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Unlisted Face or Jaw Prosthesis Service

South Carolina 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 $389 · 10th–90th $174$1,2020%5%10%10th90th$389Professionalmedian $1,778 · 10th–90th $30$1,7780%50%10th$1,778$50.0$100.0$200.0$500.0$1.0K$2.0K$5.0K

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
Professional
Modifier
Global
Typical Low
$1,778.28
Median
$1,778.28
Typical High
$1,778.28
BCBS
Setting
Facility
Modifier
Global
Typical Low
$162.18
Median
$331.13
Typical High
$501.19
BCBS
Setting
Professional
Modifier
Global
Typical Low
$660.69
Median
$660.69
Typical High
$660.69
Cigna
Setting
Facility
Modifier
Global
Typical Low
$891.25
Median
$891.25
Typical High
$891.25
Cigna
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$120.23
Typical High
$144.54
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$30.20
United
Setting
Facility
Modifier
Global
Typical Low
$223.87
Median
$1,122.02
Typical High
$4,677.35