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| HCA Order Form | 
| Division | South Atlantic Division | ||
| Site/Hospital | Trident Medical Center | ||
| Billing | Delivery | ||
| Name | Susan.Burke@hcahealthcare.com | Name | Ruth Malone | 
| George.Greene1@healthtrustpg.com | Ruth.Malone@hcahealthcare.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | Live Oak Mental Health and Wellness | 
| Address Line 2 | Clinical Education Financial Reporting | Address Line 2 | 3445 Ingleside Blvd. | 
| Address Line 3 | Suite 1100 | Address Line 3 | Att: Education/Tom Gates | 
| City | Nashville | City | Ladson | 
| State | TN | State | SC | 
| ZIP | 37203 | ZIP | 29456 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| C99007 | Brayden Adult Lung Kit Version A04 (Pack of 24) | 1 | $47.25 | 
| S17011 | Brayden Baby/Infant Artificial Lung Air Guide | 5 | $7.90 | 
| A17001 | Brayden Baby/Infant Cotton Diaper | 1 | $15.75 | 
| S17013 | Brayden Baby/Infant Replacement Airway Tube (single) | 5 | $14.45 | 
| S16402 | Brayden Pro Adult Body Skin Magnet | 2 | $7.88 | 
| C17001 | Brayden Baby/Infant Replacement Lung (single) | 3 | $28.35 | 
| A99003 | Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug | 2 | $29.30 | 
| $0.00 | |||
| Sub-Total | $150.88 | ||
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