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GS*HP*TAIGADEMO*CLINIC*20261013*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*249.48*C*CHK************20261013~
TRN*1*W-520607*11982744321~
DTM*405*20261013~
N1*PR*AETNA~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2607*1*420.00*249.48*27.72*12*PCN-CLM-2607*11*1~
CAS*CO*45*142.80~
NM1*QC*1*MUELLER*WYATT~
SVC*HC:20610*420.00*249.48**1~
CAS*CO*45*142.80~
CAS*PR*3*27.72~
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IEA*1*000020607~