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GS*HS*10000*10000*250814*0908*1487113239*X*005010X279A1~
ST*270*000030883*005010X279A1~
BHT*0022*13*000030883*2508226*0908~
HL*1**20*1~
NM1*PR*2*MEDICARE PPS*****PI*10000~
HL*2*1*21*1~
NM1*1P*2*HOMECENTRIS HEALTHCARE LLC*****XX*1487113239~
HL*3*2*22*0~
NM1*IL*1*DORR*RICHARD****MI*4RP2WJ3QU95~
DMG*D8*19530623*M~
DTP*291*RD8*20250814-20251112~
EQ*42~
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SE*14*000030883~
GE*1*30883~
IEA*1*000030883~