src/main/resources/bb-test-data/eob/-19990000002208_20.xml
<Bundle xmlns='http://hl7.org/fhir'>
<id value='75387e4c-08ca-426c-8e48-730e995490c2'/>
<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=40&_count=20&patient=-19990000002208'/>
</link>
<link>
<relation value='previous'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_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=20'/>
</link>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10967166900'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='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='-10967166900'/>
</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='1999-07-01'/>
<end value='1999-07-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</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='5960'/>
<display value='BLADDER NECK OBSTRUCTION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4779'/>
<display value='ALLERGIC RHINITIS NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='72190'/>
<display value='SPONDYLOS NOS W/O MYELOP'/>
</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='9'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-07-01'/>
<end value='1999-07-01'/>
</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='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--10976871266'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='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='-10976871266'/>
</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='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='9'/>
<code value='99212'/>
</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='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='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--10979544742'/>
<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='-10979544742'/>
</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='1999-02-01'/>
<end value='1999-02-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</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='8'/>
<code value='99212'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-02-01'/>
<end value='1999-02-01'/>
</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='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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--10983185614'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='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='-10983185614'/>
</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='1999-08-01'/>
<end value='1999-08-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4779'/>
<display value='ALLERGIC RHINITIS 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='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='5960'/>
<display value='BLADDER NECK OBSTRUCTION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='72190'/>
<display value='SPONDYLOS NOS W/O MYELOP'/>
</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='9'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-08-01'/>
<end value='1999-08-01'/>
</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='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11182864814'/>
<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='-11182864814'/>
</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='1999-10-01'/>
<end value='1999-10-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='72610'/>
<display value='ROTATOR CUFF SYND 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='8'/>
<code value='99211'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-10-01'/>
<end value='1999-10-01'/>
</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='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--11189184881'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='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='20'/>
<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='-11189184881'/>
</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='4779'/>
<display value='ALLERGIC RHINITIS 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='4019'/>
<display value='HYPERTENSION 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='8'/>
<code value='99212'/>
</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='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='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='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='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--11189941129'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='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='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='-11189941129'/>
</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='1999-11-01'/>
<end value='1999-11-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='72610'/>
<display value='ROTATOR CUFF SYND 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='8'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-11-01'/>
<end value='1999-11-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--11197756727'/>
<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='10'/>
<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='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='20'/>
<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='-11197756727'/>
</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='1999-10-01'/>
<end value='1999-10-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='72610'/>
<display value='ROTATOR CUFF SYND 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='8'/>
<code value='99212'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-10-01'/>
<end value='1999-10-01'/>
</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='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_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='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='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='inpatient--1991989294'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_pass_thru_per_diem_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_profnl_cmpnt_chrg_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_tot_pps_cptl_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ip_ddctbl_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_pta_coinsrnc_lblty_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_ip_ncvrd_chrg_amt'>
<valueMoney>
<value value='5000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_ip_tot_ddctn_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_pps_cptl_dsprprtnt_shr_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_pps_cptl_excptn_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_pps_cptl_fsp_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_pps_cptl_ime_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_pps_cptl_outlier_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_pps_old_cptl_hld_hrmls_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_drg_outlier_aprvd_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_mdcr_non_pmt_rsn_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_mdcr_non_pmt_rsn_cd'/>
<code value='Y'/>
<display value='MSP cost avoided - IRS/SSA data match project (obsolete 6/30/00)'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-1991989294'/>
</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='60'/>
<display value='Inpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='INPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='institutional'/>
<display value='Institutional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='V'/>
<display value='Part A institutional claim record (inpatient [IP], skilled nursing facility [SNF], hospice [HOS], or home health agency [HHA])'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='1'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002208'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='1999-11-01'/>
<end value='1999-11-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/nch_ptnt_stus_ind_cd'/>
<display value='NCH Patient Status Indicator Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_ptnt_stus_ind_cd'/>
<code value='A'/>
<display value='Discharged'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_ip_admsn_type_cd'/>
<display value='Claim Inpatient Admission Type Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_ip_admsn_type_cd'/>
<code value='1'/>
<display value='Emergency - The patient required immediate medical intervention as a result of severe, life threatening, or potentially disabling conditions. Generally, the patient was admitted through the emergency room.'/>
</coding>
</code>
</information>
<information>
<sequence value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_src_ip_admsn_cd'/>
<display value='Claim Source Inpatient Admission Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_src_ip_admsn_cd'/>
<code value='7'/>
</coding>
</code>
</information>
<information>
<sequence value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/nch_blood_pnts_frnshd_qty'/>
<display value='NCH Blood Pints Furnished Quantity'/>
</coding>
</category>
<valueQuantity>
<value value='0'/>
<unit value='pint'/>
<system value='http://unitsofmeasure.org'/>
<code value='[pt_us]'/>
</valueQuantity>
</information>
<information>
<sequence value='5'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_mco_pd_sw'/>
<display value='Claim MCO Paid Switch'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_mco_pd_sw'/>
<code value='0'/>
<display value='No managed care organization (MCO) payment'/>
</coding>
</code>
</information>
<information>
<sequence value='6'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='0'/>
<display value='Non-payment/zero claims'/>
</coding>
</code>
</information>
<information>
<sequence value='7'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<diagnosis>
<packageCode>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_drg_cd'/>
<code value='139'/>
</coding>
