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Unlisted Face or Jaw Prosthesis Service

Ohio 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 $1,549 · 10th–90th $219$3,9810%20%10th90th$1,549Professionalmedian $0 · 10th–90th $0$500%50%90th$0$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
Facility
Modifier
Global
Typical Low
$114.82
Median
$114.82
Typical High
$218.78
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$707.95
Median
$2,137.96
Typical High
$3,981.07
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$0.02
Median
$0.02
Typical High
$0.03
CareSource
Setting
Facility
Modifier
Global
Typical Low
$72,443.60
Median
$72,443.60
Typical High
$72,443.60
Cigna
Setting
Facility
Modifier
Global
Typical Low
$21,379.62
Median
$21,379.62
Typical High
$21,379.62
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$21,379.62
Median
$21,379.62
Typical High
$21,379.62
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$50.12
Typical High
$60.26
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$70.79
Typical High
$75.86
United
Setting
Facility
Modifier
Global
Typical Low
$181.97
Median
$758.58
Typical High
$2,818.38