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GS*HS*10353*10353*251008*1310*1073904009*X*005010X279A1~
ST*270*000000733*005010X279A1~
BHT*0022*13*000000733*2510281*1310~
HL*1**20*1~
NM1*PR*2*HUMANA GOLD CHOICE*****PI*6013~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*COSTELLO*CAROL****MI*H09130600~
DMG*D8*19330909*F~
DTP*291*RD8*20251008-20260106~
EQ*42~
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GE*1*733~
IEA*1*000000733~