How much should/could this pathology cost? (Skin cancer biopsies)

I’m going to START with three clarifications, because sometimes people don’t read footnotes. :-)  Read before proceeding.

  • I’m NOT saying there’s anything wrong here – don’t anyone assume that every time I blog, it’s a warpath. :)  I’m just asking a question. My guiding principle on medical treatments and costs is that people should know what their options are, so I’m presenting my situation and asking.
  • I’m also NOT asking for treatment advice – I’m only asking about costs and whether it sometimes makes sense to get pathology done elsewhere. (We’ve already discussed treatments and I’m satisfied.)
  • As I’ve said before, I’m NOT recommending that anyone else act as I choose to.

Also, regular readers know that as a former cancer patient in New Hampshire, my insurance options were limited, and I chose $10,000 deductible, so all of this will come out of my pocket. As I’ve blogged many times before, this turns out to be a nifty way to discover how the money actually flows in American healthcare, which is usually really hard to find out.

Below is the pathology report from some biopsies I got in January. The bill is $416 list price; after the usual insurance discount, my balance due is $312.

My questions:

  • Does this $416 / $312 sound sensible for this? (I’m not complaining; just asking. I like and value good doctors.)
  • If I decided to ask to have samples sent to another pathologist (also or instead), what issues would I run into?

So, now:

The report I received

Two spots were tested, named here A (on my left shoulder) and B (near the spine (“paraspinal”), halfway down (“mid thoracic”)).

Glossary, as I understand things, open to correction as always:

  • “R/O” means “rule out,” which basically means “check for…”
  • BCC is basal cell carcinoma (same kind of skin cancer I had last time – hardly ever fatal)
  • SBCC is superficial basal cell carcinoma
  • ISK is irritated or inflamed seborrheic keratosis (Wikipedia)

====== Pasted from the patient portal =======

—Pathologic Diagnosis—

A – Skin, left posterior shoulder, shave biopsy:
Basal cell carcinoma, superficial and invasive.

B – Skin, left mid thoracic paraspinal back, shave biopsy:
Atypical squamous proliferation, transected at the base, suspicious for squamous cell carcinoma (see Comment).


01/07/14 Verified by: [pathologist’s name]



B(left mid thoracic paraspinal back) – The biopsy shows some features of inflamed seborrheic keratosis, however, squamous atypia is seen and the architecture is quite complex. The lesion is transected at the base, it is suspicious for squamous cell carcinoma. Multiple deeper levels have been examined. Dr. B has reviewed this case and concurs with this diagnosis.

—Gross Description—
A – Labeled/Fixative: Left post shoulder, formalin.
Quantity/Size: Single, 0.7 x 0.4 x 0.1 cm.
Tissue Description: Shave of firm white skin.
Sections/Processing: Inked and trisected. (T1)

B – Labeled/Fixative: Left mid T. para back, formalin.
Quantity/Size: Single, 0.8 x 0.7 x 0.1 cm.
Tissue Description: Shave of tan skin with a central flesh-colored dome
shaped lesion.
Sections/Processing: Inked and quadrisected. (T1) ksb

—Clinical Information—
Specimen Submitted:
A – Skin, left posterior shoulder, shave biopsy

Col Date: 1/6/2014 DOB/Sex: 2/18/1950,(63 years),Male
Rec Date: 1/6/2014 LOC:


B – Skin, left mid T para back, shave biopsy

Clinical History: None provided

Clinical Diagnosis:
B – R/O ISK versus BCC

====== End of pathology report ========


34 comments to How much should/could this pathology cost? (Skin cancer biopsies)

  • Glad to hear that the news is good.

    This is a very nice piece, and a great question to ask. We have learned that these relatively simple diagnostics have a big markup (CBC blood tests, CMP, thyroid).

    Did you happen to ask the lab what the cash price would have been? That’s pretty much our magic phrase: “What’s the cash or self-pay price for that? Yes, if I pay in advance. Cash up front. How much is that? I can write a check right now, or give you my credit card.”

    Wonder what the answer would be. For a CBC blood test, quite often the billed price is in the three figures, while the cash price for this fairly routine test is anywhere from $10 to $35 …. or up to $127, depending on the provider.

