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| HCA Order Form | 
| Division | Continental Division | ||
| Site/Hospital | HCA Healthcare Center for Clinical Advancement | ||
| Billing | Delivery | ||
| Name | Scott.Bartholomew@HealthONEcares.com | Name | Scott Bartholomew | 
| George.Greene1@healthtrustpg.com | scott.bartholomew@healthonecares.com | ||
| Address Line 1 | Clinical Education Financial Reporting | Address Line 1 | 333 W Hampden Ave Ste 200 | 
| Address Line 2 | Clinical Education Financial Reporting | Address Line 2 | |
| Address Line 3 | Suite 1100 | Address Line 3 | |
| City | Nashville | City | Englewood | 
| State | CO | State | Colorado | 
| ZIP | 37203 | ZIP | 80110 | 
| Items to Order | |||
| Code | Description | Quantity | Total ($) | 
| S17013 | Brayden Baby/Infant Replacement Airway Tube (single) | 20 | $60.60 | 
| S17011 | Brayden Baby/Infant Artificial Lung Air Guide | 20 | $33.20 | 
| Sub-Total | $93.80 | ||
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