REFERENCE — EVIDENCE ARCHITECTURE

Where our numbers come from

Most agencies cite whichever figure supports the pitch. We publish the register instead. Every benchmark that appears anywhere on this site traces to a source listed below, and each source carries the tier we assigned it and the reason we trust it that far.

You are welcome to check our work. That is the point of publishing this. The figures themselves — median, quartile and top decile for each specialty — are at /benchmarks.

HOW WE RANK A SOURCE

A figure is never presented as more certain than its tier allows. When a Tier B source is the only one available, we say so on the page where it appears.

THE TWO NUMBERS NOBODY PUBLISHES

No professional association, and no federal statistical programme, publishes patient acquisition cost or patient lifetime value. Not the ADA, not MGMA, not AVMA. The only organisations that publish those two numbers are the ones selling marketing services — which is exactly why the figures are large, and exactly why we will not cite them.

It goes further than that. We went looking for the one input that would let anyone derive a dental acquisition cost honestly — marketing spend as a share of collections — and it does not exist either. The ADA's own Survey of Dental Practice aggregates every practice expense into a single figure and never breaks out advertising. Every percentage in circulation traces back to a vendor with no disclosed sample, and most are prescriptive — what a practice should spend — rather than what anyone observed.

So we do not publish an industry acquisition cost, because there isn't one to publish. We build yours from your own spend and your own instrumented new-patient count, and we show the arithmetic:

Cost per new patient	your marketing spend ÷ your new patients, instrumented at the source No credible industry percentage exists — see below
Patient lifetime value	revenue per patient per year × retained years × contribution margin ADA HPI expense ratios · MEPS · retention data, per specialty

A derived figure with published arithmetic is more defensible than a sourced figure from a vendor with an undisclosed sample. Where we show one, it is labelled derived — never presented as an industry median, and never attributed to a third party who did not publish it.

THE REGISTER — BY SPECIALTY

Each specialty measures itself differently, and the sources that matter differ with it. Where a figure is marked ✓, we have pulled and verified it against the primary document rather than a summary of it.

DSO & general dentistry

Production, collections, new patients, case acceptance, recall — not “revenue.”

TIER	SOURCE & WHY IT IS HERE
A	ADA Health Policy Institute✓ Survey of Dental Practice; Dental Practice Trends; Dental Fees Survey. The dental profession's own research arm. Publishes sample sizes and survey instruments, and has no product to sell against the result.
A	Association of Dental Support Organizations Group-practice penetration and DSO structure. The trade body for the segment; closest thing to a census of group affiliation.
B	Henry Schein One — Catalyst Index✓ New patients per location, case acceptance, appointment lead time, retention. Aggregated from practices running their software — the largest operating dataset in dentistry. Two limits we state whenever we cite it: the population skews toward technology-enabled and group-affiliated practices, and the exact sample size is not disclosed in any public document we could locate.
B	Dental Intelligence Practice-management analytics across its installed base. Independent read on the same operating metrics, from a different customer population.
B	Patterson Companies · Benco Dental Distributor demand, equipment and consumable cycles. Distributors see purchasing across the whole market, including practices that buy no analytics software at all.
C	Dykema — Annual DSO Industry Report Consolidation, deal volume, multiples. The reference document for dental M&A, published free and consistently for over a decade.
C	Academy of Dental CPAs · McGill & Hill Group Overhead ratios and profitability by practice type. They prepare the actual tax returns, so their expense benchmarks are the closest available thing to audited practice financials. Note: none of them publishes an observed marketing-spend benchmark with a stated sample — we looked.

Specialty dental — ortho, endo, OMS, perio, pedo

Starts, referrals, referring doctors, case fees. A referral is not a lead. In orthodontics, “retention” means retainers.

TIER	SOURCE & WHY IT IS HERE
A	American Association of Orthodontists Practice economics and workforce data. The specialty's governing body.
A	JCO Orthodontic Practice Study Case starts, fees, overhead, staffing — biennial. The definitive orthodontic economics series, running for decades with a consistent instrument, which makes its trend data unusually trustworthy.
A	AAE · AAOMS · AAP · AAPD Endodontic, oral-surgical, periodontal and pediatric practice data. Each specialty's own association, with membership censuses no commercial source can match.
B	Align Technology Clear-aligner case starts and average selling price, globally and by region. SEC-filed. Case-start volume is audited and reported quarterly — a rare instance of a real demand number in the public record.
B	Straumann · Envista · ZimVie Implant unit volume and pricing. Public-company filings. Implant units shipped is a hard proxy for procedure volume.
B	OrthoFi · Dolphin · Ortho2 · Cloud9 Orthodontic-specific practice and financial data. Ortho runs on contract balances and payment plans, which general dental systems do not model. These platforms see that layer.
C	Bentson Copple & Associates Orthodontic practice valuations and transitions. The specialist valuation firm for orthodontics; sees real sale financials rather than survey self-reports.

