<Claim xmlns="http://hl7.org/fhir"><id value="100151"/><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="12346"/></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><payee><type><coding><code value="provider"/></coding></type></payee><careTeam><sequence value="1"/><provider><reference value="Practitioner/example"/></provider></careTeam><supportingInfo><sequence value="1"/><category><coding><system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/><code value="missingtooth"/></coding></category><code><coding><system value="http://terminology.hl7.org/CodeSystem/ex-tooth"/><code value="15"/></coding></code><timingDateTime value="2012-04-07"/><reason><coding><system value="http://terminology.hl7.org/CodeSystem/missingtoothreason"/><code value="e"/></coding></reason></supportingInfo><supportingInfo><sequence value="2"/><category><coding><system value="http://terminology.hl7.org/CodeSystem/claiminformationcategory"/><code value="exception"/></coding></category><code><coding><system value="http://terminology.hl7.org/CodeSystem/claim-exception"/><code value="student"/></coding></code><valueString value="Happy Valley Community College"/></supportingInfo><diagnosis><sequence value="1"/><diagnosisCodeableConcept><coding><code value="123456"/></coding></diagnosisCodeableConcept></diagnosis><insurance><sequence value="1"/><focal value="true"/><coverage><reference value="Coverage/9876B1"/></coverage></insurance><item><sequence value="1"/><careTeamSequence value="1"/><productOrService><coding><system value="http://example.org/fhir/oralservicecodes"/><code value="1200"/></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></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="1000.00"/><currency value="USD"/></unitPrice><factor value="0.75"/><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>