---
type: receipt
category: medical
person: Xiuwei Jiang
date: 2026-01-17
provider: SCRC (Southern California Reproductive Center)
source: lu_scrc_iui_receipt.jpg
---

# SCRC Patient Summary & Reason for Visit

**SCRC**
600 N. Roxbury Drive, A
500 Beverly Hills, CA
Tel: (310) 277-2393
Fax: (310) 274-5112

**Physicians:**
- D.A. KUKREJA, M.D.
- M. JAHAN, M.D.
- C. ALEXANDER, M.D.
- D.A. SAHNI, M.D.
- R.E. SHAMONKI, M.D.
- A. MANSON, M.D.
- C.A. SHARK, M.D.
- C.A. HIRSHMAN, M.D.
- C.A. HIRSHMAN, M.D.

---

## Visit Information

| Field | Value |
|---|---|
| Date | 01/17/2026 07:30 AM |
| Patient | XUEWEL JIANG |
| Account | T05151 |
| Address | ART LLC |
| Phone | (254) 214-9350 |
| ZIP Code | |

---

## CPT Code Reference Lists

### Office Visit

| CPT | Description | Fee |
|---|---|---|
| 99201 | New level 1 (10-15 min) | |
| 99202 | New level 2 (15-30 min) | |
| 99024 | Statement - level 2 (30 min) | |
| 99203 | New level 3 (30 min) | |
| 99204 | New level 4 (45 min) | |

### Office Visit - Established Patient

| CPT | Description | Fee |
|---|---|---|
| 99211 | Establish - level 1 (5 min) | |
| 99212 | Establish - level 2 (10 min) | |
| 99213 | Establish - level 3 (15 min) | |
| 99214 | Procedure - level 3 (15-18 min) | |
| 99215 | Establish - level 5 | |
| 99174 | Pre Op Visit | |

### Consultation - Telephone

| CPT | Description | Fee |
|---|---|---|
| 99441 | Establish/telephone | |

### Nursing Visit

| CPT | Description | Fee |
|---|---|---|
| 96372 | Injection IM/Subq | |
| 96901 | Intrauterine 15 follicles | |
| 90460 | Dose 8 w/eval yr 30 MO | |

### Procedures

| CPT | Description | Fee |
|---|---|---|
| 100 | Smeical Results | |
| 99080 | Stannone, Initial exam | |
| 99080 | Standard/surg note dressing | |

### Diagnostics

| CPT | Description | Fee |
|---|---|---|
| 18001 | Thrombophilia | |
| 18819 | MFI | |
| 18015 | | |
| 59430 | Postpartumorgasm | |

### Office Procedures

| CPT | Description | Fee |
|---|---|---|
| 89310 | Endom Biopsy | |
| 57500 | Endom Biopsy | |
| 57010 | Colposcopy | |
| 76856 | US Pelvis | |
| 76830 | US Transvaginal | |

### Microbiology

| CPT | Description | Fee |
|---|---|---|
| 87070 | Urethera, Routine | |
| 87070 | Culture Cervical | |
| 87081 | Culture Urine | |
| 87116 | ID Mycoplasm | |
| 86317 | Immun Inf Ag | |

### Microbiology (continued)

| CPT | Description | Fee |
|---|---|---|
| 99201 | Cysteine (1 time) | |
| 88025 | Direct Nasopharyngeal | |

### Endocrinology

| CPT | Description | Fee |
|---|---|---|
| 84443 | Prolactin | |
| 84146 | Prolactin | |
| 84270 | | |

### Screening

| CPT | Description | Fee |
|---|---|---|
| 80055 | | |
| 86235 | Vitamin D (25,1,21) | |
| 84439 | | |
| 84432 | Thyroglobulin (1,21,84) | |
| 84443 | TSH | |
| 84270 | Tire Testosterone | |
| 94402 | | |

### Andrology

| CPT | Description | Fee |
|---|---|---|
| 89310 | Semen Analysis SMAC | |
| 89321 | Sperm Wash / Gradient | |

### Screening (continued)

| CPT | Description | Fee |
|---|---|---|
| 85730 | Pre-wash | |
| 87340 | HEP B Surface Ag (21.84) | |
| 86762 | | |
| 86703 | HIV 1, 10 (21.84) | |
| 86706 | HEP B ag Total | |
| 86644 | | |
| 88694 | CMV IgG | |
| 86698 | | |
| 86803 | Hep C Ab by PCR | |
| 87801 | | |
| 87491 | Chlamydia by NAAT/SDA | |
| 86850 | | |
| 84030 | Estren LH | |

### IUI/ART Related

| CPT | Description | Fee |
|---|---|---|
| 99316 | IVF | |
| 89268 | | |

### Screening (continued)

| CPT | Description | Fee |
|---|---|---|
| 86190 | Insp. B Surface Ab | |
| 88177 | Gonorrhea gC2 | |
| 87592 | Treponema | |
| 87110 | | |

### ART Related

| CPT | Description | Fee |
|---|---|---|
| | IVF/Hysteroscopy | |
| | FET | |
| | Thaw/Refreeze | |

### Diagnosis Codes

| Code | Description |
|---|---|
| Z31.89 | |
| Z31.62 | |
| Z31.83 | |
| Z31.430 | |
| Z31.440 | |

### Treatment Visit

| CPT | Description | Fee |
|---|---|---|
| 214.85 | Fertility counseled/ion cycle | |
| 1990 | Monitor, Natural | |
| D09.9 | Aspiration | |
| | Fertilization | |
| M83.3 | Maintenance | |
| I48.0 | Retrieval | |
| | Embryo Culture | |
| I48.1 | | |
| | Alzheimer's Disease | |
| N88.3 | | |
| | Cervical Stenosis | |
| E84.0 | Galactosemia | |
| E94.4 | | |

### Pregnancy Test

| CPT | Description | Fee |
|---|---|---|
| | | |

---

## Payment Summary

| Field | Value |
|---|---|
| IVF | |
| Egg | |
| FEE | |
| FRA | |
| Homologous | |
| Lim Egg | |
| LVF Egg Donor | |
| Other | |
| Other Charges | |

---

## Financial Summary

| | |
|---|---|
| Insurance | |
| Adjustments | |
| Other Resp | Extract from |
| **Today's Charges** | **170** |
| **BALANCE TO PATIENT** | **170** |

| Field | Value |
|---|---|
| RECAP | over 60, over 30, over 30 |
| TOTAL DUE | |
| PT | |
| BE | |
| FH CHOICE | |
| INSURANCE / Copay/CoI Pay | |
| BA | ST | POLICY I.D. |