Veterinary

Clients, not patients — the pet is the patient, the owner is the revenue unit. ATC, transactions, compliance, DVM production.

TIER	SOURCE & WHY IT IS HERE
A	AAHA — Financial & Productivity Pulsepoints✓ Income per veterinarian, average transaction charge, active clients, new clients. The veterinary profession's standard benchmark series, structured around the metrics practices actually manage by. One caveat we hold ourselves to: the most recent edition we could confirm is the 10th, carrying 2019 data — so we do not present its labour ratios as current without verifying a newer edition exists.
A	AAHA / VMG Chart of Accounts✓ The standard revenue and expense taxonomy for small-animal practice. Endorsed by AVMA and the major veterinary groups. Any comparison across practices that is not normalised to it is arithmetic on inconsistent categories.
A	AVMA — Economic State of the Veterinary Profession Revenue, visits, workforce supply. National association research with published methodology.
B	IDEXX Laboratories Clinical visit growth across its installed base, reported quarterly. SEC-filed and audited. IDEXX serves a large share of US small-animal practices, making its visit-volume trend the closest thing to a real-time industry index.
B	Covetrus · Zoetis · Vetsource Practice commerce, client spend, product demand. Distribution and pharmacy data spanning practices of every size.
C	Brakke Consulting Animal-health and veterinary market research. The long-established market-research firm for the sector, cited by the manufacturers themselves.
C	VMG · Simmons & Associates✓ Peer financial benchmarking and practice sales. VMG members share real financials inside non-competing study groups; Simmons sees transaction values.

Dermatology

Two businesses: medical (encounters, wRVU, referrals) and cosmetic (consults, units, syringes, conversion). They do not share a vocabulary.

TIER	SOURCE & WHY IT IS HERE
A	American Academy of Dermatology Practice profile and workforce surveys. The specialty's association, with a membership census behind it.
A	ASDS Procedure Survey Cosmetic and medical dermatologic procedure volumes. Annual, member-surveyed, with methodology published alongside the results.
A	ASPS — Plastic Surgery Statistics Report Procedure volumes and average surgeon fees. Published free every year with a documented method. One of the few sources that reports both volume and price.
A	The Aesthetic Society — National Databank Aesthetic procedure volume and spend. Purpose-built statistical databank rather than a marketing by-product.
B	ModMed (EMA) Dermatology-specific EHR across a large specialty installed base. Built for dermatology workflow, so its data reflects how derm practices actually code and schedule.
B	Allergan Aesthetics · Galderma · Merz Injectable unit volume and consumer programme data. Manufacturers see units consumed, which is the cosmetic line's true volume metric.
C	Skytale Group Dermatology and medspa group benchmarking and M&A. Specialises in this segment, and works from client financials rather than surveys.

Behavioral health

Census, admissions, length of stay, levels of care, verification of benefits. Not “new patients.”

TIER	SOURCE & WHY IT IS HERE
A	SAMHSA — N-SUMHSS National census of mental-health and substance-use treatment facilities. Federal. A facility-level census rather than a sample, and free to the public.
A	National Association for Behavioral Healthcare Provider economics and policy data. The trade association for treatment providers.
A	CARF · The Joint Commission Accreditation status and standards data. Accreditors verify operations on site. Their data reflects inspection, not self-report.
B	Kipu Health The dominant EMR in addiction treatment. Sees admissions, level-of-care movement and length of stay across a large share of licensed programmes.
B	SimplePractice · TherapyNotes · Qualifacts Outpatient and community behavioral health operations. Cover the outpatient side, which the residential-focused sources miss entirely.
C	Mertz Taggart Quarterly behavioral health M&A reports. Published free and consistently; the reference series for deal activity and valuation in the sector.
C	Provident Healthcare Partners · VERTESS Sector transaction data and multiples. Active advisors in the segment, working from real deal financials.

Emergency & urgent care

Visits per clinic per day (VCPD), door-to-door time, acuity mix, left-without-being-seen. Walk-in led, not appointment led.

