Remittances / 99900004410

Fernhollow Community Care

Payment 99900004410, paper check dated Sep 15, 2026. From FCC_835_A.edi, imported Sep 16, 2026 by Dana Whitfield.

Balances to the cent

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Payments dated Sep 15, 2026 to Sep 15, 2026, as of Oct 7, 2026. Whole organization, every site.

Payment

$12,919.92

Paper check

Claims

57 matched to billed claims

Claim payments

$12,919.92

Before provider adjustments

Provider adjustments

$0.00

Interest added, recoveries taken

Claims in this payment

Matched to what was billed and checked against the contract rate.

Claim	Match	Result	Charged	Allowed	Paid	Patient	At stake
RHP100131	Claim number matched exactly	Paid as expected	$221.00	$71.76	$71.76	$0.00
RHP100132	Claim number matched exactly	Paid as expected	$331.00	$107.64	$107.64	$0.00
RHP100133	Claim number matched exactly	Paid as expected	$240.00	$70.20	$70.20	$0.00
RHP100134	Claim number matched exactly	Denied	$408.00	$0.00	$0.00	$0.00	$132.60
RHP100135	Claim number matched exactly	Partially denied	$262.00	$85.02	$85.02	$0.00	$15.60
RHP100136	Claim number matched exactly	Denied	$140.00	$0.00	$0.00	$0.00	$45.24
RHP100202	Claim number matched exactly	Paid as expected	$449.00	$145.86	$145.86	$0.00
RHP100600	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP100601	Claim number matched exactly	Denied	$528.00	$0.00	$0.00	$0.00	$171.60
RHP100602	Claim number matched exactly	Paid as expected	$449.00	$145.86	$145.86	$0.00
RHP100603	Claim number matched exactly	Paid as expected	$2,520.00	$819.00	$819.00	$0.00
RHP100604	Claim number matched exactly	Paid as expected	$140.00	$45.24	$45.24	$0.00
RHP100605	Claim number matched exactly	Paid as expected	$576.00	$187.20	$187.20	$0.00
RHP100606	Claim number matched exactly	Paid as expected	$310.00	$100.62	$100.62	$0.00
RHP100607	Claim number matched exactly	Paid as expected	$338.00	$109.98	$109.98	$0.00
RHP100608	Claim number matched exactly	Paid as expected	$228.00	$74.10	$74.10	$0.00
RHP100609	Claim number matched exactly	Paid as expected	$1,728.00	$561.60	$561.60	$0.00
RHP100610	Claim number matched exactly	Paid as expected	$319.00	$103.74	$103.74	$0.00
RHP100611	Claim number matched exactly	Paid as expected	$624.00	$202.80	$202.80	$0.00
RHP100612	Claim number matched exactly	Paid as expected	$240.00	$78.00	$78.00	$0.00
RHP100613	Claim number matched exactly	Paid as expected	$3,480.00	$1,131.00	$1,131.00	$0.00
RHP100614	Claim number matched exactly	Denied	$439.00	$0.00	$0.00	$0.00	$142.74
RHP100615	Claim number matched exactly	Paid as expected	$912.00	$296.40	$296.40	$0.00
RHP100616	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP100617	Claim number matched exactly	Paid as expected	$528.00	$171.60	$171.60	$0.00
RHP100618	Claim number matched exactly	Paid as expected	$449.00	$145.86	$145.86	$0.00
RHP100619	Claim number matched exactly	Paid as expected	$2,520.00	$819.00	$819.00	$0.00
RHP100620	Claim number matched exactly	Paid as expected	$140.00	$45.24	$45.24	$0.00
RHP100621	Claim number matched exactly	Paid as expected	$576.00	$187.20	$187.20	$0.00
RHP100622	Claim number matched exactly	Paid as expected	$310.00	$100.62	$100.62	$0.00
RHP100623	Claim number matched exactly	Paid as expected	$338.00	$109.98	$109.98	$0.00
RHP100624	Claim number matched exactly	Paid as expected	$228.00	$74.10	$74.10	$0.00
RHP100625	Claim number matched exactly	Paid as expected	$1,728.00	$561.60	$561.60	$0.00
RHP100626	Claim number matched exactly	Paid as expected	$319.00	$103.74	$103.74	$0.00
RHP100627	Claim number matched exactly	Denied	$624.00	$0.00	$0.00	$0.00	$202.80
RHP100628	Claim number matched exactly	Paid as expected	$240.00	$78.00	$78.00	$0.00
RHP100629	Claim number matched exactly	Paid as expected	$3,480.00	$1,131.00	$1,131.00	$0.00
RHP100630	Claim number matched exactly	Paid as expected	$439.00	$142.74	$142.74	$0.00
RHP100631	Claim number matched exactly	Paid as expected	$912.00	$296.40	$296.40	$0.00
RHP100632	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP100633	Claim number matched exactly	Paid as expected	$528.00	$171.60	$171.60	$0.00
RHP100634	Claim number matched exactly	Paid as expected	$449.00	$145.86	$145.86	$0.00
RHP100635	Claim number matched exactly	Paid as expected	$2,520.00	$819.00	$819.00	$0.00
RHP100636	Claim number matched exactly	Paid as expected	$140.00	$45.24	$45.24	$0.00
RHP100637	Claim number matched exactly	Paid as expected	$576.00	$187.20	$187.20	$0.00
RHP100638	Claim number matched exactly	Paid as expected	$310.00	$100.62	$100.62	$0.00
RHP100639	Claim number matched exactly	Paid as expected	$338.00	$109.98	$109.98	$0.00
RHP100640	Claim number matched exactly	Denied	$228.00	$0.00	$0.00	$0.00	$74.10
RHP100641	Claim number matched exactly	Paid as expected	$1,728.00	$561.60	$561.60	$0.00
RHP100642	Claim number matched exactly	Paid as expected	$319.00	$103.74	$103.74	$0.00
RHP100643	Claim number matched exactly	Paid as expected	$624.00	$202.80	$202.80	$0.00
RHP100644	Claim number matched exactly	Paid as expected	$240.00	$78.00	$78.00	$0.00
RHP100645	Claim number matched exactly	Paid as expected	$3,480.00	$1,131.00	$1,131.00	$0.00
RHP100646	Claim number matched exactly	Paid as expected	$439.00	$142.74	$142.74	$0.00
RHP100647	Claim number matched exactly	Paid as expected	$912.00	$296.40	$296.40	$0.00
RHP100648	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP100649	Claim number matched exactly	Paid as expected	$528.00	$171.60	$171.60	$0.00

