Cover,Sewing Pattern

SESOB7100 1 $1,710.00

Seat-Itemized Cushion (Unfinished) SESOB7105 1 $1,253.00

Sizes 16x18,17x16,17x17,18 X16 SESOB6020 1 $434.00

Sizes 17x18,18x17,18x18,19 X16 SESOB6025 1 $434.00

Sizes 19x18,20x16,20x18 SESOB6030 1 $446.00

Standard Sizes SESOB8040 1 $541.00

Standard Sizes Smaller Than 16x17 SESOB6015 1 $422.00

Terra Cushion 15"x16" to 20"x18" SE0000689 1 $328.00

Permobil Corpus Ergo Air SE0001267 1 $325.00

Ergo Seat - All Sizes SES1P0005 1 $351.00

Physipro C3S Cushion - All Sizes SE0001119 1 $235.00

LXA Cushion - All Sizes SE0001070 1 $319.00

Ultra Cushion - All Sizes SE0001120 1 $254.00

Ultra Cushion with Gel - All Sizes SE0001121 1 $435.00

Zero Pressure Cushion - All Sizes SE0001122 1 $258.00

Zero Pressure Cushion with Gel - All Sizes

SE0001123 1 $424.00


STOPUS (oversize) anti-slip waterproof seat cushion multidensity foam (all sizes)

SE0001445 1 $750.00

STOPUS anti-slip seat waterproof cushion multidensity foam (all sizes)

SE0001444 1 $650.00

Page: 50 of 89





Allowed Qty.

Approved Price

Seat Cushion Power Plus Mobility

Relax Comfy SESWM0030 1 $538.00

Relax Firm SESWM0040 1 $676.00

Relax Soft SESWM0050 1 $414.00

Precision Rehab Manufacturing

Base Cushion Seat Sewn Cover Waterproof Foam, Includes Labour For Digitizing Or Plastering

SESWB0010 1 $1,476.00

Base Cushion Seat Vacuum Formed Cover, Includes Labour For Digitizing Or Plastering

SESWB0005 1 $1,241.00

Base Cushion Seat With All Modifications, Includes Labour For Digitizing Or Plastering

SESWB0015 1 $1,793.00

Comfort -Fit 12x12 to 20x20 SE0000754 1 $184.00

Contoured-Fit (Moderate Positioning Air Option) 12x12 to 20x20

SE0000757 1 $567.00

Contoured-Fit (Moderate Positioning Gel Option) 12x12 to 20x20

SE0000756 1 $446.00

Contoured-Fit (Moderate Positioning Visco-Foam) 12X12 20X20

SE0000755 1 $446.00

Contoured-Fit Aggressive Positioning Air Option 12x12 to 20x20

SE0000760 1 $567.00

Contoured-Fit Agressive Positioning Gel Option 12x12 to 20x20

SE0000759 1 $446.00

Contoured-Fit Agressive Positioning Visco-Foam 12x12 to 20x20

SE0000758 1 $446.00

Precision-Fit Cushion Upcharge, Extra Seat Depth 20"-24"

SESWB0024 1 $264.00

Precision-Fit Cushion Upcharge, Extra Seat Width 20"-24"

SESWB0022 1 $264.00

Precision-Fit Cushion, Subtle, Moderate Or Aggressive Positioning. Includes Shape Adjustments, Inner Cover, Outer Cover And Cushion Rigidizer.

SESWB0020 1 $931.00


Contoured Seat Cushion - All Sizes SESK20005 1 $269.00

Synergy Simplicity All Sizes SESX10080 1 $103.00

Synergy Solution Cushion Standard Sizes

SESX10015 1 $275.00

Synergy Solution Cushion Custom Sizes

SESX10020 1 $310.00

Page: 51 of 89





Allowed Qty.

Approved Price

Seat Cushion Pride Mobility Products

Synergy Solution SG Cushion Sizes 14" X 14" - 20" X 18"

SESX10100 1 $185.00

Synergy Solution SG Cushion Sizes 20" X 20" - 24" X 24"

SESX10105 1 $220.00

Synergy Spectrum Cushion Viscoelastic Insert,Standard Sizes

SESX10025 1 $379.00

Synergy Spectrum Cushion Twin Cell Insert,Custom Sizes

SESX10040 1 $413.00

Synergy Spectrum Cushion Twin Cell Insert,Standard Sizes

SESX10035 1 $379.00

Synergy Spectrum Cushion Viscoelastic Insert,Custom Sizes

SESX10030 1 $413.00

Synergy Tru Comfort/ Tru Comfort 2 Cushion Sizes 22" X 16" - 22" X 24"

SESX10095 1 $344.00

Synergy Tru Comfort/ Tu Comfort 2 Cushion Sizes 16" X 14" - 20" X 24"

SESX10090 1 $275.00

Tru Comfort 2 non standard sizes, including air mesh cover

SE0001050 1 $413.00

Tru Comfort 2 standard sizes, including air mesh cover

SE0001049 1 $344.00

Quickie 2", 3" Or 4" Cushion With Cover SESQU0355 1 $105.00

BREEZY RELAX2 COMFORT CUSHION

SE0000118 1 $1,722.00

Contour Seat - Tilt Fx SESQU0400 1 $338.00

JAY X2 with cover SE0001155 1 $580.00

Ride Designs Ride Custom Cushion 2 SE0001358 1 $1,456.00

Ride Custom Cushion: Standard (12-20"), Extra Wide (21-22"), Custom Sizes.

SESR40005 1 $1,474.00

Ride Forward Cushion - All Sizes SESR41020 1 $407.00

Ride Java SE0001223 1 $524.00

Roho Adaptor 9x13x1" (Maximum 5) SESRO1105 5 $180.00

Airlite Cushion With Built In Cover All Sizes

SESRO9005 1 $388.00

Contour Select Cushion Custom Sizes SESRO9025 1 $663.00

Contour Select Cushion Standard Sizes SESRO9020 1 $620.00

Custom (Made To Order) Cushion W/Cover

SESRO030L 2 $663.00

Enhancer, Custom Sizes,Dual Valve,Cover

SESRO8010 1 $625.00

Enhancer, Standard Adult & Paediatric Sizes, Dual Valve, With Cover

SESRO8005 1 $561.00

Page: 52 of 89





Allowed Qty.

Approved Price

Seat Cushion Roho Harmony Cushion With Cover-Sizes 14x16, 20x18

SESRO9050 1 $430.00

High-Profile - LTC Cushion, Including Cover

SESRO3015 1 $632.00

High-Profile, All Standard Adult & Paediatric Sizes Including Cover

SESRO3005 1 $561.00

High-Profile, Custom Sizes Including Cover

SESRO3010 1 $625.00

Hybrid Elite/Hybrid Elite LTC Cushion, Dual Valve, With Cover Sizes 14x14 ,20x20

SESRO9503 1 $681.00

Hybrid Elite/Hybrid Elite LTC Cushion, Dual Valve, With Cover, Sizes 22x18, 24x20

SESRO9504 1 $693.00

Hybrid Elite/Hybrid Elite LTC Cushion, Single Valve With Cover, Sizes 14x14 , 20x20

SESRO9501 1 $640.00

Hybride Elite/Hybrid Elite LTC Cushion, Single Valve With Cover, Sizes 22x18, 24x20

SESRO9502 1 $652.00

Low-Profile, All Standard Adult & Pediatric Sizes Including Cover

SESRO3105 1 $561.00

Low-Profile, Custom Sizes Including Cover

SESRO3110 1 $625.00

Low-Profile, LTC Cushion, Including Cover

SESRO3115 1 $632.00

Mid-Profile, All Standard Adult & Paediatric Sizes Including Cover

SESRO2005 1 $568.00

Mid-Profile, Custom Sizes Including Cover

SESRO2010 1 $637.00

Mini-Max Cushion, Standard Sizes (Does Not Include Cover)

SESRO4005 1 $513.00

Nexus Spirit Cushion With Cover, Standard Sizes

SESRO6010 1 $505.00

Nexus Spirit Cushion, Custom Sizes, With Cover

SESRO6015 1 $525.00

Quatro Select LTC Cushion, Including Cover

SESRO7055 1 $687.00

Quatro Select Low Or High Profile Cushion, Custom Sizes With Cover

SESRO7040 1 $663.00

Quatro Select, Low Or High Profile Cushion With Cover, Standard Sizes

SESRO7035 1 $620.00

Solus Medical Manufacturing Inc

EquaGel Pro Flex I SE0001113 1 $199.00

EquaGel Pro Flex II SE0001114 1 $468.00

Page: 53 of 89





Allowed Qty.

Approved Price

Seat Cushion Solus Medical Manufacturing Inc

EquaGel Pro Flex II Hybrid SE0001115 1 $344.00

EquaGel Pro Flex III Hybrid SE0001116 1 $392.00

EquaGel Pro Flex Ultra SE0001117 1 $668.00

Star Cushion Products Inc.

All Sizes 12x12 Through 22x22 SESTJ2005 1 $459.00

Custom Cell Height Cushion Standard Sizes

SESTJ0115 1 $555.00

Custom Sizes Over 22" In Two Directions Width And Depth

SESTJ0110 1 $618.00

Custom Sizes Over 22" One Direction Width Or Depth

SESTJ0105 1 $555.00

Galaxy Cushion - All Sizes SESTJ3005 1 $449.00

Mid Contour Cushion 3" Cells With SESTJ0015 1 $428.00Cover

Short Contour Cushion 2" Cells With Cover

SESTJ0010 1 $428.00

Standard Contour Cushion 4" Cells With Cover

SESTJ0005 1 $428.00

Stealth Products Essence Basic (sizes greater than 20" X 20")

SE0001482 1 $376.00

Essence Basic (sizes up to 20" X 20") SE0001481 1 $335.00

Essence Low Contour (sizes greater than 20" x 20")

SE0001484 1 $414.00

Essence Low Contour (sizes up to 20" x 20")

SE0001483 1 $369.00

Essence Medium Contour (sizes greater than 20" x 20")

SE0001486 1 $493.00

Essence Medium Contour (sizes up to 20" X 20")

SE0001485 1 $438.00

Essence Plus (sizes greater than to 20" X 20")

SE0001488 1 $562.00

Essence Plus (sizes up to 20" X 20") SE0001487 1 $500.00

Sunrise Medical Seat Cushion -Sellaskin 16x16,16x18,18x16,18x18

SESM90005 1 $135.00

Sedeo Pro-comfort Cushion 16"w to 18"w (fits 16" w to 20" deep)

SE0000667 1 $345.00

Sedeo Pro-comfort Cushion 20"w and SE0000668 1 $380.0022"w (fits 16" to 20" deep)

Sedeo Pro-contour Cushion 16"w and 18"w (fits 16"w to 20" deep)

SE0000669 1 $414.00

Sedeo Pro-contour Cushion 20"w and 22"w (fits 16" to 2-" deep)

SE0000698 1 $449.00

Sedeo Pro-stability Cushion 20"w and 22"w (fits 16" to 20" deep)

SE0000671 1 $449.00

Page: 54 of 89





Allowed Qty.

