8-K
RadNet, Inc. (RDNT)
UNITED
STATES
SECURITIES
AND EXCHANGE COMMISSION
Washington, D.C. 20549
FORM 8-K
CURRENT REPORT
Pursuant to Section 13 or 15(d) of theSecurities Exchange Act of 1934
Date of Report (Date of earliest event reported):
March 8, 2021
RadNet,Inc. ****
(Exact name of registrant as specified in its charter)
| Delaware | 001-33307 | 13-3326724 |
|---|---|---|
| (State or other jurisdiction of incorporation) | (Commission File Number) | (IRS Employer<br><br>Identification Number) |
1510 Cotner Avenue
Los Angeles, California 90025
(Address of Principal Executive Offices) (Zip Code)
(310) 445-2800
(Registrant’s Telephone Number, Including Area Code)
(Check the appropriate box below if the Form 8-K filing is intended to simultaneously satisfy the filing obligation of the registrant under any of the following provisions (see General Instruction A.2. below):
| ¨ | Written communications pursuant to Rule 425 under the Securities Act (17 CFR 230.425) |
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| ¨ | Soliciting material pursuant to Rule 14a-12 under the Exchange Act (17 CFR 240.14a-12) |
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| ¨ | Pre-commencement communications pursuant to Rule 14d-2(b) under the Exchange Act (17 CFR 240.14d-2(b)) |
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| ¨ | Pre-commencement communications pursuant to Rule 13e-4(c) under the Exchange Act (17 CFR 240.13e-4(c)) |
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Securities registered pursuant to Section 12(b) of the Act:
| Title of Each Class | Trading Symbol(s) | Name of each exchange on which registered |
|---|---|---|
| Common Stock, $.0001 par value | RDNT | NASDAQ |
Indicate by check mark whether the registrant is an emerging growth company as defined in Rule 405 of the Securities Act of 1933 (§230.405 of this chapter) or Rule 12b-2 of the Securities Exchange Act of 1934 (§240.12b-2 of this chapter).
Emerging growth company ¨
If an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act. ¨
| Item 2.02 | RESULTS OF OPERATIONS AND FINANCIAL CONDITION |
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On March 8, 2021 RadNet, Inc. (“RadNet”) issued a press release and held a conference call regarding our financial results for the fourth quarter and year ended December 31, 2020. A copy of the press release is furnished as Exhibit 99.1 and a copy of the transcript of the conference call is furnished as Exhibit 99.2 to this Current Report.
The information in Item 2.02 of this Current Report, including Exhibit 99.1 and Exhibit 99.2 is being furnished and shall not be deemed “filed” for purposes of Section 18 of the Securities Exchange Act of 1934 or otherwise subject to the liabilities of that Section. The information in Item 2.02 of this Current Report, including Exhibit 99.1 and Exhibit 99.2 shall not be incorporated by reference into any registration statement or other document filed with the Commission.
| Item 9.01 | FINANCIAL STATEMENTS AND EXHIBITS. |
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(d) Exhibits
| Exhibit No. | Description |
|---|---|
| 99.1 | Press Release dated March 8, 2021 relating to RadNet, Inc.’s<br>financial results for the year ended December 31, 2020. |
| 99.2 | Transcript of conference call. |
| 104 | Cover Page Interactive Data File (embedded within the Inline<br> XBRL document). |
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SIGNATURES
Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned hereunto duly authorized.
| Date: March 8, 2021 | RadNet, Inc. | |
|---|---|---|
| By: | /s/ Mark Stolper | |
| Name: | Mark Stolper | |
| Title: | Chief Financial Officer |
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Exhibit 99.1
FOR IMMEDIATE RELEASE
RadNet Reports Fourth QuarterResults with Record Revenue and Adjusted EBITDA and Releases 2021 Financial Guidance
| · | Despite the ongoing impact of COVID-19, RadNet reports record fourthquarter 2020 Total Net Revenue (“Revenue”) of $308.5 million and Adjusted EBITDA^([1])^of$50.7 million; Revenue increased 2.5% and Adjusted EBITDA^(1)^ increased 8.1% as compared with the same quarter in 2019 |
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| · | Improved reimbursement from expanded implementation of 3D mammographyand increases in capitation contracts and cash collections drove increased Revenue |
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| · | Focus on cost reductions, center consolidations and operationalefficiencies throughout the COVID-19 period resulted in an Adjusted EBITDA^(1)^ margin of 16.4%, an improvement of 0.8%,or 80 basis points relative to last year’s fourth quarter |
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| · | *Adjusted Net Income^(3)^*for the fourth quarter of 2020 was $10.2 million, or $0.20 per dilutedshare as compared with $9.9 million, or $0.19 per diluted share for the same period in 2019 |
| --- | --- |
| · | RadNet announces 2021 guidance ranges, anticipating material increasesin Revenue, Adjusted EBITDA^(1)^ and Free Cash Flow from 2019 and 2020 levels |
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LOS ANGELES, California, March 8, 2021– RadNet, Inc. (NASDAQ: RDNT), a national leader in providing high-quality, cost-effective, fixed-site outpatient diagnostic imaging services through a network of 331 owned and/or operated outpatient imaging centers, today reported financial results for its fourth quarter and full year ended December 31, 2020.
