Contour Static Seating on ROVI X3 Base US PRICE LIST AND ORDER FORM Price Effective August 15, 2017
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1 Contour Static Seating on ROVI X3 Base US PRICE LIST AND ORDER FORM Price Effective August 15, 2017 REQUIRED INFORMATION Date of Order: Dealer Account #: Dealer Name: PO #: Tag Base PO #: After Market Items shipping to Motion Concepts: Yes No List Items: PO #: Name of the Manufacturer: Purchasing Contact: Phone: Fax: RTS/Therapist: Ship to Address: City: State: Zip: Client Gender: M F Special Client Conditions: REQUIRED MEASUREMENTS To ensure system is accurately configured please fill in all required measurements. 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: Weight Capacity is up to 300lbs unless specified otherwise G A D E F I B C H BASE VITALS HCPCS CODES SUSPENSION SYSTEM BASE WIDTH BASE LENGTH 36.5 DRIVE WHEEL SIZE (1) 14 CASTER WHEEL SIZE (front/rear) 6 TURNING RADIUS 20 DRIVETRAIN K0848/, K0849 Active Ride Control (ARC) 4-pole EAD Motors BATTERIES BATTERY CHARGER BATTERIES WEIGHT (each) RANGE (2) WEIGHT CAPACITY BASE WEIGHT (w/o batteries) GROUND CLEARANCE 3 MAXIMUM SPEED 2 x M34 8A, Off Board 38.5 lbs (M34) 17.7 miles 300 lbs 157 lbs 6.2 mph (1) All X3 wheels come with solid inserts (2) Actual driving range and speed may vary due to factors such as user weight, type and grade of terrain, battery condition & charge level; type and condition of the drive wheels, and variations in the drive and control systems. SOLID SEAT PAN - K0848 CAPTAIN SEAT - K0849 Grey Black PAGE 1 of 5
2 Dealer Name: PO #: Tag: BASE COLOR Select Color: Standard With Lights (1)..... $1,195 Blizzard White Part # Part # Matte BlackPart # Part # Solar YellowPart # Part # Motion Green Part # Part # Original OrangePart # Part # Bright Blue Part # Part # Red DeliciousPart # Part # Party Pink Part # C Part # C Purple ReignPart # Part # Matching Battery Doors (select fender color first).. $ Fully integratd LED lighting kit. Includes headlights, taillights and turn signals. Must select Joystick for Lights feature or Omni for operation. CUSTOM FENDER OPTIONS Custom Fender Design by Bob Rice.... $500 Please refer to Page 4 for Custom fender options by Bob Rice Standard Fender Configuration.... N/C Fenders w/lights Configuration... $1195 FULL CAPTAIN-STYLE SEAT - K0849 All bases below come standard with Full Captain-Style Seat in Grey or Black Vinyl and 22 high backrest. Includes a Semi-Recline hinge of 120 with left side only adjustable lever. Standard adjustable height, flip-back armrests and a foot platform that measures 12 wide by 9 deep. ROVI X 3 (1) HCPCS Code: K0849 Part # 888WNLEX3-SP-SC $6,695 Select One: Standard 5.0 mph High Torque Motors N/C Part # HTM5 Optional 5.8 mph Quick Speed Motors (2) $200 Part # QSM58 Optional 6.2 mph High Speed Motors (2).... $1,550 with OnTraxx Enhanced Driving Module Part # HSM62 Select: Grey Seat Size: 18 x18 Part # V18171/222RG 20 x20 Part # SV /2RG Black Seat Size: 18 x18 Part # SV18171/222RB 20 x20 Part # SV /2RB Select STF (2) : 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 300 lbs. 2. Seat to floor height is measured at the front of the seat pan based on a standard seat size. Seat to floor heights may vary +/-.25 dependent on conditions of the power base and on seat depths greater than 18. SOLID SEAT PAN & CAPTAIN-STYLE SEAT - K0848 Dipped Fender Designs $395 Please refer to Page 5 for Custom Dipped fender options Standard Fender Configuration.... N/C Fenders w/lights Configuration... $1195 Front/Rear Battery Doors $750 Front Battery Doors $395 Rear Battery Doors $395 Fenders & Front/Rear Battery Doors......$1100 TIRE OPTIONS Standard Solid Tires Part # STIRES STD Pneumatic Tires Part # PTIRES $199 MILITARY DECAL 3 Diameter Decal (Uninstalled) $50 Army Navy Air Force Marines All bases above come standard with a Solid Seat Pan style Captain Seat in Grey or Black Vinyl and 22 high backrest. Includes a Semi-Recline hinge of 120 with left side only adjustable lever. Standard adjustable height, flip-back armrests and a foot platform that measures 12 wide by 9 deep. ROVI X 3 (1) HCPCS Code: K0848 Part # 888WNLEX3-SP-SS $6,550 Select One: Standard 5.0 mph High Torque Motors N/C Part # HTM5 Optional 5.8 mph Quick Speed Motors (2) $200 Part # QSM58 Optional 6.2 mph High Speed Motors (2).... $1,550 with OnTraxx Enhanced Driving Module Part # HSM62 Select: Grey Seat Size: 18 x18 Part # SP181821RG 20 x20 Part # SP202023RG Black Seat Size: 18 x18 Part # SP181821RB 20 x20 Part # SP202023RB Select STF (2) : 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 300 lbs. 2. Seat to floor height is measured at the front of the seat pan based on a standard seat size. Seat to floor heights may vary +/-.25 dependent on conditions of the power base and on seat depths greater than 18. PAGE 2 of 5