    • e-Patient Dave

      Hi Jeanne –

      I sent my draft to a pathologist friend for a fact-check, and she schooled me (gently, as we all should) on an important point that nobody had never pointed out: Pathology is not lab work.

      Lab work typically involves sticking a sample (blood or whatever) in a machine and getting a printout. Pathology involves an M.D. looking at specimens until a microscope and making a judgment on what s/he’s seeing: “What is this thing?”

      In my first draft I’d said “How much should this lab work cost,” but that was wrong. In my PORTAL it shows up in the same place – “test results” – but pathology is MD work, not lab tech work. Good thing for e-patients and informed shoppers to be aware of.

  • Hi Dave–

    I should say — right off the bat — I am not a physician. But — I have had a nasty skin cancer (basal but infiltrated) and come from a family where skin cancer has affected many people: basal, squamous, and melanoma. So, I have had several biopsies of unusual moles in addition to the biopsy that led to dx of the basal cell cancer.

    That said — the cost of the biopsies seems OK to me.

    Having samples sent for a second opinion should not be a problem. There may be a fee involved, but it shouldn’t be out of range with the “read and report” portion of the invoices you already have.

    If the diagnoses are confirmed and if it were me — I’d get rid of both lesions as soon as I could conveniently do so. Just wouldn’t want them “hanging around.”

    Good luck with this.

  • Muffincat

    Agree that pathology is not lab work, but its done usually in the same building![and in this case of the firm below, they have merged the names!]
    here are some lab charges plus some histology that might be of interest to be getting a basic idea.

  • I don’t know the answer to this question. But our Prince works with surgeons, and just the other day a topic of discussion was about another doctor, a friend of one of the surgeons, who had surgery at a large and prominent local hospital.

    This doctor purchased and provided all the equipment and materials required for her surgery at her own cost (reported to be about $4000). She reportedly received a bill from the hospital (for facilities use/materials, not for any of the doctors involved) that was six figures. Now, I know that this also includes the services of the RN’s involved in her care, as well as sheets etc… in recovery. But all hospital charges remain funny money IMO See:

  • JennieD

    If you paid $312 for two biopsies, your pricing for these skin biopsies is in line. Your cost was $156. Not bad at all if it covered both the technical portion and the pro fee. They’re usually separate bills, but some labs set it up so the patient gets one bill for both tech and pro fee for some biopsies. The technical portion means a Med Tech prepared the biopsy specimen and set up the slides; the pro fee is for the pathologist, who reads and interprets. Sometimes, additional testing is performed where needed for diagnosis, such as special stains, which will increase the price. As for sending for a second opinion or consult, that’s often covered by insurance, but as you mentioned, this part is out of pocket for you. Sending to a specialty pathologist may cost about the same as you already paid, but may be worth it for the final result. However, it looks like you already had a specialty pathologist look at it (dermatopathologist), and that pathologist had another pathologist look at it (“Dr. B concurred).

  • Victoria

    Thats cheap…I just had had a needle biopsy on a lymph node in my neck. Stanford Medical Center billed my insurance company $9,335.00 (and that was just for the lab work). Granted Cigna paid less that than that.
    So far my Reactive Lymph Node ordeal….Stanford Medical Center has billed Cigna close to 18k..I still haven’t seen how much for the ENT or if the pathologist (who did the needle biopsy) charges.
    So far my out-of-pocket expenses are about 1200.00.
    It’s a good thing I am not sick…because I can’t afford it.
    They also did a cat scan on my neck and a ultrasound.

    • e-Patient Dave

      I’ve just finished attending a conference on keeping patients in the dark. Were you offered any alternatives or options to decline?

  • william

    I had a couple of skin cancers removed and was told they had to be sent to a pathologist? whats up withthat?

    • e-Patient Dave

      Hi William – I’m no physician so I can’t say, but from what I’ve heard others say, I’d expect they’d be sent to a pathologist to confirm that they got it all: that the edge of what they cut out didn’t still have cancer showing, because that would mean they didn’t get it all.

      But again, I don’t know, so don’t take this as trained medical advice. Anyone? (Have you looked anywhere like the Mayo Clinic’s patient info?)

  • Dave — your cost was reasonable and average.

