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?

The one 2026 dialysis capital budget we can point to that a state agency actually reviewed and approved is $2,948,634 of capital plus $795,549 of start-up and initial operating expense — $3,744,183 committed to reach opening day. Those are the figures DaVita filed and North Carolina regulators approved in March 2026. Two things that budget is not. It is not a national average: it is a single project, by the largest US operator, and it relocates ten existing stations from two other DaVita facilities rather than building demand from scratch. And it contains no land or building acquisition — it is a fit-out on a leased site, so if you are buying property your number is materially higher. The biggest cost driver is not equipment. It is the months of carrying cost between finishing construction and earning your first Medicare dollar.

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. Dashes mean we could not verify a figure, not that the cost is zero. There is no defensible high case for total capital: we could retrieve only two agency-approved budgets, both North Carolina filings, both at large-operator pricing, neither an upper bound, neither including land or a building. The $1,649,076 low is a two-station home training facility — a different build type, so treat it as a floor for a different business rather than a small version of the same one. The $3,744,183 headline is the Typical column of the first three rows added together, not a range across build types.

What actually drives the cost?

The largest single item in the filed 10-station budget is the construction contract, at $1,946,661 of the $2,948,634 total. Equipment is a much smaller share of the money than founders expect.

Be careful using that filing as a template. Its own capital table does not reconcile: the line items and the stated total are $400,000 apart, and we cannot tell from the outside which figure is wrong. The agency approved the lower total. If you are building your budget off this filing, ask NC DHSR which figure controls before you rely on either.

The cost mix is driven by water. 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. That means a reverse-osmosis plant, a sanitisable loop to every station, and dedicated drainage and electrical — in our experience closer to a small process plant than to a clinic fit-out. Part 494 also makes water treatment system technicians a personnel category you have to staff (§ 494.140(f)).

We publish no dollar range for the water plant, deliberately. The filed budget does not break it out, and no source we could reach gives a verifiable figure. The ranges that circulate on competitor pages cite nothing, so we are not repeating them.

The other drivers are the certification gap, Certificate of Need where it applies, and scale — North Carolina's 2026 State Medical Facilities Plan holds 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 (§ 131E-182(b)). We could not verify any other state's dialysis CON fee from a primary source — see the section below.
2. State facility licence, separate from Medicare certification in most states. 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. Enrol with Medicare on Form CMS-855A and pay the CY 2026 application fee of $750, then wait on your MAC. The only processing standard we can source is CMS Program Integrity Manual Pub. 100-08, Transmittal 134, § 15: 99% of initial applications within 180 days. That transmittal is dated 30 December 2005, so check it against the current PIM Chapter 15 and your MAC's contract standards before planning a construction loan around that 180-day tail.
5. Pass the initial certification survey — an unannounced 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 organisation. We could not confirm from a primary source which organisations hold ESRD deeming authority today, so ask CMS for the current approved list rather than relying on this page.
6. Billing starts on the certification date. Under 42 CFR § 489.13 the agreement takes effect on the survey date if you meet every requirement that day, otherwise when you meet all conditions or the agency receives an acceptable plan of correction. No retroactive payment for the build-out.

Which states require a Certificate of Need for dialysis?

The state counts that circulate refer to general CON programmes, not to dialysis-specific review, and that difference decides whether you can open at all. 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% utilisation or higher; 100% utilisation is four patients per station per week. Without a need determination you cannot develop a new facility with new stations that year. Relocating stations that are already certified is a separate route and does not depend on a county need determination — that is how the ten-station project this page is built on was approved, by moving four stations from one existing facility and six from another.

For every other state, call the state health planning agency before you sign anything. We drafted this page with CON fees, station standards and licence rules for several other states and cut all of them: none was verifiable to the standard a capital commitment deserves. The no-CON lists in trade press are not a substitute — the one we checked omitted a state conventionally counted as having no CON programme, so either its count or its list is wrong.

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

CMS treats ESRD initial surveys as top priority. The FY 2026 Mission & Priorities Document lists them as Tier 1: "States must conduct initial certification surveys within 90 days of the MAC approval of the CMS-855, unless the supplier has elected a deeming option."

What sits in front of those 90 days is the problem. Stack the sourced intervals — CON cycle, construction, licensure, up to 180 days of MAC processing, up to 90 days to survey, then correction of deficiencies before § 489.13 sets your effective date — and you get 9 to 18 months from breaking ground to first Medicare payment. That range is our own planning figure, built by adding up the sourced intervals; no agency publishes it. It is why the filed budget carries $795,549 of working capital against $2,948,634 of capital, a 27% uplift — and that project inherited its patients from two existing facilities. A true de novo needs more.

One further trap: under the same CMS document, relocations and added stations are Tier 3 priority. Growing after you open is slower than opening.

How do people finance it?

SBA 7(a): maximum $5,000,000 under SOP 50 10 8 (effective 1 June 2025). 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 — every cost required to become operational, regardless of the source of funds. On a $3.75M project that is $375,000 of cash. There is also an upfront guaranty fee; the SOP presents its table as maximums and SBA can vary them by Information Notice, so ask your lender for the fee in force on the day you close.

