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GS*HS*10000*10000*260211*1402*1487113239*X*005010X279A1~
ST*270*000036346*005010X279A1~
BHT*0022*13*000036346*260242*1402~
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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*FICKUS*DIANE****MI*1KW3T27VH11~
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DTP*291*RD8*20260211-20260512~
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IEA*1*000036346~