Remittances / EFT9990000411

Tallow Creek Health Plan

Payment EFT9990000411, electronic funds transfer dated Aug 23, 2026. From TCH_835_A.x12, imported Aug 24, 2026 by Dana Whitfield.

Balances to the cent

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Payments dated Aug 23, 2026 to Aug 23, 2026, as of Oct 6, 2026. Whole organization, every site.

Payment

$21,792.88

Electronic funds transfer

Claims

75 matched to billed claims

Claim payments

$21,792.88

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
RHP100101	Claim number matched exactly	Paid as expected	$345.00	$187.20	$157.20 patient $30.00	$30.00
RHP100102	Claim number matched exactly	Paid as expected	$221.00	$119.60	$0.00 patient $119.60	$119.60
RHP100103 Superseded by a later result	Claim number matched exactly	Underpaid	$449.00	$223.65	$223.65	$0.00	$19.45
RHP100104	Claim number matched exactly	Partially denied	$377.00	$119.60	$119.60	$0.00	$84.50
RHP100105	Claim number matched exactly	Underpaid	$439.00	$169.00	$169.00	$0.00	$68.90
RHP100106	Claim number matched exactly	Partially denied	$468.00	$169.00	$169.00	$0.00	$84.50
RHP100107	Claim number matched exactly	Paid as expected	$221.00	$119.60	$95.68 patient $23.92	$23.92
RHP100108	Claim number matched exactly	Denied	$396.00	$0.00	$0.00	$0.00	$214.50
RHP100109	Claim number matched exactly	Overpaid	$312.00	$194.35	$194.35	$0.00	$25.35
RHP100241 Superseded by a later result	Claim number matched exactly	Denied	$967.00	$0.00	$0.00	$0.00	$523.90
RHP100300	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100301	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100302	Claim number matched exactly	Denied	$310.00	$0.00	$0.00	$0.00	$167.70
RHP100303	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100304	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100305	Claim number matched exactly	Paid as expected	$1,728.00	$936.00	$748.80 patient $187.20	$187.20
RHP100306	Claim number matched exactly	Paid as expected	$319.00	$172.90	$138.32 patient $34.58	$34.58
RHP100307	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100308	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100309	Claim number matched exactly	Paid as expected	$3,480.00	$1,885.00	$1,696.50 patient $188.50	$188.50
RHP100310	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100311	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00
RHP100312	Claim number matched exactly	Paid as expected	$269.00	$145.60	$105.60 patient $40.00	$40.00
RHP100313	Claim number matched exactly	Paid as expected	$528.00	$286.00	$228.80 patient $57.20	$57.20
RHP100314	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100315	Claim number matched exactly	Denied	$2,520.00	$0.00	$0.00	$0.00	$1,365.00
RHP100316	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100317	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100318	Claim number matched exactly	Paid as expected	$310.00	$167.70	$167.70	$0.00
RHP100319	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100320	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100321	Claim number matched exactly	Paid as expected	$1,728.00	$936.00	$748.80 patient $187.20	$187.20
RHP100322	Claim number matched exactly	Paid as expected	$319.00	$172.90	$138.32 patient $34.58	$34.58
RHP100323	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100324	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100325	Claim number matched exactly	Paid as expected	$3,480.00	$1,885.00	$1,696.50 patient $188.50	$188.50
RHP100326	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100327	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00
RHP100328	Claim number matched exactly	Denied	$269.00	$0.00	$0.00	$0.00	$145.60
RHP100329	Claim number matched exactly	Paid as expected	$528.00	$286.00	$228.80 patient $57.20	$57.20
RHP100330	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100331	Claim number matched exactly	Paid as expected	$2,520.00	$1,365.00	$1,092.00 patient $273.00	$273.00
RHP100332	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100333	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100334	Claim number matched exactly	Paid as expected	$310.00	$167.70	$167.70	$0.00
RHP100335	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100336	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100337	Claim number matched exactly	Paid as expected	$1,728.00	$936.00	$748.80 patient $187.20	$187.20
RHP100338	Claim number matched exactly	Paid as expected	$319.00	$172.90	$138.32 patient $34.58	$34.58
RHP100339	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100340	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100341	Claim number matched exactly	Denied	$3,480.00	$0.00	$0.00	$0.00	$1,885.00
RHP100342	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100343	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00
RHP100344	Claim number matched exactly	Paid as expected	$269.00	$145.60	$105.60 patient $40.00	$40.00
RHP100345	Claim number matched exactly	Paid as expected	$528.00	$286.00	$228.80 patient $57.20	$57.20
RHP100346	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100347	Claim number matched exactly	Paid as expected	$2,520.00	$1,365.00	$1,092.00 patient $273.00	$273.00
RHP100348	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100349	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100350	Claim number matched exactly	Paid as expected	$310.00	$167.70	$167.70	$0.00
RHP100351	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100352	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100353	Claim number matched exactly	Paid as expected	$1,728.00	$936.00	$748.80 patient $187.20	$187.20
RHP100354	Claim number matched exactly	Denied	$319.00	$0.00	$0.00	$0.00	$172.90
RHP100355	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100356	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100357	Claim number matched exactly	Paid as expected	$3,480.00	$1,885.00	$1,696.50 patient $188.50	$188.50
RHP100358	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100359	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00
RHP100360	Claim number matched exactly	Paid as expected	$269.00	$145.60	$105.60 patient $40.00	$40.00
RHP100361	Claim number matched exactly	Paid as expected	$528.00	$286.00	$228.80 patient $57.20	$57.20
RHP100362	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100363	Claim number matched exactly	Paid as expected	$2,520.00	$1,365.00	$1,092.00 patient $273.00	$273.00
RHP100364	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08

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The payer's remittance file (835)

Payer ID 99901. Payee RIDGELINE HEALTH PARTNERS, NPI 9999999001. Transaction 0001, 990 segments.

