With insurance, what you pay per visit depends on where you are in your deductible and whether your plan uses a copay or coinsurance. KFF’s 2025 survey of employer plans found an average single-coverage deductible of $1,886, an average specialist copay of $45 among plans that use copays, and an average coinsurance rate of 19%. Before the deductible is met you usually pay the full negotiated rate; after it, you pay the copay or your share until you reach your out-of-pocket maximum. The only reliable number is the one your plan quotes for your own benefits.
Last reviewed By the Monon Therapy Collective editorial team
What decides your share of each physical therapy visit?
Four parts of your plan set your share: the deductible, the copay or coinsurance, the out-of-pocket maximum and the network status of the therapist. A fifth, the negotiated rate the insurer has agreed with the practice, sits behind all of them and is the number your percentage is taken from.
The same visit can therefore cost very different amounts in January and in October. Early in the plan year, before the deductible is met, many people pay the whole negotiated rate. Later, they pay a flat copay or a percentage. Once the out-of-pocket maximum is reached, covered in-network care is paid in full by the plan for the rest of the year.
- Deductible: what you pay for covered care before the plan starts sharing costs
- Copay: a flat amount per visit, common in HMO and many PPO plans
- Coinsurance: a percentage of the negotiated rate, common in high-deductible plans
- Out-of-pocket maximum: the yearly ceiling on deductible, copays and coinsurance for in-network care
- Network status: in-network rates are capped by contract; out-of-network care can cost far more or not be covered
What do national figures say about deductibles, copays and coinsurance?
KFF’s 2025 Employer Health Benefits Survey is the most widely cited national snapshot. It reports an average general annual deductible of $1,886 for workers with single coverage, an average specialist-visit copay of $45, and an average coinsurance rate of 19% for primary care and specialist visits. Many plans treat physical therapy like a specialist visit, though some use a separate therapy copay.
For marketplace plans bought through HealthCare.gov, federal rules cap the 2026 out-of-pocket maximum at $10,600 for an individual and $21,200 for a family, and employer plans face the same ceiling. Those caps limit your worst case for in-network care in a year, but they do not include premiums or anything the plan does not cover.
Why does the first evaluation usually cost more than later visits?
The first visit is billed as an evaluation, a separate code that often carries a higher negotiated rate than a routine treatment visit. Physical therapy evaluations are coded by complexity, as 97161, 97162 or 97163, and some plans apply a different copay to them.
Follow-up visits are billed in units of time for what was done, such as 97110 for therapeutic exercise or 97140 for manual therapy, so a longer or more varied session can mean a higher charge. If you are paying coinsurance or have not met your deductible, asking which codes are usually billed for your kind of problem is the quickest way to estimate a typical visit. The first visit guide explains what that evaluation covers.
Which costs catch people by surprise?
Most surprises come from rules rather than rates: visit limits, prior authorization, facility fees and network status. A plan may cover 20 or 30 therapy visits a year and then stop, or require approval after the first few visits; a practice owned by a hospital may bill a separate facility charge; and a therapist outside your network can leave you with the gap between their charge and what the plan allows.
The answers on how many visits insurance covers and prior authorization for physical therapy go into each in detail. If you have no coverage, or choose to pay directly, the No Surprises Act entitles you to a good faith estimate before care.
- A yearly cap on therapy visits, sometimes shared with occupational and speech therapy
- Prior authorization before the first visit or after an initial block of visits
- Hospital outpatient facility fees on top of the therapist’s charge
- Out-of-network balance billing
- Plans that require a referral even though Indiana law does not
How can you get a reliable estimate before your first visit?
Call the member services number on your insurance card, or use your insurer’s online cost estimator, and ask the questions below about outpatient physical therapy specifically. Write down the date, the representative’s name and a reference number for the call.
You do not have to do this alone. Before you book, the matching team checks which therapists in the network work with your plan, and the therapist’s office confirms your benefits before the first visit so the cost is clear up front. The cost and insurance page explains that process, and the two-minute questionnaire asks for your plan so the check can start straight away.
- How much of my deductible is left this year, and does physical therapy apply to it?
- What is my copay or coinsurance for an outpatient physical therapy evaluation and for follow-up visits?
- Is there a yearly visit limit, and is it shared with other therapies?
- Do I need prior authorization or a referral?
- How much of my out-of-pocket maximum is left?
Related questions
Is physical therapy cheaper with an HSA?
An HSA does not lower the price, but it lets you pay with pre-tax money, which reduces the real cost to you. Physical therapy for a medical condition is generally an eligible expense.
Does every visit cost the same once my deductible is met?
With a flat copay, usually yes. With coinsurance, the amount varies with what was billed that day, so a longer session can cost a little more.
Can I use insurance for some visits and pay cash for others?
Sometimes, for example after your covered visits run out. Ask the therapist’s office before you start how they handle visits your plan will not pay for.
Why did my bill differ from the estimate?
Common reasons are a different evaluation code, extra treatment units, or a deductible that had not been updated when the estimate was given. Ask for an itemized statement and compare it with your explanation of benefits.
Keep reading
- Does insurance cover physical therapy?
- Copay vs coinsurance for physical therapy: what will I pay?
- Is physical therapy covered before I meet my deductible?
- How cost and insurance work with the network
- Paying for physical therapy with an HSA or FSA
- Out-of-network physical therapy reimbursement
Sources
This page is general education, not medical advice. A physical therapist can only advise on your situation after an examination.
