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Yanxin Lu
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documents/medical/scrc/lu_scrc_iui_receipt.jpg
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---
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type: receipt
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category: patient_summary
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person: Xiuwei Jiang
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date: 2026-01-17
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provider: SCRC (Southern California Reproductive Center)
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source: lu_scrc_iui_receipt.jpg
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---
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# SCRC Patient Summary & Reason for Visit
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**SCRC**
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600 N. Roxbury Drive, A
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500 Beverly Hills, CA
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Tel: (310) 277-2393
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Fax: (310) 274-5112
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**Physicians:**
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- D.A. KUKREJA, M.D.
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- M. JAHAN, M.D.
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- C. ALEXANDER, M.D.
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- D.A. SAHNI, M.D.
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- R.E. SHAMONKI, M.D.
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- A. MANSON, M.D.
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- C.A. SHARK, M.D.
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- C.A. HIRSHMAN, M.D.
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- C.A. HIRSHMAN, M.D.
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---
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## Visit Information
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| Field | Value |
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|---|---|
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| Date | 01/17/2026 07:30 AM |
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| Patient | XUEWEL JIANG |
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| Account | T05151 |
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| Address | ART LLC |
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| Phone | (254) 214-9350 |
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| ZIP Code | |
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---
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## CPT Code Reference Lists
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### Office Visit
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| CPT | Description | Fee |
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|---|---|---|
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| 99201 | New level 1 (10-15 min) | |
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| 99202 | New level 2 (15-30 min) | |
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| 99024 | Statement - level 2 (30 min) | |
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| 99203 | New level 3 (30 min) | |
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| 99204 | New level 4 (45 min) | |
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### Office Visit - Established Patient
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| CPT | Description | Fee |
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|---|---|---|
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| 99211 | Establish - level 1 (5 min) | |
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| 99212 | Establish - level 2 (10 min) | |
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| 99213 | Establish - level 3 (15 min) | |
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| 99214 | Procedure - level 3 (15-18 min) | |
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| 99215 | Establish - level 5 | |
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| 99174 | Pre Op Visit | |
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### Consultation - Telephone
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| CPT | Description | Fee |
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|---|---|---|
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| 99441 | Establish/telephone | |
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### Nursing Visit
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| CPT | Description | Fee |
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|---|---|---|
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| 96372 | Injection IM/Subq | |
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| 96901 | Intrauterine 15 follicles | |
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| 90460 | Dose 8 w/eval yr 30 MO | |
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### Procedures
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| CPT | Description | Fee |
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|---|---|---|
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| 100 | Smeical Results | |
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| 99080 | Stannone, Initial exam | |
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| 99080 | Standard/surg note dressing | |
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### Diagnostics
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| CPT | Description | Fee |
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|---|---|---|
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| 18001 | Thrombophilia | |
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| 18819 | MFI | |
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| 18015 | | |
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| 59430 | Postpartumorgasm | |
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### Office Procedures
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| CPT | Description | Fee |
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|---|---|---|
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| 89310 | Endom Biopsy | |
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| 57500 | Endom Biopsy | |
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| 57010 | Colposcopy | |
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| 76856 | US Pelvis | |
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| 76830 | US Transvaginal | |
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### Microbiology
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| CPT | Description | Fee |
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|---|---|---|
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| 87070 | Urethera, Routine | |
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| 87070 | Culture Cervical | |
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| 87081 | Culture Urine | |
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| 87116 | ID Mycoplasm | |
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| 86317 | Immun Inf Ag | |
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### Microbiology (continued)
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| CPT | Description | Fee |
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|---|---|---|
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| 99201 | Cysteine (1 time) | |
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| 88025 | Direct Nasopharyngeal | |
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### Endocrinology
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| CPT | Description | Fee |
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|---|---|---|
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| 84443 | Prolactin | |
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| 84146 | Prolactin | |
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| 84270 | | |
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### Screening
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| CPT | Description | Fee |
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|---|---|---|
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| 80055 | | |
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| 86235 | Vitamin D (25,1,21) | |
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| 84439 | | |
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| 84432 | Thyroglobulin (1,21,84) | |
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| 84443 | TSH | |
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| 84270 | Tire Testosterone | |
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| 94402 | | |
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### Andrology
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| CPT | Description | Fee |
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|---|---|---|
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| 89310 | Semen Analysis SMAC | |
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| 89321 | Sperm Wash / Gradient | |
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### Screening (continued)
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| CPT | Description | Fee |
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|---|---|---|
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| 85730 | Pre-wash | |
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| 87340 | HEP B Surface Ag (21.84) | |
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| 86762 | | |
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| 86703 | HIV 1, 10 (21.84) | |
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| 86706 | HEP B ag Total | |
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| 86644 | | |
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| 88694 | CMV IgG | |
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| 86698 | | |
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| 86803 | Hep C Ab by PCR | |
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| 87801 | | |
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| 87491 | Chlamydia by NAAT/SDA | |
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| 86850 | | |
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| 84030 | Estren LH | |
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### IUI/ART Related
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| CPT | Description | Fee |
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|---|---|---|
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| 99316 | IVF | |
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| 89268 | | |
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### Screening (continued)
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| CPT | Description | Fee |
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|---|---|---|
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| 86190 | Insp. B Surface Ab | |
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| 88177 | Gonorrhea gC2 | |
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| 87592 | Treponema | |
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| 87110 | | |
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### ART Related
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| CPT | Description | Fee |
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|---|---|---|
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| | IVF/Hysteroscopy | |
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| | FET | |
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| | Thaw/Refreeze | |
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### Diagnosis Codes
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| Code | Description |
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|---|---|
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| Z31.89 | |
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| Z31.62 | |
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| Z31.83 | |
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| Z31.430 | |
