ISA*00*          *00*          *27*SSSSSS         *27*PPPPP          *101025*1248*^*00501*000000012*0*T*>~
GS*HC*AA*BB*20101025*2312*100000001*X*005010X222~
ST*837*AB10*005010X222~
BHT*0019*00*ABCDE12345*20101025*2312*CH~
NM1*41*2*5010 SUBMITTER*****46*SSSSSS~
PER*IC*TEST SUBMITTER*TE*4105551212~
NM1*40*2*TEST 5010 PART B*****46*PPPPP~
HL*1**20*1~
NM1*85*2*MASTERS CLINIC*****XX*NNNNNNNNNN~
N3*234 ANYSTREET LN.*SUITE 450~
N4*DALLAS*TX*781231212~
REF*EI*EEEEEEEEE~
PER*IC*MASTERS CLINIC CONTACT*TE*9725551212*FX*9725551213~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*PUBLIC*JOHN*Q***MI*1111111111F~
N3*123 BEST STREET*APT 5432~
N4*DALLAS*TX*752401234~
DMG*D8*19580713*M~
NM1*PR*2*TEST 5010 PART B*****PI*PPPPP~
N4*BALTIMORE*MD*212121212~
CLM*PR9xxxxxx.BHT01.0001*950***22>B>1*Y*A*Y*Y~
HI*BK>5920~
NM1*82*1*DOE*JOHN****XX*NNNNNNNNNN~
NM1*77*2*ANYWHERE HOSPITAL~
N3*123 MAINSTREET~
N4*DALLAS*TX*725121212~
LX*1~
SV1*HC>00873>QK*950*MJ*50***1~
DTP*472*D8*20101025~
REF*6R*200910060000000008H0001~
SE*30*AB10~
GE*1*100000001~
IEA*1*000000012~
