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Unlisted Face or Jaw Prosthesis Service

California 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 $3,090 · 10th–90th $83$7,5860%10%10th90th$3,090Professionalmedian $257 · 10th–90th $245$6310%20%40%10th90th$257$0.0$0.2$2.0$20.0$200.0$2.0K$20.0K

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
Aetna
Setting
Professional
Modifier
Global
Typical Low
$245.47
Median
$257.04
Typical High
$257.04
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$1,548.82
Median
$3,090.30
Typical High
$7,585.78
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$0.02
Median
$0.02
Typical High
$0.02
Blue Shield
Setting
Facility
Modifier
Global
Typical Low
$72.44
Median
$4,168.69
Typical High
$8,709.64
Cigna
Setting
Facility
Modifier
Global
Typical Low
$2,691.53
Median
$2,691.53
Typical High
$2,691.53
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$630.96
Typical High
$1,698.24
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$54.95
Median
$56.23
Typical High
$56.23
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$1,548.82
Median
$2,187.76
Typical High
$2,187.76
Optum
Setting
Professional
Modifier
Global
Typical Low
$54.95
Median
$54.95
Typical High
$70.79
Providence
Setting
Facility
Modifier
Global
Typical Low
$2,691.53
Median
$2,691.53
Typical High
$2,691.53
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$79.43
Typical High
$79.43
United
Setting
Facility
Modifier
Global
Typical Low
$588.84
Median
$1,584.89
Typical High
$6,456.54