Quantum Q6 Edge 2.0 Order Form with Contoured, Synergy, and TRU-Balance Flex Seating

Page 1 of 18

INFINFB3538/RevO/09DEC2019

Q6 Edge

2.0 Order Form with Contoured, Synergy, and TRU-Balance Flex Seating

Quantum

Rehab

401 York Ave., Duryea, PA 18642

Phone: 866-800-2002 | Fax: 866-707-3422 | Email: quantumorders@pridemobility.com

Account Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

Weight:________ Height:________

____________________________________________________________

A. Shoulder Width: _______

B. Chest Width: _________

C. Hip Width: ___________

D. Max Sitting Height: ____

E. Shoulder Height: ______

F. Axilla Height: _________

G. Thigh Depth: _________

H. Lower Leg Length: ____

I. Elbow Height: ________

This form is interactive when viewed with Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. Com-

plete the form by placing checks in the desired boxes and provide information in the interactive elds. Buttons shown at the bottom of the form may be

utilized to print or submit the order form through a desktop email application. To email via a web-based application, please ‘Save As’ and attach the PDF

to your email.

This order form contains a large variety of options to fulll various patient needs. Descriptions and section notes, such as optional or required, are

included to help you complete your order. Please contact Quantum Sales at 866-800-2002 if assistance is needed. Send the completed order form by fax

(866-707-3422) or email (quantumorders@pridemobility.com). Incomplete forms may delay the quote or order. Customer service will contact you if the

order is incomplete or if there are compatibility issues. If special order requests are needed, be sure that the Patient Information section is completed or

include a completed physical assessment form with this order form.

HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for deter-

mining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices

are MSRP. Prices, specications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available

when congured as a complete power chair. Please contact technical service for accurate parts ordering. Options noted with "XRef" have multiple possible

part numbers based on system conguration. Please see cross-reference spreadsheet for the XRef part numbers.

Thank you for choosing Quantum!

INTRODUCTION

PATIENT INFORMATION

1. BASE MODEL

REQUIRED. Select a group 3 power base. 300 lb. weight capacity with standard 6mph programmable motors and 8 amp o board charger. Dimensions of base

without legrests: 24”Wx35.5”L

Quantum Q6 Edge 2.0 3S-SS .......................................... $7,595

Part: Q6 EDGE 2.0 3S-SS. HCPCS: K0848

Solid seat pan standard with no power option.

Quantum Q6 Edge 2.0 3SP-SS ........................................ $7,595

Part: Q6 EDGE 2.0 3SP-SS. HCPCS: K0856

Single power option for Power Elevating Seat.

Quantum Q6 Edge 2.0 3S-C ........................................... $7,595

Part: Q6 EDGE 2.0 3S-C. HCPCS: K0849

Contoured Seat (Captain) Standard.

Quantum Q6 Edge 2.0 3SP-C ......................................... $7,595

Part: Q6 EDGE 2.0 3SP-C. HCPCS: K0857

Contoured seat (captain), single power option for 12" lift.

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INFINFB3538/RevO/09DEC2019

Base Mounted Foot Platform ...................................... Standard

Part: FRMASMB16077

Bell Shaped, Base Mounted Foot Platform .......................... $235

Part: RIGASMB7120041

Omit base mounted foot platform ............................. No Charge

Part: PTOINDV3674

3”x14” Flat Free Black Tires ...................................... Standard

Part: PTOINDV3525 (pair). Wheel color accent part: WHL1611297 x2

4”x14” Knobby, Flat Free Black Tires ....................... $275.50 ea.

Part: WHL147601 x2

3”x14” Pneumatic Black Tires .................................. No Charge

Part: WHL150034 x2. Wheel color accent part: WHL1611296 x2

4”x14” Knobby, Pneumatic Black Tires ..................... $275.50 ea.

Part: WHL147599 x2

6 mph Drive Motors ................................................. Standard

Part: MOT147433

Accu-Trac Motor Technology ......................................... $1,295

Part: MOT147881. HCPCS: K0108

Requires Q-Logic 3 electronics. Delivers enhanced traction and track-

ing, especially with switched drive controls.

Account Number: ___________ Date: ________________ Marked for: _____________________________________

2. BASE COLOR

REQUIRED. Select one shroud color. Colors shown here may dier from actual product depending on monitor/printer calibration used.

2.2. Standard Shrouds

8. WHEEL OPTIONS

REQUIRED. Select a type of drive wheels and accent color. Knobby tires increase overall base width by 1.5”.

5. DRIVE MOTORS

REQUIRED.

6. BASE MOUNTED FOOT PLATFORM

REQUIRED. May interfere with seat mounted legrests. Not available with center mount foot platforms.

8.1. Drive Wheels

Match All Color Options to Selection Below

Part: N/A. Any subsequent color selections, if available, will be matched to color chosen below when the order is placed. Please note that some

color selections, such as joystick armor, may have a MSRP.

2.1. Match Colors

Base Mounted, LED, Full Light Package ............................................................................................. $995

Part without iLevel: ELE1705999. Part with iLevel: ELE168643

Fender lights will be omited with Base Mounted, LED, Full Light Package.

Seat Mounted, LED, Full Light Package ............................................................................................. $995

Flex part: ELE131477. Synergy part: ELEASMB5719

Not available with contoured seating.

Seat Mounted LED

Lights (One Shown)

4. FULL LIGHT PACKAGES

Optional. Requires Q-Logic 3 Joystick for Full Light Package. Select one available package below.

3. FENDER LIGHTS

Optional. Fender lights operate by pressing included single switch button. Fender lighting is not available with Single Actuator Control through Toggle Box.

Switch Fender Lights .................................................................................................................................................... $250*

Part: DGN154117

*Will be included at no charge with iLevel 12" Lift system.

7. BATTERIES

REQUIRED. The powerchair requires 2 batteries and will be installed if ordered.

NF-22, Gel Cell, Interceptor Battery..............................$310 ea.

Part: BAT1704613. HCPCS: E2361

No batteries. Provider will assume responsibility of batteries.

Part: Conguration selection

NF-22, AGM, MK Battery ............................................ $395 ea.

Part: BAT121346. HCPCS: E2361

NF-22, Gel Cell, MK Battery ....................................... $395 ea.

Part: BATGEL1008. HCPCS: E2361

Drive wheel section continued on following page.

Red Corvette

Part: DGN153201-PRD1

Electric Blue

Part: DGN153201-PBU9

Back in Black

Part: DGN153201-PBK1

Night Train

Part: DGN153201-PBK3

White Satin

Part: DGN153201-PWT2

Pretty in Pink

Part: DGN153201-PPK3

Evolution Orange

Part: DGN1801101-POR7

Deep Purple

Part: DGN153201-PPR5

Grey Street

Part: DGN153201-PSL3

Midnight Blue

Part: DGN153201-PBU10

Lemon Crush

Part: DGN1801101-PYL4

Green Machine

Part: DGN1801101-PGN11

Military Green

Part: DGN153201-PGN8

To Be Determined

Part: N/A

Page 3 of 18

INFINFB3538/RevO/09DEC2019

Match to Base Color

Part: Conguration selection, see specic part below

Non-matching Color

Part: Conguration selection, see specic part below

Back in Black ......................... $24.98 ea.

Part: DGN164245-PBK1 x2

Red Corvette ......................... $24.98 ea.

Part: DGN164245-PRD1 x2

Electric Blue ......................... $24.98 ea.

Part: DGN164245-PBU9 x2

White Satin ........................... $24.98 ea.

Part: DGN164245-PWH2 x2

Pretty in Pink ........................ $24.98 ea.

Part: DGN164245-PPK3 x2

Evolution Orange .................... $24.98 ea.

Part: DGN164245-POR7 x2

Night Train ............................ $24.98 ea.

Part: DGN164245-PBK3 x2

Deep Purple .......................... $24.98 ea.

Part: DGN164245-PPR5 x2

Grey Street ........................... $24.98 ea.

Part: DGN164245-PSL3 x2

Midnight Blue ........................ $24.98 ea.

Part: DGN164245-PBU10 x2

Lemon Crush ......................... $24.98 ea.

Part: DGN164245-PYL4 x2

Green Machine ...................... $24.98 ea.

Part: DGN164245-PGN11 x2

Military Green ....................... $24.98 ea.

Part: DGN164245-PGN8 x2

To Be Determined

Follow-up required.

8.2. Drive Wheel Accent Color

Optional. Sold in Pairs (parts below will be quantity of 2). Not available with knobby tires.

Account Number: ___________ Date: ________________ Marked for: _____________________________________



12" Power Lift for Captain Seat with iLevel ........................$2600

Part: PTOINDV3857. HCPCS: E2300

For use with K0857 base code. Must select Power Lift Captain Seat

in contoured seat section. Includes armrests and lap belt. Available

with swing away legrests or manually adjustable center mount foot

platform.

Power Elevating Seat with 7” Stroke ............................... $1,895

Contoured seat part: FRMASMB16310. HCPCS: E2300

Comfort contoured seat part: MEC133630. HCPCS: E2300

Synergy seat part: FRMASMB16312. HCPCS: E2300

Power Elevating Seat with 6” Stroke ............................... $1,895

Contoured seat part: FRMASMB16309. HCPCS: E2300

Comfort contoured seat part: MEC133629. HCPCS: E2300

Synergy seat part: FRMASMB16311. HCPCS: E2300

Standard Seat Towers ............................................... Standard

Part: Conguration selection, no part number

Extended Seat Towers ............................................ No Charge

Part: MEC120301

Increases seat to oor height.

9.1b. Power Adjustable Seat Height

The seat to oor height will be increased. Lift/elevate will be operated through the joystick. Power elevating seat includes a 1/4 speed inhibit.

9.1a. Power Base Seat Towers

9. SEAT TOWERS/POWER ADJUSTABLE SEAT HEIGHT

REQUIRED. Select one option below.

1. Q-Logic 3 Required Components

Q-Logic 3 expandable controls require the controller module and expandable harness below. If a Q-Logic joystick or specialty control

is selected, Customer Service will quote the order with these items.

2. Q-Logic 3 Joystick

NE+ 6 Key Joystick

NE 4-Key Joystick .................................... Standard

Part: CTLDC1554

Non available with power seating.

NE+ 6-Key Joystick (1 Actuator) ................ No Charge

Part: CTLDC1560

Control of one actuator through joystick on single power

base model (3SP-SS & 3SP-C) only.

NE+ 6-Key Joystick (2 Actuators) ..................... $200

Part: CTLDC1560

Control up to 2 actuators through joystick.

NE+ 8-Key Joystick (2 Actuators) .....................$400

Part: CTLDC1561

Control up to 2 actuators through joystick and full light

package.

