Mobility Devices Product Manual

Transcription

Mobility Devices
Product Manual
Effective Date : June 01, 2015
Assistive Devices Program
Ministry of Health and Long-Term Care
Printed Date: Mar 5, 2015
Page: 1 of 80
Product Manual
Mobility Devices
Effective From: June 01, 2015
Ambulation Aids
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Adult Wheeled Walker Type 1
Airway Surgical
Top Release 5051/5051-J
MW1AR0005
1
$82.00
Walker 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.
Amg Medical
Deluxe Folding Wheeled Walker
MW1GM0010
1
$82.00
Drive Medical
10263KDR Travel Folding
Walker
AA0000560
1
$82.00
One Button Or Dual Trigger
Release
MW1D50005
1
$82.00
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
Human Care Canada
Inc.
Deluxe Regular
MW1DG0020
1
$82.00
Deluxe Small
MW1DG0025
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
Airway Surgical
5314
MW2AR0010
1
$324.00
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.
Amg Medical
Airgo Adventure 6
MW2GM0040
1
$324.00
Airgo Ultra Light
MW2GM0050
1
$324.00
Duet 795b Rollator
MW2D00010
1
$324.00
Go-Lite Deluxe
MW2D50005
1
$324.00
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
4200 Dx
MW2DG0010
1
$324.00
4200 Lx
MW2DG0005
1
$324.00
Nexus 1 (Cable Brake)
MW2DG0050
1
$324.00
Rollite 65100
MW2IN0050
1
$324.00
Three Wheels
MW2IN0030
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
Guardian
Drive Medical
Evolution Medical
Human Care Canada
Inc.
Invacare
Page: 2 of 80
Product Manual
Mobility Devices
Ambulation Aids
Device Type
surfaces. ADP price includes frame, four small
wheels (less than 6" diameter), hand braking
Walker type most suitable for active use on
most terrains. ADP price includes frame,four
large wheels (6"/8" diameter), hand braking
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Prode3
ProDe3 Victr/ 17,19 21 inches
AA0000320
1
$324.00
Sunburst Medical
Freedom Plus
MW22S0005
1
$324.00
Freedom Plus Short
MW22S0010
1
$324.00
Active
MW3V80005
1
$417.00
Breeze
MW3V80010
1
$417.00
5305 Adult Type 3 Walker
AA0000315
1
$417.00
5307 Rollator
AA0000460
1
$417.00
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
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
Diamond 740r Rollator
MW3D50010
1
$417.00
Nitro
AA0001036
1
$417.00
Nitro Hemi
AA0001193
1
$417.00
Nitro Tall
AA0001194
1
$417.00
Volaris S7
AA0000456
1
$417.00
Volaris S7 Smart
AA0000457
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, Xpresso Lite
MW3EV0040
1
$417.00
Access Vital As
Airway Surgical
Amg Medical
Dolomite
Drive Medical
EUROVEMA AB
Page: 3 of 80
Product Manual
Mobility Devices
Ambulation Aids
Device Type
most terrains. ADP price includes frame,four
large wheels (6"/8" diameter), hand braking
Manufacturer
Approved
Price
AA0000453
1
$417.00
Handicare
Gemino
AA0001082
1
$417.00
Gemino 60
AA0001236
1
$417.00
4200swx
MW3DG0035
1
$417.00
4200wx
MW3DG0030
1
$417.00
Nexus Ii (Cable Brake)
MW3DG0040
1
$417.00
Nexus Iii (Cable Free Braking
System)
MW3DG0045
1
$417.00
Solo
MW3DG0010
1
$417.00
Ats 906 0vation
MW3NM0015
1
$417.00
MW3NM1005
1
$417.00
MW3NM1010
1
$417.00
ProDe3 Aurora 19/21/23 inches
AA0000321
1
$417.00
ProDe3 Balius/21 wide
AA0000319
1
$417.00
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
Olympos
MW3TV0020
1
$417.00
Human Care Canada
Inc.
Sunburst Medical
Topro
Paediatric Specific Walking Frame
Max
Allowed
Qty.
HYBRID LX Rollator
Prode3
1 Pair of Forearm Crutches from the following
manufacturers may be billed under this code.
Device Code
GF HEALTH
PRODUCTS
Nighthawk
Forearm Crutches
Device
Troja
MW3TV0010
1
$417.00
Triumph Mobility Inc
Escape
AA0001084
1
$417.00
Wheelzahead USA,
LLC
Wheelzahead Track III Rollator
AA0001235
1
$417.00
Approved ADP
Manufacturers Only
Forearm Crutches
MKZND0005
1
$121.00
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
Mini-Meywalk
MW6CD0050
1
$2,578.00
Nimbo KA1200N
AA0000110
1
$220.00
Nimbo KA2200N
AA0000111
1
$220.00
Nimbo KA3200N
AA0000112
1
$220.00
ADP 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
sizes.
Drive Medical
Page: 4 of 80
Product Manual
Mobility Devices
Ambulation Aids
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Paediatric Specific Walking Frame
Drive Medical
Nimbo KA4200N
AA0000105
1
$220.00
ADP 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
sizes.
Hoggi
Flux Gait Trainer
MW6K20005
1
$2,578.00
Ormesa
Dynamico
MW6R80055
1
$2,578.00
Paediatric Specific Wheeled Walker
Type 1
surfaces. ADP price includes frame, two or four
small wheels, and braking system (if available).
See Ambulation Aids Options Chart for
adolescent sizes.
Paediatric Specific Wheeled Walker
Type 2
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
Strider Tweener G07783
MW4GU0035
1
$220.00
Strider Tyke G07782
MW4GU0030
1
$220.00
Tyke G07751
MW4GU0010
1
$220.00
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
Guardian
Kaye
Otto Bock
most terrains. ADP price includes all
components and options.
Paediatric Standing Frame Type 1
Otto Bock
Youth 2 Wheels
MW4KY0035
1
$220.00
Youth 4 Wheels
MW4KY0040
1
$220.00
Youth 4 Wheels/Swivel
MW4KY0045
1
$220.00
Nurmi Neo
MW5OB0005
1
$1,524.00
Yogi Walker
AA0000683
1
$1,524.00
Vertical Stander
MS1HY0005
1
$1,219.00
Page: 5 of 80
Product Manual
Mobility Devices
Ambulation Aids
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
ADP price includes frame, positioning straps,
trunk, pelvic, knee and foot supports, and tray.
adolescent sizes.
Prime Engineering
Up-Right Stander
MS12P0015
1
$1,219.00
Paediatric Standing Frame Type 2
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
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
Leckey Mygo Stander
AA0000692
1
$3,285.00
Squiggle Stander
AA0000700
1
$3,285.00
Kidstand & Grandstand 111
MS22P0010
1
$3,285.00
Superstand,Small & Youth
MS22P0005
1
$3,285.00
Symmetry Standing Frame
MS22P0015
1
$3,285.00
Prodije
Baby,Kid & Junior
MS2JP0010
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
ADP price includes frame, positioning straps,
trunk, pelvic, knee and foot supports, and tray.
adolescent sizes.
Ormesa
Otto Bock
Prime Engineering
Page: 6 of 80
Product Manual
Mobility Devices
Ambulation Aids
OPTIONS:
Device Type
AA - Custom Modifications
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
MOCM
1
AA5
1
$100.00
AA7
1
$300.00
AA6
1
$200.00
AA8
1
$100.00
AA1
2
$200.00
AA2
1
$100.00
AA3
1
$150.00
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
Additional funding for adolescent sized
paediatric walkers. Authorizer must document
clinical requirements. Selected device must
meet size requirements.
Adolescent Size Paediatric Standing
Frame
paediatric standing frames (device type ms1 &
ms2). Authorizer must document clinical
requirements. Selected device must meet size
requirements.
Adolescent Size Paediatric Walking
Frame
paediatric walking frames (device type mw6).
Authorizer must document clinical
requirements. Selected device must meet size
requirements.
Extra Wide Adult Wheeled Walker
Extra 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
Forearm attachments for wheeled walkers.
Authorizer must provide clinical rationale to
support request (maximum 2).
Heavy Duty Package Client Weight
275-350 lbs
Heavy duty package for wheeled walkers, client
weight 275-350 lbs. Authorizer must document
client weight. Selected device must meet weight
requirements.
350-400 lbs
Page: 7 of 80
Product Manual
Mobility Devices
Ambulation Aids
OPTIONS:
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
AA4
1
$200.00
AA9
1
$100.00
weight 350-400 lbs. Authorizer must document
requirements.
Exceeded 400 lbs
weight exceeds 400lbs. Authorizer must
document client weight. Selected device must
meet weight requirements.
