Home / Industries / How Much Does It Cost to Start a Dialysis Center? (2026 Figures, Sourced)

How much does it cost to start a dialysis center?

Reviewed by Muhammad Tayyab Shabbir · Last updated 12 October 2026

Two new in-center dialysis facilities that North Carolina approved in March 2026 budgeted $3,345,046 (11 stations) and $3,744,183 (10 stations) in capital and working capital: $2,608,727 and $2,948,634 of capital, plus $736,319 and $795,549 of start-up and initial operating expense. Both applications came from Total Renal Care of North Carolina, LLC, which is 85% owned by a DaVita Inc. subsidiary. These budgets are not a national average: they are two projects in one state from one operator, and each relocates existing stations from the applicant's other facilities rather than building demand from scratch. And neither is a property purchase: both are leasehold fit-outs, so if you are buying property your number is materially higher. In the 10-station budget the largest line is the construction contract, $1,946,661; working capital adds 27% on top of capital.

By Muhammad Tayyab Shabbir, UCL, published textbook author. Business Plan Firm is the US practice of Avvale, a London consultancy.

Verify before you commit capital. Fees, base rates and state rules change annually, and several claims that normally appear on pages like this have been cut here because we could not retrieve a primary source. Confirm current requirements with CMS, your Medicare Administrative Contractor and your state survey agency or Certificate of Need office before signing a lease or a loan.

Cost at a glance

How to read this table. n/a means we have no verified figure, not that the cost is zero. Low and Typical are two budgets, not a distribution: Newton and Garner are the two new in-center facilities among the 17 dialysis decisions on North Carolina's 2026 index as retrieved on 11 October 2026 (the other 15 add stations or are home training facilities, and we have not read them). Both come from one operator and neither is an upper bound, so there is no defensible high case. Each total is that column's capital plus working capital. The home training facility is a different business, not a small version of the same one.

What actually drives the cost?

The largest single item in the Garner budget is the construction contract, $1,946,661 of the $2,948,634 total; medical and non-medical equipment together come to $698,582.

Be careful using the Garner filing as a template. Its capital table as printed in the findings does not add up: the line items come to $3,348,634, $400,000 more than the stated total, and the agency approved $2,948,634. One line, Architect/Engineering Fees, is printed as 495,620 with no dollar sign; at $95,620 the table would add up, which is our reading, not the agency's. Ask NC DHSR before you rely on that line.

Water is the part of this build that an ordinary clinic fit-out does not have. 42 CFR § 494.40 requires water and dialysate meeting the AAMI standard incorporated into the rule, and § 494.40(b) requires a chlorine and chloramine removal component plus a backup carbon tank in series. The section's own text does not lay out the rest of the plant (it points to the AAMI publication for equipment requirements), and its paragraph (e) separately covers in-center use of preconfigured hemodialysis systems. In our experience a central water treatment system with a distribution loop to the stations and dedicated drainage and electrical is closer to a small process plant than to a clinic fit-out. Part 494 also requires an approved training program for the technicians who monitor and test the water treatment system (§ 494.140(f)).

We publish no dollar range for the water plant, deliberately. Neither filed budget breaks it out, and we found no primary source that gives a figure.

The other drivers are the certification gap, Certificate of Need where it applies, and scale: a basic principle of North Carolina's 2026 State Medical Facilities Plan is that new facilities must have a projected need for at least 10 stations to be cost-effective and to ensure quality of care.

What is the licensing pathway, step by step?

