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obsidian-yanxin/documents/medical/scrc/lu_scrc_iui_receipt.md
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type, category, person, date, provider, source
type category person date provider source
receipt medical Xiuwei Jiang 2026-01-17 SCRC (Southern California Reproductive Center) 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
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