Quickie QXi FSS Net Order Form/Price List (SIN F-1) Effective December 2014 FSS #V797P-3220M - TID

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1 Mark For: Date: Dealer Acct #: Dealer: Dealer Contact: Dealer Address: Dealer City: ST: Dealer Phone: ( ) Fax: ( ) Confirmation Confirm Via: Quickie QXi FSS Net Order Form/Price List (SIN F-1) Effective December 2014 FSS #V797P-3220M - TID ZIP: Submitting for: Address: Address: Ship To City: Quote Fax Ship To Phone: ( ) Fax: ( ) The HCPCS CODES provided are based on code verification through PDAC or our interpretation of the code definitions. The use of HCPCS CODES does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy. Option # HCPCS Definition Price Option # HCPCS 1. FRAME STYLE & SETUP Includes Modification P00092 PO#: Ship To: Attention: ST: Order ADDITIONAL SHIPPING INFORMATION Definition ZIP: Price Base Model 196WM78 K0005 Quickie QXi (265 lbs) For 14" sizes use E1236 $ Frame Style See Seat Height Matrix on page 2 196FS9 Standard Frame 196FS30 Hemi Frame Frame Width 196W5 14" 196W6 15" 196W7 16" 196W8 17" 196W9 18" 196W10 19" 196W11 E " $ Transit 196TO38 Transit System $ SD7 196SD8 196SD9 196SD10 196SD11 196SD71 196SD13 E " 15" 16" 17" 18" 19" 20" Seat Depth $ Quickie QXi, Ultra Lightweight Adjustable Folding Wheelchair Quickie QXi featuring the Jay ION cushion Page 1

2 2. FRONT SEAT HEIGHT SET UP Front Seat Height Front Seat Height Matrix See Front Seat Height Matrix & 13.0 only available w/ 60 hanger 12.5" & 13" only available w/ Alum Angle Adj Footplate 196SH " 196SH " Standard Stem Bolt 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " SH " 196SH " 4 x 1.25 Semi Pneu SH " 196SH " SH " 196SH " 5 x 1.5 Semi Pneu SH " N/A N/A N/A N/A N/A N/A N/A N/A Wheels N/A N/A N/A N/A CW3 4" Low Profile Polyurethane 8 x 1.5 Semi Pneu N/A N/A N/A N/A CW44 4" x 1.25" Semi Pneumatic $ " FORK 7" FORK 196CW5 5" Low Profile Polyurethane 196CW7 5" x 1.5" Semi Pneumatic $ CW34 6" Polyurethane 4 x 1.25 Semi Pneu CW35 6" x 1.5" Semi Pneumatic $ CW32 8" Polyurethane 5 x 1.5 Semi Pneu CW39 8" x 1.5" Semi Pneumatic Fork $ N/A N/A N/A N/A CF71 3.5" (standard stem bolt only) 8 x 1.5 Semi Pneu N/A CF12 196CF17 196CF " 6" 7" For 3/4" and 1 1/2" Stem bolt matrix see page 5 D 196CS1 196CS5 196CS9 Stem Bolt Standard 3/4" 1 1/2" 3. HANGER & FOOTPLATE OPTIONS Front Hangers Footplate mounts with Extension Tube using clamping hardware 196H H H Swing In/Out Hanger 70 Swing In/Out Hanger 80 Swing In/Out Hanger 196H143 E0990 Elevating Legrest (Front Latch) All ELR's will be Black paint $ H144 Omit Hanger & Footplate Extension Tubes See Lower Leg Length Matrix for range 196E1 196E2 196E5 Short Medium Long Footplate Heel loop not included, see Footplate Option section below 196F1 196F3 K0040 Composite Footplate Aluminum Angle Adj. Footplate 196F5 Aluminum Only available w/elevating Legrest $67.71 Lower Leg Length Range Matrix Hanger Ext Tube Footplate Composite Alum Angle Adj Aluminum Short 11.25" " 9.25" " NA 60 Medium 11.25" " 9.25" " NA Long 12.50" " 10.75" " NA Short 12.00" " 10.00" " NA 70 Medium 12.00" " 10.75" " NA Long 13.75" " 12.25" " NA Short 10.50" " 10.50" " NA 80 Medium 11.75" " 11.75" " NA Long 13.50" " 11.75" " NA Short 11.25" " 11.00" " 11.50" " ELR Medium 12.50" " 11.25" " 13.50" " Long 14.50" " 13.00" " 15.25" " All values are ± 0.25" and based on flat seat heights and do not account for the minimum 2" ground clearance or footplate thickness. Full ELR values based on 70 hanger angle 196HL A02 Hanger & Footplate Options E0951 Adjustable Heel Loop Gel Cover For Hangers (Pair) $12.81 $40.26 Page 2

