Comaprison of MassHealth Dental Coverage, 2010 and 2017, by Service Code
Children Children All Adults Adults (DDS) Adults
Under 21 Under 21 21 and Older 21 and Older 21 and Older
January 2010 January 2021 January 1, 2010 January 1, 2021 January 1, 2021
Code Code Description Covered Service
DIAGNOSTIC SERVICES See 130 CMR 420.422 for service description and limitations.
D0120 Periodic oral evaluation- established patient Yes Yes Yes Yes Yes
D0140 Limited oral evaluation- problem focused Yes Yes Yes Yes Yes
oral evaluation for a patient under 3 years of age
D0145 Yes Yes No No No
and counseling with primary caregiver
Comprehensive oral evaluation - new or
D0150 Yes Yes Yes Yes Yes
established patient
D0160 Detailed and extensive oral evaluation Yes No- Yes No- No-
Comprehensive periodontal evaluation - new or
D0180 No Yes No Yes Yes
established patient
D0190 Screening of a patient N/A Yes N/A Yes Yes
D0191 Assessment of patient N/A Yes N/A Yes Yes
RADIOGRAPHS See 130 CMR 420.423 for service description and limitations.
D0210 Intraoral - complete series (including bitewings) Yes Yes Yes Yes Yes
D0220 Intraoral - periapical, first film Yes Yes Yes Yes Yes
D0230 Intraoral - periapical, each additional film Yes Yes Yes Yes Yes
D0240 Intraoral - occlusal film No Yes No No No
D0270 Bitewing - single film Yes Yes Yes Yes Yes
D0272 Bitewings - two films Yes Yes Yes Yes Yes
D0273 Bitewings - three films Yes Yes Yes Yes Yes
D0274 Bitewings - four films Yes Yes Yes Yes Yes
D0330 Panoramic film (non-surgical) yes Yes No* Yes Yes
D0330 Panoramic film (surgical) yes Yes Yes yes Yes
D0340 Cephalometric radiographic image Yes Yes Yes Yes* Yes*
D0350 2D Oral/facial photographic image Yes No- Yes No- No-
D0470 Diagnostic cast Yes No- Yes No- No-
PREVENTIVE SERVICES See 130 CMR 420.424 for service description and limitations.
Yes Yes
D1110 Prophylaxis - adult Yes Yes Yes
(ages 14-21) (age 14 to 21)
Yes Yes
D1120 Prophylaxis - child No No No
(ages 0 - 14) (ages up to 14)
D1203 Topical application of fluoride- child Yes CDT Code Deleted No CDT Code Deleted CDT Code Deleted
D1204 Topical application of fluoride- adult N/A CDT Code Deleted No* CDT Code Deleted CDT Code Deleted
D1206 Topical fluoride varnish; therapeutic application Yes Yes Yes* Yes* Yes*
D1208 Topical application of fluoride- excluding varnish N/A Yes N/A Yes* Yes*
D1351 Sealant - per tooth Yes Yes No No No
interim caries arresting medicament application-
D1354 N/A Yes N/A Yes Yes
per tooth
D1510 Space maintainer - fixed-unilateral Yes Yes No No No
D1515 Space maintainer - fixed-bilateral Yes CDT Code Deleted No CDT Code Deleted CDT Code Deleted
D1516 Space maintainer- fixed-unilateral N/A Yes N/A No No
D1517 Space maintainer- fixed-bilateral, mandibular N/A Yes+ N/A No No
D1520 Space maintainer - removable-unilateral Yes Yes No No No
D1525 Space maintainer - removable-bilateral Yes CDT Code Deleted No CDT Code Deleted CDT Code Deleted
D1526 Space maintainer- removable-bilateral, maxillary N/A Yes+ N/A No No
Space maintainer-removable-bilateral,
D1527 N/A Yes+ N/A No No
mandibular
D1550 Re-cement or re-bond space maintainer Yes CDT Code Deleted No CDT Code Deleted CDT Code Deleted
D1701 Pfizer COVID-19 vaccine- first dose N/A Yes++ N/A Yes++ Yes++
D1702 Pfizer COVID-19 vaccine- second dose N/A Yes++ N/A Yes++ Yes++
D1703 Moderna Covid-19 vaccine- first dose N/A Yes++ N/A Yes++ Yes++
D1704 Moderna Covid-19 vaccine- second dose N/A Yes++ N/A Yes++ Yes++
D1707 Janssen COVID-19 vaccine- Single dose N/A Yes++ N/A Yes++ Yes++
RESTORATIVE SERVICES See 130 CMR 420.425 for service description and limitations.