1. Certificate of Need, if your state applies it to dialysis. North Carolina charges $5,000 plus 0.3% of capital expenditure above $1 million, capped at $50,000 (N.C. Gen. Stat. § 131E-182(c)). We could not verify any other state's dialysis CON fee from a primary source. See the section below.
2. State facility license, where your state requires one. We could not verify a national fee range or any individual state's ESRD licensure rule from a primary source. Ask your state licensure agency for its current rule and fee schedule in writing.
3. Build to the Conditions for Coverage at 42 CFR Part 494: infection control (§ 494.30), water and dialysate quality (§ 494.40), reuse (§ 494.50), physical environment and fire safety (§ 494.60), emergency preparedness (§ 494.62).
4. Enroll with Medicare on Form CMS-855A and pay the CY 2026 application fee of $750, then wait on your MAC. The current standards are in the Medicare Program Integrity Manual, Chapter 10, § 10.5. For an initial application filed online that requires a site visit, further information from you or fingerprinting, the contractor is to process 95% within 50 calendar days of receipt and 100% within 85; on paper, within 65 and 100. But "The processing timeliness clock temporarily stops" in listed situations, such as a fingerprint request or a question to the state agency, so ask your MAC what it is seeing before you plan a construction loan around the standard.
5. Pass the initial certification survey: a state survey against Part 494, or an accreditation survey. Section 50403 of the Bipartisan Budget Act of 2018 (Pub. L. 115-123) permitted ESRD facilities to use a CMS-approved accrediting organization. The Federal Register notices we found approve two: the National Dialysis Accreditation Commission (through 4 January 2029) and the Accreditation Commission for Health Care (through April 2029). Ask CMS whether the list has changed.
6. Billing starts on the certification date. Under 42 CFR § 489.13(b) the approval is effective on the date the survey is completed, or on the effective date of the accreditation decision, if you meet all applicable federal requirements on that date. If a health and safety standard is not met that day and no other federal requirement is outstanding, under § 489.13(c)(2) it is the date you meet all applicable Conditions for Coverage or, if you are found to meet all conditions but have lower-level deficiencies, the date CMS or the state survey agency receives an acceptable plan of correction for them. No retroactive payment for the build-out.

Which states require a Certificate of Need for dialysis?

We were able to verify dialysis-specific CON rules from primary sources for exactly one state. We are not going to guess on a question that can void a project, so this list is short on purpose.

• North Carolina: yes, and binding. Under the 2026 State Medical Facilities Plan a county shows need for additional stations only when the projected station deficit is 10 or more and every facility there is at 80% utilization or higher; 100% utilization is four patients per station per week. When a county need determination exists, the plan lets anyone apply to develop a new facility; when a facility need determination exists, only the facility that generated the need may apply to add stations. Policy ESRD-3 in the same plan lets a licensed acute care hospital apply to develop or expand an outpatient dialysis facility on a hospital campus "without regard to a county or facility need determination" if the conditions it lists are all met. Relocating stations that are already certified is a separate route and does not depend on a county need determination: that is how both projects on this page were approved, Garner by moving four stations from one existing facility and six from another, Newton by moving 11 from one.

For every other state, call the state health planning agency before you sign anything. We drafted this page with CON fees, station standards and license rules for several other states and cut all of them: none was verifiable to the standard a capital commitment deserves.

How long does it take, and what does the wait cost?

The 90-day survey clock is statutory: under 42 U.S.C. § 1395rr(b)(1) the initial survey of a renal dialysis facility "shall be initiated not later than 90 days after" the date on which the enrollment form has been determined complete and the enrollment status shows approval pending the survey. Initiated, not finished. CMS's FY 2027 Mission & Priorities Document lists ESRD initial surveys as Tier 1, its highest priority.

What sits in front of those 90 days is the problem: the CON cycle, construction, licensure, MAC processing under the standards above, then correction of any deficiencies before § 489.13 sets your effective date. Our planning figure is 9 to 18 months from breaking ground to first Medicare payment; it is our figure, not an agency's. Both approved timetables allow about nine and a half months from construction contract (17 March 2027) to Medicare certification (1 January 2028). Garner's $795,549 of working capital, 27% on top of capital, is $191,565 of start-up cost (supplies, staff labor and training in "the timeframe between the completion of leasehold improvements and certification") plus $603,984 of initial operating expenses, about half of its first-year operating budget, and its opening census is patients transferring from the applicant's existing facilities. Plan for more if you start with none.

