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GS*HS*15004*15004*251106*1311*1073904009*X*005010X279A1~
ST*270*000000127*005010X279A1~
BHT*0022*13*000000127*2511310*1311~
HL*1**20*1~
NM1*PR*2*MEDICARE PPS*****PI*10000~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*SPRIGGS JOHNSON*CATHERINE****MI*3WC9RD7AK28~
DMG*D8*19500824*F~
DTP*291*RD8*20251106-20260204~
EQ*42~
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IEA*1*000000127~