Elias Dermatology

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Expansion Location #1 — Opening First

Palm Coast, FL — Flagler County

3 hours on I-95 · Steven on the ground · Dbora rotating · 31.8% over-65 · Only 3 practices for 110,000+ people

Population

110K+

6th fastest growing county FL

Median HH income

$77.4K

7.3% poverty — low Medicaid

Median age

50.4

31.8% are 65+ — peak derm

Local derm practices

ADCS, Mid Florida, Parks

Why Palm Coast is our first move

Only 3 practices for 110,000+ people — critically underserved; national average is 3.7 dermatologists per 100K, Palm Coast has 2.7 in-city
31.8% of residents are 65+ — nearly double the national average — peak skin cancer and AK demand
Largest single age cohort is 70-74 at 8.9% — ~9,500 people in one age band at peak lifetime skin cancer risk
6th fastest-growing county in FL — +21.7% since 2020; new retirees arriving monthly without a dermatologist
Steven lives there — trusted former employee who can evaluate locations, check in on the office, and make introductions
Dbora willing to rotate — trained in our systems, generates revenue on days we're not there; solves the #1 satellite risk
Athena backfills the home offices — new PA ramping to 10 pts/day by year-end; when Matthew/Merrick/Dbora rotate to Palm Coast, Athena covers the vacated FLL and Pines days, significantly reducing the true opportunity cost of the rotation model
3 hours on I-95 — most manageable satellite in our expansion geography
7.3% poverty rate — our no-Medicaid model excludes virtually no one here
AdventHealth built a $167M second hospital specifically because patient demand overwhelmed the first one — no employed dermatologist

Key differences from Fort Lauderdale / Pembroke Pines

No Mohs surgery initially — our FLL Mohs revenue (~$25K/mo) won't replicate day one. Target Month 3-6 for in-house Mohs lab.
Laser devices — Ultherapy + Clear & Brilliant rotate in immediately (both portable). Deka Tetra CO2/CoolPeel is not portable enough to rotate — but we have redundancy in FLL and can permanently relocate it to Palm Coast at Month 3-6 once cosmetic volume justifies it.
Medicare-heavy but higher procedure volume per visit — 65+ population means ~60% Medicare. However, elderly sun-damaged patients average far more procedures per visit than younger FLL patients. A typical PC 65+ visit generates 99214 + 17000 + 17003×4 + 11102 = ~$294 Medicare vs a simple 99213 follow-up at $90. Higher biopsy and cryo procedure volume more than compensates for lower E/M rates — Palm Coast per-claim revenue is likely higher than FLL on a per-patient basis.
Better commercial rates expected — as the only physician-owned derm in an underserved market, we have leverage with BCBS, Humana, Aetna we don't have in Broward
Lower starting RPP, growing to near-FLL levels — estimated $150/pt Phase 1, growing to $180/pt at maturity
~2,000 SF needed — larger than typical satellite to accommodate Mohs lab, 5-6 exam rooms, cosmetic suite

Our Actual Practice Metrics — The Baseline (YTD 2026)

Collected per patient

$181.56

BI confirmed — real RPP

Avg patients / month

941

Both FL locations combined

Avg monthly payments

$243K

Trending to $263K+

Current DSO

23 days

Excellent — industry avg 30-45

Care Team Breakdown — YTD 2026 (Jan–Jun) vs Full Year 2025

Current structure: Dr. Matthew anchors Fort Lauderdale. Dr. Merrick anchors Pembroke Pines. Dbora PA-C splits: 1 day/week Pines, remainder FLL. Athena PA-C (new July 2026): same split, ramping to ~10 pts/day by year-end. When providers rotate to Palm Coast, Athena backfills revenue at the vacated offices.

Care Team Member	Location anchor	2025 Full Year Payments	2025 Avg/Mo	2026 YTD Payments	2026 Avg/Mo	YoY
Dr. Matthew	Fort Lauderdale	$1,438,379	$119,865	$759,788	$126,631	+5.6%
Dr. Merrick	Pembroke Pines	$654,076	$54,506	$333,622	$55,604	+2.0%
Dbora PA-C	FLL + Pines (1d/wk)	$500,814	$41,734	$241,554	$40,259	−3.5%*
Athena PA-C	FLL + Pines (1d/wk)	—	—	Ramping	Jul 2026 start	New
3 established providers		$2,593,269	$216,106	$1,334,964	$222,494	+3.0%

*Dbora's slight dip reflects months at 85% billing. Switch to 100% incident-to (mid-July 2026) adds ~$7,100/mo and ~$85,000/year — watch July–August payments to confirm. Athena not yet in BI data; her collections will appear from July 2026 forward and are expected to reach ~$15-20K/month by year-end as she approaches 10 pts/day.

In-House Dermatopathology Lab — Revenue Extension to Palm Coast

We own our pathology lab in Fort Lauderdale (Dr. Fran Brettschneider)

All biopsies from Palm Coast ship to our FLL lab and we bill global pathology under Dr. Brettschneider (dermatopathologist). We pay her $20/slide and collect the full 88305 reimbursement (~$45-65/slide). This means every biopsy taken at Palm Coast generates two revenue streams: the surgical biopsy code (11102 ~$68) billed to the patient's insurer, AND the pathology interpretation (88305 ~$48 avg) billed globally through our lab.

Current lab revenue (YTD 2026): ~$3,930/month from FLL + Pines volume alone. Palm Coast adds ~49 additional slides/month at stabilization = ~$1,360/month net additional lab revenue.

Palm Coast biopsy volume will be higher than FLL on a per-patient basis

31.8% of Palm Coast residents are 65+ with decades of coastal sun exposure. Biopsy rate in this demographic runs ~30% of visits vs ~20% in our FLL mix. At Phase 3 capacity (162 pts/month), expect ~49 biopsies/month at Palm Coast vs ~32 at an equivalent FLL cohort. The retirement market is not just higher volume per claim — it also drives higher lab revenue per patient seen.

Lab metric	Current (FLL + Pines)	+ Palm Coast (Phase 3)
Monthly lab payments	~$3,930	~$5,290
Dr. Brettschneider cost ($20/slide)	~$1,747	~$2,719
Net lab contribution	~$2,183/mo	~$2,571/mo additional
Annual net lab revenue	~$26,200/yr	~$57,000/yr combined

Competitors

Practice	Locations	Threat	Notes
Advanced Derm & Cosmetic Surgery (ADCS)	2 (8 Office Park Dr + 3 Pine Cone Dr)	Medium	PE-owned national chain. Mohs capability (Dr. Schulze). Volume-optimized, impersonal. Our opportunity: be the locally-owned physician-relationship alternative that retirement communities specifically prefer.
Mid Florida Dermatology	1 satellite (14 Office Park Dr)	Lower	Satellite of Orlando chain. WellMed/MA-affiliated. PA "Brent" is the face. Minimal local investment. Easy to differentiate against.
Parks Dermatology Center	1 Palm Coast + multi-site regional	Medium	Dr. Coppola has genuine patient loyalty — don't target his patients. Capture the steady flow of new retirees who haven't established a dermatologist yet. Parks also offers cosmetic (Botox, microneedling, fillers) — confirming cash-pay market exists.

Best Locations

★ Top Pick — Palm Coast Medical Center

New 90,000 SF institutional-grade medical complex actively leasing to specialists. Purpose-built AHCA-compliant infrastructure. Minimal buildout cost. Developer positioning it as the Flagler County healthcare hub. Steven should visit and get leasing details this week.

Option 2 — AdventHealth Palm Coast Pkwy MOB

Medical office building on the new hospital campus houses orthopedics, cardiology, GI, urology — dermatology is a conspicuous absence. Being in the hospital MOB means immediate referrals from affiliated physicians. Contact AdventHealth physician relations directly.

