Phenylephrine 10.16 Mg/ml And Ketorolac 2.88 Mg/ml Ophthalmic Irrigation Solution, 1 Ml in South Dakota

South Dakota Pricing in Context

In South Dakota, CPT code J1097 (Phenylephrine 10.16 Mg/ml And Ketorolac 2.88 Mg/ml Ophthalmic Irrigation Solution, 1 Ml) carries an average Medicare payment of $75.68 — 0% below the national benchmark of $76.05. 8 providers across the state submitted claims for this procedure in 2023, performing 22.4K total services. Individual payments in SD ranged from N/A at the low end to N/A at the high end, reflecting differences in provider setting (office vs. facility), modifiers, and the specific geographic locality code applied within the state.

The average billed charge in South Dakota is $159.13, which is the figure uninsured patients would most likely encounter before any negotiation or charity discount. Medicare, by statute, only reimburses the allowed amount — the balance between billed and paid is written off under provider participation agreements. Insured patients generally pay a negotiated rate that falls between these two figures; the exact amount depends on plan design, deductible status, and in-network participation. Because South Dakota sits below the national Medicare average, commercial rates in the state may also run lower than the US median.

Using RAND 2024 commercial-to-Medicare ratios for Drugs (Administered) procedures, the estimated commercial insurance price in South Dakota lands near $194.66, with self-pay cash prices typically around $114.98. Before scheduling, patients can request a Good Faith Estimate under the No Surprises Act, compare cash rates from hospital Machine-Readable Files, and confirm whether the provider is in-network with their specific plan. This page presents CMS reference data for informational use; it does not constitute medical or financial advice.