Home / Industries / How Much Does It Cost to Start an Ambulatory Surgery Center? (2026 Sourced Figures)

How Much Does It Cost to Start an Ambulatory Surgery Center?

Reviewed by Muhammad Tayyab Shabbir · Last updated 13 October 2026

Publicly filed capital expenditures are the only whole-project cost figures we can verify. North Carolina regulators approved a total capital expenditure of $9,990,000 for a new ambulatory surgical facility with up to four GI endoscopy procedure rooms in Cary, and $2,946,129 for a project that relocates a Hickory center and takes it to six endoscopy rooms on completion. Read those two numbers narrowly: they are the capital expenditures those certificates approve, nothing else. The certificates do not state whether regulatory fees are inside those totals, and they say nothing at all about working capital, which in our experience is where most ASC plans actually fail, because Medicare cannot pay you until your certification survey is complete and CMS has set your effective date.

By Muhammad Tayyab Shabbir, UCL, published textbook author. Business Plan Firm is the US practice of Avvale, a London consultancy. Our team has produced $1B+ in funding documents for 500+ businesses across 30+ countries, including Shark Tank and Dragons' Den clients.

Verify before you commit capital. Every figure below is tied to a named source and a date. Medicare payment rates and the CMS application fee are reset every year, and state fees and Certificate of Need rules can change in any year. Confirm current requirements directly with your state health department, your CMS Regional Office and your Medicare Administrative Contractor before signing a lease or a loan, and with the SBA or your lender before relying on any loan-program figure here.

Cost at a glance

How to read this table: the rows do not add up to a total, and that is deliberate. The first two rows are complete approved capital expenditures for two specific filed projects. The next three rows are separate regulatory fees, and neither certificate states whether those fees sit inside its approved capital expenditure. The last two rows are the costs we could not put a number on at all. So there is no headline all-in range on this page. If you want one you have to build it, and anyone quoting you a single cost-to-start-an-ASC number is estimating the two rows nobody can verify.

What actually drives the cost of an ambulatory surgery center?

Four things, in the order we see them bite in client work.

Room type and specialty. A GI endoscopy room is not the same build as a Class C operating room fitted out for orthopedics or spine. Be careful about turning filed capital expenditures into a cost per room: the two North Carolina certificates above cover different project scopes, and neither explains its cost build-up, so a per-room figure derived from either one is arithmetic on a single project rather than a benchmark you can apply to yours.

Whether your state requires a Certificate of Need. In CON states you pay for the application, the consultants and the delay, and you may lose. North Carolina's fee alone reaches $50,000 at the cap, and it is non-refundable whether or not a certificate is issued (N.C. Gen. Stat. § 131E-182(c)). CON coverage is also shrinking: MedPAC's March 2026 report lists South Carolina eliminating CON requirements for ASCs in 2023, Georgia exempting some single-specialty ASCs in 2024 and "North Carolina eliminating CON requirements for ASCs locating in counties with populations over 125,000 in 2025". Check whether your state and county still require one.

Exclusive-use space. CMS's ASC certification and compliance guidance does not permit an ASC to mix functions and operations with an adjacent physician's office in common space during concurrent or overlapping hours, and the anti-kickback safe harbor separately protects investor returns only where the center is one "whose operating and recovery room space is dedicated exclusively to the ASC" (42 CFR § 1001.952(r)). A plan that saves money by sharing operating or recovery rooms with your practice does not meet that condition. The FAQ below sets out the sharing rules in full.

The gap between opening and getting paid. Covered below, in our experience it is the item most business plans get wrong.

What does the licensing and certification pathway look like, step by step?

Minnesota's Department of Health publishes an unusually clear public description of the sequence, so we use it as the worked example below. Be careful with it: the federal elements, the CMS forms, the survey, the Conditions for Coverage, the CCN, apply everywhere, but the state steps and any pre-survey case requirement are Minnesota's own, and yours will differ. Confirm the sequence with your own state agency.

