Mobility Devices Product Manual
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Mobility Devices Product Manual Effective Date : June 01, 2015 Assistive Devices Program Ministry of Health and Long-Term Care Printed Date: Mar 5, 2015 Page: 1 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Ambulation Aids Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price Adult Wheeled Walker Type 1 Airway Surgical Top Release 5051/5051-J MW1AR0005 1 $82.00 Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, two or four small wheels (less than 6" diameter) and braking system (if available). See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required. Amg Medical Deluxe Folding Wheeled Walker MW1GM0010 1 $82.00 Drive Medical 10263KDR Travel Folding Walker AA0000560 1 $82.00 One Button Or Dual Trigger Release MW1D50005 1 $82.00 Red Dot Extra Wide G07767 MW1GU0020 1 $82.00 Red Dot G07756 MW1GU0035 1 $82.00 Red Dot Standard G07755 & G07756 MW1GU0015 1 $82.00 Human Care Canada Inc. Deluxe Regular MW1DG0020 1 $82.00 Deluxe Small MW1DG0025 1 $82.00 Invacare Adult MW1IN0010 1 $82.00 Lumex Dual Release Adult/Junior MW1LU0020 1 $82.00 Lightweight Adult/Junior MW1LU0010 1 $82.00 Rubbermaid Deluxe MW1C60010 1 $82.00 Sunrise Medical Breezy Everyday Folding Walking Frame with wheels AA0001152 1 $82.00 Adult Wheeled Walker Type 2 Airway Surgical 5314 MW2AR0010 1 $324.00 Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, four small wheels (less than 6" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required. Amg Medical Airgo Adventure 6 MW2GM0040 1 $324.00 Airgo Ultra Light MW2GM0050 1 $324.00 Duet 795b Rollator MW2D00010 1 $324.00 Go-Lite Deluxe MW2D50005 1 $324.00 Challenger Grande MW2EV0025 1 $324.00 Challenger Mini MW2EV0010 1 $324.00 Sprite & Sprite Mini MW2EV0005 1 $324.00 Sprite Grande MW2EV0020 1 $324.00 4200 Dx MW2DG0010 1 $324.00 4200 Lx MW2DG0005 1 $324.00 Nexus 1 (Cable Brake) MW2DG0050 1 $324.00 Rollite 65100 MW2IN0050 1 $324.00 Three Wheels MW2IN0030 1 $324.00 MEDLINE INDUSTRIES INC. Translator AA0000459 1 $324.00 Nighthawk Ats 902 Handi Lite MW2NM0005 1 $324.00 Ats 903 Handi Lite MW2NM0010 1 $324.00 Ats 904 Handi Lite MW2NM0015 1 $324.00 Ovation Compact 807-6 MW2NM1005 1 $324.00 Guardian Drive Medical Evolution Medical Human Care Canada Inc. Invacare Page: 2 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Ambulation Aids Device Type Adult Wheeled Walker Type 2 Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, four small wheels (less than 6" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required. Adult Wheeled Walker Type 3 Walker type most suitable for active use on most terrains. ADP price includes frame,four large wheels (6"/8" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required. Manufacturer Device Device Code Max Allowed Qty. Approved Price Prode3 ProDe3 Victr/ 17,19 21 inches AA0000320 1 $324.00 Sunburst Medical Freedom Plus MW22S0005 1 $324.00 Freedom Plus Short MW22S0010 1 $324.00 Active MW3V80005 1 $417.00 Breeze MW3V80010 1 $417.00 5305 Adult Type 3 Walker AA0000315 1 $417.00 5307 Rollator AA0000460 1 $417.00 AIRGO EXCURSION XWD AA0000124 1 $417.00 Airgo Adventure 8 MW3GM0060 1 $417.00 Airgo Comfort Plus Xwd MW3GM0055 1 $417.00 Airgo Comfort-Plus MW3GM0050 1 $417.00 Airgo Duo MW3GM0040 1 $417.00 Airgo Excursion MW3GM0065 1 $417.00 Airgo Fusion Rollator AA0000694 1 $417.00 Airgo Navigator MW3GM0015 1 $417.00 Alpha Advanced MW3DO1085 1 $417.00 Alpha Basic MW3DO1080 1 $417.00 Jazz MW3DO2000 1 $417.00 Opal Futura Symphony MW3DO1055 1 $417.00 Opal Legacy MW3DO1040 1 $417.00 Opal Maxi / Maxi+ MW3DO1035 1 $417.00 Soprano MW3DO1095 1 $417.00 Diamond 740r Rollator MW3D50010 1 $417.00 Nitro AA0001036 1 $417.00 Nitro Hemi AA0001193 1 $417.00 Nitro Tall AA0001194 1 $417.00 Volaris S7 AA0000456 1 $417.00 Volaris S7 Smart AA0000457 1 $417.00 Enkatsu Solutions Prima Rollator MW3EH0005 1 $417.00 Evolution Medical Challenger Low Wide MW3EV0035 1 $417.00 Challenger Wide MW3EV0030 1 $417.00 Evolution Dx, Ldx, Wdx, Lwdx MW3EV0005 1 $417.00 Horizon Dx, Wdx, Lwdx, Tdx MW3EV0010 1 $417.00 Piper Dx, Mdx, Smdx, Tdx MW3EV0020 1 $417.00 Xpresso, Xpresso Lite MW3EV0040 1 $417.00 Access Vital As Airway Surgical Amg Medical Dolomite Drive Medical EUROVEMA AB Page: 3 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Ambulation Aids Device Type Adult Wheeled Walker Type 3 Walker type most suitable for active use on most terrains. ADP price includes frame,four large wheels (6"/8" diameter), hand braking system, seat, and back support. See Ambulation Aids Options Chart if heavy duty frame and/or forearm attachments required. Manufacturer Approved Price AA0000453 1 $417.00 Handicare Gemino AA0001082 1 $417.00 Gemino 60 AA0001236 1 $417.00 4200swx MW3DG0035 1 $417.00 4200wx MW3DG0030 1 $417.00 Nexus Ii (Cable Brake) MW3DG0040 1 $417.00 Nexus Iii (Cable Free Braking System) MW3DG0045 1 $417.00 Solo MW3DG0010 1 $417.00 Ats 906 0vation MW3NM0015 1 $417.00 Ovation Compact 805-8 MW3NM1005 1 $417.00 Ovation Compact 806-8 MW3NM1010 1 $417.00 ProDe3 Aurora 19/21/23 inches AA0000321 1 $417.00 ProDe3 Balius/21 wide AA0000319 1 $417.00 Freedom All Terrain MW32S0010 1 $417.00 Freedom Xl MW32S0015 1 $417.00 Freedom Xls MW32S0005 1 $417.00 Mirage 4900 MW32S0030 1 $417.00 Mirage 4925 MW32S0040 1 $417.00 Mirage 4950 MW32S0035 1 $417.00 Shopper 4700 MW32S0020 1 $417.00 Titan MW32S0050 1 $417.00 Olympos MW3TV0020 1 $417.00 Human Care Canada Inc. Sunburst Medical Topro Paediatric Specific Walking Frame Max Allowed Qty. HYBRID LX Rollator Prode3 1 Pair of Forearm Crutches from the following manufacturers may be billed under this code. Device Code GF HEALTH PRODUCTS Nighthawk Forearm Crutches Device Troja MW3TV0010 1 $417.00 Triumph Mobility Inc Escape AA0001084 1 $417.00 Wheelzahead USA, LLC Wheelzahead Track III Rollator AA0001235 1 $417.00 Approved ADP Manufacturers Only Forearm Crutches MKZND0005 1 $121.00 Can-Dan Rehatec Buddy Roamer AA0001101 1 $2,578.00 Meywalk 3, Meywalk 4 MW6CD0045 1 $2,578.00 Meywalk, Medium & Large MW6CD0040 1 $2,578.00 Mini-Meywalk MW6CD0050 1 $2,578.00 Nimbo KA1200N AA0000110 1 $220.00 Nimbo KA2200N AA0000111 1 $220.00 Nimbo KA3200N AA0000112 1 $220.00 ADP price includes frame, four wheels, hand grips (including arm supports), and built in sitting support (e.g. sling/saddle seat). See Ambulation Aids Options Chart for adolescent sizes. Drive Medical Page: 4 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Ambulation Aids Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price Paediatric Specific Walking Frame Drive Medical Nimbo KA4200N AA0000105 1 $220.00 ADP price includes frame, four wheels, hand grips (including arm supports), and built in sitting support (e.g. sling/saddle seat). See Ambulation Aids Options Chart for adolescent sizes. Hoggi Flux Gait Trainer MW6K20005 1 $2,578.00 Ormesa Dynamico MW6R80055 1 $2,578.00 Paediatric Specific Wheeled Walker Type 1 Walker type most suitable for use on hard, flat surfaces. ADP price includes frame, two or four small wheels, and braking system (if available). See Ambulation Aids Options Chart for adolescent sizes. Paediatric Specific Wheeled Walker Type 2 Grillo MW6OA0005 1 $2,578.00 Prime Engineering Kidwalk MW62P0005 1 $2,578.00 Rifton Equipment Pacer Gait Trainer MW6RF0005 1 $2,578.00 Snug Seat Inc. Bronco,Sizes 0,1,2 MW6R80060 1 $2,578.00 Crocodile Reverse Walker MW6R80070 1 $2,578.00 Gator MW6R80005 1 $2,578.00 Mustang Gait Trainer AA0000693 1 $2,578.00 Pony,Size 0 MW6R80040 1 $2,578.00 Pony,Size 1 MW6R80045 1 $2,578.00 Pony,Size 2 MW6R80050 1 $2,578.00 Pony,Size 3 MW6R80052 1 $2,578.00 Strider Tweener G07783 MW4GU0035 1 $220.00 Strider Tyke G07782 MW4GU0030 1 $220.00 Tyke G07751 MW4GU0010 1 $220.00 Adolescent 2 Wheels MW4KY0065 1 $220.00 Adolescent 4 Wheels MW4KY0070 1 $220.00 Adolescent 4 Wheels/Swivel MW4KY0075 1 $220.00 Child 2 Wheels MW4KY0020 1 $220.00 Child 4 Wheels MW4KY0025 1 $220.00 Child 4 Wheels/Swivel MW4KY0030 1 $220.00 Child Small 2 Wheels MW4KY0005 1 $220.00 Child Small 4 Wheels MW4KY0010 1 $220.00 Child Small 4 Wheels/Swivel MW4KY0015 1 $220.00 Pre-Adolescent 2 Wheels MW4KY0050 1 $220.00 Pre-Adolescent 4 Wheels MW4KY0055 1 $220.00 Pre-Adolescent 4 Wheels/Swivel MW4KY0060 1 $220.00 Guardian Kaye Otto Bock Walker type most suitable for active use on most terrains. ADP price includes all components and options. Paediatric Standing Frame Type 1 Otto Bock Youth 2 Wheels MW4KY0035 1 $220.00 Youth 4 Wheels MW4KY0040 1 $220.00 Youth 4 Wheels/Swivel MW4KY0045 1 $220.00 Nurmi Neo MW5OB0005 1 $1,524.00 Yogi Walker AA0000683 1 $1,524.00 Vertical Stander MS1HY0005 1 $1,219.00 Page: 5 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Ambulation Aids Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price ADP price includes frame, positioning straps, trunk, pelvic, knee and foot supports, and tray. See Ambulation Aids Options Chart for adolescent sizes. Prime Engineering Up-Right Stander MS12P0015 1 $1,219.00 Paediatric Standing Frame Type 2 Altimate Medical Easy Stand 5000&7000 Magician MS2HC0005 1 $3,285.00 Easy Stand Bantam MS2HC0015 1 $3,285.00 Easy Stand Evolv MS2HC0010 1 $3,285.00 Dondolino, Size 1 MS2OA0010 1 $3,285.00 Dondolino, Size 2 MS2OA0015 1 $3,285.00 Dondolino, Size 3 MS2OA0020 1 $3,285.00 Mini Standy MS2OA0030 1 $3,285.00 Standy MS2OA0035 1 $3,285.00 Leckey Mygo Stander AA0000692 1 $3,285.00 Squiggle Stander AA0000700 1 $3,285.00 Kidstand & Grandstand 111 MS22P0010 1 $3,285.00 Superstand,Small & Youth MS22P0005 1 $3,285.00 Symmetry Standing Frame MS22P0015 1 $3,285.00 Prodije Baby,Kid & Junior MS2JP0010 1 $3,285.00 Snug Seat Inc. Buffalo/ Caribou, all sizes MS2R80005 1 $3,285.00 Gazelle,Size 1 MS2R80020 1 $3,285.00 Gazelle,Size 2 MS2R80025 1 $3,285.00 Gazelle,Size 3 MS2R80030 1 $3,285.00 ADP price includes frame, positioning straps, trunk, pelvic, knee and foot supports, and tray. See Ambulation Aids Options Chart for adolescent sizes. Ormesa Otto Bock Prime Engineering Page: 6 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Ambulation Aids OPTIONS: Device Type AA - Custom Modifications Manufacturer Device Device Code Max Allowed Qty. Approved Price MOCM 1 AA5 1 $100.00 AA7 1 $300.00 AA6 1 $200.00 AA8 1 $100.00 AA1 2 $200.00 AA2 1 $100.00 AA3 1 $150.00 The MOCM code may be used when custom modifications are required to an ADP listed ambulation aid or paediatric stander, and there is no ADP code with assigned funding available. The following documentation must be submitted: 1. Authorizer must provide clinical rationale to support the request. 2. Vendor must provide a breakdown of the cost of labour (not to exceed $40.00/hour), and parts. Adolescent Size Paediatric Specific Walker Additional funding for adolescent sized paediatric walkers. Authorizer must document clinical requirements. Selected device must meet size requirements. Adolescent Size Paediatric Standing Frame Additional funding for adolescent sized paediatric standing frames (device type ms1 & ms2). Authorizer must document clinical requirements. Selected device must meet size requirements. Adolescent Size Paediatric Walking Frame Additional funding for adolescent sized paediatric walking frames (device type mw6). Authorizer must document clinical requirements. Selected device must meet size requirements. Extra Wide Adult Wheeled Walker Extra wide adult wheeled walker (greater than 18" between push handles) due to client stature. Client weight less than 275lbs. Authorizer must document client's requirements. Forearm Attachments Forearm attachments for wheeled walkers. Authorizer must provide clinical rationale to support request (maximum 2). Heavy Duty Package Client Weight 275-350 lbs Heavy duty package for wheeled walkers, client weight 275-350 lbs. Authorizer must document client weight. Selected device must meet weight requirements. Heavy Duty Package Client Weight 350-400 lbs Page: 7 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Ambulation Aids OPTIONS: Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price AA4 1 $200.00 AA9 1 $100.00 Heavy duty package for wheeled walkers, client weight 350-400 lbs. Authorizer must document client weight. Selected device must meet weight requirements. Heavy Duty Package Client Weight Exceeded 400 lbs Heavy duty package for wheeled walkers, client weight exceeds 400lbs. Authorizer must document client weight. Selected device must meet weight requirements. Unilateral Hand Brake Unilateral hand brake. allows locking/braking of both brakes using one hand. Authorizer must document clinical requirements. (max 1) Page: 8 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Action Products Adaptive Engineering Lab Adaptive Equipment Systems (Aes) Device Device Code Max Allowed Qty. Approved Price Twister Cb Back 15"-16" Width X 11"-16" Height SEBAN0005 1 $388.00 Twister Cb Back 15"-16" Width X 17"-21" Height SEBAN0025 1 $388.00 Twister Cb Back 17"-18" Width X 11"-16" Height SEBAN0010 1 $388.00 Twister Cb Back 17"-18" Width X 17"-21" Height SEBAN0030 1 $388.00 Twister Cb Back 19"-20" Width X 11"-16" Height SEBAN0015 1 $457.00 Twister Cb Back 19"-20" Width X 17"-21" Height SEBAN0035 1 $457.00 Twister Cb Back 21"-23" Width X 11"-16" Height SEBAN0020 1 $457.00 Twister Cb Back 21"-23" Width X 17"-21" Height SEBAN0040 1 $457.00 DROP-IN R-BACK CURVED - SUNMATE OR PUDGEE FOAM SEBE10035 1 $201.00 Drop-In R-Back Curved With 1.5" Poly Foam SEBE10030 1 $192.00 Drop-In R-Back Curved With Sun-Mate Or Pudgee Foam SEBE10040 1 $230.00 Drop-In R-Back With 1" Poly Foam SEBE10005 1 $153.00 Drop-In R-Back With 1.5" Poly Foam SEBE10010 1 $168.00 Drop-In R-Back With Sun-Mate Or Pudgee Foam SEBE10020 1 $168.00 Drop-In T-Back Curved - Sun-Mate Or Pudgee Foam SEBE10075 1 $249.00 Drop-In T-Back Curved With Sun-Mate Or Pudgee Foam SEBE10080 1 $219.00 Drop-In T-Back With Sun-Mate Or Pudgee Foam SEBE10060 1 $216.00 Adjustable Bi-Angular Solid Back Insert, SEB2L1025 Includes T-Nuts & Adjustment Brackets. 1 $378.00 I Or T Or Curved Syle Solid Back Insert, SEB2L1015 Includes T-Nuts. 1 $236.00 Oversize Upcharge For Backs Over 2o" But Less Than 28". SEB2L1040 1 $69.00 Quick-Fit Contour/Bi-Angular Solid Back Insert, Incudes T-Nuts. SEB2L1030 1 $519.00 Sculptured Solid Back Insert, Includes T-Nuts. SEB2L1035 1 $862.00 Page: 9 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Adaptive Equipment Systems (Aes) Advanced Mobility Amysystems Blake Medical Device Device Code Max Allowed Qty. Approved Price Sculpturefit Back W/Attaching Hardware, Custom. SEB2L0015 1 $1,066.00 Solid Back Insert Package W/Universal Hardware Or E-Z Mount Mount Hardware & Rotating Hold Downs. SEB2L0005 1 $555.00 Solid Back Insert Package, Li'L Kiddos, 14" Wide Or Less. SEB2L0020 1 $632.00 Solid Back Insert Package, Li'L Kiddos, Contoured, 14" Wide. SEB2L0025 1 $775.00 Solid Back Insert, Includes T-Nuts, Li'L Kiddos, 14" Wide Or Less. SEB2L1010 1 $213.00 Solid Back Insert, Includes T-Nuts. SEB2L1005 1 $158.00 Solid Back W/Drop Hooks & Fixed Hold Downs. SEB2L0010 1 $230.00 Contoured Back SEBAO0040 1 $259.00 Deep "U" Back SEBAO0035 1 $293.00 Ez Back Basic SEBAO0060 1 $304.00 Ez Back System Complete SEBAO0055 1 $354.00 Pro Back Support SEBAO0065 1 $449.00 U Form Deep Contour Back Support SEBAO0050 1 $744.00 Contour Back Support For Heavy Duty SEB4P0020 1 $825.00 Contour Back Support, Non-Standard Sizes SEB4P0015 1 $524.00 Contour Back Support, Standard Sizes SEB4P0010 1 $442.00 Silverback Max 16/18/20" wide SE0001109 1 $872.00 Silverback Prime 16/18/20" wide SE0001108 1 $742.00 Body Ryzm Life Sciences / Perspectis, Inc. JazzRX SE0001205 1 $63.00 Broda Back Pad SEBB-0010 1 $58.00 Custom Fabricated Back With Permanent Lateral Supports, Vinyl Cover, Without Mounting Hardware SEBCF114L 1 $561.00 Complex Indirect Molded Back, Without Cover And Mounting Hardware SEBCF118L 1 $1,259.00 Complex Molded Back (Foam In Place), SEBCF117L Without Cover And Mounting Hardware 1 $1,122.00 Contoured Back (Foam On Rigid Base), SEBCF112L Minimal Trunk Support, Vinyl Cover, Without Mounting Hardware 1 $431.00 Page: 10 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Custom Fabricated Dynamic Health Care Solutions Future Mobility Device Device Code Max Allowed Qty. Approved Price Custom Contoured Back, Moderate Trunk Support, Vinyl Cover, Without Mounting Hardware SEBCF113L 1 $673.00 Custom Shaped Sculptured Back, Includes Cover, Without Mounting Hardware SEBCF115L 1 $819.00 Flat Back/Planar Design, Vinyl Cover Without Mounting Hardware SEBCF110L 1 $259.00 Simple Molded Back (Foam In Place), Without Cover And Mounting Hardware SEBCF116L 1 $810.00 Cushion Size 14" - 21" SEBD30005 1 $475.00 Cushion Sizes 14" - 21" SEBD30015 1 $579.00 HAKC Back Support 10" - 14" SE0001129 1 $476.00 MAPS Back Support 14" - 24" SE0001130 1 $687.00 NXT AC BACK 12" TO 20" SE0000340 1 $496.00 NXT ACT Back, Cushion Size 14"- 21" SEBD30010 1 $496.00 NXT HA AC BACK - 22 " SE0001182 1 $497.00 NXT HA AC BACK 16" TO 20" SE0000335 1 $475.00 NXT HA PC BACK 16" TO 20" SE0000336 1 $475.00 NXT HA PC BACK 22" SE0000338 1 $496.00 NXT HA SC 22" SE0000334 1 $496.00 NXT PC BACK 12" TO 20" SE0000341 1 $579.00 NXT SC BACK 12" TO 20" SE0000339 1 $475.00 NXT VC BACK SE0000120 1 $756.00 Nxt Carbon Fiber FHAC Back, FM SE0001221 1 $756.00 Nxt Carbon Fiber FHAC Back, QR SE0001222 1 $756.00 Nxt FH AC 22" HD Back SE0001215 1 $497.00 Nxt FH PC 22" HD Back SE0001216 1 $566.00 Nxt Optima