3 4. REAR SEAT HEIGHT SET UP Rear Seat Height Matrix Rear Wheel Size See Rear Tire & Wheel Matrix for availability Rear Wheel Size 20" Rear Wheel 22" Rear Wheel 24" Rear Wheel 25" Rear Wheel 26" Rear Wheel Std Frame 13.0" " 14.0" " 15.0" " 15.5" " 16.0" " Rear Seat Height Hemi Frame 12.0" " 12.5" " 13.5" " 14.0" " 14.5" " 196RW3 196RW8 196RW1 196RW90 196RW91 196RW92 196RW RW101 20" Mag Wheel 22" Mag Wheel 24" Mag Wheel 20" Lite Spoke Wheel 22" Lite Spoke Wheel 24" Lite Spoke Wheel 25" Lite Spoke Wheel 26" Lite Spoke Wheel See Rear Seat Height Matrix 196RW25 Omit 196RH9 196RH10 196RH11 12" 12.5" 13" Rear Wheel Tire See Rear Tire & Wheel Matrix for availability 196RH " 196RT1 196RH13 14" E2212 Pneumatic 196RH " 196RT2 Pneumatic w/ Airless Insert 196RH15 15" E2213 $ RH " 196RT3 E2218 Full Poly 196RH17 16" 196RT6 High-Pressure Clincher 196RH " E2212 $ RH19 196RH26 196RH20 17" 17.5" 18" Handrim Natural Fit only available w/ 22, 24, 25 Lite Spoke. Plastic NA w/ 25, 26" 196RH " 196HR1 Aluminum Anodized 196RH21 19" Seat Squeeze Matrix 196HR4 196HR22 196HR23 Plastic Natural Fit - Standard Grip Natural Fit - Super Grip $34.77 $ $ Frame Depth Max Seat Squeeze 14" 2.0" 15" - 16" 2.5" 17" - 18" 2.5" 19" - 20" 3.0" Rear Tire & Wheel Matrix Wheel Tire Mag Spoke Pneumatic 20,22,24,26 20,22,24,26 Pneumatic w/ Airless Insert 20,22,24,26 20,22,24,26 Full Poly Tire 20,22,24 20,22,24 High Pressure Clincher N/A 22,24,25,26 22" = 489 mm 24" = 540 mm Extension Handle Ext. handles only available with high mount push or pull wheel locks 196EH7 E0961 Extension Handle (Pair) 196WL1 196WL2 196WL30 196WL10 196WL12 196AX1 196AX11 Wheel Lock High Mount Push High Mount Pull Compact Omit Wheel Lock Do Not Mount Axle Quick Release Steel Quad Quick Release Steel NA on Spoke $ $23.79 $ ARMREST Some limitations when used with the Angle Adjustable Back in the rear most setting Please circle a setting, will default to 11" if no selection is made E0973 Padded Swing-Away (9" to 13") $ AA18 Setting 9" 10" 11" 12" 13" Armrest - Padded Swing Away Armrest - Height Adjustable 196AA104 E0973 Single Post Ht. Adj - Std (9.75"-14.75") $ AA105 E0973 Single Post Ht Adj - Low (8.25"-12.25") $ AA65 E0973 Flip Back Ht Adj LITE (10"-15") $ AA14 Omit Armrest 196AA103 E0973 Dual Post Flip Back Ht Adj $ AM23 196AM A01 Armpad - For Height Adjustable Desk Length (10") Full Length - Full (14") Armrest Options Gel Cover For Swing Away Arms (pair) $ Page 3

