Guide

Practice valuation basics: what 2026 multiples actually look like

DSO multiples compressed through 2025. Here is where the market is now, what adjustments buyers are making, and what to do if your practice does not fit the new template.

By Blane Jackson, DDS/MBA · Former owner of 8 practices · Updated April 2026

The easy money in DSO acquisitions was 2019 through 2022. Multiples expanded, capital was cheap, and the rollup thesis looked like an obvious arbitrage: buy practices at 5x EBITDA, bolt them into a platform, sell the platform at 10x.

That is not the market in 2026. Capital costs more. Growth through acquisition slowed. Several large DSOs are working through operational indigestion from acquisitions they made too quickly. Valuations adjusted accordingly.

Here is what the market actually looks like now, in rough ranges based on publicly disclosed comparable transactions and private communications with multiple acquirers active in 2026.

Multiple ranges by practice size, 2026

Payer mix adjustments

Payer mix is the single largest valuation adjustment after practice size. A fee-for-service practice and a Medicaid-heavy practice with identical revenue are not worth the same to a buyer, because they are not the same practice.

• Fee-for-service (60 percent or more): Full multiple. Buyers pay premium for FFS because reimbursement is predictable and margin per chair is higher.
• PPO-weighted (60–90 percent PPO): Multiple holds, but buyers will adjust for PPO concentration risk. Aspen and Heartland are active here.
• Medicaid-heavy (50 percent or more): Multiple compresses 15–25 percent. Buyer universe narrows to Sonrava and a short list of state-focused operators. Fewer bidders, lower price.

What changed since 2023

Three things that look different in 2026 than in 2023:

Debt costs

Cost of capital for DSOs roughly doubled from 2022 to 2024 and has come down only modestly since. Buyers now solve for their own debt service first, which puts a ceiling on what they can pay without destroying their unit economics. Multiples compressed most at the top of the range.

Earnout weighting

Deals in 2022 averaged 80 percent cash at close, 20 percent deferred. Deals in 2026 average closer to 65 percent cash at close, 35 percent deferred (earnout plus rollover plus holdback). The transaction still looks similar on the term sheet; the risk has moved to the seller.

Quality of earnings

QoE reviews are longer, deeper, and more confrontational than they were three years ago. Budget for a 60–90 day process with real operational disruption. Buyers will push back on EBITDA adjustments that would not have been challenged in 2022.

Practical conclusion

If you are planning an exit in the next 24 months and you do not have a modeled valuation with explicit assumptions on payer mix, hygiene productivity, doctor compensation normalization, and rent adjustment to market, you are selling blind. A pre-LOI valuation from a dental-specific advisor is the single highest-leverage spend in a practice sale, and the number is rarely above $8,000.

The alternative — letting a DSO present a valuation as if it were the valuation — has cost owners hundreds of thousands of dollars on deals I have been close to in the last five years.