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Unlisted Face or Jaw Prosthesis Service

Illinois 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 $407 · 10th–90th $204$1,8200%10%10th90th$407Professionalmedian $347 · 10th–90th $120$1,9950%20%10th90th$347$100.0$200.0$500.0$1.0K$2.0K$5.0K$10.0K

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

Insurance Carrier
BCBS
Setting
Facility
Modifier
Global
Typical Low
$302.00
Median
$338.84
Typical High
$416.87
Cigna
Setting
Professional
Modifier
Global
Typical Low
$794.33
Median
$794.33
Typical High
$10,000.00
Hally Health
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$199.53
Typical High
$346.74
Hally Health
Setting
Facility
Modifier
Global
Typical Low
$100.00
Median
$100.00
Typical High
$100.00
Molina
Setting
Professional
Modifier
Global
Typical Low
$1,513.56
Median
$1,995.26
Typical High
$2,511.89
United
Setting
Facility
Modifier
Global
Typical Low
$204.17
Median
$645.65
Typical High
$2,089.30