1. Certificate of Need, if your state requires one, and if your specific project is not exempt. CON coverage and exemptions for ASCs change; ask your state health planning agency about your county and your project, not about ASCs in general.
2. State ASC licensure. "To become Medicare certified, the facility must first be licensed": Minnesota Department of Health.
3. Federal forms: CMS-370 (Health Insurance Benefits Agreement), CMS-377 (Request to Establish Eligibility) and CMS-855B (Medicare enrollment), with the $750 CY 2026 application fee.
4. MAC approval. Minnesota states it "will not proceed with the initial Medicare certification process until after we have received a copy of the 855B and approval letter from the fiscal intermediary."
5. Perform cases: where your state agency requires it. Minnesota's instruction is conditional and worth quoting in full: "If you choose to have MDH conduct the initial certification survey, it is required a minimum of 10 procedures be performed before the initial certification survey." That is a Minnesota requirement attached to the state-agency survey route. We found no federal 10-procedure minimum in 42 CFR Part 416, and you should not assume one applies in your state or on an accreditation route. Ask your state agency and your accreditor directly what they require before they will survey.
6. Survey, by the state agency or by a CMS-approved accrediting organization with deemed status, against the Conditions for Coverage at 42 CFR Part 416, Subpart C. Subpart C covers considerably more than the handful of conditions most summaries list. Plan survey readiness off its current text in full, not off any summary, this one included.
7. Plan of correction for any deficiencies, then the CMS Regional Office issues your CMS Certification Number.

On choosing an accreditor: see the FAQ below. We can source two CMS-deemed routes directly, neither publishes a fee schedule, and we are not printing a roster of the rest. Ask your CMS Regional Office for the current list before you choose a route or budget for it.

How long does it take, and when can you actually bill Medicare?

This is the number that sinks projects. Under 42 CFR § 489.13(b): "The agreement or approval is effective on the date the State agency, CMS, or the CMS contractor survey (including the Life Safety Code survey, if applicable) is completed, or on the effective date of the accreditation decision, as applicable, if on that date the provider or supplier meets all applicable Federal requirements as set forth in this chapter." The same provision adds that the effective date may not be earlier than the latest of the dates on which CMS determines that each applicable federal requirement is met.

Now read that against step 5. Where your surveying body requires completed cases before it will survey, as Minnesota does on the state-agency route, you must open, staff and operate the center, paying rent, debt service, nurses, techs and anesthesia, and get through those cases before the survey can happen. Everything before your effective date is non-billable to Medicare. That is the structural reason an ASC needs a working capital reserve measured in months of full burn, not weeks.

On elapsed time, the Cary certificate is instructive. It took effect 28 May 2026, and its own timetable puts "Services Offered" at 1 June 2027: more than a year after the certificate itself. We could not confirm when the original project was first approved, so we make no claim about total elapsed time from first approval to first case, and you should discount any page that does.

Do Stark and the Anti-Kickback Statute allow physicians to own the center?

Yes, but the rules are specific.

Stark generally does not reach the facility fee. Under 42 CFR § 411.351, designated health services exclude services paid by Medicare as part of a composite rate, expressly including ASC services identified at § 416.164(a). Stark can still apply where the center bills designated health services outside that composite rate, such as clinical laboratory services. The definitions in the same section also exclude drugs and radiology that are covered ancillary services under § 416.164(b) for which separate payment is made to an ASC, so check each service against the definitions.

The Anti-Kickback Statute is the real gate. The ASC safe harbor at 42 CFR § 1001.952(r) protects returns on physician investment only if the entity is a certified ASC under Part 416, its operating and recovery room space is dedicated exclusively to the ASC, patients referred by an investor are fully informed of that investor's interest, and all standards in one of four categories are met: surgeon-owned (r)(1), single-specialty (r)(2), multi-specialty (r)(3), or hospital/physician (r)(4). The recurring standards, paraphrased rather than quoted, read the regulation itself before you rely on any of this, are:

• The one-third income test, in the surgeon-owned, single-specialty and multi-specialty categories: § 1001.952(r)(1)(ii), (r)(2)(ii) and (r)(3)(ii). At least one-third of each investor's medical practice income from all sources, for the previous fiscal year or previous 12-month period, must derive from performing procedures as that paragraph defines them. Hospital/physician ASCs at (r)(4) contain no one-third income test of their own: they reach it only indirectly, by requiring each physician investor to meet the standards in (r)(1), (r)(2) or (r)(3).
• The one-third procedures test, in multi-specialty ASCs only, at § 1001.952(r)(3)(iii): at least one-third of the procedures, as that paragraph defines them, performed by each physician investor in the previous fiscal year or previous 12-month period must be performed at the investment entity.
• No investor financing. The entity and its investors must not loan funds to, or guarantee a loan for, an investor buying in.
• Returns strictly proportional to capital contributed; offering terms unrelated to referral volume.
• Ancillary services must be integral to primary procedures and never separately billed to a federal program; federal beneficiaries must be treated non-discriminatorily.