One further trap: the same CMS document puts relocations and added stations in Tier 3, below the survey that opens you.

How do people finance it?

SBA 7(a): maximum $5,000,000 for any one Standard 7(a) loan under SOP 50 10 8.1 (effective 1 October 2026), Section B, Chapter 1. A business generating revenue for a year or less is a start-up, requiring an equity injection of at least 10% of total project costs, which the SOP spells out as "all costs required to become operational, regardless of the source of funds, except for lines of credit and 504 loans". On a $3.75M project that is $375,000. It need not all be cash (see SBA equity injection requirements). There is also an upfront guaranty fee, set for each fiscal year by SBA notice. For loans of $700,001 to $5,000,000 with a maturity over 12 months that are approved from 1 October 2026 through 30 September 2027, Information Notice 5000-881797 sets it at "3.5% of the guaranteed portion of the loan up to and including $1,000,000, plus 3.75% of the guaranteed portion over $1,000,000".

SBA 504. SOP 50 10 8.1, Section C, Chapter 1 (Borrower's Contribution) lists "Hospitals, surgery centers, urgent care centers, and other health or medical facilities" among its examples of Limited or Special Purpose Properties. The list does not name dialysis centers; "CDCs must address whether the Project Property is Limited or Special Purpose in their credit memorandum", and "SBA may determine that other properties meet the Limited or Special Purpose Property definition". A project that is both a new business, here one "in operation for 2 years or less at the time the loan is approved" (Appendix 3, not the 1-year start-up test used for 7(a) equity), and a special-purpose property must contribute at least 20%, with the debenture no more than 30% and a third-party lender at 50% or more. If you buy the property instead, your project cost rises well above these fit-out budgets and your 20% rises with it. Confirm eligibility with your CDC before you model it; the structure is set out in SBA 504 loan requirements.

Leased space, either program. Under SOP 50 10 8.1, Section A, Chapter 3, where $500,000 or 30% of loan proceeds, whichever is less, will be used for leasehold improvements, the lender must obtain the written lease, and: "For 7(a) loans, the lease term, including renewal options exercisable only by the Borrower, should equal or exceed the term of the loan. For 504 loans, the lease term must equal or exceed the term of the loan. An assignment of lease and Landlord's waiver should be obtained." A 504 loan matures in 10, 20 or 25 years; for 7(a), Appendix 17 caps loans for leasehold improvements, other than on a leasehold interest in land, at 10 years plus up to 12 months to complete them. On 504 collateral, Section C, Chapter 1 says: "Because leasehold improvements provide minimal collateral value, the CDC must consider requiring additional collateral".

Nephrologist joint ventures. DaVita's FY 2025 Form 10-K describes the structure: "We generally hold controlling interests in these joint ventures, with nephrologists, hospitals, management services organizations, and/or other healthcare providers holding minority equity interests". The findings for the home training facility in the table: "FMS Cornelius Home, LLC is a joint venture between Bio-Medical Applications of North Carolina, Inc., and Metrolina Nephrology Associates, P.A." Do not treat the Stark analysis as settled in your favor. The definition of designated health services in 42 CFR § 411.351 says "DHS do not include services that are paid by Medicare as part of a composite rate", but that sentence's examples are skilled nursing facility Part A payments and ambulatory surgical center services, not the ESRD bundle; whether the bundle qualifies is a question for counsel. The exception at § 411.355(g) covers "EPO and other dialysis-related drugs" furnished in or by an ESRD facility, and the Anti-Kickback safe harbor regulation, 42 CFR § 1001.952, does not mention dialysis. Get healthcare regulatory counsel on the structure before you take physician money.

What do the operating economics look like?

The CY 2026 ESRD PPS base rate is $281.71 per treatment, up from $273.82. Your rate is then adjusted for case mix, wage index, rural and low-volume status, a training add-on for home and self-dialysis, and outliers. CMS has proposed $299.55 for CY 2027; no final rule had been published when we checked on 11 October 2026.

