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GS*HS*15004*15004*260726*1007*1073904009*X*005010X279A1~
ST*270*000002625*005010X279A1~
BHT*0022*13*000002625*2607207*1007~
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*BOISCLAIR*SUZANNE****MI*9G70F17JP07~
DMG*D8*19191130*F~
DTP*291*RD8*20260726-20261024~
EQ*42~
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GE*1*2625~
IEA*1*000002625~