No Joystick, Setup for NE+ Joystick ........... No Charge

Part: Conguration selection

10.1a. Non-Expandable Controls

Select a joystick below or omit selection if another controller type is desired. Non-expandable does not allow supplementary drive

controllers.

10.1b. Expandable Controls - Quantum Intelligent Systems™

Select expandable controls or omit selection if another controller type is desired. Expandable controls allow multiple or specialized controllers.

Q-Logic 3 EX Controller Module .......................$695

Part: See XRef. HCPCS: E2377

Q-Logic 3 Expandable Controller Harness ...........$425

Part: HAR144005. HCPCS: E2313

Q-Logic 3 EX Joystick ....................................$700

Part: CTL167724

No Joystick, Setup for Q-Logic

Part: Conguration selection.

Q-Logic 3 EX Joystick for Full Lights .................$700

Part: CTL167725

Q-Logic 3 EX Joystick

10. ELECTRONICS

REQUIRED. Select a type of drive control from the following sections. The No Joystick option is used to omit the joystick and utilize another control, such as a

specialty control at the end of this form or found on the Alternative Controls and Electronics Order Form.

Electronics section continued on following page.

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INFINFB3538/RevO/09DEC2019

Account Number: ___________ Date: ________________ Marked for: _____________________________________

Black, Soft Touch ................. Standard

Part: DGN124307

Non-matching Armor .................... $50

Part: PTOINDV3422

Select color below

Match Armor to Base Color ............$50

Part: PTOINDV3421

10.2. Q-Logic 3 Joystick Armor

REQUIRED with Q-Logic 3 Joystick selections above. Reference colors shown on page 2. *Night train joystick armor will be the black, soft touch.



Mushroom Handle (B) ..................................... $85

Part: ACCASMB1860. HCPCS: E2323

Chin Cup (C) ................................................. $85

Part: ACCASMB1861. HCPCS: E2323 (E2324 when chin

control)

T-Bar (D) .................................................... $120

Part: ACCASMB1858. HCPCS: E2323

Medium Ball Handle (E) ................................... $65

Part: ACCASMB1859. HCPCS: E2323

Soft Ball Handle (F) ........................................ $65

Part: ACCASMB1856. HCPCS: E2323

Extended I-Handle (G) .................................... $85

Part: ACCASMB1857. HCPCS: E2323

Bodypoint 3” Goal Post Handle ......................... $99

Part: PLSKNCP1057. HCPCS: E2323

Bodypoint 4” Goal Post Handle ......................... $99

Part: PLSKNCP1058. HCPCS: E2323

Q-Logic 3 Carrot Handle (A) .....................No Charge

Part: DGN124308

Joystick Handles

11. JOYSTICK HANDLES

Optional. The NE/NE Plus Joysticks are standard with a carrot handle (See A in image). The optional handle will be mounted to the joystick and the standard handle

will be shipped with the unit.

12.1b. Swing-Away (Retractable) Joystick Bracket

Allows the joystick to retract to the side of the armrest while maintaining the same joystick orientation. "Inline bracket" will be oset 1"

when used with tube style arms. Select "Oset Bracket" to have the joystick inline with armpad on tube style armrests.

12.1c. Specialty Joystick Mounts

Select a bracket and side to mount it.

Specialty Mount Side

12.1a. Fixed, In-line Joystick Bracket

12. JOYSTICK MOUNTING BRACKETS

Optional. Select a mount to be used with a joystick selected in previous section.

Omit Joystick Mounting Bracket

Swing-away, Inline, Left Side Mount .................. $245

Part: See XRef. HCPCS: E1028

Swing-away, Inline, Right Side Mount ................$245

Part: See XRef. HCPCS: E1028

 .............$245

Part: See XRef. HCPCS: E1028

 ............ $245

Part: See XRef. HCPCS: E1028

Swing Away Joystick

Inline Mount (Right)

Swing Away Joystick

Offset Mount (Right)

Multi-Axis Joystick

Mount

Retract4

Left Side Mount

Part: PTOINDV1225

Right Side Mount

Part: PTOINDV1226

Fixed, In-line, Bracket .............................................................................................................Standard

Q-Logic Part: FRMASMB10617. NE/NE+ Part: FRMASMB12744

Left Side Mount

Part: PTOINDV1225

Right Side Mount

Part: PTOINDV1226

Retract4 Mount ............................................ $350

NE/NE+ Part: MEC138876. HCPCS: E1028

Q-Logic Part: MEC138860. HCPCS: E1028

Full 180° of movement that translates into multi-position

use, straight, right oset, left oset, or fold away. Joy-

stick orientation varies as bracket is adjusted.

Multi-axis Mount .......................................... $10 0

NE/NE+ Part: ACC142528. HCPCS: E1028

Q-Logic Part: ACC131216. HCPCS: E1028

SAJ Part: ACC142740. HCPCS: E1028

Allows height adjustment of joystick.

Stealth Swing-Away/Flip Down Bracket ..........$294.25

NE/NE+ Part: ST-TWBM480QL-Q. HCPCS: E1028

Q-Logic Part: ST-TWBM480QL-Q. HCPCS: E1028

SAJ Part: ST-TWBM480CJ-Q. HCPCS: E1028

Allows the joystick to pivot to side of armrest,

or ip-down if bracket is adjusted. Not available with

contoured seating.

Red Corvette

Part: DGN124336-PRD1

Electric Blue

Part: DGN124336-PBU9

Back in Black

Part: DGN124336-PBK1

Night Train

See Black, Soft Touch

White Satin

Part: DGN124336-PWH2

Pretty in Pink

Part: DGN124336-PPK3

Evolution Orange

Part: DGN124336-POR7

Deep Purple

Part: DGN124336-PPR5

Grey Street

Part: DGN124336-PSL3

Midnight Blue

Part: DGN124336-PBU10

Lemon Crush

Part: DGN124336-PYL4

Green Machine

Part: DGN124336-PGN11

Military Green

Part: DGN124336-PGN8

Page 5 of 18

INFINFB3538/RevO/09DEC2019

13.4. Set Depth Selection for Comfort Seat

Required with Comfort Seat selection above.

14” Depth

Part: SETDPTH1004

16" Depth

Part: SETDPTH1006

18” Depth

Part: SETDPTH1008

20" Depth

Part: SETDPTH1010

13.3. Seat to Floor Height

Required with any contoured seating selection.

Lowest Seat to Floor

Part: PTOINDV3558

Middle Seat to Floor

Part: PTOINDV3559

Not available with Comfort high back seat.

Highest Seat to Floor

Part: PTOINDV3560

WC-19 Occupied Transit Option for Contoured Seat ............................................................................................................... $350

Part: KIT122609

Only available with Comfort, Depth Adjustable, Height Adjustable, High Back with Limited Recline. To determine if your chair is WC-19 compliant

(occupied), please refer to this website: http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs

13.2. Occupied Transit, WC-19

1a. Comfort, Depth Adjustable, Height Adjustable, High Back with Limited Recline and Solid Seat Pan

Comfort Seat, full length armrests must be selected with a depth adjustable high back.

Account Number: ___________ Date: ________________ Marked for: _____________________________________

16”Wx16”D ..........................No Charge

Part: SETASMB3178

16”Wx18”D ..........................No Charge

Part: SETASMB3179

16”Wx20”D ..........................No Charge

Part: SETASMB3180

16”Wx22”D ..........................No Charge

Part: SETASMB5006

18”Wx16”D ..........................No Charge

Part: SETASMB3181

18”Wx18”D .......................... No Charge

Part: SETASMB2848

18”Wx20”D..........................No Charge

Part: SETASMB3182

18”Wx22”D ..........................No Charge

Part: SETASMB5007

20”Wx16”D .......................... No Charge

Part: SETASMB3183

20”Wx18”D ..........................No Charge

Part: SETASMB3184

20”Wx20”D .........................No Charge

Part: SETASMB3185

20”Wx22”D .........................No Charge

Part: SETASMB5008

13.1b. Contoured Seat with Solid Seat Pan

1c. High Back with Limited Recline and Solid Seat Pan

1d. Medium Back with Solid Seat Pan

1e. Medium Back

16”Wx16” ............ No Charge

Part: SETASMB2488

16”Wx18” ............ No Charge

Part: SETASMB2560

18”Wx16” ............ No Charge

Part: SETASMB2159

18”Wx18” ............ No Charge

Part: SETASMB2551

16”Wx16” ............ No Charge

Part: SETASMB3112

16”Wx18” ............ No Charge

Part: SETASMB3113

18”Wx16” ............ No Charge

Part: SETASMB2492

18”Wx18” ............ No Charge

Part: SETASMB3114

16”Wx16”D ..........................No Charge

Part: SETASMB2770

16”Wx18”D ..........................No Charge

Part: SETASMB2771

16”Wx20”D ..........................No Charge

Part: SETASMB2772

16”Wx22”D ..........................No Charge

Part: SETASMB4887

18”Wx16”D ..........................No Charge

Part: SETASMB2775

18”Wx22”D ..........................No Charge

Part: SETASMB4888

20”Wx16”D .......................... No Charge

Part: SETASMB2780

20”Wx22”D .........................No Charge

Part: SETASMB4889

1d. High Back with Limited Recline

18”Wx18”-20”D with 60" Lap Belt ............................. No Charge

Part: SETASMB6895

20”Wx18”-20”D with 60" Lap Belt ............................. No Charge

Part: SETASMB6896

22”Wx20”-22”D with 70" Lap Belt ............................. No Charge

Part: SETASMB6897

16”Wx16”-18”D ..................... No Charge

Part: SET1701577

18”Wx18”-20”D ....................No Charge

Part: SET1701578

20”Wx20”-22”D ....................No Charge

Part: SET1701579

13.1a. Captain Style Seating

1b. Depth Adjustable High Back with Limited Recline

Full length armrests must be selected with a depth adjustable high back.

1c. Power Lift, Fold Flat Captain Seat

Only available with 12" power lift for captain seat with iLevel. Includes armrests and 60" lap belt.

16”Wx16”-18”D ..................... No Charge

Part: SET131843

18”Wx18”-20”D ........................... $150

Part: SET131844

20”Wx18”-20”D ........................... $150

Part: SET131845

1a. Comfort, Depth Adjustable, Height Adjustable, High Back with Limited Recline

Comfort seat, full length armrests must be selected with a depth adjustable high back. Includes 60" lap belt.

16”Wx16”-18”D ..................... No Charge

Part: SET1701580

18”Wx18”-20”D ....................No Charge

Part: SET1701581

20”Wx20”-22”D ....................No Charge

Part: SET1701582

1b. Power Lift, Fold Flat Contoured Seat with Solid Seat Pan

Only available with 12" Power Lift with iLevel. Includes armrests and 60" lap belt.

