ISA*00*          *00*          *ZZ*TAIGADEMO      *ZZ*CLINIC         *260726*1200*^*00501*000020075*0*T*:~
GS*HP*TAIGADEMO*CLINIC*20260726*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*190.08*C*CHK************20260726~
TRN*1*OHP-520075*11982744321~
DTM*405*20260726~
N1*PR*OREGON HEALTH PLAN~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2075*1*320.00*190.08*21.12*12*PCN-CLM-2075*11*1~
CAS*CO*45*108.80~
NM1*QC*1*REYES*LEO~
SVC*HC:99215*320.00*190.08**1~
CAS*CO*45*108.80~
CAS*PR*3*21.12~
AMT*B6*211.20~
SE*15*0001~
GE*1*1~
IEA*1*000020075~