Financial Results
Fourth Quarter Report:
Dr. Howard Berger, President and Chief Executive Officer of RadNet, commented “Despite a continuing impact from COVID-19, our results in the fourth quarter were the strongest quarterly performance in our Company’s history. The recovery we experienced in the third quarter continued to gain momentum throughout the fourth quarter. Improved reimbursement from both private and capitated payers and our widespread adoption of 3D mammography, or tomosynthesis, were responsible for our achieving the Revenue growth in the quarter. Our mammography volume, alone, during the fourth quarter increased 11.7% from the fourth quarter of 2019. In addition, significant changes we made during the COVID-19 period to reduce costs and refine our operating protocols contributed to our record Adjusted EBITDA^(1)^ and strong profitability during the quarter. This aggressive cost management resulted in Adjusted EBITDA^(1)^ margin improvement from 15.6% in 2019’s fourth quarter to 16.4% during this fourth quarter.”
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“Throughout the COVID-19 period, we have focused on managing our liquidity and financial leverage. At year-end 2020, we had a cash balance of $102.0 million and our net debt leverage ratio was reduced to under four times Adjusted EBITDA^(1)^, essentially the same leverage we had at year-end 2019, prior to COVID-19. Our Days Sales Outstanding (DSOs) at December 31, 2020 was 36.2 days, the lowest in our Company’s history. I would like to thank our entire employee base, those on the front lines and those in support functions and in our corporate office, for their tireless efforts during this global pandemic. These extraordinary efforts have helped secure the future of RadNet and positioned our Company for growth and success in 2021 and beyond,” Dr. Berger noted.
“Though 2020 was a challenging time for all, RadNet was there to respond to the needs of its patients. I am proud of the resiliency of our business, and it is indicative of the critical role we play in the healthcare delivery system of the markets in which we service,” added Dr. Berger.
For the fourth quarter of 2020, RadNet reported Revenue of $308.5 million and Adjusted EBITDA^(1)^ of $50.7 million. Revenue increased $7.7 million (or 2.5%) and Adjusted EBITDA^(1)^ increased $3.8 million (or 8.1%) from the fourth quarter of 2019.
Adjusted Diluted Net Income Attributable to RadNet, Inc. Common Stockholders (Adjusted Net Income^(3)^) for the fourth quarter of 2020 was $10.2 million, or $0.20 per diluted share as compared with $9.9 million, or $0.19 per diluted share for the same period in 2019. Net Income Attributable to RadNet, Inc. Common Shareholders (“Net Income”) for the fourth quarter of 2020 was $6.0 million, or $0.11 per diluted share. This compares to Net Income of $10.4 million, or $0.21 per diluted share, in the fourth quarter of 2019. These per share values are based upon weighted average number of diluted shares outstanding of 52.2 million in the fourth quarter of 2020 and 50.6 million of diluted shares outstanding in the fourth quarter of 2019.
Affecting Net Income in the fourth quarter of 2020 were certain non-cash expenses and non-recurring items including: $---2.3 million of non-cash employee stock compensation expense; $2.7 million of severance paid in connection with headcount reductions related to cost savings initiatives; $657,000 loss on the disposal of certain capital equipment; $750,000 of non-cash gain from interest rate swaps; $4.2 million loss on impairment of intangible assets associated with trade names the Company discontinued; $4.0 million gain on the extinguishment of certain debt; and $1.1 million of amortization of deferred financing costs and loan discount related to our existing credit facilities.
For the fourth quarter of 2020, as compared with the prior year’s fourth quarter, MRI volume decreased 1.8%, CT volume increased 2.4% and PET/CT volume decreased 2.8%. Overall volume, taking into account routine imaging exams, inclusive of x-ray, ultrasound, mammography and other exams, decreased 0.5% over the prior year’s fourth quarter. On a same-center basis, including only those centers which were part of RadNet for both the fourth quarters of 2020 and 2019, MRI volume decreased 1.5%, CT volume increased 1.4% and PET/CT volume decreased 1.3%. Overall same-center volume, taking into account routine imaging exams, inclusive of x-ray, ultrasound, mammography and other exams, decreased 0.2% from the prior year’s same quarter.
Annual Report:
For full year 2020, RadNet reported Revenue (inclusive of provider relief funding) of $1,098 million and Adjusted EBITDA^(1)^ of $139.5 million. Revenue decreased $56.1 million (or 4.9%) and Adjusted EBITDA^(1)^ decreased $24.7 million (or 15.0%) as compared with 2019.
Net Loss for 2020 was $14.8 million, or $(0.29) per diluted share. This compares to Net Income of $14.8 million, or $0.29 per diluted share, in 2019. These per share values are based upon weighted average number of diluted shares outstanding of 50.9 million in 2020 and 50.2 million of diluted shares outstanding in 2019.