4 6. BACKREST Back Type 196BT10 Standard 196BT100 Angle Adjustable Back $60.39 Backrest Height 196B5 Med (13"-17") 196B9 Tall (16"-20") 196BU1 196BU70 196BU71 196BU14 Back Upholstery Standard Upholstery E2611 Backrest Tension Adj Ballistic Nylon *Reference 186BU70 for billing $ E2611 Backrest Tension Adj 3DX Vented *Reference 186BU71 for billing $ Omit Back Upholstery -$ PH6 196PH5 196PH2 Push Handles Integral Push Handles 8 for Std Backrest, Straight for Angle Adj. Backrest Fold-Down Push Handles Only available with Adjustable Upholstery. Used in combination w/angle Adjust only avail in 16"-20" Omit Push Handles 8 for Std Backrest, Straight for Angle Adj. Backrest $ JB01 JAY J3 Back JAY J3 Back See OF Military Service Patches Only available on tension adjustable upholstery and Jay 3 Back 196VU1 196VU2 196VU3 196VU4 196VU12 196VU5 196VU8 196VU9 196VU10 196VU11 196VU13 US Marines Patch US Army Patch US Navy Patch US Air Force Patch US Coast Guard Purple Heart Purple Heart with Marines Patch Purple Heart with Army Patch Purple Heart with Navy Patch Purple Heart with Air Force Patch Purple Heart with Coast Guard 7. SEATING Seat Sling 196SL23 Seat Sling Depth Adjustable 196SL6 Omit Seat Sling -$5.49 JAY Cushions (Optional) To order any JAY cushions on-chair, please see the JAY price list. Cushion name or part number must be filled out with desired width and depth JAY Bundled Cushion 196JC20 Cushion Name or Part # Price List Width: Depth: 8. Key Options & Accessories 196AT1 E0971 Anti Tips Anti Tips (Pair) $ A01 Spoke Guards K0065 Quickie Black Spoke Guard $42.09 Side Guards 196SG33 K0108 Plastic - Standard (8.5" High) $ SG29 K0108 Plastic - Low (6.5" High) $ A03 196A2100 E2207 Miscellaneous Caddy Crutch Holder $16.47 $71.37 Pack Accessories 196A1 Backpack - Black/Charcoal Adult Open Market 1961A01 Seat Pouch Black Open Market Positioning Belt 196A141 E " Auto Buckle w/ Clamps $ A804 K0108 Positioning Belt Slide Clamps $18.30 Frame Color 196C2 Black 196C10 Black Opal 196C38 Blue Opal 196C36 Candy Blue 196C35 Candy Red Page 4

5 4 x 1.25 Semi Pneu 5 x 1.5 Semi Pneu 8 x 1.5 Semi Pneu 4 x 1.25 Semi Pneu 5 x 1.5 Semi Pneu 8 x 1.5 Semi Pneu Front Seat Height Matrix Cont. 3/4" STEM 1 1/2" STEM N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A x 1.25 Semi Pneu N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A x 1.5 Semi Pneu N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A x 1.5 Semi Pneu N/A N/A N/A N/A " FORK 7" FORK 7" FORK N/A N/A x 1.25 Semi Pneu N/A N/A x 1.5 Semi Pneu N/A N/A N/A N/A N/A N/A N/A N/A x 1.5 Semi Pneu N/A N/A N/A N/A " FORK Page 5

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