Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com DCN0236.3 Pricing and specifications subject to change without notice Page 3 of 7
Ki Mobility Axiom SP Fluid Wheelchair Cushion | Ki Mobility Cushions / Backs
SUBMIT FORM This form must be opened in Adobe Acrobat. The Submit Form button will not work from most browser windows. Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com Company: _________________________________________________ Ship To: ___________________________________________________ Account Number: ___________________ Date: __________________ Address: __________________________________________________ q Quote q PO Number: ___________________________________ City: _________________________________ State: ______________ RTS: ______________________________________________________ Zip: _________________ Phone: ______________________________ Marked For: _______________________________________________ Email/Fax: _________________________________________________ Effective 02/17/2020 Axiom G, S and P Cushions Fill quantity needed in the box corresponding with the size. Available sizes are shown in white boxes. Weight capacity: 350 lbs. Axiom G Cushion 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) HCPC Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $120 E2601 XG1414 XG1415 XG1416 XG1417 XG1418 15" $120 E2601 XG1515 XG1516 XG1517 XG1518 XG1519 XG1520 16" $120 E2601 XG1615 XG1616 XG1617 XG1618 XG1619 XG1620 XG1621 XG1622 17" $120 E2601 XG1716 XG1717 XG1718 XG1719 XG1720 Width 18" $120 E2601 XG1816 XG1817 XG1818 XG1819 XG1820 XG1821 XG1822 19" $120 E2601 XG1916 XG1917 XG1918 XG1919 XG1920 XG1921 XG1922 20" $120 E2601 XG2016 XG2017 XG2018 XG2019 XG2020 XG2021 XG2022 21" $120 E2601 22" $199 E2602 XG2218 XG2219 XG2220 XG2221 XG2222 Depth HCPCS codes provided are based on code verification by the PDAC or our interpretation of the code definitions. Proper use of HCPCS codes does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy. DCN0236.3 Pricing and specifications subject to change without notice Page 1 of 7 Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com Axiom G, S and P Cushions continued Fill quantity needed in the box corresponding with the size. Available sizes are shown in white boxes. Weight capacity: 350 lbs. Axiom S Cushion 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) HCPC Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $210 E2603 XS1414 XS1415 XS1416 XS1417 XS1418 15" $210 E2603 XS1515 XS1516 XS1517 XS1518 XS1519 XS1520 16" $210 E2603 XS1615 XS1616 XS1617 XS1618 XS1619 XS1620 XS1621 XS1622 17" $210 E2603 XS1716 XS1717 XS1718 XS1719 XS1720 Width 18" $210 E2603 XS1816 XS1817 XS1818 XS1819 XS1820 XS1821 XS1822 19" $210 E2603 XS1916 XS1917 XS1918 XS1919 XS1920 XS1921 XS1922 20" $210 E2603 XS2016 XS2017 XS2018 XS2019 XS2020 XS2021 XS2022 21" $210 E2603 Depth Axiom P Cushion 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) HCPC Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $355 E2605 XP1414 XP1415 XP1416 XP1417 XP1418 Depth 15" $355 E2605 XP1515 XP1516 XP1517 XP1518 XP1519 XP1520 16" $355 E2605 XP1615 XP1616 XP1617 XP1618 XP1619 XP1620 XP1621 XP1622 17" $355 E2605 XP1716 XP1717 XP1718 XP1719 XP1720 Width 18" $355 E2605 