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GS*HP*TAIGADEMO*CLINIC*20260903*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*190.08*C*CHK************20260903~
TRN*1*OHP-521197*11982744321~
DTM*405*20260903~
N1*PR*OREGON HEALTH PLAN~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-3197*1*320.00*190.08*21.12*12*PCN-CLM-3197*11*1~
CAS*CO*45*108.80~
NM1*QC*1*CONWAY*EMMA~
SVC*HC:99215*320.00*190.08**1~
CAS*CO*45*108.80~
CAS*PR*3*21.12~
AMT*B6*211.20~
SE*15*0001~
GE*1*1~
IEA*1*000021197~