Approved Price

Seat Cushion Sunrise Medical Sedeo Pro-stability cushion 16" w and 18"w (fits 16"to 20" deep)

SE0000670 1 $414.00

Spex High-Contour sizes from 16"x16" to 17"x18"

SE0001497 1 $735.00


SE0001498 1 $890.00


SE0001502 1 $1,094.00


SE0001499 1 $956.00

Spex High-Contour sizes up to 14"x16" SE0001496 1 $711.00

Spex Super High-Contour sizes from 16"x16" to 17"x18"

SE0001501 1 $963.00

Spex Super High-Contour sizes up to 14"x16"

SE0001500 1 $932.00

Support Seat Cushion SESM90020 1 $259.00

Supracor Bariatric Cushion (Classic) Clb 20-24" SESRR0016 1 $652.00

Bariatric Cushion (Classic) Clb 25-28" SESRR0017 1 $750.00

Bariatric Cushion (Classic) Clb 29-31" SESRR0018 1 $897.00

Bariatric Cushion (Classic) Clb 32-35" SESRR0019 1 $1,044.00

Classic Cushion 14x16-20x20 SESRR0010 1 $470.00

Classic Sling Bottom Cushion 14x16-20x20

SESRR0015 1 $489.00

Contoured Cushion 14x16-20x20 SESRR0020 1 $574.00

Contoured Cushion, Standard Sizes SESRR0060 1 $549.00

Contoured Sling Bottom Cushion 14x16-20x20

SESRR0025 1 $568.00

Corbee Cushion 10x10-14x14 SESRR0100 1 $296.00

Corbee Sling 10x10-14x14 SESRR0110 1 $320.00

Paediatric Contoured Cushion, Custom Sizes

SESRR0065 1 $405.00

Slimline Cushion 16x16-20x18 SESRR0030 1 $380.00

Slimline Sling Bottom Cushion 16x16-20x18

SESRR0035 1 $405.00

The Comfort Company

Curve Cushion, Stretch Air Or Fusion Cover, All Sizes

SES7C0050 1 $116.00

Curve Cushion, Stretch Air Or Fusion Cover, Custom Sizes

SES7C0055 1 $211.00

Custom Embrace Anti Thrust Cushion SE0000127 1 $591.00

Custom Embrace Anti Thrust Cushion Hook and Loop non skid bottom

SE0000130 1 $701.00

Page: 55 of 89





Allowed Qty.

Approved Price

Seat Cushion The Comfort Company

Custom Embrace Zero Elevation Cushion

SE0000128 1 $591.00

Custom Embrace Zero Elevation Cushion Hook and Loop non skid bottom

SE0000129 1 $701.00

Embrace Anti-Thrust Cushion Hook and loop non-skid bottom

SE0000113 1 $369.00

Embrace Zero Elevation Cushion SE0000125 1 $369.00

Embrace Zero Elevation Cushion Hook and Loop non-skid bottom

SE0000126 1 $438.00

Hyalite Cushion, Condura Knit Or Stretch Air Cover, All Sizes

SES7C0030 1 $345.00

Hyalite Cushion, Condura Knit Or Stretch Air Cover, Custom Sizes

SES7C0035 1 $618.00

Maxx Cushion, Round Or Flat Bottom, Fusion Or Stretch Air Cover, All Sizes

SES7C0020 1 $443.00

Maxx Cushion, Round Or Flat Bottom, Fusion Or Stretch Air Cover, Custom Sizes

SES7C0025 1 $782.00

Ridge Cushion, Stretch Air Or Fusion Cover, All Sizes

SES7C0040 1 $420.00

Ridge Cushion, Stretch Air Or Fusion Cover, Custom Sizes

SES7C0045 1 $771.00


Tops Seat Cushion (10" & 12" Width) SESTP0005 1 $212.00

Trulife Gelcell Contour Cushion, All Sizes SESCZ0080 1 $286.00

Relax Duogel Contour Cushion, All Sizes

SESCZ0040 1 $201.00

Relax Easy Cushion All Sizes SESCZ0070 1 $201.00

Relax Gelcell, All Sizes SESCZ0045 1 $275.00

Relax Trio Cushion, All Sizes SESCZ0035 1 $91.00

Varilite Medical Products

Evolution Bariatric Cushion Standard Or Psv, All Sizes, Includes Cover And Pressure Setting Valve

SESVP0408 1 $616.00

Evolution Cushion Standard Or Psv, All Sizes, Includes Cover And Pressure Setting Valve

SESVP0406 1 $580.00

Evolution Wave Bariatric Cushion Includes, Cover And Positioning Base

SESVP0402 1 $705.00

Page: 56 of 89





Allowed Qty.

Approved Price

Seat Cushion Varilite Medical Products

Evolution Wave, All Sizes, Includes Cover And Positioning Base

SESVP0401 1 $604.00

Junior Cushion SE0001146 1 $562.00

Meridian Bariatric Cushion, All Sizes, Includes Cover

SESVP0605 1 $652.00

Meridian Cushion, All Sizes, Includes Cover

SESVP0600 1 $543.00

Meridian Wave Bariatric Cushion, All Sizes, Includes Cover

SESVP0615 1 $741.00

Meridian Wave Cushion, All Sizes, Includes Cover

SESVP0610 1 $636.00

Proform Nx Cushion, Single, Dual, All Sizes Includes Cover

SESVP0351 1 $575.00

Reflex Cushion, All Sizes, Includes Cover

SESVP6020 1 $342.00

Solo Cushion, Standard Or Psv, All Sizes, Includes Cover

SESVP0200 1 $418.00

Stratus Cushion, All Sizes, Includes Cover

SESVP0410 1 $318.00

Zoid Cushion, All Sizes, Includes Cover SESVP0500 1 $479.00

Vicair Academy Adjuster SESV10020 1 $543.00

Academy Junior Adjuster SESV10010 1 $467.00

Academy Vector SESV10025 1 $584.00

Upcharge For Custom Sizes SESV11005 1 $69.00

Vicair Active: Sizes 12X12 - 18X18 SE0001102 1 $500.00

Vicair Active: Sizes 18X20 - 20X20 SE0001103 1 $549.00


Epic Cushion: custom sizes (up to 19x19)

SE0000673 1 $418.00

Epic Cushion: standard sizes: 16x16 1/2 to 18x18

SE0000672 1 $373.00

Epic Drop Seat: Custom Sizes (up to 19x19)

SE0000675 1 $544.00

Epic Drop Seat: standard sizes: 16x16 1/2 to 18x18

SE0000674 1 $485.00

Epic Plus Cushion Standard Sizes 16x20 to 20x18

SE0000676 1 $418.00

Epic Plus Cushion: Bariatric Custom sizes, 20x20 to 24x24

SE0000677 1 $502.00

Epic Plus Drop Seat: Bariatric Custom sizes, 20x20 to 24x24

SE0000679 1 $674.00

Epic Plus Drop Seat: Standard Sizes 16x20 to 20x18

SE0000678 1 $545.00

Page: 57 of 89





Allowed Qty.

Approved Price

Seat Cushion Vision Wheelchair Seating Systems Inc.

Upcharge for custom Cushions 20"X20 - 24"X24"

SESVC4510 1 $169.00

Upcharge for custom Cushions Up To 20" X 19", Inclusive

SESVC4500 1 $116.00

Upcharge for custom Drop-Seat up to 20"X19", Inclusive

SESVC4520 1 $132.00

Upcharge for custom Drop-Seats 20"X20 - 24"X24"

SESVC4530 1 $186.00

V3 Cushion Bariatric Custom Sizes (up to 24")

SE0001456 1 $929.00

V3 Cushion Custom Sizes (up to 20 x 19)

SE0001455 1 $840.00

V3 Cushion Standard Sizes SE0001454 1 $683.00

V3 Gel Cushion Bariatric Custom Sizes (up to 24")

SE0001459 1 $999.00

V3 Gel Cushion Custom Sizes (up to 20 x 19)

SE0001458 1 $904.00

V3 Gel Cushion Standard Sizes SE0001457 1 $735.00

VIVE -Deep Leg Trough -Drop Seat; Standard Sizes 16x16 1/2 to 20x18

SESVC4180 1 $858.00

VIVE -Deep Leg Trough Cushion; Standard Sizes 16x16 1/2 to 20x18

SESVC4170 1 $658.00

VIVE -Drop Seat; Standard Sizes 16x16 1/2 to 20x18

SESVC4160 1 $819.00

VIVE Cushion; Standard Sizes 16x16 1/2 to 20x18

SESVC4150 1 $627.00

Very Soft Drop-Seat; Standard Sizes 16x16 1/2 to 20x18

SESVC4030 1 $752.00

VerySOFT -Deep Leg Trough Cushion; Standard Sizes 16x16 1/2 to 20x18

SESVC4100 1 $585.00

VerySOFT Cushion, Standard Sizes 16x16 1/2 to 20x18

SESVC4000 1 $590.00

VerySOFT- Deep Leg Trough -Drop Seat; Standard Sizes 16x16 1/2 to 20x18

SESVC4120 1 $793.00

Page: 58 of 89




SeatingOPTIONS:


Qty.

