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GS*HP*TAIGADEMO*CLINIC*20261009*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*190.08*C*CHK************20261009~
TRN*1*W-520612*11982744321~
DTM*405*20261009~
N1*PR*AETNA~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2612*1*320.00*190.08*21.12*12*PCN-CLM-2612*11*1~
CAS*CO*45*108.80~
NM1*QC*1*MUELLER*WYATT~
SVC*HC:99215*320.00*190.08**1~
CAS*CO*45*108.80~
CAS*PR*3*21.12~
AMT*B6*211.20~
SE*15*0001~
GE*1*1~
IEA*1*000020612~