The safe harbor is voluntary, falling outside it is not automatically illegal, but structures that miss it lose the bright line. Get health care counsel to model your investor roster against the one-third tests before you take subscriptions, not after.

How do people actually finance an ASC?

In the engagements we run, the standard stack is physician equity plus conventional bank debt plus a landlord tenant-improvement allowance. That is our own observation from client work, not a surveyed figure, and it is not a claim about the market as a whole. SBA is possible but collides with syndication in three specific ways, all traceable to SBA SOP 50 10 8.1, effective 1 October 2026 (checked against SBA's current posting on 11 October 2026).

1. A surgery center is a named special-purpose property. In the 504 program, the SOP's list of examples of a Limited or Special Purpose Property (Section C, Chapter 1, Paragraph E, under Borrower's Contribution) expressly includes "Hospitals, surgery centers, urgent care centers, and other health or medical facilities". The contribution rule printed just above that list is what makes that matter: a business with a Limited or Special Purpose Property must contribute at least 15% of the project cost, and at least 20% if the project also involves a new business, which Appendix 3 defines as a business that has been "in operation for 2 years or less at the time the loan is approved", with operations "deemed to begin when the business begins generating revenue from its intended operations". The same definition adds: "When an existing business starts a business that is in the same 3-digit NAICS code with identical ownership, and they are Co-Borrowers, SBA considers this to be a business expansion and not a new business." Physician offices and surgery centers share code 621 (point 3), so a practice building its own center should test that sentence before modeling 20%. Where that 20% applies, the debenture "will finance no more than 30% of the Project" and at least 50% comes from banks or the other institutions the SOP lists. So at least 50% from those sources, at most 30% from the debenture, at least 20% from you. See our guides to SBA 504 loan requirements and SBA equity injection requirements.

2. At least one owner must guarantee the whole loan. Under Section A, Chapter 5, Paragraph A (Guaranties), which covers 7(a) and 504 loans alike, any individual with direct and/or indirect ownership of 20% or more must provide an unlimited full guaranty. With twelve to twenty physician investors on equal stakes nobody crosses 20%, which does not help, because the same paragraph provides that "If no one individual or entity is a direct and/or indirect owner of 20% or more of the Applicant, at least one of the owners must provide a full unconditional guaranty." At least one of your partners backstops the entire loan for everyone. Cutting a stake below 20% before applying does not by itself remove the guaranty: under the six-month lookback rule, anyone subject to the guaranty requirements "6 months prior to the date of the loan application" stays subject to them, with listed exceptions. Spouses who, with minor children, hold a combined 20% or more must each guarantee in full.

3. Affiliation can put you over the size standard. The size standard for NAICS 621493, Freestanding Ambulatory Surgical and Emergency Centers, is $19.0 million in annual receipts (13 CFR § 121.201). Under Section A, Chapter 1, Paragraph D of the SOP, the applicant alone must not exceed it, and the applicant combined with its affiliates must not exceed the standard for its own primary industry or the combined group's, whichever is higher. Affiliation turns on ownership: the SOP notes that SBA's 2023 rule removed control as a basis for it. A business that owns more than 50% of the ASC is an affiliate, and where no owner holds more than 50%, so is an owner of 20% or more that "is a business that operates in the same 3-digit NAICS subsector as the Applicant". Physician offices (NAICS 621111) share subsector 621 with surgery centers, so a group practice holding that much brings its own receipts into the calculation. Where no owner holds more than 50% and an owner of 20% or more "also owns more than 50 percent of another business entity that operates in the same 3-digit NAICS subsector as the Applicant", that entity is an affiliate too: a surgeon's majority-owned practice, for example. An applicant over the industry standard may still qualify under the alternative size standard: with affiliates, tangible net worth of no more than $20 million and average net income after federal income taxes (excluding carry-over losses) of no more than $6.5 million for the 2 full fiscal years before application.

If a management company will run the center. A business whose management agreement "gives the management company sole discretion over the business operations" is an ineligible passive business (Section A, Chapter 1, Paragraph E). The applicant is eligible where the manager lacks that discretion and the applicant exercises meaningful oversight, including of the employees operating the business, "who must be employees of the Applicant". Under the Guaranties paragraph in point 2, SBA or a delegated lender may also require a guaranty from a manager with no ownership interest.

