HCPCS Level II J1097: Phenylephrine and Ketorolac Ophthalmic Irrigation, 1 ml
HCPCS Level II code J1097 describes a combined phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution supplied per 1 ml; this medication is used as an intraoperative ophthalmic irrigating agent for procedures requiring pupil dilation and intraocular anti-inflammatory/analgesic effect, typically administered in the operating room or procedure suite during ophthalmic surgery as an intraoperative irrigation/instillation service.
For related coverage guidance, see recent payer policy updates: Epithelial Cell Cytology in Breast Cancer Risk Assessment, Chemotherapy Observation or Inpatient Hospitalization (for New Mexico Only), Umbilical Cord Blood Harvesting and Storage for Future Use (for Indiana Only).
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National Reimbursement Benchmarks
National commercial pricing centers on BUCA’s average commercial rate of $114.30, which sits near the mid-range of the payer mix and provides a useful benchmark for comparison. Blue Cross Blue Shield and Cigna cluster closely around their medians near $120, while Aetna’s distribution is broader with a lower median but a wide span between its lower and upper quartiles. UnitedHealth Group shows the highest mean and extreme upper potential but also a notable spread.
Looking at interquartile dispersion (P75 minus P25), Blue Cross Blue Shield is tight with a spread of $9.00 ($123.0 - $114.2), and Cigna is effectively zero dispersion at $0.00 ($120.4 - $120.4), indicating highly concentrated negotiated rates. UnitedHealth Group has the widest IQR of $8.40 ($126.4 - $118.0), while Aetna’s IQR is $9.50 ($117.0 - $23.2). BUCA’s IQR is $19.70 ($122.30 - $102.60), showing the largest middle-50 variability among the listed benchmarks.