FH AC Back SE0001217 1 $476.00 Nxt Optima FH PC Back SE0001219 1 $545.00 nxt HA SC Back 16" to 20" SE0000337 1 $475.00 Custom Lunar Back SE0000684 1 $656.00 Custom Lunar Back HD SE0000685 1 $1,242.00 Full Back - Sizes From 14" To 22" Lateral SEBFM3040 1 $549.00 Full Back - Sizes From 14" To 22" Ultra Lateral SEBFM3050 1 $590.00 Full Back - Sizes From 18" To 24" No Lateral SEBFM3020 1 $507.00 Page: 11 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Future Mobility Device Device Code Max Allowed Qty. Approved Price Full Back Style Heaby Duty SEBFM3060 1 $725.00 Low Back - Sizes From 14" To 22" Lateral SEBFM3035 1 $483.00 Low Back - Sizes From 16" To 20" - No Lateral SEBFM3010 1 $431.00 Mid Back - Sizes From 14" To 22" Lateral SEBFM3030 1 $531.00 Mid Back - Sizes From 14" To 22" Ultra Lateral SEBFM3045 1 $573.00 Mid Back - Sizes From 16" To 20" - No Lateral SEBFM3015 1 $490.00 Mid Back Style Heavy Duty SEBFM3055 1 $690.00 Orion Back SEBFM3005 1 $400.00 Prism Air Back - Custom Sizes SEBFM0045 1 $742.00 Prism Air Back - Non Standard Sizes SEBFM0040 1 $656.00 Prism Air Back Fits 16,18,20" Wide W/C SEBFM0035 1 $552.00 Prism Bariatric Air Back 21x16 Though 24x20 SEBFM2025 1 $828.00 Prism Bariatric Air Back- Custom Size SEBFM2030 1 $914.00 Prism Bariatric Basic Back - Custom Size SEBFM2010 1 $742.00 Prism Bariatric Basic Back 21x16 Through 42x20 SEBFM2005 1 $690.00 Prism Bariatric Ultra Back 21x16 Through 24x20 SEBFM2015 1 $697.00 Prism Bariatric Ultra Back- Custom Size SEBFM2020 1 $794.00 Prism Basic Back - Custom Sizes SEBFM0015 1 $569.00 Prism Basic Back - Non Standard Sizes SEBFM0010 1 $518.00 Prism Basic Back Fits 16,18,20" Wide W/C SEBFM0005 1 $424.00 Prism Max Back - Upcharge SEBFM0150 1 $86.00 Prism Phantom Back 12-18" Width X 7" Height SEBFM0070 1 $275.00 Prism Super Back For Kids - Custom Sizes SEBFM0090 1 $569.00 Prism Super Back For Kids - Non Standard Sizes SEBFM0085 1 $493.00 Prism Super Back For Kids Fits 10, 12, 14 And 16" Wide W/C SEBFM0080 1 $431.00 Prism Truefitt Back - Bariatric Sizes SEBFM0060 1 $863.00 Prism Truefitt Back - Custom Sizes SEBFM0065 1 $707.00 Page: 12 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Future Mobility Handicare Hoggi Innovators 1993 Inc Invacare Device Device Code Max Allowed Qty. Approved Price Prism Truefitt Back - Non Standard Sizes SEBFM0055 1 $638.00 Prism Truefitt Back Fits 16,18,20" Wide W/C SEBFM0050 1 $604.00 Prism Ultra Back - Custom Sizes SEBFM0030 1 $697.00 Prism Ultra Back - Non Standard Sizes SEBFM0025 1 $621.00 Prism Ultra Back Fits 16,18,20" Wide W/C SEBFM0020 1 $535.00 Back Cushion 16x20,18x20, 20x20 SEBM90005 1 $169.00 Backrest "Plush", Deep Or Active Contour SEBM90020 1 $459.00 Lateral Support Backrest 16x20,18x20 SEBM90010 1 $297.00 Sedeo Pro-Comfort Backrest 16"w to 18"w x 20"h SE0000655 1 $518.00 Sedeo Pro-Comfort Backrest 20"w x 20"h SE0000656 1 $552.00 Sedeo Pro-comfort Backrest 22"w x 20" h SE0000657 1 $587.00 Sedeo Pro-deep Backrest 16"w to 18"w x to 20"h SE0000658 1 $587.00 Sedeo Pro-deep Backrest 20"w x 20"h SE0000659 1 $620.00 Sedeo Pro-deep Backrest, Active cut 16"w to 18"w x 20"h SE0000661 1 $587.00 Sedeo Pro-deep Backrest, Active cut 20" w x 20"h SE0000662 1 $620.00 Sedeo Pro-deep Backrest, Active cut 22"w x 20" h SE0000663 1 $656.00 Sedeo Pro-deep backrest 22"w x 20 h SE0000660 1 $656.00 Smartsit Comfort Back - All Sizes SEBM90100 1 $549.00 Back Cushion Shaped SE0000469 1 $272.00 Back Cushion trough Shaped SE0000466 1 $322.00 Xps Adaptive Back Cushion SEBK20050 1 $259.00 K Special Back-Custom SEBI30020 1 $152.00 K Special Back-Standard SEBI30010 1 $130.00 K-Combo Back SEBI30060 1 $173.00 K-Combo Back Custom SEBI30065 1 $191.00 Key-Hole Back SEBI30030 1 $152.00 Key-Hole Back Custom SEBI30040 1 $169.00 Key-Hole Back Custom Adjustable Top SEBI30045 1 $169.00 Contour U Back Includes All Modifications & Vacuum/Vinyl SEBNS1030 1 $1,156.00 Page: 13 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Invacare Invacare - Matrx Seating Device Device Code Max Allowed Qty. Approved Price Curved Back Fits 10" To 20" Wide W/C SEBNS0030 1 $432.00 Curved Back Pneumatic Fits 10" To 20" Wide W/C SEBNS0040 1 $474.00 Curved Back Pneumatic Special Size & Modifications SEBNS0045 1 $562.00 Curved Back Special Size & Modifications SEBNS0035 1 $519.00 Naked Contour U Back, Includes All Modifications & Vacuum/Moisture Proof Coating/Removable Cover & Cover Pattern. SEBNS1035 1 $1,375.00 Personal Back Bariatric Builder Size SEBNS0058 1 $657.00 Personal Back Fits 16", 18", 20" Wide W/C SEBNS0052 1 $444.00 Personal Back Plus - Bariatric Builder Size SEBNS0088 1 $771.00 Personal Back Plus - Fits 16", 18", 20" Wide W/C SEBNS0062 1 $558.00 Silhoutte Back Support SEBNS1020 1 $545.00 Deep Heavy Duty Posture Back, All Sizes SEB1M0020 1 $922.00 Deep Posture Back, All Sizes SEB1M0015 1 $681.00 Genera Back SEB1M0050 1 $382.00 Heavy Duty Posture Back Fits W/C 20"-25" Width & 16"-20" Height SEB1M0010 1 $801.00 Matrx Elite HD, greater than 24" SE0001052 1 $1,113.00 Matrx Elite HD, up to 24" SE0001051 1 $703.00 Matrx Elite TR - Adult SE0001214 1 $596.00 Matrx High Back Fits W/C 16" - 21" Width & 20" - 30" Height SEB1M1005 1 $560.00 Matrx MX1 Superlite, 12" SE0001054 1 $785.00 Matrx MX1 Superlite, 16" SE0001055 1 $854.00 Matrx MX1 Superlite, 9" SE0001053 1 $716.00 Matrx Mini - Paediatric SE0001213 1 $583.00 PB Elite Deep All Sizes SEB1M0026 1 $618.00 PB Extra Wide Deep Heavy Duty Backs From 16 To 20 Inches SEB1M0040 1 $1,239.00 PB Extra Wide Heavy Duty Backs Sizes SEB1M0035 16 To 20 Inches 1 $1,133.00 PB Posture Back Elite, Posture Back 1 $584.00 Upholstery SEB1M0025 Page: 14 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Invacare - Matrx Seating Jay Medical Device Device Code Max Allowed Qty. Approved Price Posture Back Fits W/C 13"-20" Width & 12"-20"Height SEB1M0005 1 $560.00 Trx Rehab Back, Fits W/C 18" - 25" Width SEB1M1050 1 $204.00 Foam Back SEBJA5040 1 $99.00 J2 Deep Contour Back 14w-19w, Includes Mounting Hardware, Cover, Lumbar Supports & Lateral Wedges SEBJA7000 1 $523.00 J2 Deep Contour Back 20wx20h, Includes Mounting Hardware, Cover, Lumbar Supports & Lateral Wedges SEBJA7005 1 $557.00 J3 Lower Thoracic Back, All Sizes SEBJA0900 1 $380.00 J3 Mid Thoracic Back, All Sizes SEBJA0905 1 $511.00 J3 Shoulder Height Back, All Sizes SEBJA0915 1 $618.00 J3 Upper Thoracic Back, All Sizes SEBJA0910 1 $600.00 JAY 2 Plus 20-23", 23-26" J2 Back Assembly For 0 Or 8 Degree Backposts SEBJA0300 1 $982.00 JAY Zip Back All Sizes SE0000640 1 $587.00 Jay 2 Back Includes Mounting Hardware (""K"" Or ""G"" Type), Cover & Lumbar Supports (14""-19"") SEBJA0100 1 $501.00 Jay 2 Back Includes Mounting Hardware, Cover & Lumbar Supports (12"/13") SEBJA0105 1 $501.00 Jay 2 Back- Includes Mounting Hardware (""K"" Or ""G"" Type), Cover & Lumbar Supports (20"") SEBJA0110 1 $560.00 Jay 2 Plus 20-23", 23-26" Back Assembly For 0 To 8 Degree Backposts, With Headrest Mounting Kit SEBJA0310 1 $1,052.00 Jay 2 Tall Back- Includes Mounting Hardware, Cover & Lumbar Supports (20") SEBJA0130 1 $662.00 Jay 2 Tall Back- Includes Mounting Hardware, Cover & Lumbar Supports (14"/16"/17"/18") SEBJA0120 1 $574.00 Jay 3 Back Shoulder Height - Sizes 21 Height To 22 Width SEBJA8215 1 $1,221.00 Jay 3 Back- Posterior Upper thoracicSizes 18 Height To 24 Width SEBJA8210 1 $1,121.00 Elite Full Back, All Sizes Page: 15 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Jay Medical Device Device Code Max Allowed Qty. Approved Price Jay 3 Back- Posterior mid thoracic Sizes 12 Height To 26 Width Sizes 15 Height To 26 Width SEBJA8205 1 $1,052.00 Jay Active Back 18"-14" Quick Release Mount SEBJA1010 1 $364.00 Jay Active Back 18"-14" Rigid Mount SEBJA1015 1 $337.00 Jay Active Back 18"/16" Tall Quick Release Mount SEBJA1012 1 $396.00 Jay Active Back 20" Tall SEBJA1014 1 $464.00 Jay Active Back With Permanent Mount (Large) SEBJA1019 1 $432.00 Jay Basic Back, Fixed Clamp Style, All Sizes SEBJA2025 1 $350.00 Jay Basic Back, Fixed Strap Style, All Sizes SEBJA2020 1 $322.00 Jay Care Back 15-18" Wide SEBJA5000 1 $440.00 Jay Care Back 19-20" Plus Width SEBJA5010 1 $527.00 Jay Care Back Foam Large Size SEBJA5045 1 $136.00 Jay Care Back Shell Large Size SEBJA5055 1 $282.00 Jay Encompass Back SEBJA8200 1 $311.00 Jay Fit Back Adjustable Contour Back For 10" Or 12" Frame Width, Various Back Heights SEBJA4005 1 $290.00 Jay Fit Back Adjustable Contour Back For 14" Or 16" Frame Width, Various Back Heights SEBJA4010 1 $328.00 Jay Fit Back Adjustable Contour Back For 18" Frame Width, Various Back Heights SEBJA4015 1 $366.00 Jay Focus Point Back, All Sizes SEBJA8100 1 $540.00 Jay Modual Back Custom Contoured Insert 18"/16"/14" SEBJA3050 1 $602.00 Jay Modual Back Custom Contoured Insert 20" SEBJA3055 1 $695.00 Jay Modual Back Standard Insert 18"/16"/14" SEBJA3005 1 $359.00 Jay Modual Back Standard Insert 20" SEBJA3010 1 $469.00 Jay Modular Back Adjustable Aluminum Shell 20" SEBJA3002 1 $640.00 Jay Modular Back Adjustable Aluminum Shell (18",16",14") SEBJA3000 1 $552.00 Jay Union Back Standard with 4 point hardware SE0000644 1 $620.00 Page: 16 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Jay Medical Kid Kart Lpa Medical Inc. Maple Leaf Wheelchair Motion Concepts Nighthawk Device Device Code Max Allowed Qty. Approved Price Jay Union Back Standard with standard hardware SE0000643 1 $586.00 Jay Union Back Tall with 4 point Hardware SE0000646 1 $703.00 Jay Union Back Tall with Standard Hardware SE0000645 1 $668.00 I-Back Cushion Tlc SEBKT2015 1 $101.00 Xpress T-Back 1" Short, Regular, Or Tall SEBKT2025 1 $112.00 Xpress T-Back 2.5" Short, Regular, Or Tall SEBKT2030 1 $112.00 Adjustable Tension Back SEBO12010 1 $172.00 Contour Back Cushion SEBO12005 1 $93.00 Contour Padded Personal Back SEBWM0005 1 $248.00 ML Deep SE0001085 1 $419.00 ML Kyphothic SE0001089 1 $574.00 ML Mid SE0001086 1 $483.00 ML Shallow SE0001087 1 $375.00 ML Shape SE0001088 1 $566.00 MX1 Dual Mount 14-18 wide x 9 hgh SE0000135 1 $825.00 MX1 Dual Mount 14-18 x 16 high SE0000137 1 $960.00 MX1 Dual mount 14-18 wide x 12 high SE0000136 1 $894.00 MX1 Mono Mount 14-18 wide x 16 high SE0000134 1 $928.00 MX1 Mono Mount 14-18 wide x 9 high SE0000132 1 $790.00 MX1 Mono mount 14-18 wide x 12 high SE0000133 1 $859.00 MX1 Quick Release Dual Mount 14-18 wide x 16 high SE0000140 1 $980.00 MX1 Quick Release Dual Mount 14-18 x 12 high SE0000139 1 $911.00 MX1 Quick Release Dual Mount 14-18 x 9 high SE0000138 1 $842.00 Trx Contour Back, For Trx Systems, 16, 18, 22" Wide Wheelchairs, Height Adjustable 18-26" SEBZG0005 1 $237.00 Trx Onyx Contour Back & Trx Single Post Cloth Contour Back, For Trx Systems SEBZG0020 1 $318.00 Trx Single Post Onyx Contour Back For Trx Systems SEBZG0025 1 $318.00 Key-Hole Back SEBNM0050 1 $197.00 Relaxed Back High SEBNM0010 1 $159.00 Page: 17 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Nighthawk Orthofab Otto Bock Performance Health Products Permobil Physipro Power Plus Device Device Code Max Allowed Qty. Approved Price Relaxed Back High With Flap SEBNM0020 1 $168.00 Relaxed Back Low SEBNM0005 1 $159.00 High Profile Contoured 14-20"Width, 16-20" Height SEBOF2005 1 $367.00 High Profile Contoured Non Standard Sizes SEBOF2010 1 $407.00 High Profile Tall Contoured 14-20" Width, 18-22" Height SEBOF2015 1 $345.00 High Profile Tall Contoured Non Standard Sizes & Options SEBOF2020 1 $407.00 Low Profile Contoured 14-20" Width, 16-20" Height SEBOF2025 1 $345.00 Low Profile Contoured Non Standard Sizes SEBOF2030 1 $407.00 Modular Mild Or Deep Contour 14-20" Width & 16,18,20" Height SEBOF1005 1 $449.00 Modular Mild Or Deep Contour Non Standard Sizes SEBOF1010 1 $497.00 Back System 1, 15" To 17" & 18" To 20" SEBOB9555 1 $342.00 Back System 2, 15" To 17" & 18" To 20" SEBOB9600 1 $438.00 Back System 3, 15" To 17" & 18" To 20" SEBOB9605 1 $523.00 Back System 4, 15" - 20" Sizes SEBOB9610 1 $684.00 Back-Finished With Spray Coating,Cover,Sewing Pattern SEBOB9650 1 $1,710.00 Back-Itemized Cushion (Unfinished) SEBOB9655 1 $1,253.00 V-Trak Ax-Sb Back Support Connisting Of 1 Insert, All Sizes SEBP00015 1 $555.00 V-Trak Ax-Sb Back Support Consisting Of 2 Inserts, All Sizes SEBP00020 1 $876.00 V-Trak Ax-Sb Back Support Consisting Of 3 Inserts, All Sizes SEBP00025 1 $1,152.00 V-Trak Axh Back Support, All Sizes SEBP00010 1 $752.00 V-Trak Axs Back Support, All Sizes SEBP00005 1 $673.00 Ergo Back - Fixed - All Sizes SEB1P0005 1 $692.00 Ergo Back - Recline - All Sizes SEB1P0010 1 $692.00 Rectangular Back - All Sizes SEB1P0015 1 $1,052.00 HP2 Back Support, all models, all sizes SE0001071 1 $480.00 Premium Back Support, all sizes SE0001072 1 $480.00 Deep U Back Custom Sizes SEBWM0015 1 $621.00 Page: 18 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Mobility Precision Rehab Manufacturing Pride Mobility Products Device Device Code Max Allowed Qty. Approved Price Deep U Back Standard Sizes SEBWM0010 1 $524.00 Kyphotic Tension Back Rest - Shallow Or Deep U SEBWM0030 1 $718.00 Mid U Back Standard Sizes SEBWM0027 1 $604.00 Shallow U Back Standard Sizes SEBWM0020 1 $469.00 Shallow U Back Custom Sizes SEBWM0025 1 $524.00 Shape U Back Standard Sizes SEBWM0026 1 $707.00 Upcharge For Custom Height SEBWM0040 1 $152.00 Upcharge For Custom Width SEBWM0035 1 $152.00 Back Sewn Cover Waterproof Foam, Includes Labour For Digitizing Or Plastering SEBWB0010 1 $1,476.00 Back Vacuum Formed, Includes Labour For Digitizing Or Plastering SEBWB0005 1 $1,241.00 Base Cushion Back, Includes All Modifications & Labour For Digitizing Or Plastering SEBWB0015 1 $1,793.00 Precision - Fit Back Cushion Upcharge, Extra Wide Or Extra Tall, 20" - 24" SEBWB0022 1 $207.00 Precision - Fit Back Cushion, Subtle, Moderate Or Aggresive Positioning. Includes Hinged Or Fixed Laterals And Cover. SEBWB0020 1 $930.00 Adjustable Height Back System SEBK20060 1 $293.00 Back Cushion - All Sizes SEBK20005 1 $259.00 Synergy Shape 2 Back - Low SEBX10030 1 $450.00 Synergy Shape 2 Back - Standard SEBX10035 1 $496.00 Synergy Shape 2 Back - Tall SEBX10040 1 $512.00 Synergy Shape Back Sizes 14x19 & 22x19 SEBX10005 1 $551.00 Synergy Shape Back Sizes 16x19, 18x19, 20x19 SEBX10010 1 $551.00 Synergy Shape Deep Standard Sizes SEBX10055 1 $569.00 Synergy Shape Deep Tall Sizes SEBX10060 1 $587.00 Synergy Shape GP Back Sizes 14x19 16x19 18x19 SEBX10045 1 $342.00 Synergy Shape GP Sizes 20x19 And 22x19 SEBX10050 1 $375.00 Synergy Standard Back Support, up to 20". For additional sizing see SEBND0015. SE0000971 1 $311.00 Page: 19 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Pride Mobility Products Device Device Code Max Allowed Qty. Approved Price Synergy Tru Comfort Back Standard, Reclining Or Tilt And Recline Back Greater Than 20" Wide SEBX10025 1 $518.00 Synergy Tru-Comfort Back Synergy Tru Comfort Back Standard, Reclining Or Tilt And Recline Back Up To 20" Wide SEBX10020 1 $480.00 BREEZY RELAX2 COMFORT BACK ANATOMICAL SHAPE SE0000117 1 $1,722.00 Contour Back - Tilt Fx SEBQU0400 1 $359.00 Corbac Adjustable Contour Back Support, All Sizes SEBR40005 1 $338.00 Ride Custom Back Support SEBR40010 1 $2,254.00 Ride Decaf, all sizes SE0001045 1 $542.00 Ride Java Back Grande SE0001144 1 $561.00 Ride Java Back Grande Deep SE0001145 1 $638.00 Ride Java Back Regular/Tall Deep SE0001143 1 $618.00 Agility Back - Custom Design - All Variation SE0001167 1 $1,439.00 Agility Back Support SE0000970 1 $636.00 Agility Max Contour Back - all sizes SE0001118 1 $822.00 Low Back (10" Height) All Standard Sizes 14" - 18" SEBRO3010 1 $1,031.00 Lumbar Support Cushion (Made To Order) SEBRO2015 1 $341.00 Recliner Wheelchair Cushion Made To Order (One Piece Back & Seat- 2 Sections,2 Valves) SEBRO2005 1 $1,035.00 Recliner Wheelchair Cushion-Custom (More Than 2 Sections And/Or 2 Halves) SEBRO2010 1 $1,208.00 Standard Back (16" Height) All Standard Sizes 14" - 18" SEBRO3005 1 $1,289.00 Starkey Viennatone Butterfly Back System SEBV10005 1 $293.00 Supracor Stimulite Lumbar Support SEBRR0010 1 $110.00 The Comfort Company Acta Relief Back - All Variations SE0001168 1 $877.00 Acta-Back, All Variations, All Sizes SEB7C0010 1 $650.00 Acta-Back, All Variations, Custom Sizes SEB7C0015 1 $1,155.00 Incrediback, Modable, Tall, Deep, TallDeep, Custom Sizes 1 $1,311.00 Quickie Ride Designs Roho SEB7C0025 Page: 20 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Back Support Manufacturer Device Device Code Max Allowed Qty. Approved Price The Comfort Company Incrediback, Moldable, Tall, Deep, TallDeep, All Sizes SEB7C0020 1 $644.00 Toronto Orthopedic Ltd. Tops Back Cushion (10" & 12" Width) SEBTP0005 1 $212.00 Varilite Medical Products Evolution Back - Regular SEBVP0050 1 $674.00 Evolution Back - Regular Bariatric SEBVP0055 1 $942.00 Evolution Back - Tall SEBVP0060 1 $746.00 Evolution Deep Back - All Sizes SEBVP0070 1 $978.00 Icon Back - Bariatric SEBVP0120 1 $965.00 Icon Back - Deep SEBVP0115 1 $884.00 Icon Back - Low SEBVP0100 1 $618.00 Icon Back - Tall SEBVP1110 1 $724.00 Icon Back -Mid SEBVP0105 1 $643.00 Junior Backs SE0001147 1 $643.00 Talon Back - All Sizes SEBVP0080 1 $479.00 Viscount Tall Back Support For 16' Or 18" W/C SEBVC0030 1 $1,036.00 Viscount Tall Back Support, Custom Sizes SEBVC0035 1 $1,308.00 Viva Contoured Postural Back 14"-16" W/C Or 16"-18" W/C SEBVC0015 1 $198.00 Adaptive Engineering Lab Contoured Seat System (Includes Seat, Back, Support Pads, Hardware) SECE10020 1 $1,057.00 Adaptive Equipment Systems (Aes) Basis Contoured Seat & Back Including Connecting Hinge (Select Type). Does Not Include Mounting Hardware. SEC2L0010 1 $742.00 Basis Contoured Seat & Back Including SEC2L0020 Connecting Hinge Package. Li'L Kiddos,14" Wide Or Less. Does Not Include Mounting Hardware. 