Option 3 — Office Park Drive cluster

Where ADCS and Mid Florida already are — proven patient traffic. Patients searching for a dermatologist find this corridor. If first choice has a 6-week wait, you're one door down. Lease rates ~$25/SF/yr.

Option 4 — Palm Coast Pkwy / Belle Terre

Highest-traffic commercial spine in the city. Flagler Health+ building health village at Matanzas Woods & Belle Terre — additional referral physicians incoming. Town Center Palm Coast location at 145 City Place available.

Steven's Immediate Tasks

1. Visit Palm Coast Medical Center (binaproperties.com) — report available suite size, lease rate, current tenants, timeline to occupancy.
2. Visit AdventHealth Palm Coast Parkway MOB — ask physician relations about specialist space and referral program.
3. Drive Office Park Drive during business hours — note ADCS and Mid Florida foot traffic, parking, signage.
4. Drive Palm Coast Pkwy and Belle Terre Pkwy — flag any "medical office for lease" signage.

Phase 1 Rotation — 9 Days/Month, 5-Week Cycle

Week 1 — Dr. Matthew

3 physician days. New patient intake priority — full skin exams, biopsies, AK destructions, excisions. Schedule complex cases for physician days. Highest procedure revenue per day.

Week 2 — Dbora PA-C

3 PA days. Follow-ups, acne, rosacea, eczema, cosmetic consults. Bills at 100% incident-to when supervising physician available. Flag complex cases for Merrick's week. Consider rotating one physician in on Wednesday to satisfy incident-to presence requirement for established patients.

Week 3 — Dr. Merrick

3 physician days. Process biopsy results from Weeks 1-2. Excisions for confirmed malignancies. Complex cases flagged by Dbora. New patients who couldn't book Week 1.

Week 4 — Unstaffed (or Athena)

Option A (Phase 1): Operational week only. FLL front desk handles Palm Coast scheduling remotely. Steven checks facility. Pre-schedule all follow-ups into next cycle before the gap.

Option B (Phase 2+): Athena rotates. Once Athena is established at 8-10 pts/day (Q1 2027), she becomes the natural solution for Week 4. She's already splitting FLL/Pines — adding Palm Coast is the same model. This hasn't been discussed with her yet but is a strong operational fit.

Phase 2 — Athena + Local PA/NP (Target: Month 6-18)

Athena as the interim bridge: Once Athena reaches 8-10 pts/day (est. Q1 2027), she can absorb Week 4 Palm Coast rotations, making the site effectively fully covered with no unstaffed weeks. This defers the local hire decision by 6-12 months and uses an existing trusted team member.

Local hire trigger: When average daily patient count consistently exceeds 13-15 pts/day, a Palm Coast-based PA/NP hire pays for themselves within 3-4 sessions. At that point Athena can fully pull back to South FL, the local hire runs 4-5 days/week, and Matthew and Merrick reduce to 1 rotation/month each — freeing bandwidth to open the next satellite using the same model.

Revenue Per HCP Day — At Stabilized Capacity

Care Team Member	Type	Pts/day	Est. RPP	Rev/day	Days/mo Ph.1	Monthly contribution
Dr. Matthew	MD	18	$180	—	3	—
Dbora PA-C	PA — incident-to	18	$165*	—	3	—
Dr. Merrick	MD	18	$180	—	3	—
Phase 1 Total					9 days	—

*Dbora RPP slightly lower — does not perform surgical excisions independently.

Adjustable Revenue Model

Adjust any slider — all figures update instantly. Based on $181.56 actual RPP at FLL. Palm Coast starts lower (no Mohs, limited cosmetic) and grows toward FLL levels at maturity.

Patients per HCP day

18 pts/day

FLL avg ~21/day. Palm Coast starts 18 — retirement pts slightly more complex.

Staffed days / month

9 days/mo

Phase 1: Matthew 3 + Dbora 3 + Merrick 3 = 9. Slide to 14-16 to model Phase 2.

Revenue per patient — Phase 1

$175 /pt

High procedure volume (AK cryo, biopsies) drives PC above simple E/M rates. FLL actual $181.56 but lower procedure density. PC Phase 1 estimate $165-185.

Revenue per patient — Mature

$210 /pt

Mohs operational, cosmetic built out, high procedure volume per elderly patient. Expected to exceed FLL RPP at maturity.

Stabilized monthly

—

Month 18+

Stabilized annual

—

Pre-overhead gross

Month 1 estimate

—

25% util, ~4-5 pts/day

RPP range

—

Phase 1 → mature

Revenue by Payer Category (Phase 3)

Payer	% of visits	Avg rev/visit	Monthly revenue	Notes
Medicare (FFS)	60%	~$155	—	31.8% of Palm Coast is 65+ — our core demographic
Commercial (BCBS, Humana, Aetna, Cigna)	22%	~$195	—	Better rates than South FL — scarcity leverage in Flagler County
Cash pay / cosmetic	18%	~$480	—	Botox avg $600, fillers $900, peels $350, microneedling $400
Total monthly gross (Phase 3)			—

Palm Coast cosmetic pricing strategy

Our South FL prices are appropriate — Palm Coast median HH income ($77K) is comparable to Broward. Active retirees are highly motivated to maintain appearance. Open at standard prices with an optional 3-month "Grand Opening" 10-15% introductory discount to build volume, then normalize. Do not permanently discount.

Injectable Pricing

Service	Our Price	Product Cost	Gross Margin	Margin %	PC Market Fit
Botox — 1 area (~20 units)	$400	~$120	$280	70%	✓ High — preventive injectors 45-65
Botox — 2 areas (~37 units)	$700	~$225	$475	68%	✓ High — most common visit type
Botox — 3 areas (~60 units)	$900	~$360	$540	60%	✓ High — full face treatment
Botox — Hands/Underarms	$1,750	~$600	$1,150	66%	Moderate — specialty indication
Filler — any syringe	$900	~$280	$620	69%	✓ High — volume loss in 55-70+ cohort

Procedure Pricing — No Laser Required to Start

Service	Price	Product Cost	Margin	PC Demand	Monthly volume target (mature)
VI Peel / Perfect Derma	$325–$500	~$85	$240 (74%)	★★★★★ Sun damage correction	10-20/month
Microneedling (Procell)	$400	~$25	$375 (94%)	★★★★★ Best margin — no device investment	8-15/month
Hydrafacial Signature	$200–$300	~$40	$160 (80%)	★★★★☆ Entry-point, drives packages	15-25/month
Asclera (vein injection)	$600	~$100	$500 (83%)	★★★★★ Very high 65+ demand — untapped	5-10/month
Aquagold	$850	~$200	$650 (76%)	★★★☆☆ Premium — smaller audience	3-6/month

Laser rotation strategy — Deka Tetra CO2/CoolPeel + Ultherapy + Clear & Brilliant

CoolPeel is ideal for Palm Coast — no-downtime CO2 resurfacing for active retirees with photodamage. Device strategy: The Deka Tetra CO2 is not portable enough to rotate but we have redundancy in Fort Lauderdale — if Palm Coast volume justifies it, we relocate the Deka Tetra permanently to Palm Coast. Ultherapy and Clear & Brilliant are portable and can rotate in for dedicated laser days immediately. Schedule 4 laser days/month: 6-8 patients × $650 avg = $3,900-5,200/laser day. The Deka Tetra permanent relocation decision can be made at Month 3-6 based on cosmetic demand.

Revenue Phases

Phase 1 · Months 1-6

Ramp & Establish

—

25-50% utilization. ~4-9 pts/day. Steven's introductions, AdventHealth PCP meetings, Google Business Profile. Week 4 unstaffed. Cash-flow negative — budget $80-100K launch reserve. Fixed-cost break-even around Month 4-5.

