<Claim xmlns="http://hl7.org/fhir"><id value="100153"/><text><status value="generated"/><div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div></text><identifier><system value="http://happyvalley.com/claim"/><value value="12355"/></identifier><status value="active"/><type><coding><system value="http://terminology.hl7.org/CodeSystem/claim-type"/><code value="oral"/></coding></type><use value="preauthorization"/><subject><reference value="Patient/1"/></subject><created value="2015-03-16"/><insurer><reference value="Organization/2"/></insurer><provider><reference value="Organization/1"/></provider><priority><coding><code value="normal"/></coding></priority><fundsReserve><coding><code value="provider"/></coding></fundsReserve><payee><type><coding><code value="provider"/></coding></type></payee><careTeam><sequence value="1"/><provider><reference value="Practitioner/example"/></provider></careTeam><diagnosis><sequence value="1"/><diagnosisCodeableConcept><coding><system value="http://hl7.org/fhir/sid/icd-10"/><code value="K07.3"/></coding></diagnosisCodeableConcept></diagnosis><insurance><sequence value="1"/><focal value="true"/><coverage><reference value="Coverage/9876B1"/></coverage></insurance><item><sequence value="1"/><careTeamSequence value="1"/><diagnosisSequence value="1"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="ORTHPLAN"/></coding></productOrService><servicedDate value="2015-05-16"/><unitPrice><value value="9000.00"/><currency value="USD"/></unitPrice><net><value value="9000.00"/><currency value="USD"/></net><detail><sequence value="1"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="ORTHOEXAM"/></coding></productOrService><unitPrice><value value="1000.00"/><currency value="USD"/></unitPrice><net><value value="1000.00"/><currency value="USD"/></net></detail><detail><sequence value="2"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="ORTHODIAG"/></coding></productOrService><unitPrice><value value="1500.00"/><currency value="USD"/></unitPrice><net><value value="1500.00"/><currency value="USD"/></net></detail><detail><sequence value="3"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="ORTHOINITIAL"/></coding></productOrService><unitPrice><value value="500.00"/><currency value="USD"/></unitPrice><net><value value="500.00"/><currency value="USD"/></net></detail><detail><sequence value="4"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="ORTHOMONTHS"/></coding></productOrService><quantity><value value="24"/></quantity></detail><detail><sequence value="5"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="ORTHOPERIODIC"/></coding></productOrService><quantity><value value="24"/></quantity><unitPrice><value value="250.00"/><currency value="USD"/></unitPrice><net><value value="250.00"/><currency value="USD"/></net></detail></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"/><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"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="27211"/></coding></productOrService><servicedDate value="2014-08-16"/><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="36"/></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="750.00"/><currency value="USD"/></unitPrice><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></Claim>