    You had biopsies of two relatively common skin cancers that “folks of a certain age” are prone to grow, especially if they had lots of sun over the years. Your dermatologist, family doc, or whomever removed them performed a professional service for you. That individual made his/her presumptive (“clinical”) diagnosis and recommended removal of those lesions based on their worrisome gross (naked eye) appearance. To ensure that their clinical diagnosis is correct, good medical practice requires that they consult a pathologist to examine the tissue and make a final diagnosis.

    The diagnosis of any cancer and in fact any medical problem requiring biopsy for diagnosis is made by a pathologist. Before pathology became a specialty (~150 years ago) the basis of most diseases were unknown; rashes,tumors, and other disorders were generally classified as either “benign” or “malignant”; malignant was typically diagnosed post-mortem. What most patients don’t realize, including your most recent poster, is that the final diagnosis of any biopsy, skin or otherwise, depends upon the skill and experience of a pathologist such as myself to “read” your biopsy under a microscope. All skin lesions need to be sent to a pathologist for diagnosis. As you have learned this includes categorizing the lesion as well as assessment of margins for assurance that it’s “all out”.

    All this costs money. Your tissue is transported from the doctor’s office or clinic to the pathology lab where it is again examined and described grossly at the bench, sometimes divided into smaller pieces for a better look in cross section, then processed overnight in various fixative and dehydrating solutions, embedded in paraffin wax, cut in 5 micron sections, laid upon a glass slide, and then stained in order for your tissue so the cells and other tissue elements can be seen microscopically.

    Processing, cutting, and embedding in wax for cutting are the “technical” cost of your bill. My interpretation represents the “professional” cost of your bill; our lab’s total charge, technical plus professional for routine cases such as yours, is $125 per specimen. This is a reasonable price in my experience; most labs charge more, very few charge less. Challenging or difficult cases may require the use of “special stains” which can raise the cost substantially; this is especially true in lymph node and bone marrow biopsies which can generate bills in the thousands.

    As far as options regarding labs, especially pathology lab services, your primary care physician makes the choice as to which lab they prefer. Their choice is driven by a number of factors, primarily whether or not the lab they use is allowed to participate in your insurance plan, but also the level of service, ease of use, and confidence in the labs quality. Cost is only a factor with indigent, self-pay, or patients with high deductibles like yourself.

    One last comment: remember that health insurance is a racket somewhat like gambling, except the house ALWAYS wins. I have a $7000 deductible insurance plan with a monthly premium of $1480 (!!). We have never met the deductible or out of pocket expenses (medicines, etc.) in any given year (I should be thanking God for that) so I regard health insurance as “mortgage insurance” essentially. I could go on and on about how physicians and hospitals are getting royally screwed by insurance companies but that’s for another day.

    • e-Patient Dave

      Dr. Fair, thank you – sorry for the travel-induced delay in clearing your comment.

      I’m grateful for your generosity in explaining all this – what made you do it, may I ask? This was a lot of patient explanation.

      I hope it’s clear from my post that I’m not saying “Why does this cost so much???” My question, per the title, was simply how much should it cost. And I’m especially grateful for your direct top-line answer (“reasonable and average”), followed by the explanation. Exemplary – and empowering/enabling. Thanks!

    • Sheila

      I am not a doctor or pathologist. I wanted to comment on your $1480/month health insurance premiums. When our insurance increased to $1300/month in January 2015, we researched Christian Health Care Ministries. It is similar to a co-op. We pay $450 for 3 family members/month. Members pay in and 100% of bills are paid. Many things are out of pocket and there is a $500 deductible on any procedure/illness/injury. We ask for the self-pay price. We’re happy with it so far. $1300 and climbing was just ridiculous. Might be worth looking into.

  • Notpleased

    I had 2 blemishes removed for biopsy earlier this year at a dermatologist clinic. I had no insurance so when I scheduled the appointment they said I had to pay $180 up front and the final bill would be give or take a couple hundred. Fair enough. I went in and the doc looked at my knee and back to examine the 2 concerns I had. She said she wasn’t too concerned and the chance of cancer was 5% but recommended excision and biopsy to be safe. Well, 1 out of 20 seems like bad odds so I agreed. The nurse injected lidocaine in both sites and the doc cut both out with a flexible razor. My entire appointment lasted no more than 30 minutes. On my way out I asked the receptionist what my bill would be but she said I could get a separate bill from pathology so just wait. Anyway, I Got my bill 2 weeks later and was passed. The doctor bill was $800 and the lab bill was $4200 for a whopping total of $5000 for biopsy of 2 lesions that were 2mm each. Don’t get me wrong, I am glad that they were benign but does this cost even seem reasonable? I feel as if I were mislead about the potential costs and the need for biopsy. Any ideas? Thanks.