Approved Price

Arm Support Hardware Approved ADP Manufacturers Only

Non Standard Modular Mounting Hardware Required For Positioning (Maximum 2)

SEAND0025 2 $138.00

Custom Fabricated

Swivel Armrest Hardware (Maximum 2) SEICF301L 2 $60.00

Arm Support Options Approved ADP Manufacturers Only

Add Modular Pressure Relief To Armrest - Specialty Foam/Gel (Maximum 2)

SEAND0030 2 $65.00

Custom Fabricated

Rigid Side Panel For Custom Arm Support (Maximum 2)

SEMCF601L 2 $52.00

Side Panel Pad For Custom Arm Support (Maximum 2)

SEMCF602L 2 $35.00

Arm Support(s) Approved ADP Manufacturers Only

Extra Wide &/Or Extended Length For Modular Arm Supports - Includes Mounting Hardware (Maximum 2)

SEAND0010 2 $91.00

Modular Arm Support - Includes Mounting Hardware (Maximum 2)

SEAND0005 2 $237.00

Modular Hand Support - Flat/Cone - Includes Mounting Hardware (Maximum 2)

SEAND0015 2 $65.00

Custom Fabricated

Complex Arm Support, Multi Component, Includes Hardware (Maximum 2)

SEACF102L 2 $216.00

Fixed Arm Support, One Piece, Includes Hardware (Maximum 2)

SEACF101L 2 $129.00

Full Sling Arm Support, Includes Hardware (Maximum 2)

SEACF104L 2 $259.00

Heavy Duty Solid Padded Armrest Support, Replaces Padded W/C Armpad, Includes Hardware (Maximum 2)

SEACF103L 2 $65.00

Back Cover Custom Fabricated

Removable Cover For Back With Laterals

SEMCF103L 2 $198.00

Removable Cover For Contoured/Custom Contoured Back

SEMCF102L 2 $155.00

Removable Cover For Flat Back SEMCF101L 2 $104.00

Removable Cover For Sculptured Or Molded Back

SEMCF104L 2 $233.00

Back Hardware Approved ADP Manufacturers Only

Complex Specialized Mounting Hardware - Including Hardware For Custom Molded Modular

SEBND0010 2 $345.00

Page: 59 of 89




SeatingOPTIONS:


Qty.

Approved Price

Back Hardware Systems

Custom Fabricated

Simple Back Interface Mounts Back To Wheelchair Frame

SEICF160L 1 $168.00

Back Support Options Approved ADP Manufacturers Only

Additional Pressure Relief - Gel/Air Inserts/Pads Etc. (Maximum 6)

SEBND0020 6 $116.00

Custom Modifications And Sizing - Including Custom Sizes, Additional Postural Support - Lumbar Pad, Foam Pads Etc. (Maximum 6)

SEBND0015 6 $47.00

Custom Fabricated

Back Channeling - Upgrade For Slots For Lateral Adjustments

SEMCF201L 1 $129.00

Back Plaster Molding/Vacuum Form, for Custom Fabricated Device Only

SEUCF003L 1 $138.00

Back Reinforcement - Heavy Duty Upgrade

SEMCF202L 1 $86.00

Modify Or Refurbish Existing Custom Fabricated Back, Includes Parts, Hardware & Labour

SEMCF200L 1 $194.00

Foot/Leg Support Hardware Approved ADP Manufacturers Only

Complex Specialized Mounting Hardware

SEFND0030 2 $86.00

Custom Fabricated

Mount Footrest To Seating System SEICF501L 2 $104.00

Foot/Leg Support Options Approved ADP Manufacturers Only

Extra Padding For Specific Pressure Relief - (Maximum 2)

SEFND0035 2 $43.00

Custom Fabricated

Footrest Discrepancy Upcharge - Accommodates Differences Between Left & Right Leg

SEMCF801L 1 $69.00

Footrest Extension, Not Padded (Maximum 2)

SE0000322 2 $65.00

Footrest Padding (Maximum2) SEMCF803L 2 $52.00

Footrest Reinforcement Upcharge - Heavy Duty Upgrade To Reinforce Footrest

SEMCF802L 2 $121.00

Foot/Leg Support(s) Approved ADP Manufacturers Only

1 Piece Foot Board - Includes Mounting Hardware & Padding

SEFND0015 1 $95.00

Amputee Board/Stump Support - Includes Mounting Hardware & Padding

SEFND0005 1 $246.00

Calf Panel - Includes Mounting Hardware & Padding

SEFND0010 2 $43.00

Page: 60 of 89




SeatingOPTIONS:


Qty.

Approved Price

Foot/Leg Support(s) Approved ADP Manufacturers Only

Foot Box - Includes Mounting Hardware & Padding - Foot Box May Be 1 Piece Or 2 Piece (Each Foot)

SEFND0020 2 $207.00

Custom Fabricated

Calf Support, Padded And Removable SEFCF107L 2 $168.00

Complex Foot Rest (One Or Two Piece), Includes Parts, Hardware, And Labour

SEFCF102L 1 $380.00

Footpocket, Not Padded ( Maximum 2) SEFCF106L 2 $173.00

One Piece Double Footbox, Not Padded

SEFCF103L 1 $256.00

One Piece Fixed Footrest, Not Padded

SEFCF101L 1 $129.00

Headrest/Neckrest Hardware Approved ADP Manufacturers Only

Bracket To Mount Headrest To Seating System/Back Support Or Wheelchair

SEHND0020 1 $86.00

Complex Specialized Mounting Hardware

SEHND0015 1 $259.00

Non Standard Mounting Hardware Not Included In Base Device - Removable, Allows Multi Axis Adjustments

SEHND0010 1 $138.00

Standard Mounting Hardware Not Included In Base Device - Removable, Allows Height, Anterior & Posterior Adjustments

SEHND0005 1 $121.00

Custom Fabricated

Complex Headrest Hardware, Allows For Removability & Height And Forward Adjustment

SEICF007L 1 $134.00

Multi-Axis Headrest Hardware, Allows For Removability And Multi Adjustments

SEICF008L 1 $225.00

Simple Headrest Hardware, Allows For Removability & Height Adjustment

SEICF006L 1 $60.00

Wheelchair Mounting Bracket For Headrest Hardware

SEICF009L 1 $190.00

Headrest/Neckrest Options Custom Fabricated

Complex Extension Pad, Mounted (Maximum 2)

SEMCF006L 2 $259.00

Removable Cover For Complex Headrests, Use For Complex Headrest & Headrest/Neckrest Combinations

SEMCF002L 2 $155.00

Removable Headrest/Neckrest Cover, SEMCF001L 2 $104.00

Page: 61 of 89




SeatingOPTIONS:


Qty.

Approved Price

Headrest/Neckrest Options Custom Fabricated

Any Fabric, Use For Flat/Contoured Headrest & Neckrest

Simple Extension Pad, Mounted (Maximum 2)

SEMCF005L 2 $173.00

Quickie RELAX HEADREST PAD SE0000119 1 $235.00

Lateral Support Hardware Custom Fabricated

Fixed Lateral Hardware, Non-Adjustable (Maximum 2)

SEICF201L 2 $52.00

Hinged Swingaway Lateral Hardware, Height& Width Adjustable (Maximum 2)

SEICF202L 2 $173.00

Removable Lateral Hardware, Height & Width Adjustable (Maximum 2)

SEICF203L 2 $86.00

Lateral Support Options Custom Fabricated

Extra Padding (Maximum 2) SEMCF651L 2 $52.00

Lateral Support(s) Approved ADP Manufacturers Only

Complex Shape Lateral Supports, Each - Includes Padding & Mounting Hardware (Maximum 4)

SELND0015 4 $166.00

Fixed Lateral Supports, Each - Includes Padding & Mounting Hardware (Maximum 4)

SELND0005 4 $104.00

Shoulder Wings, Each - Includes Padding & Mounting Hardware (Maximum 2)

SELND0020 2 $47.00

Swingaway Lateral Supports, Each - Includes Padding & Mounting Hardware (Maximum 4)

SELND0010 4 $155.00

Custom Fabricated

Complex Shaped Thoracolumbar Supports, Non Adjustable, Includes Cover (Maximum 2)

SELCF102L 2 $151.00

Shoulder Wings, Non Adjustable, Includes Cover

SELCF103L 2 $82.00

Thoracolumbar Supports, Rigid & Non Adjustable, Includes Cover (Maximum 2)

SELCF101L 2 $69.00

Pommel Hardware Custom Fabricated

Hardware For Fixed Pommel SEICF401L 1 $73.00

Hardware For Flip-Down Pommel SEICF403L 1 $259.00

Hardware For Removable Pommel SEICF402L 1 $151.00

Pommel/Adductors Approved ADP Manufacturers Only

Pommel, Flip Down, All Components Including Hardware

SESND1043 1 $259.00

Custom Fabricated

Custom Pommel Without Hardware SEMCF701L 1 $138.00

Page: 62 of 89




SeatingOPTIONS:


Qty.

Approved Price

Pommel/Adductors Custom Fabricated

Fixed Padded Adductor Includes Cover (Maximum 2)

SEMCF702L 2 $104.00

Removable Padded Adductor Includes Cover (Maximum 2)

SEMCF703L 2 $164.00

Positioning Belts Approved ADP Manufacturers Only

Any 2 Point Strap For Positioning Only - Any Closure - Includes Padding & Mounting Hardware -Chest, Hip, Thigh, Calf, Ankle, Foot (Maximum 6)

SERND0030 6 $56.00

Any 4 Point Strap For Positioning Only - Any Closure - Includes Padding & Mounting Hardware - Pelvic "Y" Strap, "H" Leg Strap (Maximum 2)

SERND0020 2 $129.00

Chest Harness For Positioning Only - Any Closure - Includes Padding & Mounting Hardware

SERND0001 1 $121.00

Non Standard Chest Or Shoulder Harness Required For Positioning Support Only

SERND0035 1 $397.00

Shoulder Straps For Positioning Only - Any Closure - Includes Padding & Mounting Hardware (Maximum 2)

SERND0010 2 $52.00

Custom Fabricated

Custom Chest Support, Includes Attachments

SERCF103L 1 $129.00

Custom Positioning Belt, Includes Attachments. Specify Upper &/Or Lower Extremity &/Or Chest (Maximum 12)

SERCF105L 12 $47.00

Custom Shoulder Harness, Includes Padding & Attachments

SERCF104L 1 $181.00

Pelvic "Y" Belt Or Groin Strap, Includes Attachments

SERCF101L 1 $52.00

Positioning Belts Options Custom Fabricated

Complex Control Pads (Maximum 4) SEMCF503L 4 $142.00

Positioning Control Pads (Maximum 12) SEMCF502L 12 $47.00

Positioning Support Pads (Maximum 12)

SEMCF501L 12 $47.00

SE - Custom Modifications Approved ADP Manufacturers Only

Custom Modifications Required To Adp Listed Wheelchair To Facilitate Installation Of Custom Fabricated Positioning

SEMCF990L 1

Page: 63 of 89




SeatingOPTIONS:


Qty.

