How much does Medicare pay for HCPCS J1096?

Medicare allowed an average of $116.54 per service and paid $92.85 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $296.21, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is HCPCS code J1096?

Dexamethasone, lacrimal ophthalmic insert, 0.1 mg. It was billed 356,215 times to 54,601 Medicare beneficiaries by 285 providers in 2024.

Does J1096 pay differently in an office than a hospital?

Yes. The allowed amount averaged $142.22 in an office setting and $115.59 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills J1096 most?

Ambulatory Surgical Center, with 343,562 services from 260 clinicians. Next are Optometry, Ophthalmology, Internal Medicine.

HCPCS J1096

Dexamethasone, lacrimal ophthalmic insert, 0.1 mg

$116.54Medicare-allowed amount per service, averaged across 356,215 services

Providers submitted

$296.21

Asking price, not received

Medicare allowed

$116.54

The fee schedule figure

Medicare paid

$92.85

Balance is patient coinsurance

Providers submitted an average of $296.21 for this code and Medicare allowed $116.54 — 2.5× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $92.85 (80%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $142.22
Hospital / facility: $115.59

The office rate is higher because the practice supplies the room, staff and equipment out of that payment. In a hospital the facility bills those separately, so the clinician's share is smaller — the total cost to Medicare is usually higher, not lower. 12,653 services were billed in an office setting and 343,562 in a facility.

Services: 356,215
Beneficiaries: 54,601
Providers billing it: 285
Total allowed: $41,513,296

What Medicare pays for HCPCS J1096

Across 356,215 services billed by 285 providers to 54,601 beneficiaries, Medicare allowed an average of $116.54 per service. That is 6.5 services per beneficiary, so this is a code patients typically receive more than once. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills J1096

Specialty	Services	Beneficiaries	Avg allowed	Providers
Ambulatory Surgical Center	343,562	53,050	$115.59	260
Optometry	7,553	725	$144.35	9
Ophthalmology	5,047	806	$140.12	15
Internal Medicine	53	20	$39.37	1

J1096 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
New Jersey	40,806	$115.60	$92.21	24
Arizona	38,873	$115.88	$92.36	19
Florida	31,602	$119.23	$95.01	35
Virginia	31,272	$115.68	$92.22	11
New York	20,149	$116.63	$93.00	11
Texas	19,756	$116.26	$93.55	19
California	15,371	$115.89	$92.41	16
Pennsylvania	15,311	$126.18	$100.53	13
Mississippi	12,161	$116.30	$92.87	9
Kansas	8,810	$115.44	$91.99	5
Georgia	8,615	$115.80	$92.39	8
Maryland	8,226	$115.71	$92.24	7
Massachusetts	8,216	$115.74	$92.21	5
Ohio	7,915	$115.96	$92.48	8
Illinois	7,914	$115.23	$92.09	9
Wisconsin	7,571	$115.73	$92.21	6
South Carolina	7,280	$115.76	$92.25	8
New Hampshire	5,776	$115.60	$92.20	1
Missouri	5,622	$115.70	$92.21	6
Tennessee	5,462	$115.77	$92.58	7
Michigan	5,172	$114.88	$91.63	7
Delaware	5,137	$115.87	$92.32	2
New Mexico	4,630	$115.47	$92.18	3
Indiana	3,694	$115.96	$92.34	6
Connecticut	3,658	$116.19	$92.57	3
Iowa	3,553	$114.54	$92.29	1
North Carolina	3,317	$115.16	$92.56	8
Alabama	3,049	$115.25	$92.14	3
Oklahoma	2,855	$115.34	$92.42	4
Nevada	1,979	$115.36	$92.77	2
Arkansas	1,901	$115.63	$92.13	3
Nebraska	1,860	$115.55	$92.27	1
Louisiana	1,821	$115.59	$92.43	6
Rhode Island	1,732	$115.28	$91.59	1
Colorado	1,473	$115.61	$91.93	2
Wyoming	1,450	$114.44	$92.28	1
Kentucky	1,430	$116.67	$92.95	4
Minnesota	796	$114.23	$91.01	1

Related codes

J1010Injection, methylprednisolone acetate, 1 mg$0.13
J1071Injection, testosterone cypionate, 1 mg$0.02
J1097Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigati$95.35
J1030Injection, methylprednisolone acetate, 40 mg$6.28
J1040Injection, methylprednisolone acetate, 80 mg$9.59
J1020Injection, methylprednisolone acetate, 20 mg$6.69
J1000Injection, depo-estradiol cypionate, up to 5 mg$33.58

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.