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Unlisted Face or Jaw Prosthesis Service

Minnesota 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 $692 · 10th–90th $363$1,7380%10%10th90th$692Professionalmedian $525 · 10th–90th $525$1,8620%20%40%90th$525$200.0$500.0$1.0K$2.0K$5.0K

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
$524.81
Median
$524.81
Typical High
$1,862.09
BCBS
Setting
Facility
Modifier
Global
Typical Low
$309.03
Median
$575.44
Typical High
$1,659.59
Medica
Setting
Facility
Modifier
Global
Typical Low
$363.08
Median
$1,445.44
Typical High
$2,691.53
United
Setting
Facility
Modifier
Global
Typical Low
$602.56
Median
$1,778.28
Typical High
$3,715.35