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GS*HP*TAIGADEMO*CLINIC*20261023*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*831.60*C*CHK************20261023~
TRN*1*OHP-521088*11982744321~
DTM*405*20261023~
N1*PR*OREGON HEALTH PLAN~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-3088*1*1400.00*831.60*92.40*12*PCN-CLM-3088*11*1~
CAS*CO*45*476.00~
NM1*QC*1*FOSTER*ARIA~
SVC*HC:73721*1400.00*831.60**1~
CAS*CO*45*476.00~
CAS*PR*3*92.40~
AMT*B6*924.00~
SE*15*0001~
GE*1*1~
IEA*1*000021088~