src/main/resources/bb-test-data/eob/-19990000002209_10.xml
<Bundle xmlns='http://hl7.org/fhir'>
<id value='4fe66690-ef0e-4f83-877c-01e84ffd37cf'/>
<meta>
<lastUpdated value='2020-04-24T18:46:46.726+00:00'/>
</meta>
<type value='searchset'/>
<total value='27'/>
<link>
<relation value='first'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=20&patient=-19990000002209'/>
</link>
<link>
<relation value='previous'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=20&patient=-19990000002209'/>
</link>
<link>
<relation value='last'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=20&_count=20&patient=-19990000002209'/>
</link>
<link>
<relation value='self'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_count=20&_format=application%2Fjson%2Bfhir&patient=-19990000002209&startIndex=10'/>
</link>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9308383566'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9308383566'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='2001-01-01'/>
<end value='2001-01-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7020'/>
<display value='ACTINIC KERATOSIS'/>
</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--19990000002209'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='M1B'/>
<display value='Office visits - established'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='1'/>
<display value='Medical care'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='99212'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-01-01'/>
<end value='2001-01-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<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--9326202605'/>
<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='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='-9326202605'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='2001-01-01'/>
<end value='2001-01-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7020'/>
<display value='ACTINIC KERATOSIS'/>
</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--19990000002209'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='P5A'/>
<display value='Ambulatory procedures - skin'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='2'/>
<display value='Surgery'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='17000'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-01-01'/>
<end value='2001-01-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='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_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='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--9519964171'/>
<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='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='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='-9519964171'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='2001-02-01'/>
<end value='2001-02-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='36511'/>
<display value='PRIM OPEN ANGLE GLAUCOMA'/>
</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='37202'/>
<display value='AC FOLLIC CONJUNCTIVITIS'/>
</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--19990000002209'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='M1B'/>
<display value='Office visits - established'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='1'/>
<display value='Medical care'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='0'/>
<code value='99213'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-02-01'/>
<end value='2001-02-01'/>
</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='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='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='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='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--9883965662'/>
<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='450'/>
<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='-9883965662'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='36612'/>
<display value='INCIPIENT CATARACT'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='1'/>
<display value='Medical care'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92014'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='2'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92083'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='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_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='N'/>
<display value='Medically unnecessary'/>
</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='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='3'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92135'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='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_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='N'/>
<display value='Medically unnecessary'/>
</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='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='4'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92135'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='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_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='N'/>
<display value='Medically unnecessary'/>
</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--9884040508'/>
<meta>
<lastUpdated value='2020-01-01T00:00:00.000+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='450'/>
<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='-9884040508'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='36612'/>
<display value='INCIPIENT CATARACT'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='36504'/>
<display value='OCULAR 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--19990000002209'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='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='92014'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='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='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='2'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92083'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='3'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92135'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='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='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='4'/>
<diagnosisLinkId value='3'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='92135'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='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='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier--9885046438'/>
<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='70'/>
<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='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='-9885046438'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='2001-05-01'/>
<end value='2001-05-01'/>
</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='2780'/>
<display value='OBESITY'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='2724'/>
<display value='HYPERLIPIDEMIA NEC/NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='56210'/>
<display value='DVRTCLO COLON W/O HMRHG'/>
</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--19990000002209'/>
</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>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='2001-05-01'/>
<end value='2001-05-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='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_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='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_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='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='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='5'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='1'/>
<code value='93000'/>
</coding>
</service>
<servicedPeriod>
<start value='2001-05-01'/>
<end value='2001-05-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='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-11072662431'/>
<meta>
<lastUpdated value='2020-02-14T13:40:46.032+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='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='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='11072662431'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</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='25070'/>
<display value='DMII CIRC NT ST UNCNTRLD'/>
</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='44381'/>
<display value='ANGIOPATHY IN OTHER DIS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='7038'/>
<display value='DISEASES OF NAIL NEC'/>
</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--19990000002209'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='P5A'/>
