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Supporting Pediatric Care:
A Data-Driven Partnership between PMI and AAP
Pediatric Management Institute (PMI) and the American Academy of Pediatrics (AAP) have partnered to provide a powerful resource for pediatricians. This analysis displays negotiated payment rates for the most common CPT codes in pediatric practices and offers insights into the valuation of pediatric services across the country by major payers.
PMI and AAP are committed to fostering a thriving healthcare environment for children and the professionals who care for them.
Background
This initiative was completed by the Pediatric Management Institute (PMI) using data sourced from TrekHealth.io. The analysis evaluated negotiated payment rates for the most common CPT codes in ambulatory practice pediatricians across four major commercial payers: Aetna, Cigna, UnitedHealthcare, and the Blue Cross/Blue Shield plans (collectively referred to as “Blues”). The tool allows users to assess variations across payers, billing codes, and states.
Purpose
The primary objective of this analysis was to assess statistical benchmarks for negotiated rates of 70 common CPT codes used in pediatric practice, many of which are codes used in primary care. The data displayed, including frequency, percentiles, median, and mean, helps to identify trends and variations by payer and state. These insights are intended to support practices in comparative assessment of payment for services they deliver and to support advocacy efforts to promote fair and sustainable payment rates for pediatric care.
Data Quality
The tool displays 70 specific CPT codes of interest to primary care pediatricians. PMI obtained negotiated rate data from each of the four major payers across all 50 states and the District of Columbia.
From an initial set of 30 million records, the data was refined to 18 million records specific to pediatric primary care. Key fields included payer, state, billing code, negotiated rate, and specialty (taxonomy code). The data was assessed for completeness and consistency to ensure the validity of findings.
Data Highlights
- Provider Representation: The dataset included 51,081 unique NPI values, reflecting a broad representation of primary care pediatric providers nationwide.
- Payer Distribution: The Blues accounted for the highest number of unique NPI values (35,454), followed by Cigna (34,861), Aetna (34,615), and UnitedHealthcare (31,723).
- Geographic Variation: State-by-payer cross-tabulations revealed regional differences in expected payment levels.
- Statistical Overview: Analysis of billing code-level metrics across states and payers uncovered notable differences in rate distributions, highlighting inconsistencies in contracted negotiated amounts for identical services.
- Specialty Impact: While the results contained herein are limited to primary care pediatricians, there were noted variations in negotiated rates observed across provider taxonomy codes, suggesting differential contracted rates for the same CPT codes based on specialty classifications.
Key Takeaways
This analysis highlights the complexity and inconsistency of contracted rates for pediatric providers across commercial payers and geographies. The findings provide critical insights for pediatricians, industry stakeholders, and policymakers, reinforcing the importance of transparent, data-driven advocacy for equitable payment structures. Ongoing monitoring and evaluation will be essential to address disparities and support the financial viability of pediatric care.How To Use The Search Tools
The three search tools below allow you to select a specific state and payer to see various statistical metrics associated with 70 specific CPT codes important to primary care pediatricians.
- State Research Tool: You can select the state and payer to see the statistical analysis for 70 specific CPT codes negotiated between major payers and primary care pediatricians.
- National Comparison: Allows you to examine the median rates of 70 specific CPT codes across all 50 states (plus the District of Columbia)
- State Payer Comparison Summary: This tool enables the end user to select a state for a side-by-side comparison of 70 CPT codes essential to primary care pediatricians.
Column Descriptions:
- NPI Count: Included to provide insight on the sample sizes, it shows the count of unique NPI numbers associated with reported values for the specified CPT code.
- National Medicare Rate: 2025 National Medicare Rate or CDC Private Sector Cost per Dose (for vaccine-related drugs).
- CDC PSCPD: CDC Private Sector Cost Per Dose for vaccine-related drugs. (June 2025)
- 15th Percentile: 15th percentile of specified for the specified CPT code, state, and payer.
- Mean: The average of reported negotiated rates for the specified CPT code, state, and payer.
- 85th Percentile: 85th percentile of specified for the specified CPT code, state, and payer.
- Median: The middle value of reported negotiated rates for the specified CPT code, state, and payer.
- Analysis focused on the following taxonomy codes:
- 208000000X: Pediatrics Physician
- 2080A0000X: Pediatric Adolescent Medicine Physician
- Contracted rates reported by TrekHealth data services via PMI's PayerIntel Services (June 2025)
State Research Tool
National Comparison
State Payer Comparison Summary
For more information, check out the resources from the AAP
CPT codes, descriptions and other data only are copyright 1995 - 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
