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Unlisted Face or Jaw Prosthesis Service

Wisconsin 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?

$1,585

Typical facility fee. In Wisconsin, October 2026.

Insurers have agreed to pay about $1,585 for this service. Most negotiated rates run $955 to $2,818.

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 7 insurance carriers under federal price transparency rules.

How much rates vary

Facilitymedian $1,585 · 10th to 90th $347 to $4,266Professionalmedian $2,138 · 10th to 90th $2,138 to $2,138
$200$500$1K$2K$5Kfacility $1,585professional $2,138

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
Anthem BCBS
Setting
Facility
Modifier
None
Typical Low
$1,174.90
Median
$2,754.23
Typical High
$4,897.79
Cigna
Setting
Facility
Modifier
None
Typical Low
$758.58
Median
$1,071.52
Typical High
$3,630.78
DeanCare
Setting
Facility
Modifier
None
Typical Low
$2,398.83
Median
$3,090.30
Typical High
$5,370.32
Medica
Setting
Facility
Modifier
None
Typical Low
$204.17
Median
$954.99
Typical High
$1,778.28
Medica
Setting
Professional
Modifier
None
Typical Low
$2,137.96
Median
$2,137.96
Typical High
$2,137.96
Network Health
Setting
Facility
Modifier
None
Typical Low
$831.76
Median
$954.99
Typical High
$2,344.23
Quartz
Setting
Facility
Modifier
None
Typical Low
$758.58
Median
$1,071.52
Typical High
$3,630.78
United
Setting
Facility
Modifier
None
Typical Low
$218.78
Median
$1,148.15
Typical High
$1,862.09

Where Wisconsin 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.

Wisconsin· 5th of 51

$1,585

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.