Show the raw file (994 segments)

1  ISA*00*          *00*          *ZZ*PAYER99901     *ZZ*RIDGELINE999   *260822*0800*^*00501*000000103*0*T*:
2  GS*HP*PAYER99901*RIDGELINE999*20260822*0800*103*X*005010X221A1
3  ST*835*0001
4  BPR*I*21792.88*C*ACH*CCP*01*999999992*DA*000111222*1999999999**01*999999993*DA*000333444*20260823
5  TRN*1*EFT9990000411*1999999901
6  DTM*405*20260822
7  N1*PR*TALLOW CREEK HEALTH PLAN
8  REF*2U*99901
9  N1*PE*RIDGELINE HEALTH PARTNERS*XX*9999999001
10  REF*TJ*999999999
11  LX*1
12  CLP*RHP100101*1*345*157.2*30*CI*999010411001*11*1
13  NM1*QC*1*SYNTHETIC*PATIENT100101****MI*ZZ0100101
14  DTM*232*20260728
15  DTM*233*20260728
16  SVC*HC:99214*312*139**1
17  DTM*472*20260728
18  CAS*CO*45*143
19  CAS*PR*3*30
20  REF*6R*RHP100101-1
21  AMT*B6*169
22  SVC*HC:36415*7*3.9**1
23  DTM*472*20260728
24  CAS*CO*45*3.1
25  REF*6R*RHP100101-2
26  AMT*B6*3.9
27  SVC*HC:80053*26*14.3**1
28  DTM*472*20260728
29  CAS*CO*45*11.7
30  REF*6R*RHP100101-3
31  AMT*B6*14.3
32  LX*2
33  CLP*RHP100102*1*221*0*119.6*CI*999010411002*11*1
34  NM1*QC*1*SYNTHETIC*PATIENT100102****MI*ZZ0100102
35  DTM*232*20260730
36  DTM*233*20260730
37  SVC*HC:99213*221*0**1
38  DTM*472*20260730
39  CAS*CO*45*101.4
40  CAS*PR*1*119.6
41  REF*6R*RHP100102-1
42  AMT*B6*119.6
43  LX*3
44  CLP*RHP100103*1*449*223.65*0*CI*999010411003*11*1
45  NM1*QC*1*SYNTHETIC*PATIENT100103****MI*ZZ0100103
46  DTM*232*20260801
47  DTM*233*20260801
48  SVC*HC:99204*408*203.32**1
49  DTM*472*20260801
50  CAS*CO*45*204.68
51  REF*6R*RHP100103-1
52  AMT*B6*203.32
53  SVC*HC:93000*41*20.33**1
54  DTM*472*20260801
55  CAS*CO*45*20.67
56  REF*6R*RHP100103-2
57  AMT*B6*20.33
58  LX*4
59  CLP*RHP100104*1*377*119.6*0*CI*999010411004*11*1
60  NM1*QC*1*SYNTHETIC*PATIENT100104****MI*ZZ0100104
61  DTM*232*20260802
62  DTM*233*20260802
63  SVC*HC:99213:25*221*119.6**1
64  DTM*472*20260802
65  CAS*CO*45*101.4
66  REF*6R*RHP100104-1
67  AMT*B6*119.6
68  SVC*HC:20610*156*0**1
69  DTM*472*20260802
70  CAS*CO*197*156
71  REF*6R*RHP100104-2
72  AMT*B6*0
73  LX*5
74  CLP*RHP100105*1*439*169*0*CI*999010411005*11*1
75  NM1*QC*1*SYNTHETIC*PATIENT100105****MI*ZZ0100105
76  DTM*232*20260803
77  DTM*233*20260803
78  SVC*HC:99214*439*169**1*HC:99215
79  DTM*472*20260803
80  CAS*CO*45*270
81  REF*6R*RHP100105-1
82  AMT*B6*169
83  LX*6
84  CLP*RHP100106*1*468*169*0*CI*999010411006*11*1
85  NM1*QC*1*SYNTHETIC*PATIENT100106****MI*ZZ0100106
86  DTM*232*20260804
87  DTM*233*20260804
88  SVC*HC:99214*312*169**1
89  DTM*472*20260804
90  CAS*CO*45*143
91  REF*6R*RHP100106-1
92  AMT*B6*169
93  SVC*HC:20610*156*0**1
94  DTM*472*20260804
95  CAS*CO*97*156
96  REF*6R*RHP100106-2
97  AMT*B6*0
98  LQ*HE*M15
99  LX*7
100  CLP*RHP100107*1*221*95.68*23.92*CI*999010411007*11*1
101  NM1*QC*1*SYNTHETIC*PATIENT100107****MI*ZZ0100107
102  DTM*232*20260805
103  DTM*233*20260805
104  SVC*HC:99213*221*95.68**1
105  DTM*472*20260805
106  CAS*CO*45*101.4
107  CAS*PR*2*23.92
108  REF*6R*RHP100107-1
109  AMT*B6*119.6
110  LX*8
111  CLP*RHP100108*4*396*0*0*CI*999010411008*11*1
112  NM1*QC*1*SYNTHETIC*PATIENT100108****MI*ZZ0100108
113  DTM*232*20260714
114  DTM*233*20260714
115  SVC*HC:71046*84*0**1
116  DTM*472*20260714
117  CAS*CO*16*84
118  REF*6R*RHP100108-1
119  AMT*B6*0
120  LQ*HE*MA130
121  SVC*HC:99214*312*0**1
122  DTM*472*20260714
123  CAS*CO*16*312
124  REF*6R*RHP100108-2
125  AMT*B6*0
126  LQ*HE*MA130
127  LX*9
128  CLP*RHP100109*1*312*194.35*0*CI*999010411009*11*1
129  NM1*QC*1*SYNTHETIC*PATIENT100109****MI*ZZ0100109
130  DTM*232*20260807
131  DTM*233*20260807
132  SVC*HC:99214*312*194.35**1
133  DTM*472*20260807
134  CAS*CO*45*117.65
135  REF*6R*RHP100109-1
136  AMT*B6*194.35
137  LX*10
138  CLP*RHP100241*4*967*0*0*CI*999010411010*11*1
