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GS*HS*0000*0000*260114*1401*1073904009*X*005010X279A1~
ST*270*000001482*005010X279A1~
BHT*0022*13*000001482*260114*1401~
HL*1**20*1~
NM1*PR*2*CIGNA PPO POS OPEN ACCESS*****PI*10158~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*FANTA*BAHRE****MI*47701113701~
DMG*D8*19510721*M~
DTP*291*RD8*20260114-20260414~
EQ*42~
EQ*30~
SE*14*000001482~
GE*1*1482~
IEA*1*000001482~