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Unlisted Face or Jaw Prosthesis Service

New York 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 $4,467 · 10th–90th $2,239$9,1200%10%20%10th90th$4,467Professionalmedian $398 · 10th–90th $398$5370%50%90th$398$50.0$200.0$1.0K$5.0K$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
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$2,630.27
Median
$4,786.30
Typical High
$9,120.11
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$50.12
Typical High
$50.12
Cigna
Setting
Facility
Modifier
Global
Typical Low
$34.67
Median
$34.67
Typical High
$34.67
MVP Health Care
Setting
Facility
Modifier
Global
Typical Low
$50,118.72
Median
$53,703.18
Typical High
$75,857.76
MVP Health Care
Setting
Professional
Modifier
Global
Typical Low
$398.11
Median
$398.11
Typical High
$537.03
United
Setting
Facility
Modifier
Global
Typical Low
$1,071.52
Median
$2,511.89
Typical High
$4,897.79
United
Setting
Professional
Modifier
Global
Typical Low
$64.57
Median
$64.57
Typical High
$977.24