Use the explanation of benefits to answer the following questions: Walden-Martin Family Medical Clinic 1234 Anystreet Anytown, AK 12345-1234 Treatment Dates Patient Name Yan, Tai Gomez, Pedro Green, Jana XYZ Insurance Company Explanation of Benefits 01/07/20XX Totals CPT Charge Reason Covered Deductible Code Amount Code Amount Amount 132.28 03 15.00 11.34 158.62 01/06/20XX 99206 01/06/20XX 82947 01/06/20XX 86580 Totals 99212 28.55 28.55 70.92 03 40.97 03 111.89 01/04/20XX 99203 01/04/20XX 71020 Totals Reason Code: 03 Allowed amount per insurance contract 125.00 15.00 11.34 151.34 28.55 28.55 69.23 34.95 104.18 0.00 0.00 0.00 0.00 0.00 0.00 Co-Pay Amount Paid At 0.00 80% 0.00 80% 0.00 80% 0.00 80% 0.00 80% 0.00 80% Check No: 56390 01/20/20XX 6. For Tai Yan's office visti, 99205 there is a difference between the charge amount and the covered amount. Based on the reason code supplied what will be done with the difference? 7. How much is Tai Yan responsible for? 8. How much is Jana Green responsible for? 9. What is the covered amount for services provided to Pedro Gomez? Payment Amount 100.00 12.00 9.07 121.07 22.84 22.84 55.38 27.96 83.34 $227.25