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?

Publicly filed capital expenditures are the only 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 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 300+ 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. Fee schedules, Certificate of Need rules and Medicare payment rates all change annually. 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)).

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 requires that operating and recovery room space be dedicated exclusively to the ASC (42 CFR § 1001.952(r)). You cannot economize by borrowing your practice's rooms. 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 bites when your ASC separately bills designated health services — lab, imaging, outpatient drugs — outside the composite rate.

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, effective 1 June 2025.

1. A surgery center is a named special-purpose property. The SOP's list of examples of a Limited or Special Purpose Property, at printed page 355, expressly includes "Hospitals, surgery centers, urgent care centers, and other health or medical facilities". The borrower-contribution rule on the preceding page (p. 354) is what makes that matter: a business in a Limited or Special Purpose Property must contribute at least 15%, and at least 20% if the project also involves a new business. Where that 20% applies, the SOP provides on the next page (p. 355) that the debenture finances no more than 30% of the project and at least 50% comes from banks or other institutions. So roughly 50% bank, 30% debenture, 20% cash.

2. Somebody must personally guarantee the whole loan. Any individual with direct and/or indirect ownership of 20% or more must provide an unlimited full guaranty. With twelve to twenty physician investors nobody crosses 20% — which does not help, because the SOP also provides (p. 89) 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." One of your partners personally backstops the entire facility for everyone.

3. Affiliation can destroy eligibility outright. The size standard for NAICS 621493, Freestanding Ambulatory Surgical and Emergency Centers, is $19.0 million in average annual receipts (13 CFR § 121.201). The applicant alone must be under it, and the applicant combined with all affiliates must be under it. A large physician group that controls the ASC brings its own receipts into the calculation.

Maximum sizes, and one figure to get right. Standard 7(a) loans have a maximum of $5,000,000. For 504, the SOP (p. 351) provides that "For all 504 Projects except for Eligible Energy Public Policy Projects and Projects for Small Manufacturers, the gross debenture is limited to an outstanding balance of $5,000,000 maximum in the aggregate for each small business concern, including its affiliates." The $5,500,000 ceiling you will see quoted for 504 applies only to eligible energy public policy projects and to small manufacturers. An ASC gets $5,000,000, not $5,500,000 — do not model the extra half-million.

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). That puts the ASC rate at 61.6% of the hospital outpatient rate for the same work — your competitive advantage against hospitals and your margin constraint at the same time. Miss the ASC Quality Reporting Program and you take a two-percentage-point reduction.

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.
• An investor roster that fails the one-third tests — discovered after subscriptions are taken.
• Assuming SBA will fill the gap, then hitting the 20% special-purpose equity requirement, the guaranty rule, the $5,000,000 debenture ceiling, or the $19.0 million affiliation ceiling.
• 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 a prospective investor's practice income is mostly office-based E&M, injections or non-ASC-list work, they fail, and in a multi-specialty center they must also move a third of their procedures into 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 calendar time measured in years. 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. Counts of CON programs generally run higher than counts of states with CON requirements for ASCs specifically, which is why you will see larger numbers quoted elsewhere. Coverage, thresholds and exemptions also change, so confirm your own state and your own project directly 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?

CMS says no. Its ASC certification and compliance guidance states that the regulatory definition of an ASC does not allow the ASC and another entity, such as an adjacent physician's office, to mix functions and operations in common space during concurrent or overlapping hours, and sharing with a hospital outpatient surgery department or a Medicare-participating IDTF is prohibited outright. The anti-kickback safe harbor at 42 CFR § 1001.952(r) separately requires operating and recovery space dedicated exclusively to the ASC. Confirm the current guidance with your CMS Regional Office before you sign a lease built on shared rooms.

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. Surgery centers are named on SBA's list of examples of a Limited or Special Purpose Property, so a new business in one must contribute at least 20% equity, with the debenture then capped at 30% of project cost. Standard 7(a) tops out at $5,000,000, and the 504 gross debenture is limited to $5,000,000 outstanding in the aggregate for the business and its affiliates — the $5,500,000 figure applies only to eligible energy public policy projects and small manufacturers, and an ASC is neither. Affiliation with a large physician group can breach the $19.0 million size standard and end eligibility.

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 CY 2026 ASC conversion factor 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).

Book a free 30-minute call

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.