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SCHEDULE OF BENEFITS (Continued) <br />Your and Your <br />Dependent's <br />Code Service Co -Payment <br />D9430 Office visit for observation (during regularly scheduled hours) — no other <br />services performed $0 <br />09440 Office visit— after regularly scheduled hours $0 <br />09952 Occlusal adjustment — complete <br />D9986 Missed appointment <br />(less than 24 -hr notice) <br />D9987 Cancelled appointment <br />(if less than 24 -hr notice, see D9986) <br />0041 -D -SOB <br />Current Dental Terminology 0 American Dental Association <br />25C-46 <br />$0 <br />Not to exceed <br />$25 <br />$0 <br />