www.motionconcepts.com PAGE 1 of 10 Prices subject to change without notice. 700 Ensminger Rd., Suite 112, Tonawanda, NY 14150 TOLL FREE TEL: 1.888.433.6818 TOLL FREE FAX: 1.888.433.6834 TRD0559, REV B To ensure system is accurately configured please fill in all required measurements. Date of Order: __________________ Quote Order Dealer Name: _______________________________________________ Dealer Account #: ___________PO #: ___________________________ Tag _________________________________________________________ Purchasing Contact: __________________________________________ Phone: __________________________ Fax: _______________________ E-mail: ______________________________________________________ ATP/Therapist: _______________________________________________ Ship to Address: _____________________________________________ City: ____________________________ State: _____________________ Zip: _____________________________ Special Client Conditions: ____________________________________ Client Gender: M F REQUIRED MEASUREMENTS REQUIRED INFORMATION MPS Mini Modular Power Standing System on ROVI A 3 US PRICE LIST AND ORDER FORM Price Effective July 1, 2020 Weight Capacity is up to 200lbs unless specified otherwise stated. HCPCS CODES K0861 SUSPENSION SYSTEM Active Ride Control (ARC) BASE WIDTH 25.5” BASE LENGTH 36.5” DRIVE WHEEL SIZE (1) 14” CASTER WHEEL SIZE (front/rear) 6” TURNING RADIUS 20.5” DRIVETRAIN 4-pole EAD Motors BATTERIES 2 x M34 BATTERY CHARGER 8A, Off Board BATTERIES WEIGHT (each) 38.5 lbs (M34) RANGE (2) 17.7 miles WEIGHT CAPACITY 200 lbs BASE WEIGHT (w/o batteries) 159 lbs GROUND CLEARANCE 3” MAXIMUM SPEED 5.8 mph BASE VITALS (1) All A3 wheels come with solid inserts (2) Driving range is affected by selection of battery, drive motor, and tire options. It may also vary due to other factors, such as user weight, terrain, battery condition, tire condition, as well as variations in drive and control systems. MULTI-POSITION STANDING MAXX SYSTEM Client Height: Client Weight (lbs): A. Seat to Shoulder: B. Trunk Depth: C. Chest Width: D. Knee to Back: E. Seat to Top of Head: F. Elbow to Hand: G. Seat to Elbow: H. Hip Width: I. Knee to Heel: Cushion Thickness:
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www.motionconcepts.com PAGE 1 of 10Prices subject to change without notice.
700 Ensminger Rd., Suite 112, Tonawanda, NY 14150 TOLL FREE TEL: 1.888.433.6818 TOLL FREE FAX: 1.888.433.6834 TRD0559, REV B
To ensure system is accurately configured please fill in all required measurements.
Date of Order: __________________ Quote Order Dealer Name: _______________________________________________
(1) All A3 wheels come with solid inserts(2) Driving range is affected by selection of battery, drive motor, and tire options. It may also vary due to other factors, such as user weight, terrain, battery condition, tire condition, as well as variations in drive and control systems.
MULTI-POSITION STANDING MAXX SYSTEM
Client Height:
Client Weight (lbs):
A. Seat to Shoulder:
B. Trunk Depth:
C. Chest Width:
D. Knee to Back:
E. Seat to Top of Head:
F. Elbow to Hand:
G. Seat to Elbow:
H. Hip Width:
I. Knee to Heel:
Cushion Thickness:
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www.motionconcepts.com PAGE 2 of 10Prices subject to change without notice.
700 Ensminger Rd., Suite 112, Tonawanda, NY 14150 TOLL FREE TEL: 1.888.433.6818 TOLL FREE FAX: 1.888.433.6834 TRD0559, REV B
BASE FENDER COLORSelect Color: STD With Lights(1) $1,195
Blizzard White Part # 800914-00200-03 Part # 800914-00201-03Matte BlackPart # 800914-00200-50 Part # 800914-00201-50Solar YellowPart # 800914-00200-69 Part # 800914-00201-69Motion Green Part # 800914-00200-36 Part # 800914-00201-36Original OrangePart # 800914-00200-23 Part # 800914-00201-23Bright BluePart # 800914-00200-40 Part # 800914-00201-40Red DeliciousPart # 800914-00200-21 Part # 800914-00201-21Party Pink Part # 800914-00200-2C Part # 800914-00201-2CPurple ReignPart # 800914-00200-80 Part # 800914-00201-80Matching Battery Doors Part # MBD (select fender color first) . . .$495
1. Fully integratd LED lighting kit. Includes headlights, taillights and turn signals. Must select Joystick for Lights feature or Omni for operation.