139  NM1*QC*1*SYNTHETIC*PATIENT100241****MI*ZZ0100241
140  DTM*232*20260809
141  DTM*233*20260809
142  SVC*HC:99215*439*0**1
143  DTM*472*20260809
144  CAS*CO*16*439
145  REF*6R*RHP100241-1
146  AMT*B6*0
147  LQ*HE*MA130
148  SVC*HC:93306*528*0**1
149  DTM*472*20260809
150  CAS*CO*16*528
151  REF*6R*RHP100241-2
152  AMT*B6*0
153  LQ*HE*MA130
154  LX*11
155  CLP*RHP100300*1*140*60.32*15.08*CI*999010411011*11*1
156  NM1*QC*1*SYNTHETIC*PATIENT100300****MI*ZZ0100300
157  DTM*232*20260811
158  DTM*233*20260811
159  SVC*HC:97110*140*60.32**2
160  DTM*472*20260811
161  CAS*CO*45*64.6
162  CAS*PR*2*15.08
163  REF*6R*RHP100300-1
164  AMT*B6*75.4
165  LX*12
166  CLP*RHP100301*1*576*262*50*CI*999010411012*11*1
167  NM1*QC*1*SYNTHETIC*PATIENT100301****MI*ZZ0100301
168  DTM*232*20260810
169  DTM*233*20260810
170  SVC*HC:64483*576*262**1
171  DTM*472*20260810
172  CAS*CO*45*264
173  CAS*PR*3*50
174  REF*6R*RHP100301-1
175  AMT*B6*312
176  LX*13
177  CLP*RHP100302*4*310*0*0*CI*999010411013*11*1
178  NM1*QC*1*SYNTHETIC*PATIENT100302****MI*ZZ0100302
179  DTM*232*20260809
180  DTM*233*20260809
181  SVC*HC:99213*221*0**1
182  DTM*472*20260809
183  CAS*CO*22*221
184  REF*6R*RHP100302-1
185  AMT*B6*0
186  SVC*HC:90471*41*0**1
187  DTM*472*20260809
188  CAS*CO*22*41
189  REF*6R*RHP100302-2
190  AMT*B6*0
191  SVC*HC:90686*48*0**1
192  DTM*472*20260809
193  CAS*CO*22*48
194  REF*6R*RHP100302-3
195  AMT*B6*0
196  LX*14
197  CLP*RHP100303*1*338*83.3*100*CI*999010411014*11*1
198  NM1*QC*1*SYNTHETIC*PATIENT100303****MI*ZZ0100303
199  DTM*232*20260808
200  DTM*233*20260808
201  SVC*HC:99214*312*69**1
202  DTM*472*20260808
203  CAS*CO*45*143
204  CAS*PR*1*100
205  REF*6R*RHP100303-1
206  AMT*B6*169
207  SVC*HC:80053*26*14.3**1
208  DTM*472*20260808
209  CAS*CO*45*11.7
210  REF*6R*RHP100303-2
211  AMT*B6*14.3
212  LX*15
213  CLP*RHP100304*1*228*98.5*25*CI*999010411015*11*1
214  NM1*QC*1*SYNTHETIC*PATIENT100304****MI*ZZ0100304
215  DTM*232*20260807
216  DTM*233*20260807
217  SVC*HC:99213*221*94.6**1
218  DTM*472*20260807
219  CAS*CO*45*101.4
220  CAS*PR*3*25
221  REF*6R*RHP100304-1
222  AMT*B6*119.6
223  SVC*HC:36415*7*3.9**1
224  DTM*472*20260807
225  CAS*CO*45*3.1
226  REF*6R*RHP100304-2
227  AMT*B6*3.9
228  LX*16
229  CLP*RHP100305*1*1728*748.8*187.2*CI*999010411016*11*1
230  NM1*QC*1*SYNTHETIC*PATIENT100305****MI*ZZ0100305
231  DTM*232*20260806
232  DTM*233*20260806
233  SVC*HC:29881*1728*748.8**1
234  DTM*472*20260806
235  CAS*CO*45*792
236  CAS*PR*2*187.2
237  REF*6R*RHP100305-1
238  AMT*B6*936
239  LX*17
240  CLP*RHP100306*1*319*138.32*34.58*CI*999010411017*11*1
241  NM1*QC*1*SYNTHETIC*PATIENT100306****MI*ZZ0100306
242  DTM*232*20260805
243  DTM*233*20260805
244  SVC*HC:99214*312*135.2**1
245  DTM*472*20260805
246  CAS*CO*45*143
247  CAS*PR*2*33.8
248  REF*6R*RHP100306-1
249  AMT*B6*169
250  SVC*HC:36415*7*3.12**1
251  DTM*472*20260805
252  CAS*CO*45*3.1
253  CAS*PR*2*0.78
254  REF*6R*RHP100306-2
255  AMT*B6*3.9
256  LX*18
257  CLP*RHP100307*1*624*188*150*CI*999010411018*11*1
258  NM1*QC*1*SYNTHETIC*PATIENT100307****MI*ZZ0100307
259  DTM*232*20260804
260  DTM*233*20260804
261  SVC*HC:73721*624*188**1
262  DTM*472*20260804
263  CAS*CO*45*286
264  CAS*PR*1*150
265  REF*6R*RHP100307-1
266  AMT*B6*338
267  LX*19
268  CLP*RHP100308*1*240*130*0*CI*999010411019*11*1
269  NM1*QC*1*SYNTHETIC*PATIENT100308****MI*ZZ0100308
270  DTM*232*20260803
271  DTM*233*20260803
272  SVC*HC:99213*221*119.6**1
273  DTM*472*20260803
274  CAS*CO*45*101.4
275  REF*6R*RHP100308-1
276  AMT*B6*119.6
277  SVC*HC:85025*19*10.4**1
278  DTM*472*20260803
279  CAS*CO*45*8.6
280  REF*6R*RHP100308-2
281  AMT*B6*10.4
282  LX*20
283  CLP*RHP100309*1*3480*1696.5*188.5*CI*999010411020*11*1
284  NM1*QC*1*SYNTHETIC*PATIENT100309****MI*ZZ0100309
