<?xml version="1.0" encoding="UTF-8"?><ExplanationOfBenefit xmlns="http://hl7.org/fhir">
  <id value="EB3500"/>
  <meta>
    <security>
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/>
      <code value="HTEST"/>
      <display value="test health data"/>
    </security>
  </meta>
  <text>
    <status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the ExplanationOfBenefit</div>
  </text>
  <identifier>
    <system value="http://www.BenefitsInc.com/fhir/explanationofbenefit"/>
    <value value="987654321"/>
  </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/pat1"/>
  </subject>
  <created value="2014-08-16"/>
  <enterer>
    <reference value="Practitioner/1"/>
  </enterer>
  <insurer>
    <reference value="Organization/3"/>
  </insurer>
  <provider>
    <reference value="Practitioner/1"/>
  </provider>
  <payee>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/payeetype"/>
        <code value="provider"/>
      </coding>
    </type>
    <party>
      <reference value="Organization/2"/>
    </party>
  </payee>
  <facility>
    <reference value="Location/1"/>
  </facility>
  <claim>
    <reference value="Claim/100150"/>
  </claim>
  <claimResponse>
    <reference value="ClaimResponse/R3500"/>
  </claimResponse>
  <outcome value="complete"/>
  <disposition value="Claim settled as per contract."/>
  <careTeam>
    <sequence value="1"/>
    <provider>
      <reference value="Practitioner/example"/>
    </provider>
  </careTeam>
  <insurance>
    <focal value="true"/>
    <coverage>
      <reference value="Coverage/9876B1"/>
    </coverage>
  </insurance>
  <item>
    <sequence value="1"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
        <code value="1205"/>
      </coding>
    </productOrService>
    <servicedDate value="2014-08-16"/>
    <unitPrice>
      <value value="135.57"/>
      <currency value="USD"/>
    </unitPrice>
    <net>
      <value value="135.57"/>
      <currency value="USD"/>
    </net>
    <udi>
      <reference value="Device/example"/>
    </udi>
    <encounter>
      <reference value="Encounter/example"/>
    </encounter>
    <adjudication>
      <category>
        <coding>
          <code value="eligible"/>
        </coding>
      </category>
      <amount>
        <value value="120.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="eligpercent"/>
        </coding>
      </category>
      <quantity>
        <value value="0.80"/>
      </quantity>
    </adjudication>
    <adjudication>
      <category>
        <coding>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="96.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
  </item>
  <item>
    <sequence value="2"/>
    <careTeamSequence value="1"/>
    <productOrService>
      <coding>
        <code value="group"/>
      </coding>
    </productOrService>
    <servicedDate value="2014-08-16"/>
    <net>
      <value value="200.00"/>
      <currency value="USD"/>
    </net>
    <adjudication>
      <category>
        <coding>
          <code value="benefit"/>
        </coding>
      </category>
      <amount>
        <value value="180.00"/>
        <currency value="USD"/>
      </amount>
    </adjudication>
    <detail>
      <sequence value="1"/>
      <productOrService>
        <coding>
          <code value="group"/>
        </coding>
      </productOrService>
      <net>
        <value value="200.00"/>
        <currency value="USD"/>
      </net>
      <udi>
        <reference value="Device/example"/>
      </udi>
      <adjudication>
        <category>
          <coding>
            <code value="benefit"/>
          </coding>
        </category>
        <amount>
          <value value="180.00"/>
          <currency value="USD"/>
        </amount>
      </adjudication>
      <subDetail>
        <sequence value="1"/>
        <productOrService>
          <coding>
            <system value="http://terminology.hl7.org/CodeSystem/ex-USCLS"/>
            <code value="1205"/>
          </coding>
        </productOrService>
        <unitPrice>
          <value value="200.00"/>
          <currency value="USD"/>
        </unitPrice>
        <net>
          <value value="200.00"/>
          <currency value="USD"/>
        </net>
        <udi>
          <reference value="Device/example"/>
        </udi>
        <adjudication>
          <category>
            <coding>
              <code value="eligible"/>
            </coding>
          </category>
          <amount>
            <value value="200.00"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
        <adjudication>
          <category>
            <coding>
              <code value="eligpercent"/>
            </coding>
          </category>
          <quantity>
            <value value="0.90"/>
          </quantity>
        </adjudication>
        <adjudication>
          <category>
            <coding>
              <code value="benefit"/>
            </coding>
          </category>
          <amount>
            <value value="180.00"/>
            <currency value="USD"/>
          </amount>
        </adjudication>
      </subDetail>
    </detail>
  </item>
  <total>
    <category>
      <coding>
        <code value="submitted"/>
      </coding>
    </category>
    <amount>
      <value value="135.57"/>
      <currency value="USD"/>
    </amount>
  </total>
  <total>
    <category>
      <coding>
        <code value="benefit"/>
      </coding>
    </category>
    <amount>
      <value value="96.00"/>
      <currency value="USD"/>
    </amount>
  </total>
</ExplanationOfBenefit>