3 Dealer Name: PO #: Tag: SEAT CUSHION REFERENCE GUIDE JOYSTICK MOUNT Meshtex Spacetex Startex Fusion SEAT CUSHION OPTIONS - FOR SOLID SEAT Matrx Libra Seat Cushion 18 w-20 w HCPCS Code E2624.$485 Matrx PS Seat Cushion 18 w - 20 w HCPCS Code E2605..$345 Matrx Vi Seat Cushion 18 w - 20 w HCPCS Code E2607..$425 FABRIC OPTIONS FOR CUSHIONS Spacetex Fabric Option for Libra Cushion Part # SFLF..... N/C Infection Control Fabric Option for Libra Cushion Part # ICFL $50 Fusion Fabric Upgrade for Matrx Vi Cushion Part # FFV... $150 Onyx Fabric Upgrade for Matrx Vi Cushion Part # OCUMA... $100 Startex Fabric Upgrade for Matrx Vi Cushion Smooth Side up Part # SFVS $50 Fabric Side up Part # SFVF $50 SINGLE FUNCTION CONTROL OPTIONS VR2 Non-Expandable Joystick Part # D STD R-Net LED Remote Joystick (1)(2) Part # D51122SC......$295 R-Net LED Remote Joystick for Lights (1) Part # D $500 R-Net Color Remote Joystick with Monojacks (1)(2) Part # D $600 R-Net Color Remote Joystick with Monojacks for Lights (1) Part # D $650 R-Net Advanced Joystick (1) Part # D $ high-resolution VGA color display I IR Control as standard I Optional,Integrated Bluetooth module available now $600 R-Net Expandable Controller (3) $615 HCPCS Code: E2377 Part # D51109 R-Net Harness for Expandable Controller (3)......$415 HCPCS Code:E2313 Part # REH 1. Requires an R-Net Controller and Harness 2. Light package not available with the joystick. 3. Required for R-Net Remote Joysticks. Infection Control Onyx Cushion Meshtex Startex Infection Spacetex Fusion Onyx Libra N/A STD $50 N/C N/A N/A PS N/A STD - Reversible STD - Reversible N/A N/A N/A Vi STD $50 $50 N/A $150 $100 Square Joystick Mount Receiver Part # STD Square Joystick Mount Part # STD Swing Away Mount Bracket Part # A3.... STD Select Mounting Position: Left Right JOYSTICK HANDLES Part # ML MR T Handle for Joystick Knob $115 HCPCS Code: E2323 Part # SA80941 Ball Handle for Joystick Knob $115 HCPCS Code: E2323 Part # SA72441 BodyPoint Joystick Handle HCPCS Code: E $120 3 U-Shaped Part # PC101B-20 4 U-Shaped Part # PC102B-20 Domed Rubber Part # PC107B-20 ELECTRONIC OPTIONS R-Net Output Module(EMC) (1)2) $995 Part # D50883 R-Net Bluetooth Module (1)(2) $895 Select OS: ios Apple Part # D51580Android/PC Part # D51111 Smart Phone Holder Part # SPH N/C 1. Requires an R-Net Controller and Harness order above 2. Must order R-Net Color Remote joystick with these options ARMRESTS (MUST BE SELECTED) Adjustable Height Flip Back Arm Left Part # $125 Adjustable Height Flip Back Arm Right Part # $125 OTHER OPTIONS Wheelchair Transport Brackets (1) Part # XBKTS......$ For unoccupied use only BATTERIES 2 x MK GROUP 34 Batteries Part # M34 SLD G (Two)....$650 HCPCS Code: E2359 Total Retail Value $ PAGE 3 of 5
4 Dealer Name: PO #: Tag: CUSTOM FENDER DESIGN BY BOB RICE DESIGN DESCRIPTION (PLEASE USE IF YOU SELECTED PERSONALIZED OPTION Flames Personalized Camouflage Silver Concrete U.S. Navy U.S. Coast Guard U.S. Air Force DEALER SIGN OFF This concept is agreed to and accepted by: U.S. Marines U.S. Army Dealer Name: PO #: Approved with no changes Approved with changes Review again Date: Signature: PAGE 4 of 5
5 Dealer Name: Dealer Name: Dealer Name: Account Number: Dealer PO #: Account Number: PO #: PO Tag: #: Tag: Tag: CUSTOM DIPPED FENDER DESIGNS Graphity U.S. Flag Animal Paw Print Camouflage Electric Circuit Flames 80's Green Rock 80's Black Rock Front Battery Door Rear Battery Door Pink Camo Fenders Flower Power CUSTOM DIPPED BATTERY DOOR DESIGN Please select Fender option first, if battery doors. are to match the fenders. If not make the design selection below Matching Front Battery Door $395 Matching Rear Battery Door $395 Front Battery Door $395 Rear Battery Door $395 U.S. Flag 80 s Black Rock Camouflage Pink Camo Electric Circuit Flower Power Flames 80's Green Rock Graphity Animal Paw Print PAGE 5 of 5
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