Phase 2 · Months 7-18

Growth & Systematize

—

50-75% utilization. Established patients returning for AK re-checks, biopsy follow-ups, cosmetic maintenance. Mohs lab opens Month 3-6. Hire trigger around Month 12-15.

Phase 3 · Month 18+

Stabilized

—

85%+ utilization. Local hire running 4-5 days/week. Mohs + laser fully operational. 18+ months of clean auditable financials. Template ready for next satellite.

Monthly gross revenue vs overhead — 24-month projection

Gross revenueTotal overhead

Overhead Model — Editable

Edit any value below — EBITDA updates automatically. Sized at ~2,000 SF to accommodate Mohs lab + 5-6 exam rooms + cosmetic suite.

Fixed Monthly

Office size (SF) SF

Rent per SF / year$ /SF/yr

Monthly rent (calculated)—

Malpractice (FL satellite)$

EHR / PM satellite license$

Medical supplies (cryo, biopsies)$

Cosmetic inventory (Botox, fillers)$

Phone / utilities / internet$

Fixed total / month—

Variable Monthly (Phase 3)

Billing / RCM rate%

RCM cost (calculated)—

Front desk / MA staffing$

Marketing$

Travel & lodging (rotations)$

Contingency (3%)—

Variable total (Phase 3)—

Mohs Lab & Laser Revenue Additions

Mohs Lab (Target: Month 3-6)

Cryostat + histotech enables in-house Mohs. High BCC/SCC incidence in elderly sun-exposed population. CoolPeel CO2 creates a natural same-day pairing: treat the cancer, resurface the surrounding sun damage.

Mohs cases / month

Avg revenue per case$

Monthly Mohs revenue—

Lab overhead (histotech + supplies)$

Mohs net contribution—

Laser Services (Deka CO2/CoolPeel + Ultherapy + C&B)

Ultherapy and Clear & Brilliant rotate in immediately — both are portable. Deka Tetra CO2/CoolPeel: not portable for rotation but can be permanently relocated to Palm Coast at Month 3-6 if cosmetic demand justifies it (we have redundancy in Fort Lauderdale). CoolPeel ideal for sun-damaged retirees — no downtime, minimal healing.

Laser days / month

Patients per laser day

Avg laser revenue per patient$

Monthly laser revenue—

Consumables + device transport$

Laser net contribution—

EBITDA Summary

Scenario	Monthly gross	Fixed OH	Variable OH	Monthly EBITDA	Annual EBITDA	Margin

Care team rotation cost — partially offset by Athena

Days spent in Palm Coast are days not in Fort Lauderdale or Pembroke Pines. At FLL RPP $181.56 vs PC Phase 1 RPP $150, each rotation day in PC generates ~$560 less than staying in South FL. However, Athena backfills the vacated Fort Lauderdale days. Fort Lauderdale is the main revenue engine — when Matthew or Dbora rotate to Palm Coast, Athena covers FLL. When Merrick rotates (Week 3), Athena covers Pines. By Q1 2027 at 10 pts/day and ~$165 RPP, Athena generates ~$1,650/day backfilling FLL, substantially reducing the true net cost of each Palm Coast rotation. By Phase 2, the rotation may be revenue-neutral at the practice level even before Palm Coast reaches full capacity.

2026 Medicare Physician Fee Schedule — non-facility (office) rates. Flagler County uses the "Rest of Florida" GPCI locality — adjustments ±2-4% from national averages. Commercial payers in Palm Coast estimated at 140-160% of Medicare given our scarcity leverage as the only physician-owned independent derm.

E/M Codes

CPT	Description	Medicare 2026	PC Commercial (est. 145%)	When we use it
99202	New patient, low complexity	$93	$135	Simple first visit
99203	New patient, moderate complexity	$152	$220	New patient full skin exam
99204	New patient, high complexity	$220	$319	Complex history, multiple conditions
99213	Established, low complexity	$90	$131	Simple follow-up — our #1 billed code
99214	Established, moderate complexity	$136	$197	Annual skin exam with findings
99215	Established, high complexity	$186	$270	Complex multi-problem visit

Procedure Codes

CPT	Description	Medicare 2026	PC Commercial (est.)	Palm Coast notes
11102	Shave biopsy — 1st lesion	$68	$99	Our #5 billed code — very high volume at PC
+11103	Each additional shave lesion	$42	add-on	Frequently ×2-4 per elderly patient
17000	AK destruction — 1st lesion	$66	$96	Will be our most-billed procedure code at PC
+17003	Each additional AK (2nd-14th)	$6	add-on	Retirement pts average 4-8 AKs → $24-48 per visit
17004	AK destruction — 15+ flat rate	$138	$200	Better than 17000+17003×14 — always use when 15+
17110	Benign lesion destruction — up to 14	$78	$113	SKs, warts — very common in elderly population
11400	Benign excision, trunk/extremity ≤0.5cm	$112	$162	Add repair code if closure needed
11600	Malignant excision ≤0.5cm	$167	$242	BCC/SCC — very common in 65+ coastal population
13121	Repair/closure after excision	$180	$261	Additive to excisions — our #9 billed code
17311	Mohs stage 1	$850	$1,233	After Mohs lab opens Month 3-6
17313	Mohs stage 2	$580	$841	Multi-stage cases — our #2 revenue code in FLL

The Palm Coast "power visit" — what one typical elderly patient generates

71-year-old with beach/outdoor history: 99214 (annual skin exam, Modifier 25) + 11102 (shave biopsy suspicious lesion) + 17000 (1st AK, cryotherapy) + 17003×4 (4 additional AKs) = Medicare $136 + $68 + $66 + $24 = $294 one visit. Returns 3 weeks for result: 99213 + 11400 (benign excision) = $90 + $112 = $202. One patient generates $496 in two visits — and they return annually.

Market Statistics

Population (Jul 2024 Census)

106,729

Estimated 110K+ now

Flagler County growth (2020-25)

+21.7%

6th fastest growing in FL

Residents 65+

31.8%

Nearly 2× national average

Largest age cohort

70-74

8.9% = ~9,500 people

Median HH income

$77,350

7.3% poverty rate

Median age

50.4

Good dual medical + cosmetic

Actual in-city derm practices

Not 31 — radius search inflated

Hospital campuses

AdventHealth × 2 — no employed derm

Why Commercial Rates Will Be Better Here

Why Flagler County commercial rates exceed South FL

Broward County has thousands of physicians competing for contracts — insurers have enormous leverage and pay low rates. Flagler County has 3 dermatology practices for 110,000 people. When we call BCBS Florida and Humana to credential, we credibly say: "We are opening the only physician-owned dermatology practice in Palm Coast. Your members currently drive to Daytona or Jacksonville for specialty care." Request rates 20-25% above our current South FL commercial contracts. In a supply-scarce specialty market, we may actually get it.

Calls to make before lease signing

BCBS Florida provider relations — Flagler County fee schedule: 800-727-2227
Humana provider contracting — NE Florida / Flagler rates: 800-448-6262
AdventHealth Palm Coast physician relations — MOB space + referral program
Verify Aetna, Cigna FL Flagler County rates through their online portals

AdventHealth — The Referral Opportunity

$167M second hospital built because first one was overwhelmed

In its first year, AdventHealth Palm Coast Parkway served 29,000 individual patients, saw a 36% increase in ED visits countywide, and hired 650 employees when they planned for 300-500. Their medical office building houses orthopedics, cardiology, GI, surgical, urology, and gynecology — dermatology is a conspicuous absence. AdventHealth actively recruits specialists. A dermatology practice in their MOB gets immediate referral access from the primary care and hospitalist physicians affiliated with the hospital. This is a relationship conversation first, a real estate conversation second. Steven can make the introduction.