<display value='Ambulatory procedures - skin'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='4'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='2'/>
<display value='Surgery'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='G0127'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='1999-11-01'/>
<end value='1999-11-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<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-11373571348'/>
<meta>
<lastUpdated value='2020-02-14T13:40:46.032+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='11373571348'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='1999-03-01'/>
<end value='1999-03-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='1733'/>
<display value='MAL NEO SKIN FACE 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--19990000002209'/>
</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='T1G'/>
<display value='Lab tests - other (Medicare fee schedule)'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='5'/>
<display value='Diagnostic laboratory'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='88305'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='1999-03-01'/>
<end value='1999-03-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='50'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier-11378383216'/>
<meta>
<lastUpdated value='2020-02-14T13:40:46.032+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='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='11378383216'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</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='36616'/>
<display value='SENILE NUCLEAR CATARACT'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</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='99214'/>
</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='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='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>
<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-11382220315'/>
<meta>
<lastUpdated value='2020-02-14T13:40:46.032+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='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='90'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='11382220315'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</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='36616'/>
<display value='SENILE NUCLEAR CATARACT'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</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='99214'/>
</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='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_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='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_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='M5C'/>
<display value='Specialist - ophthalmology'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='2'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='Q'/>
<display value='Vision items or services'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='8'/>
<code value='92015'/>
</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='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='C'/>
<display value='Non-covered care'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier-11382284538'/>
<meta>
<lastUpdated value='2020-02-14T13:40:46.032+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_alowd_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='11382284538'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='1999-01-01'/>
<end value='1999-01-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4019'/>
<display value='HYPERTENSION NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='9999999'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</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='1999-01-01'/>
<end value='1999-01-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_pmt_amt'/>
<display value='Line Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prvdr_pmt_amt'/>
<display value='Line Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_ptb_ddctbl_amt'/>
<display value='Line Beneficiary Part B Deductible Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_sbmtd_chrg_amt'/>
<display value='Line Submitted Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier-11383925767'/>
<meta>
<lastUpdated value='2020-02-14T13:40:46.032+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_carr_clm_sbmtd_chrg_amt'>
<valueMoney>
<value value='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='11383925767'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='1999-01-01'/>
<end value='1999-01-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='43310'/>
<display value='OCL CRTD ART WO INFRCT'/>
</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--19990000002209'/>
</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='I3D'/>
<display value='Echography/ultrasonography - carotid arteries'/>
</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='9'/>
<code value='93880'/>
</coding>
</service>
<modifier>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='99999'/>
</coding>
</modifier>
<servicedPeriod>
<start value='1999-01-01'/>
<end value='1999-01-01'/>
</servicedPeriod>
<locationCodeableConcept>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_state_cd'/>
<code value='99'/>
<display value='With 000 county code is American Samoa; otherwise unknown'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prvdr_zip'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_zip'/>
<code value='999999999'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_prcng_lclty_cd'/>
<code value='99'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_place_of_srvc_cd'/>
<code value='99'/>
<display value='Other Place of Service. Other place of service not identified above.'/>
</coding>
</locationCodeableConcept>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<display value='Carrier Line Reduced Payment Physician Assistant Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_rdcd_pmt_phys_astn_c'/>
<code value='0'/>
<display value='N/A'/>
</coding>
</reason>
</adjudication>
<adjudication>
<extension url='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_pmt_80_100_cd'/>
<code value='0'/>
<display value='80%'/>
</valueCoding>
</extension>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_nch_pmt_amt'/>
<display value='Line NCH Medicare Payment Amount'/>
</coding>
</category>
<amount>
<value value='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='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='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/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='carrier-11383928460'/>
<meta>
<lastUpdated value='2020-02-14T13:40:46.032+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/carr_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_clm_pmt_dnl_cd'/>
<code value='1'/>
<display value='Physician/supplier'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/asgmntcd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/asgmntcd'/>
<code value='A'/>
<display value='Assigned claim'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_clm_cash_ddctbl_apld_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_clm_prvdr_pmt_amt'>
<valueMoney>
<value value='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='300'/>
<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='11383928460'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</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/-19990000002209'/>
</patient>
<billablePeriod>
<start value='1999-03-01'/>
<end value='1999-03-01'/>
</billablePeriod>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='1733'/>
<display value='MAL NEO SKIN FACE 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--19990000002209'/>
</coverage>
</insurance>
<item>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cd'/>
<code value='3'/>
<display value='Services'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/carr_line_mtus_cnt'>
<valueQuantity>
<value value='1'/>
</valueQuantity>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/betos_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/betos_cd'/>
<code value='P5A'/>
<display value='Ambulatory procedures - skin'/>
</valueCoding>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/line_service_deductible'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/line_service_deductible'/>
<code value='0'/>
<display value='Service Subject to Deductible'/>
</valueCoding>
</extension>
<sequence value='1'/>
<diagnosisLinkId value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_cms_type_srvc_cd'/>
<code value='2'/>
<display value='Surgery'/>
</coding>
</category>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<version value='9'/>
<code value='17281'/>
</coding>
</service>
<servicedPeriod>
<start value='1999-03-01'/>
