Average dental Claim with Information (Missing Teeth and Student)

{
  "resourceType" : "Claim",
  "id" : "100151",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the Oral Health Claim</div>"
  },
  "identifier" : [{
    "system" : "http://happyvalley.com/claim",
    "value" : "12346"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "oral"
    }]
  },
  "use" : "claim",
  "patient" : {
    "reference" : "Patient/1"
  },
  "created" : "2014-08-16",
  "insurer" : {
    "reference" : "Organization/2"
  },
  "provider" : {
    "reference" : "Organization/1"
  },
  "priority" : {
    "coding" : [{
      "code" : "normal"
    }]
  },
  "payee" : {
    "type" : {
      "coding" : [{
        "code" : "provider"
      }]
    }
  },
  "careTeam" : [{
    "sequence" : 1,
    "provider" : {
      "reference" : "Practitioner/example"
    }
  }],
  "supportingInfo" : [{
    "sequence" : 1,
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
        "code" : "missingtooth"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/ex-tooth",
        "code" : "15"
      }]
    },
    "timingDate" : "2012-04-07",
    "reason" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/missingtoothreason",
        "code" : "e"
      }]
    }
  },
  {
    "sequence" : 2,
    "category" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/claiminformationcategory",
        "code" : "exception"
      }]
    },
    "code" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/claim-exception",
        "code" : "student"
      }]
    },
    "valueString" : "Happy Valley Community College"
  }],
  "diagnosis" : [{
    "sequence" : 1,
    "diagnosisCodeableConcept" : {
      "coding" : [{
        "code" : "123456"
      }]
    }
  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/9876B1"
    }
  }],
  "item" : [{
    "sequence" : 1,
    "careTeamSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "1200"
      }]
    },
    "servicedDate" : "2014-08-16",
    "unitPrice" : {
      "value" : 135.57,
      "currency" : "USD"
    },
    "net" : {
      "value" : 135.57,
      "currency" : "USD"
    }
  },
  {
    "sequence" : 2,
    "careTeamSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "21211"
      }]
    },
    "servicedDate" : "2014-08-16",
    "unitPrice" : {
      "value" : 105.00,
      "currency" : "USD"
    },
    "net" : {
      "value" : 105.00,
      "currency" : "USD"
    },
    "bodySite" : [{
      "site" : [{
        "concept" : {
          "coding" : [{
            "system" : "http://fdi.org/fhir/oraltoothcodes",
            "code" : "21"
          }]
        }
      }],
      "subSite" : [{
        "coding" : [{
          "system" : "http://fdi.org/fhir/oralsurfacecodes",
          "code" : "L"
        }]
      }]
    }]
  },
  {
    "sequence" : 3,
    "careTeamSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "27211"
      }]
    },
    "servicedDate" : "2014-08-16",
    "unitPrice" : {
      "value" : 1100.00,
      "currency" : "USD"
    },
    "net" : {
      "value" : 1100.00,
      "currency" : "USD"
    },
    "bodySite" : [{
      "site" : [{
        "concept" : {
          "coding" : [{
            "system" : "http://fdi.org/fhir/oraltoothcodes",
            "code" : "36"
          }]
        }
      }]
    }],
    "detail" : [{
      "sequence" : 1,
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/oralservicecodes",
          "code" : "27211"
        }]
      },
      "unitPrice" : {
        "value" : 1000.00,
        "currency" : "USD"
      },
      "factor" : 0.75,
      "net" : {
        "value" : 750.00,
        "currency" : "USD"
      }
    },
    {
      "sequence" : 2,
      "productOrService" : {
        "coding" : [{
          "system" : "http://example.org/fhir/oralservicecodes",
          "code" : "lab"
        }]
      },
      "unitPrice" : {
        "value" : 350.00,
        "currency" : "USD"
      },
      "net" : {
        "value" : 350.00,
        "currency" : "USD"
      }
    }]
  }]
}