Expansion Location #2

Nocatee / Ponte Vedra, FL — St. Johns County

Highest income market in our entire expansion geography · Cosmetic-forward practice · Prime preventive Botox/filler cohort

Median HH income

$131K

Average HH income $199K

Median age

40.1

Prime cosmetic cohort 35-55

Poverty rate

4.83%

Virtually zero Medicaid impact

Bachelor's degree+

65.9%

Highly educated population

Why Nocatee is our #2 move

Highest income of all our markets — $131K median, $199K average HH income. Patients who will pay full price for premium cosmetic services without hesitation.
Ideal cosmetic age profile — median age 40.1 means the core cohort is 35-55, the "preventive Botox and filler" demographic that generates the highest cosmetic lifetime patient value. These patients come every 3-4 months, not once a year.
Physician differentiation is powerful — Nocatee has multiple med spas but all are RN/NP-operated. A board-certified dermatologist offering cosmetic services commands a credential premium and earns trust the spas can't match, especially with an educated population that researches their providers.
No Medicaid impact — 4.83% poverty rate means our no-Medicaid model excludes virtually no one.
Growing fast — one of the fastest-growing master-planned communities in the US, adding thousands of high-income families annually. New patient pipeline builds itself.
AQUA presence is not a disqualifier — AQUA (Intracoastal Derm) has a location in Nocatee Town Center but they are one of 35+ potential PE buyers. We don't optimize our locations around one buyer's existing footprint.

Key considerations

Medical derm demand is lower — young healthy families, not aging retirees. Annual skin checks are less urgent for this cohort. This is primarily a cosmetic practice.
Med spa saturation — Aesthetix Plus (inside Flagler Health Village at Nocatee), Reverie Medical Aesthetics, Bluewater Wellness, Amason Aesthetics, Hello Smooth. Competitive cosmetic landscape — physician credential differentiation is essential.
Practice model must lean heavily cosmetic — lead with Botox, fillers, laser, peels, microneedling. Don't expect Palm Coast-level medical derm volume.
Mohs cases refer to Palm Coast — Nocatee patients requiring Mohs surgery travel to Palm Coast (~45 min). We keep the case in-house, bill global pathology through our FLL lab, and the patient stays within the Elias system.
Marketing investment higher — to break through med spa noise, Google/Instagram spend needed, particularly targeting the 30-50 female demographic.
Distance from FLL — ~5 hours vs Palm Coast's 3. Rotation logistics require overnight or early start.

Competitor Landscape

Competitor	Type	Threat level	Our advantage
Intracoastal Dermatology (AQUA-owned)	Board-certified derm	Medium	They are medically focused. Cosmetic is secondary. An AQUA PE chain practice optimizes for volume, not relationship depth. We differentiate on cosmetic expertise and personalized care.
Aesthetix Plus Medical Spa	Med spa (inside Flagler Health Village)	Medium	Not physician-led. Our board-cert derm credential + ability to diagnose skin conditions underlying cosmetic concerns is a real differentiator.
Reverie Medical Aesthetics	Med spa	Low	Non-physician. Patients with complex skin conditions choose us.
Bluewater Wellness / Amason / Hello Smooth	Med spas	Low	Non-physician. All compete on price not credentials.

Best Location

Nocatee Town Center area / Ponte Vedra / Palm Valley Rd corridor

Position in a professional medical office building near but not directly in Nocatee Town Center (which already has Aesthetix Plus and Intracoastal Derm). The Palm Valley Rd and US-1 corridor captures residents from Nocatee, Ponte Vedra Beach, and South Jacksonville. Look for 1,500-2,000 SF with a dedicated cosmetic consultation room with appropriate ambiance — cosmetic patients at this income level judge the environment. Lighting, finishes, and the feel of the space matters.

Nocatee cosmetic strategy — physician-grade services at South FL prices

At $131K median / $199K average HH income, Nocatee can bear full South FL pricing with no discounting. The educated, dual-income professional demographic here is accustomed to paying for quality and will choose a board-certified dermatologist over a nurse-injector spa if they know the option exists. Marketing message: "Real dermatologist. Board-certified. Not a med spa."

Priority Services for Nocatee

Service	Priority	Price	Why it fits Nocatee	Frequency
Botox (all areas)	★★★★★ Primary	$400–$1,750	The 35-55 professional cohort is the core Botox market. Dual-income households. Every 3-4 months recurring.	Every 3-4 months
Fillers	★★★★★ Primary	$900/syringe	Volume restoration for the 40-55 cohort. High ticket, high margin, high loyalty. Average 1-3 syringes per session.	Every 6-12 months
Laser (CoolPeel, C&B, Fraxel)	★★★★☆ High	$500–$2,500	Sun damage from outdoor-active lifestyle. Texture and pigmentation concerns in the 35-50 demographic.	1-3×/year
Microneedling / RF	★★★★☆ High	$400–$800	Collagen stimulation, texture, mild laxity. Very popular in the 35-50 female demographic.	3-4×/year
Annual skin checks	★★★☆☆ Supporting	$152–$220	Door opener to cosmetic relationship. Less volume than Palm Coast or Fernandina but consistent.	Annually
VI Peels / chemical peels	★★★☆☆ Supporting	$325–$500	Accessible price point, good margin. Works well as a package add-on with Botox visits.	3-4×/year

Market Statistics

Population (CDP)

~25,600

St. Johns County total: 400K+

Median HH income

$131K

Average $199K — very high earners

Median age

40.1

Prime cosmetic cohort

Poverty rate

4.83%

Lowest of all our markets

Family households

83.9%

Dual-income professional families

Bachelor's degree+

65.9%

Research-savvy patients

US citizens

89.8%

Low foreign-born population

Children under 15

26.9%

Young family community

The cosmetic patient lifetime value at Nocatee income levels

A 42-year-old Nocatee patient on a typical treatment plan: Botox 3 areas every 4 months ($900 × 3 = $2,700/yr) + 2 syringes filler every 12 months ($1,800/yr) + 1 CoolPeel treatment ($900/yr) + annual skin check ($190/yr) = approximately $5,590 per year per patient. At 100 established cosmetic patients, that's $559,000 annual revenue from returning patients alone — before any new patient acquisition. This is why the Nocatee cosmetic patient is the most valuable patient in our entire expansion portfolio.

Revenue Estimate — Nocatee (Cosmetic-Forward)

Note: Nocatee is primarily a cosmetic practice. Revenue model differs from Palm Coast — fewer medical derm procedures, higher per-visit cosmetic ticket. RPP will be higher than Palm Coast at maturity due to cosmetic mix but slower to ramp as cosmetic patient relationships take longer to build than medical derm (which benefits from supply shortage).

Phase	Timing	Utilization	Pts/day	Est. RPP	Monthly gross (est.)
Phase 1 — Ramp	Months 1-6	20-35%	3-5 pts/day	$280	$15,000–$25,000
Phase 2 — Growth	Months 7-18	40-65%	7-12 pts/day	$380	$40,000–$65,000
Phase 3 — Stabilized	Month 18+	75-85%	13-16 pts/day	$480–$580	$90,000–$145,000

Higher RPP than Palm Coast reflects cosmetic-dominant mix. Ramp is slower — cosmetic patient acquisition relies on word-of-mouth and marketing rather than supply shortage demand. Budget $100K+ launch reserve.

