src/main/resources/bb-test-data/eob/-19990000002210_60.xml
<Bundle xmlns='http://hl7.org/fhir'>
<id value='bcf1e37d-2801-4d0e-a700-bd316de036de'/>
<meta>
<lastUpdated value='2020-04-24T18:46:46.726+00:00'/>
</meta>
<type value='searchset'/>
<total value='68'/>
<link>
<relation value='first'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=0&_count=20&patient=-19990000002210'/>
</link>
<link>
<relation value='previous'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=40&_count=20&patient=-19990000002210'/>
</link>
<link>
<relation value='last'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit?_format=application%2Fjson%2Bfhir&startIndex=60&_count=20&patient=-19990000002210'/>
</link>
<link>
<relation value='self'/>
<url value='https://sandbox.bluebutton.cms.gov/v1/fhir/ExplanationOfBenefit/?_count=20&_format=application%2Fjson%2Bfhir&patient=-19990000002210&startIndex=60'/>
</link>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='outpatient-1761815683'/>
<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='150'/>
<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='150'/>
<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='1761815683'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='3'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='2001-05-01'/>
<end value='2001-05-01'/>
</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='53081'/>
<display value='ESOPHAGEAL REFLUX'/>
</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='4299'/>
<display value='HEART DISEASE NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<procedure>
<sequence value='1'/>
<date value='2001-05-01T00:00:00+00:00'/>
<procedureCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4229'/>
<display value='ESOPHAGEAL DX PROC NEC'/>
</coding>
</procedureCodeableConcept>
</procedure>
<procedure>
<sequence value='2'/>
<date value='2001-05-01T00:00:00+00:00'/>
<procedureCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='8932'/>
<display value='ESOPHAGEAL MANOMETRY'/>
</coding>
</procedureCodeableConcept>
</procedure>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0270'/>
<display value='Medical/surgical supplies-general classification (also see 062X)'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='90'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/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='0750'/>
<display value='Gastro-intestinal services-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='91010'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='500'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='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='0750'/>
<display value='Gastro-intestinal services-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='91033'/>
</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='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='2000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='2000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<payment>
<amount>
<value value='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='outpatient-1762835193'/>
<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='60'/>
<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='1762835193'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='3'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='2001-06-01'/>
<end value='2001-06-01'/>
</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='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='2449'/>
<display value='HYPOTHYROIDISM NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0301'/>
<display value='Laboratory-chemistry'/>
</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='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='80061'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='3'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='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='84443'/>
</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='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='4'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='B'/>
<display value='Non-allowed item or service for OPPS; may be paid under a different bill type (e.g., CORF)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0305'/>
<display value='Laboratory-hematology'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='85027'/>
</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='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>
<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='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='0307'/>
<display value='Laboratory-urology'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='81000'/>
</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='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>
<item>
<sequence value='6'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='200'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='200'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<payment>
<amount>
<value value='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='outpatient-1763420391'/>
<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='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='1763420391'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='3'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='2001-02-01'/>
<end value='2001-02-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='1'/>
<display value='Admit thru discharge claim'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='assist'/>
<display value='Assisting Provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='3'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='other'/>
<display value='Other'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='4'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='5'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='999999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='2449'/>
<display value='HYPOTHYROIDISM 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--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0301'/>
<display value='Laboratory-chemistry'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='84436'/>
</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='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>
<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='0301'/>
<display value='Laboratory-chemistry'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='84443'/>
</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='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='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='0301'/>
<display value='Laboratory-chemistry'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='84479'/>
</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='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='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-1765383236'/>
<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='60'/>
<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='50'/>
<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='1765383236'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='3'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='5'/>
<display value='Debit adjustment'/>
</valueCoding>
</extension>
<start value='2001-03-01'/>
<end value='2001-03-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='1'/>
<display value='Admit thru discharge claim'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='assist'/>
<display value='Assisting Provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='3'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='other'/>
<display value='Other'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='4'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='5'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='999999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='78791'/>
<display value='DIARRHEA'/>
