{
  "resourceType" : "ExplanationOfBenefit",
  "id" : "EOBOral2",
  "meta" : {
    "lastUpdated" : "2021-10-28T10:23:00-05:00",
    "profile" : ["http://hl7.org/fhir/us/carin-bb/StructureDefinition/C4BB-ExplanationOfBenefit-Oral|2.2.0"]
  },
  "language" : "en",
  "text" : {
    "status" : "generated"
  },
  "identifier" : [{
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBIdentifierType",
        "code" : "uc"
      }]
    },
    "system" : "https://www.example.com/fhir/EOBIdentifier",
    "value" : "210300012"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "version" : "1.0.1",
      "code" : "oral"
    }],
    "text" : "Oral"
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/Patient2"
  },
  "billablePeriod" : {
    "start" : "2021-10-01",
    "end" : "2021-10-31"
  },
  "created" : "2021-10-28T10:23:00-05:00",
  "insurer" : {
    "reference" : "Organization/DentalPayer1",
    "display" : "XXX Health Plan"
  },
  "provider" : {
    "reference" : "Practitioner/PractitionerDentalProvider1",
    "display" : "XXX Dental Plan"
  },
  "outcome" : "complete",
  "supportingInfo" : [{
    "sequence" : 3,
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
        "code" : "clmrecvddate"
      }]
    },
    "timingDate" : "2021-03-18"
  },
  {
    "sequence" : 4,
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
        "code" : "servicefacility"
      }]
    },
    "valueReference" : {
      "reference" : "Organization/ProviderOrganization1"
    }
  },
  {
    "sequence" : 8,
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
        "code" : "patientaccountnumber"
      }]
    },
    "valueString" : "PATIENTACCTNO3"
  },
  {
    "sequence" : 9,
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
        "code" : "additionalbodysite"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem",
        "code" : "1"
      }]
    }
  },
  {
    "sequence" : 10,
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBSupportingInfoType",
        "code" : "additionalbodysite"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ADAUniversalToothDesignationSystem",
        "code" : "2"
      }]
    }
  }],
  "insurance" : [{
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/CoverageDental1"
    }
  }],
  "item" : [{
    "sequence" : 1,
    "informationSequence" : [6,
    7,
    9,
    10,
    11],
    "productOrService" : {
      "coding" : [{
        "system" : "http://www.ada.org/cdt",
        "code" : "D0220",
        "display" : "Intraoral - periapical first radiographic image"
      }]
    },
    "servicedDate" : "2021-10-28",
    "locationCodeableConcept" : {
      "coding" : [{
        "system" : "https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set",
        "code" : "11",
        "display" : "Office"
      }]
    },
    "bodySite" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ADAAreaOralCavitySystem",
        "code" : "10",
        "display" : "Upper right quadrant"
      }]
    },
    "subSite" : [{
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes",
        "code" : "O"
      }]
    },
    {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ADAToothSurfaceCodes",
        "code" : "I"
      }]
    }],
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
          "code" : "benefitpaymentstatus"
        }]
      },
      "reason" : {
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
          "code" : "innetwork"
        }]
      }
    },
    {
      "category" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
          "version" : "1.0.1",
          "code" : "submitted"
        }]
      },
      "amount" : {
        "value" : 150,
        "currency" : "USD"
      }
    }]
  }],
  "adjudication" : [{
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
        "code" : "renderingnetworkstatus"
      }]
    },
    "reason" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
        "code" : "innetwork"
      }]
    }
  },
  {
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
        "code" : "benefitpaymentstatus"
      }]
    },
    "reason" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
        "code" : "innetwork"
      }]
    }
  },
  {
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudicationDiscriminator",
        "code" : "billingnetworkstatus"
      }]
    },
    "reason" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBPayerAdjudicationStatus",
        "code" : "innetwork"
      }]
    }
  }],
  "total" : [{
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
        "version" : "1.0.1",
        "code" : "submitted"
      }],
      "text" : "Submitted Amount"
    },
    "amount" : {
      "value" : 150,
      "currency" : "USD"
    }
  },
  {
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
        "version" : "1.0.1",
        "code" : "benefit"
      }],
      "text" : "Benefit Amount"
    },
    "amount" : {
      "value" : 110,
      "currency" : "USD"
    }
  },
  {
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
        "code" : "discount"
      }],
      "text" : "Discount Amount"
    },
    "amount" : {
      "value" : 40,
      "currency" : "USD"
    }
  },
  {
    "category" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/us/carin-bb/CodeSystem/C4BBAdjudication",
        "code" : "paidtoprovider"
      }],
      "text" : "Amount Paid to Provider"
    },
    "amount" : {
      "value" : 100,
      "currency" : "USD"
    }
  }]
}