Economical Comparison: In-Office CBCT vs. Outsource

 In the past few years the pressure to purchase an in-office CBCT unit by your dental vendors has increased dramatically.  To date, this is the most expensive piece of capital equipment that has ever been sold into the private practice dental market, so it is imperative that you scrutinize this decision very closely.  How and when should I utilize CBCT?  Is it for every patient?  What are all of the true costs associated with an in-office unit?  What are the medico-legal consequences to consider?  Will it improve my ability to practice dentistry?  Will it affect my patient work-flow and make me more or less efficient?  Does it make sense for me to buy my own CBCT machine or outsource to an imaging center?

The purpose of this article is to analyze the true costs of owning an in-office CBCT and offer an unbiased economical matrix that will aide you in your decision making process when determining if purchasing or outsourcing is best for your practice.  Interesting enough, I was surprised that after extensive research, I was not able to find an economic matrix to help determine the true costs and break-even point of owning a CBCT.  Most of the information found was created by equipment manufacturers and was biased to favor ownership.

First, let’s explore why some dentists have purchased in-office CBCT units that range from $120,000 - $200,000.  To break-down the decision process, let’s look at it from the clinical, marketing and economical perspectives.

Download "True Costs of CBCT" Matrix

To customize the "True Costs of CBCT" Matrix, email Bret Royal for excel spreadsheet. 

Clinical: 

·    Increase diagnostics & improve treatment planning.  CBCT provides accurate diagnostic information that greatly improves the dentists’ ability to formulate a treatment plan based on the medical needs and economics of the patient.  However, CBCT is not for every patient according to most Oral & Maxillofacial Radiologists.  Dr. Earnest Lam, Head of Oral and Maxillofacial Radiology, Faculty of Dentistry, University of Toronto, provides these guidelines of CBCT utilization:

-    CBCT should not be routinely used for the diagnosis of dental caries, periodontal disease, periapical inflammatory disease, the assessment of the craniofacial skeleton, or when an assessment of soft tissues is required. For orthodontics in particular, large volume CBCT should not be used routinely for diagnosis or monitoring of treatment.

-    CBCT should be used when conventional projection radiography does not provide adequate information for treatment planning. Such clinical situations may include the evaluation of persistent disease, the localization of unerupted or impacted teeth, the evaluation of palatal clefts, dentoalveolar trauma and in selected implant cases.

Marketing: 

·    Increase patient education/Increase case acceptance.  CBCT offers powerful images that support patient awareness and education, thus, increasing case acceptance.  As valuable as a marketing tool as the intra-oral camera is, CBCT has the same “ah-ha” and “wow” factor to legitimize treatment plans. 

·    Maintain practice as a “high-tech” office.   Some dentists have created a reputation within their community, amongst their referrals and patients, that they are the most up to date technological office in town and practice on the cutting-edge.  CBCT definitely validates that reputation.

Utilizing CBCT to increase case acceptance or maintain your cutting-edge persona can still be accomplished by outsourcing your patients to a CBCT center and then purchasing a 3^rd party software like Simplant, InVivo, Nobel Guide or the manufacturers’ free viewing software to get the same powerful effect upon your patients or referral sources.  You don’t have to spend $120,000 to $200,000 to get the clinical and marketing benefits.

·    Convenience.  “I need the information NOW and do not want to wait on an imaging center to schedule my patient.”  Or, “My patients don’t want to go to an imaging center”.  The convenience factor to have immediate access to a CBCT x-ray is a great luxury to both the dentist and patient.  However, it is a very expensive luxury.  Your patients are accustomed to being referred for advanced diagnostic services (blood work, CT, MRI, Ultrasounds, etc.)  Medical practices have learned to outsource these services because of economics.  Good Managerial Accounting teaches us to focus time and office resources on maximizing the services that are most profitable.  Outsource the rest. 

·    Ego.  “My competition down the road bought one and I don’t want to lose my referrals to them!  This sounds sophomoric, but it is very true.  Some professionals have significant ego’s and take great pride in being the first….at everything!  As soon as one CBCT unit goes into a dental community, it is very common for others to follow suit, especially competing specialists.  I have seen this behavior amongst all specialties.   Hard to overcome the competitive nature of professionals, but if the economics aren’t there to justify the purchase, this is one of the most common and craziest reasons to buy an in-office CBCT!  As my wise mentor always says, “patients choose doctors – not machines”.

Economics: 

·    Profit potential:  “If I scan 12 patients a month, I can cover my monthly payment and everything extra is “gravy”!  I have heard this many times from different vendors.  While it sounds great and simple, the only way to prove this is to create an economic matrix that takes into consideration ALL of the “real” costs of owning an in-office CBCT.  Unfortunately, no vendor has done this, but instead, focus on anecdotal phrases and fuzzy math.  

REAL costs of owning a CBCT

Before we get into the basic economic principles that will help us determine the real costs, it is important to point out that some factors cannot be fully measured by dollars or time and applied to this model, but are still critical components to consider.  For example, I have not placed a value on the hassle factor and management costs of owning and operating your own CBCT.  These machines are powerful and have many moving parts, computers, motherboards, and other advanced technologies.  CBCT machines are fragile and not as reliable as your pano or ceph.  You can anticipate that these machines to stop working much more frequently and the down-time can be longer due to the need for specialized technicians. 

·    Capital Equipment cost - $120,000 – $200,000.  This price needs to include taxes and installation.

·    Opportunity value of money:  What is the opportunity cost of $120,000 to $200,000 vs. investing in the stock market, mutual fund or other office equipment?  Businesses use the Applicable Federal Rate for long term investments (now 4.3%) to determine Opportunity Value of Money.

·    Depreciation:  Factor in a 7 year depreciation schedule.

