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Unlisted Face or Jaw Prosthesis Service

Utah 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?

$200

Typical facility fee. In Utah, October 2026.

Insurers have agreed to pay about $200 for this service. Most negotiated rates run $44.67 to $603.

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 5 insurance carriers under federal price transparency rules.

How much rates vary

Facilitymedian $550 · 10th to 90th $200 to $4,467Professionalmedian $45 · 10th to 90th $30 to $60
$50$100$200$500$1K$2K$5Kfacility $550professional $45

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
Cigna
Setting
Facility
Modifier
None
Typical Low
$630.96
Median
$630.96
Typical High
$630.96
Molina
Setting
Professional
Modifier
None
Typical Low
$30.20
Median
$44.67
Typical High
$60.26
Regence BlueShield
Setting
Facility
Modifier
None
Typical Low
$380.19
Median
$478.63
Typical High
$691.83
Select Health
Setting
Facility
Modifier
None
Typical Low
$5,011.87
Median
$5,011.87
Typical High
$5,011.87
Select Health
Setting
Professional
Modifier
None
Typical Low
$5,011.87
Median
$5,011.87
Typical High
$6,309.57
United
Setting
Facility
Modifier
None
Typical Low
$199.53
Median
$1,023.29
Typical High
$4,466.84

Where Utah 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.

Utah· 45th of 51

$200

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.