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GS*HP*TAIGADEMO*CLINIC*20260927*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*237.60*C*CHK************20260927~
TRN*1*OHP-520674*11982744321~
DTM*405*20260927~
N1*PR*OREGON HEALTH PLAN~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2674*1*400.00*237.60*26.40*12*PCN-CLM-2674*11*1~
CAS*CO*45*136.00~
NM1*QC*1*YATES*LAYLA~
SVC*HC:99205*400.00*237.60**1~
CAS*CO*45*136.00~
CAS*PR*3*26.40~
AMT*B6*264.00~
SE*15*0001~
GE*1*1~
IEA*1*000020674~