Simple Pharmacy Compound Claim

{
  "resourceType" : "Claim",
  "id" : "760152",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Pharmacy Claim</div>"
  },
  "identifier" : [{
    "system" : "http://happypharma.com/claim",
    "value" : "7612345"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "pharmacy"
    }]
  },
  "use" : "claim",
  "subject" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [{
      "code" : "stat"
    }]
  },
  "payee" : {
    "type" : {
      "coding" : [{
        "code" : "provider"
      }]
    }
  },
  "careTeam" : [{
    "sequence" : 1,
    "provider" : {
      "reference" : "Practitioner/example"
    }
  }],
  "supportingInfo" : [{
    "sequence" : 1,
    "category" : {
      "coding" : [{
        "code" : "pharmacyrefill"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/pharmacy-refill",
        "code" : "new"
      }]
    }
  },
  {
    "sequence" : 2,
    "category" : {
      "coding" : [{
        "code" : "pharmacyinformation"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
        "code" : "refillsremaining"
      }]
    },
    "valueQuantity" : {
      "value" : 0
    }
  },
  {
    "sequence" : 3,
    "category" : {
      "coding" : [{
        "code" : "pharmacyinformation"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/pharmacy-information",
        "code" : "dayssupply"
      }]
    },
    "valueQuantity" : {
      "value" : 10
    }
  },
  {
    "sequence" : 4,
    "category" : {
      "coding" : [{
        "code" : "pharmacy"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://example.org/fhir/CodeSystem/pharmacy-form",
        "code" : "capsule"
      }]
    }
  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "code" : "654456"
      }]
    }
  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/9876B1"
    }
  }],
  "item" : [{
    "sequence" : 1,
    "careTeamSequence" : [1],
    "informationSequence" : [1,
    2,
    3,
    4],
    "productOrService" : {
      "coding" : [{
        "system" : "http://localdruglist.org",
        "code" : "compound",
        "display" : "Custom compound"
      }]
    },
    "servicedDate" : "2014-08-16",
    "quantity" : {
      "value" : 30,
      "unit" : "TAB",
      "system" : "http://terminology.hl7.org/CodeSystem/v3-orderableDrugForm",
      "code" : "TAB"
    },
    "net" : {
      "value" : 155.00,
      "currency" : "USD"
    },
    "detail" : [{
      "sequence" : 1,
      "productOrService" : {
        "coding" : [{
          "system" : "http://localdruglist.org",
          "code" : "44001",
          "display" : "Acetaminophen 250mg"
        }]
      },
      "quantity" : {
        "value" : 250,
        "unit" : "mg"
      },
      "net" : {
        "value" : 20.00,
        "currency" : "USD"
      },
      "subDetail" : [{
        "sequence" : 1,
        "productOrService" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/ex-pharmaservice",
            "code" : "drugcost"
          }]
        },
        "net" : {
          "value" : 20.00,
          "currency" : "USD"
        }
      }]
    },
    {
      "sequence" : 2,
      "productOrService" : {
        "coding" : [{
          "system" : "http://localdruglist.org",
          "code" : "44035",
          "display" : "Phenacetin 50mg"
        }]
      },
      "quantity" : {
        "value" : 50,
        "unit" : "mg"
      },
      "net" : {
        "value" : 25.00,
        "currency" : "USD"
      },
      "subDetail" : [{
        "sequence" : 1,
        "productOrService" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/ex-pharmaservice",
            "code" : "drugcost"
          }]
        },
        "net" : {
          "value" : 25.00,
          "currency" : "USD"
        }
      }]
    },
    {
      "sequence" : 3,
      "productOrService" : {
        "coding" : [{
          "system" : "http://localdruglist.org",
          "code" : "44057",
          "display" : "Codeine 25mg"
        }]
      },
      "quantity" : {
        "value" : 25,
        "unit" : "mg"
      },
      "net" : {
        "value" : 28.00,
        "currency" : "USD"
      },
      "subDetail" : [{
        "sequence" : 1,
        "productOrService" : {
          "coding" : [{
            "system" : "http://hl7.org/fhir/ex-pharmaservice",
            "code" : "drugcost"
          }]
        },
        "net" : {
          "value" : 28.00,
          "currency" : "USD"
        }
      }]
    },
    {
      "sequence" : 2,
      "productOrService" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/ex-pharmaservice",
          "code" : "markup"
        }]
      },
      "net" : {
        "value" : 22.00,
        "currency" : "USD"
      }
    },
    {
      "sequence" : 3,
      "productOrService" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/ex-pharmaservice",
          "code" : "compoundfee"
        }]
      },
      "net" : {
        "value" : 60.00,
        "currency" : "USD"
      }
    }]
  }],
  "total" : {
    "value" : 155.00,
    "currency" : "USD"
  }
}