| ISA*00* *00* *ZZ*SENDER ID *ZZ*RECEIVER ID *080101*0554*U*00401*154229289*0*P*^~GS*HP*SENDER ID*RECEIVER ID*20080101*05541600*1*X*004010X091A1~ST*835*000000002~BPR*I*116.58*C*CHK************20071228~TRN*1*0074834046*1953760980~DTM*405*20071228~N1*PR*STANDARD BLUE CROSS ACCOUNT~N3*21555 OXNARD STREET~N4*WOODLAND HILLS*CA*91367~N1*PE*DOE JOHN*XX*1234567890~N3*123 MAIN ST #120~N4*REDDING*CA*96001~REF*TJ*1234567899~LX*1167~CLP*DANNE000-1896*2*55*7.53**12*07362GH7346~NM1*QC*1*DANNER*GAYLE*L***MI*523A71394~NM1*IL*1*DANNER*GAYLE*L***MI*523A71394~REF*1L*00555E~REF*CE*PARTICIPATING PROVIDER~DTM*232*20070312~DTM*233*20070312~PER*CX*I CUSTOMER SERVICE DEPARTMENT*TE*8003333883~SVC*HC^99212*55*7.53**1~DTM*472*20070312~CAS*CO*45*17.35*1*23*30.12*1~REF*6R*DANNE000-1896~AMT*B6*55~CLP*DANNE000-1897*2*55*7.53**12*07362GH7347~NM1*QC*1*DANNER*GAYLE*L***MI*523A71394~NM1*IL*1*DANNER*GAYLE*L***MI*523A71394~REF*1L*00555E~REF*CE*PARTICIPATING PROVIDER~DTM*232*20070725~DTM*233*20070725~PER*CX*I CUSTOMER SERVICE DEPARTMENT*TE*8003333883~SVC*HC^99212*55*7.53**1~DTM*472*20070725~CAS*CO*45*17.35*1*23*30.12*1~REF*6R*DANNE000-1897~AMT*B6*55~CLP*DANNE000-1898*2*55*7.53**12*07362GH7348~NM1*QC*1*DANNER*GAYLE*L***MI*523A71394~NM1*IL*1*DANNER*GAYLE*L***MI*523A71394~REF*1L*00555E~REF*CE*PARTICIPATING PROVIDER~DTM*232*20071203~DTM*233*20071203~PER*CX*I CUSTOMER SERVICE DEPARTMENT*TE*8003333883~SVC*HC^99212^25*55*7.53**1~DTM*472*20071203~CAS*CO*45*17.35*1*23*30.12*1~REF*6R*DANNE000-1898~AMT*B6*55~CLP*DANNE000-1899*2*120*11.89**12*07362GH7349~NM1*QC*1*DANNER*GAYLE*L***MI*523A71394~NM1*IL*1*DANNER*GAYLE*L***MI*523A71394~REF*1L*00555E~REF*CE*PARTICIPATING PROVIDER~DTM*232*20071203~DTM*233*20071203~PER*CX*I CUSTOMER SERVICE DEPARTMENT*TE*8003333883~SVC*HC^11056^Q8*85*10.17**1~DTM*472*20071203~CAS*CO*45*34.14*1*23*40.69*1~REF*6R*DANNE000-1899~AMT*B6*85~SVC*HC^G0127^99^Q8*35*1.72**1~DTM*472*20071203~CAS*CO*45*26.41*1*23*6.87*1~REF*6R*DANNE000-1899~AMT*B6*35~SE*70*000000002~GE*1*1~IEA*1*154229289~ |