285  DTM*232*20260802
286  DTM*233*20260802
287  SVC*HC:27447*3480*1696.5**1
288  DTM*472*20260802
289  CAS*CO*45*1595
290  CAS*PR*2*188.5
291  REF*6R*RHP100309-1
292  AMT*B6*1885
293  LX*21
294  CLP*RHP100310*1*439*214.11*23.79*CI*999010411021*11*1
295  NM1*QC*1*SYNTHETIC*PATIENT100310****MI*ZZ0100310
296  DTM*232*20260801
297  DTM*233*20260801
298  SVC*HC:99215*439*214.11**1
299  DTM*472*20260801
300  CAS*CO*45*201.1
301  CAS*PR*2*23.79
302  REF*6R*RHP100310-1
303  AMT*B6*237.9
304  LX*22
305  CLP*RHP100311*1*912*494*0*CI*999010411022*11*1
306  NM1*QC*1*SYNTHETIC*PATIENT100311****MI*ZZ0100311
307  DTM*232*20260731
308  DTM*233*20260731
309  SVC*HC:45380*912*494**1
310  DTM*472*20260731
311  CAS*CO*45*418
312  REF*6R*RHP100311-1
313  AMT*B6*494
314  LX*23
315  CLP*RHP100312*1*269*105.6*40*CI*999010411023*11*1
316  NM1*QC*1*SYNTHETIC*PATIENT100312****MI*ZZ0100312
317  DTM*232*20260730
318  DTM*233*20260730
319  SVC*HC:99203*269*105.6**1
320  DTM*472*20260730
321  CAS*CO*45*123.4
322  CAS*PR*3*40
323  REF*6R*RHP100312-1
324  AMT*B6*145.6
325  LX*24
326  CLP*RHP100313*1*528*228.8*57.2*CI*999010411024*11*1
327  NM1*QC*1*SYNTHETIC*PATIENT100313****MI*ZZ0100313
328  DTM*232*20260729
329  DTM*233*20260729
330  SVC*HC:93306*528*228.8**1
331  DTM*472*20260729
332  CAS*CO*45*242
333  CAS*PR*2*57.2
334  REF*6R*RHP100313-1
335  AMT*B6*286
336  LX*25
337  CLP*RHP100314*1*449*243.1*0*CI*999010411025*11*1
338  NM1*QC*1*SYNTHETIC*PATIENT100314****MI*ZZ0100314
339  DTM*232*20260728
340  DTM*233*20260728
341  SVC*HC:99204*408*221**1
342  DTM*472*20260728
343  CAS*CO*45*187
344  REF*6R*RHP100314-1
345  AMT*B6*221
346  SVC*HC:93000*41*22.1**1
347  DTM*472*20260728
348  CAS*CO*45*18.9
349  REF*6R*RHP100314-2
350  AMT*B6*22.1
351  LX*26
352  CLP*RHP100315*4*2520*0*0*CI*999010411026*11*1
353  NM1*QC*1*SYNTHETIC*PATIENT100315****MI*ZZ0100315
354  DTM*232*20260727
355  DTM*233*20260727
356  SVC*HC:29827*2520*0**1
357  DTM*472*20260727
358  CAS*CO*197*2520
359  REF*6R*RHP100315-1
360  AMT*B6*0
361  LX*27
362  CLP*RHP100316*1*140*60.32*15.08*CI*999010411027*11*1
363  NM1*QC*1*SYNTHETIC*PATIENT100316****MI*ZZ0100316
364  DTM*232*20260726
365  DTM*233*20260726
366  SVC*HC:97110*140*60.32**2
367  DTM*472*20260726
368  CAS*CO*45*64.6
369  CAS*PR*2*15.08
370  REF*6R*RHP100316-1
371  AMT*B6*75.4
372  LX*28
373  CLP*RHP100317*1*576*262*50*CI*999010411028*11*1
374  NM1*QC*1*SYNTHETIC*PATIENT100317****MI*ZZ0100317
375  DTM*232*20260725
376  DTM*233*20260725
377  SVC*HC:64483*576*262**1
378  DTM*472*20260725
379  CAS*CO*45*264
380  CAS*PR*3*50
381  REF*6R*RHP100317-1
382  AMT*B6*312
383  LX*29
384  CLP*RHP100318*1*310*167.7*0*CI*999010411029*11*1
385  NM1*QC*1*SYNTHETIC*PATIENT100318****MI*ZZ0100318
386  DTM*232*20260811
387  DTM*233*20260811
388  SVC*HC:99213*221*119.6**1
389  DTM*472*20260811
390  CAS*CO*45*101.4
391  REF*6R*RHP100318-1
392  AMT*B6*119.6
393  SVC*HC:90471*41*22.1**1
394  DTM*472*20260811
395  CAS*CO*45*18.9
396  REF*6R*RHP100318-2
397  AMT*B6*22.1
398  SVC*HC:90686*48*26**1
399  DTM*472*20260811
400  CAS*CO*45*22
401  REF*6R*RHP100318-3
402  AMT*B6*26
403  LX*30
404  CLP*RHP100319*1*338*83.3*100*CI*999010411030*11*1
405  NM1*QC*1*SYNTHETIC*PATIENT100319****MI*ZZ0100319
406  DTM*232*20260810
407  DTM*233*20260810
408  SVC*HC:99214*312*69**1
409  DTM*472*20260810
410  CAS*CO*45*143
411  CAS*PR*1*100
412  REF*6R*RHP100319-1
413  AMT*B6*169
414  SVC*HC:80053*26*14.3**1
415  DTM*472*20260810
416  CAS*CO*45*11.7
417  REF*6R*RHP100319-2
418  AMT*B6*14.3
419  LX*31
420  CLP*RHP100320*1*228*98.5*25*CI*999010411031*11*1
421  NM1*QC*1*SYNTHETIC*PATIENT100320****MI*ZZ0100320
422  DTM*232*20260809
423  DTM*233*20260809
424  SVC*HC:99213*221*94.6**1
425  DTM*472*20260809
