{

"resourceType": "Claim",
"id": "100153",
"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": "12355"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://hl7.org/fhir/ex-claimtype",
      "code": "oral"
    }
  ]
},
"use": "proposed",
"patient": {
  "reference": "Patient/1"
},
"created": "2015-03-16",
"insurer": {
  "reference": "Organization/2"
},
"organization": {
  "reference": "Organization/1"
},
"priority": {
  "coding": [
    {
      "code": "normal"
    }
  ]
},
"fundsReserve": {
  "coding": [
    {
      "code": "provider"
    }
  ]
},
"payee": {
  "type": {
    "coding": [
      {
        "code": "provider"
      }
    ]
  }
},
"careTeam": [
  {
    "sequence": 1,
    "provider": {
      "reference": "Practitioner/example"
    }
  }
],
"diagnosis": [
  {
    "sequence": 1,
    "diagnosisCodeableConcept": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/sid/icd-10",
          "code": "123457"
        }
      ]
    }
  }
],
"insurance": [
  {
    "sequence": 1,
    "focal": true,
    "coverage": {
      "reference": "Coverage/9876B1"
    }
  }
],
"item": [
  {
    "sequence": 1,
    "careTeamLinkId": [
      1
    ],
    "diagnosisLinkId": [
      1
    ],
    "service": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "ORTHPLAN"
        }
      ]
    },
    "servicedDate": "2015-05-16",
    "unitPrice": {
      "value": 9000.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 9000.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "detail": [
      {
        "sequence": 1,
        "service": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "ORTHOEXAM"
            }
          ]
        },
        "unitPrice": {
          "value": 1000.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 1000.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "sequence": 2,
        "service": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "ORTHODIAG"
            }
          ]
        },
        "unitPrice": {
          "value": 1500.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 1500.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "sequence": 3,
        "service": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "ORTHOINITIAL"
            }
          ]
        },
        "unitPrice": {
          "value": 500.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 500.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "sequence": 4,
        "service": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "ORTHOMONTHS"
            }
          ]
        },
        "quantity": {
          "value": 24
        }
      },
      {
        "sequence": 5,
        "service": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "ORTHOPERIODIC"
            }
          ]
        },
        "quantity": {
          "value": 24
        },
        "unitPrice": {
          "value": 250.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 250.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    ]
  },
  {
    "sequence": 2,
    "careTeamLinkId": [
      1
    ],
    "service": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "21211"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 105.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 105.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "bodySite": {
      "coding": [
        {
          "system": "http://fdi.org/fhir/oraltoothcodes",
          "code": "21"
        }
      ]
    },
    "subSite": [
      {
        "coding": [
          {
            "system": "http://fdi.org/fhir/oralsurfacecodes",
            "code": "L"
          }
        ]
      }
    ]
  },
  {
    "sequence": 3,
    "careTeamLinkId": [
      1
    ],
    "service": {
      "coding": [
        {
          "system": "http://example.org/fhir/oralservicecodes",
          "code": "27211"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 1100.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 1100.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "bodySite": {
      "coding": [
        {
          "system": "http://fdi.org/fhir/oraltoothcodes",
          "code": "36"
        }
      ]
    },
    "detail": [
      {
        "sequence": 1,
        "service": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "27211"
            }
          ]
        },
        "unitPrice": {
          "value": 750.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 750.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "sequence": 2,
        "service": {
          "coding": [
            {
              "system": "http://example.org/fhir/oralservicecodes",
              "code": "lab"
            }
          ]
        },
        "unitPrice": {
          "value": 350.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 350.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    ]
  }
]

}