    • e-Patient Dave

      Well, I’m not in a position to say what’s reasonable in your situation – I can only speak from the perspective of an ordinary person trying to responsible about the cost of healthcare, which so many people say is out of control.

      Personally, if that’s what they told me and that’s the bill I got, I’d be irate! Did you yell at them or something?

      The pathology charge sounds absurd. Did you tell them you were self-pay? As has shown, saying “self-pay” can often produce a radical change in the price they charge.

      • Notpleased

        Yes I did tell them I had no insurance and all expenses would be out of pocket, hence, that is why they wanted the $180 up front. I would never have gone ahead with the biopsy had the doc not put doubt in my mind about the prognosis. No, I did not yell at them, I am contemplating what to do now. I don’t agree with the price and feel gouged, at the same time collections and getting sued don’t seem like good options. I honestly expected something in the area of $1000 which I would have paid in a timely fashion, but as you stated, it is absurd. Thank you very much for responding so promptly. Your website is a great resource.

  • Chris

    My wife just had a small mole removed at her annual dermatology skin check. It was sent off for pathology just to be sure. We got a bill from the doctor for something like $150 for the removal (we have a high-deductible plan with an HSA). Just received a separate bill for the pathology of over $900!! I almost hit the floor. We called the dermatologist office and they simply said, “we sent it out to X and I guess that’s what they charge.” This price seems outrageous and I am not paying it.

    • e-Patient Dave

      Wow – $900…. note that apparently your dermatologist’s office seems to think the lab can charge whatever they want. There’s so much cultural awakening to be done.

      Why not name “X”? I wonder what they think about this – not at the level of the clerks who answer the phone, but the people who make such business decisions.

      If you can establish that the same pathology would cost much much less elsewhere I think you have every reason to talk to your doctor (the dermatologist) and ask what s/he thinks about it too. I personally would say “Doc, if we had known it was going to be NINE HUNDRED DOLLARS we would have said no – or we would at LEAST have helped your office find a better price.”

      As I’ve often said, the issue IMO is not just the impact on you (and perhaps the chance of kickbacks to your doc, which you should ask about); the issue is that if there’s a GOOD lab out there, trying to offer a great service at a fair price, market forces can’t reward their efforts if you don’t know the available options.

  • Chris — I’m replying to your thread because I sympathize with your frustration. At our lab we occasionally get irate calls from patients demanding an explanation about their “outrageous” bill. Sometimes it’s just a matter of helping them understand the EOB (explanation of benefits) that the insurance company issues; I have trouble figuring them out myself and wonder what the heck insurance is really for.

    Ironically, I am sort of grateful when we get such calls because it gives us a chance to educate the patient on unfamiliar matters. Sometimes we can answer questions they may not be aware of even to ask. I suggest you call the lab yourself; their contact information should be on your wife’s biopsy report, although she may have to request it herself from the dermatologist office because of patient privacy (HIPAA) regulations.

    Be sure that you’re not confusing the lab’s standard charges with what you will be ultimately expected to pay. If they participate with your insurance the lab must accept whatever the insurance company will pay (“the allowable”),regardless of your deductible. This is the “negotiated” rate and should be considerably less than the standard charges. Because you have not met your high deductible you will be responsible for the allowed charges. (P.S. I have a $7000 individual/$12000 family deductible; I have not and probably never will meet it since I assume the risk of routine health care costs in an effort to hold down the ridiculous premiums I have pay each month, just like you. I am currently paying $1620/month for myself and my family!!)

    Why is the bill seem so high compared to the dermatologist? There are a number of reasons for this. Was the mole an ordinary mole or an atypical (“dysplastic”) mole that resembled melanoma?