426  CAS*CO*45*101.4
427  CAS*PR*3*25
428  REF*6R*RHP100320-1
429  AMT*B6*119.6
430  SVC*HC:36415*7*3.9**1
431  DTM*472*20260809
432  CAS*CO*45*3.1
433  REF*6R*RHP100320-2
434  AMT*B6*3.9
435  LX*32
436  CLP*RHP100321*1*1728*748.8*187.2*CI*999010411032*11*1
437  NM1*QC*1*SYNTHETIC*PATIENT100321****MI*ZZ0100321
438  DTM*232*20260808
439  DTM*233*20260808
440  SVC*HC:29881*1728*748.8**1
441  DTM*472*20260808
442  CAS*CO*45*792
443  CAS*PR*2*187.2
444  REF*6R*RHP100321-1
445  AMT*B6*936
446  LX*33
447  CLP*RHP100322*1*319*138.32*34.58*CI*999010411033*11*1
448  NM1*QC*1*SYNTHETIC*PATIENT100322****MI*ZZ0100322
449  DTM*232*20260807
450  DTM*233*20260807
451  SVC*HC:99214*312*135.2**1
452  DTM*472*20260807
453  CAS*CO*45*143
454  CAS*PR*2*33.8
455  REF*6R*RHP100322-1
456  AMT*B6*169
457  SVC*HC:36415*7*3.12**1
458  DTM*472*20260807
459  CAS*CO*45*3.1
460  CAS*PR*2*0.78
461  REF*6R*RHP100322-2
462  AMT*B6*3.9
463  LX*34
464  CLP*RHP100323*1*624*188*150*CI*999010411034*11*1
465  NM1*QC*1*SYNTHETIC*PATIENT100323****MI*ZZ0100323
466  DTM*232*20260806
467  DTM*233*20260806
468  SVC*HC:73721*624*188**1
469  DTM*472*20260806
470  CAS*CO*45*286
471  CAS*PR*1*150
472  REF*6R*RHP100323-1
473  AMT*B6*338
474  LX*35
475  CLP*RHP100324*1*240*130*0*CI*999010411035*11*1
476  NM1*QC*1*SYNTHETIC*PATIENT100324****MI*ZZ0100324
477  DTM*232*20260805
478  DTM*233*20260805
479  SVC*HC:99213*221*119.6**1
480  DTM*472*20260805
481  CAS*CO*45*101.4
482  REF*6R*RHP100324-1
483  AMT*B6*119.6
484  SVC*HC:85025*19*10.4**1
485  DTM*472*20260805
486  CAS*CO*45*8.6
487  REF*6R*RHP100324-2
488  AMT*B6*10.4
489  LX*36
490  CLP*RHP100325*1*3480*1696.5*188.5*CI*999010411036*11*1
491  NM1*QC*1*SYNTHETIC*PATIENT100325****MI*ZZ0100325
492  DTM*232*20260804
493  DTM*233*20260804
494  SVC*HC:27447*3480*1696.5**1
495  DTM*472*20260804
496  CAS*CO*45*1595
497  CAS*PR*2*188.5
498  REF*6R*RHP100325-1
499  AMT*B6*1885
500  LX*37
501  CLP*RHP100326*1*439*214.11*23.79*CI*999010411037*11*1
502  NM1*QC*1*SYNTHETIC*PATIENT100326****MI*ZZ0100326
503  DTM*232*20260803
504  DTM*233*20260803
505  SVC*HC:99215*439*214.11**1
506  DTM*472*20260803
507  CAS*CO*45*201.1
508  CAS*PR*2*23.79
509  REF*6R*RHP100326-1
510  AMT*B6*237.9
511  LX*38
512  CLP*RHP100327*1*912*494*0*CI*999010411038*11*1
513  NM1*QC*1*SYNTHETIC*PATIENT100327****MI*ZZ0100327
514  DTM*232*20260802
515  DTM*233*20260802
516  SVC*HC:45380*912*494**1
517  DTM*472*20260802
518  CAS*CO*45*418
519  REF*6R*RHP100327-1
520  AMT*B6*494
521  LX*39
522  CLP*RHP100328*4*269*0*0*CI*999010411039*11*1
523  NM1*QC*1*SYNTHETIC*PATIENT100328****MI*ZZ0100328
524  DTM*232*20260801
525  DTM*233*20260801
526  SVC*HC:99203*269*0**1
527  DTM*472*20260801
528  CAS*CO*4*269
529  REF*6R*RHP100328-1
530  AMT*B6*0
531  LX*40
532  CLP*RHP100329*1*528*228.8*57.2*CI*999010411040*11*1
533  NM1*QC*1*SYNTHETIC*PATIENT100329****MI*ZZ0100329
534  DTM*232*20260731
535  DTM*233*20260731
536  SVC*HC:93306*528*228.8**1
537  DTM*472*20260731
538  CAS*CO*45*242
539  CAS*PR*2*57.2
540  REF*6R*RHP100329-1
541  AMT*B6*286
542  LX*41
543  CLP*RHP100330*1*449*243.1*0*CI*999010411041*11*1
544  NM1*QC*1*SYNTHETIC*PATIENT100330****MI*ZZ0100330
545  DTM*232*20260730
546  DTM*233*20260730
547  SVC*HC:99204*408*221**1
548  DTM*472*20260730
549  CAS*CO*45*187
550  REF*6R*RHP100330-1
551  AMT*B6*221
552  SVC*HC:93000*41*22.1**1
553  DTM*472*20260730
554  CAS*CO*45*18.9
555  REF*6R*RHP100330-2
556  AMT*B6*22.1
557  LX*42
558  CLP*RHP100331*1*2520*1092*273*CI*999010411042*11*1
559  NM1*QC*1*SYNTHETIC*PATIENT100331****MI*ZZ0100331
560  DTM*232*20260729
561  DTM*233*20260729
562  SVC*HC:29827*2520*1092**1
563  DTM*472*20260729
564  CAS*CO*45*1155
565  CAS*PR*2*273
566  REF*6R*RHP100331-1
567  AMT*B6*1365