Approved Price

SE - Custom Modifications Approved ADP Manufacturers Only

Devices (Seating). Authorizer Must Provide Clinical Rational To Support Request. Clinic Must Provide A Breakdown Of The Cost Of Parts And Labour (Not To Exceed $40.00/Hour).

Custom Modifications To An Adp Listed Modular Seating Device & No Adp Code With Assigned Funding Is Available - Authorizer Must Provide Clinical Rationale To Support Request - Vendor Must Provide Breakdown Of Cost Of Parts & Labour (Not To Exceed $40.00/Hour)

SEMND2005 1

Transfer Existing Adp Approved Modular Seating System Into New Or Modified Adp Approved Wheelchair - Labour Only, When No Parts Required

SEMND1005 1 $69.00

Custom Fabricated

Transfer Existing Adp Approved Custom Seating System Into A New Or Modified Adp Approved Wheelchair. Labour Only, No Parts Required.

SEUCF200L 1 $69.00

Seat Cushion Cover(s) Approved ADP Manufacturers Only

Extra Cover Bariatric Sizes SESND1060 2 $134.00

Extra Cover Non Standard Sizes SESND1055 2 $99.00

Extra Cover Standard Sizes SESND1050 2 $65.00

Custom Fabricated

Removable Cover For Flat Seat, For Incontinence (Maximum 2)

SEMCF105L 2 $108.00

Removable Cover For Sculptured Or Molded Seat, For Incontinence (Maximum 2)

SEMCF107L 2 $216.00

Removable Cover For Wedged Or Contoured Seat, For Incontinence (Maximum 2)

SEMCF106L 2 $155.00

Seat Hardware Approved ADP Manufacturers Only

Complex Specialized Mounting Hardware - Including Hardware For Custom Molded Modular Systems

SESND1010 1 $259.00

Custom Fabricated

Complex Interface Mounts Seat & Back To Wheelchair Frame

SEICF170L 1 $302.00

Hardware To Mount Positioning Device Into Paediatric Stroller

SEICF190L 1 $86.00

Page: 64 of 89




SeatingOPTIONS:


Qty.

Approved Price

Seat Hardware Custom Fabricated

Hardware To Mount Seat & Back Into Dynamic Tilt Wheelchair

SEICF180L 1 $492.00

Seat Rigidizer - Flat Rigid Insert SEICF192L 1 $52.00

Securing Hardware That Mounts Hardware To Mobility Device (Maximum 8)

SEICF191L 8 $22.00

Simple Seat Interface Mounts Seat To Wheelchair Frame

SEICF150L 2 $168.00

Strap Interface (2) Mounts Seat To Wheelchair

SEICF140L 2 $86.00

Seat Options Approved ADP Manufacturers Only

Additional Pressure Relief - Specialty Foam, Air, Gel

SESND1045 1 $358.00

Custom Modifications And Sizing - Including Custom Sizes, Static Adductors & Pommels, Wedges & Anti-Thrust Devices, Leg Length Discrepancy Allowance (Maximum 6).

SESND1040 6 $69.00

Drop Base And Hooks (4) SESND1020 1 $216.00

Roho Bolster SESND1035 1 $155.00

Solid Seat Insert SESND1015 1 $69.00

Subasis Bar, Complete, Including Hardware

SESND1041 1 $173.00

Custom Fabricated

2" Convolute Foam Cut To Size (Maximum 2)

SEMCF403L 2 $35.00

2" Polyfoam Cut To Size (Maximum 2)

SEMCF406L 2 $26.00


SEMCF404L 2 $39.00

3" Polyfoam Cut To Size (Maximum 2)

SEMCF407L 2 $30.00


SEMCF405L 2 $43.00

Add Waterproof Skin On Complex Indirect Molded Seat

SEMCF210L 2 $86.00

Complex Pelvic Stabilizers, Each (Maximum 2)

SEMCF206L 2 $194.00

Contoured Cushion With Troughing Secured In Front Of A Roho Cushion, Not Including Roho Cushion, Includes Cover

SEMCF209L 1 $328.00

Heavy Duty Upgrade To Reinforce Seat SEMCF207L 1 $65.00

Page: 65 of 89




SeatingOPTIONS:


Qty.

Approved Price

Seat Options Custom Fabricated

Modify Or Refurbish Existing Custom Fabricated Seat, Includes Parts, Hardware & Labour

SEMCF212L 1 $194.00

Pelvic Stabilizer (Maximum 2) SEMCF204L 2 $185.00

Polymer Supplement Pad (Maximum 2)

SEMCF402L 2 $129.00

Seat Plaster Molding/Vacuum Form, for Custom Fabricated Device Only

SEUCF005L 1 $138.00

Simple Cushion Secured In Front Of A Roho Cushion, Not Including Roho Cushion, Includes Cover

SEMCF208L 1 $173.00

Single Complex Pelvic Stabilizer For Seat Or Back

SEMCF205L 1 $259.00

Upgrade To Provide Extra Pressure Relief, Gel/Foam/Air/Liquid Etc. (Maximum 2)

SEMCF203L 2 $129.00

Viscoelastic Foam Or Pudgee 1" Thick/1 Square Foot (Maximum 2)

SEMCF401L 2 $52.00

Tray Approved ADP Manufacturers Only

Full Tray For Positioning Support Only - Standard Adult & Paediatric Sizes, Includes Mounting Hardware

SETND0005 1 $164.00

Full Tray Non Standard Size For Positioning Support Only - Adult & Paediatric Sizes, Includes Mounting Hardware

SETND0010 1 $280.00

Half Tray For Positioning Support Only - Non Standard Adult & Paediatric Sizes, Includes Mounting Hardware

SETND0020 2 $272.00

Half Tray For Positioning Support Only - Standard Adult & Paediatric Sizes, Includes Mounting Hardware

SETND0015 2 $203.00

Custom Fabricated

Customized Lexan Tray, Includes Mounting Hardware

SETCF103L 1 $362.00

Kydex Tray, Includes Mounting Hardware

SETCF104L 1 $311.00

Plastic Tray, Includes Mounting Hardware

SETCF101L 1 $302.00

Wood/Arborite Tray, Includes Mounting Hardware

SETCF102L 1 $220.00

Page: 66 of 89




SeatingOPTIONS:


Qty.

Approved Price

Tray Options Approved ADP Manufacturers Only

Add Modular Elbow Or Hip Blocks To Any Modular Tray - (Maximum 4)

SETND0030 4 $56.00

Add Padding To Any Tray SETND0035 2 $65.00

Custom Fabricated

Clear Tray Cover, Removable SEMCF301L 1 $69.00

Elbow Block Padding Including Cover (Maximum 2)

SEMCF306L 2 $52.00

Elbow Blocks (Maximum 2) SEMCF305L 2 $73.00

Large/Full Tray Pad (Maximum 2) SEMCF304L 2 $125.00

Small Tray Pad (Maximum 2) SEMCF303L 2 $69.00

Page: 67 of 89




Wheelchairs (Manual)Device Type Manufacturer Device Device Code Max

Allowed Qty.

Approved Price

Adult High Performance Rigid Manual WheelchairWheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Invacare A-4 WMA4IN015 1 $3,098.00

Crossfire T6/Ti WMA4IN110 1 $3,098.00

Crossfire T7a WMA4IN130 1 $3,098.00

Terminator WMA4IN105 1 $3,098.00

Ki Mobility Rogue WM0001043 1 $3,098.00

Tsunami WMA4KI015 1 $3,098.00

LEVO AG LEVO compact-easy LCEV with battery powered stand-up feature

WM0000471 1 $3,098.00

Motion Composites Apex WM0001305 1 $3,098.00

Veloce WM0001029 1 $3,098.00

Pantera AB Panthera S2 WM0000972 1 $3,098.00

Panthera U2 WM0000973 1 $3,098.00

Product Design Group

Elevation WM0001203 1 $3,098.00

Quickie Quickie Gp/Gpv WMA4QU005 1 $3,098.00

Quickie Gt WMA4QU030 1 $3,098.00

Quickie Q7, Q7R, Q7RS WMA4QU040 1 $3,098.00

Quickie QRi WM0000991 1 $3,098.00

Rgk Wheelchairs Hi-Lite WMA4RZ005 1 $3,098.00

Maxima WM0000696 1 $3,098.00

Sunrise Medical Quickie 5R WM0001272 1 $3,098.00

TiLite Tilite Aero T WM0001252 1 $3,098.00

Tilite Aero Z WMA4TZ010 1 $3,098.00

Tilite Yr/Tr,Yra/Tra,Trc,Zra/Zr WMA4TZ005 1 $3,098.00

iCON Icon A1 WM0000945 1 $3,098.00

Adult Lightweight Performance Manual WheelchairWheelchair type offers maximum adjustments and options. Suitable for the very active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Future Mobility Galaxy Lite WMA3FM010 1 $2,290.00

Northern Lite WMA3FM005 1 $2,290.00

Invacare Compass Xe (Allegro) WMA3IN030 1 $2,290.00

Mvp WMA3IN060 1 $2,290.00

Myon Active WMA3IN065 1 $2,290.00

Myon HC WM0001299 1 $2,290.00

Prospin X4 WMA3IN035 1 $2,290.00

Xtra WMA3IN005 1 $2,290.00

Ki Mobility Catalyst 5, 5ti WMA3KI010 1 $2,290.00

Catalyst 5vx WMA3KI015 1 $2,290.00


EZ Ride WMA3WM005 1 $2,290.00

Motion Composites Helio A6 WM0001489 1 $2,290.00

Page: 68 of 89





Allowed Qty.

