| Code | Description | States | Median rate |
|---|---|---|---|
| 21010 | Open jaw joint surgery (arthrotomy) | 46 | $563.70 |
| 21031 | Removal of a bony growth on the lower jaw | 45 | $297.95 |
| 21032 | Removal of a bony growth on the palate | 46 | $295.87 |
| 21045 | Radical removal of a lower jaw cancer | 46 | $935.98 |
| 21050 | Removal of the jaw joint condyle | 46 | $699.06 |
| 21060 | Removal of the jaw joint disc | 46 | $631.51 |
| 21073 | Jaw joint manipulation under anesthesia | 43 | $289.90 |
| 21076 | Custom surgical obturator (palate) prosthesis | 41 | $737.77 |
| 21077 | Custom artificial eye socket (orbital) prosthesis | 39 | $1,816.61 |
| 21079 | Custom interim obturator (palate) prosthesis | 41 | $1,253.44 |
| 21080 | Custom definitive obturator (palate) prosthesis | 41 | $1,393.87 |
| 21081 | Custom lower jaw resection prosthesis | 40 | $1,275.27 |
| 21082 | Custom palatal augmentation prosthesis | 41 | $1,212.42 |
| 21083 | Custom palatal lift prosthesis | 41 | $1,162.40 |
| 21084 | Custom speech aid prosthesis | 41 | $1,295.18 |
| 21085 | Custom oral surgical splint | 43 | $569.93 |
| 21086 | Custom artificial ear (auricular prosthesis) | 42 | $1,313.91 |
| 21087 | Custom artificial nose (nasal prosthesis) | 41 | $1,308.94 |
| 21088 | Custom facial prosthesis | 26 | $1,185.71 |
| 21116 | Injection for a jaw joint X-ray (arthrogram) | 46 | $148.83 |
| 21120 | Chin augmentation with graft or implant | 44 | $570.94 |
| 21121 | Chin reshaping by sliding bone cut | 46 | $543.86 |
| 21122 | Chin reshaping with two or more bone cuts | 45 | $594.41 |
| 21125 | Jaw body or angle augmentation with implant | 46 | $1,909.15 |
| 21208 | Facial bone augmentation with graft or implant | 46 | $1,196.12 |
| 21209 | Facial bone reduction (contouring) | 45 | $642.26 |
| 21215 | Bone graft to the lower jaw | 46 | $2,647.26 |
| 21230 | Rib cartilage graft to the face, nose or ear | 47 | $626.10 |
| 21243 | Jaw joint replacement with prosthesis | 46 | $1,218.95 |
| 21270 | Cheekbone augmentation with implant | 45 | $805.42 |
| 21299 | Unlisted head or face bone procedure | 10 | $166.64 |
| 21315 | Closed treatment of a broken nose, without stabilization | 48 | $129.77 |
| 21320 | Closed treatment of a broken nose, with stabilization | 48 | $176.55 |
| 21343 | Open treatment of a depressed frontal sinus fracture | 47 | $830.44 |
| 21344 | Open treatment of a complex frontal sinus fracture | 47 | $1,074.36 |
| 21400 | Eye socket fracture, closed treatment, no manipulation | 46 | $185.40 |
| 21406 | Open eye socket fracture repair, no implant | 47 | $468.37 |
| 21408 | Open eye socket fracture repair with bone graft | 47 | $720.73 |
| 21422 | Open treatment of an upper jaw (LeFort I) fracture | 47 | $519.21 |
| 21423 | Open upper jaw (LeFort I) fracture repair, complicated | 47 | $635.14 |
| 21445 | Open treatment of a jaw ridge (alveolar) fracture | 46 | $603.88 |
| 21450 | Lower jaw fracture, closed treatment, no manipulation | 46 | $411.28 |
| 21451 | Closed treatment of a lower jaw fracture, with manipulation | 48 | $602.33 |
| 21480 | Jaw joint dislocation, closed treatment | 46 | $112.58 |
| 21485 | Jaw joint dislocation, closed treatment, complicated | 45 | $716.40 |
| 21490 | Open treatment of a jaw joint dislocation | 46 | $645.04 |
| 21499 | Unlisted head bone or joint procedure | 11 | $179.87 |
| 21615 | Removal of the first or cervical rib | 46 | $527.00 |
| 21620 | Partial removal of the breastbone | 47 | $413.55 |
| 21627 | Breastbone debridement | 46 | $447.21 |
| 21630 | Radical removal of the breastbone | 46 | $988.64 |
| 21742 | Sunken chest (pectus) repair, minimally invasive (Nuss) | 36 | $857.77 |
| 21743 | Sunken chest (pectus) repair, Nuss, with chest scope | 34 | $954.68 |
| 21750 | Re-closure of a separated breastbone | 47 | $575.85 |
| 21811 | Open rib fracture repair with plates, 1 to 3 ribs | 43 | $472.98 |
| 21812 | Open rib fracture repair with plates, 4 to 6 ribs | 44 | $567.71 |
| 21813 | Open rib fracture repair with plates, 7 or more ribs | 44 | $772.28 |
| 21825 | Open treatment of a breastbone fracture | 47 | $458.15 |
| 21899 | Unlisted neck or chest bone procedure | 12 | $179.87 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.