568  LX*43
569  CLP*RHP100332*1*140*60.32*15.08*CI*999010411043*11*1
570  NM1*QC*1*SYNTHETIC*PATIENT100332****MI*ZZ0100332
571  DTM*232*20260728
572  DTM*233*20260728
573  SVC*HC:97110*140*60.32**2
574  DTM*472*20260728
575  CAS*CO*45*64.6
576  CAS*PR*2*15.08
577  REF*6R*RHP100332-1
578  AMT*B6*75.4
579  LX*44
580  CLP*RHP100333*1*576*262*50*CI*999010411044*11*1
581  NM1*QC*1*SYNTHETIC*PATIENT100333****MI*ZZ0100333
582  DTM*232*20260727
583  DTM*233*20260727
584  SVC*HC:64483*576*262**1
585  DTM*472*20260727
586  CAS*CO*45*264
587  CAS*PR*3*50
588  REF*6R*RHP100333-1
589  AMT*B6*312
590  LX*45
591  CLP*RHP100334*1*310*167.7*0*CI*999010411045*11*1
592  NM1*QC*1*SYNTHETIC*PATIENT100334****MI*ZZ0100334
593  DTM*232*20260726
594  DTM*233*20260726
595  SVC*HC:99213*221*119.6**1
596  DTM*472*20260726
597  CAS*CO*45*101.4
598  REF*6R*RHP100334-1
599  AMT*B6*119.6
600  SVC*HC:90471*41*22.1**1
601  DTM*472*20260726
602  CAS*CO*45*18.9
603  REF*6R*RHP100334-2
604  AMT*B6*22.1
605  SVC*HC:90686*48*26**1
606  DTM*472*20260726
607  CAS*CO*45*22
608  REF*6R*RHP100334-3
609  AMT*B6*26
610  LX*46
611  CLP*RHP100335*1*338*83.3*100*CI*999010411046*11*1
612  NM1*QC*1*SYNTHETIC*PATIENT100335****MI*ZZ0100335
613  DTM*232*20260725
614  DTM*233*20260725
615  SVC*HC:99214*312*69**1
616  DTM*472*20260725
617  CAS*CO*45*143
618  CAS*PR*1*100
619  REF*6R*RHP100335-1
620  AMT*B6*169
621  SVC*HC:80053*26*14.3**1
622  DTM*472*20260725
623  CAS*CO*45*11.7
624  REF*6R*RHP100335-2
625  AMT*B6*14.3
626  LX*47
627  CLP*RHP100336*1*228*98.5*25*CI*999010411047*11*1
628  NM1*QC*1*SYNTHETIC*PATIENT100336****MI*ZZ0100336
629  DTM*232*20260811
630  DTM*233*20260811
631  SVC*HC:99213*221*94.6**1
632  DTM*472*20260811
633  CAS*CO*45*101.4
634  CAS*PR*3*25
635  REF*6R*RHP100336-1
636  AMT*B6*119.6
637  SVC*HC:36415*7*3.9**1
638  DTM*472*20260811
639  CAS*CO*45*3.1
640  REF*6R*RHP100336-2
641  AMT*B6*3.9
642  LX*48
643  CLP*RHP100337*1*1728*748.8*187.2*CI*999010411048*11*1
644  NM1*QC*1*SYNTHETIC*PATIENT100337****MI*ZZ0100337
645  DTM*232*20260810
646  DTM*233*20260810
647  SVC*HC:29881*1728*748.8**1
648  DTM*472*20260810
649  CAS*CO*45*792
650  CAS*PR*2*187.2
651  REF*6R*RHP100337-1
652  AMT*B6*936
653  LX*49
654  CLP*RHP100338*1*319*138.32*34.58*CI*999010411049*11*1
655  NM1*QC*1*SYNTHETIC*PATIENT100338****MI*ZZ0100338
656  DTM*232*20260809
657  DTM*233*20260809
658  SVC*HC:99214*312*135.2**1
659  DTM*472*20260809
660  CAS*CO*45*143
661  CAS*PR*2*33.8
662  REF*6R*RHP100338-1
663  AMT*B6*169
664  SVC*HC:36415*7*3.12**1
665  DTM*472*20260809
666  CAS*CO*45*3.1
667  CAS*PR*2*0.78
668  REF*6R*RHP100338-2
669  AMT*B6*3.9
670  LX*50
671  CLP*RHP100339*1*624*188*150*CI*999010411050*11*1
672  NM1*QC*1*SYNTHETIC*PATIENT100339****MI*ZZ0100339
673  DTM*232*20260808
674  DTM*233*20260808
675  SVC*HC:73721*624*188**1
676  DTM*472*20260808
677  CAS*CO*45*286
678  CAS*PR*1*150
679  REF*6R*RHP100339-1
680  AMT*B6*338
681  LX*51
682  CLP*RHP100340*1*240*130*0*CI*999010411051*11*1
683  NM1*QC*1*SYNTHETIC*PATIENT100340****MI*ZZ0100340
684  DTM*232*20260807
685  DTM*233*20260807
686  SVC*HC:99213*221*119.6**1
687  DTM*472*20260807
688  CAS*CO*45*101.4
689  REF*6R*RHP100340-1
690  AMT*B6*119.6
691  SVC*HC:85025*19*10.4**1
692  DTM*472*20260807
693  CAS*CO*45*8.6
694  REF*6R*RHP100340-2
695  AMT*B6*10.4
696  LX*52
697  CLP*RHP100341*4*3480*0*0*CI*999010411052*11*1
698  NM1*QC*1*SYNTHETIC*PATIENT100341****MI*ZZ0100341
699  DTM*232*20260806
700  DTM*233*20260806
701  SVC*HC:27447*3480*0**1
702  DTM*472*20260806
703  CAS*CO*27*3480
704  REF*6R*RHP100341-1
705  AMT*B6*0
706  LX*53
707  CLP*RHP100342*1*439*214.11*23.79*CI*999010411053*11*1
708  NM1*QC*1*SYNTHETIC*PATIENT100342****MI*ZZ0100342
709  DTM*232*20260805