Approved Price

Adult Lightweight Performance Manual WheelchairWheelchair type offers maximum adjustments and options. Suitable for the very active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Motion Composites Helio A7 WM0001020 1 $2,290.00

Helio C2 WM0000964 1 $2,290.00

Helio XC2 WM0001260 1 $2,290.00

Orthofab Prima WMA3OF010 1 $2,290.00

Physipro XL-5/XL-5 ci WM0001132 1 $2,290.00

Power Plus Mobility Glyder WM0001061 1 $2,290.00


Litestream Xf WMA3X1010 1 $2,290.00


Eclipse 600 WMA3MV005 1 $2,290.00

Quickie Quickie 2 (VIP 2) WMA3QU005 1 $2,290.00

Quickie 2 Hp WMA3QU010 1 $2,290.00

Quickie 2 Lite WMA3QU020 1 $2,290.00

Quickie Gtx WMA3QU040 1 $2,290.00

Quickie Lxi WMA3QU405 1 $2,290.00

Quickie M6 WMA3QU420 1 $2,290.00

Quickie QXi WM0000562 1 $2,290.00

Quickie Revolution WMA3QU410 1 $2,290.00

Quickie Xenon WM0001156 1 $2,299.00

Rgk Wheelchairs Maxima WMA3RZ005 1 $2,290.00

Sunrise Medical Legend 2 Exigo/Exigo WMA3M9015 1 $2,290.00

TiLite TiLite AERO X WM0001169 1 $2,290.00

Tilite X, Sx, Tx WMA3TZ005 1 $2,290.00

Adult Lightweight Standard Manual WheelchairWheelchair type most suitable for user who is independently mobile and requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Drive Medical Design & Manufacturing

Viper Plus GT WM0000317 1 $1,449.00

Future Mobility Stellato WMA2FM005 1 $1,449.00

Stellato II WM0001188 1 $1,449.00

Invacare 9000 SL WMA2IN030 1 $1,449.00

9000 Topaz WMA2IN055 1 $1,449.00

9000 Xt WMA2IN025 1 $1,449.00

Myon Manual Wheelchair WMA2IN060 1 $1,449.00

Patriot WMA2IN050 1 $1,449.00

Ki Mobility Catalyst 4, 4c WMA2KI010 1 $1,449.00


NRG+ WMA2WM005 1 $1,449.00

NRG+ Gold WM0001134 1 $1,449.00

Swift WMA2WM010 1 $1,449.00

Motion Composites Move WM0001196 1 $1,449.00

Page: 69 of 89





Allowed Qty.

Approved Price

Adult Lightweight Standard Manual WheelchairWheelchair type most suitable for user who is independently mobile and requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Orthofab Ch+ WMA2OF005 1 $1,449.00

Power Plus Mobility Magic Plus WM0001062 1 $1,449.00

Voyager Plus WM0001063 1 $1,449.00


Litestream Xf Ltd WMA2X1010 1 $1,449.00

Stylus 400 WMA2X1005 1 $1,449.00

Quickie Breezy 600 WMA2QU001 1 $1,449.00

Breezy RubiX2 WM0000567 1 $1,449.00

Breezy Ultra 4 WMA2QU010 1 $1,449.00

Quickie Lx WMA2QU105 1 $1,449.00

Quickie Qx WM0001310 1 $1,449.00

Adult Manual Dynamic Tilt WheelchairWheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 18" wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Advanced Mobility Ams Itilt2 WMA5AO020 1 $2,110.00

Tilt Recline/ I Tilt WMA5AO015 1 $2,110.00

Broda Comfort Tilt 587V3 WMA5B-025 1 $2,110.00

Elite 785 WMA5B-020 1 $2,110.00

Models 80 & 48 WMA5B-005 1 $2,110.00

Models 85 & 35 & 75 WMA5B-010 1 $2,110.00

Future Mobility Capella (20), Capella 45 WM0000559 1 $2,110.00

Orion 500 WMA5FM010 1 $2,110.00

Orion III WM0001195 1 $2,110.00

Orion Ii WMA5FM005 1 $2,110.00

Invacare Concept 45 WMA5IN020 1 $2,110.00

Freedom NXT WM0001366 1 $2,110.00

Htr WMA5IN025 1 $2,110.00

Solara 2g WMA5IN035 1 $2,110.00

Solara 3g WMA5IN040 1 $2,110.00

Ki Mobility Focus CR WM0001160 1 $2,110.00

Lpa Medical Inc Comp-Position WMA5LQ010 1 $2,110.00

Dyn-Ergo WMA5LQ020 1 $2,110.00

Evolution WMA5LQ015 1 $2,110.00

Optimum Posturo-Pedic WMA5LQ005 1 $2,110.00


Lowrider WM0001080 1 $2,110.00

MLT 700 A/B WMA5WM015 1 $2,110.00

MLTR 500/600 WMA5WM010 1 $2,110.00

Supertilt Oval Frame (maximum tilt 45 deg)

WM0001111 1 $2,110.00

Supertilt Square Frame (maximum tilt 35 deg)

WM0001166 1 $2,110.00

Page: 70 of 89





Allowed Qty.

Approved Price

Adult Manual Dynamic Tilt Wheelchair My Life Health The Avenger WM0001286 1 $2,110.00Wheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 18" wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Orthofab Tango WMA5OF005 1 $2,110.00

Physipro Neox Tilt-in-Space and Neox HD WM0001255 1 $2,110.00

Power Plus Mobility Extreme WM0001041 1 $2,110.00

NV Tilt WM0001076 1 $2,110.00

Supertilt Plus WM0001040 1 $2,110.00


Litestream Traverse WM0001030 1 $2,110.00


Bentley WMA5MV005 1 $2,110.00

Fuze T20 WMA5MV025 1 $2,110.00

Fuze T50 WMA5MV020 1 $2,110.00

Stellar, Stellar GL, Stellar HD WMA5MV010 1 $2,110.00

Quickie Breezy Relax2 WM0000454 1 $2,110.00

Quickie Iris WMA5QU015 1 $2,110.00

Quickie SR-45 WM0000474 1 $2,110.00

Quickie Ts WMA5QU005 1 $2,110.00

Tilt Fx WMA5QU020 1 $2,110.00

Seating Matters Limited

Phoenix WM0000974 1 $2,110.00

Sorrento WM0000975 1 $2,110.00

Sunrise Medical Emineo WMA5M9010 1 $2,110.00

Ibis WMA5M9005 1 $2,110.00

Adult Standard Manual Wheelchair Drive Medical Airgo WMA1GM005 1 $1,228.00Wheelchair type most suitable for user who is not consistently independently mobile and requires minimal adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Everest & Jennings Traveler WMA1EJ005 1 $1,228.00

Invacare 900 WMA1IN015 1 $1,228.00

Tracer WMA1IN005 1 $1,228.00

Quickie Easy Care 2000 & 4000 WMA1QU015 1 $1,228.00

Paediatric High Performance Rigid Manual WheelchairWheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Hoggi Supra WM0000462 1 $3,354.00

Invacare Crossfire T6a WMK4IN130 1 $3,354.00

Ki Mobility Little Wave Clik WM0001298 1 $3,354.00

Rogue WM0001044 1 $3,354.00

Tsunami WMK4KI005 1 $3,354.00

LEVO AG LEVO compact-easy LCEV with battery operated Stand-up feature

WM0000472 1 $3,354.00

Pantera AB Bambino WM0000976 1 $3,354.00

Page: 71 of 89





Allowed Qty.

Approved Price

Paediatric High Performance Rigid Manual WheelchairWheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Quickie Quickie Gp WMK4QU010 1 $3,354.00

Quickie Gt WMK4QU030 1 $3,354.00

Quickie Q7, Q7R, Q7RS WMK4QU035 1 $3,354.00

Quickie QRi WM0000992 1 $3,354.00

Quickie Ti WMK4QU025 1 $3,354.00

Zippie WMK4QU005 1 $3,354.00

Zippie Zone WMK4QU040 1 $3,354.00

Rgk Wheelchairs Hi-Lite WMK4RZ005 1 $3,354.00

Maxima WM0000697 1 $3,354.00

TiLite TiLite Twist WM0001187 1 $3,354.00

Tilite Aero Z WMK4TZ010 1 $3,354.00

Tilite Yr/Tr,Yra/Tra,Trc,Zra/Zr WMK4TZ005 1 $3,354.00

iCON Icon A1 WM0000946 1 $3,354.00

Paediatric Lightweight Performance Manual WheelchairWheelchair type offers maximum adjustments and options. Suitable for the active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Invacare Compass Xe (Allegro) WMK3IN020 1 $2,310.00

Mvp Junior WMK3IN030 1 $2,310.00

Myon Jr Manual Wheelchair WMK3IN040 1 $2,310.00

Prospin X4 WMK3IN035 1 $2,310.00

Ki Mobility Catalyst 5 WM0001313 1 $2,310.00

Catalyst Spark WM0000695 1 $2,310.00

Motion Composites Helio Kids WM0000563 1 $2,310.00

Quickie Quickie 2 (VIP 2) WMK3QU010 1 $2,310.00

Quickie 2 Hp WMK3QU015 1 $2,310.00

Quickie 2 Lite WMK3QU020 1 $2,310.00

Quickie Gtx WMK3QU040 1 $2,310.00

Quickie Lxi WMK3QU030 1 $2,310.00

Quickie Xenon WM0001157 1 $2,310.00

Zippie 2 WMK3QU005 1 $2,310.00

Zippie Gs WMK3QU035 1 $2,310.00

Rgk Wheelchairs Maxima WMK3RZ005 1 $2,310.00

Sunrise Medical Zippie X'Cape WM0001239 1 $2,310.00

TiLite TILite AERO X WM0001170 1 $2,310.00

Tilite X, Sx, Tx WMK3TZ005 1 $2,310.00

Paediatric Lightweight Standard Manual WheelchairWheelchair type most suitable for user who requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable

Invacare 9000 Jymni WMK2IN010 1 $1,596.00


Litestream Xf WMK2X1010 1 $1,596.00

Quickie Quickie Lx WMK2QU020 1 $1,596.00

Quickie Qx WM0001311 1 $1,596.00

Page: 72 of 89





Allowed Qty.

Approved Price

footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Sunrise Medical Legend 2 Exigo/Exigo WMK2M9020 1 $1,596.00

Paediatric Manual Dynamic Tilt WheelchairWheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 16" wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP.