1 $897.00 Basis Seat & Back Including Connecting Hinge (Select Type). Does Not Include Mounting Hardware. SEC2L0005 1 $511.00 Basis Seat & Back Including Connecting Hinge Package. Li'L Kiddos,14" Wide Or Less. Does Not Include Mounting Hardware. SEC2L0015 1 $595.00 Amysystems Bariatric Power Recline With Integrated Shear Reduction (Isr) SEC4P0065 1 $6,999.00 Broda Hsp Padding Package SECB-0005 1 $486.00 Vision Wheelchair Seating Systems Inc. Complete Assembly Page: 21 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Manufacturer Complete Assembly Device Device Code Max Allowed Qty. Approved Price (Includes Short Wing Cover, Extended Shoulder Bolsters, Full Extension Foot Pad, F-2 Foot Rest, Thigh Belt) Custom Fabricated Modify Or Refurbish Existing Custom Seating System. Includes Parts,Hardware,Labour Changes To Head Rest,Back Support,Seat, & Footrest Etc. SEMCF900L 1 $431.00 Hoggi Adjustible Height Back System Planar Back Cushion SE0000467 1 $272.00 Bingo Ius Or Xps Seat Frame Size 1 SECK20005 1 $1,352.00 Bingo Ius Or Xps Seat Frame Size 2 SECK20010 1 $1,373.00 Configurable Adjustible Height I Back System SE0000468 1 $272.00 Ius Adaptive Seat And Back Cushions With Airflex SECK20105 1 $607.00 Ius Adaptive Seat And Back Cushions Breathable SECK20100 1 $224.00 Kinesthetic Seating System Fits 10" To 14" Wide W/C, (Includes Basic Headrest, Lateral Supports, Padded Lap Belt, Ulti-Mate Base, Curved Back & Growth Bracket) SECNS0005 1 $1,131.00 Kinesthetic Seating System Fits 16" To 20" Wide W/C, (Includes Basic Headrest, Lateral Supports, Padded Lap Belt, Ulti-Mate Base & Curved Back) SECNS0010 1 $1,131.00 Tlc Shell Assembly With Contour Seating SECKT2010 1 $990.00 Tlc Shell Assembly With Planar Seating SECKT2005 1 $790.00 Xpress Adjustable Contour Seating Package SECKT3005 1 $773.00 Xpress Shell Assembly With Contour Seating SECKT3015 1 $773.00 Xpress Shell Assembly With Planar Seating SECKT3010 1 $555.00 Motion Concepts Power Tilt Only For Invacare, Quantum, And Quickie Bases. SECZG2005 1 $4,528.00 Otto Bock Kimba Neo Basic Seat - Size 2 Includes Elevating Legrests, Flip-Up Footrest, Laterals, Adjustable Hip Pads & Padding. SE0001159 1 $1,467.00 Kimba Spring Multifunctional Seating SECOB3005 1 $1,308.00 Invacare Kid Kart Page: 22 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Complete Assembly Manufacturer Otto Bock Spenco Device Device Code Max Allowed Qty. Approved Price Kimba Spring Multifunctional Seating Unit - Size 2 Includes Elevating Legrests, Flip-Up Footrest, Laterals, Adjustable Hip Pads & Padding. SECOB3010 1 $1,377.00 Kimba Spring Plus Adjustable Seating System - Size 1 Includes Armrests, Elevating Legrests, Adjustable Footplates & Recline. SECOB4005 1 $1,256.00 Kimba Spring Plus Adjustable Seating System - Size 2 Includes Armrests, Elevating Legrests, Adjustable Footplates & Recline. SECOB4010 1 $1,415.00 Kimbo Neo Basic Seat - Size 1 Includes Elevating Legrests, Flip-Up Footrest, Laterals, Adjustable Hip Pads & Padding. SE0001158 1 $1,394.00 Mygo Seat Shell Size 1 Includes Seat Shell And Cushions SECOB4015 1 $1,559.00 Mygo Seat Shell Size 2 Includes Seat Shell Cushions And Shoulder Support SECOB4020 1 $1,793.00 OBSS Ortho-Shape SE0001046 1 $3,723.00 OBSS Ortho-Shape, greater than 20" wide and/or deep SE0001047 1 $4,033.00 OBSS Ortho-Shape, including additional liner for growth SE0001048 1 $3,964.00 Squiggle Seating System SE0000701 1 $1,477.00 Silicore Wheelchair Seat With Back and Sides SECSO0010 1 $105.00 Unit - Size 1 Includes Elevating Legrests, Flip-Up Footrest, Laterals, Adjustable Hip Pads & Padding. THOMASHILFEN EasyS or EasyS Modular Headrest/Neckrest SE0001026 1 $1,377.00 Thevo Twist SE0001025 1 $1,477.00 Toronto Orthopedic Ltd. Tops Seating System Includes Butterfly Chest Strap, Combination Head/Neckrest Tilt Tray, Stroller Interface, Back And Seat SECTP0005 1 $1,347.00 Adaptive Engineering Lab Curved Headrest SEHE10015 1 $88.00 Tri-Pad Headrest SEHE10005 1 $272.00 Adaptive Curved Hr Pad Or Contoured Hr Pad Or SEH2L0035 1 $455.00 Page: 23 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Manufacturer Max Allowed Qty. Approved Price Curved Hr Pad Or Contoured Hr Pad Or SEH2L0030 Bell Curved Hr Pad, Cobra Headrest Bracket. 1 $381.00 Lateral-Posterior Head Support, Adjustable Depth Bracket, 6-1/2"W X 7"H. SEH2L0015 1 $355.00 Lateral-Posterior Head Support, Adjustable Depth Bracket, Hinged. SEH2L0005 1 $388.00 Lateral-Posterior Head Support, Adjustable Depth Bracket, Paediatric 4" X 4" Or 5"X 5" Or 6"X 6". SEH2L0010 1 $337.00 Lateral-Posterior Head Support, Cobra Headrest Bracket, 5" X 5"Or 6" X 6" Or 7" X 7"Or 8" X 8". SEH2L0020 1 $464.00 Lateral-Posterior Head Support, Cobra Style Headrest Bracket, Flip-Down 5" X 5"Or 6"X6" Or 7"X7" Or 8" X8". SEH2L0025 1 $536.00 Custom Headrest SEHAO0015 1 $173.00 Deep "U" Headrest SEHAO0020 1 $135.00 Large Padded Headrest SEHAO0025 1 $100.00 Macintosh Oxbow Headrest SEHAO0010 1 $173.00 So Soft Oval Headrest SEHAO0030 1 $135.00 Standard Curved Padded Headrest SEHAO0005 1 $100.00 Amysystems Curved Headrest, All Sizes SEH4P0010 1 $161.00 Broda Neckrest Cushion SEHB-0010 1 $41.00 Custom Fabricated Adjustable Headrest With Neckrest, Vinyl Cover, Without Hardware SEHCF080L 1 $362.00 Complex Headrest/Contoured Or Molded, Vinyl Cover, Without Hardware SEHCF060L 1 $267.00 Contoured Headrest/Curved Surface, Vinyl Cover, Without Hardware SEHCF050L 1 $173.00 Flat Headrest/Planar Head Support, Vinyl Cover, Without Hardware SEHCF040L 1 $108.00 Head Or Neckrest Incorporated With Mobility Switches, Vinyl Cover, Without Hardware SEHCF090L 1 $267.00 Neckrest With Vinyl Cover, Without SEHCF070L 1 $164.00 Equipment Systems (Aes) Advanced Mobility Device Device Code Bell Curved Hr Pad, Cobra Headrest Bracket, Flip-Down. Page: 24 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Manufacturer Device Device Code Max Allowed Qty. Approved Price Custom Fabricated Hardware Daher Specialty Foam Products Combination Headrest SEHDH0010 1 $50.00 Full Support Headrest SEHDH0015 1 $66.00 Large Headrest SEHDH0005 1 $50.00 Dynamic Health Care Solutions MultiFit Headrest SE0001131 1 $155.00 Future Mobility Large Headrest With Multi-Axial Hardware SEHFM0015 1 $245.00 Large Padded Headrest SEHFM0005 1 $190.00 Small Headrest With Multi-Axial Hardware SEHFM0020 1 $242.00 Small Padded Headrest SEHFM0010 1 $186.00 Emineo Advanced Headrest SEHM90105 1 $311.00 Emineo Basic Headrest SEHM90100 1 $204.00 Large Headrest SEHM90015 1 $128.00 Lateral Support Headrest SEHM90010 1 $121.00 Offset Headrest Large SEHM90030 1 $183.00 Offset Headrest Lateral SEHM90025 1 $176.00 Offset Headrest Small SEHM90020 1 $169.00 Sedeo Pro Flexible Headrest Pad SE0000665 1 $93.00 Sedeo Pro Large Headrest Pad SE0000666 1 $100.00 Sedeo Pro small headrest pad SE0000664 1 $69.00 Handicare Small Headrest Assesmbly SEHM90005 1 $114.00 Hoggi Ius Headrest SEHK20005 1 $248.00 Invacare Basic Headrest - Adult SEHNS1010 1 $191.00 Basic Headrest - Child SEHNS1005 1 $191.00 Curved Adjustable Headrest System SEHNS1030 1 $284.00 Large Adjustable Headrest System SEHNS1020 1 $305.00 Small Adjustable Headrest System SEHNS1015 1 $305.00 Two Step Adjustable Headrest System SEHNS1025 1 $284.00 Four Pad Headrest - Junior SEHJA0016 1 $254.00 Four Pad Rotational Headrest - Junior SEHJA0018 1 $380.00 Four Pad Rotational Headrest Standard SEHJA0017 1 $380.00 Full Width Headrest SEHJA0020 1 $127.00 Single Pad Headrest - Large SEHJA0006 1 $72.00 Single Pad Headrest - Small SEHJA0005 1 $72.00 Jay Medical Page: 25 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Manufacturer Jay Medical Kid Kart Lpa Medical Inc. Device Device Code Max Allowed Qty. Approved Price Three Pad Headrest - Large SEHJA0011 1 $181.00 Three Pad Headrest - Large Junior SEHJA0013 1 $181.00 Three Pad Headrest - Small SEHJA0010 1 $181.00 Three Pad Headrest - Small Junior SEHJA0012 1 $181.00 Three Pad Rotational Headrest - Large SEHJA0027 1 $304.00 Three Pad Rotational Headrest - Large Junior SEHJA0029 1 $304.00 Three Pad Rotational Headrest - Small SEHJA0026 1 $304.00 Three Pad Rotational Headrest - Small Junior SEHJA0028 1 $304.00 Xpress Micro Adjustable Head Support SEHKT3010 1 $211.00 Xpress Planar Head Support SEHKT3015 1 $138.00 Xpress Tri-Wing Adjustable Head Support SEHKT3005 1 $107.00 Cervical Support SEHO12005 1 $36.00 Contour Headrest SEHO12010 1 $86.00 Maple Leaf Wheelchair ML Contour SE0001133 1 $179.00 Metalcraft Industries Contoured Headrest With Mounting Hardware Small, Large, Xlarge SEHNG0005 1 $260.00 Occipital Ring With Mounting Hardware Small & Large Child Or Adult SEHNG0015 1 $298.00 Occipital Ring, Add-On, With Mounting Hardware Small & Large Child Or Adult SEHNG0020 1 $260.00 Motion Concepts Onyx Auto Style Headrest SEHZG0005 1 $161.00 Orthofab Padded Contour Support Without Mounting Hardware, Small, Medium, Or Large SEHOF1005 1 $91.00 Otto Bock Adjustable Wing Headrest (Size 1 & 2) SEHOB6020 1 $485.00 Contoured Headrest (Size 1 & 2) SEHOB6010 1 $138.00 Fixed Wing Headrest (Size 1 & 2) SEHOB6015 1 $342.00 Headrest - Combination SEHOB0010 1 $72.00 Headrest - Large/Small SEHOB0100 1 $72.00 Headrest - Lateral Control SEHOB0050 1 $117.00 Headrest Support (Size 1 & 2) SEHOB6005 1 $247.00 Neckrest - All Sizes SEHOB0250 1 $82.00 Soft Headrest - Large/Small SEHOB0110 1 $104.00 X-Style Headrest/Neckrest Combination, Adult & SEHOB0015 1 $108.00 Page: 26 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Manufacturer Device Device Code Max Allowed Qty. Approved Price Otto Bock Paediatric Sizes. Performance Health Products V-Trak Headrest, All Sizes, All Configurations SEHP00005 1 $311.00 Permobil Headrest - For Ergo Back SEH1P0005 1 $405.00 Physipro Headrest SE0001073 1 $147.00 Power Plus Mobility Contour Headrest Including Brackets SEHWM0005 1 $221.00 Precision Rehab Manufacturing Headreast - Large (14") Or Small (10") Pad SEHWB0010 1 $104.00 Pride Mobility Products Kids Up Including Mounting Hardware SE0001154 1 $266.00 TRU-Comfort 2 Including Mounting Hardware SE0001153 1 $243.00 Stealth Products Stealth Combo Headrest With Multi Axis Hardware, Large & Small Sizes SEHNS2050 1 $462.00 Stealth Comfort Plus Large 14" Comfort Pad Only (With Ring) SEHNS3015 1 $142.00 Stealth Comfort Plus Medium 10" Comfort Pad Only (With Ring) SEHNS3025 1 $142.00 Stealth Comfort Plus, Large 14" Pad /Multi Axis Hardware SEHNS3020 1 $292.00 Stealth Comfort Plus, Large 14" Pad/Standard Hardware SEHNS3005 1 $242.00 Stealth Comfort Plus, Medium 10" Pad/Multi Axis Hardware SEHNS3030 1 $292.00 Stealth Comfort Plus, Medium 10" Pad/Standard Hardware SEHNS3010 1 $242.00 Stealth Comfort Plus, Swingaway Both Sides, Standard Lateral Pad/Spot Pad/Long Lateral Pad SEHNS3060 1 $426.00 Stealth Comfort Plus, Swingaway Left Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad SEHNS3070 1 $323.00 Stealth Comfort Plus, Swingaway Right Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad SEHNS3065 1 $323.00 Stealth I2i Headrest System - All Sizes SEHNS2060 1 $709.00 Stealth Occipital/Sub Occipital & Laterals, Adult & Paediatric Sizes (Specify Swingaway) SEHNS2005 1 $977.00 Stealth Otto Bock Style, Swing Away Both Sides, Standard Lateral Pad/Spot Pad/Long Lateral Pad SEHNS3075 1 $480.00 Page: 27 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Manufacturer Device Device Code Max Allowed Qty. Approved Price Stealth Products Stealth Otto Bock Style, Swingaway Left Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad SEHNS3085 1 $367.00 Stealth Otto Bock Style, Swingaway Right Side, Standard Lateral Pad/Spot Pad/Long Lateral Pad SEHNS3080 1 $367.00 Stealth Ultra Channel With Ring, Large & Small Sizes SEHNS2020 1 $558.00 Stealth Ultra Large Combo With Large Sub Occipital SEHNS2007 1 $885.00 Stealth Ultra Occipital & Laterals, Small & Large Sizes (Specify Swingaway) SEHNS2015 1 $693.00 Stealth Ultra Occipital Large/Small SEHNS2030 1 $285.00 Stealth Ultra Small & Occipital/Sub Occipital SEHNS2010 1 $568.00 Stealth Ultra Small Combo With Large Sub Occipital SEHNS2009 1 $885.00 Stealth Ultra Sub Occipital Large/Small SEHNS2025 1 $285.00 Stealth Ultra Swing Both Sides, Standard Lateral Pad/Spot Pad/Long Lateral Pad SEHNS2035 1 $409.00 Stealth Ultra Swingaway Standard & Long Lateral Pad, Or Spot Pad SEHNS2045 2 $323.00 Stealth Ultra-Ac Adjustable Channel SEHNS2040 1 $270.00 The Comfort Company Headrest - Moldable, Includes Cover SEH7C0015 1 $188.00 Vision Wheelchair Seating Systems Inc. Vector Head N Neck Support, 11"W X 8"D Pad SEHVC0005 1 $200.00 Vector Head N Neck Support, Custom Pad SEHVC0010 1 $283.00 Whitmyer Biomechanix 10" Plush Occipital Pad & Single SubOccipital Pad With Linx Vertical/Horizontal Mount SEHWH7005 1 $361.00 10" Plush Occipital Pad & Single SubOccipital Pad With Onyx Vertical/Horizontal Mount SEHWH7020 1 $339.00 10" Plush Occipital Pad & Single SubOccipital Pad With Pro Verticial/Horizontal Mount SEHWH7035 1 $371.00 14" Plush Pad With Linx Vertical/Horizontal Mount SEHWH5010 1 $197.00 14" Plush Pad With Onyx Vertical/Horizontal Mount SEHWH5030 1 $197.00 Page: 28 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Manufacturer Whitmyer Biomechanix Device Device Code Max Allowed Qty. Approved Price 14" Plush Pad With Pro Vertical/Horizontal Mount SEHWH5040 1 $210.00 19" Plush Pad With Link Vertical/Horizontal Mount SEHWH5015 1 $288.00 19" Plush Pad With Onyx Vertical/Horizontal Mount SEHWH5032 1 $260.00 19" Plush Pad With Pro Vertical/Horizontal Mount SEHWH5045 1 $292.00 4"X6" Occipital Pad & Single SubOccipital Pad With Onyx Vertical/Horizontal Mount SEHWH7025 1 $288.00 4"X6" Occipital Pad & Single SubOccipital Pad With Pro Vertical/Horizontal Mount SEHWH7040 1 $320.00 4"X6"Occipital Pad & Single SubOccipital Pad With Lynx Vertical/Horizontal Mount SEHWH7010 1 $316.00 4"X6"Occipital Pad With Size 1/2 SubOccipital Pads With Lynx Vertical/Horizontal Mount SEHWH7050 1 $380.00 4"X6"Occipital Pad With Size 1/2 SubOccipital Pads With Onyx Vertical/Horizontal Mount SEHWH7065 1 $297.00 4"X6"Occipital Pad With Size 1/2 SubOccipital Pads With Pro Vertical/Horizontal Mount SEHWH7080 1 $416.00 8" Or 10" Plush Pad With Lightweight Vertical/Horizontal Mount SEHWH5020 1 $188.00 8" Or 10" Plush Pad With Linx Vertical/Horizontal Mount SEHWH5005 1 $188.00 8" Or 10" Plush Pad With Onyx Vertical/Horizontal Mount SEHWH5025 1 $188.00 8" Or 10" Plush Pad With Pro Vertical/Horizontal Mount SEHWH5035 1 $202.00 8"/10" Plush Occipital Pad With Size 1 Sub-Occipital Pads With Pro Vertical/Horizontal Mount SEHWH7085 1 $467.00 8"/10" Plush Occipital Pad With Size 1sub-Occipital Pads With Lynx Vertical/Horizontal Mount SEHWH7055 1 $430.00 8"/10" Plush Occipital Pad With Size 1sub-Occipital Pads With Onyx Vertical/Horizontal Mount SEHWH7070 1 $453.00 Adjust-A-Plush Headrest System SEHWH7260 1 $235.00 Bilateral Lfc With Pads And Interface Plate SEHWH7235 1 $398.00 Page: 29 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Manufacturer Whitmyer Biomechanix Device Device Code Max Allowed Qty. Approved Price For Plush & Contoured Cradle Systems Heads Up Pad All Sizes Add On Occipital Pads Optional SE0001099 1 $207.00 Large Pad With Lightweight Vertical/Horizontal Mount SEHWH5075 1 $142.00 Large Pad With Linx Vertical/Horizontal Mount SEHWH5060 1 $142.00 Large Pad With Onyx Vertical/Horizontal Mount SEHWH5090 1 $183.00 Large Pad With Pro Vertical/Horizontal Mount SEHWH5110 1 $197.00 Lateral Facial Component With Pad SEHWH7250 2 $183.00 Medium Pad With Lightweight Vertical/Horizontal Mount, LWS-CCS3 SEHWH5070 1 $133.00 Medium Pad With Lightweight Vertical/Horizontal Mount, ONYX-CCS3 SEHWH5085 1 $174.00 Medium Pad With Linx Vertical/Horizontal Mount SEHWH5055 1 $133.00 Medium Pad With Pro Vertical/Horizontal Mount SEHWH5105 1 $151.00 Occipital Pad With Size 3/4 SubOccipital Pads 1"X4",4"X6",1"X4" With Lynx Vertical/Horizontal Mount SEHWH7105 1 $380.00 Occipital Pad With Size 3/4 SubOccipital Pads 1"X4",4"X6",1"X4" With Onyx Vertical/Horizontal Mount SEHWH7115 1 $393.00 Occipital Pad With Size 3/4 SubOccipital Pads 1"X4",4"X6",1"X4" With Pro Vertical/Horizontal Mount SEHWH7125 1 $416.00 Single Pad Dynamic Forehead Strap System All Sizes SEHWH7200 1 $252.00 Single Pad Static Forehead Strap System All Sizes SEHWH7205 1 $266.00 Small Pad With Lightweight Vertical/Horizontal Mount SEHWH5065 1 $123.00 Small Pad With Linx Vertical/Horizontal Mount SEHWH5050 1 $123.00 Small Pad With Onyx Vertical/Horizontal Mount SEHWH5080 1 $165.00 Small Pad With Pro Vertical/Horizontal Mount SEHWH5095 1 $142.00 T-Bar Occipital Pads & Single Sub- SEHWH7015 1 $562.00 Page: 30 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Headrest/Neckrest Seat Cushion Manufacturer Whitmyer Biomechanix Action Products Device Device Code Max Allowed Qty. Approved Price T-Bar Occipital Pads & Single SubOccipital Pad 2.25"X7" & 2.25"X5" With Onyx Vertical/Horizontal Mount SEHWH7030 1 $535.00 T-Bar Occipital Pads & Single SubOccipital Pad 2.25"X7" & 2.25"X5" With Pro Vertical/Horizontal Mount SEHWH7045 1 $572.00 T-Bar Occipital Pads With Size 1 SubOccipital Pads 2.25"X7" With Pro Vertical/Horizontal Mount SEHWH7090 1 $636.00 T-Bar Occipital Pads