src/main/resources/bb-test-data/eob/-19990000002208.xml
<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&startIndex=0&_count=20&patient=-19990000002208'/>
</link>
<link>
<relation value='next'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=20&_count=20&patient=-19990000002208'/>
</link>
<link>
<relation value='last'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=40&_count=20&patient=-19990000002208'/>
</link>
<link>
<relation value='self'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_count=20&_format=application%2Fjson%2Bfhir&patient=-19990000002208&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'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'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'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'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'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'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'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'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'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'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'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'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'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'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'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'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'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'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'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'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>