{

"resourceType": "Claim",
"id": "100151",
"text": {
  "status": "generated",
  "div": "<div>A human-readable rendering of the Oral Health Claim</div>"
},
"type": "oral",
"identifier": [
  {
    "system": "http://happyvalley.com/claim",
    "value": "12346"
  }
],
"created": "2014-08-16",
"target": {
  "reference": "Organization/2"
},
"organization": {
  "reference": "Organization/1"
},
"use": "complete",
"priority": {
  "code": "normal"
},
"payee": {
  "type": {
    "code": "provider"
  }
},
"diagnosis": [
  {
    "sequence": 1,
    "diagnosis": {
      "code": "123456"
    }
  }
],
"patient": {
  "reference": "Patient/1"
},
"coverage": [
  {
    "sequence": 1,
    "focal": true,
    "coverage": {
      "reference": "Coverage/9876B1"
    },
    "relationship": {
      "code": "self"
    }
  }
],
"item": [
  {
    "sequence": 1,
    "type": {
      "code": "CSINV"
    },
    "provider": {
      "reference": "Practitioner/example"
    },
    "service": {
      "system": "http://hl7.org/fhir/oralservicecodes",
      "code": "1200"
    },
    "serviceDate": "2014-08-16",
    "unitPrice": {
      "value": 135.57,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 135.57,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    }
  },
  {
    "sequence": 2,
    "type": {
      "code": "CSINV"
    },
    "provider": {
      "reference": "Practitioner/example"
    },
    "service": {
      "system": "http://hl7.org/fhir/oralservicecodes",
      "code": "21211"
    },
    "serviceDate": "2014-08-16",
    "unitPrice": {
      "value": 105.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 105.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "bodySite": {
      "system": "http://fdi.org/fhir/oraltoothcodes",
      "code": "21"
    },
    "subSite": [
      {
        "system": "http://fdi.org/fhir/oralsurfacecodes",
        "code": "L"
      }
    ]
  },
  {
    "sequence": 3,
    "type": {
      "code": "CPNDDRGING"
    },
    "provider": {
      "reference": "Practitioner/example"
    },
    "service": {
      "system": "http://hl7.org/fhir/oralservicecodes",
      "code": "27211"
    },
    "serviceDate": "2014-08-16",
    "unitPrice": {
      "value": 1100.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "net": {
      "value": 1100.00,
      "system": "urn:iso:std:iso:4217",
      "code": "USD"
    },
    "bodySite": {
      "system": "http://fdi.org/fhir/oraltoothcodes",
      "code": "36"
    },
    "detail": [
      {
        "sequence": 1,
        "type": {
          "code": "CSINV"
        },
        "service": {
          "system": "http://hl7.org/fhir/oralservicecodes",
          "code": "27211"
        },
        "unitPrice": {
          "value": 750.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 750.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      },
      {
        "sequence": 2,
        "type": {
          "code": "CSINV"
        },
        "service": {
          "system": "http://hl7.org/fhir/oralservicecodes",
          "code": "lab"
        },
        "unitPrice": {
          "value": 350.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        },
        "net": {
          "value": 350.00,
          "system": "urn:iso:std:iso:4217",
          "code": "USD"
        }
      }
    ]
  }
]

}