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The payer's remittance file (835)

Payer ID 99904. Payee RIDGELINE HEALTH PARTNERS, NPI 9999999001. Transaction 0001, 700 segments.

Show the raw file (704 segments)

1  ISA*00*          *00*          *ZZ*PAYER99904     *ZZ*RIDGELINE999   *260914*0800*^*00501*000000106*0*T*:
2  GS*HP*PAYER99904*RIDGELINE999*20260914*0800*106*X*005010X221A1
3  ST*835*0001
4  BPR*I*12919.92*C*CHK************20260915
5  TRN*1*99900004410*1999999904
6  DTM*405*20260914
7  N1*PR*FERNHOLLOW COMMUNITY CARE
8  REF*2U*99904
9  N1*PE*RIDGELINE HEALTH PARTNERS*XX*9999999001
10  REF*TJ*999999999
11  LX*1
12  CLP*RHP100131*1*221*71.76*0*MC*999044410001*11*1
13  NM1*QC*1*SYNTHETIC*PATIENT100131****MI*ZZ0100131
14  DTM*232*20260823
15  DTM*233*20260823
16  SVC*HC:99213*221*71.76**1
17  DTM*472*20260823
18  CAS*CO*45*149.24
19  REF*6R*RHP100131-1
20  AMT*B6*71.76
21  LX*2
22  CLP*RHP100132*1*331*107.64*0*MC*999044410002*11*1
23  NM1*QC*1*SYNTHETIC*PATIENT100132****MI*ZZ0100132
24  DTM*232*20260824
25  DTM*233*20260824
26  SVC*HC:99214*312*101.4**1
27  DTM*472*20260824
28  CAS*CO*45*210.6
29  REF*6R*RHP100132-1
30  AMT*B6*101.4
31  SVC*HC:85025*19*6.24**1
32  DTM*472*20260824
33  CAS*CO*45*12.76
34  REF*6R*RHP100132-2
35  AMT*B6*6.24
36  LX*3
37  CLP*RHP100133*1*240*70.2*0*MC*999044410003*11*1
38  NM1*QC*1*SYNTHETIC*PATIENT100133****MI*ZZ0100133
39  DTM*232*20260825
40  DTM*233*20260825
41  SVC*HC:11102*240*70.2**1
42  DTM*472*20260825
43  CAS*CO*45*169.8
44  REF*6R*RHP100133-1
45  AMT*B6*70.2
46  LX*4
47  CLP*RHP100134*4*408*0*0*MC*999044410004*11*1
48  NM1*QC*1*SYNTHETIC*PATIENT100134****MI*ZZ0100134
49  DTM*232*20260826
50  DTM*233*20260826
51  SVC*HC:99204*408*0**1
52  DTM*472*20260826
53  CAS*CO*22*408
54  REF*6R*RHP100134-1
55  AMT*B6*0
56  LX*5
57  CLP*RHP100135*1*262*85.02*0*MC*999044410005*11*1
58  NM1*QC*1*SYNTHETIC*PATIENT100135****MI*ZZ0100135
59  DTM*232*20260827
60  DTM*233*20260827
61  SVC*HC:99213*221*71.76**1
62  DTM*472*20260827
63  CAS*CO*45*149.24
64  REF*6R*RHP100135-1
65  AMT*B6*71.76
66  SVC*HC:90471*41*13.26**1
67  DTM*472*20260827
68  CAS*CO*45*27.74
69  REF*6R*RHP100135-2
70  AMT*B6*13.26
71  LX*6
72  CLP*RHP100136*4*140*0*0*MC*999044410006*11*1
73  NM1*QC*1*SYNTHETIC*PATIENT100136****MI*ZZ0100136
74  DTM*232*20260828
75  DTM*233*20260828
76  SVC*HC:97110*140*0**2
77  DTM*472*20260828
78  CAS*CO*151*140
79  REF*6R*RHP100136-1
80  AMT*B6*0
81  LX*7
82  CLP*RHP100202*1*449*145.86*0*MC*999044410007C*11*1
83  NM1*QC*1*SYNTHETIC*PATIENT100202****MI*ZZ0100202
84  DTM*232*20260721
85  DTM*233*20260721
86  SVC*HC:99204*408*132.6**1
87  DTM*472*20260721
88  CAS*CO*45*275.4
89  REF*6R*RHP100202-1
90  AMT*B6*132.6
91  SVC*HC:93000*41*13.26**1
