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 ========


15 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!

  • 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.

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