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GS*HS*10000*10000*260103*1501*1487113239*X*005010X279A1~
ST*270*000038121*005010X279A1~
BHT*0022*13*000038121*260103*1501~
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*BURGESS*HELEN****MI*8MM3U01VA60~
DMG*D8*19400318*M~
DTP*291*RD8*20260103-20260403~
EQ*42~
EQ*30~
SE*14*000038121~
GE*1*38121~
IEA*1*000038121~