Maximum sizes, and one figure to get right. Standard 7(a) loans have a maximum of $5,000,000. For 504, the SOP (Section C, Chapter 1, Paragraph D.1) provides that "For all 504 Projects, the gross debenture is limited to an outstanding maximum balance of $5,000,000 in the aggregate for each small business concern, including its affiliates", except for Eligible Energy Public Policy Projects and Projects for Small Manufacturers (primary NAICS code in Sectors 31, 32 and 33). The $5,500,000 ceiling you will see quoted for 504 applies only to those two exceptions. In SOP 50 10 8.1 the limit counts "only all SBA 504 loans, committed or outstanding, that the Applicant and its affiliates have received"; the 1 June 2025 edition also counted 7(a) guaranties. An ASC is not a manufacturer, so model $5,000,000, not $5,500,000, unless the project itself qualifies as an Eligible Energy Public Policy Project. New since the 1 June 2025 edition (Section C, Chapter 1, Paragraph B): on a 504 project "with total project costs of at least $5,000,000", the Third Party Lender's credit memorandum or underwriting analysis must be submitted to SBA.

What do the operating economics look like once you are open?

ASC payment is a conversion factor times a relative weight. For CY 2026, CMS set the ASC conversion factor at $56.322 for centers meeting quality reporting, up from $54.895 in CY 2025, and the OPPS conversion factor at $91.415 (CY 2026 OPPS/ASC final rule, CMS-1834-FC, Federal Register 25 November 2025). The ASC conversion factor is 61.6% of the OPPS conversion factor, but ASC relative weights are scaled as well (the CY 2026 weight scalar is 0.872), and the same rule states that, in general, "ASC payment rates are roughly 55 percent of the payment rate under the OPPS": your competitive advantage against hospitals and your margin constraint at the same time. Miss the ASC Quality Reporting Program requirements and the annual update to the ASC conversion factor is cut by 2.0 percentage points. CMS has proposed $57.766 for CY 2027 (Federal Register, 7 July 2026); no final CY 2027 rule had appeared there when we searched on 11 October 2026.

Market context from MedPAC's March 2026 report to Congress: 6,436 Medicare-certified ASCs operated in 2024, with 248 opening and 108 closing or merging that year. Most are single-specialty, gastroenterology and ophthalmology being the most common. The same chapter states that Medicare does not require ASCs to submit cost data, so there is no cost-report dataset to benchmark your own operating costs against.

What makes ASC projects fail?

• Budgeting the build, not the runway. No Medicare revenue until the effective date under § 489.13(b), and where your state agency requires completed cases before it will survey, as Minnesota does, you are operating at full cost before the clock even starts.
• Cost overruns on long-dated approvals. The Cary project's approved capital expenditure rose from $3,565,982 to $9,990,000, and the Hickory project's from $1,593,735 to $2,946,129 after a change of scope and cost overrun.
• An investor roster that fails the one-third tests, discovered after subscriptions are taken.
• Assuming SBA will fill the gap, then hitting the 20% contribution for a new business in a special purpose property, the guaranty rule, the $5,000,000 debenture ceiling, or the $19.0 million size standard once affiliates are counted.
• Case mix outside the ASC Covered Procedures List. CMS expanded the list for CY 2026, but if your intended volume is not on it, the capex is not recoverable from Medicare.
• Space-sharing that breaks the Conditions for Coverage or the safe harbor.

Is an ambulatory surgery center actually viable for you?

Often, in our view, no. Three tests before you spend anything: these are our screening criteria, not a regulator's:

Do your surgeons pass the one-third income test today? If less than one-third of a prospective investor's medical practice income comes from procedures on Medicare's list of ASC-covered procedures, they fall outside the safe harbor's income test, and in a multi-specialty center at least one-third of each physician investor's listed procedures must also be performed in your building. Our own rule of thumb: if you cannot name the physicians who clear both tests, you do not have a deal yet.

Can you fund the runway without the revenue? Model the months from certificate of occupancy to CCN with full staffing and zero Medicare receipts. Our view, from the deals we work on, is that if that reserve is not sitting in the capital stack the project is not financeable, and a lender will find this before you do. We deliberately do not publish a dollar threshold here, because Medicare collects no ASC cost reports to set one against.

