<Claim xmlns="http://hl7.org/fhir">
  <id value="core-examples-Claim-example3" />
  <meta>
    <versionId value="1" />
    <lastUpdated value="2016-09-08T11:37:45.889+00:00" />
  </meta>
  <text>
    <status value="generated" />
    <div xmlns="http://www.w3.org/1999/xhtml">A human-readable rendering of the Oral Health Claim</div>
  </text>
  <type value="oral" />
  <identifier>
    <system value="http://happyvalley.com/claim" />
    <value value="12345" />
  </identifier>
  <created value="2014-08-16" />
  <target>
    <reference value="Organization/2" />
  </target>
  <organization>
    <reference value="Organization/1" />
  </organization>
  <use value="complete" />
  <priority>
    <code value="normal" />
  </priority>
  <payee>
    <type>
      <code value="provider" />
    </type>
  </payee>
  <diagnosis>
    <sequence value="1" />
    <diagnosis>
      <code value="123456" />
    </diagnosis>
  </diagnosis>
  <patient>
    <reference value="Patient/1" />
  </patient>
  <coverage>
    <sequence value="1" />
    <focal value="true" />
    <coverage>
      <reference value="Coverage/9876B1" />
    </coverage>
    <relationship>
      <code value="self" />
    </relationship>
  </coverage>
  <item>
    <sequence value="1" />
    <type>
      <code value="service" />
    </type>
    <provider>
      <reference value="Practitioner/example" />
    </provider>
    <service>
      <code value="1200" />
    </service>
    <serviceDate value="2014-08-16" />
    <unitPrice>
      <value value="135.57" />
      <system value="urn:iso:std:iso:4217" />
      <code value="USD" />
    </unitPrice>
    <net>
      <value value="135.57" />
      <system value="urn:iso:std:iso:4217" />
      <code value="USD" />
    </net>
  </item>
</Claim>