The Gamma Knife is considered by many to be the ‘gold standard’ radiosurgery unit throughout the world. However, its benefits must be weighed against its cost and availability. A comparison was made between two tertiary-care, not-for-profit, medical-school-affiliated medical centers located in northeastern Ohio. Both applied for a certificate of need for a Leksell Gamma Knife. A requirement for on-site imaging and anesthesia support at one site resulted in considerable extra costs. One center then altered its application for a Gamma Knife to be used by its own four neurosurgeons. The other center modified its proposal to create a Gamma Knife center at the perimeter of its medical center, yet attached to existing imaging facilities. It would also allow regional hospitals, patients, health plans and qualified physicians and researchers to have access to the unit. This plan resulted in a marked reduction in costs. Moreover, it was estimated that this plan would greatly increase the volume of treated patients. This was the proposal endorsed by the regional Health Systems Agency by a vote of 19 to 1. The proposal from the other center for a closed system was rejected.