{

"resourceType": "ExplanationOfBenefit",
"id": "EB3500",
"text": {
  "status": "generated",
  "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A human-readable rendering of the ExplanationOfBenefit</div>"
},
"identifier": [
  {
    "system": "http://www.BenefitsInc.com/fhir/explanationofbenefit",
    "value": "987654321"
  }
],
"status": "active",
"type": {
  "coding": [
    {
      "system": "http://hl7.org/fhir/ex-claimtype",
      "code": "oral"
    }
  ]
},
"patient": {
  "reference": "Patient/pat1"
},
"created": "2014-08-16",
"enterer": {
  "reference": "Practitioner/1"
},
"provider": {
  "reference": "Practitioner/1"
},
"organization": {
  "reference": "Organization/2"
},
"facility": {
  "reference": "Location/1"
},
"claim": {
  "reference": "Claim/100150"
},
"claimResponse": {
  "reference": "ClaimResponse/R3500"
},
"outcome": {
  "coding": [
    {
      "system": "http://hl7.org/fhir/remittance-outcome",
      "code": "complete"
    }
  ]
},
"disposition": "Claim settled as per contract.",
"payee": {
  "type": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/payeetype",
        "code": "provider"
      }
    ]
  },
  "resourceType": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/resource-type-link",
        "code": "organization"
      }
    ]
  },
  "party": {
    "reference": "Organization/2"
  }
},
"careTeam": [
  {
    "sequence": 1,
    "provider": {
      "reference": "Practitioner/example"
    }
  }
],
"insurance": {
  "coverage": {
    "reference": "Coverage/9876B1"
  }
},
"item": [
  {
    "sequence": 1,
    "careTeamLinkId": [
      1
    ],
    "service": {
      "coding": [
        {
          "system": "http://hl7.org/fhir/service-uscls",
          "code": "1200"
        }
      ]
    },
    "servicedDate": "2014-08-16",
    "unitPrice": {
      "value": 135.57,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 135.57,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "encounter": [
      {
        "reference": "Encounter/example"
      }
    ],
    "adjudication": [
      {
        "category": {
          "coding": [
            {
              "code": "eligible"
            }
          ]
        },
        "amount": {
          "value": 120.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "category": {
          "coding": [
            {
              "code": "eligpercent"
            }
          ]
        },
        "value": 0.80
      },
      {
        "category": {
          "coding": [
            {
              "code": "benefit"
            }
          ]
        },
        "amount": {
          "value": 96.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    ]
  }
],
"totalCost": {
  "value": 135.57,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
},
"totalBenefit": {
  "value": 96.00,
  "system": "urn:iso:std:iso:4217",
  "code": "USD"
}

}