<?xml version="1.0" encoding="UTF-8"?>

<Claim xmlns="http://hl7.org/fhir">
  <id value="100156"/>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div>
  </text>
  <!--  rest of the resource omitted for brevity  -->
  <contained>
    <Device>
      <id value="device-bridge"/>
    </Device>
  </contained>
  <!--  rest of the resource omitted for brevity  -->
  <contained>
    <ServiceRequest>
      <id value="referral"/>
      <status value="active"/>
      <intent value="order"/>
      <subject>
        <reference value="Patient/1"/>
      </subject>
    </ServiceRequest>
  </contained>
  <identifier>
    <system value="http://happyvalley.com/claim"/>
    <value value="123466"/>
  </identifier>
  <status value="active"/>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/claim-type"/>
      <code value="oral"/>
    </coding>
  </type>
  <use value="claim"/>
  <subject>
    <reference value="Patient/1"/>
  </subject>
  <created value="2014-08-16"/>
  <insurer>
    <reference value="Organization/2"/>
  </insurer>
  <provider>
    <reference value="Organization/1"/>
  </provider>
  <priority>
    <coding>
      <code value="normal"/>
    </coding>
  </priority>
  <related>
    <claim>
      <reference value="Claim/100151"/>
    </claim>
    <relationship>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship"/>
        <code value="associated"/>
      </coding>
    </relationship>
    <!--  case number  -->
    <reference>
      <value value="CASE156746B"/>
    </reference>
  </related>
  <payee>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
        <code value="other"/>
      </coding>
    </type>
    <party>
      <reference value="RelatedPerson/peter"/>
    </party>
  </payee>
  <referral>
    <reference value="#referral"/>
  </referral>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/example"/>
    </provider>
  </careTeam>
  <!--  original placement  -->
  <supportingInfo>
    <sequence value="1"/>
    <category>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/>
        <code value="prosthesis"/>
      </coding>
    </category>
    <code>
      <coding>
        <system value="http://hl7.org/fhir/ex-oralprostho"/>
        <code value="2"/>
        <display value="Maryland Bridge"/>
      </coding>
    </code>
    <timingDateTime value="2001-04-07"/>
  </supportingInfo>
  <procedure>
    <sequence value="1"/>
    <date value="2014-07-04"/>
    <procedureCodeableConcept>
      <text value="Resection of gum to increase exposed tooth."/>
    </procedureCodeableConcept>
  </procedure>
  <insurance>
    <sequence value="1"/>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <informationSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="67221"/>
        <display value="Maryland Bridge"/>
      </coding>
    </productOrService>
    <servicedDate value="2014-08-16"/>
    <locationCodeableConcept>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/>
        <code value="11"/>
      </coding>
    </locationCodeableConcept>
    <unitPrice>
      <value value="1400.00"/>
      <currency value="USD"/>
    </unitPrice>
    <factor value="0.75"/>
    <!--  student discount  -->
    <net>
      <value value="1050.00"/>
      <currency value="USD"/>
    </net>
    <udi>
      <reference value="#device-bridge"/>
    </udi>
    <bodySite>
      <site>
        <concept>
          <coding>
            <system value="http://fdi.org/fhir/oraltoothcodes"/>
            <code value="01"/>
          </coding>
        </concept>
      </site>
    </bodySite>
  </item>
  <item>
    <sequence value="2"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="21211"/>
      </coding>
    </productOrService>
    <servicedDate value="2014-08-16"/>
    <locationCodeableConcept>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/>
        <code value="11"/>
      </coding>
    </locationCodeableConcept>
    <unitPrice>
      <value value="105.00"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="105.00"/>
      <currency value="USD"/>
    </net>
    <bodySite>
      <site>
        <concept>
          <coding>
            <system value="http://fdi.org/fhir/oraltoothcodes"/>
            <code value="21"/>
          </coding>
        </concept>
      </site>
      <subSite>
        <coding>
          <system value="http://fdi.org/fhir/oralsurfacecodes"/>
          <code value="L"/>
        </coding>
      </subSite>
    </bodySite>
  </item>
  <item>
    <sequence value="3"/>
    <careTeamSequence value="1"/>
    <procedureSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://example.org/fhir/oralservicecodes"/>
        <code value="27211"/>
      </coding>
    </productOrService>
    <servicedDate value="2014-08-16"/>
    <locationCodeableConcept>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-serviceplace"/>
        <code value="11"/>
      </coding>
    </locationCodeableConcept>
    <unitPrice>
      <value value="1100.00"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="1100.00"/>
      <currency value="USD"/>
    </net>
    <bodySite>
      <site>
        <concept>
          <coding>
            <system value="http://fdi.org/fhir/oraltoothcodes"/>
            <code value="24"/>
          </coding>
        </concept>
      </site>
    </bodySite>
    <detail>
      <sequence value="1"/>
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="27211"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="1000.00"/>
        <currency value="USD"/>
      </unitPrice>
      <factor value="0.75"/>
      <!--  Student discount  -->
      <net>
        <value value="750.00"/>
        <currency value="USD"/>
      </net>
    </detail>
    <detail>
      <sequence value="2"/>
      <productOrService>
        <coding>
          <system value="http://example.org/fhir/oralservicecodes"/>
          <code value="lab"/>
        </coding>
      </productOrService>
      <unitPrice>
        <value value="350.00"/>
        <currency value="USD"/>
      </unitPrice>
      <net>
        <value value="350.00"/>
        <currency value="USD"/>
      </net>
    </detail>
  </item>
  <total>
    <value value="2255.00"/>
    <currency value="USD"/>
  </total>
</Claim>