CMSgov/dpc-app

<Bundle xmlns='http://hl7.org/fhir'>
    <id value='691d64eb-edb2-4428-a055-1688ff304ebf'/>
    <meta>
        <lastUpdated value='2020-04-24T18:46:46.726+00:00'/>
    </meta>
    <type value='searchset'/>
    <total value='68'/>
    <link>
        <relation value='first'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&amp;startIndex=0&amp;_count=20&amp;patient=-19990000002210'/>
    </link>
    <link>
        <relation value='next'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&amp;startIndex=60&amp;_count=20&amp;patient=-19990000002210'/>
    </link>
    <link>
        <relation value='previous'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&amp;startIndex=20&amp;_count=20&amp;patient=-19990000002210'/>
    </link>
    <link>
        <relation value='last'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&amp;startIndex=60&amp;_count=20&amp;patient=-19990000002210'/>
    </link>
    <link>
        <relation value='self'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_count=20&amp;_format=application%2Fjson%2Bfhir&amp;patient=-19990000002210&amp;startIndex=40'/>
    </link>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--9925427952'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='200'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='-9925427952'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='2001-09-01'/>
                    <end value='2001-09-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='7802'/>
                            <display value='SYNCOPE AND COLLAPSE'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-09-01'/>
                        <end value='2001-09-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='2'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-09-01'/>
                        <end value='2001-09-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='M'/>
                                <display value='Multiple submittal--duplicate line item'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='3'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-09-01'/>
                        <end value='2001-09-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='M'/>
                                <display value='Multiple submittal--duplicate line item'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='4'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-09-01'/>
                        <end value='2001-09-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='M'/>
                                <display value='Multiple submittal--duplicate line item'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--9925815758'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='70'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='60'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='-9925815758'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='2001-10-01'/>
                    <end value='2001-10-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='5990'/>
                            <display value='URIN TRACT INFECTION NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4241'/>
                            <display value='AORTIC VALVE DISORDER'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-10-01'/>
                        <end value='2001-10-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='2'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-10-01'/>
                        <end value='2001-10-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='T1C'/>
                            <display value='Lab tests - urinalysis'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='1'/>
                            <display value='Service Not Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='3'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='5'/>
                            <display value='Diagnostic laboratory'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='81002'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-10-01'/>
                        <end value='2001-10-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='1'/>
                                <display value='100%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='L'/>
                                <display value='CLIA'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--9926660751'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='-9926660751'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='2001-10-01'/>
                    <end value='2001-10-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='5990'/>
                            <display value='URIN TRACT INFECTION NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='T1C'/>
                            <display value='Lab tests - urinalysis'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='1'/>
                            <display value='Service Not Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='5'/>
                            <display value='Diagnostic laboratory'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='81002'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-10-01'/>
                        <end value='2001-10-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='1'/>
                                <display value='100%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='R'/>
                                <display value='Reprocessed--adjustments based on subsequent reprocessing of claim'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--9928387966'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='20'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='-9928387966'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='2001-11-01'/>
                    <end value='2001-11-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='5990'/>
                            <display value='URIN TRACT INFECTION NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-11-01'/>
                        <end value='2001-11-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='20'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--9929844804'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='20'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='100'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='150'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='150'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='-9929844804'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='2001-09-01'/>
                    <end value='2001-09-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='7802'/>
                            <display value='SYNCOPE AND COLLAPSE'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M2A'/>
                            <display value='Hospital visit - initial'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99223'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-09-01'/>
                        <end value='2001-09-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='100'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='100'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='150'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='150'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='100'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--9930061937'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='-9930061937'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='2001-09-01'/>
                    <end value='2001-09-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4240'/>
                            <display value='MITRAL VALVE DISORDER'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-09-01'/>
                        <end value='2001-09-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--9946574525'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='-9946574525'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='2001-12-01'/>
                    <end value='2001-12-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='2720'/>
                            <display value='PURE HYPERCHOLESTEROLEM'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2001-12-01'/>
                        <end value='2001-12-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11079420166'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='350'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='1000'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='450'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11079420166'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-06-01'/>
                    <end value='1999-06-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='71946'/>
                            <display value='JOINT PAIN-L/LEG'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='I2D'/>
                            <display value='Advanced imaging - MRI/MRA: other'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='4'/>
                            <display value='Diagnostic radiology'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='73721'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='1999-06-01'/>
                        <end value='1999-06-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='350'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='350'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='90'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='1000'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='450'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='350'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11083624281'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11083624281'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-06-01'/>
                    <end value='1999-06-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='7179'/>
                            <display value='INT DERANGEMENT KNEE NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='1999-06-01'/>
                        <end value='1999-06-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11096633494'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='60'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='60'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11096633494'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-06-01'/>