Staffing model for Nocatee

Unlike Palm Coast where the supply shortage fills our schedule quickly, Nocatee requires active marketing to build cosmetic patient volume. Consider: (1) dedicated cosmetic coordinator who handles consultations and follow-up, (2) Instagram/Google spend targeting Nocatee zip codes 32081-32082, (3) relationship with Flagler Hospital physicians for skin check referrals as the door-opener to cosmetic conversion. The rotation model (Matthew + Merrick + Dbora) works identically — just with a more cosmetic-focused booking profile.

Expansion Location #3

Fernandina Beach / Amelia Island, FL — Nassau County

Best dual medical + cosmetic market · Highest income + oldest median age · 29-year monopoly being challenged for the first time · No physician-led cosmetic derm on the island

Avg HH income

$137K

Median $97.9K

Median age

58.6

Best dual med + cosmetic age

Above poverty line

92.4%

Very low Medicaid exposure

In professional roles

82.5%

Affluent established residents

Why Fernandina Beach is exceptional — the dual driver market

The only market combining high income AND high medical derm demand — $137K average HH income (near-Nocatee level) with a 58.6 median age that drives both skin cancer demand AND cosmetic demand simultaneously
28-29 year monopoly just cracking — Beaches Dermatology was the only derm practice on Amelia Island for nearly three decades. They just moved to a new freestanding building at 791 Amelia Island Pkwy because they couldn't keep up with demand. Their expansion validates the market size; their capacity limitation creates our opening.
No physician-led cosmetic derm on the island — every cosmetic competitor is nurse-injector or non-dermatologist. A board-certified derm offering physician-grade cosmetics is a first for the island.
Snowbird + resort revenue — Amelia Island has significant vacation-home and snowbird population (Nov-Apr). Patients maintaining cosmetic treatments during Florida season, annual skin checks for snowbirds who come to their island home.
Coastal UV sun damage — decades of beach/outdoor exposure means every patient has photodamage needing both medical treatment (AKs, biopsies) and cosmetic correction (IPL, peels, resurfacing). The crossover from medical to cosmetic is natural, ethical, and highly profitable.

Considerations

Island location — bridge traffic — all patients cross the causeway; can back up in season. Schedule appointments with buffer time in mind.
Real estate premium — Amelia Island commercial lease rates higher than mainland; budget $28-35/SF vs $24-26/SF at Palm Coast
Beaches Dermatology just expanded — they added a 4th physician at their new location, signaling they know the market is large. Their medical derm focus leaves cosmetic largely uncaptured.
Seasonal fluctuation — snowbird season (Nov-Apr) surges; summer slows relative to peak season. Staff rotation schedule for this.
Fernandina Beach hosts the second Mohs lab — not Georgia. Florida commercial patients cannot use a Georgia facility in-network. Fernandina gets its own Mohs capability serving Nassau County and St. Johns County overflow.
All biopsies ship to our FLL pathology lab — 88305 global billing under Dr. Brettschneider. At 30%+ biopsy rate in the 58.6 median age population, Fernandina generates the highest per-patient pathology revenue of any satellite. Every AK treatment visit that also yields a biopsy = two insurance claims.
Nassau County brand carries from Palm Coast — by the time we open Fernandina, "Elias Dermatology" will be known in Nassau County from Palm Coast referrals and word-of-mouth up the coast
Fernandina is the northern Mohs lab location — not Georgia. Florida commercial insurance patients cannot practically use a Georgia facility in-network. Fernandina Beach hosts the second Mohs lab; Georgia patients (Camden/Glynn County) have separate coverage and access the GA Mohs capability there.

Competitor Analysis

Practice	Type	Threat	Notes
Beaches Dermatology	Board-certified MD — full service	Medium	Just expanded to new building at 791 Amelia Island Pkwy. Adding 4th physician — overwhelmed. Medical-focused. Their cosmetic offering is minimal. The expansion is a market validation, not a competitive threat. Their patients who want cosmetic derm come to us.
11 North Aesthetics	RN-owned med spa	Low	4924 1st Coast Hwy. Botox, body sculpting, IV hydration. Not a physician. No diagnosis capability. Different credential level entirely.
London Medical Spa	EM physician	Low	Emergency medicine board certification — not a dermatologist. Patients seeking physician-dermatologist cosmetics choose us.
Amelia Aesthetics & Wellness	PA-C / APRN	Low	Laser/Botox by PA. Not a dermatologist. Important distinction for patients with skin conditions who also want cosmetic work.
L. Moore Aesthetics	Esthetician	Minimal	Skincare and facials. Not medical. Different market entirely.

Best Location

Amelia Island Pkwy / Sadler Rd corridor — on the island, not the mainland

The primary commercial spine of Fernandina Beach. High visibility from the bridge, accessible from all island neighborhoods. Being on the island rather than Yulee/mainland matters strongly — Fernandina/Amelia Island patients prefer not to drive off the island for care. Look for 1,800-2,200 SF to accommodate 4-5 exam rooms plus a dedicated cosmetic suite. The suite needs to feel premium — $137K average HH income patients have expectations. Target space within 1 mile of Beaches Dermatology's new location to capture their overflow.

The Fernandina cosmetic opportunity — physician derm fills a genuine void

Amelia Island has a spa culture driven by resort tourism and affluent full-time residents. The existing cosmetic operators are all non-physician. Our positioning: "Board-certified dermatologist — see a real skin doctor for your Botox." This resonates powerfully with the educated, medically sophisticated 55-70 cohort that makes up the core island demographic. They've been going to nurse injectors because there was no physician alternative. Now there is.

Sun Damage Crossover — The Unique Fernandina Revenue Driver

Medical diagnosis + cosmetic treatment = same patient, same visit

A 63-year-old who has lived on Amelia Island for 20 years has: actinic keratoses that need cryotherapy (medical, billable to Medicare), a suspicious lesion that needs biopsy (medical), and extensive brown spots / skin texture damage from 20 years of beach sun (cosmetic, cash-pay). We treat all three in the same appointment. The 99214 + 17000 + 17003×3 + IPL/peel = one visit generating $294 Medicare + $650 cosmetic cash-pay = $944 from a single patient interaction. This crossover is more pronounced at Fernandina Beach than any other market in our expansion due to the combination of age, income, and coastal lifestyle.

Recommended Cosmetic Service Menu — Fernandina Beach

Service	Price	Why it's perfect for Fernandina	Expected monthly volume
Botox — all areas	$400–$900	Affluent retirees and seasonal residents maintaining appearance. Recurring every 3-4 months.	30-50 visits/month
Fillers	$900/syringe	Volume loss very visible in 55-70 cohort. High demand, high margin, high loyalty.	10-20 syringes/month
IPL / photorejuvenation	$400–$600	Sun spots, brown spots, redness — directly caused by coastal FL lifestyle. Huge unmet demand.	15-25/month
CoolPeel CO2 resurfacing	$900–$1,500	Photodamage correction at physician level. No med spa on island has this capability. Significant competitive gap.	8-15/month
VI Peel / chemical peels	$325–$500	Sun damage and pigmentation extremely common. Accessible price point — good entry-level cosmetic service.	15-25/month
Asclera (vein injections)	$600	Very high demand in 55-70+ cohort. No current physician offering on the island.	8-15/month
Ultherapy	$750–$4,500	Active affluent retirees invested in non-surgical lifting. Device can rotate in quarterly.	4-8/month

Market Statistics — Amelia Island / Fernandina Beach

Fernandina Beach population

13,963

Nassau County total: ~115K

Avg annual HH income

$137,029

2024 Census data

Median HH income

$97,903

Top 15% of FL cities

Median age

58.6

Best age profile in expansion

Above poverty line

92.4%

Very low Medicaid exposure

In professional roles

82.5%

Established career/retirement income

Nassau County growth

+12%

Since 2020 census

Resort/vacation homes

Significant

Ritz Carlton, resort community

Nassau County strategic importance beyond just Fernandina Beach

By the time we open Fernandina (Expansion #3), we will already have Palm Coast operating. Nassau County sits between Flagler County (Palm Coast) and Duval County (Jacksonville). Our Fernandina location creates a continuous coastal corridor — patients from Palm Coast who move to Nassau County stay with us. Referrals travel in both directions. And Nassau County is where our next location (Wildlight/Yulee) also sits, meaning we'll eventually have two Nassau County locations covering both the island and the western growth corridor, with a full county domination narrative for PE buyers.