</packageCode>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='42731'/>
<display value='ATRIAL FIBRILLATION'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='admitting'/>
<display value='The diagnosis given as the reason why the patient was admitted to the hospital.'/>
</coding>
</type>
</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='42611'/>
<display value='ATRIOVENT BLOCK-1ST DEGR'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='5'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4263'/>
<display value='LEFT BB BLOCK NEC'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='6'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='43310'/>
<display value='OCL CRTD ART WO INFRCT'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-a--19990000002208'/>
</coverage>
</insurance>
<hospitalization>
<start value='1999-11-01'/>
<end value='1999-11-01'/>
</hospitalization>
<item>
<sequence value='1'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0120'/>
<display value='Semi-private 2 bed (medical or general) general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='300'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='300'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='300'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='2'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0210'/>
<display value='Coronary care-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='850'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='850'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='850'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='3'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0250'/>
<display value='Pharmacy-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='200'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='200'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='4'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0258'/>
<display value='Pharmacy-IV solutions'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='300'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='300'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='5'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0260'/>
<display value='IV therapy-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='6'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0270'/>
<display value='Medical/surgical supplies-general classification (also see 062X)'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='200'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='200'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='7'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0300'/>
<display value='Laboratory-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='8'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0320'/>
<display value='Radiology diagnostic-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='9'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0350'/>
<display value='Computed tomographic (CT) scan-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='600'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='600'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='10'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0450'/>
<display value='Emergency room - general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='11'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0480'/>
<display value='Cardiology-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='700'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='700'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='12'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0730'/>
<display value='EKG/ECG-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='13'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0732'/>
<display value='EKG/ECG-telemetry'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='14'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0921'/>
<display value='Other diagnostic services-peripheral vascular lab'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='15'/>
<revenue>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='5000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='5000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='5000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
<benefitBalance>
<category>
<coding>
<system value='http://hl7.org/fhir/benefit-category'/>
<code value='medical'/>
<display value='Medical Health Coverage'/>
</coding>
</category>
<financial>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/benefit-balance'/>
<code value='https://bluebutton.cms.gov/resources/variables/bene_tot_coinsrnc_days_cnt'/>
<display value='Beneficiary Total Coinsurance Days Count'/>
</coding>
</type>
<usedUnsignedInt value='6'/>
</financial>
<financial>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/benefit-balance'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_non_utlztn_days_cnt'/>
<display value='Claim Medicare Non Utilization Days Count'/>
</coding>
</type>
<usedUnsignedInt value='9'/>
</financial>
<financial>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/benefit-balance'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_utlztn_day_cnt'/>
<display value='Claim Medicare Utilization Day Count'/>
</coding>
</type>
<usedUnsignedInt value='1'/>
</financial>
</benefitBalance>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9426759837'/>
<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='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='80'/>
<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='-9426759837'/>
</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='2001-07-01'/>
<end value='2001-07-01'/>
</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='78605'/>
<display value='SHORTNESS OF BREATH'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='41401'/>
<display value='CRNRY ATHRSCL NATVE VSSL'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='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='1'/>
<code value='99214'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-07-01'/>
<end value='2001-07-01'/>
</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='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_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='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_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='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>
<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--9433590818'/>
<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='-9433590818'/>
</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='2001-07-01'/>
<end value='2001-07-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='42789'/>
<display value='CARDIAC DYSRHYTHMIAS NEC'/>
</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='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='49121'/>
<display value='OBS CHR BRONC W(AC) EXAC'/>
</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='1'/>
<code value='99214'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-07-01'/>
<end value='2001-07-01'/>
</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='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_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='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_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='T2A'/>
<display value='Other tests - electrocardiograms'/>
</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='4'/>
<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='93000'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-07-01'/>
<end value='2001-07-01'/>
</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='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='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='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--9435904013'/>
<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='300'/>
<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='750'/>
<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='400'/>
<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='-9435904013'/>
</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='2001-06-01'/>
<end value='2001-06-01'/>
</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='78605'/>
<display value='SHORTNESS OF BREATH'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='41401'/>
<display value='CRNRY ATHRSCL NATVE VSSL'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='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='P2F'/>
<display value='Major procedure, cardiovascular-Other'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='5'/>
<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='1'/>
<code value='93510'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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_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='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_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='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_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='400'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='250'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='I4A'/>
<display value='Imaging/procedure - heart including cardiac catheterization'/>
</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='5'/>
<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='1'/>
<code value='93543'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='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='I4A'/>
<display value='Imaging/procedure - heart including cardiac catheterization'/>
</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='5'/>
<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='1'/>
<code value='93545'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='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='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='I4A'/>