Contoured seating section continued on following page.

13. CONTOURED SEATING

Optional. Select only one seating system. Special order seat sizes can be requested by checking the seat type and writing in the seat size in the special order seat size.

16”Wx16”-18”D with 60" Lap Belt ..................................... $150

Part: SET145814

18”Wx18”-20”D with 60" Lap Belt .................................... $150

Part: SET145815

Page 6 of 18

INFINFB3538/RevO/09DEC2019

10”-14” Depth Package

Part: FRMASMB6981

14”-18” Depth Package

Part: FRMASMB17823

15”-20” Depth Package

Part: FRMASMB7732

20”-24” Depth Package

Part: FRMASMB7733

14.6. Seat Dimension - Depth Package

REQUIRED with Synergy seating. Maximum seat depth is 22".

14.2. Synergy Transit Kit

Optional. The Q6 Edge 2.0 is standard with Unoccupied Transit Loops. 60” Sure-Lok Lap Belt is required with Occupied Transit Option. To determine if your chair is

WC-19 compliant (occupied), please refer to this website: http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs

14.5. Seat Dimension - Depth

REQUIRED with Synergy seating. Maximum seat depth is 22". Part number is SETDPTH plus number following # below.

10” D

(#1000)

11” D

(#1001)

12” D

(#1002)

13” D

(#1003)

14” D

(#1004)

15” D

(#1005)

16” D

(#1006)

17” D

(#1007)

18” D

(#1008)

19” D

(#1009)

20” D

(#1010)

21” D

(#1011)

22” D

(#1012)

WC-19 Occupied Transit Option ......................................................................................................................................... $275

Part: KITASMB1830

Account Number: ___________ Date: ________________ Marked for: _____________________________________

14.1. Synergy Frame Selection

Synergy Seating System ................................................................................................................................................. $434

Part: PTOINDV2995

14.3. Seat Dimension - Width

REQUIRED with Synergy seating. Maximum seat width is 22". Part number is SETWDTH plus number following # below.

10” W

(#1000)

11” W

(#1001)

12” W

(#1002)

13” W

(#1003)

14” W

(#1004)

15” W

(#1005)

16” W

(#1006)

17” W

(#1007)

18” W

(#1008)

19” W

(#1009)

20” W

(#1010)

21” W

(#1011)

22” W

(#1012)

14.4. Seat Dimension - Width Package

REQUIRED with Synergy seating. Maximum seat width is 22".

10”-14” Width Package

Part: FRMASMB18011

14”-18” Width Package

Part: FRMASMB18012

16”-20” Width Package

Part: FRMASMB18013

20”-24” Width Package

Part: FRMASMB18014

Synergy seating section continued on following page.

13.6. Special Order Contoured Seat

Complete information below. Contact inside sales specialist for pricing.

Depth:______Width:______Type of Seat:____________________________________________________

13.7. Contoured Seat Flip-Up, Height Adjustable, Removable Armrests

REQUIRED except with fold at, power lift captain seat. Select a left and right armrest or to omit them.



Full Length, Left Armrest .................................................$85

Part: FRMASMB8614. HCPCS: E0973

Desk Length, Left Armrest ................................................$85

Part: FRMASMB8612. HCPCS: E0973

Full Length, Right Armrest ................................................$85

Part: FRMASMB8615. HCPCS: E0973

Desk Length, Right Armrest ..............................................$85

Part: FRMASMB8613. HCPCS: E0973

Comfort Seat, Right, Full Length, Armrest ............................ $85

Part: FRMASMB16315. HCPCS: E0973

Comfort Seat, Left, Full Length, Armrest .............................$85

Part: FRMASMB16316. HCPCS: E0973

No Armrest ............................................................ Standard

Part: N/A

13.5. Back Height Selection for Comfort Seat

Required with Comfort Seat selection above.

Set Back Height to Lowest Position

Part: SETHGHT1100

Set Back Height to Highest Position

Part: SETHGHT1101

14.7. Synergy Seat to Floor

REQUIRED with Synergy seating.

15.875”

Part: PTOINDV3652

16.875”

Part: PTOINDV3653

17.875”

Part: PTOINDV3654

14.8. Synergy Back Options

REQUIRED with Synergy seating. See the Synergy and TRU-Comfort back availability chart for stock order back size ranges. Other size backs may be available with

special order and extended lead time.

1. Back Cane Selection

Synergy Back Cane ................................................ No Charge

Part: FRMASMB15844

Select a back cane height.

Flip Forward Back Cane ................................................. $150

Part: FRMASMB15846

Select a back cane height. Not available with a vent tray, oxygen

holder, or cane mounted and cantilever armrests.

2” Mesomorph (1” per side) Back Cane ...............................$195

Part: FRMASMB12067

Select a cane height.

4” Mesomorph (2” per side) Back Cane ...............................$195

Part: FRMASMB12091

Select a cane height.

2” Endomorph (1” per side) Back Cane ...............................$195

Part: FRMASMB12115

Select a cane height.

4” Endomorph (2” per side) Back Cane ...............................$195

Part: FRMASMB12139

Select a cane height.

Manual Recline Back ..................................................... $750

Part: FRMASMB12910. HCPCS: E1226

Select an overall back height. Back canes will be 22” H. Not available

with ip back armrests, cantilever armrests, Shape Back, TRU-Com-

fort Back, rear accessories, power elevating seat, or articulating foot

platform. Pivot point is 2.5” above the seat pan.

14. SYNERGY SEATING SYSTEM

Optional. Widths, depths, and heights are available in 1" increments in the noted ranges. Maximum seat size 22"W x 22"D.

Page 7 of 18

INFINFB3538/RevO/09DEC2019

Full Length, Flip Back Armrests .............................. Standard

Left Part: FRMASMB7038. Right part: FRMASMB7039

Desk Length, Flip Back Armrests ............................ Standard

Left part: FRMASMB7040. Right part: FRMASMB7041

Full Length, Two-Post Armrest ................................$150 ea.

Part: See XRef.

HCPCS: E0973

Desk Length, Two-Post Armrest ..............................$150 ea.

Part: See XRef

. HCPCS: E0973

Full Length, Heavy Duty Armrests, 8"-12" H ................ $75 ea.

Left Part: FRMASMB9982. Right part: FRMASMB9983. HCPCS: E0973

Desk Length, Heavy Duty Armrests, 8"-12"H ................ $75 ea.

Left part: FRMASMB9984. Right part: FRMASMB9985. HCPCS: E0973

Full Length, Heavy Duty Armrests, 10"-14"H ................ $75 ea.

Left Part: FRMASMB9986. Right part: FRMASMB9987. HCPCS: E0973

Desk Length, Heavy Duty Armrests, 10"-14"H .............. $75 ea.

Left part: FRMASMB9988. Right part: FRMASMB9989. HCPCS: E0973

Full Length, Cantilever Armrests .......................... $97.50 ea.

Left Part: FRMASMB16188. Right part: FRMASMB16189

Desk Length, Cantilever Armrests ......................... $97.50 ea.

Left part: FRMASMB16190. Right part: FRMASMB16191

Full Length, Single Post Armrests ............................. $75 ea.

Left Part: FRMASMB8594. Right part: FRMASMB8595. HCPCS: E0973

Desk Length, Single Post Armrests ............................ $75 ea.

Left part: FRMASMB8592. Right part: FRMASMB8593. HCPCS: E0973

Pediatric, Removable Armrests ................................................................................................................................ $75 ea.

Left Part: FRMASMB10608. Right part: FRMASMB10609. HCPCS: E0973

1a. Flip Back, Cane Mounted Armrests

May interfere with swing-away laterals.

1b. Two-Post, Flip Back, Height Adjustable, Removable Armrests

Not available with a depth less than 16". Required with ip forward back and laptrays.

1c. Single-Post, Heavy Duty, 8"-12" Height Adjustable, Removable Armrests

1d. Single-Post, Heavy Duty, 10"-14" Height Adjustable, Removable Armrests

1e. Pediatric, Removable, Height Adjustable Armrests

Only available with desk length armpads.

1f. Height Adjustable, Cantilever Armrests

Height adjustment from 11"-17" depends on cane height. Not available with manual recline, ip forward back canes, or cane clamp pushbar.

1g. Single Post, Height Adjustable, Removable Armrests

Height adjustment from 11"-17" in half-inch increments.

14.9. Synergy Armrests

REQUIRED with Synergy seating. Left (L) and right (R) boxes may be checked to congure dierent size arms within one section arm type.

4. Synergy Overall Back Height

Parts: See XRef, conguration selection with back selection.

Account Number: ___________ Date: ________________ Marked for: _____________________________________

12” High

13” High

14” High

15” High

16” High

17” High

18” High

19” High

20” High

21” High

22” High

23” High

24” High

25” High

3. Back Selection

Synergy Back ............................................................... $275

Part: See XRef

TRU-Comfort, 20” Width or less....................................... $675

Part: See XRef. HCPCS: E2620

TRU-Comfort, 22” Width or greater .................................. $775

Part: See XRef. HCPCS: E2621

Sling Back ..................................................................... $98

Part: See XRef

Available 18"-25" overall heights. Back cane height must match back

height. Not available with ip up cantilever arms.

Omit Back ............................................................ No Charge

Part: PTOINDV1287

Width

Synergy and TRU-Comfort Back Availability Chart

Synergy Back Synergy or TRU-Comfort Back

Overall Height

2. Synergy Back Cane Height

Omit this selection if a TRU-Comfort back is desired. 16" and 17" back canes are not available with a Synergy Back and cane mounted, ip up armrests. 14" and 15"

back canes are not available without push handles.

14” High Canes

Part: FRMASMB15832

15” High Canes

Part: FRMASMB15833

16” High Canes

Part: FRMASMB15834

17” High Canes

Part: FRMASMB15835

18” High Canes

Part: FRMASMB15836

19” High Canes

Part: FRMASMB15837

20” High Canes

Part: FRMASMB15838

21” High Canes

Part: FRMASMB15839

22” High Canes

Part: FRMASMB15840

23” High Canes

Part: FRMASMB15841

24” High Canes

Part: FRMASMB15842

25” High Canes

Part: FRMASMB15843

Straight Armpads ..................................................... Standard

Desk/Desk part: UPSASMB1022. Full/Full part: UPSASMB1021.

Desk/Full part: UPSASMB1023

No Armpad Selection ............................................. No Charge

Part: PTOINDV1373

Waterfall Armpads ................................................. No Charge

Desk/Desk part: UPSASMB1025. Full/Full part: UPSASMB1024.

