| C2634 | Brachytherapy source, non-stranded, high activity, iodine-125, greater than 1.01 mci (nist), per source |
| C2635 | Brachytherapy source, non-stranded, high activity, palladium-103, greater than 2.2 mci (nist), per source |
| J0575 | Buprenorphine/naloxone, oral, greater than 10 mg buprenorphine |
| E0912 | Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar |
| A4305 | Disposable drug delivery system, flow rate of 50 ml or greater per hour |
| G9242 | Documentation of viral load equal to or greater than 200 copies/ml or viral load not performed |
| J0573 | Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg buprenorphine |
| J0574 | Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg buprenorphine |
| A6455 | Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to five inches, per yard |
| E0779 | Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater |
| V2783 | Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycarbonate, per lens |
| G9512 | Individual had a pdc of 0.8 or greater |
| G9513 | Individual did not have a pdc of 0.8 or greater |
| S2267 | Induced abortion, 32 weeks or greater |
| Q9951 | Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml |
| Q9964 | High osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml |
| E2201 | Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches |
| E1225 | Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each |
| B4180 | Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) - home mix |
| E1036 | Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs |
| G8859 | Patient receiving corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days |
| G9861 | Patient spent greater than or equal to three days in hospice care |
| G9648 | Patients with 90 day mrs score greater than 2 |
| G9582 | Door to puncture time of greater than 90 minutes, no reason given |
| A6454 | Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard |
| A6441 | Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard |
| A6456 | Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard |
| G8718 | Total kt/v greater than or equal to 1.7 per week (total clearance of urea [kt] / volume [v]) |
| G8713 | Spkt/v greater than or equal to 1.2 (single-pool clearance of urea [kt] / volume [v]) |
| G9705 | Ajcc breast cancer stage i: t1b (tumor > 0.5 cm but <= 1 cm in greatest dimension) documented |