710  DTM*233*20260805
711  SVC*HC:99215*439*214.11**1
712  DTM*472*20260805
713  CAS*CO*45*201.1
714  CAS*PR*2*23.79
715  REF*6R*RHP100342-1
716  AMT*B6*237.9
717  LX*54
718  CLP*RHP100343*1*912*494*0*CI*999010411054*11*1
719  NM1*QC*1*SYNTHETIC*PATIENT100343****MI*ZZ0100343
720  DTM*232*20260804
721  DTM*233*20260804
722  SVC*HC:45380*912*494**1
723  DTM*472*20260804
724  CAS*CO*45*418
725  REF*6R*RHP100343-1
726  AMT*B6*494
727  LX*55
728  CLP*RHP100344*1*269*105.6*40*CI*999010411055*11*1
729  NM1*QC*1*SYNTHETIC*PATIENT100344****MI*ZZ0100344
730  DTM*232*20260803
731  DTM*233*20260803
732  SVC*HC:99203*269*105.6**1
733  DTM*472*20260803
734  CAS*CO*45*123.4
735  CAS*PR*3*40
736  REF*6R*RHP100344-1
737  AMT*B6*145.6
738  LX*56
739  CLP*RHP100345*1*528*228.8*57.2*CI*999010411056*11*1
740  NM1*QC*1*SYNTHETIC*PATIENT100345****MI*ZZ0100345
741  DTM*232*20260802
742  DTM*233*20260802
743  SVC*HC:93306*528*228.8**1
744  DTM*472*20260802
745  CAS*CO*45*242
746  CAS*PR*2*57.2
747  REF*6R*RHP100345-1
748  AMT*B6*286
749  LX*57
750  CLP*RHP100346*1*449*243.1*0*CI*999010411057*11*1
751  NM1*QC*1*SYNTHETIC*PATIENT100346****MI*ZZ0100346
752  DTM*232*20260801
753  DTM*233*20260801
754  SVC*HC:99204*408*221**1
755  DTM*472*20260801
756  CAS*CO*45*187
757  REF*6R*RHP100346-1
758  AMT*B6*221
759  SVC*HC:93000*41*22.1**1
760  DTM*472*20260801
761  CAS*CO*45*18.9
762  REF*6R*RHP100346-2
763  AMT*B6*22.1
764  LX*58
765  CLP*RHP100347*1*2520*1092*273*CI*999010411058*11*1
766  NM1*QC*1*SYNTHETIC*PATIENT100347****MI*ZZ0100347
767  DTM*232*20260731
768  DTM*233*20260731
769  SVC*HC:29827*2520*1092**1
770  DTM*472*20260731
771  CAS*CO*45*1155
772  CAS*PR*2*273
773  REF*6R*RHP100347-1
774  AMT*B6*1365
775  LX*59
776  CLP*RHP100348*1*140*60.32*15.08*CI*999010411059*11*1
777  NM1*QC*1*SYNTHETIC*PATIENT100348****MI*ZZ0100348
778  DTM*232*20260730
779  DTM*233*20260730
780  SVC*HC:97110*140*60.32**2
781  DTM*472*20260730
782  CAS*CO*45*64.6
783  CAS*PR*2*15.08
784  REF*6R*RHP100348-1
785  AMT*B6*75.4
786  LX*60
787  CLP*RHP100349*1*576*262*50*CI*999010411060*11*1
788  NM1*QC*1*SYNTHETIC*PATIENT100349****MI*ZZ0100349
789  DTM*232*20260729
790  DTM*233*20260729
791  SVC*HC:64483*576*262**1
792  DTM*472*20260729
793  CAS*CO*45*264
794  CAS*PR*3*50
795  REF*6R*RHP100349-1
796  AMT*B6*312
797  LX*61
798  CLP*RHP100350*1*310*167.7*0*CI*999010411061*11*1
799  NM1*QC*1*SYNTHETIC*PATIENT100350****MI*ZZ0100350
800  DTM*232*20260728
801  DTM*233*20260728
802  SVC*HC:99213*221*119.6**1
803  DTM*472*20260728
804  CAS*CO*45*101.4
805  REF*6R*RHP100350-1
806  AMT*B6*119.6
807  SVC*HC:90471*41*22.1**1
808  DTM*472*20260728
809  CAS*CO*45*18.9
810  REF*6R*RHP100350-2
811  AMT*B6*22.1
812  SVC*HC:90686*48*26**1
813  DTM*472*20260728
814  CAS*CO*45*22
815  REF*6R*RHP100350-3
816  AMT*B6*26
817  LX*62
818  CLP*RHP100351*1*338*83.3*100*CI*999010411062*11*1
819  NM1*QC*1*SYNTHETIC*PATIENT100351****MI*ZZ0100351
820  DTM*232*20260727
821  DTM*233*20260727
822  SVC*HC:99214*312*69**1
823  DTM*472*20260727
824  CAS*CO*45*143
825  CAS*PR*1*100
826  REF*6R*RHP100351-1
827  AMT*B6*169
828  SVC*HC:80053*26*14.3**1
829  DTM*472*20260727
830  CAS*CO*45*11.7
831  REF*6R*RHP100351-2
832  AMT*B6*14.3
833  LX*63
834  CLP*RHP100352*1*228*98.5*25*CI*999010411063*11*1
835  NM1*QC*1*SYNTHETIC*PATIENT100352****MI*ZZ0100352
836  DTM*232*20260726
837  DTM*233*20260726
838  SVC*HC:99213*221*94.6**1
839  DTM*472*20260726
840  CAS*CO*45*101.4
841  CAS*PR*3*25
842  REF*6R*RHP100352-1
843  AMT*B6*119.6
844  SVC*HC:36415*7*3.9**1
845  DTM*472*20260726
846  CAS*CO*45*3.1
847  REF*6R*RHP100352-2
848  AMT*B6*3.9
849  LX*64
850  CLP*RHP100353*1*1728*748.8*187.2*CI*999010411064*11*1
851  NM1*QC*1*SYNTHETIC*PATIENT100353****MI*ZZ0100353
