Regulatory costs on aquaculture farms have been shown to be of a magnitude that warrants additional analysis. The drivers of farm-level costs of fish health inspections were identified in this study from national survey data on U.S. salmonid farms. The greatest costs identified were related primarily to state fish health requirements for inspection and testing to certify that fish are free of specific pathogens prior to approval of necessary permits to sell and/or transport animals. Fish health inspection costs included laboratory testing, farm personnel time, veterinary fees, and shipping samples to laboratories, with laboratory testing and the value of farm personnel time being the most expensive components. Principal cost drivers were the number of tests and whether required sampling was farmwide or for each lot as identified by the collector. Farmers who primarily sold into recreational markets had greater fish health costs than farmers who primarily sold food fish because of the greater numbers of species and size-/age-classes of salmonids on their farms. Regulatory requirements to test all species and size-/age-classes on farms increased inspection costs by increasing the total number of tests, the total value of fish sacrificed, and shipping costs. Consequently, for farms with more than one species or more than one size-/age-class, annual farm-level testing was less costly than annual lot-based testing. Increased numbers of tests in a given year, although reported by only a few respondents, can increase costs dramatically and turn profitable farms unprofitable, even food fish farms. Smaller salmonid farms experienced disproportionately greater inspection cost burdens than did larger farms. The fish health inspection scenario of only one annual inspection of only the most susceptible species and size-/age-class showed a cost burden that did not generate economic distress, even on smaller salmonid farms. Other scenarios modeled (based on survey data) that included lot-based surveys of multiple species and size-/age-classes resulted in substantially greater fish health inspection costs that led to unprofitability for various farm sizes and business types. Study results suggest that implementing Comprehensive Aquaculture Health Program Standards might allow for risk- and pathogen-based reductions in the total number of inspections and fish sampled while maintaining equivalent or greater health status compared to current methods. American Fisheries Society-Fish Health Section Blue Book inspection methods are interpreted and applied inconsistently across states and generally yield lot- rather than farm-level health attestations because the history of testing results, risk assessment, and biosecurity practices are not typically taken into account. The cost effects of alternative fish health sampling and testing requirements should be considered in decisions and policy on fish health regulation.