IMDGP10HDR|DGP|TSTABD05072026|20260507|10|5|2.60
IMDGP10PMT|4G7K2M9A1Z||0.50|Refund||||||||||
IMDGP10DTL|Refund for overpayment at time of service|0.50|20250814|||||||||
IMDGP10TRS|Provider Organization|124 Main St||Irvine|CA|16075|||2157893680|Liam|Carter|1880 JFK boulevard||Philadelphia|PA|19103||
IMDGP10COS|LC482|Liam||Carter|20010101
IMDGP10PMT|B8N1R6T3YQ||0.51|Refund||||||||||
IMDGP10DTL|Refund for overpayment at time of service|0.51|20250814|||||||||
IMDGP10TRS|Provider Organization|124 Main St||Irvine|CA|16075|||2157893680|Emma|Hayes|1880 JFK boulevard||Philadelphia|PA|19103||
IMDGP10COS|EH917|Emma||Hayes|20010101
IMDGP10PMT|M1D5V9C2X7||0.52|Refund||||||||||
IMDGP10DTL|Refund for overpayment at time of service|0.52|20250814|||||||||
IMDGP10TRS|Provider Organization|124 Main St||Irvine|CA|16075|||2157893680|Noah|Bennett|1880 JFK boulevard||Philadelphia|PA|19103||
IMDGP10COS|NB305|Noah||Bennett|20010101
IMDGP10PMT|H9P3S6L1Q8||0.53|Refund||||||||||
IMDGP10DTL|Refund for overpayment at time of service|0.53|20250814|||||||||
IMDGP10TRS|Provider Organization|124 Main St||Irvine|CA|16075|||2157893680|Olivia|Mason|1880 JFK boulevard||Philadelphia|PA|19103||
IMDGP10COS|OM764|Olivia||Mason|20010101
IMDGP10PMT|T2W7F4J9N5||0.54|Refund||||||||||
IMDGP10DTL|Refund for overpayment at time of service|0.54|20250814|||||||||
IMDGP10TRS|Provider Organization|124 Main St||Irvine|CA|16075|||2157893680|Ethan|Reed|1880 JFK boulevard||Philadelphia|PA|19103||
IMDGP10COS|ER128|Ethan||Reed|20010101
IMDGP10BTR|TSTABD05072026