                    <end value='1999-06-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='7179'/>
                            <display value='INT DERANGEMENT KNEE NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99214'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='1999-06-01'/>
                        <end value='1999-06-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11269359497'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='20'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11269359497'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-04-01'/>
                    <end value='1999-04-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='6119'/>
                            <display value='BREAST DISORDER NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='I1C'/>
                            <display value='Standard imaging - breast'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='4'/>
                            <display value='Diagnostic radiology'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='76091'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-04-01'/>
                        <end value='1999-04-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='20'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11292205268'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11292205268'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-05-01'/>
                    <end value='1999-05-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='6111'/>
                            <display value='HYPERTROPHY OF BREAST'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='7231'/>
                            <display value='CERVICALGIA'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='71941'/>
                            <display value='JOINT PAIN-SHLDER'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='4'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='61171'/>
                            <display value='MASTODYNIA'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='5'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='5'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='1999-05-01'/>
                        <end value='1999-05-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11377169356'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='60'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='60'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11377169356'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-11-01'/>
                    <end value='1999-11-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='36616'/>
                            <display value='SENILE NUCLEAR CATARACT'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M5C'/>
                            <display value='Specialist - ophthalmology'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='92014'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-11-01'/>
                        <end value='1999-11-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='50'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11377614619'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='100'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='150'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='150'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11377614619'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-12-01'/>
                    <end value='1999-12-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='36616'/>
                            <display value='SENILE NUCLEAR CATARACT'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M5C'/>
                            <display value='Specialist - ophthalmology'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='92004'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-12-01'/>
                        <end value='1999-12-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='70'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='70'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='80'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='80'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='I3A'/>
                            <display value='Echography/ultrasonography - eye'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='2'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='4'/>
                            <display value='Diagnostic radiology'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='76519'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-12-01'/>
                        <end value='1999-12-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='I3A'/>
                            <display value='Echography/ultrasonography - eye'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='3'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='4'/>
                            <display value='Diagnostic radiology'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='76519'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-12-01'/>
                        <end value='1999-12-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='100'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11384998515'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11384998515'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-05-01'/>
                    <end value='1999-05-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='71590'/>
                            <display value='OSTEOARTHROS NOS-UNSPEC'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='7245'/>
                            <display value='BACKACHE NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-05-01'/>
                        <end value='1999-05-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11385105874'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11385105874'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-01-01'/>
                    <end value='1999-01-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='71590'/>
                            <display value='OSTEOARTHROS NOS-UNSPEC'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4011'/>
                            <display value='BENIGN HYPERTENSION'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='8'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='8'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-01-01'/>
                        <end value='1999-01-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier-11385746835'/>
                <meta>
                    <lastUpdated value='2020-02-14T13:40:44.356+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
                        <code value='1'/>
                        <display value='Physician/supplier'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='A'/>
                        <display value='Assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
                    <valueMoney>
                        <value value='70'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
                    <valueMoney>
                        <value value='70'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='11385746835'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='71'/>
                        <display value='Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='CARRIER'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='O'/>
                        <display value='Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <start value='1999-05-01'/>
                    <end value='1999-05-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='7245'/>
                            <display value='BACKACHE NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <diagnosis>
                    <sequence value='2'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='71598'/>
                            <display value='OSTEOARTHRO NOS-OTH SITE'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='9999999'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='M1B'/>
                            <display value='Office visits - established'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='1'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='1'/>
                            <display value='Medical care'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-05-01'/>
                        <end value='1999-05-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='30'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='40'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='I1B'/>
                            <display value='Standard imaging - musculoskeletal'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='2'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='4'/>
                            <display value='Diagnostic radiology'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='72100'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-05-01'/>
                        <end value='1999-05-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <item>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
                            <code value='3'/>
                            <display value='Services'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
                        <valueQuantity>
                            <value value='1'/>
                        </valueQuantity>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
                            <code value='I1B'/>
                            <display value='Standard imaging - musculoskeletal'/>
                        </valueCoding>
                    </extension>
                    <extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
                            <code value='0'/>
                            <display value='Service Subject to Deductible'/>
                        </valueCoding>
                    </extension>
                    <sequence value='3'/>
