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GS*HP*TAIGADEMO*CLINIC*20260827*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*1069.20*C*CHK************20260827~
TRN*1*CIG-520493*11982744321~
DTM*405*20260827~
N1*PR*CIGNA~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2493*1*1800.00*1069.20*118.80*12*PCN-CLM-2493*11*1~
CAS*CO*45*612.00~
NM1*QC*1*BROOKS*ELLA~
SVC*HC:72148*1800.00*1069.20**1~
CAS*CO*45*612.00~
CAS*PR*3*118.80~
AMT*B6*1188.00~
SE*15*0001~
GE*1*1~
IEA*1*000020493~