Page 1 of 2 INFINFB4384/RevA/26AUG2021 Go-Go Ultra X, 3-Wheel, Black ..................................... $1,329 Part: S39. HCPCS: K0899 — Power Mobility Device, not coded by DME PDAC or does not meet criteria. Go-Go Ultra X, 4-Wheel, Black ..................................... $1,469 Part: S49. HCPCS: K0899 — Power Mobility Device, not coded by DME PDAC or does not meet criteria. Go-Go ® Ultra X 3-Wheel and 4-Wheel Travel Mobility Scooter — Quick Ship Order Form Pride ® Mobility Products Corporation 401 York Avenue, Duryea, PA 18642 Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected] Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ ACCESSORIES Optional. Micro Black Weather Cover ...............................................$140 Part: ACCCOVR1020 Cup Holder ............................................................................ $30 Part: ACCASMB2288 50″ Lap Belt ................................................................ Standard Part: ACCBELT1000 Safety Flag ............................................................................ $38 Part: ACCASMB2079 Saddle Bag (12.5″ × 9.875″) .................................................. $40 Part: DWR1020D010 Under-Seat Storage ............................................................. $80 Part: ACC160129 2.1A XLR USB Charger ................................................... $42.99 Part: KIT2001524 Rearview Mirror.................................................................... $25 Part: ACC134496 MODEL REQUIRED. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/go-go-ultra-x-3-wheel or pridemobility.com/go-go-ultra-x-4-wheel. Standard Features • 12Ah battery pack • 2-amp off-board charger • Front basket • 8″ flat-free tires • Mesh-back seat (17″W × 17″D) INTRODUCTION This form is interactive when viewed in Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete scooter. Pride Providers may contact Technical Services for accurate parts ordering. Thank you for choosing Pride Mobility Products! FDA Class II Medical Device* Back-Mounted Accessories Optional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware. Rear Basket (15.25″ × 9.75″ × 9.5″) . $90 Part: ACCBSKT1010 Oxygen Tank Holder ...................... $98 Part: ACCASMB1017 Walker Holder ................................. $98 Part: ACCASMB1018