265 lines
4.7 KiB
Markdown
265 lines
4.7 KiB
Markdown
---
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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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| 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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| 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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| 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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| 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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| 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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| 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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| 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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| 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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| 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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| 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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| 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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| 99316 | IVF | |
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| 89268 | | |
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### Screening (continued)
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| CPT | Description | Fee |
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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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| 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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| 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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## Payment Summary
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| Field | Value |
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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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| 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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| 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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