How much does Medicare pay for HCPCS J1097?

Medicare allowed an average of $95.35 per service and paid $75.95 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $272.48, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is HCPCS code J1097?

Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml. It was billed 697,684 times to 106,949 Medicare beneficiaries by 410 providers in 2024.

Which specialty bills J1097 most?

Ambulatory Surgical Center, with 697,640 services from 409 clinicians. Next are Ophthalmology.

HCPCS J1097

Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml

$95.35Medicare-allowed amount per service, averaged across 697,684 services

Providers submitted

$272.48

Asking price, not received

Medicare allowed

$95.35

The fee schedule figure

Medicare paid

$75.95

Balance is patient coinsurance

Providers submitted an average of $272.48 for this code and Medicare allowed $95.35 — 2.9× 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 $75.95 (80%); the rest is the patient’s coinsurance and deductible.

Services: 697,684
Beneficiaries: 106,949
Providers billing it: 410
Total allowed: $66,524,169

What Medicare pays for HCPCS J1097

Across 697,684 services billed by 410 providers to 106,949 beneficiaries, Medicare allowed an average of $95.35 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 J1097

Specialty	Services	Beneficiaries	Avg allowed	Providers
Ambulatory Surgical Center	697,640	106,938	$95.35	409
Ophthalmology	44	11	$98.40	1

J1097 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
Florida	52,745	$95.46	$76.21	41
California	48,968	$95.45	$76.19	26
Virginia	37,450	$95.54	$76.14	11
New York	36,045	$95.48	$76.12	16
New Jersey	34,610	$95.49	$76.13	19
Maryland	31,232	$95.36	$76.18	15
Texas	31,091	$95.38	$76.18	22
Pennsylvania	30,390	$95.33	$75.93	24
Georgia	29,002	$95.40	$76.12	12
Mississippi	27,273	$95.30	$76.24	12
Ohio	26,514	$95.28	$76.09	19
North Carolina	26,169	$95.23	$76.14	14
Tennessee	25,365	$95.54	$76.16	12
South Carolina	23,013	$95.25	$76.17	13
Illinois	22,611	$95.18	$75.98	13
South Dakota	18,031	$95.01	$76.29	4
Arkansas	15,286	$95.52	$76.13	6
Michigan	14,579	$95.15	$76.20	6
Missouri	14,497	$95.52	$75.89	8
Iowa	11,195	$93.78	$76.18	4
Alabama	11,028	$95.64	$76.27	7
Wisconsin	11,011	$95.48	$76.11	7
North Dakota	10,744	$94.81	$76.27	4
Oklahoma	9,817	$95.27	$76.21	6
New Hampshire	9,032	$95.62	$76.23	2
Massachusetts	8,841	$95.55	$76.12	6
Colorado	8,467	$95.33	$76.25	6
Arizona	8,016	$95.34	$76.10	15
Indiana	7,818	$95.53	$76.17	4
Louisiana	7,561	$95.28	$76.16	10
Nebraska	7,416	$95.19	$76.23	5
Minnesota	5,547	$95.44	$76.11	10
Delaware	5,405	$95.59	$76.16	2
Hawaii	5,332	$95.17	$76.22	4
Wyoming	5,264	$95.05	$76.21	3
Nevada	4,141	$95.78	$76.31	2
West Virginia	3,085	$94.82	$76.35	1
Kentucky	3,005	$95.56	$76.18	3
Alaska	2,570	$95.06	$76.30	1
Oregon	2,508	$95.10	$76.19	3
Connecticut	1,815	$95.60	$76.17	4
Washington	1,440	$94.57	$76.29	2
Kansas	651	$95.53	$76.11	1
Utah	540	$95.54	$76.14	2
Rhode Island	496	$95.50	$75.83	2
Idaho	68	$95.32	$75.95	1

Related codes

J1010Injection, methylprednisolone acetate, 1 mg$0.13
J1071Injection, testosterone cypionate, 1 mg$0.02
J1096Dexamethasone$116.54
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.