Revenue Estimate — Fernandina Beach

Fernandina is the strongest dual-driver in the entire expansion. Medical derm demand is immediate (supply gap, aging population). Cosmetic demand layers on top. Revenue ramp is faster than Nocatee because the supply shortage (one practice for the island for 29 years) creates immediate new patient demand.

Phase	Timing	Utilization	Pts/day	Est. RPP	Monthly gross (est.)
Phase 1 — Ramp	Months 1-6	30-50%	5-9 pts/day	$200	$22,000–$36,000
Phase 2 — Growth	Months 7-18	55-75%	10-14 pts/day	$240	$55,000–$75,000
Phase 3 — Stabilized	Month 18+	85%+	15-18 pts/day	$290–$340	$120,000–$165,000

Higher RPP than Palm Coast reflects premium income demographics and stronger cosmetic mix. Faster ramp than Nocatee due to supply shortage driving immediate medical derm demand. Ultherapy revenue ($750-4,500/treatment) meaningfully boosts monthly numbers once established.

Annual EBITDA estimate at stabilized Phase 3

At $140,000/month gross (including pathology and Mohs contributions), 35% EBITDA margin after full overhead including premium island rent: approximately $588,000/year EBITDA contribution from Fernandina Beach at stabilization — the highest EBITDA-per-location of any satellite. Combined with Palm Coast ($290K) and Nocatee ($390K), by Year 3 we are approaching $2M+ in total satellite EBITDA before Georgia, before the FLL/Pines anchor EBITDA. That is a compelling PE acquisition story at any multiple.

Expansion Location #4

Wildlight / Yulee, FL — Nassau County (West)

Second Nassau County location · Purpose-built medical district with UF Health + Baptist already open · Long-term growth play · Del Webb 55+ community on-site

Nassau County proj. pop. 2035

148K

+46.9% from today

Wildlight master plan

24,000

Homes at full buildout

Medical anchors open now

UF Health, Baptist, HCA

Garden District homes

4,100+

Sales began 2026

Why Wildlight is our second Nassau location

Medical district is already built and operating — UF Health opened 2019 in Wildlight, Baptist Nassau Crossing opened late 2024, HCA emergency center Q1 2025. The referral ecosystem exists right now.
Purpose-built healthcare hub — Rayonier/Wildlight specifically designed a medical district with 30,000 SF Baptist retail office building already open and leasing to specialists. We're the obvious missing specialty.
UF Health primary care = immediate referral pipeline — they need a local dermatologist. Being in their building makes us their automatic referral.
Del Webb 55+ active adult community on-site — built-in medical derm patient base within walking distance. Sun-damaged active retirees who golf, walk, and spend time outdoors.
Nassau County brand carries from Fernandina — by Year 4, "Elias Dermatology" is established in Nassau County. Yulee patients who don't want to cross the bridge come here.
All biopsies ship to our FLL pathology lab — same global billing model as all locations. Del Webb 55+ community at Wildlight has strong medical derm demand; expect ~25-30% biopsy rate, generating meaningful 88305 revenue through our lab from day one.
First-mover advantage narrows with time — as Wildlight matures, national PE-chain derm groups will notice. Getting in early (Year 3-4) before they arrive matters.

Timing considerations

Residential density still building — Garden District sales only began 2026; full Wildlight density is a 20-30 year plan. Volume ramp is slower than Palm Coast or Fernandina — this is a growth investment, not immediate revenue.
Lease rates at premium — Wildlight medical corridor priced $22-30/SF vs older Yulee strip centers at $15-18/SF. Pay for the location — being in the medical district next to UF Health matters more than saving on rent.
Open after Fernandina is established — Fernandina gives us the Nassau County brand foundation. Wildlight inherits that brand.
Complements not competes — serves the western Nassau / I-95 corridor population; entirely different catchment from Amelia Island patients.

Best Location

Baptist Nassau Crossing / Wildlight Commerce Park — FL-200 east of I-95

The 30,000 SF Baptist Nassau retail office building on FL-200 is the anchor of the Wildlight medical district. Specialist suites available adjacent to Baptist primary care and the UF Health ambulatory center. The Wildlight Commerce Park spec building (opened March 2026) is an alternative. FL-200 east of I-95 is the spine of the entire Wildlight development — highest daily traffic, maximum visibility. Every new resident of the Garden District, Founder's Park, and Westerly Park neighborhoods drives FL-200 daily. The Del Webb community entrance is directly off this corridor.

Wildlight Development Status (as of 2026)

Development Phase	Status	Relevance to our practice
UF Health Wildlight ambulatory center	Open 2019	Immediate referral source — they have been sending patients to Fernandina/Jacksonville for derm
Baptist Nassau Crossing MOB	Open late 2024	Our target location. Baptist primary care physicians = direct referral pipeline
HCA emergency center	Open Q1 2025	Emergency dermatology referrals, wound care, post-surgical follow-up
Del Webb 55+ community	Active sales	Built-in medical derm patient base — active adult community within walking distance of medical district
Garden District (4,100+ homes)	Sales began 2026	Young professional families — cosmetic derm as they age. 5-10 year cosmetic ramp.
Wildlight Commerce Park spec building	Opened March 2026	Alternative to Baptist MOB — same corridor, lower rent, flexible space
Westerly Park / Park & Garden districts	Under construction	Future residential density — supports long-term patient volume growth

Revenue Estimate — Wildlight / Yulee

Wildlight is a growth investment, not an immediate revenue generator. The medical infrastructure is there but residential density is still building. Model this as a 3-5 year ramp to full volume rather than the 18-month ramp we expect at Palm Coast or Fernandina.

Phase	Timing	Primary demand driver	Est. RPP	Monthly gross (est.)
Phase 1 — Early	Months 1-12	Del Webb residents + UF Health referrals	$170	$12,000–$25,000
Phase 2 — Growth	Months 12-36	Garden District families + brand recognition	$200	$35,000–$60,000
Phase 3 — Stabilized	Month 36+	Full Nassau County western coverage + Del Webb path volume	$235–$270	$85,000–$120,000

The Wildlight PE value proposition

Wildlight's value to a PE buyer is the growth story, not the current revenue. A practice already embedded in a 24,000-home master-planned community with guaranteed residential growth, adjacent to three hospital-system anchors, with a secured position as the medical district's dermatologist — this is exactly the kind of "planted flag in a high-growth market" that PE buyers value at a multiple premium. The combination of Fernandina Beach (established affluent island market) + Wildlight (high-growth mainland market) gives a PE buyer complete Nassau County coverage, which in a rapidly growing county tells a compelling story.

