This round will feature hospitals and other health providers sparring over three operating rooms that state regulators have ruled will be needed in Wake County.

WakeMed, Rex Healthcare and Duke Raleigh Hospital all submitted applications last week to the N.C. Certificate of Need office to meet a state deadline. Novant Health, a Winston-Salem hospital chain, applied to build an $8.2 million surgery center in Holly Springs.

Every year, regulators review projected demand in each county and determine whether there will be a need for additional hospital beds, operating rooms and more. Then the state accepts bids, reviews applications and determines which project makes the best case on the basis of need, cost and other factors.

WakeMed applied to spend $5.9 million to add three ORs to its Cary hospital, which now has nine ORs. That hospital is serving a growing population in western Wake County and beyond, said Stan Taylor, WakeMed's vice president of corporate planning.

"It's an existing facility with a great deal of need," Taylor said. "We're optimistic we'll be successful in winning these in a competitive fight."

Rex announced last month it wants to add two ORs to an outpatient facility under construction in Holly Springs, and another OR at its main campus in Raleigh. The one at Rex's flagship hospital would be related to a larger expansion of its cancer services. Combined, the proposed additions would cost $8.7 million.

Duke Raleigh proposed spending $8.7 million to add two ORs at its main hospital, as part of a broader expansion planned for the North Raleigh facility.

"This application is yet another step in executing a master plan that is necessary to transform our facility from one that was designed for light elective surgery at its inception in the 1970s to one that provides the people of Wake County sophisticated specialty and subspecialty care," said Duke Raleigh CEO Douglas Vinsel, in a statement.

Novant, which saw its bid to build a full-service hospital in Holly Springs rejected by regulators last year, hasn't abandoned its fight to establish a foothold in the fast-growing Wake County market.

"While we are unable to build a hospital at this time in Holly Springs, we're hoping a surgery center can help us create a larger and stronger presence over time," said Novant spokeswoman Kati Everett. "Eventually, we would like to have a hospital in that area."

State regulators will take about six months to review the bids. The proposals each include letters of support from people in the community, physicians and elected officials. The state's initial ruling will almost certainly be appealed by losing parties, setting up a long legal fight.

"It could be next year or later before we know who gets these ORs," WakeMed's Taylor said.