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Affecting Net Income in 2020 were certain non-cash expenses and non-recurring items including: $---12.4 million of non-cash employee stock compensation expense; $4.4 million of severance paid in connection with headcount reductions related to cost savings initiatives; $1.2 million loss on the disposal of certain capital equipment; $6.0 million of non-cash loss from interest rate swaps; $4.2 million loss on impairment of intangible assets associated with trade names the Company discontinued; $4.0 million gain on the extinguishment of certain debt; and $4.4 million of amortization of deferred financing costs and loan discount related to our existing credit facilities.
For the year ended December 31, 2020, as compared to 2019, MRI volume decreased 11.9%, CT volume decreased 6.8% and PET/CT volume decreased 4.1%. Overall volume, taking into account routine imaging exams, inclusive of x-ray, ultrasound, mammography and other exams, decreased 12.9% for the twelve months of 2020 over 2019.
2021 Fiscal Year Guidance
For its 2021 fiscal year, RadNet announces its guidance ranges as follows:
| Total Net Revenue | $1,250 million - $1,300 million |
|---|---|
| Adjusted EBITDA^(1)^ | $180 million - $190 million |
| Capital Expenditures ^(a)^ | $70 million - $75 million |
| Cash Paid for Interest | $39 million - $44 million |
| Free Cash Flow Generation ^(b)(2)^ | $60 million - $70 million |
| (a) | Net of proceeds from the sale of equipment, imaging centers and joint venture interests, and excludes<br>New Jersey Imaging Network capital expenditures. |
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| (b) | Defined by the Company as Adjusted EBITDA^(1)^ less<br>Capital Expenditures and Cash Paid for Interest. |
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Dr. Berger noted, “For the second half of 2020, we exceeded $600 million of Revenue and $96 million of Adjusted EBITDA^(1)^. This performance is the result of a strong recovery of our procedural volumes and the significant impact from cost reduction programs we instituted throughout the COVID-19 period. Our guidance ranges for 2021 are built with this momentum in mind and the assumption that our business will continue to strengthen as COVID-19 restrictions are lifted in the states in which we operate. We believe there is upside to our guidance ranges, which could result from accretive tuck-in acquisitions we may complete during the year, further benefit from the cost reduction measures implemented in 2020, increases in reimbursement from private and capitated payors and the expansion of our joint venture initiatives. Additionally, achieving growth in the Arizona marketplace through our Dignity Health joint venture will be a major focus throughout 2021, which could include both de novo centers as well as acquisitions. In 2021, we will also complete our upgrade to 3D mammography and continued development of our AI solutions. Sometime around the middle 2021, we hope to receive FDA approval for our initial mammography AI product submitted in the fourth quarter of 2020, and we anticipate filing with the FDA for its review a second mammography AI offering by year end.”
Conference Call for Today
Dr. Howard Berger, President and Chief Executive Officer, and Mark Stolper, Executive Vice President and Chief Financial Officer, will host a conference call today, at 10:30 a.m. Eastern Time. During the call, management will discuss the Company's 2020 fourth quarter and year-end results.
Conference Call Details:
Date: Monday, March 8, 2021
Time: 10:30 a.m. ET
Dial In-Number: 800-437-2398
International Dial-In Number: 786-204-3966
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There will also be simultaneous and archived webcasts available at http://public.viavid.com/player/index.php?id=143719 or http://www.radnet.com under the “About RadNet” menu section and “News & Press Releases” sub-menu of the website. An archived replay of the call will also be available and can be accessed by dialing 844-512-2921 from the U.S., or 412-317-6671 for international callers, and using the passcode 8718718.
About RadNet, Inc.
RadNet, Inc. is the leading national provider of freestanding, fixed-site diagnostic imaging services in the United States based on the number of locations and annual imaging revenue. RadNet has a network of 331 owned and/or operated outpatient imaging centers. RadNet's core markets include California, Maryland, Delaware, New Jersey, New York and Arizona. Together with affiliated radiologists, and inclusive of full-time and per diem employees and technicians, RadNet has a total of approximately 8,300 employees. For more information, visit http://www.radnet.com.
Forward Looking Statements
This press release contains “forward-looking statements” within the meaning of the safe harbor provisions of the U.S. Private Securities Litigation Reform Act of 1995. Forward-looking statements are expressions of our current beliefs, expectations and assumptions regarding the future of our business, future plans and strategies, projections, and anticipated future conditions, events and trends. Forward-looking statements can generally be identified by words such as: “anticipate,” “intend,” “plan,” “goal,” “seek,” “believe,” “project,” “estimate,” “expect,” “strategy,” “future,” “likely,” “may,” “should,” “will” and similar references to future periods. Forward-looking statements in this press release include, among others, statements we make regarding response to and the expected future impacts of COVID-19, including statements about our anticipated business results, balance sheet and liquidity and our future liquidity, burn rate and our continuing ability to service or refinance our current indebtedness.
