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Unlisted Face or Jaw Prosthesis Service

South Dakota 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 $813 · 10th–90th $813$8130%50%100%$813Professionalmedian $479 · 10th–90th $479$4790%50%100%$479$500.0

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
Medica
Setting
Facility
Modifier
Global
Typical Low
$812.83
Median
$812.83
Typical High
$812.83
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$478.63
Median
$478.63
Typical High
$478.63
United
Setting
Facility
Modifier
Global
Typical Low
$812.83
Median
$812.83
Typical High
$812.83