CMSgov/dpc-app

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src/main/resources/bb-test-data/eob/-19990000002208.xml

Summary

Maintainability
Test Coverage
<Bundle xmlns='http://hl7.org/fhir'>
    <id value='4c3e581d-8578-4bbc-9bfa-b2eaa7485bc5'/>
    <meta>
        <lastUpdated value='2020-04-24T18:46:46.726+00:00'/>
    </meta>
    <type value='searchset'/>
    <total value='59'/>
    <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=-19990000002208'/>
    </link>
    <link>
        <relation value='next'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&amp;startIndex=20&amp;_count=20&amp;patient=-19990000002208'/>
    </link>
    <link>
        <relation value='last'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&amp;startIndex=40&amp;_count=20&amp;patient=-19990000002208'/>
    </link>
    <link>
        <relation value='self'/>
        <url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_count=20&amp;_format=application%2Fjson%2Bfhir&amp;patient=-19990000002208&amp;startIndex=0'/>
    </link>
    <entry>
        <resource>
            <ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
                <id value='carrier--10177349616'/>
                <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='10'/>
                        <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='10'/>
                        <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='-10177349616'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-11-01'/>
                    <end value='2000-11-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='6273'/>
                            <display value='ATROPHIC VAGINITIS'/>
                        </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--19990000002208'/>
                    </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='T1H'/>
                            <display value='Lab tests - other (non-Medicare fee schedule)'/>
                        </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='88164'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-11-01'/>
                        <end value='2000-11-01'/>
                    </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='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='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='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='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='10'/>
                        <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--10192733163'/>
                <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='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='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='80'/>
                        <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='-10192733163'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-07-01'/>
                    <end value='2000-07-01'/>
                </billablePeriod>
                <organization>
                    <identifier>
                        <system value='http://hl7.org/fhir/sid/us-npi'/>
                        <value value='2111111110'/>
                    </identifier>
                </organization>
                <careTeam>
                    <sequence value='2'/>
                    <provider>
                        <identifier>
                            <system value='http://hl7.org/fhir/sid/us-npi'/>
                            <value value='2459425221'/>
                        </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='2724'/>
                            <display value='HYPERLIPIDEMIA NEC/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--19990000002208'/>
                    </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='0'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-07-01'/>
                        <end value='2000-07-01'/>
                    </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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='T1H'/>
                            <display value='Lab tests - other (non-Medicare fee schedule)'/>
                        </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='2'/>
                    <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='0'/>
                            <code value='80061'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-07-01'/>
                        <end value='2000-07-01'/>
                    </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='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='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='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>
                <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='T1H'/>
                            <display value='Lab tests - other (non-Medicare fee schedule)'/>
                        </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='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='0'/>
                            <code value='84450'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-07-01'/>
                        <end value='2000-07-01'/>
                    </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='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>
                <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='T1A'/>
                            <display value='Lab tests - routine venipuncture (non-Medicare fee schedule)'/>
                        </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='4'/>
                    <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='0'/>
                            <code value='G0001'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-07-01'/>
                        <end value='2000-07-01'/>
                    </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='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--10322272827'/>
                <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='80'/>
                        <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='100'/>
                        <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='-10322272827'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-11-01'/>
                    <end value='2000-11-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='3814'/>
                            <display value='NONSUPP OTITIS MEDIA 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--19990000002208'/>
                    </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>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='2000-11-01'/>
                        <end value='2000-11-01'/>
                    </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='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_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='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_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='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='T2D'/>
                            <display value='Other tests - 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='2'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='K'/>
                            <display value='Hearing items and services'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='92557'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-11-01'/>
                        <end value='2000-11-01'/>
                    </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='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='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='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='T2D'/>
                            <display value='Other tests - 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='3'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='K'/>
                            <display value='Hearing items and services'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='92567'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-11-01'/>
                        <end value='2000-11-01'/>
                    </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='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='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='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>
                <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='carrier--10388016035'/>
                <meta>
                    <lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
                </meta>
                <extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
                    <valueMoney>
                        <value value='30'/>
                        <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='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='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='-10388016035'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-04-01'/>
                    <end value='2000-04-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='185'/>
                            <display value='MALIGN NEOPL PROSTATE'/>
                        </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--19990000002208'/>
                    </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='0'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-04-01'/>
                        <end value='2000-04-01'/>
                    </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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='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_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='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_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='S'/>
                                <display value='Secondary payer'/>