The bundled rate is not where the money is. DaVita's FY 2025 Form 10-K states that payments from commercial payors "generate nearly all of our profits", with a commercial plan generally responsible for up to a patient's first 33 months of dialysis. Across its US dialysis business, average patient service revenue was $409.56 per treatment against patient care costs of $273.34. Dividing that segment's $2,084 million of operating income by its 28,733,980 treatments gives about $73 of operating income per treatment: our own calculation, not a figure DaVita reports. That is a company-wide figure, not a forecast for one new center.

For breakeven, the Garner filing counts 148 treatments per patient-year (three sessions a week for 52 weeks, less a 5% missed-treatment allowance) and projects 4,341 year-one treatments producing $1,539,579 of net revenue against $1,207,969 of operating cost. That is $354.66 of net revenue per treatment on our own arithmetic; dividing the operating cost by it gives 3,406 treatments, or 23 patients.

Two cautions. It is a breakeven on total operating cost as the findings report it, and the method treats every dollar of that cost as fixed, which no clinic's cost base is. And the Garner findings give an average operating expense per treatment of $355 while their own totals give $278.27: the second place where that filing contradicts itself. Treat both filings as well-documented data points, not benchmarks.

What makes these projects fail?

• Running out of cash in the certification gap. Construction finishes, payroll starts, § 489.13 says no Medicare billing until the survey clears. Budget the wait as a line item, not a contingency.
• Building where CON says no, signing a lease before checking the county's need determination with the agency itself.
• Underbuilding the water system. Water and dialysate quality is a Condition for Coverage (§ 494.40), and under § 489.13 the effective date waits until every condition is met.
• Assuming Medicare-only economics work. DaVita's roughly $73 of operating income per treatment is earned with a commercial book.
• No referral base. Without a medical director and referral relationship secured before you file, you are building an empty building.
• Budgeting from a fit-out figure while buying property. Both budgets above are leasehold fit-outs.

Is this actually viable for you?

Often, no. In our view this is not your project if you cannot carry the project through the 9 to 18 months we plan for before a first Medicare payment; if you have no nephrologist relationship; if your county has no CON need determination in a CON state; if you are planning fewer than ten stations; or if your payer mix is almost entirely Medicare and Medicaid. The national dialysis population grew 0.2% a year from 2018 to 2023, and about 15% of patients dialyzed at home in 2023 (USRDS figures, as DaVita's Form 10-K reports them). This is a share-shift market, not a growth market.

It can work if you can recruit the referral base, sit in an area of unmet need or a state that does not apply CON to dialysis, and have a path to commercially insured patients. On equity: the SBA 7(a) floor for a start-up is 10% of total project cost, about $375,000 on a $3.75M project. Our own underwriting view, Business Plan Firm's opinion, not a rule and not a lender's requirement, is that $1M or more of committed equity on a $3M to $4M project is what survives a slow ramp, because the SBA minimum funds the closing, not the certification gap. Your lender may take a different view; ask them.

A home dialysis training program is a smaller build, $1,649,076 of capital for the approved two-station facility above, but its findings show $986,530 of working capital and a projected net loss in each of its first two full years. It is a different business, not a scaled-down one, so model it separately rather than dividing the in-center numbers.

Frequently asked questions

How much does one dialysis station cost?

About $237,157 to $294,863 of capital per in-center station, from two North Carolina budgets approved in March 2026: $2,608,727 for 11 stations and $2,948,634 for 10. With working capital, $304,095 to $374,418 per station. These are our own calculations, dividing each filed total by its station count, and neither budget is a property purchase: both projects were leasehold fit-outs.

Do I need a Certificate of Need to open a dialysis center?

