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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 July 2026.

Facilitymedian $562 · 10th–90th $331$5,0120%10%10th90th$562Professionalmedian $603 · 10th–90th $603$6030%50%$603$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. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Professional
Modifier
Global
Typical Low
$602.56
Median
$602.56
Typical High
$602.56
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$44.67
Typical High
$60.26
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$331.13
Median
$467.74
Typical High
$691.83
Select Health
Setting
Facility
Modifier
Global
Typical Low
$5,011.87
Median
$5,011.87
Typical High
$5,011.87
Select Health
Setting
Professional
Modifier
Global
Typical Low
$5,011.87
Median
$5,011.87
Typical High
$5,011.87
United
Setting
Facility
Modifier
Global
Typical Low
$660.69
Median
$4,466.84
Typical High
$5,128.61