SBA 504 — and a mismatch worth naming. SOP 50 10 8, Section C, Chapter 1 lists "Hospitals, surgery centers, urgent care centers, and other health or medical facilities" among Limited or Special Purpose Properties. A project that is both a new business 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. But the $2,948,634 budget above is a leasehold fit-out. 504's real-estate route is built for a borrower that owns and occupies the property, so it does not fit a leased site — and if you buy, your project cost rises well above $2.9M and your 20% rises with it. Confirm eligibility with your CDC before you model it.

Nephrologist joint ventures. In the engagements we run, a joint venture with the referring nephrologists is the usual capital structure for an independent center, because referrals follow the physicians — our own observation from client work, not a surveyed figure. On the legal side, founders often assume the Stark analysis is settled in their favour. It is not: 42 CFR § 411.351 excludes from designated health services what Medicare pays as part of a composite rate, but it does not name ESRD, and reading the ESRD PPS bundle as a composite rate is a contested interpretation rather than a rule. Nor would that make such deals safe — the Anti-Kickback Statute has no dialysis-specific safe harbour. 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, and outliers.

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 commercial plans generally covering 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. Working that segment's operating income back to a per-treatment number gives about $73 of operating income per treatment — our own calculation, not a figure DaVita reports. That is what the country's best-scaled operator earns per treatment.

For breakeven, the 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 full-cost breakeven, not a cash one: the operating cost includes non-cash depreciation, and the method treats every dollar of it as fixed, which no clinic's cost base is. And the same form states "Average Operating Expense per Treatment $355" while its own totals give $278.27 — the second place where this filing contradicts itself. Treat it as a well-documented single data point, not a benchmark.

What makes these projects fail?

• Running out of cash in the certification gap. Construction finishes, payroll starts, § 489.13 says no revenue 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. A plant that cannot hold AAMI limits produces condition-level deficiencies, pushing your billing date out.
• Assuming Medicare-only economics work. The largest operator earns about $73 per treatment 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. The $2.9M above contains no land or building.

Is this actually viable for you?

Often, no. In our view this is not your project if you cannot fund 9 to 18 months of operating cost with no revenue; 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 just 0.2% a year from 2018 to 2023 on USRDS data, and about 15% of patients now dialyse at home. 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 $3–4M 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 much smaller build — $1,649,076 for the approved two-station facility above — and a lower-risk entry point. 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 $294,863 of capital per station, from the only publicly filed, agency-approved 2026 budget we could verify: $2,948,634 for a 10-station facility in Wake County, North Carolina. All-in, $374,418 per station. Both are our own calculations, dividing the filed totals by ten, and both exclude land and building — that project was a leasehold fit-out.

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 directly, and its 2026 plan will not show need for additional stations in a county unless the projected station deficit is 10 or more and every existing facility is at 80% utilisation or higher; relocating already-certified stations is a separate route that does not turn on that test. For every other state we could not retrieve a primary source, so we state no position — ask the state health planning agency, in writing, before you sign 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.

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 classifies health and medical facilities as Limited or Special Purpose Properties, so a new-business dialysis project contributes at least 20% equity, the debenture no more than 30% and a bank 50% or more. But 504's real-estate route assumes you own and occupy the property; it does not fit a leased fit-out like the budget on this page.

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

About 23 in-center patients on 10 stations, on the 2026 filed pro forma above: $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 a full-cost breakeven including depreciation, treating all operating cost as fixed, and it is our calculation rather than a figure in the filing. That project also had an inherited patient base, so a de novo should stress-test a slower ramp.

What a lender will ask you for

• A capital budget itemised 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 utilisation ramp tied to a breakeven treatment count.
• Two to three years of projections with written assumptions.

That is the document set we build. Business Plan Firm has produced $1B+ in funding documents for 300+ businesses across 30 countries, including Shark Tank and Dragons' Den clients. If you want it built properly the first time, we can walk through your county and payer mix.

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Sources

All retrieved 22 August 2026 unless noted: CMS CY 2026 ESRD PPS Final Rule (CMS-1830-F) fact sheet, 20 Nov 2025; CMS FY 2026 Mission & Priorities Document, Appendix 2; CMS Program Integrity Manual Pub. 100-08, Transmittal 134 (CR 4213), 30 Dec 2005, § 15; 42 CFR Parts 411, 489 and 494 (eCFR as of 1 Aug 2026); Federal Register doc. 2025-21877, 3 Dec 2025 (provider enrollment application fee, CY 2026); Bipartisan Budget Act of 2018, Pub. L. 115-123, § 50403; NC DHSR Required State Agency Findings J-12727-26 (Garner Dialysis, Mar 2026) and CON conditional approval F-12697-25 (Cornelius Home Dialysis, Dec 2025); NC DHHS 2026 State Medical Facilities Plan, Ch. 9; N.C. Gen. Stat. § 131E-182(b); SBA SOP 50 10 8, effective 1 June 2025, Section B Ch. 1 and Section C Ch. 1; DaVita Inc. Form 10-K, FY2025 (SEC).

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, a capital-overrun ceiling, an itemised breakdown of the North Carolina project's capital table, and a claim that CMS had approved a named accrediting organisation's ESRD programme. 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.