                            </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--10414946175'/>
                <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='0'/>
                        <display value='Denied'/>
                    </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='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='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='-10414946175'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-04-01'/>
                    <end value='2000-04-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='185'/>
                            <display value='MALIGN NEOPL PROSTATE'/>
                        </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--19990000002208'/>
                    </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='0'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-04-01'/>
                        <end value='2000-04-01'/>
                    </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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='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_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='O'/>
                                <display value='Other'/>
                            </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--10532196841'/>
                <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='40'/>
                        <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='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='-10532196841'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-11-01'/>
                    <end value='2000-11-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='73300'/>
                            <display value='OSTEOPOROSIS 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='2724'/>
                            <display value='HYPERLIPIDEMIA NEC/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--19990000002208'/>
                    </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='0'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-11-01'/>
                        <end value='2000-11-01'/>
                    </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='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_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='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_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='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='40'/>
                        <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--10553023028'/>
                <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='150'/>
                        <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='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='-10553023028'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-10-01'/>
                    <end value='2000-10-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='3814'/>
                            <display value='NONSUPP OTITIS MEDIA 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--19990000002208'/>
                    </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='M1A'/>
                            <display value='Office visits - new'/>
                        </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='99203'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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_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='T2D'/>
                            <display value='Other tests - 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='2'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='K'/>
                            <display value='Hearing items and services'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='92557'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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='T2D'/>
                            <display value='Other tests - 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='3'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='K'/>
                            <display value='Hearing items and services'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='92567'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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='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='T2D'/>
                            <display value='Other tests - 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='4'/>
                    <diagnosisLinkId value='2'/>
                    <category>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
                            <code value='K'/>
                            <display value='Hearing items and services'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='1'/>
                            <code value='92568'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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='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='150'/>
                        <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--10619299136'/>
                <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='0'/>
                        <display value='Denied'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
                    <valueCoding>
                        <system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
                        <code value='N'/>
                        <display value='Non-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='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='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='-10619299136'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-01-01'/>
                    <end value='2000-01-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='72673'/>
                            <display value='CALCANEAL SPUR'/>
                        </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='72871'/>
                            <display value='PLANTAR FIBROMATOSIS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='3556'/>
                            <display value='PLANTAR NERVE LESION'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='4'/>
                    <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--19990000002208'/>
                    </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='4'/>
                    <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='2000-01-01'/>
                        <end value='2000-01-01'/>
                    </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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='O'/>
                                <display value='Other'/>
                            </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--10652062735'/>
                <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='80'/>
                        <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='100'/>
                        <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='-10652062735'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-10-01'/>
                    <end value='2000-10-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4019'/>
                            <display value='HYPERTENSION 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='2409'/>
                            <display value='GOITER NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='73309'/>
                            <display value='OSTEOPOROSIS NEC'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='4'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='2729'/>
                            <display value='LIPOID METABOL DIS NOS'/>
                        </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--19990000002208'/>
                    </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='0'/>
                            <code value='99215'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='0'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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_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='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_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='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='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_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='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='carrier--10652596794'/>
                <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='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='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='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='-10652596794'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-08-01'/>
                    <end value='2000-08-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4019'/>
                            <display value='HYPERTENSION 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--19990000002208'/>
                    </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='0'/>
                            <code value='99212'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-08-01'/>
                        <end value='2000-08-01'/>
                    </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='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='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--10655264083'/>
                <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='60'/>
                        <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='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='-10655264083'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-10-01'/>
                    <end value='2000-10-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='2409'/>
