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GS*HS*12345*12345*251230*0812*1234567891*X*005010X279A1~
ST*270*000005680*005010X279A1~
BHT*0022*13*000005680*2512364*0812~
HL*1**20*1~
NM1*PR*2*MEDICARE ARIZONA*****PI*00832~
HL*2*1*21*1~
NM1*1P*2*HOME HEALTH CARES*****XX*1234567891~
HL*3*2*22*0~
NM1*IL*1*GRIDMAN*HARRY****MI*7GJ1QE6JE38~
DMG*D8*19340417*M~
DTP*291*RD8*20251230-20260330~
EQ*42~
EQ*30~
SE*14*000005680~
GE*1*5680~
IEA*1*000005680~