ISA*00*          *00*          *ZZ*TAIGADEMO      *ZZ*CLINIC         *261006*1200*^*00501*000021412*0*T*:~
GS*HP*TAIGADEMO*CLINIC*20261006*1200*1*X*005010X221A1~
ST*835*0001~
BPR*I*237.60*C*CHK************20261006~
TRN*1*BCB-521412*11982744321~
DTM*405*20261006~
N1*PR*BLUE CROSS BLUE SHIELD~
N1*PE*TAIGA DEMO CLINIC*XX*1982744321~
LX*1~
CLP*VISIT-2026-3412*1*400.00*237.60*26.40*12*PCN-CLM-3412*11*1~
CAS*CO*45*136.00~
NM1*QC*1*VEGA*HARPER~
SVC*HC:99205*400.00*237.60**1~
CAS*CO*45*136.00~
CAS*PR*3*26.40~
AMT*B6*264.00~
SE*15*0001~
GE*1*1~
IEA*1*000021412~