92  DTM*472*20260721
93  CAS*CO*45*27.74
94  REF*6R*RHP100202-2
95  AMT*B6*13.26
96  LX*8
97  CLP*RHP100600*1*269*87.36*0*MC*999044410008*11*1
98  NM1*QC*1*SYNTHETIC*PATIENT100600****MI*ZZ0100600
99  DTM*232*20260903
100  DTM*233*20260903
101  SVC*HC:99203*269*87.36**1
102  DTM*472*20260903
103  CAS*CO*45*181.64
104  REF*6R*RHP100600-1
105  AMT*B6*87.36
106  LX*9
107  CLP*RHP100601*4*528*0*0*MC*999044410009*11*1
108  NM1*QC*1*SYNTHETIC*PATIENT100601****MI*ZZ0100601
109  DTM*232*20260902
110  DTM*233*20260902
111  SVC*HC:93306*528*0**1
112  DTM*472*20260902
113  CAS*CO*50*528
114  REF*6R*RHP100601-1
115  AMT*B6*0
116  LQ*HE*N130
117  LX*10
118  CLP*RHP100602*1*449*145.86*0*MC*999044410010*11*1
119  NM1*QC*1*SYNTHETIC*PATIENT100602****MI*ZZ0100602
120  DTM*232*20260901
121  DTM*233*20260901
122  SVC*HC:99204*408*132.6**1
123  DTM*472*20260901
124  CAS*CO*45*275.4
125  REF*6R*RHP100602-1
126  AMT*B6*132.6
127  SVC*HC:93000*41*13.26**1
128  DTM*472*20260901
129  CAS*CO*45*27.74
130  REF*6R*RHP100602-2
131  AMT*B6*13.26
132  LX*11
133  CLP*RHP100603*1*2520*819*0*MC*999044410011*11*1
134  NM1*QC*1*SYNTHETIC*PATIENT100603****MI*ZZ0100603
135  DTM*232*20260831
136  DTM*233*20260831
137  SVC*HC:29827*2520*819**1
138  DTM*472*20260831
139  CAS*CO*45*1701
140  REF*6R*RHP100603-1
141  AMT*B6*819
142  LX*12
143  CLP*RHP100604*1*140*45.24*0*MC*999044410012*11*1
144  NM1*QC*1*SYNTHETIC*PATIENT100604****MI*ZZ0100604
145  DTM*232*20260830
146  DTM*233*20260830
147  SVC*HC:97110*140*45.24**2
148  DTM*472*20260830
149  CAS*CO*45*94.76
150  REF*6R*RHP100604-1
151  AMT*B6*45.24
152  LX*13
153  CLP*RHP100605*1*576*187.2*0*MC*999044410013*11*1
154  NM1*QC*1*SYNTHETIC*PATIENT100605****MI*ZZ0100605
155  DTM*232*20260829
156  DTM*233*20260829
157  SVC*HC:64483*576*187.2**1
158  DTM*472*20260829
159  CAS*CO*45*388.8
160  REF*6R*RHP100605-1
161  AMT*B6*187.2
162  LX*14
163  CLP*RHP100606*1*310*100.62*0*MC*999044410014*11*1
164  NM1*QC*1*SYNTHETIC*PATIENT100606****MI*ZZ0100606
165  DTM*232*20260828
166  DTM*233*20260828
167  SVC*HC:99213*221*71.76**1
168  DTM*472*20260828
169  CAS*CO*45*149.24
170  REF*6R*RHP100606-1
171  AMT*B6*71.76
172  SVC*HC:90471*41*13.26**1
173  DTM*472*20260828
174  CAS*CO*45*27.74
175  REF*6R*RHP100606-2
176  AMT*B6*13.26
177  SVC*HC:90686*48*15.6**1
178  DTM*472*20260828
179  CAS*CO*45*32.4
180  REF*6R*RHP100606-3
181  AMT*B6*15.6
182  LX*15
183  CLP*RHP100607*1*338*109.98*0*MC*999044410015*11*1
184  NM1*QC*1*SYNTHETIC*PATIENT100607****MI*ZZ0100607
185  DTM*232*20260827
186  DTM*233*20260827
187  SVC*HC:99214*312*101.4**1
188  DTM*472*20260827
189  CAS*CO*45*210.6
190  REF*6R*RHP100607-1
191  AMT*B6*101.4
192  SVC*HC:80053*26*8.58**1
193  DTM*472*20260827
194  CAS*CO*45*17.42
195  REF*6R*RHP100607-2