Convaid Safari Tilt WMK5CO040 1 $2,804.00

Future Mobility Super Chair For Kids WMK5FM010 1 $2,804.00

Hoggi Bingo/Bingo Evolution WMK5K2010 1 $2,804.00

Swingbo Plus WM0000461 1 $2,804.00

Invacare Freedom NXT WM0001367 1 $2,804.00

Orbit/Tiger WMK5IN010 1 $2,804.00

Spree 3g WMK5IN030 1 $2,804.00

Spree Gt WMK5IN025 1 $2,804.00

Spree Xt WMK5IN020 1 $2,804.00

Ki Mobility Focus CR WM0001161 1 $2,804.00

Little Wave Flip XP WM0001342 1 $2,804.00

Kid Kart Kid Kart Xpress WMK5KT020 1 $2,804.00

Kid-Tlc WMK5KT010 1 $2,804.00

Otto Bock Kimba Spring & Kimba Spring Plus WMK5OB010 1 $2,804.00

Physipro NEOX Junior WM0001312 1 $2,804.00


Fuze T20 WMK5MV025 1 $2,804.00

Fuze T50 WMK5MV020 1 $2,804.00

Quickie Quickie SR-45 WM0000473 1 $2,804.00

Zippie Iris (Folding & Non Folding) WMK5QU010 1 $2,804.00

Zippie Ts WMK5QU005 1 $2,804.00

THOMASHILFEN Easy S WM0000326 1 $2,804.00

Thevo Twist WM0000325 1 $2,804.00

Paediatric Specific Specialty StrollerADP price includes stroller frame and upholstery, foot support, seat and back supports, headrest, chest and pelvic positioning straps (harness), abductor, and wheels. See Manual Wheelchair Options Chart for additional basic components funded by ADP.

Alvema Series 100/Pix1 WMK6AL005 1 $1,303.00

Convaid Cruiser Cx WMK6CO005 1 $1,303.00

Ez Rider WMK6CO050 1 $1,303.00

Metro WMK6CO030 1 $1,303.00

Rodeo Tilt WMK6CO060 1 $1,303.00

Trekker WM0001374 1 $1,303.00

Maclaren Buggy WMK6AM005 1 $1,303.00

Ormesa New Bug WM0001271 1 $1,303.00

Otto Bock Kimba Kruze WM0001302 1 $1,303.00

Kimba Neo WM0001100 1 $1,303.00

Quickie Zippie Voyage WM0001083 1 $1,303.00

Page: 73 of 89





Allowed Qty.

Approved Price

Paediatric Specific Specialty StrollerADP price includes stroller frame and upholstery, foot support, seat and back supports, headrest, chest and pelvic positioning straps (harness), abductor, and wheels. See Manual Wheelchair Options Chart for additional basic components funded by ADP.

THOMASHILFEN Swifty Stroller - Paediatric specific specialty stroller type 6

WM0000318 1 $1,303.00

Thevo Swifty Stroller WM0000316 1 $1,303.00

Page: 74 of 89




Wheelchairs (Manual)OPTIONS:


Qty.

Approved Price

Amputee Axle Plates (pair) WAMT 1 $89.00

Caster Pin Locks (pair) WAMS 1 $135.00

Clothing Guards WAMV 1 $99.00

Elevating Legrests (pair) WAMK 1 $318.00

Grade Aids (pair) WAMR 1 $91.00

Heavy Duty Cross Braces & Upholstery

WAMC 1 $536.00

Hub-Eez Easy Push Wheel WAMM 1 $564.00

MW - Adjustable Tension Back Upholstery over 18" Frame Width

WAME 1 $189.00

MW - Adjustable Tension Back Upholstery up to 18" Frame Width

WAMD 1 $110.00

MW - Angle Adjustable Footplates (pair)

WAMJ 1 $102.00

MW - Custom Modifications MWCM 1

MW - Heavy Duty Model, Client Weight Exceeds 250 LbsHeavy duty model required, client weight exceeds 250lbs. Authorizer must document client weight. Selected device must meet weight requirements.

WAMF 1 $575.00


WAMG 1 $781.00


WAMH 1 $874.00

MW - Oxygen Tank Holder WAMX 1 $154.00

MW - Seat Depth Required is Greater Than 18"

WAMB 1 $209.00

Page: 75 of 89




Wheelchairs (Manual)OPTIONS:


Qty.

Approved Price

MW - Seat Width Required is Greater Than 18"

WAMA 1 $314.00

MW - Ventilator Tray WAMY 1 $335.00

One Arm/Lever Drive WAML 1 $824.00

Plastic Coated Handrims WAMO 1 $106.00

Power Add-On Device Dolomite Alber E.Motion WPS1DO005 1 $4,831.00Device is added onto a manual wheelchair to assist the user meet their long term basic and essential mobility requirements. User must be able to operate the manual wheelchair independently. This code may be used only when it is not anticipated that the user will require the use of a power wheelchair to meet their long term basic and essential mobility requirements. ADP funding assistance is not provided for a power add on device and a power wheelchair.

Invacare Twion WM0001376 1 $4,831.00

Magicwheels Magicwheels WPS1WS005 1 $4,831.00

Max Mobility Smart Drive WM0001081 1 $4,831.00

Quickie Quickie Xtender WPS1QU005 1 $4,831.00

Projected Handrims (pair) WAMQ 1 $176.00

Quick Release Axles (pair) WAMU 1 $87.00

Recliner Option WAMI 1 $415.00

Spoke Protectors (pair) WAMP 1 $91.00

Standard Manual Wheelchair Frame with Manual Dynamic Tilt *Standard manual wheelchair with manual dynamic tilt. Frame offers ongoing adjustability and facilitates independent mobility. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

WANA 1 $945.00

Stroller Handles/Paediatric WAMW 1 $116.00

Titanium Frame * WAMZ 1 $1,181.00Titanium/Composite Frame *. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Uni-Lateral Wheel Lock WAMN 1 $117.00

Page: 76 of 89




Wheelchairs (Power)Device Type Manufacturer Device Device Code Max

Allowed Qty.

Approved Price

Adult Power Base Type 1 Invacare Nutron Series R51lxp WPA1IN065 1 $4,392.00Wheelchair type most suitable for use on hard, flat surfaces. Primarily for user who requires minimal adjustments to support independent mobility. ADP price includes seat and back frame (sizes up to 18" wide x 18"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components funded by ADP.

Pronto M51 WPA1IN075 1 $4,392.00

KYMCO (Canadian Mobility Corp.)

K-ACTIV WP0001448 1 $4,392.00

Power Plus Mobility

Mp1 WPA1WN005 1 $4,392.00


J6 Jazzy WP0000564 1 $4,392.00

Jazzy Elite ES Portable WP0001224 1 $4,392.00

Jazzy Select 6 WPA1X1230 1 $4,392.00

Shoprider/Pihsiang

Shoprider P424l WPA1S7015 1 $4,392.00

Shoprider P424m WPA1S7010 1 $4,392.00

Adult Power Base Type 2 Invacare 3g Ranger X Storm Series WPA2IN040 1 $5,812.00Wheelchair type suitable for use on most surfaces. Primarily for user who requires postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes seat and back frame (sizes up to 18" wide x 18"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, and wheels. See Power Wheelchair Options Chart for other basic components funded by ADP.

Power Plus Mobility

Mp2 WPA2WN005 1 $5,812.00

Adult Power Base Type 3Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure and standard joystick control. See Power Wheelchair Options Chart for other basic components funded by ADP.

Future Mobility Orion Explorer Magellan WPA3FM005 1 $6,125.00

Orion Explorer Viking WPA3FM010 1 $6,125.00

Invacare Action Torque Storm WPA3IN015 1 $6,125.00

Arrow Storm Rwd WPA3IN020 1 $6,125.00

Fdx WPA3IN080 1 $6,125.00

Pronto M91 WPA3IN050 1 $6,125.00

Pronto M94 WPA3IN052 1 $6,125.00

TDXSP2 WP0001447 1 $6,125.00

Tdx Sp/Sr WPA3IN070 1 $6,125.00

Tdx-Sc WPA3IN075 1 $6,125.00

LEVO AG LEVO C3 WP0001140 1 $6,125.00

Motion Concepts Rovi X3 WP0001287 1 $6,125.00

Permobil C300 WPA31P010 1 $6,125.00

C350 WPA31P030 1 $6,125.00

C400 WPA31P015 1 $6,125.00

C500 WPA31P020 1 $6,125.00

Chairman Hd3 WPA31P025 1 $6,125.00

Page: 77 of 89





Allowed Qty.

Approved Price

Adult Power Base Type 3 Permobil F3 Corpus (Adult) WP0001258 1 $6,125.00Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure and standard joystick control. See Power Wheelchair Options Chart for other basic components funded by ADP.

F5 / F5 VS Corpus (Adult) WP0001256 1 $6,125.00

M3 Corpus WP0001401 1 $6,125.00

M300 WP0000455 1 $6,125.00

M300 Corpus HD R-Net WP0001165 1 $6,125.00

M5 Corpus WP0001449 1 $6,125.00

Street WPA31P005 1 $6,125.00

Power Plus Mobility

Mp5 WPA3WM005 1 $6,125.00


Jazzy/Quantum 1113 WPA3X1100 1 $6,125.00



Jazzy/Quantum 1402 & 1420 WPA3X1020 1 $6,125.00


Q6 Edge HD WP0001058 1 $6,125.00

Quantum 1450 WP0001021 1 $6,125.00

Quantum 4Front WP0001441 1 $6,125.00

Quantum 600 WPA3X1220 1 $6,125.00

Quantum 6000 WPA3X1240 1 $6,125.00

Quantum 6000z WPA3X1245 1 $6,125.00

Quantum 610 WPA3X1225 1 $6,125.00

Quantum Q6 Edge 2.0 (Adult) WP0001254 1 $6,125.00

Quantum Q6 Edge Adult WP0000108 1 $6,125.00

Quantum Q6 Edge Z (Adult) WP0001269 1 $6,125.00

Quantum R4000 WPA3X1250 1 $6,125.00

Quantum Rival WP0000968 1 $6,125.00

Quickie Quickie P-222 WPA3QU240 1 $6,125.00

Quickie Pulse 6 WP0000637 1 $6,125.00

Quickie QM-710, 715, 720 WP0000686 1 $6,125.00

Quickie S-646 (S-626) WPA3QU230 1 $6,125.00

Quickie X2 WPA3QU290 1 $6,125.00

Quickie XCEL & Quickie XCEL 2 WPA3QU300 1 $6,125.00

Quickie Xperience & Quickie Xperience 2

WPA3QU280 1 $6,125.00

Quickie Xplore & Quickie Xplore 2 WPA3QU270 1 $6,125.00

Ranger Wheelchairs

Express WP0001023 1 $6,125.00

Sunrise Medical Alex Power Wheelchair WPA3M9005 1 $6,125.00

Page: 78 of 89





Allowed Qty.