Are you in a CON state, and does your project need one? Where CON applies, budget for a non-refundable application fee, up to $50,000 in North Carolina's case, and for the time the review takes. Our opinion, not a sourced finding: many surgeons in CON states are better served joining an existing center than developing one, and you should expect incumbent providers to participate in the review process against you. Ask your state health planning agency how its review actually works, and whether your project is covered at all, before you assume either point applies to you.

If you cannot answer all three, the right next step is a feasibility study, not a lease.

Frequently asked questions

How many states require a Certificate of Need for an ASC?

MedPAC's March 2026 report to Congress refers to "the 22 states (plus the District of Columbia) that have CON laws" in the context of ASCs, and stresses that stringency varies substantially between them. It also lists states that have cut CON back for ASCs, including North Carolina in 2025. Confirm your own state and project with its health planning agency rather than relying on any published list, this one included.

What is the Medicare enrollment fee for a new ASC in 2026?

$750.00. CMS set the CY 2026 institutional provider application fee in a notice published in the Federal Register on 3 December 2025 (doc. 2025-21877). It applies to CMS-855B enrollments filed on or after 1 January 2026 and on or before 31 December 2026, and covers initial enrollment, revalidation, and adding a new practice location.

Can an ASC share space with the physicians' existing practice?

Not during concurrent or overlapping hours. CMS says an ASC and another entity, such as an adjacent physician's office, may not mix functions and operations in a common space during those hours. Sharing with a hospital outpatient surgery department or Medicare-participating IDTF is barred even when temporally separated. The anti-kickback safe harbor at 42 CFR § 1001.952(r) also requires operating and recovery room space dedicated exclusively to the ASC.

Is accreditation required, or can the state survey us?

Either route works: you may be surveyed by your state agency or by a CMS-approved accrediting organization holding deemed status. We can source two such ASC routes directly, The Joint Commission's ambulatory care accreditation and AAAHC's Medicare deemed status program, and neither publishes a fee schedule, so expect a facility-specific quote based on services and volume. We could not retrieve an authoritative current CMS list of approved accrediting organizations for ASCs, so ask your CMS Regional Office for it rather than working from any roster you find online.

What does a state ASC license cost?

It varies by more than an order of magnitude. Missouri charges an annual license fee of $200 under 19 CSR 30-30.010(2)(A). Texas charges $5,200 for an initial license and $5,200 to renew, each for a two-year term, under 26 Tex. Admin. Code § 508.3, and fees are non-refundable. We verified only these two directly; check your own state's rule rather than assuming a midpoint. Where we could not verify a state's fee at source, Florida, for one, we publish nothing rather than guess.

Can I use an SBA loan to build an ASC?

Sometimes. Under SOP 50 10 8.1, surgery centers are among SBA's examples of a Limited or Special Purpose Property, so a new business (in operation for 2 years or less) must contribute at least 20% of a 504 project's cost, with the debenture capped at 30%. An affiliated physician group adds its receipts to the $19.0 million size test, and an applicant over it must meet the alternative size standard.

How much revenue can an ASC expect per case?

We can source no reliable public per-case benchmark. MedPAC's March 2026 report states that Medicare does not require ASCs to submit cost data, unlike other facility types, so there is no cost-report dataset underneath any per-case cost or margin figure you are quoted. Build your projections from your own payer mix and the published CY 2026 ASC rates for your actual CPT codes, not from industry averages.

What a lender will ask you for

In our experience you should expect every one of these before a term sheet: a case-volume forecast built bottom-up from named surgeons with their historical volumes; documentation that those surgeons pass the § 1001.952(r) one-third tests; the CON certificate or written confirmation your state does not require one; a construction budget with a contingency sized against real overrun risk; a month-by-month working capital model running from certificate of occupancy to CMS Certification Number with zero Medicare revenue in the interim; the capital stack showing physician equity, bank debt, any SBA piece and the landlord's TI allowance; the subscription and operating agreements; and three-statement projections tied to the latest final ASC conversion factor (CY 2026 as of this update) and your actual CPT mix.

That is exactly the package we build. We produce business plans ($1,000 / $1,800 / $2,800), SBA loan plans ($1,000 / $1,800 / $2,500), financial models ($750 / $1,250 / $1,950), market research ($500 / $1,200 / $2,200) and feasibility studies ($3,900 / $6,500 / $9,800, from $14,000 for complex projects).

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This page is informational and is not legal, tax or investment advice. Anti-kickback and Certificate of Need analysis is fact-specific: engage qualified health care counsel before structuring physician ownership or filing a CON application.

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