XR mandible less 4 views
| 2020 CPT/HCPCS | 70100 |
| Negotiated Private Fee | $45.00 |
| Prossam | $17.00 |
| Champva | $39.33 |
| First Medical | $19.00 |
| First Medical Vital | $26.18 |
| Plan de Salud Menonita | $24.00 |
| Menonita Vital | $26.18 |
| Humana Gold plus/ Gold choice | Ambulatory Payment classification (APC) |
| Humana | $23.00 |
| Mapfre | $24.00 |
| Mcs Classicare | $24.00 |
| MCS Life | $24.00 |
| Medicare | Ambulatory Payment classification (APC) |
| MMM | $25.86 |
| MMM Vital | $26.18 |
| Panamerican Life | $30.00 |
| PMC | $25.86 |
| Tricare | $39.33 |
| Triple S Salud | $28.00 |
| Triple S Vital | $18.52 |
| Triple S Advantage | Ambulatory Payment classification (APC) |
| Negotiated Minimum Charge | $17.00 |
| Negotiated Maximus Charge | $39.33 |
| Discounted Cash Price | $36.00 |
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