<display value='Imaging/procedure - heart including cardiac catheterization'/>
</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='5'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93555'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='I4A'/>
<display value='Imaging/procedure - heart including cardiac catheterization'/>
</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='5'/>
<diagnosisLinkId value='5'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93556'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='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='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='300'/>
<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--9436619288'/>
<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='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='550'/>
<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='400'/>
<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='-9436619288'/>
</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='2001-06-01'/>
<end value='2001-06-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4271'/>
<display value='PAROX VENTRIC TACHYCARD'/>
</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='1'/>
<code value='99263'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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_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='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_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='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='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_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='2'/>
</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='2'/>
<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='1'/>
<code value='99263'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='2'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</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='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='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<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='3'/>
</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='3'/>
<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='1'/>
<code value='99263'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='3'/>
</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='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_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='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_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='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='250'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='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_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9439261787'/>
<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='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='600'/>
<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='-9439261787'/>
</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='2001-06-01'/>
<end value='2001-06-01'/>
</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='4271'/>
<display value='PAROX VENTRIC TACHYCARD'/>
</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='T2B'/>
<display value='Other tests - cardiovascular stress tests'/>
</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='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93016'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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>
<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='T2B'/>
<display value='Other tests - cardiovascular stress tests'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='2'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93018'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='I1E'/>
<display value='Standard imaging - nuclear medicine'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='3'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='78465'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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_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='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_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='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_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='I1E'/>
<display value='Standard imaging - nuclear medicine'/>
</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='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='78478'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='I1E'/>
<display value='Standard imaging - nuclear medicine'/>
</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='5'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='78480'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9464629276'/>
<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='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='80'/>
<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='-9464629276'/>
</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='2001-06-01'/>
<end value='2001-06-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4271'/>
<display value='PAROX VENTRIC TACHYCARD'/>
</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='I3C'/>
<display value='Echography/ultrasonography - heart'/>
</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='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93307'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='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='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>
<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='I3C'/>
<display value='Echography/ultrasonography - heart'/>
</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='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93320'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='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='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='I3C'/>
<display value='Echography/ultrasonography - heart'/>
</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='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93325'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='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--9503059908'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='250'/>
<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='-9503059908'/>
</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='2001-07-01'/>
<end value='2001-07-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='51889'/>
<display value='OTHER LUNG DISEASE NEC'/>
</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='I2B'/>
<display value='Advanced imaging - CAT/CT/CTA: other'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='4'/>
<display value='Diagnostic radiology'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='71260'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-07-01'/>
<end value='2001-07-01'/>
</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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='250'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='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_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9554929006'/>
<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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9554929006'/>
</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='2001-06-01'/>
<end value='2001-06-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='49121'/>
<display value='OBS CHR BRONC W(AC) EXAC'/>
</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='4011'/>
<display value='BENIGN HYPERTENSION'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--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='1'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='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='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--9555021681'/>
<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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9555021681'/>
</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='2001-08-01'/>
<end value='2001-08-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4011'/>
<display value='BENIGN HYPERTENSION'/>
</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='49121'/>
<display value='OBS CHR BRONC W(AC) EXAC'/>
</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='1'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-08-01'/>
<end value='2001-08-01'/>
</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='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='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='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--9558878151'/>
<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='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9558878151'/>
</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='2001-07-01'/>
<end value='2001-07-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='496'/>
<display value='CHR AIRWAY OBSTRUCT NEC'/>
</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='4280'/>
<display value='CHF NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='49121'/>
<display value='OBS CHR BRONC W(AC) EXAC'/>
</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='1'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-07-01'/>
<end value='2001-07-01'/>
</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='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='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='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-10831152533'/>
<meta>
<lastUpdated value='2020-02-14T13:40:48.049+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>
</Bundle>