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GS*HP*TAIGADEMO*CLINIC*20260825*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*118.80*C*CHK************20260825~
TRN*1*W-520608*11982744321~
DTM*405*20260825~
N1*PR*AETNA~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2608*1*400.00*118.80*26.40*12*PCN-CLM-2608*11*1~
CAS*CO*45*136.00~
NM1*QC*1*MUELLER*WYATT~
SVC*HC:99205*400.00*118.80**1~
CAS*CO*45*136.00~
CAS*PR*3*26.40~
AMT*B6*264.00~
LQ*HE*N130~
SE*16*0001~
GE*1*1~
IEA*1*000020608~