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Unlisted Face or Jaw Prosthesis Service

Arizona rates for HCPCS 21089

Covers the making or fitting of an artificial replacement for a missing or damaged part of the face, jaw or mouth when no standard named service applies. These custom devices restore appearance and function after cancer surgery, injury, or a condition present from birth. Because each one is built for a single person, the specialist records exactly what was designed and fitted.

Rates data updated July 2026.

Facilitymedian $1,549 · 10th–90th $417$2,8840%5%10%10th90th$1,549Professionalmedian $490 · 10th–90th $398$9330%20%10th90th$490$100.0$200.0$500.0$1.0K$2.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
BCBS
Setting
Facility
Modifier
Global
Typical Low
$446.68
Median
$1,862.09
Typical High
$3,467.37
BCBS
Setting
Professional
Modifier
Global
Typical Low
$398.11
Median
$489.78
Typical High
$933.25
Medica
Setting
Facility
Modifier
Global
Typical Low
$707.95
Median
$1,412.54
Typical High
$2,238.72
Medica
Setting
Professional
Modifier
Global
Typical Low
$2,137.96
Median
$2,137.96
Typical High
$2,137.96
United
Setting
Facility
Modifier
Global
Typical Low
$199.53
Median
$1,047.13
Typical High
$2,137.96