Approved Price

Adult Power Base Type 3Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure and standard joystick control. See Power Wheelchair Options Chart for other basic components funded by ADP.

Sunrise Medical PUMA 40 WP0000647 1 $6,125.00

SAMM WP0001233 1 $6,125.00

Paediatric Power Base Type 1Wheelchair type most suitable for use on hard, flat surfaces. Primarily for user who requires minimal adjustments to support independent mobility. ADP price includes seat and back frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components funded by ADP.

Invacare Nutron Series R51lxp WPK1IN015 1 $4,678.00

Paediatric Power Base Type 2Wheelchair type suitable for use on most surfaces. Primarily for user who requires postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes seat and back frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components funded by ADP.

Invacare Tiger WPK2IN015 1 $5,507.00

Paediatric Power Base Type 3Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure, and standard joystick control. See Power Wheelchair Options Chart for other basic components funded by ADP.

Invacare Arrow Storm WPK3IN010 1 $5,902.00

Fdx WPK3IN080 1 $5,902.00

Storm Torque WPK3IN015 1 $5,902.00

Tdx Sp/Sr WPK3IN070 1 $5,902.00

Tdx Spree WPK3IN075 1 $5,902.00

LEVO AG LEVO C3 WP0001141 1 $5,902.00

Motion Concepts Rovi X3 WP0001443 1 $5,902.00

Permobil C300 Corpus Junior / K300 WPK31P010 1 $5,902.00

C400 Corpus Junior WPK31P015 1 $5,902.00

F3 Corpus (Paediatric) WP0001259 1 $5,902.00

F5 / F5 VS Corpus (Paediatric) WP0001257 1 $5,902.00

M3 Corpus WP0001402 1 $5,902.00

M300 WP0000987 1 $5,902.00

M5 Corpus WP0001450 1 $5,902.00

Page: 79 of 89




Wheelchairs (Power)Device Type Manufacturer Device Device Code Max Approved

Allowed PriceQty.

Paediatric Power Base Type 3Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support,


Q6 Edge HD WP0001059 1 $5,902.00

Quantum 4Front WP0001442 1 $5,902.00

Quantum 600 WPK3X1220 1 $5,902.00modifications to electronics, and other specific options to support independent mobility. ADP Quantum 6000 WPK3X1240 1 $5,902.00price includes base, 2 point seat belt any closure, and standard joystick control. See Power Wheelchair Options Chart for other basic

Quantum 610 WPK3X1225 1 $5,902.00

Quantum Q6 Edge 2.0 (Paediatric) WP0001253 1 $5,902.00components funded by ADP. Quantum Q6 Edge Paediatric Power WP0000109 1 $5,902.00

Base Type 3 Wheelchair

Quantum Q6 Edge Z (Paediatric) WP0001270 1 $5,902.00

Quantum Rival WP0000969 1 $5,902.00

Quickie Quickie P-222 WPK3QU020 1 $5,902.00

Quickie Pulse 6 with SPOT Tilt WP0000638 1 $5,902.00

Quickie QM-710, 715, 720 WP0000687 1 $5,902.00

Quickie Xperience & Zippie WPK3QU080 1 $5,902.00Xperience 2

Quickie Xplore & Zippie Xplore 2 WPK3QU070 1 $5,902.00

Sunrise Medical Alex Power Wheelchair WPK3M9005 1 $5,902.00

SAMM WP0001234 1 $5,902.00

Zippie ZM-310 WP0001261 1 $5,902.00

Paediatric Power Base with Manual Invacare Tdx Spree WPK4IN075 1 $5,611.00Dynamic TiltWheelchair type offers manual dynamic tilt required by the user who can not maintain a functional posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away Tiger WPK4IN005 1 $5,611.00detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components funded by ADP.

Power Scooter AMIGO AMIGO RD310000 - 3 WHEEL WP0000333 1 $2,395.00Device is suitable for the user who requires power mobility to meet their long term basic and essential mobility requirements, and does not require specific postural support now or in the future. ADP price includes base, tiller and seat. ADP funding for positioning devices (seating) is not available for scooters. See Power

MOBILITY INTERNATIONAL

SCOOTER

Activelite Mobility Easy Travel -3 Wh. WS16A0005 1 $2,395.00

Advanced Vehicle Concepts

Quingo Classic WS15V0005 1 $2,395.00

Wheelchair Options Chart when heavy duty Fortress 1700fs -3 Wh. WS1FS0015 1 $2,395.00models are required. 1700fs -4 Wh. WS1FS0020 1 $2,395.00

Winner -3 Wh. WS1FS0070 1 $2,395.00

Winner -4 Wh. WS1FS0075 1 $2,395.00

Invacare COLIBRI 4 -Wheel 18AH WP0001285 1 $2,395.00

Page: 80 of 89





Allowed Qty.

Approved Price

Power Scooter Invacare Comet Pro 4 Wheel Scooter WP0000121 1 $2,395.00Device is suitable for the user who requires power mobility to meet their long term basic and essential mobility requirements, and does not require specific postural support now or in the future. ADP price includes base, tiller and seat. ADP funding for positioning devices (seating) is not available for scooters. See Power Wheelchair Options Chart when heavy duty models are required.

Comet Ultra Scooter WP0000546 1 $2,395.00

Leo Scooter 3 Wheel WP0001019 1 $2,395.00

Leo Scooter 4 Wheel WS1IN0085 1 $2,395.00

Pegasus Metro 3-Wheel Scooter WP0000122 1 $2,395.00

Pegasus Metro 4-Wheel Scooter WP0000123 1 $2,395.00

Pegasus Pro 3 Wheel Scooter WP0001399 1 $2,395.00

Pegasus Pro 4 Wheel Scooter WP0001400 1 $2,395.00

KYMCO (Canadian Mobility Corp.)

Midi XL WP0001232 1 $2,395.00

Mini LS WP0001284 1 $2,395.00

Power Plus Mobility

Mp3 -3 Wh. WS1WN0005 1 $2,395.00

Mp4 -4 Wh. WS1WN0010 1 $2,395.00


Celebrity LR WP0000965 1 $2,395.00

Celebrity Xl - 4 Wh. WS1X10017 1 $2,395.00

Go Go LX 4 Wheel WP0001142 1 $2,395.00

Go Go Sport - 4 Wheel WP0001075 1 $2,395.00

Maxima -3 Wh. WS1X10060 1 $2,395.00

Maxima -4 Wh. WS1X10065 1 $2,395.00

Pursuit Scooter (Model SC713CA) WP0001262 1 $2,395.00

Victory 10 - 3 Wh, 3 Wh Twin WS1X10110 1 $2,395.00

Victory 10 - 4 Wh WS1X10115 1 $2,395.00

Victory 10 DX WP0000688 1 $2,395.00

Victory LX WP0001273 1 $2,395.00

Victory Twin DX WP0000699 1 $2,395.00

Shoprider/Pihsiang

Chameleon Gkb - 3 Wh WS1S7005 1 $2,395.00

Chameleon Gkb - 4 Wh WS1S7010 1 $2,395.00

Cobra 778el -3 Wh. WS1S70020 1 $2,395.00

Cobra 778el -4 Wh. WS1S70025 1 $2,395.00

Landcruiser 889-3wh. WS1S70035 1 $2,395.00

Landcruiser 889xls 4wh. WS1S70036 1 $2,395.00

Sovereign 888 -4 Wh. WS1S70032 1 $2,395.00

Trailblazer 889sel 4wh. WS1S70045 1 $2,395.00

Voyager 778s -3 Wh. WS1S70037 1 $2,395.00

Voyager 888sel -4 Wh. WS1S70040 1 $2,395.00

Yelle & Associates Ltd.

Safari/Ltd-3 Wh. WS1YE0020 1 $2,395.00

Solo Ltd-4 Wh. WS1YE0007 1 $2,395.00

Page: 81 of 89




Wheelchairs (Power)Device Type Manufacturer Device Device Code Max Approved

Allowed PriceQty.

Power Scooter Yelle & Solo/Ltd-3 Wh. WS1YE0005 1 $2,395.00Device is suitable for the user who requires Associates Ltd.power mobility to meet their long term basic and essential mobility requirements, and does not Solo/Xt550-4 Wh. WS1YE0010 1 $2,395.00require specific postural support now or in the future. ADP price includes base, tiller and seat. ADP funding for positioning devices (seating) is not available for scooters. See Power Wheelchair Options Chart when heavy duty

ZHE JIANY BISWIFT ENTERPRISE

Boomer Buggy (3 or 4 Wheel) WP0000561 1 $2,395.00

models are required.

Page: 82 of 89




Wheelchairs (Power)OPTIONS:


Qty.

Approved Price

Auto Correction System*Specialized electronics for power wheelchairs - Offers increased driving control through specific auto-correction system; for client with limited trunk and/or upper extremity control. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

WEPQ 1 $1,181.00

Manual Elevating Legrests (pair) WEPK 1 $308.00

Manual Recline Option WEPI 1 $590.00

Midline Control WE3D 1 $268.00

Multi-function Control Box Amysystems Multi-Function Control Box, For Use On Systems With Multiple Functions Including Tilt And Power Legs, Tilt, Recline And Power Legs Etc.

SEC4P5005 1 $1,766.00

Invacare Multi-Function Control Box For Use On Systems With Multiple Functions. Including Tilt And Power Legs, Tilt, Recline And Power Legs Etc.

SECIN5005 1 $1,588.00

Motion Concepts Trx Helix / 600 Series Multi-Function Control Box (Thmc) For Use On Systems With Multiple Functions, Including Tilt And Power Legs, Tilt, Recline, Power Legs, Etc. Includes Reduced Drive With Elevate.

SECZG5005 1 $1,570.00

Permobil Multi-Function Control Box - For Use On Systems With Multiple Functions Including, Tilt And Power Legs, Tilt, Recline And Power Legs, Etc.

