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GS*HP*TAIGADEMO*CLINIC*20260922*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*249.48*C*CHK************20260922~
TRN*1*OHP-520291*11982744321~
DTM*405*20260922~
N1*PR*OREGON HEALTH PLAN~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2291*1*420.00*249.48*27.72*12*PCN-CLM-2291*11*1~
CAS*CO*45*142.80~
NM1*QC*1*WALLACE*CHLOE~
SVC*HC:20610*420.00*249.48**1~
CAS*CO*45*142.80~
CAS*PR*3*27.72~
AMT*B6*277.20~
SE*15*0001~
GE*1*1~
IEA*1*000020291~