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Unlisted Face or Jaw Prosthesis Service

Oregon 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 $794 · 10th–90th $550$4,3650%20%10th90th$794Professionalmedian $79 · 10th–90th $71$790%50%10th$79$100.0$500.0$2.0K$10.0K$50.0K$200.0K$1.0M

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
Cigna
Setting
Facility
Modifier
Global
Typical Low
$851.14
Median
$851.14
Typical High
$851.14
Cigna
Setting
Professional
Modifier
Global
Typical Low
$446.68
Median
$446.68
Typical High
$1,288.25
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$588.84
Typical High
$588.84
Providence
Setting
Facility
Modifier
Global
Typical Low
$851.14
Median
$851.14
Typical High
$1,659,586.91
Providence
Setting
Professional
Modifier
Global
Typical Low
$70.79
Median
$79.43
Typical High
$79.43
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$549.54
Median
$794.33
Typical High
$977.24
United
Setting
Facility
Modifier
Global
Typical Low
$676.08
Median
$3,311.31
Typical High
$5,128.61