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Unlisted Face or Jaw Prosthesis Service

Vermont 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 rates vary

Facilitymedian $501 · 10th to 90th $468 to $501
$500facility $501

Distribution of negotiated rates across all payers (price axis is log-scale). Small sample; interpret with caution. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Cigna
Setting
Facility
Modifier
None
Typical Low
$467.74
Median
$467.74
Typical High
$467.74
United
Setting
Facility
Modifier
None
Typical Low
$501.19
Median
$501.19
Typical High
$501.19