Unilateral Hand Brake
Unilateral hand brake. allows locking/braking of
both brakes using one hand. Authorizer must
document clinical requirements. (max 1)
Page: 8 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Action Products
Adaptive
Engineering Lab
Adaptive
Equipment
Systems (Aes)
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Twister Cb Back 15"-16" Width X
11"-16" Height
SEBAN0005
1
$388.00
17"-21" Height
SEBAN0025
1
$388.00
11"-16" Height
SEBAN0010
1
$388.00
17"-21" Height
SEBAN0030
1
$388.00
11"-16" Height
SEBAN0015
1
$457.00
17"-21" Height
SEBAN0035
1
$457.00
11"-16" Height
SEBAN0020
1
$457.00
17"-21" Height
SEBAN0040
1
$457.00
DROP-IN R-BACK CURVED - SUNMATE 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
Adjustable Bi-Angular Solid Back Insert, SEB2L1025
Includes T-Nuts
& Adjustment Brackets.
1
$378.00
I Or T Or Curved Syle Solid Back Insert, SEB2L1015
Includes T-Nuts.
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
Page: 9 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Adaptive
Equipment
Systems (Aes)
Advanced
Mobility
Amysystems
Blake Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
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
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), SEBCF117L
1
$1,122.00
Contoured Back (Foam On Rigid Base), SEBCF112L
Minimal Trunk Support,
Vinyl Cover, Without Mounting
Hardware
1
$431.00
Page: 10 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Custom
Fabricated
Dynamic Health
Care Solutions
Future Mobility
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Custom Contoured Back, Moderate
Trunk Support,
Vinyl Cover, Without Mounting
Hardware
SEBCF113L
1
$673.00
Custom Shaped Sculptured Back,
Includes Cover,
SEBCF115L
1
$819.00
Flat Back/Planar Design, Vinyl Cover
SEBCF110L
1
$259.00
Simple Molded Back (Foam In Place),
SEBCF116L
1
$810.00
Cushion Size 14" - 21"
SEBD30005
1
$475.00
Cushion Sizes 14" - 21"
SEBD30015
1
$579.00
HAKC Back Support 10" - 14"
SE0001129
1
$476.00
MAPS Back Support 14" - 24"
SE0001130
1
$687.00
NXT AC BACK 12" TO 20"
SE0000340
1
$496.00
NXT ACT Back, Cushion Size 14"- 21"
SEBD30010
1
$496.00
NXT HA AC BACK - 22 "
SE0001182
1
$497.00
NXT HA AC BACK 16" TO 20"
SE0000335
1
$475.00
NXT HA PC BACK 16" TO 20"
SE0000336
1
$475.00
NXT HA PC BACK 22"
SE0000338
1
$496.00
NXT HA SC 22"
SE0000334
1
$496.00
NXT PC BACK 12" TO 20"
SE0000341
1
$579.00
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
Nxt Carbon Fiber FHAC Back, QR
SE0001222
1
$756.00
Nxt FH AC 22" HD Back
SE0001215
1
$497.00
Nxt FH PC 22" HD Back
SE0001216
1
$566.00
Nxt Optima FH AC Back
SE0001217
1
$476.00
Nxt Optima FH PC Back
SE0001219
1
$545.00
nxt HA SC Back 16" to 20"
SE0000337
1
$475.00
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
Page: 11 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Future Mobility
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Full Back Style Heaby 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
Mid Back - Sizes From 14" To 22" Lateral
SEBFM3030
1
$531.00
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
Page: 12 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Future Mobility
Handicare
Hoggi
Innovators 1993
Inc
Invacare
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
Prism Ultra Back - Non Standard Sizes
SEBFM0025
1
$621.00
Prism Ultra Back Fits 16,18,20" Wide
W/C
SEBFM0020
1
$535.00
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
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
20" w x 20"h
SE0000662
1
$620.00
22"w x 20" h
SE0000663
1
$656.00
Sedeo Pro-deep backrest 22"w x 20 h
SE0000660
1
$656.00
Smartsit Comfort Back - All Sizes
SEBM90100
1
$549.00
Back Cushion Shaped
SE0000469
1
$272.00
Back Cushion trough Shaped
SE0000466
1
$322.00
Xps Adaptive Back Cushion
SEBK20050
1
$259.00
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
Contour U Back Includes All
Modifications & Vacuum/Vinyl
SEBNS1030
1
$1,156.00
Page: 13 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Invacare
Invacare - Matrx
Seating
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
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
SE0001055
1
$854.00
SE0001053
1
$716.00
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 SEB1M0035
16 To 20 Inches
1
$1,133.00
PB Posture Back Elite, Posture Back
1
$584.00
Upholstery
SEB1M0025
Page: 14 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Invacare - Matrx
Seating
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
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 3 Back Shoulder Height - Sizes 21
Height To 22 Width
SEBJA8215
1
$1,221.00
Jay 3 Back- Posterior Upper thoracicSizes 18 Height To 24 Width
SEBJA8210
1
$1,121.00
Elite Full Back, All Sizes
Page: 15 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Jay 3 Back- Posterior mid thoracic Sizes 12 Height To 26 Width
Sizes 15 Height To 26 Width
SEBJA8205
1
$1,052.00
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
For 14" Or 16" Frame Width,
SEBJA4010
1
$328.00
For 18" Frame Width,
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
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
Page: 16 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Jay Medical
Kid Kart
Lpa Medical Inc.
Maple Leaf
Wheelchair
Motion Concepts
Nighthawk
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
Adjustable Tension Back
SEBO12010
1
$172.00
Contour Back Cushion
SEBO12005
1
$93.00
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
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
x 12 high
SE0000139
1
$911.00
x 9 high
SE0000138
1
$842.00
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
Key-Hole Back
SEBNM0050
1
$197.00
Relaxed Back High
SEBNM0010
1
$159.00
Page: 17 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Nighthawk
Orthofab
Otto Bock
Performance
Health Products
Permobil
Physipro
Power Plus
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Relaxed Back High With Flap
SEBNM0020
1
$168.00
Relaxed Back Low
SEBNM0005
1
$159.00
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
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
Back System 1, 15" To 17" & 18" To
20"
SEBOB9555
1
$342.00
20"
SEBOB9600
1
$438.00
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
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
Ergo Back - Fixed - All Sizes
SEB1P0005
1
$692.00
Ergo Back - Recline - All Sizes
SEB1P0010
1
$692.00
Rectangular Back - All Sizes
SEB1P0015
1
$1,052.00
HP2 Back Support, all models, all sizes
SE0001071
1
$480.00
Premium Back Support, all sizes
SE0001072
1
$480.00
Deep U Back Custom Sizes
SEBWM0015
1
$621.00
Page: 18 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Mobility
Precision Rehab
Manufacturing
Pride Mobility
Products
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Deep U Back Standard Sizes
SEBWM0010
1
$524.00
Kyphotic Tension Back Rest - Shallow
Or Deep U
SEBWM0030
1
$718.00
Mid U Back Standard Sizes
SEBWM0027
1
$604.00
Shallow U Back Standard Sizes
SEBWM0020
1
$469.00
Shallow U Back Custom Sizes
SEBWM0025
1
$524.00
Shape U Back Standard Sizes
SEBWM0026
1
$707.00
Upcharge For Custom Height
SEBWM0040
1
$152.00
Upcharge For Custom Width
SEBWM0035
1
$152.00
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
Adjustable Height Back System
SEBK20060
1
$293.00
Back Cushion - All Sizes
SEBK20005
1
$259.00
Synergy Shape 2 Back - Low
SEBX10030
1
$450.00
Synergy Shape 2 Back - Standard
SEBX10035
1
$496.00
Synergy Shape 2 Back - Tall
SEBX10040
1
$512.00
Synergy Shape Back Sizes 14x19 &
22x19
SEBX10005
1
$551.00
Synergy Shape Back Sizes 16x19,
18x19, 20x19
SEBX10010
1
$551.00
Synergy Shape Deep Standard Sizes
SEBX10055
1
$569.00
Synergy Shape Deep Tall Sizes
SEBX10060
1
$587.00
Synergy Shape GP Back Sizes 14x19
16x19 18x19
SEBX10045
1
$342.00
Synergy Shape GP Sizes 20x19 And
22x19
SEBX10050
1
$375.00
Synergy Standard Back Support, up to
20". For additional sizing see
SEBND0015.