</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--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0255'/>
<display value='Pharmacy-drugs incident to radiology-subject to payment limit'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='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='0320'/>
<display value='Radiology diagnostic-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='74280'/>
</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='300'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='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='400'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/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='400'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<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='outpatient-1770816518'/>
<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='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_prvdr_pmt_amt'>
<valueMoney>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_op_bene_pmt_amt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/nch_bene_blood_ddctbl_lblty_am'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/prpayamt'>
<valueMoney>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</valueMoney>
</extension>
<extension url='https://bluebutton.cms.gov/resources/variables/fi_num'>
<valueIdentifier>
<system value='https://bluebutton.cms.gov/resources/variables/fi_num'/>
<value value='99999'/>
</valueIdentifier>
</extension>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/clm_id'/>
<value value='1770816518'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='3'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='2001-03-01'/>
<end value='2001-03-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='7'/>
<display value='Clinic services or hospital-based renal dialysis facility'/>
</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='0'/>
<display value='Unknown Value (but present in data)'/>
</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='3804'/>
<display value='IMPACTED CERUMEN'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4019'/>
<display value='HYPERTENSION NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0520'/>
<display value='Free-standing clinic-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='99212'/>
</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='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='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='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='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='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</payment>
</ExplanationOfBenefit>
</resource>
</entry>
<entry>
<resource>
<ExplanationOfBenefit xmlns='http://hl7.org/fhir'>
<id value='outpatient-1873778116'/>
<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='200'/>
<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='200'/>
<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='1873778116'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='3'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='2001-09-01'/>
<end value='2001-09-01'/>
</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='2113'/>
<display value='BENIGN NEOPLASM LG BOWEL'/>
</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='56949'/>
<display value='RECTAL & ANAL DIS NEC'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='3'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4019'/>
<display value='HYPERTENSION NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<diagnosis>
<sequence value='4'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='5699'/>
<display value='INTESTINAL DISORDER NOS'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<procedure>
<sequence value='1'/>
<date value='2001-09-01T00:00:00+00:00'/>
<procedureCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4525'/>
<display value='CLOS LARGE BOWEL BIOPSY'/>
</coding>
</procedureCodeableConcept>
</procedure>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0250'/>
<display value='Pharmacy-general classification'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='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='0270'/>
<display value='Medical/surgical supplies-general classification (also see 062X)'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='8'/>
</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='350'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='0310'/>
<display value='Laboratory pathological-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='88305'/>
</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='60'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='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='0361'/>
<display value='Operating room services-minor surgery'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='45380'/>
</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='600'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='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='0636'/>
<display value='Drugs requiring specific identification-detailed coding'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='J2175'/>
</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='6'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='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='0636'/>
<display value='Drugs requiring specific identification-detailed coding'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='J2250'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='5'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='7'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<payment>
<amount>
<value value='200'/>
<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-1879122301'/>
<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='200'/>
<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='200'/>
<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='1879122301'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='3'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='5'/>
<display value='Debit adjustment'/>
</valueCoding>
</extension>
<start value='2001-03-01'/>
<end value='2001-03-01'/>
</billablePeriod>
<provider>
<identifier>
<system value='https://bluebutton.cms.gov/resources/variables/prvdr_num'/>
<value value='999999'/>
</identifier>
</provider>
<organization>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</organization>
<facility>
<extension url='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_fac_type_cd'/>
<code value='1'/>
<display value='Hospital'/>
</valueCoding>
</extension>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</facility>
<information>
<sequence value='1'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<display value='Claim Frequency Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_freq_cd'/>
<code value='1'/>
<display value='Admit thru discharge claim'/>
</coding>
</code>
</information>
<information>
<sequence value='2'/>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/information'/>
<code value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<display value='Patient Discharge Status Code'/>
</coding>
</category>
<code>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/ptnt_dschrg_stus_cd'/>
<code value='01'/>
<display value='Discharged to home/self-care (routine charge).'/>
</coding>
</code>
</information>
<careTeam>
<sequence value='2'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='assist'/>
<display value='Assisting Provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='3'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='other'/>
<display value='Other'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='4'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='9999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<careTeam>
<sequence value='5'/>
<provider>
<identifier>
<system value='http://hl7.org/fhir/sid/us-npi'/>
<value value='999999999999'/>
</identifier>
</provider>
<role>
<coding>