·    Office remodeling:  A physicist report will be required and proper lead shielding will need to be considered.  If space is not adequate, then reconstruction will also be considered.

·    IT Upgrades– Is your current IT infrastructure robust enough?  Many times, a CBCT unit will require you to make significant and expensive upgrades to your infrastructure including your CPU’s and monitors (graphics cards, processors, etc.)

·     IT Infrastructure:  Data flow and data storage – Is your IT infrastructure (Server & cabling) prepared to handle the necessary data flow and the enormous data storage that will be required?

·    Annual Maintenance – It is imperative to purchase an annual maintenance agreement on these fragile machines which range from $8,000 - $12,000 per year depending upon your CBCT manufacture.

·    Obsolescence fund:  Similar to the light source of the LCD TV “wearing out”, flat panel sensors also experience “voxel death” and will require replacement.  These sensors are not covered by the annual maintenance and are very expensive (> $20,000) to replace.  How long will sensors last is not yet known.  But they will not last as long as a pano and will need to be replaced based on usage.  Best guess is 7 to 10 years. 

·    CBCT Patient Work Flow – Do not forget to factor in the time to wait on the Initial reconstruction of the CBCT scan, secondary reconstruction, and the time and expertise to generate a report.  Obviously, based on your overhead, this number will vary.  Most offices have to designate a team member to ensure consistent quality.

·    Staff training and redundancy:  Who will be trained?  How often will they need to go to training to keep up with the software updates?  What happens if that employee leaves?  Who is qualified to operate the CBCT unit then?

·    Professional liability insurance – Some dental specialties are recommending that additional liability insurance be purchased when a CBCT unit is in-office.

·    Liability concerns – Are you up to date on all of the potential issues?  At this time, many other countries are adopting “CBCT Position Papers” that require anyone who purchases or has a CBCT to adhere to additional policies, training and maintenance.   

·    Future government regulations:  Based upon a recent report in the NY Times, the FDA is taking a very close look at this industry and increased regulations are expected in 2011.  Many Oral & Maxillofacial Radiologists have voiced concerns that the ALARA principle is not being utilized as many dentists are using CBCT’s as a screening device.  Increased exposure to children and adolescents is becoming a very hot topic right now.  The UK just released a 100+ page paper on proper usage and many US specialties are creating official “position papers” along with the AAOMR to handle industry wide concerns.  This is a moving target right now with significant unknowns.

Miscellaneous costs of buying an in-office CBCT that should also be considered:

·    Hassle factor of managing CBCT:  It takes more time to manage these machines due to their complexity.  The down-time of CBCT units vs. digital panos is significantly higher over the life of the unit.

·    Patient Perception/ Price Gouging:  As noted above, patient perception as a “high-tech” office can be a positive attribute, however, it can also back-fire on you by your referrals and patients. It needs to be duly noted that many patients are not happy when they are told that they need to take a $200 to $400 x-ray.  Many patients feel gouged and feel like you are bleeding them to help pay for your expensive new toy.  In many situations, patients have refuse to pay the cost leaving the dentist with the decision to charge much lower fees than anticipated or sometimes, they just give the scan away so they don’t lose a $5,000 case over a $300 x-ray.  In other situations, some dentists have questioned why their referring specialist is now taking a scan on every patient they refer to them and have voiced concerns or have limited their referrals to that specialists.

·    Free Scans are expensive:  Many times, dentists give CBCT scans away as a marketing tool to enhance referrals or patients to come for evaluations.  This is a very expensive marketing tool in contrast to a well-planned and executed marketing plan using social media, radio, TV and bill boards.

·    Jaded clinical decisions:  It has been documented by various radiologists that not every patient needs a CBCT and in many situations, a PA or panoramic image is just fine.    Remember, a CBCT is only complementary to a PA, not a replacement.  Will your clinical decisions to prescribe a CBCT become “jaded” if you need to pay for your $150,000 CBCT unit?

Based upon economical principles, the attached model outlines the real expenses of CBCT ownership.  Obviously, there are variables such as which machine is purchased, costs to install CBCT, how many IT upgrades be necessary, etc.  However, this model serves as a great starting point and can be customized for your specific office and business plan.

Based on the real costs of ownership, it is not prudent for most dental practices to purchase their own CBCT.  When making such a significant capital investment into your practice, only you can weigh the financial costs and benefits of the hassle vs. convenience factor to your practice.  Based on the numbers and potential unknown future government regulations, I believe that most practices should continue to outsource CBCT imaging and focus their efforts on more profitable procedures.  Instead of purchasing a CBCT unit, discuss Block pricing or discounts on scans with your local center to help generate profit and pay for your time to manipulate and diagnose these amazing, but time-consuming 3D treatment plans.

Here is a real life vignette:  A large multi-specialty practice purchased a CBCT machine and after a few months and a new administrator ran a cost/benefit analysis, it was determined that it was not wise to own the machine.  They sold it, and outsourced all volumetric scanning and associated reformatting and planning services.  This explains the large market for used CBCT machines.

Disclaimer:  I am the COO of iMagDent which has eight CBCT dental imaging centers in TX, TN, LA & NY, so yes, my opinion is biased towards outsourcing to local imaging centers.  Before you discredit my opinions, why not consider my perspective?  Surely it isn’t any less biased than the company representative who is selling the units, or the CE course that you attended that was sponsored by a CBCT manufacturer, or the speaker at a CE course who was sponsored and often times has been given a CBCT in their office or department for free from the manufacturer! 


None of this is wrong, just don’t forget to consider your sources when making such an expensive decision! In my opinion, it is next to impossible to find “unbiased” information regarding to “Buy or Outsource” regarding CBCT.