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| Z31.440 | |
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### Treatment Visit
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| CPT | Description | Fee |
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|---|---|---|
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| 214.85 | Fertility counseled/ion cycle | |
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| 1990 | Monitor, Natural | |
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| D09.9 | Aspiration | |
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| | Fertilization | |
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| M83.3 | Maintenance | |
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| I48.0 | Retrieval | |
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| | Embryo Culture | |
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| I48.1 | | |
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| | Alzheimer's Disease | |
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| N88.3 | | |
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| | Cervical Stenosis | |
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| E84.0 | Galactosemia | |
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| E94.4 | | |
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### Pregnancy Test
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| CPT | Description | Fee |
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|---|---|---|
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| | | |
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---
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## Payment Summary
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| Field | Value |
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|---|---|
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| IVF | |
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| Egg | |
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| FEE | |
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| FRA | |
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| Homologous | |
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| Lim Egg | |
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| LVF Egg Donor | |
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| Other | |
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| Other Charges | |
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---
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## Financial Summary
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| | |
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|---|---|
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| Insurance | |
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| Adjustments | |
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| Other Resp | Extract from |
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| **Today's Charges** | **170** |
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| **BALANCE TO PATIENT** | **170** |
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| Field | Value |
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|---|---|
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| RECAP | over 60, over 30, over 30 |
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| TOTAL DUE | |
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| PT | |
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| BE | |
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| FH CHOICE | |
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| INSURANCE / Copay/CoI Pay | |
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| BA | ST | POLICY I.D. |
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BIN
documents/medical/scrc/lu_scrc_iui_receipt2.jpg
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documents/medical/scrc/lu_scrc_iui_receipt2.jpg
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documents/medical/scrc/lu_scrc_iui_receipt2.md
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---
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type: receipt
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category: patient_receipt
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person: Xiuwei Jiang
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date: 2026-01-17
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provider: SCRC (Southern California Reproductive Center)
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source: lu_scrc_iui_receipt2.jpg
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---
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# Patient Receipt
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**SCRC**
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Southern California Reproductive Center
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Page 1 of 1
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---
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**Patient:** XUEWEI JIANG
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## Payment
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| Payment Type | Payment Date | Amount Paid |
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|---|---|---|
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| Debit Card | 01/17/2026 | $170.00 |
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**Total: $170.00**
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---
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**Comments:** TODAYS SERVICES
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---
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*Patient Receipt*
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1/17/2026 7:47:22 AM
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Powered by eIVF, a PracticeHwy.com product
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BIN
documents/medical/scrc/lu_scrc_iui_sample.jpg
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documents/medical/scrc/lu_scrc_iui_sample.md
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---
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type: lab_report
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category: andrology
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person: Yanxin Lu
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date: 2026-01-17
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provider: Advanced Reproductive Technologies, LLC / ART LLC
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source: lu_scrc_iui_sample.jpg
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---
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# Intrauterine Insemination Report — Fresh Sample
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**Medical Director:** Hal C. Danzer, M.D.
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450 North Roxbury Drive
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Beverly Hills, Suite 500
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CA 90210
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310.277.2393
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CLIA ID#: 05D0546234
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---
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## Patient & Partner Information
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| Field | Value |
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|---|---|
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| Patient Name | XUEWEI (ERICA) JIANG |
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| Patient ID | 105151 |
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| Patient Birth Date | 03/13/1993 |
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| Partner Name | YANXIN LU |
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| Partner ID | 105150 |
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| Partner Birth Date | 10/17/1989 |
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| Accession # | 480706 |
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| Ordering Physician | ART LLC |
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| ID Checked By | ART LLC |
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| Count Tech | DOG |
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---
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## Procedure Details
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| Field | Value |
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|---|---|
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| Date of Procedure | 01/17/2026 |
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| Abstinence Period | Day(s) |
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| Collection Date/Time | 01/17/2026 07:40 AM |
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| Collection Container | Sterile Cup |
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| Collection Method | Ejaculate |
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| Date/Time Recd in Lab | 01/17/2026 08:30 AM |
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| Reported By | |
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| Directed Donor Name | Desta Gebagay |
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---
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## Sample Analysis
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### Pre-Wash Values
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| Parameter | Value | Reference Values |
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|---|---|---|
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| Concentration | 3.0 ml | >= 1.5 mL |
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| Motility | 48 Million/mL | >= 15 million/mL |
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| Agglutination | 50% Progressive | >= 40% |
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| Round Cells | None | None-Minimal |
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| Progression | 0 Million/mL | < 1.0 Million/mL |
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| Total Motile Count | 72 M | 2+ to 3+ |
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| Media | 2+/3 | |
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| ALL (Grad Gradient) | | |
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### Post Wash Values
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| Parameter | Value |
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| Volume | 0.5 mL |
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| Concentration | 40 Million/mL |
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| Motility | 83% Progressive |
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| Total Motile Count | 16.6 M |
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---
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**Comments:** Concentration and Motility values confirmed in duplicate
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---
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## Signatures
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**Physician Signature:** Dr. Candice Tilles
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**FDA Status:**
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**Reviewed and Electronically Signed By:**
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Lab Director: Desta Gebagay, C.L.S, ASCP
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**Sample Verification:**
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**Patient Signature:** *(signed)*
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**Witness Signature:**
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**Inseminated By:** *(signature present)*
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---
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**Test Performed At:** BH - ANDROLOGY
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Intrauterine Insemination Report — Fresh Sample - 1
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Powered by eIVF, a PracticeHwy.com product
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Printed: 1/17/2026
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