XP1816 XP1817 XP1818 XP1819 XP1820 XP1821 XP1822 19" $355 E2605 XP1916 XP1917 XP1918 XP1919 XP1920 XP1921 XP1922 20" $355 E2605 XP2016 XP2017 XP2018 XP2019 XP2020 XP2021 XP2022 21" $355 E2605 22" $315 E2604 XS2218 XS2219 XS2220 XS2221 XS2222 22" $460 E2606 XP2218 XP2219 XP2220 XP2221 XP2222 DCN0236.3 Pricing and specifications subject to change without notice Page 2 of 7 Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com Axiom SP Cushions Fill quantity needed in the box corresponding with the size. Available sizes are shown in white boxes. Weight capacity: 350 lbs. Axiom SP - Visco Cushion 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) HCPC Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $430 E2607 XSP1414V XSP1415V XSP1416V XSP1417V XSP1418V XSP1419V XSP1420V 15" $430 E2607 XSP1514V XSP1515V XSP1516V XSP1517V XSP1518V XSP1519V XSP1520V XSP1521V XSP1522V 16" $430 E2607 XSP1614V XSP1615V XSP1616V XSP1617V XSP1618V XSP1619V XSP1620V XSP1621V XSP1622V 17" $430 E2607 XSP1715V XSP1716V XSP1717V XSP1718V XSP1719V XSP1720V XSP1721V XSP1722V Width 18" $430 E2607 XSP1815V XSP1816V XSP1817V XSP1818V XSP1819V XSP1820V XSP1821V XSP1822V 19" $430 E2607 XSP1916V XSP1917V XSP1918V XSP1919V XSP1920V XSP1921V XSP1922V 20" $430 E2607 XSP2016V XSP2017V XSP2018V XSP2019V XSP2020V XSP2021V XSP2022V 21" $525 E2607 XSP2118V XSP2119V XSP2120V XSP2121V XSP2122V Depth 22" $525 E2608 XSP2216V XSP2217V XSP2218V XSP2219V XSP2220V XSP2221V XSP2222V Axiom SP - Fluid Cushion 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) HCPC Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $470 E2607 XSP1414F XSP1415F XSP1416F XSP1417F XSP1418F XSP1419F XSP1420F Depth 15" $470 E2607 XSP1514F XSP1515F XSP1516F XSP1517F XSP1518F XSP1519F XSP1520F XSP1521F XSP1522F 16" $470 E2607 XSP1614F XSP1615F XSP1616F XSP1617F XSP1618F XSP1619F XSP1620F XSP1621F XSP1622F 17" $470 E2607 XSP1715F XSP1716F XSP1717F XSP1718F XSP1719F XSP1720F XSP1721F XSP1722F Width 18" $470 E2607 XSP1815F XSP1816F XSP1817F XSP1818F XSP1819F XSP1820F XSP1821F XSP1822F 19" $470 E2607 XSP1916F XSP1917F XSP1918F XSP1919F XSP1920F XSP1921F XSP1922F 20" $470 E2607 XSP2016F XSP2017F XSP2018F XSP2019F XSP2020F XSP2021F XSP2022F 21" $575 E2607 XSP2118F XSP2119F XSP2120F XSP2121F XSP2122F 22" $575 E2608 XSP2216F XSP2217F XSP2218F XSP2219F XSP2220F XSP2221F XSP2222F DCN0236.3 Pricing and specifications subject to change without notice Page 3 of 7 Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com Axiom Accessories Fill quantity needed in the box corresponding with the size. Available sizes are shown in white boxes. Axiom G Extra Outer Cover 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $75 XGC1414 XGC1415 XGC1416 XGC1417 XGC1418 15" $75 XGC1515 XGC1516 XGC1517 XGC1518 XGC1519 XGC1520 16" $75 XGC1615 XGC1616 XGC1617 XGC1618 XGC1619 XGC1620 XGC1621 XGC1622 17" $75 XGC1716 XGC1717 XGC1718 XGC1719 XGC1720 Width 18" $75 XGC1816 XGC1817 XGC1818 XGC1819 XGC1820 XGC1821 XGC1822 19" $75 XGC1916 XGC1917 XGC1918 XGC1919 XGC1920 XGC1921 XGC1922 20" $75 XGC2016 XGC2017 XGC2018 XGC2019 XGC2020 XGC2021 XGC2022 21" $75 22" $75 XGC2218 XGC2219 XGC2220 XGC2221 XGC2222 Depth Axiom S Extra Outer Cover Depth 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $85 