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Unlisted Face or Jaw Prosthesis Service

Nebraska 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 $741 · 10th–90th $355$4,5710%20%10th90th$741Professionalmedian $2,138 · 10th–90th $2,138$2,1380%50%100%$2,138$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
Aetna
Setting
Facility
Modifier
Global
Typical Low
$371.54
Median
$371.54
Typical High
$741.31
BCBS
Setting
Facility
Modifier
Global
Typical Low
$3,235.94
Median
$4,265.80
Typical High
$8,317.64
Medica
Setting
Facility
Modifier
Global
Typical Low
$288.40
Median
$1,230.27
Typical High
$4,365.16
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
$295.12
Median
$1,047.13
Typical High
$3,801.89