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GS*HS*52095*52095*251224*0812*1073904009*X*005010X279A1~
ST*270*000001301*005010X279A1~
BHT*0022*13*000001301*2512358*0812~
HL*1**20*1~
NM1*PR*2*KAISER PERMANENTE*****PI*10403~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*GADALLA*SHEHETA****MI*13318652~
DMG*D8*19591006*F~
DTP*291*RD8*20251224-20260324~
EQ*42~
EQ*30~
SE*14*000001301~
GE*1*1301~
IEA*1*000001301~