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GS*HP*TAIGADEMO*CLINIC*20260925*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*386.10*C*CHK************20260925~
TRN*1*W-520696*11982744321~
DTM*405*20260925~
N1*PR*AETNA~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-2696*1*650.00*386.10*42.90*12*PCN-CLM-2696*11*1~
CAS*CO*45*221.00~
NM1*QC*1*SCHMIDT*LILY~
SVC*HC:76700*650.00*386.10**1~
CAS*CO*45*221.00~
CAS*PR*3*42.90~
AMT*B6*429.00~
SE*15*0001~
GE*1*1~
IEA*1*000020696~