SE0000971
1
$311.00
Page: 19 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Pride Mobility
Products
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Synergy Tru Comfort Back Standard,
Reclining Or Tilt And
Recline Back Greater Than 20" Wide
SEBX10025
1
$518.00
Synergy Tru-Comfort Back Synergy Tru
Comfort Back Standard, Reclining Or
Tilt And Recline Back Up To 20" Wide
SEBX10020
1
$480.00
BREEZY RELAX2 COMFORT BACK
ANATOMICAL SHAPE
SE0000117
1
$1,722.00
Contour Back - Tilt Fx
SEBQU0400
1
$359.00
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 Grande
SE0001144
1
$561.00
Ride Java Back Grande Deep
SE0001145
1
$638.00
Ride Java Back Regular/Tall Deep
SE0001143
1
$618.00
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
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, TallDeep,
Custom Sizes
1
$1,311.00
Quickie
Ride Designs
Roho
SEB7C0025
Page: 20 of 80
Product Manual
Mobility Devices
Seating
Device Type
Back Support
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
The Comfort
Company
Incrediback, Moldable, Tall, Deep, TallDeep,
All Sizes
SEB7C0020
1
$644.00
Toronto
Orthopedic Ltd.
Tops Back Cushion (10" & 12" Width)
SEBTP0005
1
$212.00
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
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
Adaptive
Engineering Lab
Contoured Seat System
(Includes Seat, Back, Support Pads,
Hardware)
SECE10020
1
$1,057.00
Adaptive
Equipment
Systems (Aes)
Basis Contoured Seat & Back Including
Connecting Hinge
(Select Type). Does Not Include
Mounting Hardware.
SEC2L0010
1
$742.00
Basis Contoured Seat & Back Including SEC2L0020
Connecting Hinge
Package. Li'L Kiddos,14" Wide Or Less.
Does Not Include
Mounting Hardware.
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
SECB-0005
1
$486.00
Vision
Wheelchair
Seating Systems
Inc.
Complete Assembly
Page: 21 of 80
Product Manual
Mobility Devices
Seating
Device Type
Manufacturer
Complete Assembly
Device
Device Code
Max
Allowed
Qty.
Approved
Price
(Includes Short Wing Cover, Extended
Shoulder Bolsters,
Full Extension Foot Pad, F-2 Foot Rest,
Thigh Belt)
Custom
Fabricated
Modify Or Refurbish Existing Custom
Seating System.
Includes Parts,Hardware,Labour
Changes To Head Rest,Back
Support,Seat, & Footrest Etc.
SEMCF900L
1
$431.00
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
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
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
Motion Concepts
Power Tilt Only For Invacare, Quantum,
And Quickie Bases.
SECZG2005
1
$4,528.00
Otto Bock
Kimba Neo Basic Seat - Size 2 Includes Elevating Legrests, Flip-Up
Footrest, Laterals,
Adjustable Hip Pads & Padding.
SE0001159
1
$1,467.00
Kimba Spring Multifunctional Seating
SECOB3005
1
$1,308.00
Invacare
Kid Kart
Page: 22 of 80
Product Manual
Mobility Devices
Seating
Device Type
Complete Assembly
Manufacturer
Otto Bock
Spenco
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Kimba Spring Multifunctional Seating
Unit - Size 2
Includes Elevating Legrests, Flip-Up
Footrest, Laterals,
SECOB3010
1
$1,377.00
Kimba Spring Plus Adjustable Seating
System - Size 1
Includes Armrests, Elevating Legrests,
Adjustable
Footplates & Recline.
SECOB4005
1
$1,256.00
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,
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
Silicore Wheelchair Seat With Back and
Sides
SECSO0010
1
$105.00
Unit - Size 1
Includes Elevating Legrests, Flip-Up
Footrest, Laterals,
THOMASHILFEN EasyS or EasyS Modular
Headrest/Neckrest
SE0001026
1
$1,377.00
Thevo Twist
SE0001025
1
$1,477.00
Toronto
Orthopedic Ltd.
Tops Seating System
Includes Butterfly Chest Strap,
Combination Head/Neckrest
Tilt Tray, Stroller Interface, Back And
Seat
SECTP0005
1
$1,347.00
Adaptive
Engineering Lab
Curved Headrest
SEHE10015
1
$88.00
Tri-Pad Headrest
SEHE10005
1
$272.00
Adaptive
Curved Hr Pad Or Contoured Hr Pad Or SEH2L0035
1
$455.00
Page: 23 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Manufacturer
Max
Allowed
Qty.
Approved
Price
Curved Hr Pad Or Contoured Hr Pad Or SEH2L0030
Bell Curved Hr Pad,
Cobra Headrest Bracket.
1
$381.00
Lateral-Posterior Head Support,
Adjustable Depth Bracket,
6-1/2"W X 7"H.
SEH2L0015
1
$355.00
Hinged.
SEH2L0005
1
$388.00
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
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
SEHCF070L
1
$164.00
Equipment
Systems (Aes)
Advanced
Mobility
Device
Device Code
Bell Curved Hr Pad,
Cobra Headrest Bracket, Flip-Down.
Page: 24 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Custom
Fabricated
Hardware
Daher Specialty
Foam Products
Combination Headrest
SEHDH0010
1
$50.00
Full Support Headrest
SEHDH0015
1
$66.00
Large Headrest
SEHDH0005
1
$50.00
Dynamic Health
Care Solutions
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
Small Headrest With Multi-Axial
Hardware
SEHFM0020
1
$242.00
Small Padded Headrest
SEHFM0010
1
$186.00
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
Handicare
Small Headrest Assesmbly
SEHM90005
1
$114.00
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
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
Jay Medical
Page: 25 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Manufacturer
Jay Medical
Kid Kart
Lpa Medical Inc.
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
Junior
SEHJA0028
1
$304.00
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
Cervical Support
SEHO12005
1
$36.00
Contour Headrest
SEHO12010
1
$86.00
Maple Leaf
Wheelchair
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 &
SEHOB0015
1
$108.00
Page: 26 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Otto Bock
Paediatric Sizes.
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
Power Plus
Mobility
Contour Headrest Including Brackets
SEHWM0005
1
$221.00
Precision Rehab
Manufacturing
Headreast - Large (14") Or Small (10")
Pad
SEHWB0010
1
$104.00
Pride Mobility
Products
Kids Up Including Mounting Hardware
SE0001154
1
$266.00
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
SEHNS3070
1
$323.00
Stealth Comfort Plus, Swingaway Right
Side, Standard
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
SEHNS3075
1
$480.00
Page: 27 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Stealth Products
Stealth Otto Bock Style, Swingaway
Left Side, Standard
SEHNS3085
1
$367.00
Stealth Otto Bock Style, Swingaway
Right Side, Standard
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
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
The Comfort
Company
Headrest - Moldable, Includes Cover
SEH7C0015
1
$188.00
Vision
Wheelchair
Seating Systems
Inc.
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 SubOccipital Pad
With Linx Vertical/Horizontal Mount
SEHWH7005
1
$361.00
With Onyx Vertical/Horizontal Mount
SEHWH7020
1
$339.00
With Pro Verticial/Horizontal Mount
SEHWH7035
1
$371.00
14" Plush Pad With Linx
Vertical/Horizontal Mount
SEHWH5010
1
$197.00
14" Plush Pad With Onyx
SEHWH5030
1
$197.00
Page: 28 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Manufacturer
Whitmyer
Biomechanix
Device
Device Code
Max
Allowed
Qty.
Approved
Price
14" Plush Pad With Pro
SEHWH5040
1
$210.00
19" Plush Pad With Link
SEHWH5015
1
$288.00
19" Plush Pad With Onyx
SEHWH5032
1
$260.00
19" Plush Pad With Pro
SEHWH5045
1
$292.00
4"X6" Occipital Pad & Single SubOccipital Pad
SEHWH7025
1
$288.00
4"X6" Occipital Pad & Single SubOccipital Pad
With Pro Vertical/Horizontal Mount
SEHWH7040
1
$320.00
4"X6"Occipital Pad & Single SubOccipital Pad
With Lynx Vertical/Horizontal Mount
SEHWH7010
1
$316.00
4"X6"Occipital Pad With Size 1/2 SubOccipital Pads
SEHWH7050
1
$380.00
SEHWH7065
1
$297.00
SEHWH7080
1
$416.00
8" Or 10" Plush Pad With Lightweight
SEHWH5020
1
$188.00
8" Or 10" Plush Pad With Linx
SEHWH5005
1
$188.00
8" Or 10" Plush Pad With Onyx
SEHWH5025
1
$188.00
8" Or 10" Plush Pad With Pro
SEHWH5035
1
$202.00
8"/10" Plush Occipital Pad With Size 1
Sub-Occipital Pads
SEHWH7085
1
$467.00
8"/10" Plush Occipital Pad With Size
1sub-Occipital Pads
SEHWH7055
1
$430.00
8"/10" Plush Occipital Pad With Size
1sub-Occipital Pads
SEHWH7070
1
$453.00
Adjust-A-Plush Headrest System
SEHWH7260
1
$235.00
Bilateral Lfc With Pads And Interface
Plate
SEHWH7235
1
$398.00
Page: 29 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Manufacturer
Whitmyer
Biomechanix
Device
Device Code
Max
Allowed
Qty.