                    <diagnosisLinkId value='3'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='4'/>
                            <display value='Diagnostic radiology'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='72100'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-05-01'/>
                        <end value='1999-05-01'/>
                    </servicedPeriod>
                    <locationCodeableConcept>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
                                <code value='99'/>
                                <display value='With 000 county code is American Samoa; otherwise unknown'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
                                <code value='999999999'/>
                            </valueCoding>
                        </extension>
                        <extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
                                <code value='99'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
                            <code value='99'/>
                            <display value='Other Place of Service. Other place of service not identified above.'/>
                        </coding>
                    </locationCodeableConcept>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <display value='Carrier Line Reduced Payment Physician Assistant Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
                                <code value='0'/>
                                <display value='N/A'/>
                            </coding>
                        </reason>
                    </adjudication>
                    <adjudication>
                        <extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
                                <code value='0'/>
                                <display value='80%'/>
                            </valueCoding>
                        </extension>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
                                <display value='Line NCH Medicare Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
                                <display value='Line Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
                                <display value='Line Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
                                <display value='Line Beneficiary Part B Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
                                <display value='Line Primary Payer (if not Medicare) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
                                <display value='Line Beneficiary Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
                                <display value='Line Submitted Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <display value='Line Processing Indicator Code'/>
                            </coding>
                        </category>
                        <reason>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
                                <code value='A'/>
                                <display value='Allowed'/>
                            </coding>
                        </reason>
                    </adjudication>
                </item>
                <payment>
                    <amount>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='outpatient-1157236859'/>
                <meta>
                    <lastUpdated value='2020-03-20T16:42:18.971+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt'>
                    <valueMoney>
                        <value value='50'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt'>
                    <valueMoney>
                        <value value='400'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='250'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='1157236859'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='40'/>
                        <display value='Hospital Outpatient claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='OUTPATIENT'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='W'/>
                        <display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
                        <code value='3'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
                            <code value='3'/>
                            <display value='Final bill'/>
                        </valueCoding>
                    </extension>
                    <start value='2000-04-01'/>
                    <end value='2000-04-01'/>
                </billablePeriod>
                <provider>
                    <identifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
                        <value value='999999'/>
                    </identifier>
                </provider>
                <organization>
                    <identifier>
                        <system value='http://hl7.org/fhir/sid/us-npi'/>
                        <value value='9999999999'/>
                    </identifier>
                </organization>
                <facility>
                    <extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
                            <code value='1'/>
                            <display value='Hospital'/>
                        </valueCoding>
                    </extension>
                    <identifier>
                        <system value='http://hl7.org/fhir/sid/us-npi'/>
                        <value value='9999999999'/>
                    </identifier>
                </facility>
                <information>
                    <sequence value='1'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
                            <code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
                            <display value='Claim Frequency Code'/>
                        </coding>
                    </category>
                    <code>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
                            <code value='1'/>
                            <display value='Admit thru discharge claim'/>
                        </coding>
                    </code>
                </information>
                <information>
                    <sequence value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
                            <code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
                            <display value='Patient Discharge Status Code'/>
                        </coding>
                    </category>
                    <code>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
                            <code value='01'/>
                            <display value='Discharged to home/self-care (routine charge).'/>
                        </coding>
                    </code>
                </information>
                <careTeam>
                    <sequence value='2'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='assist'/>
                            <display value='Assisting Provider'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='3'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='other'/>
                            <display value='Other'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='4'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='primary'/>
                            <display value='Primary provider'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='5'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='999999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='primary'/>
                            <display value='Primary provider'/>
                        </coding>
                    </role>
                </careTeam>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='41400'/>
                            <display value='COR ATH UNSP VSL NTV/GFT'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <sequence value='1'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='V'/>
                                <display value='Medical visit to clinic or emergency department'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0258'/>
                            <display value='Pharmacy-IV solutions'/>
                        </coding>
                    </revenue>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='70'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='2'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='A'/>
                                <display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0270'/>
                            <display value='Medical/surgical supplies-general classification (also see 062X)'/>
                        </coding>
                    </revenue>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='3'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='A'/>
                                <display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0340'/>
                            <display value='Nuclear medicine-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='A4641'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='100'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='100'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='4'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='A'/>
                                <display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0340'/>
                            <display value='Nuclear medicine-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='A9505'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='80'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='80'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='5'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='N'/>
                                <display value='Packaged incidental service (no separate APC payment)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0340'/>
                            <display value='Nuclear medicine-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='78465'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='950'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='6'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='B'/>
