GCERT2010-DHMO-SOB sob Customer Service (800) 880-1800 Page 13 of 16 SGM_SOB_SGX_100-CA (01/24) Fs/f Code Service Co-payment D9945 Occlusal guard – soft appliance, full arch $85 D9946 Occlusal guard – hard appliance, partial arch $64 D9951 Occlusal adjustment – limited $0 D9952 Occlusal adjustment – complete $0 D9954 Fabrications and delivery of oral appliance therapy (OAT) morning repositioning device $16 D9972 External bleaching – per arch – performed in office $125 D9986 Missed appointment (less than 24-hr notice) Not to exceed $10 D9987 Cancelled appointment (if less than 24-hr notice, see D9986) $0 Current Dental Terminology © American Dental Association