    Pathologists at the lab are the doctors responsible for making this diagnosis. Biopsies are not like a blood tests; a biopsy is a diagnostic opinion based on the training, skill, and experience of the individual performing it. I can tell you that pathologists have very lively discussions from time to time on some atypical moles and other lesions when trying to reach a consensus of opinion. The pathologist may order special stains (immunohistochemical, immunoperoxidase, “IHC’s”, etc) to help identify antigens and other markers within the cells of the mole to help with this interpretation. You could ask to speak with the pathologist that signed the report and have him or her explain the process to you. It’s worth the effort and gives the pathologist a viewpoint that they would welcome but seldom get: feedback from the patient.

    @Dave: lab shopping is of no value unless the patient is self-pay (no insurance at all). In that instance, patients should call and inquire about a discount on their bill and state that they are self-pay; some labs will even forgive a bill entirely if the patient is truly indigent or under financial hardship.

    IMHO what is way more important for any patient is whether the quality of the work meets a consistent high standard. I would rather have my biopsy read by a trusted pathologist over the cheapest guy any day. My health means way more to me than my wealth.

    • e-Patient Dave

      Good to hear from you again.

      I certainly agree that no discussion of price is meaningful if there aren’t assumptions or evidence of quality. How can one assess that?

      • How can one assess the quality of a physician’s diagnostic skill? That’s the ten million dollar question.

        Licensure, medical board certification, and peer review are the time-honored standards, but in this day and age where the popular media takes every opportunity to amplify the misdeeds of bad apples and breed mistrust, I believe there is a pervasive undercurrent of distrust abetted by the complexity of a system that even those working within it can’t grasp in its entirety.

        I really don’t believe there are unbiased or reproducible parameters to gauge a physician’s skill, regardless of specialty. Only one’s peers have the education, experience, and opportunity to judge another’s competence and acumen; physicians don’t undergo 10+ years of medical school and residency after college because they are slow learners. Unfortunately, “trust us” isn’t very reassuring, I know. Insurance companies would have you think otherwise and are eager to somehow measure such things cost-savings, office wait times, and morbidity and mortality statistics as “quality measures” and then rank physicians accordingly, but their ultimate motivation is always profit and therefore eternally suspect. The more doctors they can drop from participation and the less access to care that patients receive, the better their bottom line at year’s end.

        Honestly I don’t think patients can measure the quality of their physician’s skills any better than the physician’s peers can, especially because the patient has a relationship with their physician that would inherently preclude objectivity. I’m not even sure I could in that situation myself. Patients can and will form opinions about how they feel about their physician and this in turn is the “quality measurement” we get by word of mouth.

        For Chris, the dermatologist chooses where to send the patient’s biopsy and, if they are not limited by the insurance plan, they will refer to labs that in their experience return meaningful, credible, and (at times) inspired diagnostic reports that are consistent with their own clinical observations and can turn the reports around in a few days time. Price is not a consideration when patients have insurance, except for HMO insurances that require specimens to go to labs they have exclusive contracts with (usually the big nationals like LabCorp, Quest, etc.).

        But which lab is better? That’s another animal altogether. With all the facts I would wager that Chris’s lab bill is justified. I wonder about the profits of insurance companies; United Health Care made $33.43 billion (with a B) in 2014. That’s more than the Gross Domestic Product of about 50% of nations across the world.

        • Arthur Sands MD

          As a family physician, I am working on a self pay program for my patients. I just made an agreement with an excellent (Stanford trained) pathologist who is going to do simple skin lesion path evaluations and report for $50 per lesion. I am going to do the surgery for $125.

          Minor surgery is relatively simple and doctors get paid much better for these procedures (you do have to have good manual skills which many physicians may not have ). However, we are paid poorly for a lot of our work which involves considerable knowledge and judgement. Evaluation and management codes pay poorly.

          Ask ahead of time for a cash price and often you can reduce your costs. Billing insurance companies is often a big game and requires a lot of overhead – most people would be better off paying cash for minor medical care and covering themselves with a high deductible for serious illnesses.

          • e-Patient Dave

            Thanks, Dr. Sands.

            > Ask ahead of time for a cash price and often you can reduce your costs.

            Somehow throughout this whole adventure (years ago) it never occurred to me to do that. It’s something that Clear Health Costs does a lot of reporting on, as time allows.

