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Unlisted Face or Jaw Prosthesis Service

Washington 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 $741 · 10th–90th $219$1,3490%10%10th90th$741Professionalmedian $50 · 10th–90th $45$850%20%40%10th90th$50$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. Need provider-level prices? Contact us.

Insurance Carrier
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$501.19
Median
$741.31
Typical High
$1,348.96
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$229.09
Cigna
Setting
Facility
Modifier
Global
Typical Low
$707.95
Median
$758.58
Typical High
$870.96
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$213.80
Median
$676.08
Typical High
$977.24
Molina
Setting
Professional
Modifier
Global
Typical Low
$44.67
Median
$50.12
Typical High
$64.57
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$83.18
Median
$234.42
Typical High
$588.84
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$446.68
Median
$707.95
Typical High
$1,318.26
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$229.09
United
Setting
Facility
Modifier
Global
Typical Low
$218.78
Median
$794.33
Typical High
$1,905.46
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$758.58
Median
$758.58
Typical High
$758.58