Page 20 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D9944 Occlusal guard – hard appliance, full arch $85 D9945 Occlusal guard – soft appliance, full arch $85 D9946 Occlusal guard – hard appliance, partial arch $64 D9951 Occlusal adjustment – limited $30 D9952 Occlusal adjustment – complete $100 D9954 Fabrications and delivery of oral appliance therapy (OAT) morning repositioning device $16 D9955 Oral appliance therapy (OAT) titration visit $10 D9986 Missed appointment (less than 24-hr notice) Not to exceed $25 D9987 Cancelled appointment (if less than 24-hr notice, see D9986) $0 Current Dental Terminology © American Dental Association