The advantage of a MF back over a DSLR is significant improvement in image quality (sort of like going from 35mm to MF, but maybe less).
The advantage of a MF back over a scanning LF back is the quickness and ease of set-up and ability to photograph subjects with motion.
In the digital world, MF is more squished by 35mm (35mm digital is quite good), but on the other hand, the differences in usability between MF and LF are larger, because LF is not one-shot.
High-end commercial jobs run in the 5 figures and often in the 6 figures, so for that amount of money clients prefer to get the best files available, just in case the extra quality is needed. Rental fees for a MF digital system are quite low in comparison to the total budget of a high-end shoot.
As to MF digital making sense economically for the fine art photographer, Charles Cramer writes:
"Over the last three years my expenses for film and processing came to around 60% of a P45 (large format film is expensive!) Although I do my own drum-scans, I contribute to a Tango scanner's maintenance contract to the tune of $2,000 per year. Add those up, and I'm 80% of the way to a P45. "
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