Desk/Full part: UPSASMB1026

14.10. Synergy Armpads

REQUIRED with armrest selection above. Waterfall armpads may cause interference with the seat back. Armpads are congured as pairs.

Synergy seating section continued on following page.



Page 8 of 18

INFINFB3538/RevO/09DEC2019

Account Number: ___________ Date: ________________ Marked for: _____________________________________

14.11. Joystick Bracket Receiver

REQUIRED.

Standard Fixed Receiver ........................................... Standard

Part: FRMASMB16062

Stealth Height Adjustable Receiver ................................... $214

Tube Arm Part: ST-ARM250C-Q. HCPCS: K0108

15.1. TRU-Balance Flex Frame Selection

TRU-Balance Flex Seating System ...............................................................................................................................No Charge

Part: PTOINDV3853

15.2. TRU-Balance Flex Seat Dimension - Width

REQUIRED with TRU-Balance Flex seating. Maximum seat width is 22". Part number is SETWDTH plus number following # below.

15” W

(#1005)

16” W

(#1006)

17” W

(#1007)

18” W

(#1008)

19” W

(#1009)

20” W

(#1010)

21” W

(#1011)

22” W

(#1012)

15.3. TRU-Balance Flex Seat Dimension - Depth

REQUIRED with TRU-Balance Flex seating. Maximum seat depth is 20". Part number is SETDPTH plus number following # below.

15” D

(#1005)

16” D

(#1006)

17” D

(#1007)

18” D

(#1008)

19” D

(#1009)

20” D

(#1010)

15.6. TRU-Balance Flex Back Cane Height Selection

REQUIRED with TRU-Balance Flex seating.

15.5. TRU-Balance Flex Back Cane Selection

REQUIRED with TRU-Balance Flex seating.

Angle Adjustable Back Cane ..................................... No Charge

Part: MEC140266

Flip Forward Back Cane ................................................. $150

Part: MEC140272

Not available with oxygen holder, or cane mounted and cantilever

armrests.

2” Mesomorph (1” per side) Back Cane ...............................$195

Part: MEC1804736

4” Mesomorph (2” per side) Back Cane ...............................$195

Part: MEC1804739

2” Endomorph (1” per side) Back Cane ...............................$195

Part: MEC141455

4” Endomorph (2” per side) Back Cane ...............................$195

Part: MEC141456

Manual Recline Back ..................................................... $750

Part: FRMASMB12910. HCPCS: E1226

Select Synergy Back and an overall back height, or to omit back. Back

canes will be 22” H. Not available with ip back armrests, cantilever

armrests, TRU-Comfort Back, Sport Back, rear accessories, or articu-

lating foot platform. Pivot point is 2.5” above the seat pan.

14” High Canes

Part: FRMASMB15832

15” High Canes

Part: FRMASMB15833

16” High Canes

Part: FRMASMB15834

17” High Canes

Part: FRMASMB15835

18” High Canes

Part: FRMASMB15836

19” High Canes

Part: FRMASMB15837

20” High Canes

Part: FRMASMB15838

21” High Canes

Part: FRMASMB15839

22” High Canes

Part: FRMASMB15840

23” High Canes

Part: FRMASMB15841

24” High Canes

Part: FRMASMB15842

25” High Canes

Part: FRMASMB15843

Synergy Back Cushion .................................................... $275

Part: See XRef

Sport Back Cushion, 20" Width or Less .............................. $375

Part: See XRef

Sport Back Cushion, 22" Width ........................................ $575

Part: See XRef

TRU-Comfort 2, 20” Width or less .................................... $675

Part: See XRef. HCPCS: E2620

TRU-Comfort 2, 22” Width or greater ............................... $775

Part: See XRef. HCPCS: E2621

Sling Back ..................................................................... $98

Part: See XRef

Overall back height must match back cane height selection above.

Omit Back ............................................................ No Charge

Part: PTOINDV1287

1. Back Selection

15.7. TRU-Balance Flex Back Options

REQUIRED with TRU-Balance Flex seating. See the back availability chart for stock order back size ranges. Other size backs may be available with special order and

extended lead time. Select a back type and overall back height for congured part number.

TRU-Balance Flex seating section continued on following page.

Back Width

TRU-Balance Flex Seat Back Availability Chart

Synergy Back Sport Back TRU-Comfort Back

Overall Height



15.4. TRU-Balance Flex Seat to Floor

REQUIRED with TRU-Balance Flex seating.

15. TRU-BALANCE FLEX SEATING SYSTEM

Optional. Seat width and depth can be adjusted in 1" increments from 15"W-22"W and 16"D-20"D. Maximum seat size 22"W x 20"D.

16.5” at front and rear

Part: PTOINDV3459

17.5” at front with 2° posterior angle

Part: PTOINDV3460

18.25” at front with 4° posterior angle

Part: PTOINDV3805

Page 9 of 18

INFINFB3538/RevO/09DEC2019

Stealth’s Worlds Best Removable .................................. $220.50

Headrest Bracket (TWB485-1) (C)

Part: FRMASMB15999. HCPCS: E1028

 ................................ $160.50

Part: HDWASMB1166. HCPCS: E1028

Stealth Multi-Axis Removable (D).................................. $160.50

Headrest Bracket (HMO475P)

Part: HDWASMB1084. HCPCS: E1028

Not available with TRU-Balance Flex seating.

16.2. Headrest Brackets

1b. Flip Back, Cane Mounted Armrests

May interfere with swing-away laterals.

1a. Straight Armpads

1b. Waterfall Armpads

1c. Falcon Gel Armpads

1a. TRU-Balance Flex Seat, Drop-In Armrests

1c. Two-Post, Flip Back, Height Adjustable, Removable Armrests

Not available with a depth less than 16". Required with ip forward back and laptrays.

1d. Single Post, Height Adjustable, Removable Armrests

Height adjustment from 11"-17" in half-inch increments.

Full Length, Flip Back Armrests (pair) ............................. $60

Left part: FRMASMB7038. Right part: FRMASMB7039

Desk Length, Flip Back Armrests (pair) ...........................$60

Left part: FRMASMB7040. Right part: FRMASMB7041

Full Length, Two-Post Armrests...............................$150 ea.

Part: See XRef. HCPCS: E0973

Desk Length, Two-Post Armrests .............................$150 ea.

Part: See XRef. HCPCS: E0973

Full Length, Single Post Armrests ............................. $75 ea.

Left part: FRMASMB8594. Right part: FRMASMB8595. HCPCS: E0973

Desk Length, Single Post Armrests ............................ $75 ea.

Left part: FRMASMB8592. Right part: FRMASMB8593. HCPCS: E0973

15.8. TRU-Balance Flex Armrests

REQUIRED with TRU-Balance Flex seating. Left (L) and right (R) boxes may be checked to congure dierent size arms within one section arm type.

15.9. TRU-Balance Flex Armpads

REQUIRED with armrest selection above, except with drop-in armrests. Waterfall armpads may cause interference with the seat back. Armpads are congured as pairs.

Straight, Full Length Left and Right ........................... No Charge

Part: ARM134275

Straight, Full Length Left, Desk Length Right ............... No Charge

Part: ARM134281

Straight, Desk Length Left, Full Length Right ............... No Charge

Part: ARM134275

Straight, Desk Length Left and Right .......................... No Charge

Part: ARM134254

Waterfall, Full Length Left and Right .......................... No Charge

Part: ARM134275

Waterfall, Full Length Left, Desk Length Right ............. No Charge

Part: ARM134281

Waterfall, Desk Length Left, Full Length Right ............. No Charge

Part: ARM134275

Waterfall, Desk Length Left and Right ........................ No Charge

Part: ARM134254

Falcon Gel, Full Length Left and Right ........................... $296.40

Part: ARM136438

Falcon Gel, Full Length Left, Desk Length Right ............... $274.22

Part: ARM136442

Falcon Gel, Desk Length Left, Full Length Right ............... $274.22

Part: ARM136439

Falcon Gel, Desk Length Left and Right ......................... $252.40

Part: ARM136437



Account Number: ___________ Date: ________________ Marked for: _____________________________________

Full Length, Drop-In Armrests .............................. No Charge

Left part: ARM1803253. Right part: ARM156742

Desk Length, Drop-In Armrests ............................ No Charge

Left part: ARM1803254. Right part: ARM156743

16. HEADRESTS

Optional. Select a headrest pad and bracket. Not available with contoured seating.

Stealth 8” Comfort Plus (CP450) ................... $151.94

Part: POS148484. HCPCS: E0955

Stealth 10” Comfort Plus (CP250) (A) ............ $151.94

Part: SETHEAD1057. HCPCS: E0955

Stealth 14” Comfort Plus (CP150) ................. $151.94

Part: INDPART2327. HCPCS: E0955

Pediatric Comfort Plus (6”Wx4.5”H) ............. $151.94

(CPN350)

Part: SETHEAD1069. HCPCS: E0955

Stealth Small Contoured (9.75”Wx3”H) ........... $64.20

(STL-OTSM250)

Part: SETHEAD1052. HCPCS: E0955

Stealth Large Contoured (11”Wx6”H) (B) ......... $80.25

(STL-OTLG150)

Part: SETHEAD1053. HCPCS: E0955

Headrests

16.1. Headrest Pads

2. TRU-Balance Flex Overall Back Height

Refer to the availability chart for stock order back size ranges.

14” Height

Part: SETHGHT1027

15” Height

Part: SETHGHT1028

16” Height

Part: SETHGHT1029

17” Height

Part: SETHGHT1030

18” Height

Part: SETHGHT1031

19” Height

Part: SETHGHT1032

20” Height

Part: SETHGHT1033

21” Height

Part: SETHGHT1034

22” Height

Part: SETHGHT1035

23” Height

Part: SETHGHT1036

24” Height

Part: SETHGHT1037

25” Height

Part: SETHGHT1038

26” Height

Part: SETHGHT1039

27” Height

Part: SETHGHT1040

28” Height

Part: SETHGHT1041

Headrests section continued on following page.

Page 10 of 18

INFINFB3538/RevO/09DEC2019

Stealth Flip-down Headrest Bracket (FDM350) ..................................................................................................................$224.70

Part: INDPART2219

Not available with TRU-Balance Flex seating. The ip-down bracket is used with a headrest bracket above but will not be mounted to the chair due

to permanent headrest post modication necessary to allow the headrest bracket to ip.

