ISA*00*          *00*          *ZZ*PAYER1         *ZZ*PROVIDER01     *260830*1200*^*00501*000000001*0*P*:~GS*HP*PAYER1*PROVIDER01*20260830*1200*1*X*005010X221A1~ST*835*0001*005010X221A1~BPR*I*1500.00*C*ACH*CTX*01*999999992*DA*12345678*1999999992*01*999999999*DA*987654321*20260830~TRN*1*123456789*1999999992~REF*EV*PAYER123~N1*PR*BLUE CROSS~N1*PE*GENERAL HOSPITAL*XX*1234567890~LX*1~CLP*CLAIM001*1*2000.00*1500.00*500.00*MC*12345678901*11*1~CAS*CO*45*500.00~NM1*QC*1*DOE*JOHN****MI*123456789~SVC*HC:99213*2000.00*1500.00~SE*12*0001~GE*1*1~IEA*1*000000001~