Forward-looking statements are neither historical facts nor assurances of future performance. Because forward-looking statements relate to the future, they are inherently subject to uncertainties, risks and changes in circumstances that are difficult to predict and many of which are outside of our control. Our actual results and financial condition may differ materially from those indicated in the forward-looking statements. Therefore, you should not place undue reliance on any of these forward-looking statements. Important factors that could cause our actual results and financial condition to differ materially from those indicated in the forward-looking statements include, among others, the following:
| · | the ongoing impact of the COVID-19 pandemic<br>on our business, suppliers, payors, customers, referral sources, partners, patients and employees, including (i) government’s<br>unprecedented action regarding existing and potential restrictions and/or obligations related to citizen and business activity<br>to contain the virus; (ii) the consequences of an economic downturn resulting from the impacts of COVID-19 and the possibility<br>of a global economic recession; (iii) the impact of the volume of canceled or rescheduled procedures, whether as a result of government<br>action or patient choice; (iv) measures we are taking to respond to the COVID-19 pandemic, including changes to business practices;<br>(v) the impact of government and administrative regulation, guidance and appropriations; (vi) changes in our revenues due to declining<br>patient procedure volumes, changes in payor mix; (vii) potential increased expenses or workforce disruptions related to our employees<br>that could lead to unavailability of key personnel; (viii) workforce disruptions related to our key partners, suppliers, vendors<br>and others we do business with; (ix) the impact of return to work orders in certain states in which we operate; and (x) increased<br>credit and collectability risks; |
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| · | the availability and terms of capital<br>to fund our business; |
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| · | our ability to service our indebtedness,<br>make principal and interest payments as those payments become due and remain in compliance with applicable debt covenants, in addition<br>to our ability to refinance such indebtedness on acceptable terms; |
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| · | changes in general economic conditions<br>nationally and regionally in the markets in which we operate; |
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| --- | | · | the availability and terms of capital<br>to fund the expansion of our business and improvements to our existing facilities; | | --- | --- | | · | our ability to maintain our current credit<br>rating and the impact on our funding costs and competitive position if we do not do so; | | --- | --- | | · | volatility in interest and exchange rates,<br>or credit markets; | | --- | --- | | · | the adequacy of our cash flow and earnings<br>to fund our current and future operations; | | --- | --- | | · | changes in service mix, revenue mix and<br>procedure volumes; | | --- | --- | | · | delays in receiving payments for services<br>provided; | | --- | --- | | · | increased bankruptcies among our partner<br>physicians or joint venture partners; | | --- | --- | | · | the impact of the political environment<br>and related developments on the current healthcare marketplace and on our business, including with respect to the future of the<br>Affordable Care Act; | | --- | --- | | · | the extent to which the ongoing implementation<br>of healthcare reform, or changes in or new legislation, regulations or guidance, enforcement thereof by federal and state regulators<br>or related litigation result in a reduction in coverage or reimbursement rates for our services, or other material impacts to our<br>business; | | --- | --- | | · | closures or slowdowns and changes in labor<br>costs and labor difficulties, including stoppages affecting either our operations or our suppliers' abilities to deliver supplies<br>needed in our facilities; | | --- | --- | | · | the occurrence of hostilities, political<br>instability or catastrophic events; | | --- | --- | | · | the emergence or reemergence of and effects<br>related to future pandemics, epidemics and infectious diseases; and | | --- | --- | | · | noncompliance by us with any privacy or<br>security laws or any cybersecurity incident or other security breach by us or a third party involving the misappropriation, loss<br>or other unauthorized use or disclosure of confidential information. | | --- | --- |
Any forward-looking statement contained in this current report is based on information currently available to us and speaks only as of the date on which it is made. We undertake no obligation to publicly update any forward-looking statement, whether written or oral, that we may make from time to time, whether as a result of changed circumstances, new information, future developments or otherwise, except as required by applicable law.
Regulation G: GAAP and Non-GAAPFinancial Information
This release contains certain financial information not reported in accordance with GAAP. The Company uses both GAAP and non-GAAP metrics to measure its financial results. The Company believes that, in addition to GAAP metrics, these non-GAAP metrics assist the Company in measuring its cash-based performance. The Company believes this information is useful to investors and other interested parties because it removes unusual and nonrecurring charges that occur in the affected period and provides a basis for measuring the Company's financial condition against other quarters. Such information should not be considered as a substitute for any measures calculated in accordance with GAAP, and may not be comparable to other similarly titled measures of other companies. Non-GAAP financial measures should not be considered in isolation from, or as a substitute for, financial information prepared in accordance with GAAP. Reconciliation of this information to the most comparable GAAP measures is included in this release in the tables which follow.
CONTACTS:
RadNet, Inc.