Approved
Price
For Plush & Contoured Cradle Systems
Heads Up Pad All Sizes Add On Occipital Pads Optional
SE0001099
1
$207.00
Large Pad With Lightweight
SEHWH5075
1
$142.00
Large Pad With Linx Vertical/Horizontal
Mount
SEHWH5060
1
$142.00
Large Pad With Onyx
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
SEHWH5055
1
$133.00
Medium Pad With Pro
SEHWH5105
1
$151.00
Occipital Pad With Size 3/4 SubOccipital Pads
1"X4",4"X6",1"X4" With Lynx
SEHWH7105
1
$380.00
1"X4",4"X6",1"X4" With Onyx
SEHWH7115
1
$393.00
1"X4",4"X6",1"X4" With Pro
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
SEHWH5065
1
$123.00
Small Pad With Linx Vertical/Horizontal
Mount
SEHWH5050
1
$123.00
Small Pad With Onyx
SEHWH5080
1
$165.00
Small Pad With Pro Vertical/Horizontal
Mount
SEHWH5095
1
$142.00
T-Bar Occipital Pads & Single Sub-
SEHWH7015
1
$562.00
Page: 30 of 80
Product Manual
Mobility Devices
Seating
Device Type
Headrest/Neckrest
Seat Cushion
Manufacturer
Whitmyer
Biomechanix
Action Products
Device
Device Code
Max
Allowed
Qty.
Approved
Price
T-Bar Occipital Pads & Single SubOccipital Pad
2.25"X7" & 2.25"X5" With Onyx
SEHWH7030
1
$535.00
T-Bar Occipital Pads & Single SubOccipital Pad
2.25"X7" & 2.25"X5" With Pro
SEHWH7045
1
$572.00
T-Bar Occipital Pads With Size 1 SubOccipital Pads
2.25"X7" With Pro Vertical/Horizontal
Mount
SEHWH7090
1
$636.00
T-Bar Occipital Pads With Size 1subOccipital Pads
2.25"X7" With Linx Vertical/Horizontal
Mount
SEHWH7060
1
$599.00
T-Bar Occipital Pads With Size 1subOccipital 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
Sub-Occipital Pads
2.25"X5" With Onyx Vertical/Horizontal
Mount
SEHWH7120
1
$612.00
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
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
Occipital Pad
2.25"X7" & 2.25"X5" With Linx
Page: 31 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Action Products
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
Sizes
SESAN4425
1
$396.00
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
SESAN9905
10x10,16x14,17x17,16x20,18x20,20x20
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
Page: 32 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Action Products
Adaptive
Engineering Lab
Adaptive
Equipment
Systems (Aes)
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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 TNuts.
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 TNuts, 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
Page: 33 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Adaptive
Equipment
Systems (Aes)
Solid Seat Package W/Universal Or E-Z SES2L0005
Mount Hardware.
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
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
Amovida Motion AV400
SE0000959
1
$189.00
Amovida Motion Comfort + AV500
SE0000960
1
$229.00
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
Amoena Medizin
Amysystems
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
Debbonair Dynamics/Cushionair
Cushion
SESGC0015
1
$583.00
Page: 34 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Products
Custom
Fabricated
Dynamic Health
Care Solutions
Future Mobility
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Cushion
- Standard Sizes
SESGC0005
1
$471.00
Cushion
- Up To 20" Width Or Depth
SESGC0010
1
$503.00
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
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
SESFM0070
1
$397.00
- Greater Than 20" Width Or Depth
Page: 35 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Future Mobility
Handicare
Hoggi
Invacare
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
22"w (fits 16" to 20" deep)
SE0000668
1
$380.00
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
Sedeo Pro-stability cushion 16" w and
18"w (fits 16"to 20" deep)
SE0000670
1
$414.00
Support Seat Cushion
SESM90020
1
$259.00
Non Standard Seat Width
SE0000464
1
$200.00
Standard Seat Width
SE0000463
1
$132.00
Swingbo Plus Seat Cushion
SE0000465
1
$174.00
Xps Adaptive Seat Cushion
SESK20050
1
$269.00
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
Through 18x20
Page: 36 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Invacare
Invacare - Matrx
Seating
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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 & SESNS0055
Modifications
1
$387.00
Ulti-mate Fits 16" To 20" Wide W/C
SESNS1030
1
$456.00
Flo-Tech Cushion Fits W/C 16" - 19"
Width & 16" - 21" Depth
SES1M0030
1
$551.00
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
Page: 37 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Invacare - Matrx
Seating
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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 SES1M1010
& 16"-19" Depth
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
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
J2 Plus Cushion, Ls Inc. Cover With
Custom Foam Kit
SESJA0770
1
$597.00
Fluid Pad
SESJA0775
1
$745.00
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
Page: 38 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
SESJA0445
1
$636.00
SESJA0465
1
$628.00
SESJA0455
1
$681.00
SESJA0475
1
$676.00
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
Cover
SESJA0405
1
$618.00
Cover
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
Jay 2 Deep Contourn with Solid Drop
SESJA0605
Seat 20x16, 20x18, 16x20, 18x20, Solid
Drop Seat Attached
1
$574.00
Seat 20x20, 22x16, 22x18, Solid Drop
Seat Attached
SESJA0610
1
$629.00
Seat Standard Sizes With Solid Drop
Seat
SESJA0600
1
$516.00
Jay 2 Standard Sizes With Air
Exchange Cover
SESJA0440
1
$481.00
Page: 39 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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, SESJA3326
12x12
1
$153.00
Jay Combi With Lumbar Support 18x20, SESJA3317
16x20
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
Regular
Adult Short 18x16
SESJA3310
1
$183.00
Regular Adult
SESJA3315
1
$183.00
Jay Combi Without Lumbar Support
14x14, 12x12
SESJA3346
1
$154.00
16x20, 18x20
SESJA3337
1
$154.00
20x18
SESJA3336
1
$154.00
Page: 40 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Jay Combi Without Lumbar Support,
Narrow
Adult Short 15.5x16
SESJA3340
1
$154.00
Narrow Adult 15.5x18
SESJA3345
1
$154.00
Regular
Adult Short 18x16
SESJA3330
1
$154.00
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
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, SESJA8040
16x18, 18x16, 18x18
1
$165.00
Jay Duo Cushion Foam Cushion 17x16, SESJA8057
17x18
1
$165.00
Jay Duo Cushion Foam Cushion 20x16
SESJA8055
1
$194.00
Jay Duo Cushion Foam Cushion 20x18
SESJA8050
1
$194.00
Jay Duo Cushion Large Adult 20x18
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
Hardware
SESJA8027
1
$354.00
Page: 41 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Jay Duo Cushion Narrow Pan 20x16
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
Seat For 14" Or 16" Frame Width,
Various Seat Depths
SESJA9705
1
$343.00
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" SE0000954
or more OR Jay Fusion Air Single Valve
depth of 22" or more
1
$677.00
Jay Fusion Cushion AIR Dual Valve
regular size
SE0000956
1
$614.00
Jay Fusion Cushion AIr Dual Valve
width of 22" or more OR Jay Fusion
Cushion AIr Dual Valve depth of 22" or
more
SE0000957
1
$688.00
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
SE0000952
1
$750.00
Jay Fusion Cushion Fluid width of 22"
or more OR Jay Fusion Cushion Fluid
SE0000951
1
$677.00
Page: 42 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Jay Medical
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
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 SESJA1200
Quadrant Pads
1
$737.00
Jay Recliner Cushion 24x20 With
Incontinent Cover
SESJA1425
1
$723.00
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
Page: 43 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Jay Medical
Kid Kart
Lpa Medical Inc.