16.3. Flip-down Headrest Bracket

Account Number: ___________ Date: ________________ Marked for: _____________________________________

One Actuator Control through NE+ Joystick ...................... $1,895

Part: See XRef. HCPCS: E2310

Two Actuator Control through NE+ Joystick ......................$2,375

Part: See XRef. HCPCS: E2311

One Actuator Control through through Q-Logic 3 ............... $1,895

Electronics

Part: See XRef. HCPCS: E2310

Multiple Actuator Control through Q-Logic 3 ..................... $2,895

Electronics

Part: See XRef. HCPCS: E2311

1. Articulating Legrest Upper Assembly

19.1. 70° Power Articulating, Swing Away Legrests

Not available with contoured or TRU-Balance Flex seating seating. 4” of articulating range. Be sure power legrest control has been selected in previous section.

Select an upper extension type and footplate. Pair (P), left (L), and right (R) congurations are selected by checking the appropriate boxes. Select legrest length in

following section.

70° Articulating, Swing-Away .......................$1,197.50 ea .

Legrest with 14.5"-18" Extension

Pair part: FRMASMB9073. HCPCS for pair: E1010+K0040+E0951.

Left part: FRMASMB9074. Right part: FRMASMB9075

70° Articulating, Swing-Away .......................$1,197.50 ea .

Legrest with 11"-13" Extension

Pair part: FRMASMB11444. HCPCS for pair: E1010+K0040+E0951.

Left part: FRMASMB11366. Right part: FRMASMB11367

Legrests section continued on following page.

3. Power Articulating, Swing-Away Legrest Accessories

Calf Pad (pair) 6”Wx6”H .......................................... No Charge

Part: MEC153735

Falcon Gel Padded Knee Adductor Buttons (KBE)(pair) ...........$125

Part: INDPART2242. HCPCS: E0953^

^Please verify the appropriate billing code to be used for this item

with all third-party payors.

4”Wx6”D

Pair part: FRMASMB7448. Left part:

RIG133543. Right part: RIG133566.

5”Wx6”D

Pair part: FRMASMB7449. Left part:

RIG133544. Right part: RIG133567.

5”Wx8”D

Pair part: FRMASMB7450. Left part:

RIG133545. Right part: RIG133568.

6”Wx8”D

Pair part: FRMASMB7451. Left part:

RIG133547. Right part: RIG133569.

6”W x11”D

Pair part: FRMASMB7452. Left part:

RIG133548. Right part: RIG133570.

8”Wx11”D

Pair part: FRMASMB7453. Left part:

RIG133549. Right part: RIG133571.

2. Angle Adjustable Footplate with Heel Loop and Wheel Bumper

¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.

This rigging configuration causes no interference issues at this seat-to-floor

height.

This rigging configuration may have less than 1.75” clearance when fully

extended and may interfere with the ground or reduce obstacle climbing ability.

70° Power Articulating, Swing-Away

Legrest Compatibility Matrix

Synergy Seat

Low Medium High

Angle Adjustable,

14.5” - 18”

11” - 13”Angle Adjustable,

18. SYNERGY POWER OPTION ELECTRONICS

REQUIRED for Synergy Seat with Power Legrests or Elevating Seat. Select the desired control type for the seating system.

38” Lap Belt

Part: ACCBELT1006

50” Lap Belt

Part: ACCBELT1000

60” Lap Belt

Part: ACCBELT1002

70” Lap Belt

Part: ACCBELT1003

80” Lap Belt

Part: ACCBELT1004

90” Lap Belt

Part: ACCBELT1001

i-Fit 60” Single Pull, Push Button, Medium ...........................$86

(7.5”) Padded, 1.5” Belt (IFPB5213)

Part: ST-IFPB5213-Q

i-Fit 60” Single Pull, Push Button, Large ..............................$86

Padded (9.5”), 2” Belt (IFPB5314)

Part: ST-IFPB5314-Q

i-Fit 60” Single Pull, Push Button, Extra Large ......................$86

Padded (11.5”), 2” Belt (IFPB5315)

Part: ST-IFPB5315-Q

60” Sure-Lok Lap Belt (Non-retractable) ............................ $120

Required with ISO 7176-19 Compliant Transit Option.

Part: ACCBELT1016

17.1a. Standard Lap Belts

17.1b. Optional Lap Belts

Not available with contoured or TRU-Balance Flex seating.

17. LAP BELTS

REQUIRED except with select contoured seats with included lap belt. Select one lap belt below.



19. LEGRESTS

Optional. All eorts will be made to accommodate legrest length selection, but minor changes may need to be made to meet shipping guidelines. Some adjustments

may be needed upon receipt of the unit. Reference the section’s compatibility matrix for legrest interference.

Page 11 of 18

INFINFB3538/RevO/09DEC2019

No interference issues at this seat-to-floor height.

May have less than 1.75” clearance when fully extended and may

interfere with the ground or reduce obstacle climbing ability.

Center Mount Foot Platform

Compatibility Matrix

Synergy Seat

Low Medium High

10”-16” Length Extension

13”-19” Length Extension

Account Number: ___________ Date: ________________ Marked for: _____________________________________

Small Calf Pads (pair) 6”Wx6”H ....................................... $150*

Part: RIGASMB7120018

Large Calf Pads (pair) 8” taper to 6”Wx8”H ....................... $150 *

Part: RIGASMB7120019

Small Calf Panel 18”Wx8”H ............................................. $150

Part: FRMASMB7110012

Large Calf Panel 24”Wx8”H ............................................ $200

Part: RIG123824

Only available on widths of 20” or greater.

Width Extension for 8”D Footplates ...................................$50

Part: RIG152517

Width Extension for 11”D Footplates .................................. $50

Part: RIG152518

2” Bell-Shaped Length Extension .......................................$50

Part: RIG152519

Not compatible with width extensions. Can be used with 6” outside

edge with 11” footplates.

4” Outside Edge (pair) .....................................................$50

Part: RIG152510

Only available with 6”D footplates and 8”D footplate extension.

6” Outside Edge (pair) .....................................................$50

Part: RIG152516

Available with 8”D and 11”D footplates and 11”D footplate extension.

Reversed Dartex Calf Pad Cover (pair) ............................... $150

Small part: RIG133717. Large part: RIG133719

Reversed Dartex Panel Cover (pair) .................................. $150

Small part: RIG134673. Large part: RIG134744

Wheel Bumpers (pair) ............................................. $12.50 ea.

Part: WHLASMB1578 x2

Footplate Connector ....................................................... $15

Part: RIGASMB7120023

8"-12" Extension, 5"x6" Footplates

Part: RIG152577

Not available with power articulating platform.

8"-12" Extension, 5"x8" Footplates

Part: RIG152578

Not available with power articulating platform.

10"-16" Extension, 5"x6" Footplates

Part: RIG150206

10"-16" Extension, 5"x8" Footplates

Part: RIG150203

10"-16" Extension, 5"x11" Footplates

Part: RIG150212

13"-19" Extension, 5"x6" Footplates

Part: RIG151505

13"-19" Extension, 5"x8" Footplates

Part: RIG151506

13"-19" Extension, 5"x11" Footplates

Part: RIG151508

Power Articulating Foot Platform .................. $2,995

Part: PTOINDV3754. HCPCS: E1012+K0040

Not available with TRU-Balance Flex seating.

Manually Adjustable Center Mount Foot Platform ... $250

12"-16" width part: FRMASMB17944. 14"-18" width part:

FRMASMB17945. 16"-20" width part: FRMASMB17946.

HCPCS: K0040.

19.2. Center Mount Foot Platform

If power articulating foot platform is selected, be sure power legrest control has been selected in earlier section. Select legrest length

in following section. Not available with contoured seating.

2. Lower Extension and Angle Adjustable Footplates

1. Foot Platform Assembly

3. Center Mount Calf Support

*Calf pads are standard with a power articulating foot platform. Select calf pads covers for additional charge. Calf pad and panel covers include 1/2” of soft visco foam.

4. Modular Footplate Extension Components

Optional. Assembly required. May require seating conguration adjustments to avoid front caster interference.

5. Additional Accessories

Power Articulating

Foot Platform

Legrests section continued on following page.

1. Pedatric Legrests Upper

2. Angle Adjustable Footplate(s)

3. Accessories

90°, Pediatric, Swing-Away Legrest (7"-10" Length Extension) ............................................................................. $162.50 ea.

Pair part: FRMASMB8808. Left: FRMASMB8809

Right: FRMASMB8810

19.3. Pediatric, Swing-Away Legrests

Not available with TRU-Balance Flex seating. Pair (P), left (L), and right (R) congurations are selected by checking the appropriate boxes. Select legrest length in

following section.

4”Wx6”D Angle Adjustable ................................. $85 ea.

Pair part: FRMASMB8812. Left: RIG133537. Right: RIG133560

HCPCS: K0040

5”Wx6”D Angle Adjustable ................................. $85 ea.

Pair part: FRMASMB8811. Left: RIG133538. Right: RIG133561

HCPCS: K0040



Heel Loops (pair) ............................................................$50

Part: FRMASMB7873. HCPCS: E0951

Wheel Bumper(s) ......................................... $12.50 ea.

Pair part:

WHL169508

. Left: WHL169510. Right: WHL169511.

5"x8" Tapered Gel Footplate Covers .................................. $205

Part: ST-FPG5008T-Q

5"x11" Tapered Gel Footplate Covers ................................. $225

Part: ST-FPG5011T-Q

6.5"x8" Tapered Gel Footplate Covers for Width Extension ..... $225

Part: ST-FPG6508T-Q

7"x11" Tapered Gel Footplate Cover for Width Extension ....... $250

Part: ST-FPG7011T-Q

6. Stealth Gel Footplate Covers

Page 12 of 18

INFINFB3538/RevO/09DEC2019

1a. 60°-90° Swing-Away Legrest Uppers

Adjustable in 5° increments.

Account Number: ___________ Date: ________________ Marked for: _____________________________________



3a. Extruded Footplate(s)

3b. Angle Adjustable Footplate(s) with Heel Loops

¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.

3c. Multi-Axis Footplate(s) with Heel Loops

¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.

60°-90° Swing-Away Legrest ............................... $81 ea.

Pair part: RIG120062. Left: FRMASMB17558.

Right: FRMASMB17559

Not available with 11"-13" extensions.

60°-90° Swing-Away Legrest, Short ...................... $81 ea.

Pair part: RIG136481. Left: RIG132607.

Right: RIG132609.

For use only with 11"-13" lower extensions.

7.25”Wx6”D Extruded Footplate ........................ Standard

Part pair: FRMASMB7847. Left: FRMASMB7861

Right: FRMASMB7862

8.5”Wx6”D Extruded Footplate ......................... Standard

Part pair: FRMASMB7848. Left: FRMASMB7863

Right: FRMASMB7864

May cause interference on seat widths less than 18.”