196  AMT*B6*8.58
197  LX*16
198  CLP*RHP100608*1*228*74.1*0*MC*999044410016*11*1
199  NM1*QC*1*SYNTHETIC*PATIENT100608****MI*ZZ0100608
200  DTM*232*20260826
201  DTM*233*20260826
202  SVC*HC:99213*221*71.76**1
203  DTM*472*20260826
204  CAS*CO*45*149.24
205  REF*6R*RHP100608-1
206  AMT*B6*71.76
207  SVC*HC:36415*7*2.34**1
208  DTM*472*20260826
209  CAS*CO*45*4.66
210  REF*6R*RHP100608-2
211  AMT*B6*2.34
212  LX*17
213  CLP*RHP100609*1*1728*561.6*0*MC*999044410017*11*1
214  NM1*QC*1*SYNTHETIC*PATIENT100609****MI*ZZ0100609
215  DTM*232*20260825
216  DTM*233*20260825
217  SVC*HC:29881*1728*561.6**1
218  DTM*472*20260825
219  CAS*CO*45*1166.4
220  REF*6R*RHP100609-1
221  AMT*B6*561.6
222  LX*18
223  CLP*RHP100610*1*319*103.74*0*MC*999044410018*11*1
224  NM1*QC*1*SYNTHETIC*PATIENT100610****MI*ZZ0100610
225  DTM*232*20260824
226  DTM*233*20260824
227  SVC*HC:99214*312*101.4**1
228  DTM*472*20260824
229  CAS*CO*45*210.6
230  REF*6R*RHP100610-1
231  AMT*B6*101.4
232  SVC*HC:36415*7*2.34**1
233  DTM*472*20260824
234  CAS*CO*45*4.66
235  REF*6R*RHP100610-2
236  AMT*B6*2.34
237  LX*19
238  CLP*RHP100611*1*624*202.8*0*MC*999044410019*11*1
239  NM1*QC*1*SYNTHETIC*PATIENT100611****MI*ZZ0100611
240  DTM*232*20260823
241  DTM*233*20260823
242  SVC*HC:73721*624*202.8**1
243  DTM*472*20260823
244  CAS*CO*45*421.2
245  REF*6R*RHP100611-1
246  AMT*B6*202.8
247  LX*20
248  CLP*RHP100612*1*240*78*0*MC*999044410020*11*1
249  NM1*QC*1*SYNTHETIC*PATIENT100612****MI*ZZ0100612
250  DTM*232*20260822
251  DTM*233*20260822
252  SVC*HC:99213*221*71.76**1
253  DTM*472*20260822
254  CAS*CO*45*149.24
255  REF*6R*RHP100612-1
256  AMT*B6*71.76
257  SVC*HC:85025*19*6.24**1
258  DTM*472*20260822
259  CAS*CO*45*12.76
260  REF*6R*RHP100612-2
261  AMT*B6*6.24
262  LX*21
263  CLP*RHP100613*1*3480*1131*0*MC*999044410021*11*1
264  NM1*QC*1*SYNTHETIC*PATIENT100613****MI*ZZ0100613
265  DTM*232*20260821
266  DTM*233*20260821
267  SVC*HC:27447*3480*1131**1
268  DTM*472*20260821
269  CAS*CO*45*2349
270  REF*6R*RHP100613-1
271  AMT*B6*1131
272  LX*22
273  CLP*RHP100614*4*439*0*0*MC*999044410022*11*1
274  NM1*QC*1*SYNTHETIC*PATIENT100614****MI*ZZ0100614
275  DTM*232*20260820
276  DTM*233*20260820
277  SVC*HC:99215*439*0**1
278  DTM*472*20260820
279  CAS*CO*22*439
280  REF*6R*RHP100614-1
281  AMT*B6*0
282  LX*23
283  CLP*RHP100615*1*912*296.4*0*MC*999044410023*11*1
284  NM1*QC*1*SYNTHETIC*PATIENT100615****MI*ZZ0100615
285  DTM*232*20260819
286  DTM*233*20260819
287  SVC*HC:45380*912*296.4**1
288  DTM*472*20260819
289  CAS*CO*45*615.6
290  REF*6R*RHP100615-1
291  AMT*B6*296.4
292  LX*24
293  CLP*RHP100616*1*269*87.36*0*MC*999044410024*11*1
294  NM1*QC*1*SYNTHETIC*PATIENT100616****MI*ZZ0100616
295  DTM*232*20260818
296  DTM*233*20260818
