ISA*00*          *00*          *ZZ*RUSHMORE      *ZZ*ACME_MED       *190316*1615*U*00401*000001234*0*P*>~
GS*HP*RUSHMORE*ACME_MED*20190316*1615*1234*X*004010~
ST*835*0001~
BPR*I*1100.00*C*ACH*CCP*01*888999777*DA*24681012*111333555**01*144444****20190316~
TRN*1*0927974940*1203174593~
REF*F2*slca435w~
DTM*405*20190316~
N1*PR*RUSHMORE LIFE INSURANCE*XX*935665544~
N3*P O BOX 1234~
N4*MOUNT_RUSHMORE*SD*57751~
PER*CX*TE*8002144844~
N1*PE*ACME MEDICAL CENTER*XX*5544667733~
N3*P O BOX 9999~
N4*DURHAM*NC*27701~
REF*TJ*777667755~
LX*1~
CLP*33344555510*1*800.00*500.00**15*5554555444*11*1**397*0.7309~
CAS*CO*94*-300.00~
NM1*QC*1*BUDD*WILLIAM****MI*33344555510~
N3*123 MAIN STREET~
N4*DURHAM*NC*27701~
MIA*0~
DTM*232*20190307~
DTM*233*20190310~
DTM*50*20190318~
SVC*HC:99213*500*350**1*~
CAS*CO*45*150*150~
SVC*HC:99214*300*150**1*~
CAS*PR*3*75*75~
CAS*CO*45*75*75~
LX*2~
CLP*44455666610*1*1200.00*600.00**15*8765432112*11*1**397*0.7309~
CAS*CO*94*-600.00~
NM1*QC*1*SETTLE*SUSAN****MI*44455666610~
N3*456 OAK AVENUE~
N4*DURHAM*NC*27702~
MIA*0~
DTM*232*20190305~
DTM*233*20190308~
DTM*50*20190318~
SVC*HC:99213*600*400**1*~
CAS*PR*2*100*100~
CAS*CO*45*100*100~
SVC*HC:99214*400*100**1*~
CAS*PR*3*150*150~
CAS*CO*45*150*150~
SVC*HC:99215*200*100**1*~
CAS*CO*45*100*100~
SE*47*0001~
GE*1*1234~
IEA*1*000001234~