4”Wx6”D .......................................................$85 ea.

Pair part: FRMASMB10564. Left: RIG133537. Right: RIG133560

HCPCS: K0040+E0951

5”Wx6”D........................................................ $85 ea.

Pair part: FRMASMB10565. Left: RIG133538. Right: RIG133561

HCPCS: K0040+E0951

5”Wx8”D ....................................................... $85 ea.

Pair part: FRMASMB10566. Left: RIG133539. Right: RIG133562

HCPCS: K0040+E0951

6”Wx8”D ......................................................$85 ea.

Pair part: FRMASMB10567. Left: RIG133540. Right: RIG133563

HCPCS: K0040+E0951

6”W x11”D ..................................................... $85 ea.

Pair part: FRMASMB10568. Left: RIG133541. Right: RIG133564

HCPCS: K0040+E0951

8”Wx11”D ..................................................... $85 ea.

Pair part: FRMASMB10569. Left: RIG133542. Right: RIG133565

HCPCS: K0040+E0951

4”Wx6”D ................................................. $247.50 e a.

Pair part: FRMASMB9456. Left: RIG133531. Right: RIG133552

HCPCS: K0040+E0951

5”Wx6”D.................................................. $247.50 ea.

Pair part: FRMASMB9457. Left: RIG133532. Right: RIG133553

HCPCS: K0040+E0951

5”Wx8”D ................................................. $247.5 0 e a .

Pair part: FRMASMB9458. Left: RIG133533. Right: RIG133554

HCPCS: K0040+E0951

6”Wx8”D ................................................ $247.50 ea.

Pair part: FRMASMB9459. Left: RIG133534. Right: RIG133555

HCPCS: K0040+E0951

6”W x11”D ............................................... $247.50 ea.

Pair part: FRMASMB9460. Left: RIG133535. Right: RIG133558

HCPCS: K0040+E0951

8”Wx11”D ............................................... $247.5 0 e a .

Pair part: FRMASMB9461. Left: RIG133536. Right: RIG133559

HCPCS: K0040+E0951

11”-13” Length

Part: See XRef

N/A with Multi-axis.

11”-16.5” Leng t h

Part: See XRef

N/A with Angle Adjustable.

13”-16.5” Length

Part: See XRef

N/A with Multi-Axis.

15.5”-19.5” Length

Part: See XRef

19.4. Swing-Away Legrests

Select a legrest upper, a legrest extension, and type of footplate. Pair (P), left (L), and right (R) congurations are selected by checking the appropriate boxes. Select

legrest length in following section.

2. Lower Extension

Legrests section continued on following page.

4. Swing-Away Legrest Accessories

5. Amputee Supports with Swing-Away Upper

Enter a quantity for the amputee supports and covers. A 60°-90° legrest upper must be selected with the amputee support. The support will be congured with the

legrest upper side that does not have a lower extension and footplate selected with it.

Heel Loops (pair) ............................................................$50

Part: FRMASMB7873. HCPCS: E0951

Standard on angle adjustable and multi-axis footplates.

Wheel Bumper ...................................................... $12.50 ea.

Part: See XRef

Gel Neoprene Footrest Sleeve (pair) ...................................$80

Part: INDPART2243. HCPCS: K0108

 ............. $230 ea.

Part: INDPART2822. HCPCS: E1020

 ..............$155 ea.

Part: INDPART2823. HCPCS: K0108

70° Swing-Away Legrest (pair) ..........................................$162

Pair part: FRMASMB7841

Not available with 11"-13" extensions.

70° Tapered, Swing-Away Legrest (pair) .............................$162

Pair part: FRMASMB7843

Not available with 11"-13" extensions.

70° Tapered, Swing-Away Legrest, Short (pair) .....................$162

Pair part: FRMASMB8052

For use only with 11"-13" lower extensions.

1b. 70° Swing-Away Legrest Uppers

Only available with occupied transit WC-19 selections. Sold only in pairs. Select lower extension and footplates as pairs.

Page 13 of 18

INFINFB3538/RevO/09DEC2019

Account Number: ___________ Date: ________________ Marked for: _____________________________________

4. Elevating Legrest Accessories

3a. Reinforced Cast Footplate(s)

3b. Angle Adjustable Footplate(s)

¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”. 4"x6"

and 5"x6" footplates are only available in pairs.

1. Elevating Legrests Upper

2. Lower Extension

7.25”Wx6”D Reinforced Footplate ...................... Standard

Pair part: FRMASMB4748. Left: RIG138055. Right: RIG138056

8.5”Wx6”D Reinforced Footplate ....................... Standard

Pair part: FRMASMB4747. Left: RIG138060. Right: RIG138062

May cause interference on seat widths less than 18.”

4”Wx6”D .......................................................$85 ea.

Pair parts: FRMASMB8812 x2.

HCPCS: K0040

5”Wx6”D........................................................ $85 ea.

Pair parts: FRMASMB8811 x2.

HCPCS: K0040

5”Wx8”D Footplates with Heel Loops ................... $85 ea.

Pair part: FRMASMB4735. Left: RIG137791. Right: RIG137792

HCPCS: K0040+E0951

6”Wx8”D Footplates with Heel Loops .................. $85 ea.

Pair part: FRMASMB4738. Left: RIG137793. Right: RIG137795

HCPCS: K0040+E0951

6”W x11”D Footplates with Heel Loops ................. $85 ea.

Pair part: FRMASMB4741. Left: RIG137796. Right: RIG137797

HCPCS: K0040+E0951

8”Wx11”D Footplates with Heel Loops ................. $85 ea.

Pair part: FRMASMB4744. Left: RIG137798. Right: RIG137799

HCPCS: K0040+E0951

Heel Loops (pair) ............................................................$50

Part: FRMASMB7873. HCPCS: E0951

Wheel Bumper ...................................................... $12.50 ea.

Part: See XRef

Available on angle adjustable footplates.

Falcon Gel Padded Knee Adductor Buttons (KBE) (pair) ..........$125

Part: INDPART2242. HCPCS: E0953^

^Please verify the appropriate billing code to be used for this item

with all third-party payors.

11”-14” Leng th

Pair: FRMASMB4755

Left: RIG138026

Right: RIG138030

For reinforced only

12”-14.5” L eng th

Part: See XRef

For angle adjustable only

14”-17” Leng th

Pair: FRMASMB4756

Left: RIG138033

Right: RIG138035

For reinforced only

14.5”-18” Leng t h

Part: See XRef

For angle adjustable only

Elevating Legrest Assembly .......................... $162.50 ea.

Pair part: FRMASMB6483. Left: RIG138012

Right: RIG138013. HCPCS: E0990

Select lower extension and footplates

19.5. Elevating Legrests

Select a legrest upper, a legrest extension, and type of footplate. Pair (P), left (L), and right (R) congurations are selected by checking the appropriate boxes. Select

legrest length in following section.



20. SET LEGREST LENGTH

REQUIRED with matching left and right legrest conguration. All eorts will be made to accommodate legrest length selection, but minor changes may need to be

made to meet shipping guidelines. Some adjustments may be needed upon receipt of the unit. Reference the section’s compatibility matrix for legrest interference.

Non-matching or individual legrest congurations lengths are not set by the manufacturer. The part number will be PTOINDV plus the number after # below.

7” L

(#3470)

7.5” L

(#3471)

8” L

(#3472)

8.5” L

(#3473)

9” L

(#3474)

9.5” L

(#3475)

10” L

(#3476)

10.5” L

(#3477)

11” L

(#3478)

11.5” L

(#3479)

12” L

(#3480)

12.5” L

(#3481)

13” L

(#3482)

13.5” L

(#3483)

14” L

(#3484)

14.5” L

(#3485)

15” L

(#3486)

15.5” L

(#3487)

16” L

(#3488)

16.5” L

(#3489)

17” L

(#3490)

17.5” L

(#3491)

18” L

(#3492)

18.5” L

(#3493)

19” L

(#3494)

19.5” L

(#3495)

20” L

(#3496)

20.5” L

(#3497)

21” L

(#3498)

21.5” L

(#3600)

22” L

(#3669)

22.5” L

(#3670)

This rigging configuration causes no interference

issues at this seat-to-floor height.

This rigging configuration may have less than 1.75”

clearance when fully extended and may interfere with

the ground or reduce obstacle climbing ability.

Elevating Legrest

Compatibility Matrix

Contoured/Synergy Seat

Low Medium High

Standard, 11”-14”

Standard, 14”-17”

Angle Adjustable, 12”-14.5”

Angle Adjustable, 14.5”-18”

21.1. Seat Cushion Model Selection

21. SEAT CUSHION

Optional. Specic cushion/component sizes available, part numbers, and special order cushions can be found on the respective complete Stealth Cushion Order

Forms. This section allows a quick selection of a single cushion. The XXYY portion of the part number directly relates to the dimensions of the cushion, where XX

represents the width and YY represents the depth.

TRU-Comfort 2 SPP, E2607, 16"W to 20" W .........$400

TRU-Comfort 2 SPP, E2608, 22"W ..................... $500

Simplicity G, E2601, 10"W to 21" W ................... $110

Simplicity G, E2602, 22"W .............................. $165

Stealth Simplicity G Cushion

General use cushion with Stealth Tek 2, 2-way stretch, breathable cover.

Part series: ST-SIMGXXYY

Stealth TRU-Comfort 2 SPP Cushion

Skin protection and positioning with Coolcore, 4-way stretch, breathable cover.

Part series: ST-TC2SPPXXYY

Seat cushion section continued on following page.

Page 14 of 18

INFINFB3538/RevO/09DEC2019

21.3. Seat Cushion Substitute/Add Fluid Proof Liners

21.4. Seat Cushion Substitute Cover

The standard cover may be substituted by checking an option below. The "*prex" of the part number will be the part prex of the cushion model selected above.

For example, SPCGSPP-NBLK1816 will be an additional coolcore cover for a Spectrum Gel cushion.

21.2. Seat Cushion Dimensions

REQUIRED with cushion model selection. Select to match or pick non-matching dimensions. See respective cushion order form for available sizes.

Account Number: ___________ Date: ________________ Marked for: _____________________________________

Contoured Seat Cup Holder...............................................$20

Part: ACCASMB2287. Part with 12" lift: ACCASMB2288

Synergy/Flex Seat Cup Holder .................................. No Charge

Part: ACCASMB2634

Not available on TRU-Balance Flex seating without two-post armrests.

Oxygen Holder for Contoured Seat ....................................$118

Part: ACCASMB2292. HCPCS: E2208

Oxygen Holder for Synergy Seat ....................................... $150

Not available with Synergy Manual Recline.

