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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 October 2026.

How much does Unlisted Face or Jaw Prosthesis Service cost?

$525

Typical facility fee. In Pennsylvania, October 2026.

Insurers have agreed to pay about $525 for this service. Most negotiated rates run $151 to $1,698.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 4 insurance carriers under federal price transparency rules.

How much rates vary

Facilitymedian $417 · 10th to 90th $78 to $1,413Professionalmedian $58,884 · 10th to 90th $58,884 to $58,884
$100$1K$10Kfacility $417professional $58,884

Distribution of negotiated rates across all payers (price axis is log-scale). Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Capital Blue Cross
Setting
Facility
Modifier
None
Typical Low
$1,202.26
Median
$1,412.54
Typical High
$56,234.13
Capital Blue Cross
Setting
Professional
Modifier
None
Typical Low
$58,884.37
Median
$58,884.37
Typical High
$58,884.37
Capital Blue Cross
Setting
Professional
Modifier
78 · Unplanned return to OR
Typical Low
$41,686.94
Median
$43,651.58
Typical High
$43,651.58
Cigna
Setting
Facility
Modifier
None
Typical Low
$380.19
Median
$645.65
Typical High
$2,290.87
UPMC Health Plan
Setting
Facility
Modifier
None
Typical Low
$229.09
Median
$323.59
Typical High
$524.81
United
Setting
Facility
Modifier
None
Typical Low
$77.62
Median
$158.49
Typical High
$1,230.27

Where Pennsylvania sits

The same service costs 38.0 times more in New York than in Montana. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Pennsylvania· 22nd of 51

$525

NY $3,020MT $79.43

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.