297  SVC*HC:99203*269*87.36**1
298  DTM*472*20260818
299  CAS*CO*45*181.64
300  REF*6R*RHP100616-1
301  AMT*B6*87.36
302  LX*25
303  CLP*RHP100617*1*528*171.6*0*MC*999044410025*11*1
304  NM1*QC*1*SYNTHETIC*PATIENT100617****MI*ZZ0100617
305  DTM*232*20260817
306  DTM*233*20260817
307  SVC*HC:93306*528*171.6**1
308  DTM*472*20260817
309  CAS*CO*45*356.4
310  REF*6R*RHP100617-1
311  AMT*B6*171.6
312  LX*26
313  CLP*RHP100618*1*449*145.86*0*MC*999044410026*11*1
314  NM1*QC*1*SYNTHETIC*PATIENT100618****MI*ZZ0100618
315  DTM*232*20260903
316  DTM*233*20260903
317  SVC*HC:99204*408*132.6**1
318  DTM*472*20260903
319  CAS*CO*45*275.4
320  REF*6R*RHP100618-1
321  AMT*B6*132.6
322  SVC*HC:93000*41*13.26**1
323  DTM*472*20260903
324  CAS*CO*45*27.74
325  REF*6R*RHP100618-2
326  AMT*B6*13.26
327  LX*27
328  CLP*RHP100619*1*2520*819*0*MC*999044410027*11*1
329  NM1*QC*1*SYNTHETIC*PATIENT100619****MI*ZZ0100619
330  DTM*232*20260902
331  DTM*233*20260902
332  SVC*HC:29827*2520*819**1
333  DTM*472*20260902
334  CAS*CO*45*1701
335  REF*6R*RHP100619-1
336  AMT*B6*819
337  LX*28
338  CLP*RHP100620*1*140*45.24*0*MC*999044410028*11*1
339  NM1*QC*1*SYNTHETIC*PATIENT100620****MI*ZZ0100620
340  DTM*232*20260901
341  DTM*233*20260901
342  SVC*HC:97110*140*45.24**2
343  DTM*472*20260901
344  CAS*CO*45*94.76
345  REF*6R*RHP100620-1
346  AMT*B6*45.24
347  LX*29
348  CLP*RHP100621*1*576*187.2*0*MC*999044410029*11*1
349  NM1*QC*1*SYNTHETIC*PATIENT100621****MI*ZZ0100621
350  DTM*232*20260831
351  DTM*233*20260831
352  SVC*HC:64483*576*187.2**1
353  DTM*472*20260831
354  CAS*CO*45*388.8
355  REF*6R*RHP100621-1
356  AMT*B6*187.2
357  LX*30
358  CLP*RHP100622*1*310*100.62*0*MC*999044410030*11*1
359  NM1*QC*1*SYNTHETIC*PATIENT100622****MI*ZZ0100622
360  DTM*232*20260830
361  DTM*233*20260830
362  SVC*HC:99213*221*71.76**1
363  DTM*472*20260830
364  CAS*CO*45*149.24
365  REF*6R*RHP100622-1
366  AMT*B6*71.76
367  SVC*HC:90471*41*13.26**1
368  DTM*472*20260830
369  CAS*CO*45*27.74
370  REF*6R*RHP100622-2
371  AMT*B6*13.26
372  SVC*HC:90686*48*15.6**1
373  DTM*472*20260830
374  CAS*CO*45*32.4
375  REF*6R*RHP100622-3
376  AMT*B6*15.6
377  LX*31
378  CLP*RHP100623*1*338*109.98*0*MC*999044410031*11*1
379  NM1*QC*1*SYNTHETIC*PATIENT100623****MI*ZZ0100623
380  DTM*232*20260829
381  DTM*233*20260829
382  SVC*HC:99214*312*101.4**1
383  DTM*472*20260829
384  CAS*CO*45*210.6
385  REF*6R*RHP100623-1
386  AMT*B6*101.4
387  SVC*HC:80053*26*8.58**1
388  DTM*472*20260829
389  CAS*CO*45*17.42
390  REF*6R*RHP100623-2
391  AMT*B6*8.58
392  LX*32
393  CLP*RHP100624*1*228*74.1*0*MC*999044410032*11*1
394  NM1*QC*1*SYNTHETIC*PATIENT100624****MI*ZZ0100624
395  DTM*232*20260828
396  DTM*233*20260828
397  SVC*HC:99213*221*71.76**1
