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GS*HP*TAIGADEMO*CLINIC*20261018*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*190.08*C*CHK************20261018~
TRN*1*UHC-520244*11982744321~
DTM*405*20261018~
N1*PR*UNITEDHEALTHCARE~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2244*1*320.00*190.08*21.12*12*PCN-CLM-2244*11*1~
CAS*CO*45*108.80~
NM1*QC*1*MATHIS*HARPER~
SVC*HC:99215*320.00*190.08**1~
CAS*CO*45*108.80~
CAS*PR*3*21.12~
AMT*B6*211.20~
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GE*1*1~
IEA*1*000020244~