XSC1414 XSC1415 XSC1416 XSC1417 XSC1418 15" $85 XSC1515 XSC1516 XSC1517 XSC1518 XSC1519 XSC1520 16" $85 XSC1615 XSC1616 XSC1617 XSC1618 XSC1619 XSC1620 XSC1621 XSC1622 17" $85 XSC1716 XSC1717 XSC1718 XSC1719 XSC1720 Width 18" $85 XSC1816 XSC1817 XSC1818 XSC1819 XSC1820 XSC1821 XSC1822 19" $85 XSC1916 XSC1917 XSC1918 XSC1919 XSC1920 XSC1921 XSC1922 20" $85 XSC2016 XSC2017 XSC2018 XSC2019 XSC2020 XSC2021 XSC2022 21" $85 22" $85 XSC2218 XSC2219 XSC2220 XSC2221 XSC2222 DCN0236.3 Pricing and specifications subject to change without notice Page 4 of 7 Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com Axiom Accessories continued Fill quantity needed in the box corresponding with the size. Available sizes are shown in white boxes. Axiom P Extra Outer Cover 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $95 XPC1414 XPC1415 XPC1416 XPC1417 XPC1418 15" $95 XPC1515 XPC1516 XPC1517 XPC1518 XPC1519 XPC1520 16" $95 XPC1615 XPC1616 XPC1617 XPC1618 XPC1619 XPC1620 XPC1621 XPC1622 17" $95 XPC1716 XPC1717 XPC1718 XPC1719 XPC1720 Width 18" $95 XPC1816 XPC1817 XPC1818 XPC1819 XPC1820 XPC1821 XPC1822 19" $95 XPC1916 XPC1917 XPC1918 XPC1919 XPC1920 XPC1921 XPC1922 20" $95 XPC2016 XPC2017 XPC2018 XPC2019 XPC2020 XPC2021 XPC2022 21" $95 22" $95 XPC2218 XPC2219 XPC2220 XPC2221 XPC2222 Depth Axiom SP Extra Visco Outer Cover Width 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) $105 $105 $105 $105 $105 $105 $105 $105 $105 14" Part Number Quantity XSPC1414V XSPC1514V XSPC1614V 15" Part Number Quantity XSPC1415V XSPC1515V XSPC1615V XSPC1715V XSPC1815V 16" Part Number Quantity XSPC1416V XSPC1516V XSPC1616V XSPC1716V XSPC1816V XSPC1916V XSPC2016V XSPC2216V 17" Part Number Quantity XSPC1417V XSPC1517V XSPC1617V XSPC1717V XSPC1817V XSPC1917V XSPC2017V XSPC2217V 18" Part Number Quantity XSPC1418V XSPC1518V XSPC1618V XSPC1718V XSPC1818V XSPC1918V XSPC2018V XSPC2118V XSPC2218V 19" Part Number Quantity XSPC1419V XSPC1519V XSPC1619V XSPC1719V XSPC1819V XSPC1919V XSPC2019V XSPC2119V XSPC2219V 20" Part Number Quantity XSPC1420V XSPC1520V XSPC1620V XSPC1720V XSPC1820V XSPC1920V XSPC2020V XSPC2120V XSPC2220V 21" Part Number Quantity XSPC1521V XSPC1621V XSPC1721V XSPC1821V XSPC1921V XSPC2021V XSPC2121V XSPC2221V 22" Part Number Quantity XSPC1522V XSPC1622V XSPC1722V XSPC1822V XSPC1922V XSPC2022V XSPC2122V XSPC2222V Depth DCN0236.3 Pricing and specifications subject to change without notice Page 5 of 7 Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com Axiom Accessories continued Fill quantity needed in the box corresponding with the size. Available sizes are shown in white boxes. Axiom SP Extra Fluid Outer Cover Width 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) $105 $105 $105 $105 $105 $105 $105 $105 $105 14" Part Number Quantity XSPC1414F XSPC1514F XSPC1614F 15" Part Number Quantity XSPC1415F XSPC1515F XSPC1615F XSPC1715F XSPC1815F 16" Part Number Quantity XSPC1416F XSPC1516F XSPC1616F XSPC1716F XSPC1816F XSPC1916F XSPC2016F XSPC2216F 17" Part Number Quantity XSPC1417F XSPC1517F XSPC1617F XSPC1717F XSPC1817F XSPC1917F XSPC2017F XSPC2217F 18" Part Number Quantity XSPC1418F XSPC1518F XSPC1618F XSPC1718F XSPC1818F XSPC1918F XSPC2018F XSPC2118F XSPC2218F 19" Part Number Quantity XSPC1419F