Maple Leaf
Wheelchair
Motion Concepts
Nighthawk
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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 SE0000354
size 14X14 TO 18X18
1
$475.00
Jay Union Cushion with additional cover SE0000355
size 18X19 TO 24X24
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
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
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
Trx Onyx Seat 16-19" Width
SESZG0005
1
$555.00
Trx Onyx Seat 20-22" Width
SESZG0010
1
$599.00
2" Standard Foam With Cover
SESNM2000
1
$82.00
3" Standard Foam With Cover
SESNM2010
1
$47.00
Page: 44 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Nighthawk
Orthofab
Otto Bock
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
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
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
Cloud Custom Sizes
SESOB6045
1
$553.00
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
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
Page: 45 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Physipro
Power Plus
Mobility
Precision Rehab
Manufacturing
Pride Mobility
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
Cozy Cushion Plus All Sizes
SESWM0050
1
$414.00
Max Comfort Bariatric Cushion All Sizes SESWM0040
1
$676.00
Max Comfort Cushion All Sizes
SESWM0030
1
$538.00
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 SESWB0020
Or Aggressive
Positioning. Includes Shape
Adjustments, Inner Cover, Outer
Cover And Cushion Rigidizer.
1
$931.00
Contoured Seat Cushion - All Sizes
1
$269.00
SESK20005
Page: 46 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Products
Quickie
Ride Designs
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Synergy Simplicity All Sizes
SESX10080
1
$103.00
Synergy Solution 1 LTC Cushion
SE0000470
1
$362.00
Synergy Solution Cushion
Standard Sizes
SESX10015
1
$275.00
Synergy Solution Cushion Custom
Sizes
SESX10020
1
$310.00
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 Air Contoured
Cushion Sizes 22" X 20" - 24" X 24"
SESX10135
1
$497.00
Synergy Spectrum Air Cushion
Sizes 14" X 12" - 20" X 24"
SESX10120
1
$400.00
Synergy Spectrum Air Cushion Sizes
22" X 20" - 24" X 24"
SESX10125
1
$428.00
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 SESX10030
Insert,Custom Sizes
1
$413.00
Synergy Sprectrum Air Contoured
Cushion
Sizes 14" X 12" - 20" X 24"
SESX10130
1
$469.00
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
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 Custom Cushion: Standard
(12-20"), Extra Wide (21-22"), Custom
Sizes.
SESR40005
1
$1,474.00
Page: 47 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Ride Designs
Roho
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Ride Forward Cushion - All Sizes
SESR41020
1
$407.00
Ride Java
SE0001223
1
$524.00
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
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
Dual Valve, With Cover, Sizes 22x18,
24x20
SESRO9504
1
$693.00
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
SESRO4005
1
$513.00
Page: 48 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Roho
Solus Medical
Manufacturing
Inc
Star Cushion
Products Inc.
Supracor
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
EquaGel Pro Flex I
SE0001113
1
$199.00
EquaGel Pro Flex II
SE0001114
1
$468.00
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
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
Cover
SESTJ0015
1
$428.00
Short Contour Cushion 2" Cells With
Cover
SESTJ0010
1
$428.00
Standard Contour Cushion 4" Cells
With Cover
SESTJ0005
1
$428.00
Bariatric Cushion (Classic) Clb 20-24"
SESRR0016
1
$652.00
SESRR0017
1
$750.00
SESRR0018
1
$897.00
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
(Does Not Include Cover)
Page: 49 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
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
Toronto
Orthopedic Ltd.
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
SESCZ0040
1
$201.00
Supracor
The Comfort
Company
Device
Page: 50 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Trulife
Varilite Medical
Products
Vicair
Vision
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Relax Easy Cushion All Sizes
SESCZ0070
1
$201.00
Relax Gelcell, All Sizes
SESCZ0045
1
$275.00
Relax Trio Cushion, All Sizes
Sizes
SESCZ0035
1
$91.00
Evolution Bariatric Cushion Standard Or SESVP0408
Psv, All Sizes,
Includes Cover And Pressure Setting
Valve
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
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
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
SE0000673
1
$418.00
Page: 51 of 80
Product Manual
Mobility Devices
Seating
Device Type
Seat Cushion
Manufacturer
Wheelchair
Seating Systems
Inc.
Device
Device Code
Max
Allowed
Qty.
Approved
Price
19x19)
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
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
VIVE -Deep Leg Trough -Drop Seat;
Standard Sizes 16x16 1/2 to 20x18
SESVC4180
1
$858.00
VIVE -Deep Leg Trough Cushion;
SESVC4170
1
$658.00
VIVE -Drop Seat; Standard Sizes 16x16 SESVC4160
1/2 to 20x18
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;
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
OPTIONS:
Page: 52 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Arm Support Hardware
Arm Support Options
Arm Support(s)
Manufacturer
Back Hardware
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
Extra Wide &/Or Extended Length For
SEAND0010
Modular Arm Supports Includes Mounting Hardware (Maximum
2)
2
$91.00
Modular Arm Support - Includes
Mounting Hardware (Maximum 2)
SEAND0005
2
$237.00
Modular Hand Support - Flat/Cone SEAND0015
Includes Mounting Hardware (Maximum
2)
2
$65.00
Complex Arm Support, Multi
Component,
Includes Hardware (Maximum 2)
SEACF102L
2
$216.00
Fixed Arm Support, One Piece,
SEACF101L
2
$129.00
Full Sling Arm Support,
SEACF104L
2
$259.00
Heavy Duty Solid Padded Armrest
Support,
Replaces Padded W/C Armpad,
SEACF103L
2
$65.00
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
Complex Specialized Mounting
Hardware - Including
Hardware For Custom Molded Modular
SEBND0010
2
$345.00
Approved ADP
Manufacturers
Only
Custom
Fabricated
Back Cover
Device
Custom
Fabricated
Approved ADP
Manufacturers
Only
Page: 53 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Manufacturer
Back Hardware
Back Support Options
Foot/Leg Support Options
Foot/Leg Support(s)
Device Code
Max
Allowed
Qty.
Approved
Price
Systems
Custom
Fabricated
Simple Back Interface Mounts Back To
Wheelchair Frame
SEICF160L
1
$168.00
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
Back Channeling - Upgrade For Slots
For Lateral Adjustments
SEMCF201L
1
$129.00
Back Plaster Molding/Vacuum Form, for SEUCF003L
Custom Fabricated Device Only
1
$138.00
Back Reinforcement - Heavy Duty
Upgrade
SEMCF202L
1
$86.00
Fabricated Back,
Includes Parts, Hardware & Labour
SEMCF200L
1
$194.00
Approved ADP
Manufacturers
Only
Hardware
SEFND0030
2
$86.00
Custom
Fabricated
Mount Footrest To Seating System
SEICF501L
2
$104.00
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
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
Custom
Fabricated
Foot/Leg Support Hardware
Device
Approved ADP
Manufacturers
Only
Page: 54 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Foot/Leg Support(s)
Headrest/Neckrest Hardware
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
Bracket To Mount Headrest To Seating
System/Back
Support Or Wheelchair
SEHND0020
1
$86.00
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
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
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
Approved ADP
Manufacturers
Only
Custom
Fabricated
Headrest/Neckrest Options
Custom
Fabricated
Page: 55 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Headrest/Neckrest Options
Lateral Support Hardware
Manufacturer
Device Code
Max
Allowed
Qty.
Approved
Price
Simple Extension Pad, Mounted
(Maximum 2)
SEMCF005L
2
$173.00
Quickie
RELAX HEADREST PAD
SE0000119
1
$235.00
Custom
Fabricated
Fixed Lateral Hardware, NonAdjustable (Maximum 2)
SEICF201L
2
$52.00
Hinged Swingaway Lateral Hardware,
Height& Width Adjustable (Maximum 2)
SEICF202L
2
$173.00
Removable Lateral Hardware,
SEICF203L
Height & Width Adjustable (Maximum 2)
2
$86.00
Custom
Fabricated
Device
Any Fabric, Use
For Flat/Contoured Headrest &
Neckrest
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
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
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
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
Custom
Fabricated
Pommel Hardware
Pommel/Adductors
Custom
Fabricated
Page: 56 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Pommel/Adductors
Positioning Belts
Manufacturer
Custom
Fabricated
Approved ADP
Manufacturers
Only
Custom
Fabricated
Positioning Belts Options
SE - Custom Modifications
Custom
Fabricated
Approved ADP
Manufacturers
Only
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Fixed Padded Adductor Includes Cover
(Maximum 2)
SEMCF702L
2
$104.00
Removable Padded Adductor Includes
Cover
(Maximum 2)
SEMCF703L
2
$164.00
Any 2 Point Strap For Positioning Only - SERND0030
Any Closure Includes Padding & Mounting
Hardware -Chest, Hip,
Thigh, Calf, Ankle, Foot (Maximum 6)
6
$56.00
Any 4 Point Strap For Positioning Only - SERND0020
Any Closure Includes Padding & Mounting Hardware
Pelvic "Y" Strap, "H" Leg Strap
(Maximum 2)
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 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
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
Custom Modifications Required To Adp
Listed Wheelchair To
Facilitate Installation Of Custom
Fabricated Positioning
SEMCF990L
1
Page: 57 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
SE - Custom Modifications
Seat Cushion Cover(s)
Manufacturer
Device Code
Max
Allowed
Qty.