Mark Stolper, 310-445-2800
Executive Vice President and ChiefFinancial Officer
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RADNET, INC. AND SUBSIDIARIES
CONSOLIDATED BALANCE SHEETS
(IN THOUSANDS EXCEPT SHARE AND PER SHARE DATA)
| 2019 | |||||
| ASSETS | |||||
| CURRENT ASSETS | |||||
| Cash and cash equivalents | 102,018 | $ | 40,165 | ||
| Accounts receivable, net | 129,585 | 154,763 | |||
| Due from affiliates | 5,836 | 1,242 | |||
| Prepaid expenses and other current assets | 32,985 | 45,004 | |||
| Total current assets | 270,424 | 241,174 | |||
| PROPERTY, EQUIPMENT AND RIGHT-OF-USE ASSETS | |||||
| Property and equipment, net | 399,335 | 367,795 | |||
| Operating lease right-of-use assets | 483,661 | 445,477 | |||
| Total property, equipment and right-of-use assets | 882,996 | 813,272 | |||
| OTHER ASSETS | |||||
| Goodwill | 472,879 | 441,973 | |||
| Other intangible assets | 52,393 | 42,994 | |||
| Deferred financing costs | 1,767 | 1,559 | |||
| Investment in joint ventures | 34,528 | 34,470 | |||
| Deferred tax assets, net of current portion | 34,687 | 34,548 | |||
| Deposits and other | 36,983 | 36,996 | |||
| Total assets | 1,786,657 | $ | 1,646,986 | ||
| LIABILITIES AND EQUITY | |||||
| CURRENT LIABILITIES | |||||
| Accounts payable, accrued expenses and other | 236,684 | $ | 207,585 | ||
| Due to affiliates | 14,010 | 14,347 | |||
| Deferred revenue related to software sales | 39,257 | 1,316 | |||
| Current portion of finance lease | 2,578 | 3,283 | |||
| Current portion of operating lease | 65,794 | 61,206 | |||
| Current portion of notes payable and long term debt | 39,791 | 39,691 | |||
| Total current liabilities | 398,114 | 327,428 | |||
| LONG-TERM LIABILITIES | |||||
| Finance lease, net of current portion | 743 | 3,264 | |||
| Operating lease, net of current portion | 463,096 | 420,922 | |||
| Notes payable, net of current portion | 612,913 | 652,704 | |||
| Other non-current liabilities | 53,488 | 9,529 | |||
| Total liabilities | 1,528,354 | 1,413,847 | |||
| EQUITY | |||||
| RadNet, Inc. stockholders' equity: | |||||
| Common stock - .0001 par value, 200,000,000 shares authorized; 51,640,044 and 50,314,328 shares issued and outstanding at December 31, 2020 and December 31, 2019, respectively | 5 | 5 | |||
| Additional paid-in-capital | 307,788 | 262,865 | |||
| Accumulated other comprehensive (loss) income | (24,051 | ) | (8,026 | ) | |
| Accumulated deficit | (117,999 | ) | (103,159 | ) | |
| Total RadNet, Inc.'s stockholders' equity | 165,743 | 151,685 | |||
| Noncontrolling interests | 92,560 | 81,454 | |||
| Total equity | 258,303 | 233,139 | |||
| Total liabilities and equity | 1,786,657 | $ | 1,646,986 |
All values are in US Dollars.
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RADNET, INC. AND SUBSIDIARIES
CONSOLIDATED STATEMENTS OF OPERATIONS
(IN THOUSANDS EXCEPT SHARE AND PER SHARE DATA)
| Years Ended December 31, | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| 2020 | 2019 | 2018 | |||||||
| REVENUE | |||||||||
| Service fee revenue | $ | 931,722 | $ | 1,028,236 | $ | 868,741 | |||
| Revenue under capitation arrangements | 140,118 | 125,943 | 106,405 | ||||||
| Total revenue | 1,071,840 | 1,154,179 | 975,146 | ||||||
| Provider relief funding | 26,264 | – | – | ||||||
| OPERATING EXPENSES | |||||||||
| Cost of operations, excluding depreciation and amortization | 965,902 | 999,692 | 867,547 | ||||||
| Depreciation and amortization | 86,795 | 80,607 | 72,899 | ||||||
| Loss (gain) on sale and disposal of equipment | 1,200 | 2,383 | (2,054 | ) | |||||
| Loss on impairment | 4,170 | – | 3,937 | ||||||
| Severance costs | 4,353 | 1,619 | 1,931 | ||||||
| Total operating expenses | 1,062,420 | 1,084,301 | 944,260 | ||||||
| INCOME FROM OPERATIONS | 35,684 | 69,878 | 30,886 | ||||||
| OTHER INCOME AND EXPENSES | |||||||||
| Interest expense | 45,882 | 48,044 | 43,456 | ||||||
| Equity in earnings of joint ventures | (7,945 | ) | (8,350 | ) | (11,377 | ) | |||
