go back

Unlisted Face or Jaw Prosthesis Service

Texas 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 $363 · 10th–90th $117$1,9950%5%10th90th$363Professionalmedian $30 · 10th–90th $30$7590%50%90th$30$50.0$200.0$1.0K$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
Facility
Modifier
Global
Typical Low
$588.84
Median
$3,981.07
Typical High
$4,466.84
BCBS
Setting
Facility
Modifier
Global
Typical Low
$173.78
Median
$338.84
Typical High
$724.44
BCBS
Setting
Professional
Modifier
Global
Typical Low
$91.20
Median
$91.20
Typical High
$91.20
Christus
Setting
Facility
Modifier
Global
Typical Low
$79.43
Median
$79.43
Typical High
$79.43
Lucent Health
Setting
Facility
Modifier
Global
Typical Low
$54.95
Median
$56.23
Typical High
$56.23
Lucent Health
Setting
Professional
Modifier
Global
Typical Low
$1,548.82
Median
$2,187.76
Typical High
$2,187.76
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$30.20
Providence
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$60.26
Typical High
$79.43
United
Setting
Facility
Modifier
Global
Typical Low
$162.18
Median
$758.58
Typical High
$2,290.87
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$758.58
Median
$758.58
Typical High
$758.58