SEC1P1005 1 $1,847.00


Multi-Function Control Box - Advanced Acutator Module (Aam)

SECX15005 1 $514.00

Quickie Multi-Function Control Box For Use On Systems With Multiple Functions, Including Tilt And Power Legrest, Tilt, Recline, Power Legrests Etc.

SECQU4005 1 $2,403.00

Sunrise Medical multi-function control box - for use on WP0000654 1 $403.00

Page: 83 of 89






Qty.

Approved Price

Multi-function Control Box systems with multiple functions including tilt and power legs, tilt and power legs, etc

One Piece 90/90 Front Riggings WEPL 1 $168.00

PW - Adjustable Tension Back Upholstery over 18" Frame Width

WEPE 1 $189.00

PW - Adjustable Tension Back Upholstery up to 18" Frame Width

WEPD 1 $110.00

PW - Angle Adjustable Footplates (pair)

WEPJ 1 $92.00

PW - Custom Modifications PWCM 1

PW - Heavy Duty Model, Client Weight Exceeds 250 LbsHeavy duty model required, client weight exceeds 250lbs. Authorizer must document client weight. Selected device must meet weight requirements.

WEPF 1 $438.00


WEPG 1 $525.00


WEPH 1 $771.00

PW - Oxygen Tank WEPX 1 $106.00

PW - Seat Depth Required is Greater Than 18"

WEPB 1 $230.00

PW - Seat Width Required is Greater Than 18"

WEPA 1 $339.00

PW - Ventilator Tray WEPY 1 $1,331.00

Power Elevating Footrests Amysystems Power Elevating & Articulating Legrests or Center mount foot platform

SEF4P0005 1 $2,250.00

Motion Concepts Power Elevating At5544 Legrest SEFZG0010 1 $2,214.00

Page: 84 of 89






Qty.

Approved Price

Power Elevating Footrests Motion Concepts Package For Invacare And Quickie Bases. Includes Legrests And Actuators.

Power Elevating Legrests For Invacare, Quantum, And Quickie Bases. Includes Legrests And Actuators.

SEFZG0005 1 $2,214.00

Permobil Power Elevating Articulating Leg Rests

SEF1P0005 1 $2,274.00


Articulating Foot Platform SEFX13010 1 $2,411.00

Power Elevating Articulating Leg Rests

SEFX13005 1 $2,193.00

Quickie Power Elevating/Articulating Leg Rests

SEFQU0005 1 $2,250.00

Sunrise Medical Power elevating and articulating legrests

WP0000653 1 $2,415.00

Tarsys (Invacare) Power Elevating Legrests SEFTY0005 1 $2,368.00

Power Recline Only Amysystems Power Recline With Integrated Shear Reduction (Isr)

SEC4P0045 1 $6,436.00

Invacare Formula CG 12" 20" Recline Only SECIN1010 1 $8,009.00

Formula CG 21" - 24" Recline Only SECIN1015 1 $8,660.00

Motion Concepts Bariatric POWER RECLINE SYSTEM WITH ESR FOR INVACARE, QUICKIE, AND QUANTUM BASES.

SECZG1010 1 $8,223.00

Modular CG Recline WP0001296 1 $7,245.00

Ultra Low POWER RECLINE ONLY WITH POWER SLIDING BACK (PSB) FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG0015 1 $7,502.00

Ultra Low POWER RECLINE SYSTEM WITH EXTENDED SHEAR REDUCTION (ESR) FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG0010 1 $7,019.00

Permobil Corpus Power Positioning System With Power Recline Only

SEC1P0010 1 $6,001.00


Quantum TRU-Balance 3 WP0001163 1 $5,432.00

Tru-Balance 2 Power Recline SECX12055 1 $5,434.00

Quickie Recline with Power Shear Reduction WP0001149 1 $6,563.00

Sunrise Medical QLASS power recline WP0000995 1 $6,842.00

Sedeo Pro recline WP0000652 1 $6,842.00

Page: 85 of 89






Qty.

Approved Price

Power Tilt Only Amysystems Bariatric CG Power Tilt SEC4P0060 1 $6,436.00

Cg Power Tilt SEC4P0040 1 $5,228.00

Invacare Formula CG 12" - 20" Tilt Only SECIN1000 1 $5,390.00

Formula CG 21" - 24" Tilt Only SECIN1005 1 $6,040.00

LEVO AG C3 Power Tilt Only WP0001151 1 $5,095.00

Motion Concepts Bariatric POWER TILT ONLY FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG1005 1 $6,436.00

Modular DG Tilt WP0001295 1 $5,232.00

Single Pivot Power Tilt Only For Invacare, Quantum, and Quickie Bases

SECZG2005 1 $4,528.00

Ultra Low CG POWER TILT ONLY FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG0005 1 $5,233.00

Permobil Corpus Hd Power Positioning System With 30 Deg. Power Tilt Only

SEC1P0105 1 $9,173.00

Corpus Power Positioning System With 45 Deg. Power Tilt Only

SEC1P0005 1 $5,309.00

Ps Power Positioning System With 45 Deg. Power Tilt Only

SEC1P0205 1 $4,504.00


Quantum TRU-Balance 3 Power Positioning

WP0001162 1 $5,211.00

Tru-Balance 2 Power Tilt SECX12050 1 $4,826.00

Tru-Balance Bariatric Power Tilt WP0001022 1 $5,630.00

Tru-Balance Power Tilt SECX12005 1 $4,589.00

Quickie Power C.G. Tilt For Quickie G-424 & S-525

SECQU1005 1 $4,684.00

Power C.G. Tilt For Quickie P-222se SECQU1015 1 $4,726.00

Power C.G. Tilt For Quickie Rhythm SECQU3005 1 $4,745.00

Power C.G. Tilt For Quickie S-626 SECQU1010 1 $4,684.00

SPOT TILT WP0000639 1 $3,466.00

Spot Tilt II WP0001148 1 $5,332.00

Sunrise Medical QLASS centre of gravity power tilt WP0000993 1 $5,232.00

Sedeo Pro centre of gravity power tilt WP0000650 1 $5,233.00

Power Tilt and Recline Amysystems Bariatric CG Power Tilt and Power Recline With Integrated Shear Reduction (Isr)

SEC4P0070 1 $10,460.00

Page: 86 of 89






Qty.

Approved Price

Power Tilt and Recline Amysystems Cg Power Tilt & Power Recline With Integrated Shear Reduction (Isr)

SEC4P0050 1 $9,253.00

Invacare Formula CG 16" 20" Tilt And Recline SECIN1020 1 $8,654.00

Formula CG 21" - 24" Tilt And Recline

SECIN1025 1 $9,605.00

Motion Concepts Bariatric POWER TILT AND POWER RECLINE WITH ESR FOR INVACARE, QUICKIE, AND QUANTUM BASES.

SECZG1015 1 $9,293.00

Modular CG Tilt and Recline WP0001297 1 $8,855.00

Single Pivot POWER TILT AND POWER RECLINE FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG2010 1 $7,647.00

Single Pivot POWER TILT AND POWER RECLINE WITH ESR FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG2015 1 $8,102.00

Single Pivot POWER TILT AND POWER RECLINE WITH PSB FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG2020 1 $8,585.00

Ultra Low CG POWER TILT AND POWER RECLINE WITH ESR FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG0020 1 $8,806.00

Ultra Low CG POWER TILT AND POWER RECLINE WITH PSB FOR INVACARE, QUANTUM, AND QUICKIE BASES.

SECZG0025 1 $9,289.00

Ultra Low POWER TILT AND POWER RECLINE FOR INVACARE, QUICKIE, AND QUANTUM BASES.

SECZG0018 1 $8,352.00

Permobil Corpus Power Positioning System With 45 Deg. Power Tilt And Power Recline

SEC1P0015 1 $8,851.00


Quantum TRU-Balance 3 WP0001164 1 $9,054.00

Tru-Balance 2 Power Tilt And Recline SECX12060 1 $9,056.00

Quickie Smart Seat Tilt & Recline System SECQU2005 1 $9,257.00

Tilt & Recline with Power Shear Reduction

WP0001150 1 $9,440.00

Sunrise Medical QLASS centre of gravity power tilt and recline

WP0000994 1 $9,096.00

Page: 87 of 89






Qty.

Approved Price

Power Tilt and Recline Sunrise Medical Quickie Sedeo Ergo Seating System WP0001341 1 $10,022.25

Sedeo Pro centre of gravity power tilt plus recline

WP0000651 1 $9,096.00

Seat Package 1 for Power BasesSeat package 1 for power bases (includes frame, sling upholstery, armrests, footrests.)

WEPN 1 $663.00

Seat Package 2 for Power BasesSeat package 2 for power bases (includes deluxe seat and back, armrests, footrests.) No positioning devices (seating) allowed with this code.

WEPO 1 $682.00

Specialty Controls 1 Non Standard Joystick*Specialty controls 1 - Simple Non-Standard Joystick (includes mounting hardware, upgraded electronics & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

WEX1 1 $1,103.00

Specialty Controls 2 Chin/Rim Control*

WEX2 1 $2,363.00

Specialty controls 2 - Complex Non-Standard Joystick (includes upgraded electronics, mounting hardware, display, joystick modifications & labour). For chin/rim control etc. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Specialty Controls 3 Simple Touch*Specialty controls 3 - Simple Touch (includes mounting hardware, upgraded electronics, display, cables, 4 switches & labour). For footplate/headrest/tray switches etc. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

WEX3 1 $5,276.00

Specialty Controls 4 Proximity Control*

WEX4 1 $5,906.00

Specialty controls 4 - Proximity Control (includes mounting hardware, upgraded electronics, display, cables, 4 switches & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Specialty Controls 5 Breath Control*Specialty Controls 5 - Breath Control - Sip'N'Puff (includes mounting hardware, upgraded electronics, display, cables & labour).

WEX5 1 $2,363.00

Page: 88 of 89






Qty.

Approved Price

Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

Specialty Controls 6 Scanners*Specialty Controls 6 - Scanners (includes mounting hardware, upgraded electronics, display, cables, scanner & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements.

WEX6 1 $3,938.00

Swingaway Mounting Bracket WEPM 1 $232.00

Page: 89 of 89

Documents

Ministry of Health and Long-Term Care Assistive Devices ... · PDF fileMobility Devices Product Manual Effective ... 2017 Assistive Devices Program Ministry of Health and Long-Term