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
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
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
Approved ADP
Manufacturers
Only
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
Approved ADP
Manufacturers
Only
Custom
Fabricated
Seat Hardware
Device
Approved
Price
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).
Page: 58 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Seat Hardware
Seat Options
Manufacturer
Custom
Fabricated
Approved ADP
Manufacturers
Only
Custom
Fabricated
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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
2" Convolute Foam Cut To Size
(Maximum 2)
SEMCF403L
2
$35.00
2" Polyfoam Cut To Size
(Maximum 2)
SEMCF406L
2
$26.00
(Maximum 2)
SEMCF404L
2
$39.00
3" Polyfoam Cut To Size
(Maximum 2)
SEMCF407L
2
$30.00
(Maximum 2)
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: 59 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Seat Options
Tray
Manufacturer
Custom
Fabricated
Approved ADP
Manufacturers
Only
Custom
Fabricated
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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 - SETND0020
Non Standard
Mounting Hardware
2
$272.00
Half Tray For Positioning Support Only - SETND0015
Standard
Mounting Hardware
2
$203.00
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: 60 of 80
Product Manual
Mobility Devices
Seating
OPTIONS:
Device Type
Tray Options
Manufacturer
Approved ADP
Manufacturers
Only
Custom
Fabricated
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
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: 61 of 80
Product Manual
Mobility Devices
Wheelchairs (Manual)
Device Type
Adult High Performance Rigid Manual
Wheelchair
Wheelchair 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.
Manufacturer
Invacare
Ki Mobility
Max
Allowed
Qty.
Approved
Price
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
Rogue
WM0001043
1
$3,098.00
Tsunami
WMA4KI015
1
$3,098.00
LEVO compact-easy LCEV with
battery powered stand-up feature
WM0000471
1
$3,098.00
Motion Composites
Veloce
WM0001029
1
$3,098.00
Otto Bock
Ventus
WM0001104
1
$3,098.00
Voyager Evo
WM0001190
1
$3,098.00
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
WMA4QU040
1
$3,098.00
Quickie QRi
WM0000991
1
$3,098.00
Hi-Lite
WMA4RZ005
1
$3,098.00
Maxima
WM0000696
1
$3,098.00
Tilite Aero Z
WMA4TZ010
1
$3,098.00
Rgk Wheelchairs
TiLite
Wheelchair type offers maximum adjustments
and options. Suitable for the very active user
who requires altered wheel placement for
optimal postural support and mobility. ADP
Device Code
LEVO AG
Pantera AB
Adult Lightweight Performance
Manual Wheelchair
Device
Tilite Yr/Tr,Yra/Tra,Trc,Zra
WMA4TZ005
1
$3,098.00
iCON
Icon A1
WM0000945
1
$3,098.00
Future Mobility
Galaxy Lite
WMA3FM010
1
$2,290.00
Northern Lite
WMA3FM005
1
$2,290.00
Handicare
Legend 2 Exigo/Exigo
WMA3M9015
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
Prospin X4
WMA3IN035
1
$2,290.00
Xtra
WMA3IN005
1
$2,290.00
Catalyst 5, 5ti
WMA3KI010
1
$2,290.00
Catalyst 5vx
WMA3KI015
1
$2,290.00
Maple Leaf
Wheelchair
EZ Ride
WMA3WM005
1
$2,290.00
Motion Composites
Helio A7
WM0001020
1
$2,290.00
Helio C2
WM0000964
1
$2,290.00
Ki Mobility
Page: 62 of 80
Product Manual
Mobility Devices
Device Type
Adult Lightweight Performance
Manual Wheelchair
and options. Suitable for the very active user
who requires altered wheel placement for
optimal postural support and mobility. ADP
Adult Lightweight Standard Manual
Wheelchair
Wheelchair 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 antitippers, 2 point seat belt any closure, brake
extensions, front casters, wheels. See Manual
Wheelchair Options Chart for other basic
components funded by ADP.
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Orthofab
Prima
WMA3OF010
1
$2,290.00
Otto Bock
Motus
WMA3OB010
1
$2,290.00
Start M5 Comfort/ M5XXL
WMA3OB005
1
$2,290.00
Permobil
TiLite AERO X
WM0001169
1
$2,290.00
Physipro
XL-5/XL-5 ci
WM0001132
1
$2,290.00
Power Plus Mobility
Glyder
WM0001061
1
$2,290.00
Pride Mobility
Products
Litestream Xf
WMA3X1010
1
$2,290.00
Product Design
Group
Eclipse 600
WMA3MV005
1
$2,290.00
Quickie
Quickie 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
TiLite
Tilite X, Sx, Tx
WMA3TZ005
1
$2,290.00
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
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
Catalyst 4, 4c
WMA2KI010
1
$1,449.00
Invacare
Ki Mobility
Maple Leaf
Wheelchair
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
Orthofab
Ch+
WMA2OF005
1
$1,449.00
Otto Bock
Start M2 Effect
WMA2OB005
1
$1,449.00
Page: 63 of 80
Product Manual
Mobility Devices
Device Type
Manufacturer
Device Code
Max
Allowed
Qty.
Approved
Price
Magic Plus
WM0001062
1
$1,449.00
Voyager Plus
WM0001063
1
$1,449.00
Pride Mobility
Products
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
Adult Manual Dynamic Tilt Wheelchair Advanced Mobility
Ams Itilt2
WMA5AO020
1
$2,110.00
Wheelchair 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),
footrests, height adjustable armrests, rear antitippers, brake extensions, 2 point seat belt any
closure, front casters, wheels. See Manual
Tilt Recline/ I Tilt
WMA5AO015
1
$2,110.00
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
Capella, 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
Emineo
WMA5M9010
1
$2,110.00
Ibis
WMA5M9005
1
$2,110.00
Concept 45
WMA5IN020
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
Adult Lightweight Standard Manual
Wheelchair
independently mobile and requires some
adjustments to accommodate postural and
mobility requirements. ADP price includes
frame (sizes up to 18"wide x 18"deep),
Power Plus Mobility
Device
Broda
Future Mobility
Handicare
Invacare
Maple Leaf
Wheelchair
Orthofab
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
Tango
WMA5OF005
1
$2,110.00
Page: 64 of 80
Product Manual
Mobility Devices
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Adult Manual Dynamic Tilt Wheelchair Power Plus Mobility
Extreme
WM0001041
1
$2,110.00
NV Tilt
WM0001076
1
$2,110.00
Supertilt Plus
WM0001040
1
$2,110.00
Pride Mobility
Products
Litestream Traverse
WM0001030
1
$2,110.00
Product Design
Group
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
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
Quickie
Adult Standard Manual Wheelchair
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),
Paediatric High Performance Rigid
Manual Wheelchair
Tilt Fx
WMA5QU020
1
$2,110.00
Seating Matters
Limited
Pheonix
WM0000974
1
$2,110.00
Sorrento
WM0000975
1
$2,110.00
Amg Medical
Airgo
WMA1GM005
1
$1,228.00
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
Hoggi
Supra
WM0000462
1
$3,354.00
Invacare
Crossfire T6a
WMK4IN130
1
$3,354.00
Ki Mobility
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
Otto Bock
Ventus
WM0001105
1
$3,354.00
Voyager Evo
WM0001191
1
$3,354.00
Pantera AB
Bambino
WM0000976
1
$3,354.00
Permobil
TiLite Twist
WM0001187
1
$3,354.00
Quickie
Quickie Gp
WMK4QU010
1
$3,354.00
Quickie Gt
WMK4QU030
1
$3,354.00
Quickie Q7
WMK4QU035
1
$3,354.00
Page: 65 of 80
Product Manual
Mobility Devices
Device Type
Paediatric High Performance Rigid
Manual Wheelchair
Manufacturer
Quickie
Rgk Wheelchairs
TiLite
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
Hi-Lite
WMK4RZ005
1
$3,354.00
Maxima
WM0000697
1
$3,354.00
Tilite Aero Z
WMK4TZ010
1
$3,354.00
Tilite Yr/Tr,Yra/Tra,Trc,Zra
WMK4TZ005
1
$3,354.00
iCON
Icon A1
WM0000946
1
$3,354.00
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 Spark
WM0000695
1
$2,310.00
Motion Composites
Helio Kids
WM0000563
1
$2,310.00
Otto Bock
Motus
WMK3OB005
1
$2,310.00
Permobil
TILite AERO X
WM0001170
1
$2,310.00
Quickie
Quickie 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
TiLite
Tilite X, Sx, Tx
WMK3TZ005
1
$2,310.00
Paediatric Lightweight Standard
Manual Wheelchair
Handicare
Legend 2 Exigo/Exigo
WMK2M9020
1
$1,596.00
Wheelchair type most suitable for user who
requires some adjustments to accommodate
postural and mobility requirements. ADP price
Invacare
9000 Jymni
WMK2IN010
1
$1,596.00
Otto Bock
Start M2 Junior
WM0001079
1
$1,596.00
Pride Mobility
Products
Litestream Xf
WMK2X1010
1
$1,596.00
Quickie
Quickie Lx
WMK2QU020
1
$1,596.00
Convaid
Safari Tilt
WMK5CO040
1
$2,804.00
Future Mobility
Super Chair For Kids
WMK5FM010
1
$2,804.00
Paediatric Lightweight Performance
Manual Wheelchair
and options. Suitable for the active user who
requires altered wheel placement for optimal
postural support and mobility. ADP price
Paediatric Manual Dynamic Tilt
Wheelchair
Page: 66 of 80
Product Manual
Mobility Devices
Device Type
Manufacturer
Hoggi
Invacare
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Bingo/Bingo Evolution
WMK5K2010
1
$2,804.00
Swingbo Plus
WM0000461
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
Kid Kart
Kid Kart Xpress
WMK5KT020
1
$2,804.00
Kid-Tlc
WMK5KT010
1
$2,804.00
Discovery Tmax
WM0001192
1
$2,804.00
Kimba Spring & Kimba Spring Plus
WMK5OB010
1
$2,804.00
Pride Mobility
Products
F.A.S.T
WMK5K2015
1
$2,804.00
Kids Rock
WMK5K2005
1
$2,804.00
Product Design
Group
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
WMK5QU010
1
$2,804.00
Zippie Ts
WMK5QU005
1
$2,804.00
Easy S
WM0000326
1
$2,804.00
Thevo Twist
WM0000325
1
$2,804.00
Otto Bock
THOMASHILFEN
Paediatric Specific Specialty Stroller
Alvema
Series 100/Pix1
WMK6AL005
1
$1,303.00
ADP 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.
