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GS*HS*52095*52095*260420*1004*1073904009*X*005010X279A1~
ST*270*000002136*005010X279A1~
BHT*0022*13*000002136*2604110*1004~
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*RUSSU*CLAVA****MI*59290815~
DMG*D8*19600210*F~
DTP*291*RD8*20260420-20260719~
EQ*42~
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IEA*1*000002136~