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| HCA Order Form | 
| Division | Far West Division | ||
| Site/Hospital | Sunrise | ||
| Billing | Delivery | ||
| Name | Elizabeth.Cabada@hcahealthcare.com | Name | Joann Nardoni | 
| George.Greene1@healthtrustpg.com | Joann.nardoni@hcahealthcare.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | 3186 S Maryland Pkwy | 
| Address Line 2 | Clinical Education Financial Reporting | Address Line 2 | |
| Address Line 3 | Suite 1100 | Address Line 3 | |
| City | Nashville | City | Las Vegas | 
| State | TN | State | NV | 
| ZIP | 37203 | ZIP | 89109 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| A99003 | Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug | 2 | $30.76 | 
| C99008 | Brayden Premium Urethane Adult Lung Kit (Pack of 6) | $0.00 | |
| C17001 | Brayden Baby/Infant Replacement Lung (single) | 6 | $59.52 | 
| S13107 | Brayden Adult Airway Valve Assembly | 1 | $3.75 | 
| S17011 | Brayden Baby/Infant Artificial Lung Air Guide | 1 | $1.66 | 
| S17013 | Brayden Baby/Infant Replacement Airway Tube (single) | 2 | $6.06 | 
| Sub-Total | $101.75 | ||
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