With Size 1subOccipital Pads 2.25"X7" With Linx Vertical/Horizontal Mount SEHWH7060 1 $599.00 T-Bar Occipital Pads With Size 1subOccipital Pads 2.25"X7" With Onyx Vertical/Horizontal Mount SEHWH7075 1 $612.00 T-Bar Occipital Pads With Size 3 Single Sub-Occipital Pads 2.25"X5" With Linx Vertical/Horizontal Mount SEHWH7110 1 $599.00 T-Bar Occipital Pads With Size 3 Single Sub-Occipital Pads 2.25"X5" With Onyx Vertical/Horizontal Mount SEHWH7120 1 $612.00 T-Bar Occipital Pads With Size 3 Single Sub-Occipital Pads 2.25"X5" With Pro Vertical/Horizontal Mount SEHWH7130 1 $636.00 Unilateral Lfc With Pads And Interface Plate For Plush & Contoured Cradle Systems SEHWH7230 1 $216.00 ACTION XACT LP2 SE0000329 1 $598.00 Action Xact LP2 SIZES XP: WIDTH: 16"/18"/20"/22" DEPTH: 16"/18"/20" SE0000570 1 $599.00 Action Xact LP2 XP: SIZES: XP 1818 TO 22X20 SE0000571 1 $686.00 Centurian Cushion 16x16,16x81,18x16,18x18 SESAN2205 1 $229.00 Centurian Cushion 18x20,20x18,20x20 SESAN2210 1 $404.00 Centurian Cushion Large Custom Sizes SESAN2225 1 $423.00 Occipital Pad 2.25"X7" & 2.25"X5" With Linx Vertical/Horizontal Mount Page: 31 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Action Products Device Device Code Max Allowed Qty. Approved Price Centurian Cushion Small Custom Sizes SESAN2215 1 $347.00 Centurian Cushion Xlarge Custom Sizes SESAN2230 1 $539.00 Commuter Cushion 16x16,16x18,18x16,18x18 SESAN4405 1 $207.00 Commuter Cushion 18x20,20x18,20x20 SESAN4410 1 $404.00 Commuter Cushion Large Custom Sizes SESAN4425 1 $396.00 Commuter Cushion Medium Custom Sizes SESAN4420 1 $351.00 Commuter Cushion Small Sizes SESAN4415 1 $319.00 Pilot Cushion 16x16,16x18,18x16,18x18 SESAN3305 1 $267.00 Pilot Cushion 18x20,20x18,20x20 SESAN3310 1 $372.00 Pilot Cushion Large Custom Sizes SESAN3325 1 $481.00 Pilot Cushion Medium Custom Sizes SESAN3320 1 $416.00 Pilot Cushion Small Custom Sizes SESAN3315 1 $361.00 Pilot Cushion Xlarge Sizes SESAN3330 1 $558.00 Pilot Cushion Xxxlarge Custom Sizes SESAN3340 1 $790.00 Professional Cushion 16x16,16x18,18x16,18x18 SESAN1105 1 $354.00 Professional Cushion 18x20,20x18,20x20 SESAN1115 1 $574.00 Professional Cushion Large Custom Sizes SESAN1130 1 $602.00 Professional Cushion Medium Custom Sizes SESAN1125 1 $515.00 Shear Smart Pad 16x16,16x18,18x16,18x18 SESAN5505 1 $181.00 Shear Smart Pad 18x20, 20x18, 20x20 SESAN5510 1 $216.00 Xact Classic Cushion SESAN9905 10x10,16x14,17x17,16x20,18x20,20x20 1 $599.00 Xact Classic Cushion 16x16,16x18,18x16,18x18 SESAN9910 1 $513.00 Xact Individual Cushion All Custom Sizes SESAN9915 1 $1,031.00 Xact Individual Cushion Custom Sizes SESAN9920 1 $1,031.00 Xact Integrated Cushion With Drop Seat 16x20,18x20, 20x20 SESAN9010 1 $647.00 Xact Integrated Drop Base Sizes 10x10 To 18x18 SESAN9005 1 $599.00 Xact Lite Cushion 16x16 - 18x18 SESAN9015 1 $367.00 Page: 32 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Action Products Adaptive Engineering Lab Adaptive Equipment Systems (Aes) Device Device Code Max Allowed Qty. Approved Price Xact Lite Cushion 18x20 - 20x20 SESAN9020 1 $427.00 Xact Soft Foam Cushion 16x16, 16x18, 18x16, 18x18 SESAN9980 1 $513.00 Xact Soft Foam Cushion 16x20,18x20, 20x16, 20x18, 20x20 SESAN9985 1 $647.00 Xact Soft Foam Cushion With Integrated Drop Seat, All Sizes SESAN9990 1 $729.00 Drop-In Seat With 1.5" Sun-Mate Or Pudgee Foam SESE10030 1 $184.00 Drop-In Seat With Contour One Foam SESE10035 1 $261.00 Drop-In Seat With Poly Foam SESE10020 1 $167.00 Full-Width Seat With 1.5" Sun-Mate Or Pudgee Foam SESE10065 1 $324.00 Full-Width Seat With 1.5" Un-Mate Or T-Foam SESE10055 1 $184.00 Full-Width Seat With Contour-One Foam SESE10070 1 $261.00 Full Width Solid Seat Package With J Or Flush Or Drop Hooks & Hold Downs. SES2L0010 1 $559.00 Offset, T Style, I Style, Anti-Thrust Or Medial Thigh Support Solid Seat Insert, Includes TNuts. SES2L1015 1 $232.00 Oversize Upcharge For Seats Over 2o" But Less Than 28". SES2L1035 1 $69.00 Quick Fit Anti-Thrust Or Contour Solid Seat Insert, Includes T-Nuts. SES2L1020 1 $423.00 Quick-Fit Contoured, Adjustable Split, Or Foam Form Solid Seat Insert, Incudes T-Nuts. SES2L1030 1 $491.00 Sculptured Solid Set Insert, Includes TNuts, Custom. SES2L1025 1 $862.00 Sculpturefit Seat Package 2/Attaching Hardware, Custom. SES2L0015 1 $1,066.00 Solid Seat Insert Package, Li'L Kiddos, 14" Wide Or Less. SES2L0020 1 $548.00 Solid Seat Insert Package, Li'L Kiddos, Contoured, 14" Wide Or Less. SES2L0025 1 $708.00 Solid Seat Insert, Includes T-Nuts, Li'L Kiddos, 14" Wide Or Less. SES2L1010 1 $213.00 Solid Seat Insert, Includes T-Nuts. SES2L1005 1 $158.00 Page: 33 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Device Device Code Max Allowed Qty. Approved Price Adaptive Equipment Systems (Aes) Solid Seat Package W/Universal Or E-Z SES2L0005 Mount Hardware. 1 $467.00 Advanced Mobility All Star Cushion Custom Sizes Includes Cover SESAO0080 1 $503.00 All Star Cushion Includes Cover And Sizes 16x16 16x18 16x18 17x17 18x16 18x18 SESAO0085 1 $445.00 All Star Drop Base, Includes Cover, Base, 4 Drop Hooks SESAO0090 1 $496.00 Comfort Contoured Cushion SESAO0030 1 $121.00 Gel Flotation Pad SESAO0110 1 $279.00 Pro Custom Cushion With Built In Drop Base SESAO0070 1 $530.00 Pro-Custom Cushion With Covers SESAO0075 1 $486.00 Superstar Cushion Includes Cover 16x16, 16x18, 18x16, 18x18 SESAO0100 1 $518.00 Superstar Drop Base, Size 17x17, Includes Cover, Base, 4 Drop Hooks SESAO0105 1 $604.00 Upcharge For Custom Sizes Other Than 17x17 SESAO0115 1 $68.00 Amovida Motion AV400 SE0000959 1 $189.00 Amovida Motion Comfort + AV500 SE0000960 1 $229.00 Contour Seat Cushion For Heavy Duty SES4P0020 1 $618.00 Contour Seat Cushion, Non-Standard Sizes SES4P0015 1 $524.00 Contour Seat Cushion, Standard Sizes SES4P0010 1 $442.00 Bioform Reha Foundation Cushion - All Sizes SESZB0005 1 $417.00 Blake Medical Geomatrix Bronze SESG00005 1 $368.00 Geomatrix Gold, Gold+ SESG00015 1 $529.00 Geomatrix Gold, Gold+ Custom Sizes SESG00020 1 $621.00 Geomatrix Hybrid Or Hybrid Deep SESG00030 1 $562.00 Geomatrix Platinum SESG00025 1 $752.00 Geomatrix Silver SESG00010 1 $483.00 Amoena Medizin Amysystems Zentury, all sizes SE0000996 1 $242.00 Body Ryzm Life Sciences / Perspectis, Inc. SambaMD SE0001204 1 $149.00 Broda Seat Pad SESB-0010 1 $53.00 Clearview Healthcare Debbonair Dynamics/Cushionair Cushion SESGC0015 1 $583.00 Page: 34 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Products Custom Fabricated Dynamic Health Care Solutions Future Mobility Device Device Code Max Allowed Qty. Approved Price Debbonair Dynamics/Cushionair Cushion - Standard Sizes SESGC0005 1 $471.00 Debbonair Dynamics/Cushionair Cushion - Up To 20" Width Or Depth SESGC0010 1 $503.00 Complex Indirect Molded Seat, Without Cover & Mounting Hardware SESCF105L 1 $1,259.00 Contoured Seat, Includes Cover, Without Hardware SESCF103L 1 $518.00 Flat Seat/Rigid Base, Includes Cover, Without Hardware SESCF101L 1 $259.00 Sculptured Seat, Includes Cover, Without Hardware SESCF104L 1 $621.00 Wedged Seat (Thigh Bar), Includes Cover, Without Hardware SESCF102L 1 $388.00 Nxt BioFit Cushion, all sizes SE0001037 1 $411.00 Nxt KulFit Cushion, all sizes SE0001039 1 $376.00 Nxt NuFit Cushion, all sizes SE0001038 1 $376.00 Prism Elite Cushion 16x16-20x20 SESFM0060 1 $259.00 Prism Elite Cushion Custom Sizes SESFM0065 1 $293.00 Prism Ideal Cushion All Sizes SESFM0050 1 $159.00 Prism Supreme Air Cushion 18x18 Through 20x20 SESFM0030 1 $500.00 Prism Supreme Air Cushion 18x19 Through 20x19 SESFM0035 1 $518.00 Prism Supreme Air Cushion Custom Sizes SESFM0040 1 $542.00 Prism Supreme Cushion 14x14 Through 18x20 SESFM0015 1 $397.00 Prism Supreme Cushion 15x16 Through 20x20 SESFM0020 1 $414.00 Prism Supreme Cushion Custom Sizes SESFM0025 1 $473.00 Prism Supreme Gel Cushion 14x14 Through 18x20 SESFM0110 1 $466.00 Prism Supreme Gel Cushion 15x16 Through 20x20 SESFM0115 1 $483.00 Prism Supreme Gel Cushion Custom Sizes SESFM0120 1 $535.00 Prism Supreme Heavy Duty Cushion SESFM0125 1 $552.00 Prism Supreme Ii Plus Cushion 14x14 SESFM0070 1 $397.00 - Greater Than 20" Width Or Depth Page: 35 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Future Mobility Handicare Hoggi Invacare Device Device Code Max Allowed Qty. Approved Price Prism Supreme Ii Plus Cushion 15x16 Through 20x20 SESFM0075 1 $414.00 Prism Supreme Ii Plus Cushion Custom Sizes SESFM0080 1 $473.00 Serene Champion SE0001226 1 $311.00 Serene Paramount SE0001227 1 $311.00 Serene Paramount Gel SE0001229 1 $362.00 Serene Paramount Visco SE0001228 1 $342.00 Serene Prime SE0001225 1 $97.00 Super Cushion For Kids 10x10 Through 16x16 SESFM0090 1 $397.00 Super Cushion For Kids 10x12 Through 16x12 SESFM0095 1 $414.00 Super Cushion For Kids Custom Sizes SESFM0100 1 $473.00 Seat Cushion -Sellaskin 16x16,16x18,18x16,18x18 SESM90005 1 $135.00 Sedeo Pro-comfort Cushion 16"w to 18"w (fits 16" w to 20" deep) SE0000667 1 $345.00 Sedeo Pro-comfort Cushion 20"w and 22"w (fits 16" to 20" deep) SE0000668 1 $380.00 Sedeo Pro-contour Cushion 16"w and 18"w (fits 16"w to 20" deep) SE0000669 1 $414.00 Sedeo Pro-contour Cushion 20"w and 22"w (fits 16" to 2-" deep) SE0000698 1 $449.00 Sedeo Pro-stability Cushion 20"w and 22"w (fits 16" to 20" deep) SE0000671 1 $449.00 Sedeo Pro-stability cushion 16" w and 18"w (fits 16"to 20" deep) SE0000670 1 $414.00 Support Seat Cushion SESM90020 1 $259.00 Non Standard Seat Width SE0000464 1 $200.00 Standard Seat Width SE0000463 1 $132.00 Swingbo Plus Seat Cushion SE0000465 1 $174.00 Xps Adaptive Seat Cushion SESK20050 1 $269.00 Absolute Fits 16" To 20" Wide W/C SESNS0005 1 $74.00 Airflo Cushion Custom Sizes SESNS2015 1 $558.00 Airflo Cushion Fits 14 To 18" Wide W/C SESNS2005 1 $489.00 Airflo Cushion Fits 20" To 22" Wide W/C SESNS2010 1 $495.00 Comfort -Mate Extra - Special Size Modifications SESNS0039 1 $143.00 Through 18x20 Page: 36 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Invacare Invacare - Matrx Seating Device Device Code Max Allowed Qty. Approved Price Comfort-Mate Extra - Fits 14" To 22" Wide W/C SESNS0037 1 $143.00 Contour U Seat Includes All Modifications & Vacuum/Vinyl Upholstery SESNS0075 1 $1,156.00 Invacare Matrx Flovair Cushion Gentle/Max Contour SE0000967 1 $449.00 Invacare Matrx Stabilite Cushion SE0000966 1 $317.00 MATRX PS POSTURE SEAT Pediatric Sizes 1010/1012/1014 SE0000131 1 $638.00 Naked Contour U Seat, Includes All Modifications & Vacuum/Moisture Proof Coating/Removable Cover & Cover Pattern. SESNS0080 1 $1,375.00 Silhouette Seat Cushion SESNS0070 1 $545.00 Single Density Cushion, Non Standard Size SESNS0015 1 $91.00 Ulti-mate Base Fits 10" To 14" Wide W/C SESNS1040 1 $416.00 Ulti-mate Base Special Adult Size & Modifications SESNS1035 1 $578.00 Ulti-mate Base Special Junior Size & Modifications SESNS1045 1 $578.00 Ulti-mate Cushion Fits 10" To 14" Wide W/C SESNS0050 1 $302.00 Ulti-mate Cushion Fits 16" To 20" Wide W/C SESNS0040 1 $373.00 Ulti-mate Cushion Special Adult Size & Modifications SESNS0045 1 $458.00 Ulti-mate Cushion Special Junior Size & SESNS0055 Modifications 1 $387.00 Ulti-mate Fits 16" To 20" Wide W/C SESNS1030 1 $456.00 Flo-Tech Cushion Fits W/C 16" - 19" Width & 16" - 21" Depth SES1M0030 1 $551.00 Flo-Tech Cushion Fits W/C 20" - 24 Width & 20" - 22" Depth SES1M0040 1 $744.00 Flo-Tech Cushion Fits W/C 20" Width & 16" - 18" Depth SES1M0035 1 $632.00 Kidabra Base Fits W/C 12"-14" Width & 12"-15" Depth SES1M2005 1 $584.00 Kidabra Fits W/C 11"-14" Width & 12"-15" Depth SES1M0015 1 $439.00 Matrx Libra - Heavy Duty SE0001237 1 $707.00 Page: 37 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Invacare - Matrx Seating Jay Medical Device Device Code Max Allowed Qty. Approved Price Matrx Libra - Standard SE0001212 1 $514.00 Matrx Posture Seat (PS Cushion) 23x30 Width To 21x30 Deep SES1M0066 1 $687.00 Matrx Posture Seat(PS Cushion), All Sizes SES1M0060 1 $383.00 Matrx Vi Base Fits W/C 16"-20" Width & 16"-19" Depth SES1M1005 1 $584.00 Matrx Vi Cushion Bariatric Sizes, Client Weight Exceeds 300lbs SES1M0011 1 $640.00 Matrx Vi Cushion Fits W/C 14"-18" Width & 15"-21" Depth SES1M0005 1 $475.00 Matrx Vi Wide Cushion Fits W/C 19"-22" Width & 16"-21" Depth SES1M0010 1 $519.00 Matrx Wide Cushion Fits W/C 20" Width SES1M1010 & 16"-19" Depth 1 $616.00 PS Cushion with Visco Foam Upgrade All Sizes SES1M0070 1 $452.00 Posture Seat (PS Cushion) 11-12 Inches Wide To 20-21 Inches Deep SES1M0065 1 $382.00 J-Gel Base SESJA6830 1 $186.00 J-Gel Cushion 16" & 18" Deep SESJA0700 1 $370.00 J-Gel Cushion 20" Deep SESJA0705 1 $370.00 J2 Base Large Sizes SESJA6810 1 $226.00 J2 Base Standard Sizes SESJA6800 1 $179.00 J2 Plus Cushion Foam Base SESJA6835 1 $143.00 J2 Plus Cushion, Ae Cover With Custom Foam Kit SESJA0755 1 $595.00 J2 Plus Cushion, Ae Cover With Fluid Pad SESJA0760 1 $745.00 J2 Plus Cushion, Ae Cover With Foam Kit SESJA0750 1 $566.00 J2 Plus Cushion, Ls Inc. Cover With Custom Foam Kit SESJA0770 1 $597.00 J2 Plus Cushion, Ls Inc. Cover With Fluid Pad SESJA0775 1 $745.00 J2 Plus Cushion, Ls Inc. Cover With Foam Kit SESJA0765 1 $609.00 J3 Cushion SESJA0800 1 $604.00 Jay 2 17x17 SESJA0485 1 $471.00 Jay 2 17x17 With Incontinent Cover SESJA0462 1 $474.00 Jay 2 17x17 With Air Exchange Cover SESJA0442 1 $481.00 Page: 38 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Jay Medical Device Device Code Max Allowed Qty. Approved Price Jay 2 18x20, 15.5x20 With Air Exchange Cover SESJA0450 1 $552.00 Jay 2 18x20, 15.5x20 With Incontinent Cover SESJA0470 1 $543.00 Jay 2 20x16 SESJA0480 1 $543.00 Jay 2 20x16, 20x18 With Air Exchange Cover SESJA0441 1 $552.00 Jay 2 20x16, 20x18 With Incontinent Cover SESJA0461 1 $543.00 Jay 2 20x18 SESJA0490 1 $533.00 Jay 2 20x20 With Air Exchange Cover SESJA0445 1 $636.00 Jay 2 20x20 With Incontinent Cover SESJA0465 1 $628.00 Jay 2 24x20 With Air Exchange Cover SESJA0455 1 $681.00 Jay 2 24x20 With Incontinent Cover SESJA0475 1 $676.00 Jay 2 Cushion 14x16 With Standard Cover SESJA0425 1 $471.00 Jay 2 Cushion 15.5x 16, 15.5 X 18 With Standard Cover SESJA0420 1 $471.00 Jay 2 Cushion 18x16, 18x18 With Standard Cover SESJA0400 1 $471.00 Jay 2 Cushion 20x20 With Standard Cover SESJA0405 1 $618.00 Jay 2 Cushion 24x20 With Standard Cover SESJA0415 1 $685.00 Jay 2 Cushion18x20, 15.5x20 With Standard Cover SESJA0410 1 $543.00 Jay 2 Deep Contour 20x16, 20x18, 16x20, 18x20 SESJA0505 1 $535.00 Jay 2 Deep Contour 20x20, 22x16, 22x18 SESJA0507 1 $619.00 Jay 2 Deep Contour 24x18 SESJA0510 1 $654.00 Jay 2 Deep Contour Standard Sizes SESJA0500 1 $492.00 Jay 2 Deep Contourn with Solid Drop SESJA0605 Seat 20x16, 20x18, 16x20, 18x20, Solid Drop Seat Attached 1 $574.00 Jay 2 Deep Contourn with Solid Drop Seat 20x20, 22x16, 22x18, Solid Drop Seat Attached SESJA0610 1 $629.00 Jay 2 Deep Contourn with Solid Drop Seat Standard Sizes With Solid Drop Seat SESJA0600 1 $516.00 Jay 2 Standard Sizes With Air Exchange Cover SESJA0440 1 $481.00 Page: 39 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Jay Medical Device Device Code Max Allowed Qty. Approved Price Jay 2 Standard Sizes With Incontinent Cover SESJA0460 1 $474.00 Jay 3 Air Cushion - Dual Valve SESJA9910 1 $618.00 Jay 3 Air Cushion - Single Valve SESJA9905 1 $607.00 Jay 3 Air Cushion -Width X Depth Greater Than 21 Inches SESJA9915 1 $752.00 Jay 3 Air Cushion- Dual Valve -Width X Depth .gt.21 Inches SESJA9920 1 $762.00 Jay Active Cushion 18x16, 16x16, 14x16 SESJA2010 1 $523.00 Jay Active Cushion 18x18, 16x18 SESJA2100 1 $523.00 Jay Active Cushion 20x18, 18x20, 16x20, With Adductor Wedges SESJA2200 1 $574.00 Jay Active Foam Base 20" Deep SESJA6325 1 $226.00 Jay Basic Pro Cushion SE0001016 1 $121.00 Jay Care Cushion 18x16, 18x8, 16x16, 16x18 SESJA5500 1 $350.00 Jay Combi Base 18x16 To 15.5x20 SESJA6400 1 $37.00 Jay Combi Base 20x18 SESJA6500 1 $71.00 Jay Combi Cushion 14x14/12x12 With Back Support SESJA3200 1 $194.00 Jay Combi Cushion 18x16 To 15.5x20 SESJA3010 1 $194.00 Jay Combi Cushion 20x18 With Back Support SESJA3100 1 $183.00 Jay Combi With Lumbar Support 14x14, SESJA3326 12x12 1 $153.00 Jay Combi With Lumbar Support 18x20, SESJA3317 16x20 1 $179.00 Jay Combi With Lumbar Support 20x18 SESJA3316 1 $179.00 Jay Combi With Lumbar Support, Narrow Adult Soft 15.5x16 SESJA3320 1 $183.00 Jay Combi With Lumbar Support, Regular Adult Short 18x16 SESJA3310 1 $183.00 Jay Combi With Lumbar Support, Regular Adult SESJA3315 1 $183.00 Jay Combi Without Lumbar Support 14x14, 12x12 SESJA3346 1 $154.00 Jay Combi Without Lumbar Support 16x20, 18x20 SESJA3337 1 $154.00 Jay Combi Without Lumbar Support 20x18 SESJA3336 1 $154.00 Page: 40 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Jay Medical Device Device Code Max Allowed Qty. Approved Price Jay Combi Without Lumbar Support, Narrow Adult Short 15.5x16 SESJA3340 1 $154.00 Jay Combi Without Lumbar Support, Narrow Adult 15.5x18 SESJA3345 1 $154.00 Jay Combi Without Lumbar Support, Regular Adult Short 18x16 SESJA3330 1 $154.00 Jay Combi Without Lumbar Support, Regular Adult Soft 18x18 SESJA3335 1 $154.00 Jay Cushion 18x16, 15.5x16, 14x16 SESJA0010 1 $528.00 Jay Cushion 18x18, 15.5x18, SESJA0100 1 $528.00 Jay Cushion 18x20, 15.5x20 SESJA0250 1 $585.00 Jay Cushion 20x20, 24x20 SESJA0200 1 $704.00 Jay Cushion Sizes 18x16 To 10x10 With Incontinent Cover SESJA0350 1 $540.00 Jay Cusion Sizes 18x16 To 10x10 With Air Exchange Cover SESJA0325 1 $550.00 Jay Duo Cushion 16x16,16x18, 18x16, 18x18 Includes Solid Seat, 2 Covers & Hardware SESJA8005 1 $354.00 Jay Duo Cushion 17x16, 17x18 Includes Solid Seat, 2 Covers & Hardware SESJA8017 1 $354.00 Jay Duo Cushion 20x16 Includes Solid Seat, 2 Covers & Hardware SESJA8015 1 $400.00 Jay Duo Cushion Foam Cushion 16x16, SESJA8040 16x18, 18x16, 18x18 1 $165.00 Jay Duo Cushion Foam Cushion 17x16, SESJA8057 17x18 1 $165.00 Jay Duo Cushion Foam Cushion 20x16 SESJA8055 1 $194.00 Jay Duo Cushion Foam Cushion 20x18 SESJA8050 1 $194.00 Jay Duo Cushion Large Adult 20x18 Includes Solid Seat, 2 Covers & Hardware SESJA8010 1 $392.00 Jay Duo Cushion Narrow Pan 16x16, 16x18, 18x16, 18x18 Includes Cushion, 2 Covers & Hardware SESJA8020 1 $347.00 Jay Duo Cushion Narrow Pan 17x16, 17x18 Includes Solid Seat, 2 Covers & Hardware SESJA8027 1 $354.00 Page: 41 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Jay Medical Device Device Code Max Allowed Qty. Approved Price Jay Duo Cushion Narrow Pan 20x16 Includes Solid Seat, 2 Covers & Hardware SESJA8025 1 $392.00 Jay Duo Cushion Narrow Pan 20x18 Includes Cushion, 2 Covers & Hardware SESJA8030 1 $392.00 Jay Easy Cushion With Flat Or Curved Bottom Sizes 14x16 Through 18x18 SESJA9805 1 $387.00 Jay Easy Cushion With Flat Or Curved Bottom Sizes 18x20 Through 20x20 SESJA9810 1 $405.00 Jay Easy Foam Base With Flat Or Curved Bottom Sizes 14x16 Through 18x18 SESJA9815 1 $102.00 Jay Easy Foam Base With Flat Or Curved Bottom Sizes 18x20 Through 20x20 SESJA9820 1 $116.00 Jay Fit Cushion Adjustable Contour Seat For 10" Or 12" Frame Width, Various Seat Depths SESJA9700 1 $308.00 Jay Fit Cushion Adjustable Contour Seat For 14" Or 16" Frame Width, Various Seat Depths SESJA9705 1 $343.00 Jay Fit Cushion Adjustable Contour Seat For 18" Frame Width, Various Seat Depths SESJA9710 1 $381.00 Jay Foam Base 20" Deep SESJA6050 1 $203.00 Jay Fusion Air Single Valve Regular size SE0000953 1 $604.00 Jay Fusion Air Single Valve width of 22" SE0000954 or more OR Jay Fusion Air Single Valve depth of 22" or more 1 $677.00 Jay Fusion Cushion AIR Dual Valve regular size SE0000956 1 $614.00 Jay Fusion Cushion AIr Dual Valve width of 22" or more OR Jay Fusion Cushion AIr Dual Valve depth of 22" or more SE0000957 1 $688.00 Jay Fusion Cushion AIr Dual Valve with width AND depth greater than 22" SE0000958 1 $762.00 Jay Fusion Cushion Air Single Valve with width AND depth greater than 22" SE0000955 1 $750.00 Jay Fusion Cushion Fluid width and depth of 22" or more SE0000952 1 $750.00 Jay Fusion Cushion Fluid width of 22" or more OR Jay Fusion Cushion Fluid depth of 22" or more SE0000951 1 $677.00 Page: 42 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Jay Medical Device Device Code Max Allowed Qty. Approved Price Jay Fusion Cushion regular size SE0000950 1 $604.00 Jay GO SE0000350 1 $172.00 Jay GS 10x13,12x15,14x17,16x19,18x20 SESJA5000 1 $512.00 Jay GS Cushion Pressure Relief Pad With Air Exchange Cover SESJA5010 1 $594.00 Jay GS Cushion Pressure Relief Pad With Incontinent Cover SESJA5005 1 $605.00 Jay Go - 19X15 to 24X24 SE0000324 1 $193.00 Jay Go Cushion Adult and Paediatric JGO14x14 to 18X24 SE0000323 1 $173.00 Jay ION SE0000348 1 $379.00 Jay Lite Cushion - All Sizes SESJA4200 1 $483.00 Jay Recline Cushion 20x20 SESJA9505 1 $685.00 Jay Recline Cushion 24x20 SESJA9515 1 $725.00 Jay Recline Cushion Large Sizes SESJA9510 1 $594.00 Jay Recline Cushion Standard Sizes SESJA9500 1 $519.00 Jay Recliner Cushion 18/15.5x20 With Incontinent Cover SESJA1375 1 $607.00 Jay Recliner Cushion 18x16 To 10x10 With Incontinent Cover SESJA1350 1 $552.00 Jay Recliner Cushion 18x16, 18x18, 15.5x16, 15.5x18, 14x16 SESJA1010 1 $550.00 Jay Recliner Cushion 18x20, 15.5x20 SESJA1100 1 $619.00 Jay Recliner Cushion 20x20 With Incontinent Cover SESJA1400 1 $690.00 Jay Recliner Cushion 20x20,24x20 With SESJA1200 Quadrant Pads 1 $737.00 Jay Recliner Cushion 24x20 With Incontinent Cover SESJA1425 1 $723.00 Jay Solution With Solid Drop Seat, Sizes 14 X 14 - 18 X 20, Includes Cover SESJA0370 1 $549.00 Jay Solution With Solid Drop Seat, Sizes 19 X 18 - 20 X 18, Includes Cover SESJA0375 1 $587.00 Jay Solution, Sizes 14 X 14 -17 X 18, Includes Cover SESJA0360 1 $413.00 Jay Solution, Sizes 18 X 16 - 20 X 18, Includes Cover SESJA0365 1 $430.00 Jay Triad Cushion 16x16, 16x18, 18x16,18x18,20x18 With Solid Drop Base SESJA9120 1 $299.00 Page: 43 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Jay Medical Kid Kart Lpa Medical Inc. Maple Leaf Wheelchair Motion Concepts Nighthawk Device Device Code Max Allowed Qty. Approved Price Jay Triad Cushion 20x18 SESJA9106 1 $299.00 Jay Triad Cushion 20x18 With Solid Drop Seat SESJA9125 1 $391.00 Jay Triad Cushion Standard Sizes SESJA9105 1 $299.00 Jay Union Cushion 14X14 TO 18X18 SE0000352 1 $440.00 Jay Union Cushion 18X19 TO 24X24 SE0000353 1 $465.00 Jay Union Cushion with additional cover SE0000354 size 14X14 TO 18X18 1 $475.00 Jay Union Cushion with additional cover SE0000355 size 18X19 TO 24X24 1 $499.00 Jay Xtreme Cushion 14x14 To 18x18 With 2 Covers SESJA9020 1 $428.00 Jay Xtreme Cushion 16x20, 18x20 With 2 Covers SESJA9040 1 $366.00 Jay Xtreme Cushion 20x20 With 2 Covers SESJA9030 1 $563.00 Jay Zip Cushion, All Sizes SESJA5550 1 $411.00 Tlc Contoured Seat Cushion SESKT2010 1 $990.00 Xpress Standard Seat Cushion Specify Short (900020/1) Or Long (900022/3) SESKT2020 1 $173.00 Xpress Contour Adjustable Cushion Specify Short (900312-28) Or Long (900329-36) SESKT2030 1 $348.00 Xpress Ledge Seat Cushion Specify Short (900028/9) Or Long (900030/1) SESKT2026 1 $319.00 Xpress Wedge Seat Cushion Specify Short (900024/5) Or Long (900026/7) SESKT2025 1 $66.00 Contour Seat Cushion With Perineal Abductor SESO12005 1 $93.00 Pre-Cure Cushion SESO12010 1 $155.00 ML Bariatric SE0001092 1 $541.00 ML Cozy SE0001090 1 $331.00 ML Extreme Comfort SE0001091 1 $431.00 Nylon/Leatherette 2" Foam Cushion SESWM0001 1 $55.00 Nylon/Leatherette 3" Foam Cushion SESWM0005 1 $62.00 Trx Onyx Seat 16-19" Width SESZG0005 1 $555.00 Trx Onyx Seat 20-22" Width SESZG0010 1 $599.00 2" Standard Foam With Cover SESNM2000 1 $82.00 3" Standard Foam With Cover SESNM2010 1 $47.00 Page: 44 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Nighthawk Orthofab Otto Bock Device Device Code Max Allowed Qty. Approved Price Aero Space Cushion, 18x16x3 SESNM9060 1 $208.00 Afg Cushion 16x16, 16x18, 18x16, 18x18 SESNM1010 1 $299.00 Bi-Sunmate Cushion & Base SESNM8070 1 $392.00 Cumfy Plus Cushion With Cover SESNM4000 1 $273.00 Gel Suspension Cushion 16x16,18x16,18x18 SESNM9045 1 $257.00 Gel Suspension Cushion 20x16, 20x18 SESNM9050 1 $216.00 Med Foam 1" Thru 4" With Cover SESNM0010 1 $221.00 Superior Cumfy Cushion & Base SESNM8000 1 $474.00 Superior Cushion With Cover SESNM2050 1 $372.00 Upcharge For Custom Sized Or Oversized Cushions SESNM0000 1 $42.00 Cushion With Contour Add Ons 15-18" Width & 15-20" Depth SESOF1005 1 $279.00 Cushion With Contour Add Ons Non Standard Sizes & Options SESOF1010 1 $331.00 Cushion With Visco Foam Insert & Contour Add Ons 14-20" Width & 15-20" Depth SESOF1025 1 $317.00 Cushion With Visco Foam Insert & Contour Add Ons Non Standard Sizes & Options SESOF1030 1 $386.00 Aerial Cushion 15"x16" to 20"x18" SE0000691 1 $480.00 All Sizes SESOB704L 1 $383.00 Aquos Cushion 15"x18" to 20"x18" SE0000690 1 $359.00 Cloud Custom Sizes SESOB6045 1 $553.00 Comfort Custom Sizes SESOB8045 1 $699.00 Seat Finished With Spray Coating,Cover,Sewing Pattern SESOB7100 1 $1,710.00 Seat-Itemized Cushion (Unfinished) SESOB7105 1 $1,253.00 Sizes 16x18,17x16,17x17,18 X16 SESOB6020 1 $434.00 Sizes 17x18,18x17,18x18,19 X16 SESOB6025 1 $434.00 Sizes 19x18,20x16,20x18 SESOB6030 1 $446.00 Standard Sizes SESOB8040 1 $541.00 Standard Sizes Smaller Than 16x17 SESOB6015 1 $422.00 Terra Cushion 15"x16" to 20"x18" SE0000689 1 $328.00 Permobil Ergo Seat - All Sizes SES1P0005 1 $351.00 Physipro C3S Cushion - All Sizes SE0001119 1 $235.00 LXA Cushion - All Sizes SE0001070 1 $319.00 Page: 45 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Physipro Power Plus Mobility Precision Rehab Manufacturing Pride Mobility Device Device Code Max Allowed Qty. Approved Price Ultra Cushion - All Sizes SE0001120 1 $254.00 Ultra Cushion with Gel - All Sizes SE0001121 1 $435.00 Zero Pressure Cushion - All Sizes SE0001122 1 $258.00 Zero Pressure Cushion with Gel - All Sizes SE0001123 1 $424.00 Cozy Cushion Plus All Sizes SESWM0050 1 $414.00 Max Comfort Bariatric Cushion All Sizes SESWM0040 1 $676.00 Max Comfort Cushion All Sizes SESWM0030 1 $538.00 Base Cushion Seat Sewn Cover Waterproof Foam, Includes Labour For Digitizing Or Plastering SESWB0010 1 $1,476.00 Base Cushion Seat Vacuum Formed Cover, Includes Labour For Digitizing Or Plastering SESWB0005 1 $1,241.00 Base Cushion Seat With All Modifications, Includes Labour For Digitizing Or Plastering SESWB0015 1 $1,793.00 Comfort -Fit 12x12 to 20x20 SE0000754 1 $184.00 Contoured-Fit (Moderate Positioning Air Option) 12x12 to 20x20 SE0000757 1 $567.00 Contoured-Fit (Moderate Positioning Gel Option) 12x12 to 20x20 SE0000756 1 $446.00 Contoured-Fit (Moderate Positioning Visco-Foam) 12X12 20X20 SE0000755 1 $446.00 Contoured-Fit Aggressive Positioning Air Option 12x12 to 20x20 SE0000760 1 $567.00 Contoured-Fit Agressive Positioning Gel Option 12x12 to 20x20 SE0000759 1 $446.00 Contoured-Fit Agressive Positioning Visco-Foam 12x12 to 20x20 SE0000758 1 $446.00 Precision-Fit Cushion Upcharge, Extra Seat Depth 20"-24" SESWB0024 1 $264.00 Precision-Fit Cushion Upcharge, Extra Seat Width 20"-24" SESWB0022 1 $264.00 Precision-Fit Cushion, Subtle, Moderate SESWB0020 Or Aggressive Positioning. Includes Shape Adjustments, Inner Cover, Outer Cover And Cushion Rigidizer. 1 $931.00 Contoured Seat Cushion - All Sizes 1 $269.00 SESK20005 Page: 46 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Products Quickie Ride Designs Device Device Code Max Allowed Qty. Approved Price Synergy Simplicity All Sizes SESX10080 1 $103.00 Synergy Solution 1 LTC Cushion SE0000470 1 $362.00 Synergy Solution Cushion Standard Sizes SESX10015 1 $275.00 Synergy Solution Cushion Custom Sizes SESX10020 1 $310.00 Synergy Solution SG Cushion Sizes 14" X 14" - 20" X 18" SESX10100 1 $185.00 Synergy Solution SG Cushion Sizes 20" X 20" - 24" X 24" SESX10105 1 $220.00 Synergy Spectrum Air Contoured Cushion Sizes 22" X 20" - 24" X 24" SESX10135 1 $497.00 Synergy Spectrum Air Cushion Sizes 14" X 12" - 20" X 24" SESX10120 1 $400.00 Synergy Spectrum Air Cushion Sizes 22" X 20" - 24" X 24" SESX10125 1 $428.00 Synergy Spectrum Cushion Viscoelastic Insert,Standard Sizes SESX10025 1 $379.00 Synergy Spectrum Cushion Twin Cell Insert,Custom Sizes SESX10040 1 $413.00 Synergy Spectrum Cushion Twin Cell Insert,Standard Sizes SESX10035 1 $379.00 Synergy Spectrum Cushion Viscoelastic SESX10030 Insert,Custom Sizes 1 $413.00 Synergy Sprectrum Air Contoured Cushion Sizes 14" X 12" - 20" X 24" SESX10130 1 $469.00 Synergy Tru Comfort/ Tru Comfort 2 Cushion Sizes 22" X 16" - 22" X 24" SESX10095 1 $344.00 Synergy Tru Comfort/ Tu Comfort 2 Cushion Sizes 16" X 14" - 20" X 24" SESX10090 1 $275.00 Tru Comfort 2 non standard sizes, including air mesh cover SE0001050 1 $413.00 Tru Comfort 2 standard sizes, including air mesh cover SE0001049 1 $344.00 2", 3" Or 4" Cushion With Cover SESQU0355 1 $105.00 BREEZY RELAX2 COMFORT CUSHION SE0000118 1 $1,722.00 Contour Seat - Tilt Fx SESQU0400 1 $338.00 JAY X2 with cover SE0001155 1 $580.00 Ride Custom Cushion: Standard (12-20"), Extra Wide (21-22"), Custom Sizes. SESR40005 1 $1,474.00 Page: 47 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Ride Designs Roho Device Device Code Max Allowed Qty. Approved Price Ride Forward Cushion - All Sizes SESR41020 1 $407.00 Ride Java SE0001223 1 $524.00 Adaptor 9x13x1" (Maximum 5) SESRO1105 5 $180.00 Airlite Cushion With Built In Cover All Sizes SESRO9005 1 $388.00 Contour Select Cushion Custom Sizes SESRO9025 1 $663.00 Contour Select Cushion Standard Sizes SESRO9020 1 $620.00 Custom (Made To Order) Cushion W/Cover SESRO030L 2 $663.00 Enhancer, Custom Sizes,Dual Valve,Cover SESRO8010 1 $625.00 Enhancer, Standard Adult & Paediatric Sizes, Dual Valve, With Cover SESRO8005 1 $561.00 Harmony Cushion With Cover-Sizes 14x16, 20x18 SESRO9050 1 $430.00 High-Profile - LTC Cushion, Including Cover SESRO3015 1 $632.00 High-Profile, All Standard Adult & Paediatric Sizes Including Cover SESRO3005 1 $561.00 High-Profile, Custom Sizes Including Cover SESRO3010 1 $625.00 Hybrid Elite/Hybrid Elite LTC Cushion, Dual Valve, With Cover Sizes 14x14 ,20x20 SESRO9503 1 $681.00 Hybrid Elite/Hybrid Elite LTC Cushion, Dual Valve, With Cover, Sizes 22x18, 24x20 SESRO9504 1 $693.00 Hybrid Elite/Hybrid Elite LTC Cushion, Single Valve With Cover, Sizes 14x14 , 20x20 SESRO9501 1 $640.00 Hybride Elite/Hybrid Elite LTC Cushion, Single Valve With Cover, Sizes 22x18, 24x20 SESRO9502 1 $652.00 Low-Profile, All Standard Adult & Pediatric Sizes Including Cover SESRO3105 1 $561.00 Low-Profile, Custom Sizes Including Cover SESRO3110 1 $625.00 Low-Profile, LTC Cushion, Including Cover SESRO3115 1 $632.00 Mid-Profile, All Standard Adult & Paediatric Sizes Including Cover SESRO2005 1 $568.00 Mid-Profile, Custom Sizes Including Cover SESRO2010 1 $637.00 Mini-Max Cushion, Standard Sizes SESRO4005 1 $513.00 Page: 48 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Roho Solus Medical Manufacturing Inc Star Cushion Products Inc. Supracor Device Device Code Max Allowed Qty. Approved Price Nexus Spirit Cushion With Cover, Standard Sizes SESRO6010 1 $505.00 Nexus Spirit Cushion, Custom Sizes, With Cover SESRO6015 1 $525.00 Quatro Select LTC Cushion, Including Cover SESRO7055 1 $687.00 Quatro Select Low Or High Profile Cushion, Custom Sizes With Cover SESRO7040 1 $663.00 Quatro Select, Low Or High Profile Cushion With Cover, Standard Sizes SESRO7035 1 $620.00 EquaGel Pro Flex I SE0001113 1 $199.00 EquaGel Pro Flex II SE0001114 1 $468.00 EquaGel Pro Flex II Hybrid SE0001115 1 $344.00 EquaGel Pro Flex III Hybrid SE0001116 1 $392.00 EquaGel Pro Flex Ultra SE0001117 1 $668.00 All Sizes 12x12 Through 22x22 SESTJ2005 1 $459.00 Custom Cell Height Cushion Standard Sizes SESTJ0115 1 $555.00 Custom Sizes Over 22" In Two Directions Width And Depth SESTJ0110 1 $618.00 Custom Sizes Over 22" One Direction Width Or Depth SESTJ0105 1 $555.00 Galaxy Cushion - All Sizes SESTJ3005 1 $449.00 Mid Contour Cushion 3" Cells With Cover SESTJ0015 1 $428.00 Short Contour Cushion 2" Cells With Cover SESTJ0010 1 $428.00 Standard Contour Cushion 4" Cells With Cover SESTJ0005 1 $428.00 Bariatric Cushion (Classic) Clb 20-24" SESRR0016 1 $652.00 Bariatric Cushion (Classic) Clb 25-28" SESRR0017 1 $750.00 Bariatric Cushion (Classic) Clb 29-31" SESRR0018 1 $897.00 Bariatric Cushion (Classic) Clb 32-35" SESRR0019 1 $1,044.00 Classic Cushion 14x16-20x20 SESRR0010 1 $470.00 Classic Sling Bottom Cushion 14x16-20x20 SESRR0015 1 $489.00 Contoured Cushion 14x16-20x20 SESRR0020 1 $574.00 Contoured Cushion, Standard Sizes SESRR0060 1 $549.00 Contoured Sling Bottom Cushion 14x16-20x20 SESRR0025 1 $568.00 (Does Not Include Cover) Page: 49 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Device Code Max Allowed Qty. Approved Price Corbee Cushion 10x10-14x14 SESRR0100 1 $296.00 Corbee Sling 10x10-14x14 SESRR0110 1 $320.00 Paediatric Contoured Cushion, Custom Sizes SESRR0065 1 $405.00 Slimline Cushion 16x16-20x18 SESRR0030 1 $380.00 Slimline Sling Bottom Cushion 16x16-20x18 SESRR0035 1 $405.00 Curve Cushion, Stretch Air Or Fusion Cover, All Sizes SES7C0050 1 $116.00 Curve Cushion, Stretch Air Or Fusion Cover, Custom Sizes SES7C0055 1 $211.00 Custom Embrace Anti Thrust Cushion SE0000127 1 $591.00 Custom Embrace Anti Thrust Cushion Hook and Loop non skid bottom SE0000130 1 $701.00 Custom Embrace Zero Elevation Cushion SE0000128 1 $591.00 Custom Embrace Zero Elevation Cushion Hook and Loop non skid bottom SE0000129 1 $701.00 Embrace Anti-Thrust Cushion Hook and loop non-skid bottom SE0000113 1 $369.00 Embrace Zero Elevation Cushion SE0000125 1 $369.00 Embrace Zero Elevation Cushion Hook and Loop non-skid bottom SE0000126 1 $438.00 Hyalite Cushion, Condura Knit Or Stretch Air Cover, All Sizes SES7C0030 1 $345.00 Hyalite Cushion, Condura Knit Or Stretch Air Cover, Custom Sizes SES7C0035 1 $618.00 Maxx Cushion, Round Or Flat Bottom, Fusion Or Stretch Air Cover, All Sizes SES7C0020 1 $443.00 Maxx Cushion, Round Or Flat Bottom, Fusion Or Stretch Air Cover, Custom Sizes SES7C0025 1 $782.00 Ridge Cushion, Stretch Air Or Fusion Cover, All Sizes SES7C0040 1 $420.00 Ridge Cushion, Stretch Air Or Fusion Cover, Custom Sizes SES7C0045 1 $771.00 Toronto Orthopedic Ltd. Tops Seat Cushion (10" & 12" Width) SESTP0005 1 $212.00 Trulife Gelcell Contour Cushion, All Sizes SESCZ0080 1 $286.00 Relax Duogel Contour Cushion, All SESCZ0040 1 $201.00 Supracor The Comfort Company Device Page: 50 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Trulife Varilite Medical Products Vicair Vision Device Device Code Max Allowed Qty. Approved Price Relax Easy Cushion All Sizes SESCZ0070 1 $201.00 Relax Gelcell, All Sizes SESCZ0045 1 $275.00 Relax Trio Cushion, All Sizes Sizes SESCZ0035 1 $91.00 Evolution Bariatric Cushion Standard Or SESVP0408 Psv, All Sizes, Includes Cover And Pressure Setting Valve 1 $616.00 Evolution Cushion Standard Or Psv, All Sizes, Includes Cover And Pressure Setting Valve SESVP0406 1 $580.00 Evolution Wave Bariatric Cushion Includes, Cover And Positioning Base SESVP0402 