                                <display value='Non-allowed item or service for OPPS; may be paid under a different bill type (e.g., CORF)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0340'/>
                            <display value='Nuclear medicine-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='78478'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='150'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='7'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='N'/>
                                <display value='Packaged incidental service (no separate APC payment)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0340'/>
                            <display value='Nuclear medicine-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='78480'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='150'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='8'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='A'/>
                                <display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0482'/>
                            <display value='Cardiology-stress test'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='93017'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='500'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='9'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='A'/>
                                <display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0001'/>
                            <display value='Total charge'/>
                        </coding>
                    </revenue>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='0'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='2000'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <totalCost>
                    <value value='2000'/>
                    <system value='urn:iso:std:iso:4217'/>
                    <code value='USD'/>
                </totalCost>
                <payment>
                    <amount>
                        <value value='250'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='outpatient-1160589908'/>
                <meta>
                    <lastUpdated value='2020-03-20T16:42:18.971+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt'>
                    <valueMoney>
                        <value value='40'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='80'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='1160589908'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='40'/>
                        <display value='Hospital Outpatient claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='OUTPATIENT'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='W'/>
                        <display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
                        <code value='3'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
                            <code value='3'/>
                            <display value='Final bill'/>
                        </valueCoding>
                    </extension>
                    <start value='2000-02-01'/>
                    <end value='2000-02-01'/>
                </billablePeriod>
                <provider>
                    <identifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
                        <value value='999999'/>
                    </identifier>
                </provider>
                <organization>
                    <identifier>
                        <system value='http://hl7.org/fhir/sid/us-npi'/>
                        <value value='9999999999'/>
                    </identifier>
                </organization>
                <facility>
                    <extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
                            <code value='1'/>
                            <display value='Hospital'/>
                        </valueCoding>
                    </extension>
                    <identifier>
                        <system value='http://hl7.org/fhir/sid/us-npi'/>
                        <value value='9999999999'/>
                    </identifier>
                </facility>
                <information>
                    <sequence value='1'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
                            <code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
                            <display value='Claim Frequency Code'/>
                        </coding>
                    </category>
                    <code>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
                            <code value='1'/>
                            <display value='Admit thru discharge claim'/>
                        </coding>
                    </code>
                </information>
                <information>
                    <sequence value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
                            <code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
                            <display value='Patient Discharge Status Code'/>
                        </coding>
                    </category>
                    <code>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
                            <code value='01'/>
                            <display value='Discharged to home/self-care (routine charge).'/>
                        </coding>
                    </code>
                </information>
                <careTeam>
                    <sequence value='2'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='assist'/>
                            <display value='Assisting Provider'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='3'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='other'/>
                            <display value='Other'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='4'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='primary'/>
                            <display value='Primary provider'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='5'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='999999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='primary'/>
                            <display value='Primary provider'/>
                        </coding>
                    </role>
                </careTeam>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='78605'/>
                            <display value='SHORTNESS OF BREATH'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <sequence value='1'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='N'/>
                                <display value='Packaged incidental service (no separate APC payment)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0460'/>
                            <display value='Pulmonary function-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='94010'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='150'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='2'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='N'/>
                                <display value='Packaged incidental service (no separate APC payment)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0460'/>
                            <display value='Pulmonary function-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='94720'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='80'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='3'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='S'/>
                                <display value='Significant procedure not subject to multiple procedure discounting'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0001'/>
                            <display value='Total charge'/>
                        </coding>
                    </revenue>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='0'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='200'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <totalCost>
                    <value value='200'/>
                    <system value='urn:iso:std:iso:4217'/>
                    <code value='USD'/>
                </totalCost>
                <payment>
                    <amount>
                        <value value='80'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='outpatient-1238565673'/>
                <meta>
                    <lastUpdated value='2020-03-20T16:42:18.971+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
                    <valueMoney>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='0'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </valueMoney>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
                    <valueIdentifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
                        <value value='99999'/>
                    </valueIdentifier>
                </extension>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
                    <value value='1238565673'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='1339493320'/>
                </identifier>
                <status value='active'/>
                <type>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
                        <code value='40'/>
                        <display value='Hospital Outpatient claim'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
                        <code value='OUTPATIENT'/>
                    </coding>
                    <coding>
                        <system value='http://hl7.org/fhir/ex-claimtype'/>
                        <code value='professional'/>
                        <display value='Professional'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
                        <code value='W'/>
                        <display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
                    </coding>
                    <coding>
                        <system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
                        <code value='3'/>
                    </coding>
                </type>
                <patient>
                    <reference value='Patient/-19990000002210'/>
                </patient>