| Non-cash change in fair value of interest rate hedge | 2,528 | – | – | ||||||
| Gain on re-measurement of pre-existing interest | – | (768 | ) | (39,539 | ) | ||||
| Gain on extinguishment of debt | (4,047 | ) | – | – | |||||
| Other expenses (income) | 120 | 1,283 | (181 | ) | |||||
| Total other expenses (income) | 36,538 | 40,209 | (7,641 | ) | |||||
| (LOSS) INCOME BEFORE INCOME TAXES | (854 | ) | 29,669 | 38,527 | |||||
| Provision for income taxes | (895 | ) | (6,229 | ) | (394 | ) | |||
| NET INCOME | (1,749 | ) | 23,440 | 38,133 | |||||
| Net income attributable to noncontrolling interests | 13,091 | 8,684 | 5,890 | ||||||
| NET (LOSS) INCOME ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | (14,840 | ) | $ | 14,756 | $ | 32,243 | ||
| BASIC NET (LOSS) INCOME PER SHARE ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | (0.29 | ) | $ | 0.30 | $ | 0.67 | ||
| DILUTED NET (LOSS) INCOME PER SHARE ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | (0.29 | ) | $ | 0.29 | $ | 0.66 | ||
| WEIGHTED AVERAGE SHARES OUTSTANDING | |||||||||
| Basic | 50,891,790 | 49,674,858 | 48,114,275 | ||||||
| Diluted | 50,891,790 | 50,244,006 | 48,678,999 |
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RADNET, INC. AND SUBSIDIARIES
CONSOLIDATED STATEMENTS OF CASH FLOWS
(IN THOUSANDS)
| Years Ended December 31, | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| 2020 | 2019 | 2018 | |||||||
| CASH FLOWS FROM OPERATING ACTIVITIES | |||||||||
| Net (loss) income | $ | (1,749 | ) | $ | 23,440 | $ | 38,133 | ||
| Adjustments to reconcile net income to net cash provided by operating activities: | |||||||||
| Depreciation and amortization | 86,795 | 80,607 | 72,899 | ||||||
| Amortization of operating right-of-use assets | 67,915 | 66,842 | – | ||||||
| Equity in earnings of joint ventures | (7,945 | ) | (8,350 | ) | (11,377 | ) | |||
| Distributions from joint ventures | 9,522 | 8,598 | 24,846 | ||||||
| Amortization and write off of deferred financing costs and loan discount | 4,413 | 4,184 | 3,898 | ||||||
| Loss (gain) on sale and disposal of equipment | 1,200 | 2,383 | (2,054 | ) | |||||
| Gain on extinguishment of debt | (4,047 | ) | – | – | |||||
| Gain on re-measurement of pre-existing interest | – | (768 | ) | (39,539 | ) | ||||
| Loss on impairment | 4,170 | – | 3,937 | ||||||
| Amortization of cash flow hedge | 3,448 | – | – | ||||||
| Non-cash change in fair value of interest rate hedge | 2,528 | – | – | ||||||
| Stock-based compensation | 12,405 | 8,730 | 7,662 | ||||||
| Other non cash item in other expenses | 242 | (371 | ) | – | |||||
| Change in value of contingent consideration | – | (3,123 | ) | 1,749 | |||||
| Changes in operating assets and liabilities, net of assets acquired and liabilities assumed in purchase transactions: | |||||||||
| Accounts receivable | 25,206 | (17,482 | ) | 2,145 | |||||
| Other current assets | 6,588 | (3,557 | ) | (9,248 | ) | ||||
| Other assets | (5,425 | ) | (2,326 | ) | (1,687 | ) | |||
| Deferred taxes | (611 | ) | (3,888 | ) | (6,935 | ) | |||
| Operating lease liability | (53,906 | ) | (66,831 | ) | – | ||||
| Deferred rent | – | – | 6,312 | ||||||
| Deferred revenue | 37,941 | (1,082 | ) | (208 | ) | ||||
| Accounts payable, accrued expenses and other | 45,069 | 17,316 | 26,221 | ||||||
| Net cash provided by operating activities | 233,759 | 104,322 | 116,754 | ||||||
| CASH FLOWS FROM INVESTING ACTIVITIES | |||||||||
| Purchase of imaging facilities | (31,265 | ) | (27,150 | ) | (73,192 | ) | |||
| Investment at cost | – | (143 | ) | (2,200 | ) | ||||
| Purchase of property and equipment | (94,172 | ) | (74,153 | ) | (72,180 | ) | |||
| Proceeds from sale of equipment | 828 | 1,160 | 2,575 | ||||||
| Proceeds from sale of equity interest in a joint venture | – | 132 | – | ||||||
| Proceeds from sale of internal use software | – | – | 248 | ||||||
| Nulogix return of capital | – | 792 | – | ||||||