Expansion Location #5+ — State #2

Coastal Georgia Expansion

St. Marys / Kingsland (Camden Co.) then Brunswick (Glynn Co.) · Adds state #2 · TRICARE payer diversification · Unlocks AQUA + PhyNet as the most competitive buyers · GA medical license already active

Kingsland median HH income

$77.9K

Camden County 10.7% poverty

NSB Kings Bay population

15,000+

TRICARE payer base

Kingsland growth rate

+3.0%/yr

Columbia-class submarine driven

GA medical license

✓ Active

Both FL and GA licensed

Why St. Marys / Kingsland is our first Georgia location

TRICARE payer diversification — Naval Submarine Base Kings Bay generates a large military family population insured by TRICARE. Government-backed, reliable reimbursement, essentially zero bad debt.
Columbia-class submarine expansion — $840M+ base renovation underway; military personnel inflows are contractually guaranteed for the next decade. The patient base grows automatically.
Only 20-25 miles from Fernandina Beach — essentially one continuous coastal patient market. We can refer between the two locations seamlessly.
Adds state #2 — multi-state practice commands higher PE acquisition multiples and unlocks additional buyers who are specifically expanding their geographic footprint.
Very limited competition — DiPreta Dermatology (SGHS-affiliated) and Atlantic Shore Dermatology (Forefront). Less crowded than any FL market in our expansion.
GA medical license already active — no credentialing delay; we can open immediately upon lease execution.

Considerations for St. Marys / Kingsland

Lower cosmetic demand than FL markets — military family demographic is more medical-derm oriented. Less Botox/filler revenue than Nocatee or Fernandina.
Pathology lab for Georgia locations — biopsies from St. Marys and Brunswick ship to our FLL lab for global billing under Dr. Brettschneider. TRICARE reimburses pathology at Medicare-equivalent rates — reliable and clean. As GA volume grows, evaluate whether a second pathology read closer to GA makes logistical sense, but FLL lab handles this at current projected volumes.
TRICARE reimbursement rates — TRICARE reimbursement is generally equivalent to Medicare, not commercial rates. Reliable but not premium.
DiPreta has SGHS hospital affiliation — they may have higher commercial rates through hospital-based billing. We need to evaluate whether SGHS affiliation is worth pursuing and whether it's possible for an independent practice. Requires healthcare attorney review.
Further from FLL than FL satellites — rotation logistics become more complex; overnight stays required every trip.

In-House Dermatopathology Lab — Revenue Extension to Palm Coast

We own our pathology lab in Fort Lauderdale (Dr. Fran Brettschneider)

Current lab revenue (YTD 2026): ~$3,930/month from FLL + Pines volume alone. Palm Coast adds ~49 additional slides/month at stabilization = ~$1,360/month net additional lab revenue.

Palm Coast biopsy volume will be higher than FLL on a per-patient basis

Lab metric	Current (FLL + Pines)	+ Palm Coast (Phase 3)
Monthly lab payments	~$3,930	~$5,290
Dr. Brettschneider cost ($20/slide)	~$1,747	~$2,719
Net lab contribution	~$2,183/mo	~$2,571/mo additional
Annual net lab revenue	~$26,200/yr	~$57,000/yr combined

Competitors

Practice	Type	Threat	Notes
DiPreta Dermatology	Independent practice, SGHS-affiliated	Medium	Located 2040 Dan Proctor Dr, St. Marys. SGHS affiliation may give higher commercial rates. Known practice — established patient loyalty. Our approach: capture new patients, military families new to the area, and referrals from HCA Kingsland.
Atlantic Shore Dermatology	Forefront-owned (PE chain)	Medium	PE chain — impersonal, volume-focused. Same differentiation opportunity as against ADCS in Palm Coast. Being physician-owned and relationship-focused wins in a military community that values trust.

Brunswick / Golden Isles — Our Second GA Location and the Corridor Capstone

Golden Isles affluent resort market — St. Simons Island, Jekyll Island, Sea Island. High-income retirees and resort visitors with strong cosmetic demand. The "Amelia Island of Georgia."
DiPreta Dermatology HQ here — they've operated profitably for decades, validating the market size.
Sea Island / Cloister resort community — some of the most affluent resort real estate in the Southeast. Cosmetic demand equivalent to Fernandina Beach.
Completes the coastal corridor — Fort Lauderdale to Brunswick GA = the full Southeast coastal spine. Every PE buyer looking at coastal Southeast consolidation needs this geography.
SGHS hospital affiliation opportunity — Southeast Georgia Health System in Brunswick may enable hospital-based billing rates that provide meaningful commercial rate advantages for affiliated practices.

Considerations

This is a later-stage move — open Brunswick after St. Marys is operational and generating revenue. St. Marys gives us GA infrastructure, Brunswick extends it.
Distance from FLL is substantial — ~7 hours. At this stage in the expansion, we should have enough local PA/NP staff at earlier locations to free up rotation capacity for GA.
SGHS affiliation requires careful legal review — any hospital-based billing structure requires a healthcare attorney experienced in GA provider-based billing before execution.
DiPreta is the entrenched competitor here — they have decades of established patient relationships in the Golden Isles. Target new patients, resort visitors, and Sea Island community members who want a physician-led cosmetic option.

Georgia Billing — Hospital Affiliation Considerations

⚠ SGHS Hospital Affiliation — Do Not Pursue Without Attorney Review

Georgia hospital systems like Southeast Georgia Health System (SGHS, affiliated with WellStar/Navicent) negotiate commercial rates significantly above independent practice rates — sometimes 140-170% of Medicare vs 120-135% for independent practices. An SGHS affiliation would require formal provider-based designation under their CMS certification. DiPreta already has this affiliation at St. Marys. Any hospital affiliation billing structure requires review by a healthcare attorney experienced in Georgia provider-based billing, Stark Law, and CMS provider-based attestation rules before any commitment is made.

What to pursue vs what to avoid in GA hospital billing

DO pursue: Formal credentialing and medical staff privileges at HCA Kingsland and SGHS Brunswick as an independent physician — this enables hospital referrals without any billing complexity
DO pursue: SGHS affiliation through legitimate means — if SGHS wants to affiliate us under their umbrella with proper CMS attestation, engage a healthcare attorney to structure it correctly
DO NOT pursue: The Augusta/WellStar mailing address workaround previously discussed — False Claims Act exposure is real and the DOJ has active focus on Florida dermatology billing
DO NOT pursue: Any arrangement that claims provider-based billing status without the corresponding CMS requirements actually being met

⚠ Florida patients cannot practically use Georgia Mohs lab — insurance coverage issue

Florida commercial plans (BCBS FL, Humana FL, Aetna FL, Cigna FL) are state-specific networks. A Florida patient going to our Georgia location would be treated as out-of-network unless they carry a national PPO plan. Out-of-network cost-sharing for Mohs can mean 40-50% patient responsibility — a significant barrier. Medicare is the exception — Medicare covers care anywhere in the US with any Medicare-accepting physician — but asking an elderly Palm Coast patient to drive to Georgia for Mohs surgery is operationally impractical regardless.

Conclusion: The Fernandina Beach location is the correct northern Mohs lab. Georgia patients (Camden and Glynn County) are served by a separate Mohs capability built specifically for that GA market and billed under GA insurance networks.

TRICARE billing — the reliable GA revenue foundation

TRICARE reimburses at approximately 115% of Medicare for most dermatology CPT codes when billing under the standard TRICARE fee schedule. Not as high as commercial, but extremely reliable — government-backed with essentially zero bad debt. For a St. Marys/Kingsland practice where 40-50% of patients may be TRICARE beneficiaries, this creates a stable predictable revenue base that insurers and PE buyers model favorably. Ensure TRICARE credentialing is completed before opening — processing takes 60-90 days.