Part: FRMASMB7030. HCPCS: E2208

Oxygen Holder for Flex Seat ........................................... $200

Part: ACC125006. HCPCS: E2208

Walker Holder ............................................................. $103

Contoured seat part: ACCASMB1912. Synergy/Flex part: FRMASMB7031

Cane/Crutch Holder .......................................................$110

Contoured seat part: ACCASMB2294. HCPCS: E2207

Synergy part: FRMASMB4822. Flex part: ACC152515. HCPCS: E2207

Cell Phone Holder for 12" Lift Captain Seat ...........................$70

Part: ACC1611300

Rear Basket .................................................................$118

Contoured seat part: ACCASMB1914

Synergy part: FRMASMB4821

Flag Holder ...................................................................$25

Contoured seat part: ACCASMB1930

Synergy/Flex part: ACCASMB2415.

Saddle Bag .................................................................... $35

Part: DWR1020D010

Stealth Cell Phone/Media Device Holder .............................$195

Part: ACC7120006

Stealth Large Tablet Holder ............................................ $375

Part: ACC7120005

Quantum Backpack ....................................................... $150

Part: ACC1905853

Grip Lap Board (20005)................................................$38.95

Part: ACC152992

Grip Drink Holder (20085) ............................................ $15.50

Part: ACC152993

Accessory Bar .............................................................. $100

12"W-16"W part: MEC145955. 16"W-20"W part: MEC143975.

20"W-22"W part: MEC146018

Large, Black, Weather Cover ........................................... $202

Part: ACCCOVR1021

Solution SPP, 10"W to 21" W, E2607 ..................$375

Solution SPP, 22"W, E2608 .............................. $430

Spectrum Gel SPP, 14"W to 20" W, E2607 ...........$460

Spectrum Gel SPP, 22"W, E2608 ....................... $530

Spectrum Foam SPP, 16"W to 20" W, E2607 ........$460

Spectrum Foam SPP, 22"W, E2608 .................... $530

Stealth Solution SPP Cushion

Skin protection and positioning with Coolcore, 4-way stretch, breathable cover.

Includes urethane liner.

Part series: ST-SOLSPPXXYY

Stealth Spectrum Gel SPP Cushion

Skin protection and positioning with Coolcore, 4-way stretch, breathable cover.

Includes urethane liner.

Part series: ST-SPCGSPPXXYY

Stealth Spectrum Foam SPP Cushion

Skin protection and positioning with Coolcore, 4-way stretch, breathable cover.

Includes urethane liner.

Part series: ST-SPCFSPPXXYY

Fluid Proof Urethane Liner ......................................... $50-$70

Part: URL1709070-XXYY

Not available with Simplicity, Essence, or TRU-Comfort 2.

Fluid Proof Polyurethane Liner .................................... $55-$75

Part: PUL1709030-XXYY

Not available with Simplicity.

Match Seat Width and Depth

Cushion Width

Stealth Tek 2 Cover ................................................ No Charge

Part: *prex-TBLKXXYY

Not available with Simplicity, TRU-Comfort 2, Essence, or Premiere.

Mesh Cover .......................................................... No Charge

Part: *prex-MBLKXXYY

Not available with Simplicity or TRU-Comfort 2.

Cushion Depth



Premiere P, 16"W to 20" W, E2605 .................... $325

Premiere P, 22" W, E2606 ............................... $475

Stealth Premiere P Cushion

Positioning with Coolcore, 4-way stretch, breathable cover.

Part series: ST-PREMPXXYY

Glacial SP, 10"W to 21"W, E2603 ......................$330

Glacial SP, 22"W, E2604 .................................$440

Stealth Glacial SP Cushion

Skin protection with Coolcore, 4-way stretch, breathable cover.

Part series: ST-GLSPXXYY

22. ACCESSORIES

Optional. Multiple accessories can be mounted along the various tracks but some interference may occur. Accessories may need to be installed by the provider.

Zen SP, 10"W to 21" W, E2603 .......................... $315

Zen SP, 22"W, E2604 .....................................$425

Stealth Zen SP Cushion

Skin protection with Coolcore, 4-way stretch, breathable cover.

Part series: ST-ZENSPXXYY

10” W

12” W

14” W

15” W

16" W

17" W

18" W

19" W

20" W

21” W

22" W

10” D

12” D

14” D

15” D

16" D

17" D

18" D

19" D

20" D

21" D

22" D

Stealth Essence SPP Cushion

Skin protection and positioning with Coolcore, 4-way stretch, breathable cover.

Part series: ST-ESSSPPXXYY

Essence SPP, No Wedge, 16"-20" Wide, E2607 ........$400

Essence SPP, No Wedge, 22" Wide, E2608 ............ $500

Essence SPP, Small Wedge, 16"-20" Wide, E2607 .... $435

Essence SPP, Small Wedge, 22" Wide, E2608 ......... $535

Essence SPP, Medium Wedge, 16"-20" Wide, E2607 . $465

Essence SPP, Medium Wedge, 22" Wide, E2608 ...... $565

Essence SPP, Large Wedge, 16"-20" Wide, E2607 .... $495

Essence SPP, Large Wedge, 22" Wide, E2608 ......... $595

Page 15 of 18

INFINFB3538/RevO/09DEC2019

Account Number: ___________ Date: ________________ Marked for: _____________________________________

23. BRANCH PATCHES

Optional.

Air Force Patch .................. $20

Part: ACC140240

Army Patch ....................... $20

Part: ACC140241

Coast Guard Patch .............. $20

Part: ACC140239

Marines Patch .................... $20

Part: ACC140243

Navy Patch ....................... $20

Part: ACC140244

Purple Heart Patch ............. $20

Part: ACC140238

Military Patches

24. ELECTRONICS ACCESSORIES

Optional.

Q-Logic EX/NE Programmer ............................................ $545

Part: ELEASMB6976

Q-Logic PC Programming Disk with Cable ........................... $750

Part: ELEASMB5216

Enhanced Display

25.1. Enhanced Display

Q-Logic 3 Enhanced Display Shroud

Required with Q-Logic 3 Enhanced Display selection above. Reference colors shown on page 2.

Q-Logic 3 Enhanced Display Kit ..................................................................................................... $1,720

Part: CTL167726

Select a color option below. Includes enhanced display, exible gooseneck and mounting bracket. Features: 3.5” LCD

display; up to 5 proles to control drive, seat, and auxiliary functions; Bluetooth connectivity for mobile devices and

mouse emulation; integrated single switch scanner; IR controls.

Black, Soft Touch ...........Standard

Part: DGN137728

Non-matching Shroud ............ $50

Select color below

Match Shroud to Base Color .... $50

Part: See color below

25.3. Q-Logic 3 SAJ

Q-Logic 3 EX SAJ ......................................................................................................................... $700

Part: CTL143980

Must be used in conjunction with Enhanced Display or Q-Logic 3 Joystick.

EX SAJ

SCIM Module for Q-Logic 3 ............................................................................................................. $525

Part: CTL168055

Allows use of joystick display for specialty devices. Available with Q-Logic 3 EX Joystick selection above. Up to 5 proles

to control drive, seat, and auxiliary functions, excluding sip-n-pu and single switch functions. A switch is required to

operate the input device attached to the SCIM module.

SCIM Module

25.2. SCIM Module

25.4. Head Array

Adult, i-Drive Tri-Array Series, 3-Switch ......... $4,414

Head Array (IDHBT200-1)

Part: ST-IDHBT200-1-Q. HCPCS: E2330

Features bluetooth, head support, 3 non-proportional

proximity sensors for drive control, an egg switch for re-

set mode change, and i-Drive smart box.

Adult, i-Drive Pro Series Head Array .............. $4,461

(IDHBT300-1)

Part: ST-IDHBT300-1-Q. HCPCS: E2330

Features bluetooth, head support with occipital pad and

2 swing-away spot pads for left and right side, 3 non-pro-

portional proximity sensors, an egg switch for reset

mode change, and i-Drive smart box.

Adult Pro-Series



Sip & Puff Module

 .........$294.25

Left Mount (SP625-CL)

Part: ST-SP625-CL-Q. HCPCS: E2326

Includes straw and mounting hardware. Use with Stealth

Comfort Plus headrests.

 .........$294.25

Right Mount (SP622-CR)

Part: ST-SP625-CR-Q. HCPCS: E2326

Includes straw and mounting hardware. Use with Stealth

Comfort Plus headrests.

 .........$294.25

Head Array (SP625-U)

Part: ST-SP625-U-Q. HCPCS: E2326

Includes straw and mounting hardware. Use with Stealth

i-Drive Head Arrays.

Stealth Sip & Puff

 ..................................................................................................$1,895

Part: CTL168056. HCPCS: E2325

Includes module and mounting hardware.





Alternative controls and electronics section continued on following page.

25. ALTERNATIVE CONTROLS AND ELECTRONICS

Optional. Not available with Contoured or TRU-Balance Flex seating. Select a type of specialty controls below or to refer to the specialty controls order form.

Red Corvette

Part: DGN137729-PRD1

Electric Blue

Part: DGN137729-PBU9

Back in Black

Part: DGN137729-PBK1

Night Train

Part: DGN137729-PBK3

White Satin

Part: DGN137729-PWH2

Pretty in Pink

Part: DGN137729-PPK3

Evolution Orange

Part: DGN137729-POR7

Deep Purple

Part: DGN137729-PPR5

Grey Street

Part: DGN137729-PSL3

Midnight Blue

Part: DGN137729-PBU10

Lemon Crush

Part: DGN137729-PYL4

Green Machine

Part: DGN137729-PGN11

Military Green

Part: DGN137729-PGN8

Page 16 of 18

INFINFB3538/RevO/09DEC2019

Account Number: ___________ Date: ________________ Marked for: _____________________________________

4. UniLink Pelvic/Thigh Guide Installation

Install on Left

Part: PTOINDV3585

Install on Right

Part: PTOINDV3586

Do Not Install

Part: PTOINDV3719

1. UniLink Pelvic/Thigh Hardware

2. UniLink Pelvic/Thigh Pads

^Please verify the appropriate billing code to be used for this item with all third-party payors.

3. UniLink Pelvic/Thigh Additional Links

26.2. Stealth UniLink Pelvic/Thigh Guide

UniLink, 5" Height Adjustable, ..............$245 ea.

Removable Mounting Hardware

Part: ST-UTTP5-Q

UniLink, 7" Height Adjustable, ..............$255 ea.

Removable Mounting Hardware

Part: ST-UTTP7-Q

UniLink, 4" x 4" Pad ..............................$95 ea.

Part: ST-UTP544056100-Q

UniLink, 4" x 8" Pad ............................. $105 ea.