TIER	SOURCE & WHY IT IS HERE
A	Urgent Care Association — Benchmarking Report Visit volume, staffing, payer mix, centre economics. The industry association's own benchmarking series, with a disclosed respondent base.
A	College of Urgent Care Medicine · ACEP Clinical and workforce standards. Professional bodies rather than commercial publishers.
B	Experity✓ Visits per clinic per day, diagnosis mix, seasonality — reported quarterly. The dominant urgent-care practice-management platform. Its visit index is drawn from live clinic operations across thousands of centres, which is why it tracks flu season in real time.
B	Solv Consumer booking and same-day demand behaviour. Sees the patient-side search and booking journey that clinic systems never observe.
B	Phreesia Patient intake and access volume. Processes intake across a very large ambulatory footprint; publishes real access data.
C	Trilliant Health · Definitive Healthcare Claims-based volume and market share. Claims data covers every site of care regardless of what software it runs.

Multi-specialty MSO

Encounters, wRVU, service lines, referral leakage and capture, contribution margin. Not “verticals.”

TIER	SOURCE & WHY IT IS HERE
A	MGMA — DataDive Practice operations; provider compensation and production. The standard reference for medical group economics, with decades of consistent methodology and a large disclosed respondent base.
A	AMGA Medical group operations and finance survey. Focused specifically on larger multi-specialty groups.
A	CMS · AHRQ (MEPS) · CDC (NAMCS) National expenditure, utilisation, and ambulatory visit data. Federal statistical programmes. Free, methodologically documented, and the population denominator everything else is measured against.
B	Epic Cosmos De-identified clinical data across a very large national footprint. One of the largest datasets in US healthcare, with research access and published methodology.
B	athenahealth Ambulatory practice performance across its network. Publishes real operational data drawn from a network spanning many specialties and geographies.
C	VMG Health · HealthCare Appraisers Valuation and compensation benchmarks. Produce fair-market-value opinions that must withstand regulatory scrutiny.
C	Bain — Global Healthcare Private Equity Report Investment activity, multiples, sector outlook. Published free each year with a stated method; the reference document for healthcare PE.

Optometry

Exams, capture rate, revenue per exam, optical margin, second-pair rate, annual supply. A clinic bolted to a retail business.

TIER	SOURCE & WHY IT IS HERE
A	American Optometric Association Optometric practice survey — revenue, exam volume, practice modes. The profession's association, surveying its own membership.
A	The Vision Council — Vision Watch Consumer eyewear purchasing and unit volume. Continuous consumer panel with published methodology; covers the retail side no clinical source sees.
B	VSP Global The largest vision plan in the United States. Sees actual claims for exams and eyewear across a very large covered population — real transactions, not survey recall.
B	Alcon · CooperVision · Bausch + Lomb Contact lens unit volume. Manufacturer shipments are a hard measure of the recurring-supply business.
C	IDOC — Books & Benchmarks✓ Overhead, cost of goods, profit margin, cash flow. Built from participating practices' actual bookkeeping rather than self-reported survey answers.
C	Cleinman Performance Partners✓ Practice performance benchmarking and consulting data. Long-running optometry-specific benchmarking against a consistent peer set.

PE platforms & rollups

Adjusted EBITDA, same-store growth, de novo, add-on, quality of earnings, entry and exit multiples. The one setting where CAC and payback are native.

TIER	SOURCE & WHY IT IS HERE
B	PitchBook · Preqin · S&P Capital IQ Deal comparables, fund activity, transaction multiples. Transaction databases built from filings and confirmed deal reporting.
C	Bain — Global Healthcare Private Equity Report Deal volume, multiples, sector theses. Free, annual, consistently methodologically stated.
C	Dykema · Mertz Taggart · Provident Segment-specific consolidation and valuation data. Advisors publishing from real mandates in dental, behavioral health and physician services respectively.
C	VMG Health · Houlihan Lokey · Harris Williams · Lincoln International Valuation opinions and sector M&A commentary. Work from audited financials under regulatory and fiduciary scrutiny.

WHAT WE DO NOT CITE

A register is only meaningful if it also states what was excluded. We do not source practice economics from:

• Agencies publishing “average patient acquisition cost” reports without disclosing sample size, specialty mix, or how acquisition was defined.
• Call-tracking and lead-generation vendors whose benchmark figures are drawn only from practices that bought their product.
• Content sites that restate an association's figure, add their own, and cite themselves.
• Any source with a commercial interest in the number being large.

Those figures circulate widely and are easy to cite. They are also, in our experience, the reason an operator's own numbers never reconcile with the benchmark they were shown. If a source will not tell you its denominator, it does not belong under a number you are asked to make decisions on.