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GS*HP*TAIGADEMO*CLINIC*20260922*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*1425.60*C*CHK************20260922~
TRN*1*UHC-520201*11982744321~
DTM*405*20260922~
N1*PR*UNITEDHEALTHCARE~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2201*1*2400.00*1425.60*158.40*12*PCN-CLM-2201*11*1~
CAS*CO*45*816.00~
NM1*QC*1*FOSTER*ETHAN~
SVC*HC:45378*2400.00*1425.60**1~
CAS*CO*45*816.00~
CAS*PR*3*158.40~
AMT*B6*1584.00~
SE*15*0001~
GE*1*1~
IEA*1*000020201~