NOTE: 1. When claimed for a diagnostic branch block of a spinal facet joint, one call may be claimed for each individual joint blocked. For example, L4/5 and L5/S1 on the right is two calls. L4/5 and L5/S1 bilaterally is four joints; therefore four calls. 2. Up to three calls may be claimed per side when nerves for that number of joints are blocked, for a maximum of six calls. 3. The first joint (cervical, thoracic, or lumbar) for Diagnostic medial branch block(s) requires two needle placements, each additional contiguous joint requires one additional needle placement. 4. Branch blocks of a spinal facet joint may only be claimed for diagnostic procedures, not for therapeutic use. 5. May not be used in place of HSCs 16.89B, 16.89C, or 16.89D for facet joint injections when the limits for HSC 16.89 have otherwise been reached. 6. Fluoroscopy HSC (X107A) may only be submitted for the first call.

NOTE: 1. One call applies for each individual spinal facet joint treated. For example, L4/5 and L5/S1 on the right is two calls. L4/5 and L5/S1 bilaterally is four joints, therefore four calls. 2. Up to three calls may be claimed per side when nerves for that number of joints are ablated, for a maximum of six calls bilaterally. 3. HSC 18.29E or 18.29EA may not be claimed on the same day. 4. When claimed in addition to HSC 18.29FA on the same date of service, only one benefit for HSC X107A may be claimed.

NOTE: 1. Two calls may be claimed for bilateral sacroiliac joints. Refer to Price List. 2. When claimed in addition to HSC 18.29F on the same date of service, only one benefit for HSC X107A may be claimed. 3. HSC 18.29E or 18.29EA may not be claimed on the same day.