398  DTM*472*20260828
399  CAS*CO*45*149.24
400  REF*6R*RHP100624-1
401  AMT*B6*71.76
402  SVC*HC:36415*7*2.34**1
403  DTM*472*20260828
404  CAS*CO*45*4.66
405  REF*6R*RHP100624-2
406  AMT*B6*2.34
407  LX*33
408  CLP*RHP100625*1*1728*561.6*0*MC*999044410033*11*1
409  NM1*QC*1*SYNTHETIC*PATIENT100625****MI*ZZ0100625
410  DTM*232*20260827
411  DTM*233*20260827
412  SVC*HC:29881*1728*561.6**1
413  DTM*472*20260827
414  CAS*CO*45*1166.4
415  REF*6R*RHP100625-1
416  AMT*B6*561.6
417  LX*34
418  CLP*RHP100626*1*319*103.74*0*MC*999044410034*11*1
419  NM1*QC*1*SYNTHETIC*PATIENT100626****MI*ZZ0100626
420  DTM*232*20260826
421  DTM*233*20260826
422  SVC*HC:99214*312*101.4**1
423  DTM*472*20260826
424  CAS*CO*45*210.6
425  REF*6R*RHP100626-1
426  AMT*B6*101.4
427  SVC*HC:36415*7*2.34**1
428  DTM*472*20260826
429  CAS*CO*45*4.66
430  REF*6R*RHP100626-2
431  AMT*B6*2.34
432  LX*35
433  CLP*RHP100627*4*624*0*0*MC*999044410035*11*1
434  NM1*QC*1*SYNTHETIC*PATIENT100627****MI*ZZ0100627
435  DTM*232*20260825
436  DTM*233*20260825
437  SVC*HC:73721*624*0**1
438  DTM*472*20260825
439  CAS*CO*197*624
440  REF*6R*RHP100627-1
441  AMT*B6*0
442  LX*36
443  CLP*RHP100628*1*240*78*0*MC*999044410036*11*1
444  NM1*QC*1*SYNTHETIC*PATIENT100628****MI*ZZ0100628
445  DTM*232*20260824
446  DTM*233*20260824
447  SVC*HC:99213*221*71.76**1
448  DTM*472*20260824
449  CAS*CO*45*149.24
450  REF*6R*RHP100628-1
451  AMT*B6*71.76
452  SVC*HC:85025*19*6.24**1
453  DTM*472*20260824
454  CAS*CO*45*12.76
455  REF*6R*RHP100628-2
456  AMT*B6*6.24
457  LX*37
458  CLP*RHP100629*1*3480*1131*0*MC*999044410037*11*1
459  NM1*QC*1*SYNTHETIC*PATIENT100629****MI*ZZ0100629
460  DTM*232*20260823
461  DTM*233*20260823
462  SVC*HC:27447*3480*1131**1
463  DTM*472*20260823
464  CAS*CO*45*2349
465  REF*6R*RHP100629-1
466  AMT*B6*1131
467  LX*38
468  CLP*RHP100630*1*439*142.74*0*MC*999044410038*11*1
469  NM1*QC*1*SYNTHETIC*PATIENT100630****MI*ZZ0100630
470  DTM*232*20260822
471  DTM*233*20260822
472  SVC*HC:99215*439*142.74**1
473  DTM*472*20260822
474  CAS*CO*45*296.26
475  REF*6R*RHP100630-1
476  AMT*B6*142.74
477  LX*39
478  CLP*RHP100631*1*912*296.4*0*MC*999044410039*11*1
479  NM1*QC*1*SYNTHETIC*PATIENT100631****MI*ZZ0100631
480  DTM*232*20260821
481  DTM*233*20260821
482  SVC*HC:45380*912*296.4**1
483  DTM*472*20260821
484  CAS*CO*45*615.6
485  REF*6R*RHP100631-1
486  AMT*B6*296.4
487  LX*40
488  CLP*RHP100632*1*269*87.36*0*MC*999044410040*11*1
489  NM1*QC*1*SYNTHETIC*PATIENT100632****MI*ZZ0100632
490  DTM*232*20260820
491  DTM*233*20260820
492  SVC*HC:99203*269*87.36**1
493  DTM*472*20260820
494  CAS*CO*45*181.64
495  REF*6R*RHP100632-1
496  AMT*B6*87.36
497  LX*41
498  CLP*RHP100633*1*528*171.6*0*MC*999044410041*11*1
499  NM1*QC*1*SYNTHETIC*PATIENT100633****MI*ZZ0100633
