What is the standard insurance baseline for HCPCS J1097?

The standard insurance baseline reimbursement rate is $95.51. This represents the customary allowable amount established across standard fee schedules.

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HCPCS J1097Medical Service

Phenylephrine 10 16 Mg Ml and Ketorolac 2 88 Mg Ml Ophthalmic Irrigation Solution

Q: What do doctors typically charge for Phenylephrine 10 16 Mg Ml and Ketorolac 2 88 Mg Ml Ophthalmic Irrigation Solution?

The nationwide median physician charge for Phenylephrine 10 16 Mg Ml and Ketorolac 2 88 Mg Ml Ophthalmic Irrigation Solution (HCPCS J1097) is $205.91. Doctor billed charges vary based on geographic region, setting, and overhead.

Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml. Clinical pricing breakdown and utilization metrics across 443 practicing doctors nationwide.

$205.91

Peer Median Charge

Gross billed rate

$95.51

Standard Baseline

Customary allowable

2.2x

National Markup

Charge vs baseline

443

Active Physicians

Billing this code

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Understanding This Medical Fee

Gross Charge vs Negotiated Payment: The median physician charge for this service is $205.91. However, insured patients almost never pay this full amount directly. Insurers negotiate rates down toward the $95.51 baseline.

Self-Pay & Uninsured Guidance: If you are paying without insurance or out-of-network, request a prompt-pay cash discount. Most medical practices are willing to settle self-pay bills near the customary baseline rate rather than the full gross charge.

Key Questions for Your Doctor's Billing Office:

"Does Dr. [Name] participate in my specific insurance plan network?"
"What is the total self-pay or cash rate for code J1097 if paid upfront?"
"Are there separate facility, anesthesia, or pathology fees associated with this procedure?"