Please see Custom Design Options on page 9 and 10.
1. Price of the powerbase includes: Active Ride Control suspension, tie-down hardware for 4-point strap system, 8 amp off-board charger, flat free inserts and positioning belt, Weight capacity is 200 lbs.2. Requires R-Net Controller and Harness. Light package is not available with this joystick.3. This item is required when ordering power tilt, power recline, and power elevating legrests together OR when ordering an Alternative Drive Control.
1. Requires an R-Net Controller and Harness.2. Specialty Items required must ship to Motion Concepts for install. 3. Light package not available with this joystick.
1. Seat-to-floor height is measured at the front of the seat pan based on a standard seat size. Seat-to-floor height may vary +/-.25” dependent on conditions of the power base and seat depth.
Please note that the HCPCS codes indicated on this order form are our interpretation of the new codes and how we believe our products should be coded. The individual DMERCs will determine if our interpretation is appropriate and whether or not items coded will be accepted or denied. Motion Concepts cannot guarantee that use of the designated codes will ensure coverage or payment. Contact the insurer to confi rm compliance with coding and coverage policy
! Pleof DMcode
!!!
MPS Mini Modular Power Standing System Rovi A3
www.motionconcepts.com PAGE 4 of 10Prices subject to change without notice.
700 Ensminger Rd., Suite 112, Tonawanda, NY 14150 TOLL FREE TEL: 1.888.433.6818 TOLL FREE FAX: 1.888.433.6834 TRD0559, REV B
www.motionconcepts.com PAGE 7 of 10Prices subject to change without notice.
700 Ensminger Rd., Suite 112, Tonawanda, NY 14150 TOLL FREE TEL: 1.888.433.6818 TOLL FREE FAX: 1.888.433.6834 TRD0559, REV B
MAXX LATERALS PADS (1)
Fixed Mounted Lateral Trunk Support LEFT . . . . . . . .$100 HCPCS code E0956
Select Pad Size:
XS(3.25”x4.25”) Part # LATXL S(3.5”x5.25”) Part # LATSL
M(3.75”x5.75”) Part # LATML L(4.25”x6.5”) Part # LATLL
Fixed Mounted Lateral Trunk Support RIGHT . . . . . .$100 HCPCS code E0956
Select Pad Size:
XS(3.25”x4.25”) Part # LATXR S(3.5”x5.25”) Part # LATSR
M(3.75”x5.75”) Part # LATMR L(4.25”x6.5”) Part # LATLR
1. These laterals are not available with Matrx PB, PB Elite Deep and PB Deep Backs.2. The amount of offset available may be impacted by back thickness.
SELECT MAXX SWING-AWAY HARDWARE(NEXT) TO CONVERT ABOVE SUPPORTS:
MAXX SWING-AWAY HARDWARE(1)
Maxx Style Swing-away Multi-Adjustable Mounting Hardware LEFT HCPCS code E1028 Part # SALATL . . . . . . .$195
(Standard with 1” telescoping link gives 0-2.75” medial offset (2))
Maxx Style Swing-away Multi-Adjustable Mounting Hardware RIGHT HCPCS code E1028 Part # SALATR . . . . . .$195
(Standard with 1” telescoping link gives 0-2.75” medial offset (2))
Additional Telescoping Link(ea) Quantity ( ) . . . . .$75 (Adding an additional 1” telescoping link gives up to 5.5” medial offset(2))
LEFT Part # ATLL RIGHT Part # ATLR
1. These laterals are not available with Matrx PB, PB Elite Deep, PB Deep Backs and PB HD and HD Deep .2. The amount of offset available may be impacted by back thickness.