1 $705.00 Evolution Wave, All Sizes, Includes Cover And Positioning Base SESVP0401 1 $604.00 Junior Cushion SE0001146 1 $562.00 Meridian Bariatric Cushion, All Sizes, Includes Cover SESVP0605 1 $652.00 Meridian Cushion, All Sizes, Includes Cover SESVP0600 1 $543.00 Meridian Wave Bariatric Cushion, All Sizes, Includes Cover SESVP0615 1 $741.00 Meridian Wave Cushion, All Sizes, Includes Cover SESVP0610 1 $636.00 Proform Nx Cushion, Single, Dual, All Sizes Includes Cover SESVP0351 1 $575.00 Reflex Cushion, All Sizes, Includes Cover SESVP6020 1 $342.00 Solo Cushion, Standard Or Psv, All Sizes, Includes Cover SESVP0200 1 $418.00 Stratus Cushion, All Sizes, Includes Cover SESVP0410 1 $318.00 Zoid Cushion, All Sizes, Includes Cover SESVP0500 1 $479.00 Academy Adjuster SESV10020 1 $543.00 Academy Junior Adjuster SESV10010 1 $467.00 Academy Vector SESV10025 1 $584.00 Upcharge For Custom Sizes SESV11005 1 $69.00 Vicair Active: Sizes 12X12 - 18X18 SE0001102 1 $500.00 Vicair Active: Sizes 18X20 - 20X20 SE0001103 1 $549.00 Epic Cushion: custom sizes (up to SE0000673 1 $418.00 Page: 51 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating Device Type Seat Cushion Manufacturer Wheelchair Seating Systems Inc. Device Device Code Max Allowed Qty. Approved Price 19x19) Epic Cushion: standard sizes: 16x16 1/2 to 18x18 SE0000672 1 $373.00 Epic Drop Seat: Custom Sizes (up to 19x19) SE0000675 1 $544.00 Epic Drop Seat: standard sizes: 16x16 1/2 to 18x18 SE0000674 1 $485.00 Epic Plus Cushion Standard Sizes 16x20 to 20x18 SE0000676 1 $418.00 Epic Plus Cushion: Bariatric Custom sizes, 20x20 to 24x24 SE0000677 1 $502.00 Epic Plus Drop Seat: Bariatric Custom sizes, 20x20 to 24x24 SE0000679 1 $674.00 Epic Plus Drop Seat: Standard Sizes 16x20 to 20x18 SE0000678 1 $545.00 Upcharge for custom Cushions 20"X20 - 24"X24" SESVC4510 1 $169.00 Upcharge for custom Cushions Up To 20" X 19", Inclusive SESVC4500 1 $116.00 Upcharge for custom Drop-Seat up to 20"X19", Inclusive SESVC4520 1 $132.00 Upcharge for custom Drop-Seats 20"X20 - 24"X24" SESVC4530 1 $186.00 VIVE -Deep Leg Trough -Drop Seat; Standard Sizes 16x16 1/2 to 20x18 SESVC4180 1 $858.00 VIVE -Deep Leg Trough Cushion; Standard Sizes 16x16 1/2 to 20x18 SESVC4170 1 $658.00 VIVE -Drop Seat; Standard Sizes 16x16 SESVC4160 1/2 to 20x18 1 $819.00 VIVE Cushion; Standard Sizes 16x16 1/2 to 20x18 SESVC4150 1 $627.00 Very Soft Drop-Seat; Standard Sizes 16x16 1/2 to 20x18 SESVC4030 1 $752.00 VerySOFT -Deep Leg Trough Cushion; Standard Sizes 16x16 1/2 to 20x18 SESVC4100 1 $585.00 VerySOFT Cushion, Standard Sizes 16x16 1/2 to 20x18 SESVC4000 1 $590.00 VerySOFT- Deep Leg Trough -Drop Seat; Standard Sizes 16x16 1/2 to 20x18 SESVC4120 1 $793.00 OPTIONS: Page: 52 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Arm Support Hardware Arm Support Options Arm Support(s) Manufacturer Back Hardware Device Code Max Allowed Qty. Approved Price Approved ADP Manufacturers Only Non Standard Modular Mounting Hardware Required For Positioning (Maximum 2) SEAND0025 2 $138.00 Custom Fabricated Swivel Armrest Hardware (Maximum 2) SEICF301L 2 $60.00 Approved ADP Manufacturers Only Add Modular Pressure Relief To Armrest Specialty Foam/Gel (Maximum 2) SEAND0030 2 $65.00 Custom Fabricated Rigid Side Panel For Custom Arm Support (Maximum 2) SEMCF601L 2 $52.00 Side Panel Pad For Custom Arm Support (Maximum 2) SEMCF602L 2 $35.00 Extra Wide &/Or Extended Length For SEAND0010 Modular Arm Supports Includes Mounting Hardware (Maximum 2) 2 $91.00 Modular Arm Support - Includes Mounting Hardware (Maximum 2) SEAND0005 2 $237.00 Modular Hand Support - Flat/Cone SEAND0015 Includes Mounting Hardware (Maximum 2) 2 $65.00 Complex Arm Support, Multi Component, Includes Hardware (Maximum 2) SEACF102L 2 $216.00 Fixed Arm Support, One Piece, Includes Hardware (Maximum 2) SEACF101L 2 $129.00 Full Sling Arm Support, Includes Hardware (Maximum 2) SEACF104L 2 $259.00 Heavy Duty Solid Padded Armrest Support, Replaces Padded W/C Armpad, Includes Hardware (Maximum 2) SEACF103L 2 $65.00 Removable Cover For Back With Laterals SEMCF103L 2 $198.00 Removable Cover For Contoured/Custom Contoured Back SEMCF102L 2 $155.00 Removable Cover For Flat Back SEMCF101L 2 $104.00 Removable Cover For Sculptured Or Molded Back SEMCF104L 2 $233.00 Complex Specialized Mounting Hardware - Including Hardware For Custom Molded Modular SEBND0010 2 $345.00 Approved ADP Manufacturers Only Custom Fabricated Back Cover Device Custom Fabricated Approved ADP Manufacturers Only Page: 53 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Manufacturer Back Hardware Back Support Options Foot/Leg Support Options Foot/Leg Support(s) Device Code Max Allowed Qty. Approved Price Systems Custom Fabricated Simple Back Interface Mounts Back To Wheelchair Frame SEICF160L 1 $168.00 Approved ADP Manufacturers Only Additional Pressure Relief - Gel/Air Inserts/Pads Etc. (Maximum 6) SEBND0020 6 $116.00 Custom Modifications And Sizing Including Custom Sizes, Additional Postural Support - Lumbar Pad, Foam Pads Etc. (Maximum 6) SEBND0015 6 $47.00 Back Channeling - Upgrade For Slots For Lateral Adjustments SEMCF201L 1 $129.00 Back Plaster Molding/Vacuum Form, for SEUCF003L Custom Fabricated Device Only 1 $138.00 Back Reinforcement - Heavy Duty Upgrade SEMCF202L 1 $86.00 Modify Or Refurbish Existing Custom Fabricated Back, Includes Parts, Hardware & Labour SEMCF200L 1 $194.00 Approved ADP Manufacturers Only Complex Specialized Mounting Hardware SEFND0030 2 $86.00 Custom Fabricated Mount Footrest To Seating System SEICF501L 2 $104.00 Approved ADP Manufacturers Only Extra Padding For Specific Pressure Relief - (Maximum 2) SEFND0035 2 $43.00 Custom Fabricated Footrest Discrepancy Upcharge Accommodates Differences Between Left & Right Leg SEMCF801L 1 $69.00 Footrest Extension, Not Padded (Maximum 2) SE0000322 2 $65.00 Footrest Padding (Maximum2) SEMCF803L 2 $52.00 Footrest Reinforcement Upcharge Heavy Duty Upgrade To Reinforce Footrest SEMCF802L 2 $121.00 1 Piece Foot Board - Includes Mounting Hardware & Padding SEFND0015 1 $95.00 Amputee Board/Stump Support Includes Mounting Hardware & Padding SEFND0005 1 $246.00 Calf Panel - Includes Mounting Hardware & Padding SEFND0010 2 $43.00 Custom Fabricated Foot/Leg Support Hardware Device Approved ADP Manufacturers Only Page: 54 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Foot/Leg Support(s) Headrest/Neckrest Hardware Manufacturer Device Device Code Max Allowed Qty. Approved Price Approved ADP Manufacturers Only Foot Box - Includes Mounting Hardware & Padding Foot Box May Be 1 Piece Or 2 Piece (Each Foot) SEFND0020 2 $207.00 Custom Fabricated Calf Support, Padded And Removable SEFCF107L 2 $168.00 Complex Foot Rest (One Or Two Piece), Includes Parts, Hardware, And Labour SEFCF102L 1 $380.00 Footpocket, Not Padded ( Maximum 2) SEFCF106L 2 $173.00 One Piece Double Footbox, Not Padded SEFCF103L 1 $256.00 One Piece Fixed Footrest, Not Padded SEFCF101L 1 $129.00 Bracket To Mount Headrest To Seating System/Back Support Or Wheelchair SEHND0020 1 $86.00 Complex Specialized Mounting Hardware SEHND0015 1 $259.00 Non Standard Mounting Hardware Not Included In Base Device Removable, Allows Multi Axis Adjustments SEHND0010 1 $138.00 Standard Mounting Hardware Not Included In Base Device Removable, Allows Height, Anterior & Posterior Adjustments SEHND0005 1 $121.00 Complex Headrest Hardware, Allows For Removability & Height And Forward Adjustment SEICF007L 1 $134.00 Multi-Axis Headrest Hardware, Allows For Removability And Multi Adjustments SEICF008L 1 $225.00 Simple Headrest Hardware, Allows For Removability & Height Adjustment SEICF006L 1 $60.00 Wheelchair Mounting Bracket For Headrest Hardware SEICF009L 1 $190.00 Complex Extension Pad, Mounted (Maximum 2) SEMCF006L 2 $259.00 Removable Cover For Complex Headrests, Use For Complex Headrest & Headrest/Neckrest Combinations SEMCF002L 2 $155.00 Removable Headrest/Neckrest Cover, SEMCF001L 2 $104.00 Approved ADP Manufacturers Only Custom Fabricated Headrest/Neckrest Options Custom Fabricated Page: 55 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Headrest/Neckrest Options Lateral Support Hardware Manufacturer Device Code Max Allowed Qty. Approved Price Simple Extension Pad, Mounted (Maximum 2) SEMCF005L 2 $173.00 Quickie RELAX HEADREST PAD SE0000119 1 $235.00 Custom Fabricated Fixed Lateral Hardware, NonAdjustable (Maximum 2) SEICF201L 2 $52.00 Hinged Swingaway Lateral Hardware, Height& Width Adjustable (Maximum 2) SEICF202L 2 $173.00 Removable Lateral Hardware, SEICF203L Height & Width Adjustable (Maximum 2) 2 $86.00 Custom Fabricated Device Any Fabric, Use For Flat/Contoured Headrest & Neckrest Lateral Support Options Custom Fabricated Extra Padding (Maximum 2) SEMCF651L 2 $52.00 Lateral Support(s) Approved ADP Manufacturers Only Complex Shape Lateral Supports, Each Includes Padding & Mounting Hardware (Maximum 4) SELND0015 4 $166.00 Fixed Lateral Supports, Each Includes Padding & Mounting Hardware (Maximum 4) SELND0005 4 $104.00 Shoulder Wings, Each - Includes Padding & Mounting Hardware (Maximum 2) SELND0020 2 $47.00 Swingaway Lateral Supports, Each Includes Padding & Mounting Hardware (Maximum 4) SELND0010 4 $155.00 Complex Shaped Thoracolumbar Supports, Non Adjustable, Includes Cover (Maximum 2) SELCF102L 2 $151.00 Shoulder Wings, Non Adjustable, Includes Cover SELCF103L 2 $82.00 Thoracolumbar Supports, Rigid & Non Adjustable, Includes Cover (Maximum 2) SELCF101L 2 $69.00 Hardware For Fixed Pommel SEICF401L 1 $73.00 Hardware For Flip-Down Pommel SEICF403L 1 $259.00 Hardware For Removable Pommel SEICF402L 1 $151.00 Approved ADP Manufacturers Only Pommel, Flip Down, All Components Including Hardware SESND1043 1 $259.00 Custom Fabricated Custom Pommel Without Hardware SEMCF701L 1 $138.00 Custom Fabricated Pommel Hardware Pommel/Adductors Custom Fabricated Page: 56 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Pommel/Adductors Positioning Belts Manufacturer Custom Fabricated Approved ADP Manufacturers Only Custom Fabricated Positioning Belts Options SE - Custom Modifications Custom Fabricated Approved ADP Manufacturers Only Device Device Code Max Allowed Qty. Approved Price Fixed Padded Adductor Includes Cover (Maximum 2) SEMCF702L 2 $104.00 Removable Padded Adductor Includes Cover (Maximum 2) SEMCF703L 2 $164.00 Any 2 Point Strap For Positioning Only - SERND0030 Any Closure Includes Padding & Mounting Hardware -Chest, Hip, Thigh, Calf, Ankle, Foot (Maximum 6) 6 $56.00 Any 4 Point Strap For Positioning Only - SERND0020 Any Closure Includes Padding & Mounting Hardware Pelvic "Y" Strap, "H" Leg Strap (Maximum 2) 2 $129.00 Chest Harness For Positioning Only Any Closure Includes Padding & Mounting Hardware SERND0001 1 $121.00 Non Standard Chest Or Shoulder Harness Required For Positioning Support Only SERND0035 1 $397.00 Shoulder Straps For Positioning Only Any Closure Includes Padding & Mounting Hardware (Maximum 2) SERND0010 2 $52.00 Custom Chest Support, Includes Attachments SERCF103L 1 $129.00 Custom Positioning Belt, Includes Attachments. Specify Upper &/Or Lower Extremity &/Or Chest (Maximum 12) SERCF105L 12 $47.00 Custom Shoulder Harness, Includes Padding & Attachments SERCF104L 1 $181.00 Pelvic "Y" Belt Or Groin Strap, Includes Attachments SERCF101L 1 $52.00 Complex Control Pads (Maximum 4) SEMCF503L 4 $142.00 Positioning Control Pads (Maximum 12) SEMCF502L 12 $47.00 Positioning Support Pads (Maximum 12) SEMCF501L 12 $47.00 Custom Modifications Required To Adp Listed Wheelchair To Facilitate Installation Of Custom Fabricated Positioning SEMCF990L 1 Page: 57 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type SE - Custom Modifications Seat Cushion Cover(s) Manufacturer Device Code Max Allowed Qty. Custom Modifications To An Adp Listed Modular Seating Device & No Adp Code With Assigned Funding Is Available Authorizer Must Provide Clinical Rationale To Support Request - Vendor Must Provide Breakdown Of Cost Of Parts & Labour (Not To Exceed $40.00/Hour) SEMND2005 1 Transfer Existing Adp Approved Modular Seating System Into New Or Modified Adp Approved Wheelchair Labour Only, When No Parts Required SEMND1005 1 $69.00 Custom Fabricated Transfer Existing Adp Approved Custom Seating System Into A New Or Modified Adp Approved Wheelchair. Labour Only, No Parts Required. SEUCF200L 1 $69.00 Approved ADP Manufacturers Only Extra Cover Bariatric Sizes SESND1060 2 $134.00 Extra Cover Non Standard Sizes SESND1055 2 $99.00 Extra Cover Standard Sizes SESND1050 2 $65.00 Removable Cover For Flat Seat, For Incontinence (Maximum 2) SEMCF105L 2 $108.00 Removable Cover For Sculptured Or Molded Seat, For Incontinence (Maximum 2) SEMCF107L 2 $216.00 Removable Cover For Wedged Or Contoured Seat, For Incontinence (Maximum 2) SEMCF106L 2 $155.00 Approved ADP Manufacturers Only Complex Specialized Mounting Hardware - Including Hardware For Custom Molded Modular Systems SESND1010 1 $259.00 Custom Fabricated Complex Interface Mounts Seat & Back To Wheelchair Frame SEICF170L 1 $302.00 Hardware To Mount Positioning Device Into Paediatric Stroller SEICF190L 1 $86.00 Approved ADP Manufacturers Only Custom Fabricated Seat Hardware Device Approved Price Devices (Seating). Authorizer Must Provide Clinical Rational To Support Request. Clinic Must Provide A Breakdown Of The Cost Of Parts And Labour (Not To Exceed $40.00/Hour). Page: 58 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Seat Hardware Seat Options Manufacturer Custom Fabricated Approved ADP Manufacturers Only Custom Fabricated Device Device Code Max Allowed Qty. Approved Price Hardware To Mount Seat & Back Into Dynamic Tilt Wheelchair SEICF180L 1 $492.00 Seat Rigidizer - Flat Rigid Insert SEICF192L 1 $52.00 Securing Hardware That Mounts Hardware To Mobility Device (Maximum 8) SEICF191L 8 $22.00 Simple Seat Interface Mounts Seat To Wheelchair Frame SEICF150L 2 $168.00 Strap Interface (2) Mounts Seat To Wheelchair SEICF140L 2 $86.00 Additional Pressure Relief - Specialty Foam, Air, Gel SESND1045 1 $358.00 Custom Modifications And Sizing Including Custom Sizes, Static Adductors & Pommels, Wedges & Anti-Thrust Devices, Leg Length Discrepancy Allowance (Maximum 6). SESND1040 6 $69.00 Drop Base And Hooks (4) SESND1020 1 $216.00 Roho Bolster SESND1035 1 $155.00 Solid Seat Insert SESND1015 1 $69.00 Subasis Bar, Complete, Including Hardware SESND1041 1 $173.00 2" Convolute Foam Cut To Size (Maximum 2) SEMCF403L 2 $35.00 2" Polyfoam Cut To Size (Maximum 2) SEMCF406L 2 $26.00 3" Convolute Foam Cut To Size (Maximum 2) SEMCF404L 2 $39.00 3" Polyfoam Cut To Size (Maximum 2) SEMCF407L 2 $30.00 4" Convolute Foam Cut To Size (Maximum 2) SEMCF405L 2 $43.00 Add Waterproof Skin On Complex Indirect Molded Seat SEMCF210L 2 $86.00 Complex Pelvic Stabilizers, Each (Maximum 2) SEMCF206L 2 $194.00 Contoured Cushion With Troughing Secured In Front Of A Roho Cushion, Not Including Roho Cushion, Includes Cover SEMCF209L 1 $328.00 Heavy Duty Upgrade To Reinforce Seat SEMCF207L 1 $65.00 Page: 59 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Seat Options Tray Manufacturer Custom Fabricated Approved ADP Manufacturers Only Custom Fabricated Device Device Code Max Allowed Qty. Approved Price Modify Or Refurbish Existing Custom Fabricated Seat, Includes Parts, Hardware & Labour SEMCF212L 1 $194.00 Pelvic Stabilizer (Maximum 2) SEMCF204L 2 $185.00 Polymer Supplement Pad (Maximum 2) SEMCF402L 2 $129.00 Seat Plaster Molding/Vacuum Form, for Custom Fabricated Device Only SEUCF005L 1 $138.00 Simple Cushion Secured In Front Of A Roho Cushion, Not Including Roho Cushion, Includes Cover SEMCF208L 1 $173.00 Single Complex Pelvic Stabilizer For Seat Or Back SEMCF205L 1 $259.00 Upgrade To Provide Extra Pressure Relief, Gel/Foam/Air/Liquid Etc. (Maximum 2) SEMCF203L 2 $129.00 Viscoelastic Foam Or Pudgee 1" Thick/1 Square Foot (Maximum 2) SEMCF401L 2 $52.00 Full Tray For Positioning Support Only Standard Adult & Paediatric Sizes, Includes Mounting Hardware SETND0005 1 $164.00 Full Tray Non Standard Size For Positioning Support Only Adult & Paediatric Sizes, Includes Mounting Hardware SETND0010 1 $280.00 Half Tray For Positioning Support Only - SETND0020 Non Standard Adult & Paediatric Sizes, Includes Mounting Hardware 2 $272.00 Half Tray For Positioning Support Only - SETND0015 Standard Adult & Paediatric Sizes, Includes Mounting Hardware 2 $203.00 Customized Lexan Tray, Includes Mounting Hardware SETCF103L 1 $362.00 Kydex Tray, Includes Mounting Hardware SETCF104L 1 $311.00 Plastic Tray, Includes Mounting Hardware SETCF101L 1 $302.00 Wood/Arborite Tray, Includes Mounting Hardware SETCF102L 1 $220.00 Page: 60 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Seating OPTIONS: Device Type Tray Options Manufacturer Approved ADP Manufacturers Only Custom Fabricated Device Device Code Max Allowed Qty. Approved Price Add Modular Elbow Or Hip Blocks To Any Modular Tray (Maximum 4) SETND0030 4 $56.00 Add Padding To Any Tray SETND0035 2 $65.00 Clear Tray Cover, Removable SEMCF301L 1 $69.00 Elbow Block Padding Including Cover (Maximum 2) SEMCF306L 2 $52.00 Elbow Blocks (Maximum 2) SEMCF305L 2 $73.00 Large/Full Tray Pad (Maximum 2) SEMCF304L 2 $125.00 Small Tray Pad (Maximum 2) SEMCF303L 2 $69.00 Page: 61 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) Device Type Adult High Performance Rigid Manual Wheelchair Wheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Manufacturer