500  DTM*232*20260819
501  DTM*233*20260819
502  SVC*HC:93306*528*171.6**1
503  DTM*472*20260819
504  CAS*CO*45*356.4
505  REF*6R*RHP100633-1
506  AMT*B6*171.6
507  LX*42
508  CLP*RHP100634*1*449*145.86*0*MC*999044410042*11*1
509  NM1*QC*1*SYNTHETIC*PATIENT100634****MI*ZZ0100634
510  DTM*232*20260818
511  DTM*233*20260818
512  SVC*HC:99204*408*132.6**1
513  DTM*472*20260818
514  CAS*CO*45*275.4
515  REF*6R*RHP100634-1
516  AMT*B6*132.6
517  SVC*HC:93000*41*13.26**1
518  DTM*472*20260818
519  CAS*CO*45*27.74
520  REF*6R*RHP100634-2
521  AMT*B6*13.26
522  LX*43
523  CLP*RHP100635*1*2520*819*0*MC*999044410043*11*1
524  NM1*QC*1*SYNTHETIC*PATIENT100635****MI*ZZ0100635
525  DTM*232*20260817
526  DTM*233*20260817
527  SVC*HC:29827*2520*819**1
528  DTM*472*20260817
529  CAS*CO*45*1701
530  REF*6R*RHP100635-1
531  AMT*B6*819
532  LX*44
533  CLP*RHP100636*1*140*45.24*0*MC*999044410044*11*1
534  NM1*QC*1*SYNTHETIC*PATIENT100636****MI*ZZ0100636
535  DTM*232*20260903
536  DTM*233*20260903
537  SVC*HC:97110*140*45.24**2
538  DTM*472*20260903
539  CAS*CO*45*94.76
540  REF*6R*RHP100636-1
541  AMT*B6*45.24
542  LX*45
543  CLP*RHP100637*1*576*187.2*0*MC*999044410045*11*1
544  NM1*QC*1*SYNTHETIC*PATIENT100637****MI*ZZ0100637
545  DTM*232*20260902
546  DTM*233*20260902
547  SVC*HC:64483*576*187.2**1
548  DTM*472*20260902
549  CAS*CO*45*388.8
550  REF*6R*RHP100637-1
551  AMT*B6*187.2
552  LX*46
553  CLP*RHP100638*1*310*100.62*0*MC*999044410046*11*1
554  NM1*QC*1*SYNTHETIC*PATIENT100638****MI*ZZ0100638
555  DTM*232*20260901
556  DTM*233*20260901
557  SVC*HC:99213*221*71.76**1
558  DTM*472*20260901
559  CAS*CO*45*149.24
560  REF*6R*RHP100638-1
561  AMT*B6*71.76
562  SVC*HC:90471*41*13.26**1
563  DTM*472*20260901
564  CAS*CO*45*27.74
565  REF*6R*RHP100638-2
566  AMT*B6*13.26
567  SVC*HC:90686*48*15.6**1
568  DTM*472*20260901
569  CAS*CO*45*32.4
570  REF*6R*RHP100638-3
571  AMT*B6*15.6
572  LX*47
573  CLP*RHP100639*1*338*109.98*0*MC*999044410047*11*1
574  NM1*QC*1*SYNTHETIC*PATIENT100639****MI*ZZ0100639
575  DTM*232*20260831
576  DTM*233*20260831
577  SVC*HC:99214*312*101.4**1
578  DTM*472*20260831
579  CAS*CO*45*210.6
580  REF*6R*RHP100639-1
581  AMT*B6*101.4
582  SVC*HC:80053*26*8.58**1
583  DTM*472*20260831
584  CAS*CO*45*17.42
585  REF*6R*RHP100639-2
586  AMT*B6*8.58
587  LX*48
588  CLP*RHP100640*4*228*0*0*MC*999044410048*11*1
589  NM1*QC*1*SYNTHETIC*PATIENT100640****MI*ZZ0100640
590  DTM*232*20260830
591  DTM*233*20260830
592  SVC*HC:99213*221*0**1
593  DTM*472*20260830
594  CAS*CO*4*221
595  REF*6R*RHP100640-1
596  AMT*B6*0
597  SVC*HC:36415*7*0**1
598  DTM*472*20260830
599  CAS*CO*4*7
600  REF*6R*RHP100640-2
601  AMT*B6*0
602  LX*49
603  CLP*RHP100641*1*1728*561.6*0*MC*999044410049*11*1