852  DTM*232*20260725
853  DTM*233*20260725
854  SVC*HC:29881*1728*748.8**1
855  DTM*472*20260725
856  CAS*CO*45*792
857  CAS*PR*2*187.2
858  REF*6R*RHP100353-1
859  AMT*B6*936
860  LX*65
861  CLP*RHP100354*4*319*0*0*CI*999010411065*11*1
862  NM1*QC*1*SYNTHETIC*PATIENT100354****MI*ZZ0100354
863  DTM*232*20260811
864  DTM*233*20260811
865  SVC*HC:99214*312*0**1
866  DTM*472*20260811
867  CAS*CO*18*312
868  REF*6R*RHP100354-1
869  AMT*B6*0
870  SVC*HC:36415*7*0**1
871  DTM*472*20260811
872  CAS*CO*18*7
873  REF*6R*RHP100354-2
874  AMT*B6*0
875  LX*66
876  CLP*RHP100355*1*624*188*150*CI*999010411066*11*1
877  NM1*QC*1*SYNTHETIC*PATIENT100355****MI*ZZ0100355
878  DTM*232*20260810
879  DTM*233*20260810
880  SVC*HC:73721*624*188**1
881  DTM*472*20260810
882  CAS*CO*45*286
883  CAS*PR*1*150
884  REF*6R*RHP100355-1
885  AMT*B6*338
886  LX*67
887  CLP*RHP100356*1*240*130*0*CI*999010411067*11*1
888  NM1*QC*1*SYNTHETIC*PATIENT100356****MI*ZZ0100356
889  DTM*232*20260809
890  DTM*233*20260809
891  SVC*HC:99213*221*119.6**1
892  DTM*472*20260809
893  CAS*CO*45*101.4
894  REF*6R*RHP100356-1
895  AMT*B6*119.6
896  SVC*HC:85025*19*10.4**1
897  DTM*472*20260809
898  CAS*CO*45*8.6
899  REF*6R*RHP100356-2
900  AMT*B6*10.4
901  LX*68
902  CLP*RHP100357*1*3480*1696.5*188.5*CI*999010411068*11*1
903  NM1*QC*1*SYNTHETIC*PATIENT100357****MI*ZZ0100357
904  DTM*232*20260808
905  DTM*233*20260808
906  SVC*HC:27447*3480*1696.5**1
907  DTM*472*20260808
908  CAS*CO*45*1595
909  CAS*PR*2*188.5
910  REF*6R*RHP100357-1
911  AMT*B6*1885
912  LX*69
913  CLP*RHP100358*1*439*214.11*23.79*CI*999010411069*11*1
914  NM1*QC*1*SYNTHETIC*PATIENT100358****MI*ZZ0100358
915  DTM*232*20260807
916  DTM*233*20260807
917  SVC*HC:99215*439*214.11**1
918  DTM*472*20260807
919  CAS*CO*45*201.1
920  CAS*PR*2*23.79
921  REF*6R*RHP100358-1
922  AMT*B6*237.9
923  LX*70
924  CLP*RHP100359*1*912*494*0*CI*999010411070*11*1
925  NM1*QC*1*SYNTHETIC*PATIENT100359****MI*ZZ0100359
926  DTM*232*20260806
927  DTM*233*20260806
928  SVC*HC:45380*912*494**1
929  DTM*472*20260806
930  CAS*CO*45*418
931  REF*6R*RHP100359-1
932  AMT*B6*494
933  LX*71
934  CLP*RHP100360*1*269*105.6*40*CI*999010411071*11*1
935  NM1*QC*1*SYNTHETIC*PATIENT100360****MI*ZZ0100360
936  DTM*232*20260805
937  DTM*233*20260805
938  SVC*HC:99203*269*105.6**1
939  DTM*472*20260805
940  CAS*CO*45*123.4
941  CAS*PR*3*40
942  REF*6R*RHP100360-1
943  AMT*B6*145.6
944  LX*72
945  CLP*RHP100361*1*528*228.8*57.2*CI*999010411072*11*1
946  NM1*QC*1*SYNTHETIC*PATIENT100361****MI*ZZ0100361
947  DTM*232*20260804
948  DTM*233*20260804
949  SVC*HC:93306*528*228.8**1
950  DTM*472*20260804
951  CAS*CO*45*242
952  CAS*PR*2*57.2
953  REF*6R*RHP100361-1
954  AMT*B6*286
955  LX*73
956  CLP*RHP100362*1*449*243.1*0*CI*999010411073*11*1
957  NM1*QC*1*SYNTHETIC*PATIENT100362****MI*ZZ0100362
958  DTM*232*20260803
959  DTM*233*20260803
960  SVC*HC:99204*408*221**1
961  DTM*472*20260803
962  CAS*CO*45*187
963  REF*6R*RHP100362-1
964  AMT*B6*221
965  SVC*HC:93000*41*22.1**1
966  DTM*472*20260803
967  CAS*CO*45*18.9
968  REF*6R*RHP100362-2
969  AMT*B6*22.1
970  LX*74
971  CLP*RHP100363*1*2520*1092*273*CI*999010411074*11*1
972  NM1*QC*1*SYNTHETIC*PATIENT100363****MI*ZZ0100363
973  DTM*232*20260802
974  DTM*233*20260802
975  SVC*HC:29827*2520*1092**1
976  DTM*472*20260802
977  CAS*CO*45*1155
978  CAS*PR*2*273
979  REF*6R*RHP100363-1
980  AMT*B6*1365
981  LX*75
982  CLP*RHP100364*1*140*60.32*15.08*CI*999010411075*11*1
983  NM1*QC*1*SYNTHETIC*PATIENT100364****MI*ZZ0100364
984  DTM*232*20260801
985  DTM*233*20260801
986  SVC*HC:97110*140*60.32**2
987  DTM*472*20260801
988  CAS*CO*45*64.6
989  CAS*PR*2*15.08
990  REF*6R*RHP100364-1
991  AMT*B6*75.4
992  SE*990*0001
993  GE*1*103
994  IEA*1*000000103