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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 July 2026.

Facilitymedian $2,884 · 10th–90th $1,380$5,7540%10%20%10th90th$2,884Professionalmedian $33 · 10th–90th $32$2,1380%50%10th90th$33$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
Anthem BCBS
Setting
Facility
Modifier
Global
Typical Low
$1,584.89
Median
$3,090.30
Typical High
$5,754.40
DeanCare
Setting
Facility
Modifier
Global
Typical Low
$2,238.72
Median
$2,818.38
Typical High
$5,370.32
Medica
Setting
Facility
Modifier
Global
Typical Low
$616.60
Median
$1,445.44
Typical High
$2,089.30
Medica
Setting
Professional
Modifier
Global
Typical Low
$2,137.96
Median
$2,137.96
Typical High
$2,137.96
Molina
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$33.11
Typical High
$70.79
Network Health
Setting
Facility
Modifier
Global
Typical Low
$831.76
Median
$933.25
Typical High
$2,344.23
Quartz
Setting
Professional
Modifier
Global
Typical Low
$2,187.76
Median
$2,187.76
Typical High
$2,187.76
United
Setting
Facility
Modifier
Global
Typical Low
$954.99
Median
$1,479.11
Typical High
$1,949.84