XSPC1519F XSPC1619F XSPC1719F XSPC1819F XSPC1919F XSPC2019F XSPC2119F XSPC2219F 20" Part Number Quantity XSPC1420F XSPC1520F XSPC1620F XSPC1720F XSPC1820F XSPC1920F XSPC2020F XSPC2120F XSPC2220F 21" Part Number Quantity XSPC1521F XSPC1621F XSPC1721F XSPC1821F XSPC1921F XSPC2021F XSPC2121F XSPC2221F 22" Part Number Quantity XSPC1522F XSPC1622F XSPC1722F XSPC1822F XSPC1922F XSPC2022F XSPC2122F XSPC2222F Depth Axiom SP Extra Visco Inner Cover Depth 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $105 XSPI1414V XSPI1415V XSPI1416V XSPI1417V XSPI1418V XSPI1419V XSPI1420V 15" $105 XSPI1514V XSPI1515V XSPI1516V XSPI1517V XSPI1518V XSPI1519V XSPI1520V XSPI1521V XSPI1522V 16" $105 XSPI1614V XSPI1615V XSPI1616V XSPI1617V XSPI1618V XSPI1619V XSPI1620V XSPI1621V XSPI1622V 17" $105 XSPI1715V XSPI1716V XSPI1717V XSPI1718V XSPI1719V XSPI1720V XSPI1721V XSPI1722V Width 18" $105 XSPI1815V XSPI1816V XSPI1817V XSPI1818V XSPI1819V XSPI1820V XSPI1821V XSPI1822V 19" $105 XSPI1916V XSPI1917V XSPI1918V XSPI1919V XSPI1920V XSPI1921V XSPI1922V 20" $105 XSPI2016V XSPI2017V XSPI2018V XSPI2019V XSPI2020V XSPI2021V XSPI2022V 21" $105 XSPI2118V XSPI2119V XSPI2120V XSPI2121V XSPI2122V 22" $105 XSPI2216V XSPI2217V XSPI2218V XSPI2219V XSPI2220V XSPI2221V XSPI2222V DCN0236.3 Pricing and specifications subject to change without notice Page 6 of 7 Phone (800) 981-1540 | Fax (715) 254-0996 sales@kimobility.com | www.kimobility.com Axiom Accessories continued Fill quantity needed in the box corresponding with the size. Available sizes are shown in white boxes. Axiom SP Extra Fluid Inner Cover 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $105 XSPI1414F XSPI1415F XSPI1416F XSPI1417F XSPI1418F XSPI1419F XSPI1420F 15" $105 XSPI1514F XSPI1515F XSPI1516F XSPI1517F XSPI1518F XSPI1519F XSPI1520F XSPI1521F XSPI1522F 16" $105 XSPI1614F XSPI1615F XSPI1616F XSPI1617F XSPI1618F XSPI1619F XSPI1620F XSPI1621F XSPI1622F 17" $105 XSPI1715F XSPI1716F XSPI1717F XSPI1718F XSPI1719F XSPI1720F XSPI1721F XSPI1722F Width 18" $105 XSPI1815F XSPI1816F XSPI1817F XSPI1818F XSPI1819F XSPI1820F XSPI1821F XSPI1822F 19" $105 XSPI1916F XSPI1917F XSPI1918F XSPI1919F XSPI1920F XSPI1921F XSPI1922F Depth 20" $105 XSPI2016F XSPI2017F XSPI2018F XSPI2019F XSPI2020F XSPI2021F XSPI2022F 21" $105 XSPI2118F XSPI2119F XSPI2120F XSPI2121F XSPI2122F 22" $105 XSPI2216F XSPI2217F XSPI2218F XSPI2219F XSPI2220F XSPI2221F XSPI2222F Solid Seat Insert Weight capacity: 350 lbs Depth 14" 15" 16" 17" 18" 19" 20" 21" 22" Retail (Each) Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity Part Number Quantity 14" $60 XI1414 XI1415 XI1416 XI1417 XI1418 XI1419 XI1420 15" $60 XI1514 XI1515 XI1516 XI1517 XI1518 XI1519 XI1520 XI1521 XI1522 16" $60 XI1614 XI1615 XI1616 XI1617 XI1618 XI1619 XI1620 XI1621 XI1622 Width 17" 18" 19" $60 $60 $60 XI1715 XI1716 XI1717 XI1718 XI1719 XI1720 XI1721 XI1722 XI1816 XI1817 XI1818 XI1819 XI1820 XI1821 XI1822 XI1916 XI1917 XI1918 XI1919 XI1920 XI1921 XI1922 20" $60 XI2016 XI2017 XI2018 XI2019 XI2020 XI2021 XI2022 21" $60 XI2118 XI2119 XI2120 XI2121 XI2122 22" $60 XI2216 XI2217 XI2218 XI2219 XI2220 XI2221 XI2222 DCN0236.3 Pricing and specifications subject to change without notice Page 7 of 7Adobe PDF Library 15.0 Adobe InDesign 15.1 (Windows)