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GS*HS*10000*10000*250930*1509*1487113239*X*005010X279A1~
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BHT*0022*13*000033055*2509273*1509~
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NM1*PR*2*MEDICARE PPS*****PI*10000~
HL*2*1*21*1~
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HL*3*2*22*0~
NM1*IL*1*JONES*RUDOLPH****MI*9FX5X30KC98~
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IEA*1*000033055~