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GS*HP*TAIGADEMO*CLINIC*20261023*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*130.68*C*CHK************20261023~
TRN*1*W-521180*11982744321~
DTM*405*20261023~
N1*PR*AETNA~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-3180*1*220.00*130.68*14.52*12*PCN-CLM-3180*11*1~
CAS*CO*45*74.80~
NM1*QC*1*FOSTER*EMMA~
SVC*HC:71046*220.00*130.68**1~
CAS*CO*45*74.80~
CAS*PR*3*14.52~
AMT*B6*145.20~
SE*15*0001~
GE*1*1~
IEA*1*000021180~