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GS*HS*15004*15004*260511*1005*1073904009*X*005010X279A1~
ST*270*000000225*005010X279A1~
BHT*0022*13*000000225*2605131*1005~
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*GIBBS*WILLIAM****MI*7KD1UF2NT25~
DMG*D8*19500716*M~
DTP*291*RD8*20260511-20260809~
EQ*42~
EQ*30~
SE*14*000000225~
GE*1*225~
IEA*1*000000225~