type, category, person, date, provider, source
| type |
category |
person |
date |
provider |
source |
| receipt |
patient_summary |
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
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 |