            Your point about the COST of the administrative overhead is important. The cash prices reported by Clear Health Costs are so different from the insurance billed prices, and vary so widely, that it leaves me thinking “Where the heck does the rest of the money go??”

            That’s why I like CHC – it shows what THE ACTUAL WORK is worth, to both the buyer (patient) and the seller (you), when nobody else is in the middle mucking things up.

            Thank you for pitching in!

  • e-patient Patti

    I had a therapeutic colonoscopy where two polyps were removed. My insurance was charged more than $7,000 with $3,216 being charged for Biopsy specimen Pathology. The insurance paid on the Colonoscopy but refused to pay anything on the Biopsy specimen Pathology saying it should be included in the price of the colonoscopy. Is there anyway to appeal that decision. I was also billed separately by the pathologist.

  • Dr. Fair

    @ Patti

    Was the colonoscopy performed by a gastroenterologist, a general surgeon, or some other physician specialty? Was it performed in a hospital Operating Room, an outpatient surgery center affiliated with a hospital, an independent colonoscopy suite, or a medical office? Many insurance companies have different payment rules depending on the “POS” (Place of Service), as well as the individual performing the service.

    Rgeradless, $3216 for two polyp specimens, submitted together or in separate containers, seems very high even if special stains or other additional diagnostic techniques to examine your tissue were required.

  • e-patient Patti

    The colonoscopy was performed by a gastroenterologist in a hospital setting. The gastroenterologist administered his own anesthesia and there was a nurse monitoring the vitals. I paid the pathologist separately but the hospital also charged for CPT Code 88305.

  • Dr. Fair

    The 88305 charge has two components, a “PC” or Professional Component and the “TC” or Technical Component. The PC is what the pathologist gets paid for making the diagnosis and the TC is what the lab gets paid for preparing a microscope slide of your tissue for the pathologist to look at.
    In my experience, the global charge or “rack rate”, i.e., what the pathologist and/or the lab charge for an 88305 unit of service ranges between $100-350 combined. Were there any additional units of service other than 88305 attributed to the pathologist or the hospital lab on your EOB (explanation of benefits)?

  • e-patient Patti

    After reading your comment, I called the insurance back and they said that I was billed for two colonoscopies; one was 45385 and the other was 45388. The insurance paid on the 45385 but said that the 45388 is CCI mutually exclusive to the 45385 and not only paid nothing for the 45388 but also listed #3,182.00 as patient responsibility!

  • Dr. Fair

    Sounds like the lab charges are not really the problem but rather the way the work that was done was coded by the hospital. You had two polyps, probably at separate sites, and these are supposed to billed separately but it may not have been coded correctly. I suggest speaking directly to the person in billing at the hospital that coded and submitted your bill, if possible; that person should be able to determine from your insurance statement whether it should be re-submitted under more appropriate codes, including any of the increasing number of modifiers that insurance companies now require. You should know that insurance billing has become so complex that coding is a career complete with diplomas and certification exams. If you feel like you can’t navigate this sort of thing yourself then seek out the “Patient Care Representative” at the hospital for help and advice; their job is to guide you through it all. Good luck!

  • Hey e-Patient Patti and Dr. Fair, We have written a bunch about this. I’d like to hear more. Can you contact me? info (at) clearhealthcosts (dot) com. thanks!

  • e-patient Patti

    Dr. Fair,
    Thank you for the good advice. I did contact Billing and they said that they would send my bill to the Appeal department. I also filed my own appeal with a copy of the operative report to explain to my insurance that there were two different polyps in two different locations within the colon removed in two different ways hence the two different billing codes. Will it make a difference? I’ll have to wait and see.

    • e-Patient Dave

      Patti, this is a fascinating tale, and it all happened while I was busily traveling. Four months later do you have any updated news?

  • I’m with Dave – I’m fascinated (and, of course, disgusted and sadly not at all surprised). I would be very interested in hear how this story is progressing. I am so sorry you are having to go through this, Patti.

    • e-Patient Dave

      Sorry for the delay in releasing this, Mandi (and Patti) – got lost in the flood! My bad.

      (My site is set to require manual authorization the first time anyone posts their first comment.)

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