| Equity contributions in existing and purchase of interest in joint ventures | (1,635 | ) | (103 | ) | (2,000 | ) | |||
| Net cash used in investing activities | (126,244 | ) | (99,465 | ) | (146,749 | ) | |||
| CASH FLOWS FROM FINANCING ACTIVITIES | |||||||||
| Principal payments on notes and leases payable | (3,562 | ) | (6,494 | ) | (6,072 | ) | |||
| Payments on senior notes | (43,296 | ) | (40,742 | ) | (33,830 | ) | |||
| Additional deferred finance costs on revolving loan amendment | (741 | ) | – | – | |||||
| Proceeds from debt issuance, net of issuance costs | – | 97,144 | – | ||||||
| Proceeds from Payment Protection Program | 4,023 | – | – | ||||||
| Distributions paid to noncontrolling interest | (1,985 | ) | (3,057 | ) | (1,427 | ) | |||
| Proceeds from sale of noncontrolling interest | – | 5,275 | – | ||||||
| Contributions from noncontrolling partners | – | 750 | 2,640 | ||||||
| Proceeds from revolving credit facility | 250,900 | 261,200 | 204,300 | ||||||
| Payments on revolving credit facility | (250,900 | ) | (289,200 | ) | (176,300 | ) | |||
| Purchase of non-controlling interests | – | – | (200 | ) | |||||
| Proceeds from issuance of common stock upon exercise of options | – | 75 | 20 | ||||||
| Net cash (used in) provided by financing activities | (45,561 | ) | 24,951 | (10,869 | ) | ||||
| EFFECT OF EXCHANGE RATE CHANGES ON CASH | (101 | ) | (32 | ) | (69 | ) | |||
| NET INCREASE (DECREASE) IN CASH AND CASH EQUIVALENTS | 61,853 | 29,776 | (40,933 | ) | |||||
| CASH AND CASH EQUIVALENTS, beginning of period | 40,165 | 10,389 | 51,322 | ||||||
| CASH AND CASH EQUIVALENTS, end of period | $ | 102,018 | $ | 40,165 | $ | 10,389 | |||
| SUPPLEMENTAL DISCLOSURE OF CASH FLOW INFORMATION | |||||||||
| Cash paid during the period for interest | $ | 39,521 | $ | 46,254 | $ | 37,016 | |||
| Cash paid during the period for income taxes | $ | 533 | $ | 5,884 | $ | 4,933 |
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RADNET, INC. AND SUBSIDIARIES
CONSOLIDATED STATEMENTS OF OPERATIONS
(IN THOUSANDS EXCEPT SHARE DATA)
(unaudited)
| Three Months Ended | ||||||
|---|---|---|---|---|---|---|
| December 31, | ||||||
| 2020 | 2019 | |||||
| REVENUE | ||||||
| Service fee revenue | $ | 271,530 | $ | 265,484 | ||
| Revenue under capitation arrangements | 36,973 | 35,356 | ||||
| Total revenue | 308,503 | 300,840 | ||||
| OPERATING EXPENSES | ||||||
| Cost of operations, excluding depreciation and amortization | 257,808 | 255,696 | ||||
| Depreciation and amortization | 22,259 | 20,413 | ||||
| Loss (gain) on sale and disposal of equipment | 657 | 898 | ||||
| Loss on impairment | 4,170 | – | ||||
| Severance costs | 2,706 | 564 | ||||
| Total operating expenses | 287,600 | 277,571 | ||||
| INCOME FROM OPERATIONS | 20,903 | 23,269 | ||||
| OTHER INCOME AND EXPENSES | ||||||
| Interest expense | 12,439 | 11,454 | ||||
| Equity in earnings of joint ventures | (2,769 | ) | (2,278 | ) | ||
| Non-cash change in fair value interest rate hedge | (1,995 | ) | – | |||
| Gain on re-measurement of pre-existing interest | – | (1,273 | ) | |||
| Gain on extinguishment of debt | (4,047 | ) | – | |||
| Other expenses (income) | 367 | 13 | ||||
| Total other expenses | 3,995 | 7,916 | ||||
| INCOME BEFORE INCOME TAXES | 16,908 | 15,353 | ||||
| Provision for from income taxes | (5,925 | ) | (2,673 | ) | ||
| NET INCOME | 10,983 | 12,680 | ||||
| Net income attributable to noncontrolling interests | 5,028 | 2,283 | ||||
| NET INCOME<br> ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | 5,955 | $ | 10,397 | ||
| BASIC NET INCOME PER SHARE ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | 0.12 | $ | 0.21 | ||
| DILUTED NET INCOME PER SHARE ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | 0.11 | $ | 0.21 | ||
| WEIGHTED AVERAGE SHARES OUTSTANDING | ||||||
| Basic | 51,384,586 | 49,905,482 | ||||
| Diluted | 52,224,090 | 50,633,570 |
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RADNET,INC.
