HL*2*1*22*0
SBR*P*18*******MC
NM1*IL*1*JANE*DOE*M***MI*123456789
N3*6917 MAIN ROAD
N4*ELK GROVE*GA*300662040
DMG*D8*19681227*F
NM1*PR*2*ABC SOLUTIONS, LLC*****PI*123456789
CLM*12017102779120B*13.67***99:B:1*Y*A*Y*Y
CN1*09*13.67
NTE*ADD*34
CR1****A*DH*1***RE
CRC*07*N*09
HI*ABK:R6889
NM1*82*1*RON*JOHNNY****XX*9876543210
REF*0B*F3186264
NM1*PW*2
N3*8170 LAKE BLVD
N4*ELK GROVE*GA*300820201
NM1*45*2
N3*6917 MAIN ROAD
N4*ELK GROVE*GA*300662040
SBR*S*18*******12
AMT*D*13.67
OI***Y***Y
NM1*IL*1*JANE*DOE*M***MI*123456789
NM1*PR*2*LOGISTICARE, INC*****PI*582491253
DTP*573*D8*20171102
LX*1
SV1*HC:A0100:PR*13.67*UN*1***1
DTP*472*D8*20171027
CN1*09*13.67
SVD*582491253*13.67*HC:A0100:PR**1
DTP*573*D8*20171102
CLM*12017102779120A*13.67***99:B:1*Y*A*Y*Y
CN1*09*13.67
NTE*ADD*34
CR1****A*DH*1
CRC*07*N*09
HI*ABK:R6889
NM1*82*1*YAN*TOM****XX*3216549870
REF*0B*D1427177
NM1*PW*2
N3*6917 MAIN ROAD
N4*ELK GROVE*GA*300662040
NM1*45*2
N3*8170 LAKE BLVD
N4*ELK GROVE*GA*300820201
SBR*S*18*******12
AMT*D*13.67
OI***Y***Y
NM1*IL*1*JANE*DOE*M***MI*123456789
NM1*PR*2*ABC SOLUTIONS, LLC*****PI*123456789
DTP*573*D8*20171102
LX*1
SV1*HC:A0100:RP*13.67*UN*1***1
DTP*472*D8*20171027
CN1*09*13.67
SVD*582491253*13.67*HC:A0100:RP**1
DTP*573*D8*20171102
SE*71*000000001
GE*1*50002870
IEA*1*050002870