Invacare Ki Mobility Max Allowed Qty. Approved Price A-4 WMA4IN015 1 $3,098.00 Crossfire T6/Ti WMA4IN110 1 $3,098.00 Crossfire T7a WMA4IN130 1 $3,098.00 Terminator WMA4IN105 1 $3,098.00 Rogue WM0001043 1 $3,098.00 Tsunami WMA4KI015 1 $3,098.00 LEVO compact-easy LCEV with battery powered stand-up feature WM0000471 1 $3,098.00 Motion Composites Veloce WM0001029 1 $3,098.00 Otto Bock Ventus WM0001104 1 $3,098.00 Voyager Evo WM0001190 1 $3,098.00 Panthera S2 WM0000972 1 $3,098.00 Panthera U2 WM0000973 1 $3,098.00 Product Design Group Elevation WM0001203 1 $3,098.00 Quickie Quickie Gp/Gpv WMA4QU005 1 $3,098.00 Quickie Gt WMA4QU030 1 $3,098.00 Quickie Q7 WMA4QU040 1 $3,098.00 Quickie QRi WM0000991 1 $3,098.00 Hi-Lite WMA4RZ005 1 $3,098.00 Maxima WM0000696 1 $3,098.00 Tilite Aero Z WMA4TZ010 1 $3,098.00 Rgk Wheelchairs TiLite Wheelchair type offers maximum adjustments and options. Suitable for the very active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Device Code LEVO AG Pantera AB Adult Lightweight Performance Manual Wheelchair Device Tilite Yr/Tr,Yra/Tra,Trc,Zra WMA4TZ005 1 $3,098.00 iCON Icon A1 WM0000945 1 $3,098.00 Future Mobility Galaxy Lite WMA3FM010 1 $2,290.00 Northern Lite WMA3FM005 1 $2,290.00 Handicare Legend 2 Exigo/Exigo WMA3M9015 1 $2,290.00 Invacare Compass Xe (Allegro) WMA3IN030 1 $2,290.00 Mvp WMA3IN060 1 $2,290.00 Myon Active WMA3IN065 1 $2,290.00 Prospin X4 WMA3IN035 1 $2,290.00 Xtra WMA3IN005 1 $2,290.00 Catalyst 5, 5ti WMA3KI010 1 $2,290.00 Catalyst 5vx WMA3KI015 1 $2,290.00 Maple Leaf Wheelchair EZ Ride WMA3WM005 1 $2,290.00 Motion Composites Helio A7 WM0001020 1 $2,290.00 Helio C2 WM0000964 1 $2,290.00 Ki Mobility Page: 62 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) Device Type Adult Lightweight Performance Manual Wheelchair Wheelchair type offers maximum adjustments and options. Suitable for the very active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Adult Lightweight Standard Manual Wheelchair Wheelchair type most suitable for user who is independently mobile and requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Manufacturer Device Device Code Max Allowed Qty. Approved Price Orthofab Prima WMA3OF010 1 $2,290.00 Otto Bock Motus WMA3OB010 1 $2,290.00 Start M5 Comfort/ M5XXL WMA3OB005 1 $2,290.00 Permobil TiLite AERO X WM0001169 1 $2,290.00 Physipro XL-5/XL-5 ci WM0001132 1 $2,290.00 Power Plus Mobility Glyder WM0001061 1 $2,290.00 Pride Mobility Products Litestream Xf WMA3X1010 1 $2,290.00 Product Design Group Eclipse 600 WMA3MV005 1 $2,290.00 Quickie Quickie 2 WMA3QU005 1 $2,290.00 Quickie 2 Hp WMA3QU010 1 $2,290.00 Quickie 2 Lite WMA3QU020 1 $2,290.00 Quickie Gtx WMA3QU040 1 $2,290.00 Quickie Lxi WMA3QU405 1 $2,290.00 Quickie M6 WMA3QU420 1 $2,290.00 Quickie QXi WM0000562 1 $2,290.00 Quickie Revolution WMA3QU410 1 $2,290.00 Quickie Xenon WM0001156 1 $2,299.00 Rgk Wheelchairs Maxima WMA3RZ005 1 $2,290.00 TiLite Tilite X, Sx, Tx WMA3TZ005 1 $2,290.00 Drive Medical Design & Manufacturing Viper Plus GT WM0000317 1 $1,449.00 Future Mobility Stellato WMA2FM005 1 $1,449.00 Stellato II WM0001188 1 $1,449.00 9000 SL WMA2IN030 1 $1,449.00 9000 Topaz WMA2IN055 1 $1,449.00 9000 Xt WMA2IN025 1 $1,449.00 Myon Manual Wheelchair WMA2IN060 1 $1,449.00 Patriot WMA2IN050 1 $1,449.00 Catalyst 4, 4c WMA2KI010 1 $1,449.00 Invacare Ki Mobility Maple Leaf Wheelchair NRG+ WMA2WM005 1 $1,449.00 NRG+ Gold WM0001134 1 $1,449.00 Swift WMA2WM010 1 $1,449.00 Motion Composites Move WM0001196 1 $1,449.00 Orthofab Ch+ WMA2OF005 1 $1,449.00 Otto Bock Start M2 Effect WMA2OB005 1 $1,449.00 Page: 63 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) Device Type Manufacturer Device Code Max Allowed Qty. Approved Price Magic Plus WM0001062 1 $1,449.00 Voyager Plus WM0001063 1 $1,449.00 Pride Mobility Products Litestream Xf Ltd WMA2X1010 1 $1,449.00 Stylus 400 WMA2X1005 1 $1,449.00 Quickie Breezy 600 WMA2QU001 1 $1,449.00 Breezy RubiX2 WM0000567 1 $1,449.00 Breezy Ultra 4 WMA2QU010 1 $1,449.00 Quickie Lx WMA2QU105 1 $1,449.00 Adult Manual Dynamic Tilt Wheelchair Advanced Mobility Ams Itilt2 WMA5AO020 1 $2,110.00 Wheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 18" wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Tilt Recline/ I Tilt WMA5AO015 1 $2,110.00 Comfort Tilt 587V3 WMA5B-025 1 $2,110.00 Elite 785 WMA5B-020 1 $2,110.00 Models 80 & 48 WMA5B-005 1 $2,110.00 Models 85 & 35 & 75 WMA5B-010 1 $2,110.00 Capella, Capella 45 WM0000559 1 $2,110.00 Orion 500 WMA5FM010 1 $2,110.00 Orion III WM0001195 1 $2,110.00 Orion Ii WMA5FM005 1 $2,110.00 Emineo WMA5M9010 1 $2,110.00 Ibis WMA5M9005 1 $2,110.00 Concept 45 WMA5IN020 1 $2,110.00 Htr WMA5IN025 1 $2,110.00 Solara 2g WMA5IN035 1 $2,110.00 Solara 3g WMA5IN040 1 $2,110.00 Ki Mobility Focus CR WM0001160 1 $2,110.00 Lpa Medical Inc Comp-Position WMA5LQ010 1 $2,110.00 Dyn-Ergo WMA5LQ020 1 $2,110.00 Evolution WMA5LQ015 1 $2,110.00 Optimum Posturo-Pedic WMA5LQ005 1 $2,110.00 Adult Lightweight Standard Manual Wheelchair Wheelchair type most suitable for user who is independently mobile and requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Power Plus Mobility Device Broda Future Mobility Handicare Invacare Maple Leaf Wheelchair Orthofab Lowrider WM0001080 1 $2,110.00 MLT 700 A/B WMA5WM015 1 $2,110.00 MLTR 500/600 WMA5WM010 1 $2,110.00 Supertilt Oval Frame (maximum tilt 45 deg) WM0001111 1 $2,110.00 Supertilt Square Frame (maximum tilt 35 deg) WM0001166 1 $2,110.00 Tango WMA5OF005 1 $2,110.00 Page: 64 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price Adult Manual Dynamic Tilt Wheelchair Power Plus Mobility Extreme WM0001041 1 $2,110.00 Wheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 18" wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. NV Tilt WM0001076 1 $2,110.00 Supertilt Plus WM0001040 1 $2,110.00 Pride Mobility Products Litestream Traverse WM0001030 1 $2,110.00 Product Design Group Bentley WMA5MV005 1 $2,110.00 Fuze T20 WMA5MV025 1 $2,110.00 Fuze T50 WMA5MV020 1 $2,110.00 Stellar, Stellar GL, Stellar HD WMA5MV010 1 $2,110.00 Breezy Relax2 WM0000454 1 $2,110.00 Quickie Iris WMA5QU015 1 $2,110.00 Quickie SR-45 WM0000474 1 $2,110.00 Quickie Ts WMA5QU005 1 $2,110.00 Quickie Adult Standard Manual Wheelchair Wheelchair type most suitable for user who is not consistently independently mobile and requires minimal adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 18"wide x 18"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Paediatric High Performance Rigid Manual Wheelchair Wheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Tilt Fx WMA5QU020 1 $2,110.00 Seating Matters Limited Pheonix WM0000974 1 $2,110.00 Sorrento WM0000975 1 $2,110.00 Amg Medical Airgo WMA1GM005 1 $1,228.00 Everest & Jennings Traveler WMA1EJ005 1 $1,228.00 Invacare 900 WMA1IN015 1 $1,228.00 Tracer WMA1IN005 1 $1,228.00 Quickie Easy Care 2000 & 4000 WMA1QU015 1 $1,228.00 Hoggi Supra WM0000462 1 $3,354.00 Invacare Crossfire T6a WMK4IN130 1 $3,354.00 Ki Mobility Rogue WM0001044 1 $3,354.00 Tsunami WMK4KI005 1 $3,354.00 LEVO AG LEVO compact-easy LCEV with battery operated Stand-up feature WM0000472 1 $3,354.00 Otto Bock Ventus WM0001105 1 $3,354.00 Voyager Evo WM0001191 1 $3,354.00 Pantera AB Bambino WM0000976 1 $3,354.00 Permobil TiLite Twist WM0001187 1 $3,354.00 Quickie Quickie Gp WMK4QU010 1 $3,354.00 Quickie Gt WMK4QU030 1 $3,354.00 Quickie Q7 WMK4QU035 1 $3,354.00 Page: 65 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) Device Type Paediatric High Performance Rigid Manual Wheelchair Wheelchair type offers lightweight rigid frame and optimal maneuverability. Suitable for the very active user who requires postural support and altered wheel placement for mobility. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear anti-tippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Manufacturer Quickie Rgk Wheelchairs TiLite Device Device Code Max Allowed Qty. Approved Price Quickie QRi WM0000992 1 $3,354.00 Quickie Ti WMK4QU025 1 $3,354.00 Zippie WMK4QU005 1 $3,354.00 Zippie Zone WMK4QU040 1 $3,354.00 Hi-Lite WMK4RZ005 1 $3,354.00 Maxima WM0000697 1 $3,354.00 Tilite Aero Z WMK4TZ010 1 $3,354.00 Tilite Yr/Tr,Yra/Tra,Trc,Zra WMK4TZ005 1 $3,354.00 iCON Icon A1 WM0000946 1 $3,354.00 Invacare Compass Xe (Allegro) WMK3IN020 1 $2,310.00 Mvp Junior WMK3IN030 1 $2,310.00 Myon Jr Manual Wheelchair WMK3IN040 1 $2,310.00 Prospin X4 WMK3IN035 1 $2,310.00 Ki Mobility Catalyst Spark WM0000695 1 $2,310.00 Motion Composites Helio Kids WM0000563 1 $2,310.00 Otto Bock Motus WMK3OB005 1 $2,310.00 Permobil TILite AERO X WM0001170 1 $2,310.00 Quickie Quickie 2 WMK3QU010 1 $2,310.00 Quickie 2 Hp WMK3QU015 1 $2,310.00 Quickie 2 Lite WMK3QU020 1 $2,310.00 Quickie Gtx WMK3QU040 1 $2,310.00 Quickie Lxi WMK3QU030 1 $2,310.00 Quickie Xenon WM0001157 1 $2,310.00 Zippie 2 WMK3QU005 1 $2,310.00 Zippie Gs WMK3QU035 1 $2,310.00 Rgk Wheelchairs Maxima WMK3RZ005 1 $2,310.00 TiLite Tilite X, Sx, Tx WMK3TZ005 1 $2,310.00 Paediatric Lightweight Standard Manual Wheelchair Handicare Legend 2 Exigo/Exigo WMK2M9020 1 $1,596.00 Wheelchair type most suitable for user who requires some adjustments to accommodate postural and mobility requirements. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Invacare 9000 Jymni WMK2IN010 1 $1,596.00 Otto Bock Start M2 Junior WM0001079 1 $1,596.00 Pride Mobility Products Litestream Xf WMK2X1010 1 $1,596.00 Quickie Quickie Lx WMK2QU020 1 $1,596.00 Convaid Safari Tilt WMK5CO040 1 $2,804.00 Future Mobility Super Chair For Kids WMK5FM010 1 $2,804.00 Paediatric Lightweight Performance Manual Wheelchair Wheelchair type offers maximum adjustments and options. Suitable for the active user who requires altered wheel placement for optimal postural support and mobility. ADP price includes frame (sizes up to 16"wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, 2 point seat belt any closure, brake extensions, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Paediatric Manual Dynamic Tilt Wheelchair Page: 66 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) Device Type Wheelchair type offers manual dynamic tilt required by the user who can not maintain an upright posture through the use of seating components alone. ADP price includes dynamic tilt frame (sizes up to 16" wide x 16"deep), standard upholstery, swing away detachable footrests, height adjustable armrests, rear antitippers, brake extensions, 2 point seat belt any closure, front casters, wheels. See Manual Wheelchair Options Chart for other basic components funded by ADP. Manufacturer Hoggi Invacare Device Device Code Max Allowed Qty. Approved Price Bingo/Bingo Evolution WMK5K2010 1 $2,804.00 Swingbo Plus WM0000461 1 $2,804.00 Orbit/Tiger WMK5IN010 1 $2,804.00 Spree 3g WMK5IN030 1 $2,804.00 Spree Gt WMK5IN025 1 $2,804.00 Spree Xt WMK5IN020 1 $2,804.00 Ki Mobility Focus CR WM0001161 1 $2,804.00 Kid Kart Kid Kart Xpress WMK5KT020 1 $2,804.00 Kid-Tlc WMK5KT010 1 $2,804.00 Discovery Tmax WM0001192 1 $2,804.00 Kimba Spring & Kimba Spring Plus WMK5OB010 1 $2,804.00 Pride Mobility Products F.A.S.T WMK5K2015 1 $2,804.00 Kids Rock WMK5K2005 1 $2,804.00 Product Design Group Fuze T20 WMK5MV025 1 $2,804.00 Fuze T50 WMK5MV020 1 $2,804.00 Quickie Quickie SR-45 WM0000473 1 $2,804.00 Zippie Iris WMK5QU010 1 $2,804.00 Zippie Ts WMK5QU005 1 $2,804.00 Easy S WM0000326 1 $2,804.00 Thevo Twist WM0000325 1 $2,804.00 Otto Bock THOMASHILFEN Paediatric Specific Specialty Stroller Alvema Series 100/Pix1 WMK6AL005 1 $1,303.00 ADP price includes stroller frame and upholstery, foot support, seat and back supports, headrest, chest and pelvic positioning straps (harness), abductor, and wheels. See Manual Wheelchair Options Chart for additional basic components funded by ADP. Convaid Cruiser Cx WMK6CO005 1 $1,303.00 Ez Rider WMK6CO050 1 $1,303.00 Metro WMK6CO030 1 $1,303.00 Rodeo Tilt WMK6CO060 1 $1,303.00 Maclaren Buggy WMK6AM005 1 $1,303.00 Otto Bock Eco-Buggy WMK6OB005 1 $1,303.00 Kimba Neo WM0001100 1 $1,303.00 Quickie Zippie Voyage WM0001083 1 $1,303.00 THOMASHILFEN Swifty Stroller - Paediatric specific specialty stroller type 6 WM0000318 1 $1,303.00 Thevo Swifty Stroller WM0000316 1 $1,303.00 Page: 67 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) OPTIONS: Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price Amputee Axle Plates (pair) WAMT 1 $89.00 Caster Pin Locks (pair) WAMS 1 $135.00 Clothing Guards WAMV 1 $99.00 Elevating Legrests (pair) WAMK 1 $318.00 Grade Aids (pair) WAMR 1 $91.00 Heavy Duty Cross Braces & Upholstery WAMC 1 $536.00 Hub-Eez Easy Push Wheel WAMM 1 $564.00 MW - Adjustable Tension Back Upholstery over 18" Frame Width WAME 1 $189.00 MW - Adjustable Tension Back Upholstery up to 18" Frame Width WAMD 1 $110.00 MW - Angle Adjustable Footplates (pair) WAMJ 1 $102.00 MW - Custom Modifications MWCM 1 MW - Heavy Duty Model, Client Weight Exceeds 250 Lbs WAMF 1 $575.00 WAMG 1 $781.00 WAMH 1 MW - Oxygen Tank Holder WAMX 1 $154.00 MW - Seat Depth Required is Greater Than 18" WAMB 1 $209.00 Heavy duty model required, client weight exceeds 250lbs. Authorizer must document client weight. Selected device must meet weight requirements. MW - Heavy Duty Model, Client Weight Exceeds 350 Lbs Heavy duty model required, client weight exceeds 350lbs. Authorizer must document client weight. Selected device must meet weight requirements. MW - Heavy Duty Model, Client Weight Exceeds 400 Lbs $874.00 Heavy duty model required, client weight exceeds 400lbs. Authorizer must document client weight. Selected device must meet weight requirements. Page: 68 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Manual) OPTIONS: Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price MW - Seat Width Required is Greater Than 18" WAMA 1 $314.00 MW - Ventilator Tray WAMY 1 $335.00 One Arm/Lever Drive WAML 1 $824.00 Plastic Coated Handrims WAMO 1 $106.00 Dolomite Alber E.Motion WPS1DO005 1 $4,831.00 Magicwheels Magicwheels WPS1WS005 1 $4,831.00 Max Mobility Smart Drive WM0001081 1 $4,831.00 Quickie Quickie Xtender WPS1QU005 1 $4,831.00 Projected Handrims (pair) WAMQ 1 $176.00 Quick Release Axles (pair) WAMU 1 $87.00 Recliner Option WAMI 1 $415.00 Spoke Protectors (pair) WAMP 1 $91.00 Standard Manual Wheelchair Frame with Manual Dynamic Tilt * WANA 1 $945.00 Stroller Handles/Paediatric WAMW 1 $116.00 Titanium Frame * WAMZ 1 $1,181.00 WAMN 1 $117.00 Power Add-On Device Device is added onto a manual wheelchair to assist the user meet their long term basic and essential mobility requirements. User must be able to operate the manual wheelchair independently. This code may be used only when it is not anticipated that the user will require the use of a power wheelchair to meet their long term basic and essential mobility requirements. ADP funding assistance is not provided for a power add on device and a power wheelchair. Standard manual wheelchair with manual dynamic tilt. Frame offers ongoing adjustability and facilitates independent mobility. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Titanium frame manual wheelchair. