<?xml version=“1.0” encoding=“UTF-8”?><Claim xmlns=“hl7.org/fhir”>

<id value="100156"/>

<text>
        <status value="generated"/>
        <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div>
</text>

<contained>
        <Device>
                <id value="device-bridge"/>
                <!--  rest of the resource ommitted for brevity  -->
        </Device>
</contained>

<contained>
        <ReferralRequest>
                <id value="referral"/>
                <status value="active"/>
                <intent value="order"/>
                <subject>
                        <reference value="Patient/1"/>
                </subject>
                <!--  rest of the resource ommitted for brevity  -->
        </ReferralRequest>
</contained>

<identifier>
        <system value="http://happyvalley.com/claim"/>
        <value value="123466"/>
</identifier>

<status value="active"/>

<type>
        <coding>
                <system value="http://hl7.org/fhir/ex-claimtype"/>
                <code value="oral"/>
        </coding>
</type>

<use value="complete"/>

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

<created value="2014-08-16"/>

<insurer>
        <reference value="Organization/2"/>
</insurer>

<organization>
        <reference value="Organization/1"/>
</organization>

<priority>
        <coding>
                <code value="normal"/>
        </coding>
</priority>

<related>
        <claim>
                <reference value="Claim/100151"/>
        </claim>
        <relationship>
                <coding>
                        <system value="http://hl7.org/fhir/ex-relatedclaimrelationship"/>
                        <code value="associated"/>
                </coding>
        </relationship>
        <reference>
                <value value="CASE156746B"/> <!--  case number  -->
        </reference>
</related>

<payee>
        <type>
                <coding>
                        <system value="http://hl7.org/fhir/payeetype"/>
                        <code value="other"/>
                </coding>
        </type>
        <resourceType>
                <system value="http://hl7.org/fhir/ex-payee-resource-type"/>
                <code value="relatedperson"/>
        </resourceType>
        <party>
                <reference value="RelatedPerson/peter"/>
        </party>
</payee>

<referral>
        <reference value="#referral"/>
</referral>

<careTeam>
        <sequence value="1"/>
        <provider>
                <reference value="Practitioner/example"/>
        </provider>
</careTeam>

<information>
        <sequence value="1"/>
        <category>
                <coding>
                        <system value="http://hl7.org/fhir/claiminformationcategory"/>
                        <code value="prosthesis"/>
                </coding>
        </category>
        <code>
                <coding>
                        <system value="http://hl7.org/fhir/ex-oralprostho"/>
                        <code value="2"/>
                        <display value="Maryland Bridge"/>
                </coding>
        </code>
        <timingDate value="2001-04-07"/> <!--  original placement  -->
</information>

<procedure>
        <sequence value="1"/>   
        <date value="2014-07-04"/>
        <procedureCodeableConcept>
                <text value="Resection of gum to increase exposed tooth."/>
        </procedureCodeableConcept>
</procedure>

<insurance>
        <sequence value="1"/>
        <focal value="true"/>
        <coverage>
                <reference value="Coverage/9876B1"/>
        </coverage>
</insurance>

<item>
        <sequence value="1"/>
        <careTeamLinkId value="1"/>
        <informationLinkId value="1"/>
        <service>
                <coding>
                        <system value="http://example.org/fhir/oralservicecodes"/>
                        <code value="67221"/>
                        <display value="Maryland Bridge"/>
                </coding>
        </service>
        <servicedDate value="2014-08-16"/>
        <locationCodeableConcept>
                <coding>
                        <system value="http://hl7.org/fhir/ex-serviceplace"/>
                        <code value="11"/>
                </coding>
        </locationCodeableConcept>
        <unitPrice>
                <value value="1400.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </unitPrice> 
        <factor value="0.75"/> <!--  student discount  -->
        <net>
                <value value="1050.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </net> 
        <udi>
                <reference value="#device-bridge"/>
        </udi>
        <bodySite>
                <coding>
                        <system value="http://fdi.org/fhir/oraltoothcodes"/>
                        <code value="01"/>
                </coding>
        </bodySite>
</item>

<item>
        <sequence value="2"/>
        <careTeamLinkId value="1"/>
        <service>
                <coding>
                        <system value="http://example.org/fhir/oralservicecodes"/>
                        <code value="21211"/>
                </coding>
        </service>
        <servicedDate value="2014-08-16"/>
        <locationCodeableConcept>
                <coding>
                        <system value="http://hl7.org/fhir/ex-serviceplace"/>
                        <code value="11"/>
                </coding>
        </locationCodeableConcept>
        <unitPrice>
                <value value="105.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </unitPrice> 
        <net>
                <value value="105.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </net> 
        <bodySite>
                <coding>
                        <system value="http://fdi.org/fhir/oraltoothcodes"/>
                        <code value="21"/>
                </coding>
        </bodySite>
        <subSite>
                <coding>
                        <system value="http://fdi.org/fhir/oralsurfacecodes"/>
                        <code value="L"/>
                </coding>
        </subSite>
</item>

<item>
        <sequence value="3"/>
        <careTeamLinkId value="1"/>
        <procedureLinkId value="1"/>
        <service>
                <coding>
                        <system value="http://example.org/fhir/oralservicecodes"/>
                        <code value="27211"/>
                </coding>
        </service>
        <servicedDate value="2014-08-16"/>
        <locationCodeableConcept>
                <coding>
                        <system value="http://hl7.org/fhir/ex-serviceplace"/>
                        <code value="11"/>
                </coding>
        </locationCodeableConcept>
        <unitPrice>
                <value value="1100.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </unitPrice> 
        <net>
                <value value="1100.00"/>
                <system value="urn:iso:std:iso:4217"/>
                <code value="USD"/> 
        </net> 
        <bodySite>
                <coding>
                        <system value="http://fdi.org/fhir/oraltoothcodes"/>
                        <code value="24"/>
                </coding>
        </bodySite>

        <detail>
                <sequence value="1"/>
                <service>
                        <coding>
                                <system value="http://example.org/fhir/oralservicecodes"/>
                                <code value="27211"/>
                        </coding>
                </service>
                <unitPrice>
                        <value value="1000.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </unitPrice> 
                <factor value="0.75"/> <!--  Student discount  -->
                <net>
                        <value value="750.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </net> 
        </detail>

        <detail>
                <sequence value="2"/>
                <service>
                        <coding>
                                <system value="http://example.org/fhir/oralservicecodes"/>
                                <code value="lab"/>
                        </coding>
                </service>
                <unitPrice>
                        <value value="350.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </unitPrice> 
                <net>
                        <value value="350.00"/>
                        <system value="urn:iso:std:iso:4217"/>
                        <code value="USD"/> 
                </net> 
        </detail>
</item>
<total>
        <value value="2255.00"/>
        <system value="urn:iso:std:iso:4217"/>
        <code value="USD"/> 
</total>

</Claim>