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GS*HS*10000*10000*260908*1609*1487113239*X*005010X279A1~
ST*270*000050457*005010X279A1~
BHT*0022*13*000050457*2609251*1609~
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*HOLLY*DERNARD****MI*6JQ7TQ0XW20~
DMG*D8*19540221*M~
DTP*291*RD8*20260908-20261207~
EQ*42~
EQ*30~
SE*14*000050457~
GE*1*50457~
IEA*1*000050457~