                <billablePeriod>
                    <extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
                            <code value='3'/>
                            <display value='Final bill'/>
                        </valueCoding>
                    </extension>
                    <start value='2000-03-01'/>
                    <end value='2000-03-01'/>
                </billablePeriod>
                <provider>
                    <identifier>
                        <system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
                        <value value='999999'/>
                    </identifier>
                </provider>
                <organization>
                    <identifier>
                        <system value='http://hl7.org/fhir/sid/us-npi'/>
                        <value value='9999999999'/>
                    </identifier>
                </organization>
                <facility>
                    <extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
                        <valueCoding>
                            <system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
                            <code value='1'/>
                            <display value='Hospital'/>
                        </valueCoding>
                    </extension>
                    <identifier>
                        <system value='http://hl7.org/fhir/sid/us-npi'/>
                        <value value='9999999999'/>
                    </identifier>
                </facility>
                <information>
                    <sequence value='1'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
                            <code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
                            <display value='Claim Frequency Code'/>
                        </coding>
                    </category>
                    <code>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
                            <code value='1'/>
                            <display value='Admit thru discharge claim'/>
                        </coding>
                    </code>
                </information>
                <information>
                    <sequence value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
                            <code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
                            <display value='Patient Discharge Status Code'/>
                        </coding>
                    </category>
                    <code>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
                            <code value='01'/>
                            <display value='Discharged to home/self-care (routine charge).'/>
                        </coding>
                    </code>
                </information>
                <careTeam>
                    <sequence value='2'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='assist'/>
                            <display value='Assisting Provider'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='3'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='other'/>
                            <display value='Other'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='4'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='9999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='primary'/>
                            <display value='Primary provider'/>
                        </coding>
                    </role>
                </careTeam>
                <careTeam>
                    <sequence value='5'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='999999999999'/>
                        </identifier>
                    </provider>
                    <role>
                        <coding>
                            <system value='http://hl7.org/fhir/claimcareteamrole'/>
                            <code value='primary'/>
                            <display value='Primary provider'/>
                        </coding>
                    </role>
                </careTeam>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='41400'/>
                            <display value='COR ATH UNSP VSL NTV/GFT'/>
                        </coding>
                    </diagnosisCodeableConcept>
                    <type>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
                            <code value='principal'/>
                            <display value='The single medical diagnosis that is most relevant to the patient&apos;s chief complaint or need for treatment.'/>
                        </coding>
                    </type>
                </diagnosis>
                <insurance>
                    <coverage>
                        <reference value='Coverage/part-b--19990000002210'/>
                    </coverage>
                </insurance>
                <item>
                    <sequence value='1'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='A'/>
                                <display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0300'/>
                            <display value='Laboratory-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='G0001'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='2'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='N'/>
                                <display value='Packaged incidental service (no separate APC payment)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0300'/>
                            <display value='Laboratory-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='80061'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='20'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='60'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='3'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='N'/>
                                <display value='Packaged incidental service (no separate APC payment)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0300'/>
                            <display value='Laboratory-general classification'/>
                        </coding>
                    </revenue>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <code value='80076'/>
                        </coding>
                    </service>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='1'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='10'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='70'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <item>
                    <sequence value='4'/>
                    <careTeamLinkId value='5'/>
                    <revenue>
                        <extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
                            <valueCoding>
                                <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
                                <code value='N'/>
                                <display value='Packaged incidental service (no separate APC payment)'/>
                            </valueCoding>
                        </extension>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
                            <code value='0001'/>
                            <display value='Total charge'/>
                        </coding>
                    </revenue>
                    <locationAddress>
                        <state value='99'/>
                    </locationAddress>
                    <quantity>
                        <value value='0'/>
                    </quantity>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
                                <display value='Revenue Center Blood Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
                                <display value='Revenue Center Cash Deductible Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
                                <display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
                                <display value='Revenue Center Reduced Coinsurance Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
                                <display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
                                <display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
                                <display value='Revenue Center (Medicare) Provider Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
                                <display value='Revenue Center Payment Amount to Beneficiary'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
                                <display value='Revenue Center Patient Responsibility Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
                                <display value='Revenue Center (Medicare) Payment Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
                                <display value='Revenue Center Rate Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
                                <display value='Revenue Center Total Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='150'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                    <adjudication>
                        <category>
                            <coding>
                                <system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
                                <code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
                                <display value='Revenue Center Non-Covered Charge Amount'/>
                            </coding>
                        </category>
                        <amount>
                            <value value='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code value='USD'/>
                        </amount>
                    </adjudication>
                </item>
                <totalCost>
                    <value value='150'/>
                    <system value='urn:iso:std:iso:4217'/>
                    <code value='USD'/>
                </totalCost>
                <payment>
                    <amount>
                        <value value='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
</Bundle>