                            <display value='GOITER 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='2729'/>
                            <display value='LIPOID METABOL DIS NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='5641'/>
                            <display value='IRRITABLE BOWEL SYNDROME'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='4'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4019'/>
                            <display value='HYPERTENSION NOS'/>
                        </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--19990000002208'/>
                    </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='T1B'/>
                            <display value='Lab tests - automated general profiles'/>
                        </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='5'/>
                    <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='0'/>
                            <code value='80053'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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='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>
                <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='2'/>
                    <diagnosisLinkId value='5'/>
                    <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='0'/>
                            <code value='81003'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='T1D'/>
                            <display value='Lab tests - blood counts'/>
                        </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='5'/>
                    <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='0'/>
                            <code value='85027'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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='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>
                <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='T1H'/>
                            <display value='Lab tests - other (non-Medicare fee schedule)'/>
                        </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='4'/>
                    <diagnosisLinkId value='5'/>
                    <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='0'/>
                            <code value='80061'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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='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>
                <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='T1H'/>
                            <display value='Lab tests - other (non-Medicare fee schedule)'/>
                        </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='5'/>
                    <diagnosisLinkId value='5'/>
                    <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='0'/>
                            <code value='84443'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='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_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='T1A'/>
                            <display value='Lab tests - routine venipuncture (non-Medicare fee schedule)'/>
                        </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='6'/>
                    <diagnosisLinkId value='5'/>
                    <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='0'/>
                            <code value='G0001'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-10-01'/>
                        <end value='2000-10-01'/>
                    </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='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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='60'/>
                        <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--10659692428'/>
                <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='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='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='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='-10659692428'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-07-01'/>
                    <end value='2000-07-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4556'/>
                            <display value='HEMORRHOIDS 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--19990000002208'/>
                    </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='0'/>
                            <code value='99213'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-07-01'/>
                        <end value='2000-07-01'/>
                    </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='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='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--10663528372'/>
                <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='N'/>
                        <display value='Non-assigned claim'/>
                    </valueCoding>
                </extension>
                <extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
                    <valueMoney>
                        <value value='90'/>
                        <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='90'/>
                        <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='90'/>
                        <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='-10663528372'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </patient>
                <billablePeriod>
                    <start value='2000-01-01'/>
                    <end value='2000-01-01'/>
                </billablePeriod>
                <diagnosis>
                    <sequence value='1'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='70211'/>
                            <display value='INFLAMED SBRHEIC KERATOS'/>
                        </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--19990000002208'/>
                    </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='P5A'/>
                            <display value='Ambulatory procedures - skin'/>
                        </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='2'/>
                            <display value='Surgery'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='17000'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-01-01'/>
                        <end value='2000-01-01'/>
                    </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='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>
                <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='4'/>
                        </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='P5A'/>
                            <display value='Ambulatory procedures - skin'/>
                        </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='2'/>
                            <display value='Surgery'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='17003'/>
                        </coding>
                    </service>
                    <servicedPeriod>
                        <start value='2000-01-01'/>
                        <end value='2000-01-01'/>
                    </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='4'/>
                    </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--10831152533'/>
                <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='70'/>
                        <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='90'/>
                        <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='-10831152533'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </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='78650'/>
                            <display value='CHEST PAIN 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='78702'/>
                            <display value='NAUSEA ALONE'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='4019'/>
                            <display value='HYPERTENSION NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='4'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='71690'/>
                            <display value='ARTHROPATHY NOS-UNSPEC'/>
                        </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--19990000002208'/>
                    </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='M3'/>
                            <display value='Emergency room visit'/>
                        </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='9'/>
                            <code value='99284'/>
                        </coding>
                    </service>
                    <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='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/line_alowd_chrg_amt'/>
                                <display value='Line Allowed Charge 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_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='70'/>
                        <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--10833627299'/>
                <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='80'/>
                        <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='100'/>
                        <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='100'/>
                        <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='-10833627299'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </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='2222'/>
                            <display value='BENIGN NEOPLASM PROSTATE'/>
                        </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--19990000002208'/>
                    </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='M6'/>
                            <display value='Consultations'/>