It depends on the state and sometimes the county. North Carolina applies CON to dialysis: its 2026 plan shows county need for additional stations only where the projected deficit is 10 or more and every facility is at 80% utilization or higher; relocating certified stations is a separate route. For other states we retrieved no primary source, so ask the state health planning agency in writing before signing a lease.

How much does Medicare pay per dialysis treatment in 2026?

The ESRD PPS base rate for CY 2026 is $281.71 per treatment, up from $273.82, per the CMS final rule issued 20 November 2025. It is then adjusted for case mix, wage index, rural and low-volume status, home training add-ons and outliers. CMS has proposed $299.55 for CY 2027; no final rule had been published when we checked on 11 October 2026.

Can I use an SBA loan to open a dialysis center?

Yes. 7(a) caps at $5,000,000 with a minimum 10% equity injection for a start-up. For 504, SOP 50 10 8.1 lists health or medical facilities among its examples of Limited or Special Purpose Property without naming dialysis. If the center is treated as one and the business has operated for 2 years or less at approval, you contribute at least 20%. A leased fit-out adds lease-term and collateral conditions.

How many patients does a dialysis center need to break even?

About 23 in-center patients on 10 stations, on the Garner pro forma: $1,207,969 of annual operating cost ÷ $354.66 of net revenue per treatment = 3,406 treatments, ÷ 148 treatments per patient-year = 23 patients. That is our calculation, and it treats all operating cost as fixed.

What a lender will ask you for

• A capital budget itemized the way a CON filing is, site prep, construction contract, architecture and engineering, equipment, furniture, interest during construction, with land or building separately if you are buying.
• A working-capital schedule that funds the certification gap month by month.
• Evidence of CON status, or a written exemption from the state agency.
• A signed medical director agreement and documented referral base.
• A defended payer mix and a utilization ramp tied to a breakeven treatment count.
• Two to three years of projections with written assumptions.

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How we verified this

Re-read on 11 October 2026 in text extracted from each source file. North Carolina: NC DHSR findings for Garner Dialysis (J-12727-26, 27 March 2026, approval letter and timetable), Newton Dialysis (E-12728-26, 25 March 2026, approval letter and timetable) and Cornelius Home Dialysis (F-12697-25, 5 December 2025); the 2026 decisions index; the 2026 State Medical Facilities Plan, Chapter 4 (Policy ESRD-3) and Chapter 9; N.C. Gen. Stat. § 131E-182(c) (Internet Archive capture, 8 March 2026). Medicare: CMS fact sheet, CY 2026 ESRD PPS final rule (CMS-1830-F), 20 November 2025; CY 2027 proposed rule, 91 FR 38784; CY 2026 enrollment fee notice, 90 FR 55738; Program Integrity Manual, Pub. 100-08, Chapter 10 (Rev. 13717, 8 July 2026), § 10.5; FY 2027 Mission & Priorities Document, Appendix 2; 42 U.S.C. § 1395rr(b)(1) and Pub. L. 115-123, § 50403; 42 CFR § 411.351, § 411.355, § 489.13, § 494.40, § 494.140 and § 1001.952 (Cornell LII); accreditation approvals, 87 FR 60173 and 88 FR 16981. SBA: SOP 50 10 8.1, effective 1 October 2026 (Section A Ch. 3, Section B Ch. 1, Section C Ch. 1, Appendices 3 and 17), and Information Notice 5000-881797. Operator data: DaVita Inc. Form 10-K, FY 2025 (Internet Archive capture, 21 April 2026), including the USRDS figures it reports.

Cut for want of a source. Earlier drafts carried CON fees and licensure rules for several other states, a no-CON state list, a water-treatment design-standard claim, competitor cost ranges and a capital-overrun ceiling. Each was removed rather than repaired: the sources were unreachable, secondary, internally inconsistent, or said something materially different from what we had written. Where we could not source a figure we left the gap visible instead of filling it.

General information, not legal, regulatory, lending or investment advice. We are not attorneys, lenders or a CDC. Confirm every figure with the agency named beside it before you commit capital.

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