Full Expansion Plan

Expansion Sequence & PE Exit Strategy

Build what buyers need to acquire · Multi-location, multi-state, balanced medical/cosmetic · Competitive sell-side process targeting 7-13× EBITDA

Target locations

4-6

Before PE exit

Target EBITDA multiple

7-13×

Platform-ready practices

Target exit timeline

4-6 yrs

From first satellite opening

Key immediate action

Oaklins

Call before signing any lease

Full Expansion Sequence

#	Location	Timing	Primary driver	EBITDA est.	PE narrative
★	Fort Lauderdale (anchor)	Operating now	Balanced medical + cosmetic; Mohs; full service; Matthew anchors	$760K/yr payments	Primary revenue engine; $181.56 RPP; Mohs ~$25K/mo
★	Pembroke Pines (anchor)	Operating now	Balanced medical + cosmetic; Merrick anchors; both PAs rotate in 1d/wk	$334K/yr payments	Second anchor; south Broward market; growth trajectory
1	Palm Coast, FL	Year 1	Medical derm; 31.8% 65+ pop; supply gap; high procedure volume; path lab extension; Mohs Month 3-6	$200K–$380K/yr	Fills I-95 gap JAX-Daytona; retirement market; highest per-patient procedure revenue
2	Nocatee / Ponte Vedra, FL	Year 1-2	Cosmetic-forward; $131K income; preventive cosmetic cohort; Mohs refers to Palm Coast	$260K–$500K/yr	Highest-income market; St. Johns County; cosmetic lifetime patient value ~$5,590/yr
3	Fernandina Beach, FL	Year 2-3	Dual medical + cosmetic; $137K avg income; monopoly gap; 58.6 median age; second Mohs lab; highest path volume	$350K–$600K/yr	Nassau County anchor; highest EBITDA satellite; dual revenue driver per patient
4	Wildlight / Yulee, FL	Year 3-4	Growth play; UF Health referrals; Del Webb 55+ community; path lab from day one	$180K–$340K/yr	Completes Nassau County; 46.9% growth story; early mover advantage
5	St. Marys / Kingsland, GA	Year 3-4	TRICARE payer; GA license active; state #2; path lab ships to FLL	$140K–$280K/yr	Multi-state platform; unlocks AQUA + PhyNet as competitive buyers
6	Brunswick / Golden Isles, GA	Year 4-5	Golden Isles affluent resort; SGHS affiliation; Mohs lab for GA patients; coastal capstone	$220K–$440K/yr	Completes FL-to-GA coastal spine; Sea Island cosmetic demand; SGHS billing advantage
PE Exit (4-6 locations)		Year 4-6	Competitive sell-side process — multiple buyers bidding simultaneously	$1.8M–$3.8M combined	7-13× EBITDA = $13M–$49M estimated range

Most important immediate action

Contact Oaklins Heritage in Jacksonville — they were the exclusive advisor on the First Coast Mohs / AQUA transaction and know exactly what AQUA paid, on what metrics, and what geographic gaps they are trying to fill next. That single conversation, before we sign a lease anywhere, is worth more than any analysis we can do internally. The goal is to build what the buyers need — not to build and then figure out who might want it.

PE Buyer Universe — Who We're Building For

DermCare Management

Hollywood, FL · Hildred + Gemini Capital · 90+ locations

Highest fit. HQ'd in our backyard. "Southern Smile" geography covers FL → VA → TX → CA. Just entered Jacksonville (Boyne Derm, July 2024). Our North FL cluster fills their entire gap. Cosmetic + med spa expansion (Sona MedSpa, April 2025) aligns with our model.

PhyNet Dermatology

Nashville, TN · Ontario Teachers / Century Equity · 120+ affiliations

Highest fit. Opened Fort Lauderdale location April 2024. Opened Atlanta BeltLine January 2024. Actively expanding both our South FL anchor AND our Georgia target simultaneously. A practice bridging FL and GA is purpose-built for their thesis.

AQUA Dermatology

Palm Beach Gardens, FL · Gryphon + GTCR · 110+ locations

Strong interest if we go to GA. First Coast Mohs in JAX is their northernmost FL beachhead. Stated North FL / South GA expansion goal. Our Georgia locations complete their coastal corridor. Less compelling for FL-only practice since they already have FL coverage.

Skin and Cancer Associates

South Florida · Susquehanna PE · 30+ FL locations

Natural bolt-on. South FL based with extensive Broward/Dade/Palm Beach presence. No North FL presence at all. Our Nassau/St. Johns/Flagler cluster is entirely new geography for them at zero cannibalization.

Forefront Dermatology

Manitowoc, WI · Partners Group · 400+ locations, 35 states

National scale acquirer. Already in Fernandina Beach (Atlantic Shore Derm) and Kingsland GA. Would view our practice as competitive displacement or a geographic complement depending on our positioning.

QualDerm Partners

Brentwood, TN · Cressey & Co · 158 locations, 17 states

Rebranded as "Skin & Aesthetics Wellness Family" — cosmetic-heavy focus aligns with our balanced model. FL presence growing. Active acquirer post-Pinnacle merger.

The competitive sell-side process is how you maximize price

When you engage an advisor like Oaklins Heritage or Physician Growth Partners, they contact every plausible buyer simultaneously and create an auction. DermCare, PhyNet, AQUA, Forefront, and Skin & Cancer Associates all bidding at the same time is how you go from 8× EBITDA to 12-13× EBITDA. More than 35 PE-backed dermatology platforms now operate nationally. No single buyer relationship matters as much as the competitive process that creates tension among multiple bidders. Build the best practice in the best locations — the buyers will come to you.

Exit Mechanics & Valuation

What PE buyers actually pay for

Normalized EBITDA — 24+ months of clean auditable financials at each location. Start tracking location P&L from day one at Palm Coast.
Revenue quality — balanced medical (insurance-backed, recurring) + cosmetic (cash-pay, high-margin) mix is ideal. PE models these separately; both need to be growing.
Physician retention — buyers want assurance the physicians stay post-acquisition. Plan your employment and non-compete structures accordingly.
Geographic narrative — a coherent coverage story matters more than individual location volume. "Coastal FL to GA" is more compelling than "scattered locations."
Scalability demonstration — having proven the replication model at 2-3 satellites before exit shows buyers you've built a system, not just a practice.
Clean operations — billing compliance, no pending DOJ/OIG issues, malpractice history clean. The DOJ has active focus on FL derm billing — stay clean.

Rollover equity — the second bite

Typical structure: 70-80% cash at close + 20-30% rollover equity in the acquiring platform
The second bite: When the PE platform recapitalizes or sells in 3-5 years, your rollover equity gets a second liquidity event. This can equal or exceed the initial sale proceeds.
Negotiate hard on rollover % — more rollover in a high-growth platform = more upside. Less rollover = more cash now but less upside later.
Management agreements — understand what you're agreeing to operationally post-acquisition. Most PE groups want the founding physicians to stay and lead clinical operations.
Engage an M&A attorney separate from the advisor for the actual transaction documents. The advisor works on your behalf but the attorney reviews every line.

Estimated Valuation Range

Scenario	Locations at exit	Combined EBITDA	Multiple range	Estimated enterprise value
Conservative — FL only	FLL + Pines + Palm Coast + Nocatee	$1.4M–$2.1M	7-9×	$10M–$19M
Base case — Full FL corridor	FLL + Pines + 4 FL satellites	$2.3M–$3.2M	9-11×	$21M–$35M
Target — Multi-state platform	FLL + Pines + 4 FL satellites + 1-2 GA	$2.8M–$4.0M	10-13×	$28M–$52M

Estimates updated to reflect higher per-patient RPP from procedure volume (AK cryo, biopsies), in-house dermatopathology lab revenue at all locations ($20/slide cost, ~$48 avg reimbursement), and Mohs lab contributions at Palm Coast and Fernandina. Platform practices with $5M+ EBITDA can command 12-15×. Independent practices typically 4-9×. Our target is to build toward platform-level valuation by demonstrating scalability, geographic coherence, and balanced revenue across medical, cosmetic, surgical, and pathology revenue streams.