                        </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='3'/>
                            <display value='Consultation'/>
                        </coding>
                    </category>
                    <service>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99243'/>
                        </coding>
                    </service>
                    <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='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_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='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_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='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_alowd_chrg_amt'/>
                                <display value='Line Allowed 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/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='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='carrier--10841743921'/>
                <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='10'/>
                        <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='10'/>
                        <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='-10841743921'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </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='71942'/>
                            <display value='JOINT PAIN-UP/ARM'/>
                        </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--19990000002208'/>
                    </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='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='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='9'/>
                            <code value='73080'/>
                        </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='1999-06-01'/>
                        <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='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='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='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='10'/>
                        <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--10865946953'/>
                <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='0'/>
                        <display value='Denied'/>
                    </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='20'/>
                        <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='-10865946953'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </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='72633'/>
                            <display value='OLECRANON BURSITIS'/>
                        </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--19990000002208'/>
                    </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='P6C'/>
                            <display value='Minor procedures - other (Medicare fee schedule)'/>
                        </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='90782'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-06-01'/>
                        <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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='C'/>
                                <display value='Non-covered care'/>
                            </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--10866191216'/>
                <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='0'/>
                        <display value='Denied'/>
                    </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='20'/>
                        <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='-10866191216'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </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='72633'/>
                            <display value='OLECRANON BURSITIS'/>
                        </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--19990000002208'/>
                    </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='P6C'/>
                            <display value='Minor procedures - other (Medicare fee schedule)'/>
                        </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='90782'/>
                        </coding>
                    </service>
                    <modifier>
                        <coding>
                            <system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
                            <version value='9'/>
                            <code value='99999'/>
                        </coding>
                    </modifier>
                    <servicedPeriod>
                        <start value='1999-06-01'/>
                        <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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='C'/>
                                <display value='Non-covered care'/>
                            </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--10875332991'/>
                <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='90'/>
                        <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='100'/>
                        <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='-10875332991'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </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='72633'/>
                            <display value='OLECRANON BURSITIS'/>
                        </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--19990000002208'/>
                    </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='M1A'/>
                            <display value='Office visits - new'/>
                        </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='99204'/>
                        </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='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_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='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_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='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='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_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='P6C'/>
                            <display value='Minor procedures - other (Medicare fee schedule)'/>
                        </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='9'/>
                            <code value='90782'/>
                        </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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='C'/>
                                <display value='Non-covered care'/>
                            </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='O1E'/>
                            <display value='Other drugs'/>
                        </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='9'/>
                            <code value='J2000'/>
                        </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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='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='0'/>
                            <system value='urn:iso:std:iso:4217'/>
                            <code 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='O'/>
                                <display value='Other'/>
                            </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='O1E'/>
                            <display value='Other drugs'/>
                        </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='9'/>
                            <code value='J0702'/>
                        </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='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='90'/>
                        <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--10967034142'/>
                <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='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='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='-10967034142'/>
                </identifier>
                <identifier>
                    <system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
                    <value value='23945678595'/>
                </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/-19990000002208'/>
                </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='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='36653'/>
                            <display value='AFTR-CATAR OBSCUR VISION'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='3'/>
                    <diagnosisCodeableConcept>
                        <coding>
                            <system value='http://hl7.org/fhir/sid/icd-9-cm'/>
                            <code value='36250'/>
                            <display value='MACULAR DEGENERATION NOS'/>
                        </coding>
                    </diagnosisCodeableConcept>
                </diagnosis>
                <diagnosis>
                    <sequence value='4'/>
                    <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--19990000002208'/>
                    </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='4'/>
                    <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>
                    <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='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='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='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='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_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='30'/>
                        <system value='urn:iso:std:iso:4217'/>
                        <code value='USD'/>
                    </amount>
                </payment>
            </ExplanationOfBenefit>
        </resource>
    </entry>
</Bundle>