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GS*HS*10000*10000*251021*0910*1487113239*X*005010X279A1~
ST*270*000034333*005010X279A1~
BHT*0022*13*000034333*2510294*0910~
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*DISNEY*ELSIE****MI*9AP4PU1EJ07~
DMG*D8*19310329*F~
DTP*291*RD8*20251021-20260119~
EQ*42~
EQ*30~
SE*14*000034333~
GE*1*34333~
IEA*1*000034333~