Incision And Drainage Of Tear Duct Sac
What Medicare pays for 68420, what providers bill, and how the price varies across 3 states, drawn from CMS 2023 claims data.
68420 · the short answer
For incision and drainage of tear duct sac, Medicare pays about $275.58 while providers bill $717.56 on average, a 2.6× markup, one of the smaller markups in the catalog. State-level Medicare rates range 199% from lowest to highest.
- Medicare pays
- $275.58
- Providers bill
- $717.56
- Markup
- 2.6×
- Markup percentile
- 9th
Medicare amounts are CMS-published; markup = average submitted charge ÷ average Medicare payment.
Price Range Across States
What You Might Pay
Estimated using RAND 2024 commercial-to-Medicare ratios. Actual prices vary by insurer, plan, and facility.
How we estimate these prices
These estimates are based on the RAND Hospital Price Transparency Study (4th Edition, 2024), which found that commercial insurance prices average 224% of Medicare rates nationally. We apply category-specific ratios: Eye Surgery procedures average 2.24x Medicare rates. Cash/self-pay estimates blend typical cash discounts (55% of billed charges) with Medicare-based estimates (150% of allowed amounts). These are statistical estimates, not quotes. Contact your insurer or provider for actual costs.
Where this markup sits nationally
Markup (billed ÷ Medicare) across 8,901 procedures with a meaningful Medicare rate
3 more affordable than 9% of 8,901 procedures
Each bar is a band; taller bars hold more procedures. The dashed line + filled bar mark this entry. Hover or tap any bar for its full count, share, and where it sits relative to this entry.
Source CMS Medicare Physician & Other Practitioners · 2023
Prices by State
| State | Medicare Payment | Billed Charge |
|---|---|---|
| California | $357.66 | $534.92 |
| New York | $275.61 | $823.00 |
| Pennsylvania | $119.81 | $287.30 |
What the Data Says About Incision And Drainage Of Tear Duct Sac
Across 3 states with reporting providers, CPT code 68420 (Incision And Drainage Of Tear Duct Sac) shows a national average Medicare payment of $275.58 against an average billed charge of $717.56. That gap, a 2.6x markup, or 160% above the Medicare allowed amount, is among the tightest billed-to-paid spreads we track, this code's chargemaster rate tracks unusually close to the Medicare benchmark.
Eye Surgery procedures like this one saw 406 services billed to Medicare in 2023 by 167 distinct providers, serving 381 unique beneficiaries. State-level variation is significant: Pennsylvania reports the lowest average payment at $119.81, while California reports the highest at $357.66. A 199% spread this wide is typically a GPCI story: practice-expense and malpractice-premium components of the fee formula diverge sharply by locality even though the procedure code never changes.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Eye Surgery category (2.24x), the estimated commercial insurance price lands near $794.58, with self-pay cash discounts commonly bringing the figure closer to $463.37. Within Eye Surgery, Incision And Drainage Of Tear Duct Sac ranks #179 of 266 tracked procedures by national average Medicare payment.
What to do with this
If you may have incision and drainage of tear duct sac done, these steps turn the numbers above into a real-world cost estimate.
- Request a Good Faith Estimate from your provider at least 3 business days before a scheduled procedure, under the No Surprises Act it is an enforceable written price.
- Compare incision and drainage of tear duct sac costs in your state, Medicare rates vary by locality. Browse states
- Check a hospital’s published cash price, which is often far below the billed charge. Price transparency
- Understand why billed charges run several times the Medicare rate before you negotiate. Read the guide
Figures here are averages and estimates, not a quote. Confirm coverage and out-of-pocket costs with your insurer and provider.
Frequently Asked Questions
How much does Incision And Drainage Of Tear Duct Sac cost?
Incision And Drainage Of Tear Duct Sac (CPT 68420) shows unusually wide state-to-state pricing: Medicare pays $275.58 on average nationally, but the $119.81-$357.66 range across states spans more than double from cheapest to priciest.
Why do providers charge more than Medicare pays?
Providers set their own chargemaster rates (billed charges), which are typically much higher than what any insurer pays. Medicare pays a fixed rate based on the procedure code and geographic location. The billed charge is relevant mainly for uninsured patients, who may face prices closer to the submitted charge.
How much does Incision And Drainage Of Tear Duct Sac cost with insurance?
With commercial insurance, incision and drainage of tear duct sac costs an estimated $794.58 on average (range: $556.21-$1,112.41), a moderate premium over Medicare's $275.58. Without insurance, the estimated cash price is $463.37.
Which state has the lowest cost for Incision And Drainage Of Tear Duct Sac?
Pennsylvania has by far the lowest average Medicare payment for Incision And Drainage Of Tear Duct Sac at $119.81, while California pays more than double at $357.66 - a $237.85 gap.
How many providers perform Incision And Drainage Of Tear Duct Sac?
Incision And Drainage Of Tear Duct Sac is comparatively uncommon: only 167 providers nationally billed Medicare for it in 2023, serving 381 beneficiaries via 406 total services.
What is the billed-to-Medicare markup for Incision And Drainage Of Tear Duct Sac?
Providers bill 2.6x what Medicare pays for Incision And Drainage Of Tear Duct Sac - one of the smaller markups in the catalog at 160% above the Medicare rate.
Related Guides
Tips to reduce out-of-pocket costs
Your right to upfront pricing
How Medicare payments work
Decode charges and codes
Why bills exceed actual costs
Geographic pricing factors
Data from CMS Medicare Physician & Other Practitioners (2023).
Read our methodology - how this data is sourced, computed, and verified.
Related
Every figure on PlainProcedure is rendered directly from CMS Medicare Physician & Other Practitioners data, no number is typed in by an editor. This page draws directly on CMS Medicare Physician & Other Practitioners data, no figure is typed in by an editor. See our editorial standards & corrections policy, the methodology behind these numbers, or report a data error.