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~a <br />Attachment 4 <br />Changes to Dental Table of Allowances <br />Recommended Effective January 2010 <br />Increase Table of Allowances to Delta Dental's Maximum Payable Amount <br />Most Common Basic Restorative Services and Proposed Reimbursement Rates <br /> <br />2009 Proposed <br />2010 <br />Difference <br />02140 Amal am Fillin s $97 $119 $22 <br />02150 Amal am Fillin s $128 $151 $23 <br />02160 Amal am Fillin s $155 $182 $27 <br />02332 Com osite Fillin s $160 $181 $21 <br />02330 Resin-One Surface Anterior $100 $122 $22 <br />02331 Com osite Fillin s $125 $149 $24 <br />02335 Fillin s $125 $230 $105 <br />2009 Changes made to Delta Dental's Maximum Payable Amount <br />Preventive and Diagnostic Services <br />00120 Periodic oral exam $37 <br />00140 Periodic oral exam $98 <br />00150 Periodic oral exam $65 <br />00210 Full Series x-ra s $128 <br />00230 X-ra s $11 <br />00272 2 Bitewin s $35 <br />00274 4 Bitewin s $50 <br />00330 Panorex x-ra s $88 <br />01110 Pro h taxis adult $68 <br />01120 Pro h taxis child to a e 14 $53 <br />01203 Fluoride Treatment $27 <br />01351 Sealants limitation child $45 <br />