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
Maclaren
Buggy
WMK6AM005
1
$1,303.00
Otto Bock
Eco-Buggy
WMK6OB005
1
$1,303.00
Kimba Neo
WM0001100
1
$1,303.00
Quickie
Zippie Voyage
WM0001083
1
$1,303.00
THOMASHILFEN
Swifty Stroller - Paediatric specific
specialty stroller type 6
WM0000318
1
$1,303.00
Thevo Swifty Stroller
WM0000316
1
$1,303.00
Page: 67 of 80
Product Manual
Mobility Devices
OPTIONS:
Device Type
Manufacturer
Device
Device Code
Max
Allowed
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 Lbs
WAMF
1
$575.00
WAMG
1
$781.00
WAMH
1
MW - Oxygen Tank Holder
WAMX
1
$154.00
MW - Seat Depth Required is Greater
Than 18"
WAMB
1
$209.00
Heavy duty model required, client weight
exceeds 250lbs. Authorizer must document
requirements.
requirements.
$874.00
requirements.
Page: 68 of 80
Product Manual
Mobility Devices
OPTIONS:
Device Type
Manufacturer
Device
Device Code
Max
Allowed
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
Dolomite
Alber E.Motion
WPS1DO005
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 *
WANA
1
$945.00
Stroller Handles/Paediatric
WAMW
1
$116.00
Titanium Frame *
WAMZ
1
$1,181.00
WAMN
1
$117.00
Power Add-On Device
Device 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.
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.
Titanium frame manual wheelchair. Authorizer
requirements.
Uni-Lateral Wheel Lock
Page: 69 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
Device Type
Adult Power Base Type 1
Wheelchair 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
armrests, 2 point seat belt any closure, front
casters, wheels. See Power Wheelchair
Options Chart for other basic components
funded by ADP.
Wheelchair 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
casters, and wheels. See Power Wheelchair
funded by ADP.
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
Manufacturer
Invacare
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Nutron Series R51lxp
WPA1IN065
1
$4,392.00
Pronto M51
WPA1IN075
1
$4,392.00
Power Plus
Mobility
Mp1
WPA1WN005
1
$4,392.00
Pride Mobility
Products
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
Invacare
3g Ranger X Storm Series
WPA2IN040
1
$5,812.00
Power Plus
Mobility
Mp2
WPA2WN005
1
$5,812.00
Pride Mobility
Products
Jazzy 600
WPA2X1220
1
$5,812.00
Future Mobility
Orion Explorer Magellan
WPA3FM005
1
$6,125.00
Orion Explorer Viking
WPA3FM010
1
$6,125.00
Alex Power Wheelchair
WPA3M9005
1
$6,125.00
PUMA 40
WP0000647
1
$6,125.00
SAMM
WP0001233
1
$6,125.00
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
Tdx Sp/Sr
WPA3IN070
1
$6,125.00
Tdx-Sc
WPA3IN075
1
$6,125.00
LEVO AG
LEVO C3
WP0001140
1
$6,125.00
Orthofab
Oasis
WPA3OF110
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
Handicare
Invacare
Page: 70 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
Device Type
closure and standard joystick control. See
Manufacturer
Permobil
Device Code
Max
Allowed
Qty.
Approved
Price
M300
WP0000455
1
$6,125.00
M300 Corpus HD R-Net
WP0001165
1
$6,125.00
Street
WPA31P005
1
$6,125.00
Power Plus
Mobility
Mp5
WPA3WM005
1
$6,125.00
Pride Mobility
Products
Jazzy/Quantum 1113
WPA3X1100
1
$6,125.00
Jazzy/Quantum 1121
WPA3X1110
1
$6,125.00
Jazzy/Quantum 1170
WPA3X1010
1
$6,125.00
Jazzy/Quantum 1402 & 1420
WPA3X1020
1
$6,125.00
Jazzy/Quantum 1650
WPA3X1230
1
$6,125.00
Q6 Edge HD
WP0001058
1
$6,125.00
Quantum 1450
WP0001021
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 614
WPA3X1255
1
$6,125.00
Quantum Q6 Edge Adult
WP0000108
1
$6,125.00
Quantum R4000
WPA3X1250
1
$6,125.00
Quantum Rival
WP0000968
1
$6,125.00
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
WPA3QU300
1
$6,125.00
Quickie Xperience
WPA3QU280
1
$6,125.00
Quickie Xplore
WPA3QU270
1
$6,125.00
Ranger
Wheelchairs
Express
WP0001023
1
$6,125.00
Invacare
Nutron Series R51lxp
WPK1IN015
1
$4,678.00
Quickie
Paediatric Power Base Type 1
Device
Wheelchair 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),
Page: 71 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
funded by ADP.
Invacare
Tiger
WPK2IN015
1
$5,507.00
Handicare
Alex Power Wheelchair
WPK3M9005
1
$5,902.00
SAMM
WP0001234
1
$5,902.00
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
Permobil
C300 Corpus Junior / K300
WPK31P010
1
$5,902.00
C400 Corpus Junior
WPK31P015
1
$5,902.00
M300
WP0000987
1
$5,902.00
Q6 Edge HD
WP0001059
1
$5,902.00
Quantum 600
WPK3X1220
1
$5,902.00
Quantum 6000
WPK3X1240
1
$5,902.00
Quantum 6000z
WPK3X1245
1
$5,902.00
Quantum 610
WPK3X1225
1
$5,902.00
Quantum Q6 Edge Paediatric Power
Base Type 3 Wheelchair
WP0000109
1
$5,902.00
Quantum Rival
WP0000969
1
$5,902.00
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
WPK3QU080
1
$5,902.00
Quickie Xplore
WPK3QU070
1
$5,902.00
Tdx Spree
WPK4IN075
1
$5,611.00
Tiger
WPK4IN005
1
$5,611.00
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
funded by ADP.
closure, and standard joystick control. See
Invacare
Pride Mobility
Products
Quickie
Paediatric Power Base with Manual
Dynamic Tilt
required by the user who can not maintain a
functional posture through the use of seating
Invacare
Page: 72 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
funded by ADP.
Invacare
Power Scooter
AMIGO
AMIGO RD310000 - 3 WHEEL
MOBILITY
SCOOTER
INTERNATIONAL
WP0000333
1
$2,395.00
Activelite Mobility
WS16A0005
1
$2,395.00
Advanced Vehicle Quingo Classic
Concepts
WS15V0005
1
$2,395.00
Fortress
1700fs -3 Wh.
