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HCA Order Form
Division North Texas Division
Site/Hospital NTXD HHCCA
Billing Delivery
Name marlo.cooper@medicalcityhealth.com Name Marlo Cooper
Email George.Greene1@healthtrustpg.com Email Clyde.Owen@MedicalCityHealth.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 3401 Dallas Tollway
Address Line 2 Clinical Education Financial Reporting Address Line 2 Suite 900
Address Line 3 Suite 1100 Address Line 3
City Nashville City Frisco
State TN State TX
ZIP 37203 ZIP 75201
Items to Order
Code Description Quantity Total ($)
A99002 Brayden Adult Compression Spring Addon 5 $113.50
S13106 Brayden Adult Face/Mouth Connector 5 $12.60
C17003 Brayden Baby/Infant Body Skin 5 $288.75
S17011 Brayden Baby/Infant Artificial Lung Air Guide 15 $23.70
C17001 Brayden Baby/Infant Replacement Lung (single) 20 $189.00
C99008 Brayden Premium Urethane Adult Lung Kit (Pack of 6) 7 $617.40
$0.00
A99003 Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug 12 $175.80
S16402 Brayden Pro Adult Body Skin Magnet 12 $47.28
S17013 Brayden Baby/Infant Replacement Airway Tube (single) 14 $40.46
$0.00
  Sub-Total $1,508.49