Average dental Claim with Information (Missing Teeth and Student) (id = "100151")

<?xml version="1.0" encoding="UTF-8"?>

<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"/> 

  <patient> 
    <reference value="Patient/1"/> 
  </patient> 

  <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> 
    <timingDate value="2012-04-07"/> 
    <reason> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/missingtoothreason"/> 
        <code value="e"/>     <!--   Extraction   -->
      </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"/>     <!--   Student discount   -->
      <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>