D2140 Amalgam-one surface, primary or permanent Yes Yes Yes Yes Yes
D2150 Amalgam-two surfaces, primary or permanent Yes Yes Yes Yes Yes
D2160 Amalgam-three surfaces, primary or permanent Yes Yes Yes Yes Yes
Amalgam-four or more surfaces, primary or
D2161 Yes Yes Yes Yes Yes
permanent
page 1 of 5
 Comaprison of MassHealth Dental Coverage, 2010 and 2017, by Service Code
Children Children All Adults Adults (DDS) Adults
Under 21 Under 21 21 and Older 21 and Older 21 and Older
January 2010 January 2021 January 1, 2010 January 1, 2021 January 1, 2021
Code Code Description Covered Service
D2330 Resin - one surface, anterior Yes Yes Yes Yes Yes
D2331 Resin - two surfaces, anterior Yes Yes Yes Yes Yes
D2332 Resin - three surfaces, anterior Yes Yes Yes Yes Yes
Resin - four or more surfaces or involving incisal
D2335 Yes Yes Yes Yes Yes
angle (anterior)
D2390 Resin-based composite crown, anterior Yes Yes No No No
D2391 Resin-based composite - one surface, posterior Yes Yes Yes Yes Yes
D2392 Resin-based composite - two surfaces, posterior Yes Yes Yes Yes Yes
D2393 Resin-based comp Yes Yes Yes Yes Yes
Resin-based composite - four or more surfaces,
D2394 Yes Yes Yes Yes Yes
posterior
D2710 Crown - resin-based composite (indirect) Yes Yes No No No
D2740 Crown - porcelain/ceramic substrate No Yes No No No
D2750 Crown - porcelain fused to high noble metal No Yes No No No
Crown - porcelain fused to predominantly base
D2751 Yes Yes Yes Yes Yes
metal
D2752 Crown - porcelain fused to noble metal No Yes No No No
D2790 Crown - full cast high noble metal No Yes No No No
Recement inlay, onlay or partial coverage
D2910 Yes Yes Yes Yes Yes
restoration
D2920 Recement crown Yes Yes Yes Yes Yes
Prefabricated stainless steel crown - primary
D2930 Yes Yes No No No
tooth
Prefabricated stainless steel crown - permanent
D2931 Yes Yes No* Yes* No
tooth
D2932 Prefabricated resin crown Yes Yes No No No
Prefabricated esthetic coated stainless steel
D2934 Yes Yes No No No
crown - primary tooth
Pin retention - per tooth, in addition to
D2951 Yes Yes Yes Yes Yes
restoration
Post and core in addition to crown, indirectly
D2954 Yes Yes Yes Yes Yes
fabricated
D2980 Crown repair, by report Yes Yes Yes Yes Yes
D2999 Unspecified restorative procedure, by report Yes Yes Yes* Yes* Yes*
ENDODONTIC SERVICES See 130 CMR 420.426 for service description and limitations.
Therapeutic pulpotomy (excluding final
restoration) - removal of pulp coronal to the
D3220 Yes Yes No No No
dentinocemental junction and application of
medicament
D3310 Anterior (excluding final restoration) Yes Yes Yes Yes Yes
D3320 Bicuspid (excluding final restoration) Yes Yes No Yes Yes
D3330 Molar (excluding final restoration) Yes Yes No* Yes Yes
Retreatment of previous root canal therapy –
D3346 Yes Yes Yes Yes Yes
anterior
Retreatment of previous root canal therapy –
D3347 Yes Yes No* Yes Yes
bicuspid
Retreatment of previous root canal therapy –
D3348 Yes Yes No* Yes Yes
molar
D3410 Apicoectomy/periradicular surgery - anterior Yes Yes Yes Yes Yes
Apicoectomy/periradicular surgery - bicuspid
D3421 Yes Yes Yes Yes Yes
(first root)
Apicoectomy/periradicular surgery - molar (first
D3425 N/A Yes N/A Yes Yes
root)
Apicoectomy/periradicular surgery (each
D3426 Yes Yes Yes Yes Yes
additional root)
PERIODONTIC SERVICES See 130 CMR 420.427 for service description and limitations.
Gingivectomy or gingivoplasty - Four or more
D4210 contiguous teeth or bounded teeth spaces per Yes Yes Yes Yes* Yes*
quadrant
Gingivectomy or gingivoplasty - one to three
D4211 contiguous teeth or bounded teeth spaces per Yes Yes Yes Yes* Yes*
quadrant
Periodontal scaling and root planning - four or
D4341 Yes Yes Yes Yes* Yes*
more teeth per quadrant
Periodontal scaling and root planning - one to
D4342 Yes Yes Yes Yes* Yes*
three teeth, per quadrant
PROSTHODONTIC (REMOVABLE) SERVICES See 130 CMR 420.428 for service description and imitations.
D5110 Complete denture – maxillary Yes Yes Yes Yes Yes
D5120 Complete denture – mandibular Yes Yes Yes Yes Yes
page 2 of 5
 Comaprison of MassHealth Dental Coverage, 2010 and 2017, by Service Code
Children Children All Adults Adults (DDS) Adults
Under 21 Under 21