<end value='1999-03-01'/>
</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='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_bene_prmry_pyr_pd_amt'/>
<display value='Line Primary Payer (if not Medicare) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_coinsrnc_amt'/>
<display value='Line Beneficiary Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='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_sbmtd_chrg_amt'/>
<display value='Line Submitted 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/line_alowd_chrg_amt'/>
<display value='Line Allowed Charge Amount'/>
</coding>
</category>
<amount>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<display value='Line Processing Indicator Code'/>
</coding>
</category>
<reason>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/line_prcsg_ind_cd'/>
<code value='A'/>
<display value='Allowed'/>
</coding>
</reason>
</adjudication>
</item>
<payment>
<amount>
<value value='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='outpatient-1155442610'/>
<meta>
<lastUpdated value='2020-03-20T16:42:18.971+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
<valueMoney>
<value value='40'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='1155442610'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='4'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002209'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='2000-11-01'/>
<end value='2000-11-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='1'/>
<display value='Admit thru discharge claim'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='assist'/>
<display value='Assisting Provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='3'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='other'/>
<display value='Other'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='4'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='5'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='999999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='25000'/>
<display value='DMII WO CMP NT ST UNCNTR'/>
</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>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='V'/>
<display value='Medical visit to clinic or emergency department'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0300'/>
<display value='Laboratory-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='82043'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='2'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0300'/>
<display value='Laboratory-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='83036'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='3'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0301'/>
<display value='Laboratory-chemistry'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='80048'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='4'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0301'/>
<display value='Laboratory-chemistry'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='82570'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='5'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='4'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='150'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<payment>
<amount>
<value value='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='outpatient-1236708778'/>
<meta>
<lastUpdated value='2020-03-20T16:42:18.971+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
<valueMoney>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='1236708778'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='4'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002209'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='2000-11-01'/>
<end value='2000-11-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='1'/>
<display value='Admit thru discharge claim'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='assist'/>
<display value='Assisting Provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='3'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='other'/>
<display value='Other'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='4'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='5'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='999999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4019'/>
<display value='HYPERTENSION NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0301'/>
<display value='Laboratory-chemistry'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='80048'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='2'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0305'/>
<display value='Laboratory-hematology'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='G0001'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='3'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<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/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='30'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<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='outpatient-1770126721'/>
<meta>
<lastUpdated value='2020-03-20T16:42:25.127+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
<valueMoney>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='1770126721'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='4'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002209'/>
</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='2001-04-01'/>
<end value='2001-04-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='1'/>
<display value='Admit thru discharge claim'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='assist'/>
<display value='Assisting Provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='3'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='other'/>
<display value='Other'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='4'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='5'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='999999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='73390'/>
<display value='BONE & CARTILAGE DIS 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>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0309'/>
<display value='Laboratory-other laboratory'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='83520'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='2'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='S'/>
<display value='Significant procedure not subject to multiple procedure discounting'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='100'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<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='outpatient-1877442625'/>
<meta>
<lastUpdated value='2020-03-20T16:42:25.127+00:00'/>
</meta>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_profnl_cmpnt_chrg_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_ddctbl_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_ptb_coinsrnc_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
<valueMoney>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='1877442625'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='24775336229'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='4'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002209'/>
</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='2001-08-01'/>
<end value='2001-08-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='1'/>
<display value='Admit thru discharge claim'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='assist'/>
<display value='Assisting Provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='3'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='other'/>
<display value='Other'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='4'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='5'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='999999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='73390'/>
<display value='BONE & CARTILAGE DIS 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>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002209'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0309'/>
<display value='Laboratory-other laboratory'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='80053'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='2'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0309'/>
<display value='Laboratory-other laboratory'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='85025'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='10'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='3'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='S'/>
<display value='Significant procedure not subject to multiple procedure discounting'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<payment>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
</Bundle>