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Unlisted Face or Jaw Prosthesis Service

Virginia 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 $1,660 · 10th–90th $347$10,0000%5%10%10th90th$1,660Professionalmedian $1,660 · 10th–90th $933$10,0000%20%10th90th$1,660$100.0$200.0$500.0$1.0K$2.0K$5.0K$10.0K

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
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$2,137.96
Median
$2,570.40
Typical High
$2,951.21
CareFirst
Setting
Professional
Modifier
Global
Typical Low
$354.81
Median
$1,995.26
Typical High
$2,754.23
Cigna
Setting
Facility
Modifier
Global
Typical Low
$645.65
Median
$645.65
Typical High
$645.65
Sentara
Setting
Facility
Modifier
Global
Typical Low
$933.25
Median
$1,479.11
Typical High
$10,964.78
Sentara
Setting
Professional
Modifier
Global
Typical Low
$933.25
Median
$1,479.11
Typical High
$10,964.78
United
Setting
Facility
Modifier
Global
Typical Low
$204.17
Median
$1,096.48
Typical High
$2,454.71