FIXED HIP/KNEE SUPPORTS
Lateral Hip Support Pad with Fixed Mounting LEFT .$120HCPCS code E0956
Mounted at HIP Pad Size:XS(5.5”W x 4”H) Part # HSPXLH S(7”W x 6”H) Part # HSPSLH
M(9”W x 4”H) Part # HSPMLH L(13”W x 4”H) Part # HSPLLH
Mounted at KNEE Pad Size:XS(5.5”W x 4”H) Part # HSPXLK S(7”W x 6”H) Part # HSPSLK
M(9”W x 4”H) Part # HSPMLK L(13”W x 4”H) Part # HSPLLK
FIXED HIP/KNEE SUPPORTS - CONTINUEDLateral Hip Support Pad with Fixed Mounting RIGHT . . $120HCPCS code E0956
Mounted at HIP Pad Size:XS(5.5”W x 4”H) Part # HSPXRH S(7”W x 6”H) Part # HSPSRH
M(9”W x 4”H) Part # HSPMRH L(13”W x 4”H) Part # HSPLRH
Mounted at KNEE Pad Size:XS(5.5”W x 4”H) Part # HSPXRK S(7”W x 6”H) Part # HSPSRK
M(9”W x 4”H) Part # HSPMRK L(13”W x 4”H) Part # HSPLRK
SELECT MAXX SWING-AWAY HARDWARE(NEXT) TO CONVERT ABOVE SUPPORTS
REMOVABLE & SWING AWAY HARDWARE UPGRADE
HARDWARE TO CONVERT ABOVE HIP SUPPORT TO UPGRADE TO REMOVEABLE/SWINGAWAY HIP OR KNEE SUPPORTS
Lift Off Removable Hardware for Hip Support (Hip position only) HCPCS code E1028
Maxx Style Quick Release, Removable, Multi-AxisMounting Hardware for Hip Supports HCPCS code E1028
LEFT Mounted at Hip Part # MHSHLH . . . . . . . . .$215 RIGHT Mounted at Hip Part # MHSHRH . . . . . . . . .$215 LEFT Mounted at Knee Part # MHSHLK . . . . . . . .$215
RIGHT Mounted at Knee Part # MHSHRK . . . . . . . .$215
Extended Maxx Style Quick Release, Removable, Multi-AxisMounting Hardware for Hip Supports(1) HCPCS code E1028
LEFT Mounted at Hip Part # EMQHLH . . . . . . . . .$215 RIGHT Mounted at Hip Part # EMQHRH . . . . . . . .$215 LEFT Mounted at Knee Part # EMQHLK . . . . . . . .$215
RIGHT Mounted at Knee Part # EMQHRK . . . . . . . .$215
1. Recomended when finished seat cushion thickness will be greater then 3.5” high.
www.motionconcepts.com PAGE 8 of 10Prices subject to change without notice.
700 Ensminger Rd., Suite 112, Tonawanda, NY 14150 TOLL FREE TEL: 1.888.433.6818 TOLL FREE FAX: 1.888.433.6834 TRD0559, REV B
CENTER MOUNT FOOT PLATFORM OPTIONS
POWER CENTER MOUNT FOOT PLATFORM OPTIONS
Mini Power Elevating BDC Belt Drive Center MountArticulating Foot Platform Part # MBDC . . . . . . . . . . $3,295HCPCS code K0108
Seat pan to footplate:8”-11.5” Part # SPTF17
11”-15.5”/16.5(1) Part # SPTF18
Comes standard with individual calf pads Part # ICP
1. With 18.5” seat-to-floor selected the maximum seat pan to footplate is 15.5”,with 19.5” seat-to-floor height selected the seat pan to footplate is 16.5”.
MUST SELECT FOOT PLATE OPTION
Select: Footplate Option:
Left: S(5”W x 7.5”D) M(5.5”Wx9.5”D)L(6”Wx11.5”D) $165Part # IFSL IFML IFLL
Right: S(5”W x 7.5”D) M(5.5”Wx9.5”D)L(6”Wx11.5”D) $165Part # IFSR IFMR IFLR
1. Knee blocks are removable and stored on the side of the chair when not in use.2. 1.5” of height adjustment and 3” of depth adjustment and 2” of width
independent adjustment.
ELECTRONICS SWITCH MOUNTING
Select: LeftRightDo Not MountPart # ESML ESMR ESMD
Please contact Customer Service for a specialty control configuration sheet.
MULTI-FUNCTION ELECTRONICS
Multi Function Through Switches(1) Part # MFCBSS . . . $1,995
Select: 8-Way Rocker Part # EWRO
Multi Function Through Drive Control(1) Part # MFCBD$2,995HCPCS code E2311
Through Joystick Part # JOY
Through Specialty Control Part # SC
Additional Switch: Quad Push Button Part # QPBA ..................$97 Four-Way Toggle Part # FWTA ...................$97
8-Way Rocker Part # EWRA .......................$150
1. These electronics include attendant control, drive lock-out, tilt/recline limit andactuator speed control and reduced drive.
BATTERIES
MK GROUP 34 Battery (Each)Quantity ( ) Part # M34 SLD G HCPCS code E2359 . . . . . . . . . . . . $305
INSTALLATION
Installation by Motion Concepts Part # MCI . . . . . . . . . . N/C