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GS*HS*10000*10000*260507*1105*1487113239*X*005010X279A1~
ST*270*000045476*005010X279A1~
BHT*0022*13*000045476*2605127*1105~
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*DONDALSKI*BETSY****MI*3Q51NV8VE37~
DMG*D8*19530815*F~
DTP*291*RD8*20260507-20260805~
EQ*42~
EQ*30~
SE*14*000045476~
GE*1*45476~
IEA*1*000045476~