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Unlisted Face or Jaw Prosthesis Service

Pennsylvania 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 $537 · 10th–90th $224$3,8900%5%10th90th$537Professionalmedian $64,565 · 10th–90th $54,954$64,5650%50%10th$64,565$100.0$500.0$2.0K$10.0K$50.0K

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
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$1,174.90
Median
$1,258.93
Typical High
$57,543.99
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$54,954.09
Median
$64,565.42
Typical High
$64,565.42
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$218.78
Median
$295.12
Typical High
$501.19
United
Setting
Facility
Modifier
Global
Typical Low
$288.40
Median
$616.60
Typical High
$3,890.45