WS1FS0015
1
$2,395.00
1700fs -4 Wh.
WS1FS0020
1
$2,395.00
Winner -3 Wh.
WS1FS0070
1
$2,395.00
Winner -4 Wh.
WS1FS0075
1
$2,395.00
COMET 4 WHEEL SCOOTER
WP0000121
1
$2,395.00
Comet HD 4 Wheel 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 3 WHEEL SCOOTER
WP0000122
1
$2,395.00
PEGASUS 4 WHEEL SCOOTER
WP0000123
1
$2,395.00
KYMCO
(Canadian
Mobility Corp.)
Midi XL
WP0001232
1
$2,395.00
Power Plus
Mobility
Mp3 -3 Wh.
WS1WN0005
1
$2,395.00
Mp4 -4 Wh.
WS1WN0010
1
$2,395.00
Pride Mobility
Products
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
Gogo Elite Traveller Plus - 3 Wh.
WS1X10100
1
$2,395.00
Gogo Elite Traveller Plus - 4 Wh.
WS1X10105
1
$2,395.00
Maxima -3 Wh.
WS1X10060
1
$2,395.00
Maxima -4 Wh.
WS1X10065
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 Twin DX
WP0000699
1
$2,395.00
Device 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.
Invacare
Easy Travel -3 Wh.
Page: 73 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
Device Type
Power Scooter
Device 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.
Manufacturer
Shoprider/
Pihsiang
Yelle &
Associates Ltd.
ZHE JIANY
BISWIFT
ENTERPRISE
Device
Device Code
Max
Allowed
Qty.
Approved
Price
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
Safari/Ltd-3 Wh.
WS1YE0020
1
$2,395.00
Solo Ltd-4 Wh.
WS1YE0007
1
$2,395.00
Solo/Ltd-3 Wh.
WS1YE0005
1
$2,395.00
Solo/Xt550-4 Wh.
WS1YE0010
1
$2,395.00
Boomer Buggy (3 or 4 Wheel)
WP0000561
1
$2,395.00
Page: 74 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
OPTIONS:
Device Type
Manufacturer
Device
Max
Allowed
Qty.
Approved
Price
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
Auto Correction System*
Device Code
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
requirements.
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
Handicare
multi-function control box - for use on
systems with multiple functions
including tilt and power legs, tilt and
power legs, etc
WP0000654
1
$403.00
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 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
Pride Mobility
Products
Multi-Function Control Box Advanced Acutator Module (Aam)
SECX15005
1
$514.00
Quickie
Multi-Function Control Box For Use
On Systems With Multiple
SECQU4005
1
$2,403.00
Page: 75 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
OPTIONS:
Device Type
Manufacturer
Multi-function Control Box
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Functions, Including Tilt And Power
Legrest, Tilt, Recline,
Power Legrests 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
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
requirements.
requirements.
requirements.
Power Elevating Footrests
Amysystems
Power Elevating & Articulating
Legrests or Center mount foot
platform
SEF4P0005
1
$2,250.00
Handicare
Power elevating and articulating
WP0000653
1
$2,415.00
Page: 76 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
OPTIONS:
Device Type
Manufacturer
Power Elevating Footrests
Max
Allowed
Qty.
Approved
Price
Power Elevating At5544 Legrest
Package For Invacare
And Quickie Bases. Includes
Legrests And Actuators.
SEFZG0010
1
$2,214.00
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
Pride Mobility
Products
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
Tarsys (Invacare)
Power Elevating Legrests
SEFTY0005
1
$2,368.00
Amysystems
Power Recline With Integrated Shear
Reduction (Isr)
SEC4P0045
1
$6,436.00
Handicare
QLASS power recline
WP0000995
1
$6,842.00
Sedeo Pro recline
WP0000652
1
$6,842.00
Formula CG 12" 20" Recline Only
SECIN1010
1
$8,009.00
Formula CG 21" - 24" Recline Only
SECIN1015
1
$8,660.00
Power Recline Only With Power
Sliding Back (Psb) For
Invacare, Quantum, And Quickie
Bases.
SECZG0015
1
$7,502.00
Power Recline System With Esr For
Invacare,
Quickie, And Quantum Bases
SECZG1010
1
$8,223.00
Power Recline System With
Extended Shear Reduction (Esr) For
Bases.
SECZG0010
1
$7,019.00
Permobil
Corpus Power Positioning System
With Power Recline Only
SEC1P0010
1
$6,001.00
Pride Mobility
Products
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
Amysystems
Bariatric CG Power Tilt
SEC4P0060
1
$6,436.00
Cg Power Tilt
SEC4P0040
1
$5,228.00
Invacare
Motion Concepts
Power Tilt Only
Device Code
legrests
Motion Concepts
Power Recline Only
Device
Page: 77 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
OPTIONS:
Device Type
Power Tilt Only
Manufacturer
Handicare
Invacare
Device Code
Max
Allowed
Qty.
Approved
Price
QLASS centre of gravity power tilt
WP0000993
1
$5,232.00
Sedeo Pro centre of gravity power tilt
WP0000650
1
$5,233.00
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
Power Tilt Only For Invacare,
Quantum, And Quickie Base.
SECZG0005
1
$5,233.00
Power Tilt Only For Invacare,
Quantum, And Quickie Bases.
SECZG1005
1
$6,436.00
Corpus Hd Power Positioning System
With 30 Deg.
Power Tilt Only
SEC1P0105
1
$9,173.00
With 45 Deg. Power Tilt Only
SEC1P0005
1
$5,309.00
Ps Power Positioning System With 45 SEC1P0205
Deg. Power Tilt Only
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
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
Bariatric CG Power Tilt and Power
Recline With Integrated Shear
Reduction (Isr)
SEC4P0070
1
$10,460.00
Cg Power Tilt & Power Recline With
Integrated Shear
Reduction (Isr)
SEC4P0050
1
$9,253.00
QLASS centre of gravity power tilt
and recline
WP0000994
1
$9,096.00
Sedeo Pro centre of gravity power tilt
plus recline
WP0000651
1
$9,096.00
Formula CG 16" 20" Tilt And Recline
SECIN1020
1
$8,654.00
Permobil
Pride Mobility
Products
Quickie
Power Tilt and Recline
Device
Amysystems
Handicare
Invacare
Page: 78 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
OPTIONS:
Device Type
Power Tilt and Recline
Seat Package 1 for Power Bases
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
Invacare
Formula CG 21" - 24" Tilt And
Recline
SECIN1025
1
$9,605.00
Motion Concepts
Power Tilt And Power Recline For
Invacare,
Quickie, And Quantum Bases.
SECZG0018
1
$8,352.00
Power Tilt And Power Recline For
Invacare, Quantum, And
Quickie Bases.
SECZG2010
1
$7,647.00
Power Tilt And Power Recline With
Esr For Invacare,
SECZG2015
1
$8,102.00
Esr For Invacare,
Quickie, And Quantum Bases.
SECZG1015
1
$9,293.00
Psb For Invacare,
SECZG2020
1
$8,585.00
Power Tilt And Power Recline
including Psb For
Bases.
SECZG0025
1
$9,289.00
Power Tilt and Power Recline
including Esr For
Bases
SECZG0020
1
$8,806.00
Permobil
With 45 Deg. Power Tilt
And Power Recline
SEC1P0015
1
$8,851.00
Pride Mobility
Products
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
WEPN
1
$663.00
WEPO
1
$682.00
WEX1
1
$1,103.00
Seat package 1 for power bases (includes
frame, sling upholstery, armrests, footrests.)
Seat Package 2 for Power Bases
Seat package 2 for power bases (includes
deluxe seat and back, armrests, footrests.) No
positioning devices (seating) allowed with this
code.
Specialty Controls 1 Non Standard
Joystick*
Page: 79 of 80
Product Manual
Mobility Devices
Wheelchairs (Power)
OPTIONS:
Device Type
Manufacturer
Device
Device Code
Max
Allowed
Qty.
Approved
Price
WEX2
1
$2,363.00
WEX3
1
$5,276.00
WEX4
1
$5,906.00
WEX5
1
$2,363.00
WEX6
1
$3,938.00
WEPM
1
$232.00
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.
Specialty Controls 2 Chin/Rim
Control*
Specialty controls 2 - Complex Non-Standard
Joystick (includes upgraded electronics,
mounting hardware, display, joystick
modifications & labour). For chin/rim control etc.
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
requirements.
Specialty Controls 4 Proximity
Control*
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).
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
requirements.
Swingaway Mounting Bracket
Page: 80 of 80

Mobility Devices Product Manual

Transcription

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