Service Service Code Req. or Limit Code Req. or Limit 77061 IC 90378 PA; IC 77062 IC 90384 IC 77299 IC 90385 IC 77387 IC 90386 IC 77399 IC 90389 IC 77499 IC 90393 PA; IC 77799 IC 90396 IC 78099 IC 90399 IC 78199 IC 90476 IC 78299 IC 90477 IC 78399 IC 90581 IC 78499 IC 90620 IC 78599 IC 90621 IC 78699 IC 90625 IC 78799 IC 90630 Covered for members 19; ≥ 78999 IC available free of charge 79999 IC through the Massachusetts 81099 IC Immunization Program for 81162 PA children younger than 19 81211 PA years of age 81212 PA 90632 Covered for adults 19; ≥ 81215 PA available free of charge 81217 PA through the Massachusetts 81228 PA; IC Immunization Program for 81229 PA; IC children younger than 19 81420 PA; IC years of age 81479 IC 90633 IC; Covered for members ≥ 81507 PA; IC 19; available free of charge 81519 PA; IC through the Massachusetts 84999 IC Immunization Program for 88199 IC children younger than 19 85999 IC years of age 86849 IC 90636 Covered for members 19; ≥ 86999 IC available free of charge 87999 PA; IC through the Massachusetts 88299 IC Immunization Program for 88399 IC children younger than 19 89240 IC years of age IC 90651 IC; Covered for female 90281 members aged 19 to 26 years; 90283 IC available free of charge 90284 IC through the Massachusetts 90287 IC Immunization Program for 90288 IC children younger than 19 90296 IC
Service Code Req. or Limit 77061 IC 77062 IC 77299 IC 77387 IC 77399 IC 77499 IC 77799 IC 78099 IC 78199 IC 78299 IC 78399 IC 78499 IC 78599 IC 78699 IC 78799 IC 78999 IC 79999 IC 81099 IC 81162 PA 81211 PA 81212 PA 81215 PA 81217 PA 81228 PA; IC 81229 PA; IC 81420 PA; IC 81479 IC 81507 PA; IC 81519 PA; IC 84999 IC 88199 IC 85999 IC 86849 IC 86999 IC 87999 PA; IC 88299 IC 88399 IC 89240 IC 90281 IC 90283 IC 90284 IC 90287 IC 90288 IC 90296 IC Service Code Req. or Limit 90378 PA; IC 90384 IC 90385 IC 90386 IC 90389 IC 90393 PA; IC 90396 IC 90399 IC 90476 IC 90477 IC 90581 IC 90620 IC 90621 IC 90625 IC 90630 Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90632 Covered for adults ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90633 IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90636 Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90651 IC; Covered for female members aged 19 to 26 years; available free of charge through the Massachusetts Immunization Program for children younger than 19
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