604  NM1*QC*1*SYNTHETIC*PATIENT100641****MI*ZZ0100641
605  DTM*232*20260829
606  DTM*233*20260829
607  SVC*HC:29881*1728*561.6**1
608  DTM*472*20260829
609  CAS*CO*45*1166.4
610  REF*6R*RHP100641-1
611  AMT*B6*561.6
612  LX*50
613  CLP*RHP100642*1*319*103.74*0*MC*999044410050*11*1
614  NM1*QC*1*SYNTHETIC*PATIENT100642****MI*ZZ0100642
615  DTM*232*20260828
616  DTM*233*20260828
617  SVC*HC:99214*312*101.4**1
618  DTM*472*20260828
619  CAS*CO*45*210.6
620  REF*6R*RHP100642-1
621  AMT*B6*101.4
622  SVC*HC:36415*7*2.34**1
623  DTM*472*20260828
624  CAS*CO*45*4.66
625  REF*6R*RHP100642-2
626  AMT*B6*2.34
627  LX*51
628  CLP*RHP100643*1*624*202.8*0*MC*999044410051*11*1
629  NM1*QC*1*SYNTHETIC*PATIENT100643****MI*ZZ0100643
630  DTM*232*20260827
631  DTM*233*20260827
632  SVC*HC:73721*624*202.8**1
633  DTM*472*20260827
634  CAS*CO*45*421.2
635  REF*6R*RHP100643-1
636  AMT*B6*202.8
637  LX*52
638  CLP*RHP100644*1*240*78*0*MC*999044410052*11*1
639  NM1*QC*1*SYNTHETIC*PATIENT100644****MI*ZZ0100644
640  DTM*232*20260826
641  DTM*233*20260826
642  SVC*HC:99213*221*71.76**1
643  DTM*472*20260826
644  CAS*CO*45*149.24
645  REF*6R*RHP100644-1
646  AMT*B6*71.76
647  SVC*HC:85025*19*6.24**1
648  DTM*472*20260826
649  CAS*CO*45*12.76
650  REF*6R*RHP100644-2
651  AMT*B6*6.24
652  LX*53
653  CLP*RHP100645*1*3480*1131*0*MC*999044410053*11*1
654  NM1*QC*1*SYNTHETIC*PATIENT100645****MI*ZZ0100645
655  DTM*232*20260825
656  DTM*233*20260825
657  SVC*HC:27447*3480*1131**1
658  DTM*472*20260825
659  CAS*CO*45*2349
660  REF*6R*RHP100645-1
661  AMT*B6*1131
662  LX*54
663  CLP*RHP100646*1*439*142.74*0*MC*999044410054*11*1
664  NM1*QC*1*SYNTHETIC*PATIENT100646****MI*ZZ0100646
665  DTM*232*20260824
666  DTM*233*20260824
667  SVC*HC:99215*439*142.74**1
668  DTM*472*20260824
669  CAS*CO*45*296.26
670  REF*6R*RHP100646-1
671  AMT*B6*142.74
672  LX*55
673  CLP*RHP100647*1*912*296.4*0*MC*999044410055*11*1
674  NM1*QC*1*SYNTHETIC*PATIENT100647****MI*ZZ0100647
675  DTM*232*20260823
676  DTM*233*20260823
677  SVC*HC:45380*912*296.4**1
678  DTM*472*20260823
679  CAS*CO*45*615.6
680  REF*6R*RHP100647-1
681  AMT*B6*296.4
682  LX*56
683  CLP*RHP100648*1*269*87.36*0*MC*999044410056*11*1
684  NM1*QC*1*SYNTHETIC*PATIENT100648****MI*ZZ0100648
685  DTM*232*20260822
686  DTM*233*20260822
687  SVC*HC:99203*269*87.36**1
688  DTM*472*20260822
689  CAS*CO*45*181.64
690  REF*6R*RHP100648-1
691  AMT*B6*87.36
692  LX*57
693  CLP*RHP100649*1*528*171.6*0*MC*999044410057*11*1
694  NM1*QC*1*SYNTHETIC*PATIENT100649****MI*ZZ0100649
695  DTM*232*20260821
696  DTM*233*20260821
697  SVC*HC:93306*528*171.6**1
698  DTM*472*20260821
699  CAS*CO*45*356.4
700  REF*6R*RHP100649-1
701  AMT*B6*171.6
702  SE*700*0001
703  GE*1*106
704  IEA*1*000000106