<system value='http://hl7.org/fhir/claimcareteamrole'/>
<code value='primary'/>
<display value='Primary provider'/>
</coding>
</role>
</careTeam>
<diagnosis>
<sequence value='1'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='78791'/>
<display value='DIARRHEA'/>
</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>
<procedure>
<sequence value='1'/>
<date value='2001-03-01T00:00:00+00:00'/>
<procedureCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4525'/>
<display value='CLOS LARGE BOWEL BIOPSY'/>
</coding>
</procedureCodeableConcept>
</procedure>
<procedure>
<sequence value='2'/>
<date value='2001-03-01T00:00:00+00:00'/>
<procedureCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='4824'/>
<display value='CLOSED RECTAL BIOPSY'/>
</coding>
</procedureCodeableConcept>
</procedure>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='N'/>
<display value='Packaged incidental service (no separate APC payment)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0250'/>
<display value='Pharmacy-general classification'/>
</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='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='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='0270'/>
<display value='Medical/surgical supplies-general classification (also see 062X)'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='10'/>
</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='90'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/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='0310'/>
<display value='Laboratory pathological-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='88305'/>
</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='70'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='4'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='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='0320'/>
<display value='Radiology diagnostic-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='74000'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='80'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='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='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='0750'/>
<display value='Gastro-intestinal services-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='45380'/>
</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='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<item>
<sequence value='6'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ncvrd_chrg_amt'/>
<display value='Revenue Center Non-Covered Charge Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
</item>
<totalCost>
<value value='1000'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</totalCost>
<payment>
<amount>
<value value='200'/>
<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-1969044331'/>
<meta>
<lastUpdated value='2020-03-20T16:42:10.784+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='1969044331'/>
</identifier>
<identifier>
<system value='https://bluebutton.cms.gov/resources/identifier/claim-group'/>
<value value='1339493320'/>
</identifier>
<status value='active'/>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_clm_type_cd'/>
<code value='40'/>
<display value='Hospital Outpatient claim'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/eob-type'/>
<code value='OUTPATIENT'/>
</coding>
<coding>
<system value='http://hl7.org/fhir/ex-claimtype'/>
<code value='professional'/>
<display value='Professional'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/nch_near_line_rec_ident_cd'/>
<code value='W'/>
<display value='Part B institutional claim record (outpatient [HOP], HHA)'/>
</coding>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/clm_srvc_clsfctn_type_cd'/>
<code value='4'/>
</coding>
</type>
<patient>
<reference value='Patient/-19990000002210'/>
</patient>
<billablePeriod>
<extension url='https://bluebutton.cms.gov/resources/variables/claim_query_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/claim_query_cd'/>
<code value='3'/>
<display value='Final bill'/>
</valueCoding>
</extension>
<start value='1999-05-01'/>
<end value='1999-05-01'/>
</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='2724'/>
<display value='HYPERLIPIDEMIA NEC/NOS'/>
</coding>
</diagnosisCodeableConcept>
<type>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/diagnosis-type'/>
<code value='principal'/>
<display value='The single medical diagnosis that is most relevant to the patient's chief complaint or need for treatment.'/>
</coding>
</type>
</diagnosis>
<diagnosis>
<sequence value='2'/>
<diagnosisCodeableConcept>
<coding>
<system value='http://hl7.org/fhir/sid/icd-9-cm'/>
<code value='496'/>
<display value='CHR AIRWAY OBSTRUCT NEC'/>
</coding>
</diagnosisCodeableConcept>
</diagnosis>
<insurance>
<coverage>
<reference value='Coverage/part-b--19990000002210'/>
</coverage>
</insurance>
<item>
<sequence value='1'/>
<careTeamLinkId value='5'/>
<revenue>
<extension url='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'>
<valueCoding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr_stus_ind_cd'/>
<code value='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0300'/>
<display value='Laboratory-general classification'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='G0001'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='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='0301'/>
<display value='Laboratory-chemistry'/>
</coding>
</revenue>
<service>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/hcpcs'/>
<code value='80061'/>
</coding>
</service>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='1'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='20'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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='A'/>
<display value='Services not paid under OPPS; uses a different fee schedule (e.g., ambulance, PT, mammography)'/>
</valueCoding>
</extension>
<coding>
<system value='https://bluebutton.cms.gov/resources/variables/rev_cntr'/>
<code value='0001'/>
<display value='Total charge'/>
</coding>
</revenue>
<locationAddress>
<state value='99'/>
</locationAddress>
<quantity>
<value value='0'/>
</quantity>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_blood_ddctbl_amt'/>
<display value='Revenue Center Blood Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_cash_ddctbl_amt'/>
<display value='Revenue Center Cash Deductible Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_coinsrnc_wge_adjstd_c'/>
<display value='Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rdcd_coinsrnc_amt'/>
<display value='Revenue Center Reduced Coinsurance Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_1st_msp_pd_amt'/>
<display value='Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_2nd_msp_pd_amt'/>
<display value='Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_prvdr_pmt_amt'/>
<display value='Revenue Center (Medicare) Provider Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_bene_pmt_amt'/>
<display value='Revenue Center Payment Amount to Beneficiary'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_ptnt_rspnsblty_pmt'/>
<display value='Revenue Center Patient Responsibility Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_pmt_amt_amt'/>
<display value='Revenue Center (Medicare) Payment Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_rate_amt'/>
<display value='Revenue Center Rate Amount'/>
</coding>
</category>
<amount>
<value value='0'/>
<system value='urn:iso:std:iso:4217'/>
<code value='USD'/>
</amount>
</adjudication>
<adjudication>
<category>
<coding>
<system value='https://bluebutton.cms.gov/resources/codesystem/adjudication'/>
<code value='https://bluebutton.cms.gov/resources/variables/rev_cntr_tot_chrg_amt'/>
<display value='Revenue Center Total Charge Amount'/>
</coding>
</category>
<amount>
<value value='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>
<totalCost>
<value value='40'/>
<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>