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Uni-Lateral Wheel Lock Page: 69 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) Device Type Adult Power Base Type 1 Wheelchair type most suitable for use on hard, flat surfaces. Primarily for user who requires minimal adjustments to support independent mobility. ADP price includes seat and back frame (sizes up to 18" wide x 18"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components funded by ADP. Adult Power Base Type 2 Wheelchair type suitable for use on most surfaces. Primarily for user who requires postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes seat and back frame (sizes up to 18" wide x 18"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, and wheels. See Power Wheelchair Options Chart for other basic components funded by ADP. Adult Power Base Type 3 Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure and standard joystick control. See Power Wheelchair Options Chart for other basic components funded by ADP. Manufacturer Invacare Device Device Code Max Allowed Qty. Approved Price Nutron Series R51lxp WPA1IN065 1 $4,392.00 Pronto M51 WPA1IN075 1 $4,392.00 Power Plus Mobility Mp1 WPA1WN005 1 $4,392.00 Pride Mobility Products J6 Jazzy WP0000564 1 $4,392.00 Jazzy Elite ES Portable WP0001224 1 $4,392.00 Jazzy Select 6 WPA1X1230 1 $4,392.00 Shoprider/ Pihsiang Shoprider P424l WPA1S7015 1 $4,392.00 Shoprider P424m WPA1S7010 1 $4,392.00 Invacare 3g Ranger X Storm Series WPA2IN040 1 $5,812.00 Power Plus Mobility Mp2 WPA2WN005 1 $5,812.00 Pride Mobility Products Jazzy 600 WPA2X1220 1 $5,812.00 Future Mobility Orion Explorer Magellan WPA3FM005 1 $6,125.00 Orion Explorer Viking WPA3FM010 1 $6,125.00 Alex Power Wheelchair WPA3M9005 1 $6,125.00 PUMA 40 WP0000647 1 $6,125.00 SAMM WP0001233 1 $6,125.00 Action Torque Storm WPA3IN015 1 $6,125.00 Arrow Storm Rwd WPA3IN020 1 $6,125.00 Fdx WPA3IN080 1 $6,125.00 Pronto M91 WPA3IN050 1 $6,125.00 Pronto M94 WPA3IN052 1 $6,125.00 Tdx Sp/Sr WPA3IN070 1 $6,125.00 Tdx-Sc WPA3IN075 1 $6,125.00 LEVO AG LEVO C3 WP0001140 1 $6,125.00 Orthofab Oasis WPA3OF110 1 $6,125.00 Permobil C300 WPA31P010 1 $6,125.00 C350 WPA31P030 1 $6,125.00 C400 WPA31P015 1 $6,125.00 C500 WPA31P020 1 $6,125.00 Chairman Hd3 WPA31P025 1 $6,125.00 Handicare Invacare Page: 70 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) Device Type Adult Power Base Type 3 Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure and standard joystick control. See Power Wheelchair Options Chart for other basic components funded by ADP. Manufacturer Permobil Device Code Max Allowed Qty. Approved Price M300 WP0000455 1 $6,125.00 M300 Corpus HD R-Net WP0001165 1 $6,125.00 Street WPA31P005 1 $6,125.00 Power Plus Mobility Mp5 WPA3WM005 1 $6,125.00 Pride Mobility Products Jazzy/Quantum 1113 WPA3X1100 1 $6,125.00 Jazzy/Quantum 1121 WPA3X1110 1 $6,125.00 Jazzy/Quantum 1170 WPA3X1010 1 $6,125.00 Jazzy/Quantum 1402 & 1420 WPA3X1020 1 $6,125.00 Jazzy/Quantum 1650 WPA3X1230 1 $6,125.00 Q6 Edge HD WP0001058 1 $6,125.00 Quantum 1450 WP0001021 1 $6,125.00 Quantum 600 WPA3X1220 1 $6,125.00 Quantum 6000 WPA3X1240 1 $6,125.00 Quantum 6000z WPA3X1245 1 $6,125.00 Quantum 610 WPA3X1225 1 $6,125.00 Quantum 614 WPA3X1255 1 $6,125.00 Quantum Q6 Edge Adult WP0000108 1 $6,125.00 Quantum R4000 WPA3X1250 1 $6,125.00 Quantum Rival WP0000968 1 $6,125.00 Quickie P-222 WPA3QU240 1 $6,125.00 Quickie Pulse 6 WP0000637 1 $6,125.00 Quickie QM-710, 715, 720 WP0000686 1 $6,125.00 Quickie S-646 (S-626) WPA3QU230 1 $6,125.00 Quickie X2 WPA3QU290 1 $6,125.00 Quickie Xcel WPA3QU300 1 $6,125.00 Quickie Xperience WPA3QU280 1 $6,125.00 Quickie Xplore WPA3QU270 1 $6,125.00 Ranger Wheelchairs Express WP0001023 1 $6,125.00 Invacare Nutron Series R51lxp WPK1IN015 1 $4,678.00 Quickie Paediatric Power Base Type 1 Device Wheelchair type most suitable for use on hard, flat surfaces. Primarily for user who requires minimal adjustments to support independent mobility. ADP price includes seat and back frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components Page: 71 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price funded by ADP. Paediatric Power Base Type 2 Invacare Tiger WPK2IN015 1 $5,507.00 Handicare Alex Power Wheelchair WPK3M9005 1 $5,902.00 SAMM WP0001234 1 $5,902.00 Arrow Storm WPK3IN010 1 $5,902.00 Fdx WPK3IN080 1 $5,902.00 Storm Torque WPK3IN015 1 $5,902.00 Tdx Sp/Sr WPK3IN070 1 $5,902.00 Tdx Spree WPK3IN075 1 $5,902.00 LEVO AG LEVO C3 WP0001141 1 $5,902.00 Permobil C300 Corpus Junior / K300 WPK31P010 1 $5,902.00 C400 Corpus Junior WPK31P015 1 $5,902.00 M300 WP0000987 1 $5,902.00 Q6 Edge HD WP0001059 1 $5,902.00 Quantum 600 WPK3X1220 1 $5,902.00 Quantum 6000 WPK3X1240 1 $5,902.00 Quantum 6000z WPK3X1245 1 $5,902.00 Quantum 610 WPK3X1225 1 $5,902.00 Quantum Q6 Edge Paediatric Power Base Type 3 Wheelchair WP0000109 1 $5,902.00 Quantum Rival WP0000969 1 $5,902.00 Quickie P-222 WPK3QU020 1 $5,902.00 Quickie Pulse 6 with SPOT Tilt WP0000638 1 $5,902.00 Quickie QM-710, 715, 720 WP0000687 1 $5,902.00 Quickie Xperience WPK3QU080 1 $5,902.00 Quickie Xplore WPK3QU070 1 $5,902.00 Tdx Spree WPK4IN075 1 $5,611.00 Tiger WPK4IN005 1 $5,611.00 Wheelchair type suitable for use on most surfaces. Primarily for user who requires postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes seat and back frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components funded by ADP. Paediatric Power Base Type 3 Wheelchair type suitable for use on most surfaces. Primarily for the user who requires ongoing changes in postural support, modifications to electronics, and other specific options to support independent mobility. ADP price includes base, 2 point seat belt any closure, and standard joystick control. See Power Wheelchair Options Chart for other basic components funded by ADP. Invacare Pride Mobility Products Quickie Paediatric Power Base with Manual Dynamic Tilt Wheelchair type offers manual dynamic tilt required by the user who can not maintain a functional posture through the use of seating Invacare Page: 72 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price components alone. ADP price includes dynamic tilt frame (sizes up to 16" wide x 16"deep), standard joystick control, swing away detachable footrests, height adjustable armrests, 2 point seat belt any closure, front casters, wheels. See Power Wheelchair Options Chart for other basic components funded by ADP. Invacare Power Scooter AMIGO AMIGO RD310000 - 3 WHEEL MOBILITY SCOOTER INTERNATIONAL WP0000333 1 $2,395.00 Activelite Mobility WS16A0005 1 $2,395.00 Advanced Vehicle Quingo Classic Concepts WS15V0005 1 $2,395.00 Fortress 1700fs -3 Wh. WS1FS0015 1 $2,395.00 1700fs -4 Wh. WS1FS0020 1 $2,395.00 Winner -3 Wh. WS1FS0070 1 $2,395.00 Winner -4 Wh. WS1FS0075 1 $2,395.00 COMET 4 WHEEL SCOOTER WP0000121 1 $2,395.00 Comet HD 4 Wheel Scooter WP0000546 1 $2,395.00 Leo Scooter 3 Wheel WP0001019 1 $2,395.00 Leo Scooter 4 Wheel WS1IN0085 1 $2,395.00 PEGASUS 3 WHEEL SCOOTER WP0000122 1 $2,395.00 PEGASUS 4 WHEEL SCOOTER WP0000123 1 $2,395.00 KYMCO (Canadian Mobility Corp.) Midi XL WP0001232 1 $2,395.00 Power Plus Mobility Mp3 -3 Wh. WS1WN0005 1 $2,395.00 Mp4 -4 Wh. WS1WN0010 1 $2,395.00 Pride Mobility Products Celebrity LR WP0000965 1 $2,395.00 Celebrity Xl - 4 Wh. WS1X10017 1 $2,395.00 Go Go LX 4 Wheel WP0001142 1 $2,395.00 Go Go Sport - 4 Wheel WP0001075 1 $2,395.00 Gogo Elite Traveller Plus - 3 Wh. WS1X10100 1 $2,395.00 Gogo Elite Traveller Plus - 4 Wh. WS1X10105 1 $2,395.00 Maxima -3 Wh. WS1X10060 1 $2,395.00 Maxima -4 Wh. WS1X10065 1 $2,395.00 Victory 10 - 3 Wh, 3 Wh Twin WS1X10110 1 $2,395.00 Victory 10 - 4 Wh WS1X10115 1 $2,395.00 Victory 10 DX WP0000688 1 $2,395.00 Victory Twin DX WP0000699 1 $2,395.00 Device is suitable for the user who requires power mobility to meet their long term basic and essential mobility requirements, and does not require specific postural support now or in the future. ADP price includes base, tiller and seat. ADP funding for positioning devices (seating) is not available for scooters. See Power Wheelchair Options Chart when heavy duty models are required. Invacare Easy Travel -3 Wh. Page: 73 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) Device Type Power Scooter Device is suitable for the user who requires power mobility to meet their long term basic and essential mobility requirements, and does not require specific postural support now or in the future. ADP price includes base, tiller and seat. ADP funding for positioning devices (seating) is not available for scooters. See Power Wheelchair Options Chart when heavy duty models are required. Manufacturer Shoprider/ Pihsiang Yelle & Associates Ltd. ZHE JIANY BISWIFT ENTERPRISE Device Device Code Max Allowed Qty. Approved Price Chameleon Gkb - 3 Wh WS1S7005 1 $2,395.00 Chameleon Gkb - 4 Wh WS1S7010 1 $2,395.00 Cobra 778el -3 Wh. WS1S70020 1 $2,395.00 Cobra 778el -4 Wh. WS1S70025 1 $2,395.00 Landcruiser 889-3wh. WS1S70035 1 $2,395.00 Landcruiser 889xls 4wh. WS1S70036 1 $2,395.00 Sovereign 888 -4 Wh. WS1S70032 1 $2,395.00 Trailblazer 889sel 4wh. WS1S70045 1 $2,395.00 Voyager 778s -3 Wh. WS1S70037 1 $2,395.00 Voyager 888sel -4 Wh. WS1S70040 1 $2,395.00 Safari/Ltd-3 Wh. WS1YE0020 1 $2,395.00 Solo Ltd-4 Wh. WS1YE0007 1 $2,395.00 Solo/Ltd-3 Wh. WS1YE0005 1 $2,395.00 Solo/Xt550-4 Wh. WS1YE0010 1 $2,395.00 Boomer Buggy (3 or 4 Wheel) WP0000561 1 $2,395.00 Page: 74 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) OPTIONS: Device Type Manufacturer Device Max Allowed Qty. Approved Price WEPQ 1 $1,181.00 Manual Elevating Legrests (pair) WEPK 1 $308.00 Manual Recline Option WEPI 1 $590.00 Midline Control WE3D 1 $268.00 Auto Correction System* Device Code Specialized electronics for power wheelchairs Offers increased driving control through specific auto-correction system; for client with limited trunk and/or upper extremity control. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Multi-function Control Box Amysystems Multi-Function Control Box, For Use On Systems With Multiple Functions Including Tilt And Power Legs, Tilt, Recline And Power Legs Etc. SEC4P5005 1 $1,766.00 Handicare multi-function control box - for use on systems with multiple functions including tilt and power legs, tilt and power legs, etc WP0000654 1 $403.00 Invacare Multi-Function Control Box For Use On Systems With Multiple Functions. Including Tilt And Power Legs, Tilt, Recline And Power Legs Etc. SECIN5005 1 $1,588.00 Motion Concepts Trx Helix Multi-Function Control Box (Thmc) For Use On Systems With Multiple Functions, Including Tilt And Power Legs, Tilt, Recline, Power Legs, Etc. Includes Reduced Drive With Elevate. SECZG5005 1 $1,570.00 Permobil Multi-Function Control Box - For Use On Systems With Multiple Functions Including, Tilt And Power Legs, Tilt, Recline And Power Legs, Etc. SEC1P1005 1 $1,847.00 Pride Mobility Products Multi-Function Control Box Advanced Acutator Module (Aam) SECX15005 1 $514.00 Quickie Multi-Function Control Box For Use On Systems With Multiple SECQU4005 1 $2,403.00 Page: 75 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) OPTIONS: Device Type Manufacturer Multi-function Control Box Device Device Code Max Allowed Qty. Approved Price Functions, Including Tilt And Power Legrest, Tilt, Recline, Power Legrests Etc. One Piece 90/90 Front Riggings WEPL 1 $168.00 PW - Adjustable Tension Back Upholstery over 18" Frame Width WEPE 1 $189.00 PW - Adjustable Tension Back Upholstery up to 18" Frame Width WEPD 1 $110.00 PW - Angle Adjustable Footplates (pair) WEPJ 1 $92.00 PW - Custom Modifications PWCM 1 PW - Heavy Duty Model, Client Weight Exceeds 250 Lbs WEPF 1 $438.00 WEPG 1 $525.00 WEPH 1 $771.00 PW - Oxygen Tank WEPX 1 $106.00 PW - Seat Depth Required is Greater Than 18" WEPB 1 $230.00 PW - Seat Width Required is Greater Than 18" WEPA 1 $339.00 PW - Ventilator Tray WEPY 1 $1,331.00 Heavy duty model required, client weight exceeds 250lbs. Authorizer must document client weight. Selected device must meet weight requirements. PW - Heavy Duty Model, Client Weight Exceeds 350 Lbs Heavy duty model required, client weight exceeds 350lbs. Authorizer must document client weight. Selected device must meet weight requirements. PW - Heavy Duty Model, Client Weight Exceeds 400 Lbs Heavy duty model required, client weight exceeds 400lbs. Authorizer must document client weight. Selected device must meet weight requirements. Power Elevating Footrests Amysystems Power Elevating & Articulating Legrests or Center mount foot platform SEF4P0005 1 $2,250.00 Handicare Power elevating and articulating WP0000653 1 $2,415.00 Page: 76 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) OPTIONS: Device Type Manufacturer Power Elevating Footrests Max Allowed Qty. Approved Price Power Elevating At5544 Legrest Package For Invacare And Quickie Bases. Includes Legrests And Actuators. SEFZG0010 1 $2,214.00 Power Elevating Legrests For Invacare, Quantum, And Quickie Bases. Includes Legrests And Actuators. SEFZG0005 1 $2,214.00 Permobil Power Elevating Articulating Leg Rests SEF1P0005 1 $2,274.00 Pride Mobility Products Articulating Foot Platform SEFX13010 1 $2,411.00 Power Elevating Articulating Leg Rests SEFX13005 1 $2,193.00 Quickie Power Elevating/Articulating Leg Rests SEFQU0005 1 $2,250.00 Tarsys (Invacare) Power Elevating Legrests SEFTY0005 1 $2,368.00 Amysystems Power Recline With Integrated Shear Reduction (Isr) SEC4P0045 1 $6,436.00 Handicare QLASS power recline WP0000995 1 $6,842.00 Sedeo Pro recline WP0000652 1 $6,842.00 Formula CG 12" 20" Recline Only SECIN1010 1 $8,009.00 Formula CG 21" - 24" Recline Only SECIN1015 1 $8,660.00 Power Recline Only With Power Sliding Back (Psb) For Invacare, Quantum, And Quickie Bases. SECZG0015 1 $7,502.00 Power Recline System With Esr For Invacare, Quickie, And Quantum Bases SECZG1010 1 $8,223.00 Power Recline System With Extended Shear Reduction (Esr) For Invacare, Quantum, And Quickie Bases. SECZG0010 1 $7,019.00 Permobil Corpus Power Positioning System With Power Recline Only SEC1P0010 1 $6,001.00 Pride Mobility Products Quantum TRU-Balance 3 WP0001163 1 $5,432.00 Tru-Balance 2 Power Recline SECX12055 1 $5,434.00 Quickie Recline with Power Shear Reduction WP0001149 1 $6,563.00 Amysystems Bariatric CG Power Tilt SEC4P0060 1 $6,436.00 Cg Power Tilt SEC4P0040 1 $5,228.00 Invacare Motion Concepts Power Tilt Only Device Code legrests Motion Concepts Power Recline Only Device Page: 77 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) OPTIONS: Device Type Power Tilt Only Manufacturer Handicare Invacare Device Code Max Allowed Qty. Approved Price QLASS centre of gravity power tilt WP0000993 1 $5,232.00 Sedeo Pro centre of gravity power tilt WP0000650 1 $5,233.00 Formula CG 12" - 20" Tilt Only SECIN1000 1 $5,390.00 Formula CG 21" - 24" Tilt Only SECIN1005 1 $6,040.00 LEVO AG C3 Power Tilt Only WP0001151 1 $5,095.00 Motion Concepts Power Tilt Only For Invacare, Quantum, And Quickie Base. SECZG0005 1 $5,233.00 Power Tilt Only For Invacare, Quantum, And Quickie Bases. SECZG1005 1 $6,436.00 Corpus Hd Power Positioning System With 30 Deg. Power Tilt Only SEC1P0105 1 $9,173.00 Corpus Power Positioning System With 45 Deg. Power Tilt Only SEC1P0005 1 $5,309.00 Ps Power Positioning System With 45 SEC1P0205 Deg. Power Tilt Only 1 $4,504.00 Quantum TRU-Balance 3 Power Positioning WP0001162 1 $5,211.00 Tru-Balance 2 Power Tilt SECX12050 1 $4,826.00 Tru-Balance Bariatric Power Tilt WP0001022 1 $5,630.00 Tru-Balance Power Tilt SECX12005 1 $4,589.00 Power C.G. Tilt For Quickie G-424 & S-525 SECQU1005 1 $4,684.00 Power C.G. Tilt For Quickie P-222se SECQU1015 1 $4,726.00 Power C.G. Tilt For Quickie Rhythm SECQU3005 1 $4,745.00 Power C.G. Tilt For Quickie S-626 SECQU1010 1 $4,684.00 SPOT TILT WP0000639 1 $3,466.00 Spot Tilt II WP0001148 1 $5,332.00 Bariatric CG Power Tilt and Power Recline With Integrated Shear Reduction (Isr) SEC4P0070 1 $10,460.00 Cg Power Tilt & Power Recline With Integrated Shear Reduction (Isr) SEC4P0050 1 $9,253.00 QLASS centre of gravity power tilt and recline WP0000994 1 $9,096.00 Sedeo Pro centre of gravity power tilt plus recline WP0000651 1 $9,096.00 Formula CG 16" 20" Tilt And Recline SECIN1020 1 $8,654.00 Permobil Pride Mobility Products Quickie Power Tilt and Recline Device Amysystems Handicare Invacare Page: 78 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) OPTIONS: Device Type Power Tilt and Recline Seat Package 1 for Power Bases Manufacturer Device Device Code Max Allowed Qty. Approved Price Invacare Formula CG 21" - 24" Tilt And Recline SECIN1025 1 $9,605.00 Motion Concepts Power Tilt And Power Recline For Invacare, Quickie, And Quantum Bases. SECZG0018 1 $8,352.00 Power Tilt And Power Recline For Invacare, Quantum, And Quickie Bases. SECZG2010 1 $7,647.00 Power Tilt And Power Recline With Esr For Invacare, Quantum, And Quickie Bases. SECZG2015 1 $8,102.00 Power Tilt And Power Recline With Esr For Invacare, Quickie, And Quantum Bases. SECZG1015 1 $9,293.00 Power Tilt And Power Recline With Psb For Invacare, Quantum, And Quickie Bases. SECZG2020 1 $8,585.00 Power Tilt And Power Recline including Psb For Invacare, Quantum, And Quickie Bases. SECZG0025 1 $9,289.00 Power Tilt and Power Recline including Esr For Invacare, Quantum, And Quickie Bases SECZG0020 1 $8,806.00 Permobil Corpus Power Positioning System With 45 Deg. Power Tilt And Power Recline SEC1P0015 1 $8,851.00 Pride Mobility Products Quantum TRU-Balance 3 WP0001164 1 $9,054.00 Tru-Balance 2 Power Tilt And Recline SECX12060 1 $9,056.00 Quickie Smart Seat Tilt & Recline System SECQU2005 1 $9,257.00 Tilt & Recline with Power Shear Reduction WP0001150 1 $9,440.00 WEPN 1 $663.00 WEPO 1 $682.00 WEX1 1 $1,103.00 Seat package 1 for power bases (includes frame, sling upholstery, armrests, footrests.) Seat Package 2 for Power Bases Seat package 2 for power bases (includes deluxe seat and back, armrests, footrests.) No positioning devices (seating) allowed with this code. Specialty Controls 1 Non Standard Joystick* Page: 79 of 80 Assistive Devices Program Product Manual Ministry of Health and Long-Term Care Mobility Devices Effective From: June 01, 2015 Wheelchairs (Power) OPTIONS: Device Type Manufacturer Device Device Code Max Allowed Qty. Approved Price WEX2 1 $2,363.00 WEX3 1 $5,276.00 WEX4 1 $5,906.00 WEX5 1 $2,363.00 WEX6 1 $3,938.00 WEPM 1 $232.00 Specialty controls 1 - Simple Non-Standard Joystick (includes mounting hardware, upgraded electronics & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Specialty Controls 2 Chin/Rim Control* Specialty controls 2 - Complex Non-Standard Joystick (includes upgraded electronics, mounting hardware, display, joystick modifications & labour). For chin/rim control etc. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Specialty Controls 3 Simple Touch* Specialty controls 3 - Simple Touch (includes mounting hardware, upgraded electronics, display, cables, 4 switches & labour). For footplate/headrest/tray switches etc. Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Specialty Controls 4 Proximity Control* Specialty controls 4 - Proximity Control (includes mounting hardware, upgraded electronics, display, cables, 4 switches & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Specialty Controls 5 Breath Control* Specialty Controls 5 - Breath Control Sip'N'Puff (includes mounting hardware, upgraded electronics, display, cables & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Specialty Controls 6 Scanners* Specialty Controls 6 - Scanners (includes mounting hardware, upgraded electronics, display, cables, scanner & labour). Authorizer must provide clinical rationale to support the request. Selected device must meet clinical requirements. Swingaway Mounting Bracket Page: 80 of 80
