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Source1

{
  "resourceType": "DocumentReference",
  "id": "PCT-AEOB-DocumentReference-1",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/davinci-pct-aeob-documentreference"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "extension": [
    {
      "url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/requestInitiationTime",
      "valueInstant": "2025-01-08T09:01:00+05:00"
    },
    {
      "url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimateProcedureOrService",
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "http://www.ama-assn.org/go/cpt",
            "code": "70551",
            "display": "Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material"
          }
        ]
      }
    },
    {
      "url": "http://hl7.org/fhir/us/davinci-pct/StructureDefinition/estimateCondition",
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "S06.30",
            "display": "Unspecified focal traumatic brain injury"
          }
        ]
      }
    }
  ],
  "status": "current",
  "docStatus": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "111479-2",
        "display": "Advanced explanation of benefits"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://hl7.org/fhir/us/davinci-pct/CodeSystem/PCTDocumentTypeTemporaryTrialUse",
          "code": "estimate"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/patient1001"
  },
  "date": "2025-01-10T11:01:00+05:00",
  "author": [
    {
      "reference": "Organization/org1001"
    },
    {
      "reference": "Organization/Submitter-Org-1"
    }
  ],
  "content": [
    {
      "attachment": {
        "url": "http://example.org/fhir/Bundle/PCT-AEOB-Packet-1"
      }
    }
  ]
}