Part: ST-UTP548056100-Q

UniLink, 4" x 12" Pad ........................... $125 ea.

Part: ST-UTP54D056100-Q

UniLink, 1.5" Link ................................................$75 ea.

Part: ST-UIL00I150A000-Q

UniLink, 2" Link .................................................... $75 ea.

Part: ST-UIL00I200A00-Q

UniLink Pad & Hardware

1. Bracket

2. Pads

3. Installation

Swing-away, Rail Mounts, pair (TWBSTL) ........................................................................................................................ $472.50

Part: INDPART2896. HCPCS: E1028

Curved Pads, 3”x5”, pair (TWBL-3X5) ................................ $210

Part: INDPART2663. HCPCS: E0956

Curved Pads, 4”x6”, pair (TWBL-4X6) ................................ $210

Part: INDPART2664. HCPCS: E0956

Install Laterals

Part: PTOINDV3499

Do Not Install

Part: PTOINDV3500

26.1. Stealth Thoracic Laterals

Swing-away laterals may interfere with TRU-Balance 3 armrests and 2-post, ip up armrests. These laterals are not available with the back cane option.

26. POSITIONING COMPONENTS

Optional. Not available with contoured seating. More options are available on the Positioning Components Order Form.

Flip Down Bracket (TWBTLADD-HW) ................... $236.25 ea.

Part: INDPART2804. HCPCS: E1028

Removable Bracket (LP430) ............................... $262.50 ea.

Part: INDPART2805. HCPCS: E1028

 .......................... $400 ea.

(LP430 & LHW-121)

Part: INDPART2854. HCPCS: E1028

Flip Down with LEFT Full Surface Contact ................. $236.25 ea.

Feature (TWBADD-L & LPHW407)

Part: POS140428. HCPCS: E1028

Flip Down with RIGHT Full Surface Contact ................ $236.25 ea.

Feature (TWBADD-R & LPHW407)

Part: POS140429. HCPCS: E1028

1. Pelvic/Thigh Guide Bracket

2. Pelvic/Thigh Guide Adapter

26.3. Stealth Pelvic/Thigh Guides

Pelvic/thigh guides may interfere with the joystick receiver block and down posts. Please provide quantity next to check box.

2” Height Adapter Plate (LHW-122) ................................. $26.25

Part: INDPART2821. HCPCS: K0108

Height adapter is needed with TRU-Comfort seat cushions. Not avail-

able with the ip down bracket.

2 1/4” Adapter Plate (LHW-129) .....................................$53.50

Part: POS140430. HCPCS: K0108

Only available with the ip down full surface bracket.

Positioning components section continued on following page.



25.8. Switch Adapter

2 to 1 Switch Adapter .................................................................................................................................................. $13.39

Part: DWR1361H037

Connects 2 single switches to a stereo jack to act as a dual switch.

25.7. Egg Switches

Egg Switch

Red Egg Switch (ESRED) ..................... $80.85 ea.

Part: SWTMCRO1077

Blue Egg Switch (ESBLU) .................... $80.85 ea.

Part: SWTMCRO1079

Black Egg Switch (ESBLK) ................... $80.85 ea.

Part: SWTMCRO1081

Green Egg Switch (ESGRN) ................. $80.85 ea.

Part: SWTMCRO1078

Yellow Egg Switch (ESYEL) ................. $80.85 ea.

Part: SWTMCRO1080

25.9. Environmental Controls

Q-Logic 3 ECU Module Kit ............................................................................................................................................. $2,400

Part: CTL168057

Page 17 of 18

INFINFB3538/RevO/09DEC2019

2. Elbow Support Pad

1. Elbow Support Bracket

26.7. Stealth Elbow Support

3"Wx3"H Elbow Pad (ARMS-ES-3X3) .......................$52.50 ea.

Part: POS124065. HCPCS: K0108

4"Wx4"H Elbow Pad (ARMS-ES-4X4) ....................... $52.50 ea.

Part: POS124067. HCPCS: K0108

Left,Swing-Away, Elbow Support Bracket, Tube ...........$183.75 ea.

Style Arms (ARMS-ES-L)

Part: POS124064. HCPCS: E1028

Right, Swing-Away, Elbow Support Bracket, Tube .........$183.75 ea.

Style Arms (ARMS-ES-R)

Part: POS124066. HCPCS: E1028

26.8. Stealth Foot Boxes

^Please verify the appropriate billing code to be used for this item with all third-party payors.

26.9. Stealth Padded Shoe Holder

Stealth Small Foot Boxes, 5"Wx8"Dx7"H .........$498.75

(SPLE107) (pair)

Part: INDPART2786. HCPCS: E0954^

Stealth Medium Foot Boxes, 6"Wx10"Dx9"H ....$498.75

(SPLE108) (pair)

Part: INDPART2787. HCPCS: E0954^

Stealth Large Foot Boxes, 7"Wx12"Dx11"H ......$498.75

(SPLE109) (pair)

Part: INDPART2788. HCPCS: E0954^

Stealth Small Padded Shoe Holder, ...................$266

3.75"Wx6.25"D (SPLE111) (pair)

Part: INDPART2783. HCPCS: E0951+E0952

Stealth Medium Padded Shoe Holder, ................$266

4"Wx8.25"D (SPLE112) (pair)

Part: INDPART2784. HCPCS: E0951+E0952

Stealth X-Large Padded Shoe Holder, ................$266

5"Wx10.75"D (SPLE114) (pair)

Part: INDPART2785. HCPCS: E0951+E0952

Stealth Foot Boxes

Stealth Shoe Holders

Account Number: ___________ Date: ________________ Marked for: _____________________________________

Contoured and Classic

Chest Harness

26.4. Stealth i-Fit Chest Harness

26.5. Stealth i-Fit Chest Straps

Upper Classic, Medium (IFPS1103) ............... $142 ea.

Part: ST-IFPS1103-Q. HCPCS: E0960

Upper Classic, Large (IFPS1104) .................. $142 ea.

Part: ST-IFPS1104-Q. HCPCS: E0960

Upper Contour, Medium (IFPS2103) .............. $142 ea.

Part: ST-IFPS2103-Q. HCPCS: E0960

Upper Contour, Large (IFPS2104) ................ $142 ea.

Part: ST-IFPS2104-Q. HCPCS: E0960

Chest Strap, Medium w/ Belt Anchor ............. $90 ea.

(IFCS4113)

Part: ST-IFCS4113-Q. HCPCS: E0960

Chest Strap, Large w/ Belt Anchor ................ $90 ea.

(IFCS4114)

Part: ST-IFCS4114-Q. HCPCS: E0960

Chest Strap

1" Ball Kit for Facial Laterals (TWB-1BK) (D) ..... $80.25

Part: POS150532

Required with facial laterals to mount to comfort head-

rest brackets.

Egg Switch Mount (ESM) (A) ................ $52.50 ea.

Part: INDPART2815

Figure 8 Bracket with 13" Rod ............ $267.50 ea.

and Egg Switch Mount (B)

Part: ST-F8675-13-Q

Facial Pad, 4"x2" (900-Q)................... $53.50 ea.

Part: ST-900-Q. HCPCS: K0108

Facial Pad, 6"x2" (920-Q) ................... $53.50 ea.

Part: ST-920-Q. HCPCS: K0108

Swing-Away Joystick Mount, ..................$250 ea.

18" Rod (C)

Part: ST-SUS18-Q

Allows mounting of facial pads and attaches to the

headrest

26.6. Stealth Swing-Away Headrest Mounts

These swing-away headrest mounts are only available with the Stealth Comfort Series headrests. The 1" ball kit must be selected to

mount the facial lateral to the headrest bracket. Also select a facial pad(s) with the facial lateral(s).

Facial Lateral for Comfort Series .............$294.25 ea.

Right Side (CPS9-R-HW)

Part: INDPART2647. HCPCS: E1028

Facial Lateral for Comfort Series .............$294.25 ea.

Left Side (CPS9-L-HW)

Part: INDPART2648. HCPCS: E1028

Facial Laterals for Comfort Series ........... $3 47.75 ea.

Left and Right Side (CPS9-B-HW)

Part: INDPART2649. HCPCS: E1028

Left and Right Facial

Lateral with Pads

Headrest Accessories

3. Pelvic/Thigh Guide Pad

^Please verify the appropriate billing code to be used for this item with all third-party payors.

4. Pelvic/Thigh Guide Installation

Short Pad, 4”x4” (TWBADD-4X4) .............................. $75 ea.

Part: INDPART2801. HCPCS: E0953^/E0956

Medium Pad, 4”x8” (TWBADD-4X8) ...........................$75 ea.

Part: INDPART2802. HCPCS: E0953^/E0956

Long Pad, 4”x12” (TWBADD-4X12) ............................$75 ea.

Part: INDPART2803. HCPCS: E0953^/E0956

Install on Left

Part: PTOINDV3585

Install on Right

Part: PTOINDV3586

Do Not Install

Part: PTOINDV3719

2. Facial Lateral Pads and Accessories

1. Facial Lateral Hardware



Page 18 of 18

INFINFB3538/RevO/09DEC2019

Account Number: ___________ Date: ________________ Marked for: _____________________________________

Alternative Controls & Electronics Order Form Positioning Components Order Form

Quantum

Rehab

401 York Ave., Duryea, PA 18642

Phone: 866-800-2002 | Fax: 866-707-3422 | Email: quantumorders@pridemobility.com

facebook.com/

QuantumRehab

youtube.com/

QuantumRehab

instagram.com/

quantum_rehab

twitter.com/

quantumrehab

No Additional Multiplier (NA) .................................... No Charge

Part: Conguration selection

Secondary Multiplier (SM) ........................................... $221.21

Part: HAR144004



Part: Conguration selection

1 Arm 2 Arm 3+ Arm

1 Back

0 Back

2 Back

3+ Back

No additional Multiplier

Secondary Multiplier

Special Order Required

SOF

Q-Logic 3 Multiplier with Synergy Seat Chart

Arm Mounts

Joystick (Hand Control)

Enhanced Display

iAccess

USB Charger

SAJ

Back Mounts

Attendant Control

SCIM

Sip n Puff

ECU

28. REFERENCE ORDER FORMS

Optional. Select below to note that additional order forms will accompany this order form. This will also be a link in interactive forms.

27. TRU-BALANCE 3 MULTIPLIER HARNESS

REQUIRED. Multiple controllers or power accessories may require an additional multiplier harness or special order. Reference the chart below to determine the

appropriate selection. The rows refer to the total amount of arm mounted devices and the columns refer to the total amount of back mounted devices. The online

order congurator will automatically make this selection under specialty controls.