RECONCILIATIONOF GAAP NET INCOME ATTRIBUTABLE TO RADNET, INC. COMMON SHAREHOLDERS TO ADJUSTED EBITDA^(1)^
(IN THOUSANDS)
| Three Months Ended | **** | |||||
|---|---|---|---|---|---|---|
| **** | December 31, | **** | ||||
| **** | 2020 | **** | 2019 | |||
| Net Income Attributable to RadNet, Inc. Common Stockholders | $ | 5,955 | $ | 10,397 | ||
| Plus Provision for Income Taxes | 5,925 | 2,673 | ||||
| Plus Interest Expense | 12,439 | 11,454 | ||||
| Plus Severance Costs | 2,706 | 564 | ||||
| Plus Depreciation and Amortization | 22,259 | 20,413 | ||||
| Plus Non Cash Employee Stock Based Compensation | 2,260 | 1,767 | ||||
| Plus Loss on Sale and Disposal of Equipment | 657 | 898 | ||||
| Plus Other Expenses | 367 | 13 | ||||
| Plus Non Cash (Gain) in Fair Value of Interest Rate Hedge | (1,995 | ) | – | |||
| Plus Loss on Impairment | 4,170 | – | ||||
| Plus (Gain) on Extinguishment of Debt | (4,047 | ) | – | |||
| Plus (Gain) on Re-measurement of Pre-existing Interest | – | (1,273 | ) | |||
| Adjusted EBITDA^(1)^ | $ | 50,696 | $ | 46,906 | ||
| Fiscal Year Ended | **** | |||||
| --- | --- | --- | --- | --- | --- | --- |
| **** | December 31, | **** | ||||
| **** | 2020 | **** | 2019 | |||
| Net Income (Loss) Attributable to RadNet, Inc. Common Stockholders | $ | (14,840 | ) | $ | 14,756 | |
| Plus Provision for Income Taxes | 895 | 6,229 | ||||
| Plus Interest Expense | 45,882 | 48,044 | ||||
| Plus Severance Costs | 4,353 | 1,619 | ||||
| Plus Depreciation and Amortization | 86,795 | 80,607 | ||||
| Plus Non Cash Employee Stock Based Compensation | 12,405 | 8,730 | ||||
| Plus Loss on Sale and Disposal of Equipment | 1,200 | 2,383 | ||||
| Plus Other Expenses | 120 | 1,283 | ||||
| Plus Non Cash Loss in Fair Value of Interest Rate Hedge | 2,528 | – | ||||
| Plus Loss on Impairment | 4,170 | – | ||||
| Plus Legal Settlements | – | 1,248 | ||||
| Plus (Gain) on Extinguishment of Debt | (4,047 | ) | – | |||
| Plus (Gain) on Re-measurement of Pre-existing Interest | – | (768 | ) | |||
| Adjusted EBITDA^(1)^ | $ | 139,461 | $ | 164,131 |
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RADNET, INC. AND SUBSIDIARIES
SCHEDULE OF ADJUSTED EARNINGS AND EARNINGS PER SHARE ^(3)^
(IN THOUSANDS EXCEPT SHARE DATA)
(unaudited)
| Three Months Ended | ||||||
|---|---|---|---|---|---|---|
| December 31, | ||||||
| 2020 | 2019 | |||||
| NET INCOME ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | 5,955 | $ | 10,397 | ||
| Add severance costs | 2,706 | 564 | ||||
| Add loss on impairment | 4,170 | – | ||||
| Subtract gain on re-measurement of pre-existing interest | – | (1,273 | ) | |||
| Subtract non-cash gain on swap valuation | (1,995 | ) | – | |||
| Subtract gain on extinguishment of debt | (4,047 | ) | – | |||
| Total adjustments - loss (gain) | 834 | (709 | ) | |||
| Subtract tax impact of Adjustments (i) | 217 | (184 | ) | |||
| Tax effected impact of adjustments | 617 | (525 | ) | |||
| Add non-recurring tax adjustment related to joint<br> venture | 3,639 | – | ||||
| TOTAL ADJUSTMENT TO NET INCOME ATTRIBUTABLE TO RADNET, INC. COMMON SHAREHOLDERS | 4,256 | (525 | ) | |||
| ADJUSTED NET INCOME ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | 10,211 | 9,872 | ||||
| WEIGHTED AVERAGE SHARES OUTSTANDING | ||||||
| Diluted | 52,224,090 | 50,633,570 | ||||
| ADJUSTED DILUTED NET INCOME PER SHARE ATTRIBUTABLE TO RADNET, INC. COMMON STOCKHOLDERS | $ | 0.20 | $ | 0.19 |
(i) Tax effected using 26% blended federal and state effective tax rate.
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PAYOR CLASS BREAKDOWN
| Fourth Quarter | ||
|---|---|---|
| 2020 | ||
| Commercial Insurance | 58.5% | |
| Medicare | 20.5% | |
| Capitation | 12.0% | |
| Medicaid | 2.5% | |
| Workers Compensation/Personal Injury | 2.4% | |
| Other | 4.2% | |
| Total | 100.0% |
RADNET PAYMENTS BY MODALITY
| Fourth Quarter | Full Year | Full Year | Full Year | |||||
|---|---|---|---|---|---|---|---|---|
| 2020 | 2020 | 2019 | 2018 | |||||
| MRI | 34.8% | 35.4% | 35.8% | 35.2% | ||||
| CT | 16.9% | 17.6% | 16.9% | 16.5% | ||||
| PET/CT | 5.6% | 6.0% | 5.6% | 5.7% | ||||
| X-ray | 6.7% | 7.3% | 8.1% | 8.4% | ||||
| Ultrasound | 12.4% | 12.3% | 12.4% | 12.2% | ||||
| Mammography | 17.8% | 15.7% | 15.2% | 15.8% | ||||
| Nuclear Medicine | 1.0% | 1.0% | 1.0% | 1.1% | ||||
| Other | 4.9% | 4.7% | 4.9% | 5.1% | ||||
| 100.0% | 100.0% | 100.0% | 100.0% |
Footnotes
^^
^(1)^ The Company defines Adjusted EBITDA as earnings before interest, taxes, depreciation and amortization, each from continuing operations and excludes losses or gains on the disposal of equipment, other income or loss, loss on debt extinguishments, bargain purchase gains and non-cash equity compensation. Adjusted EBITDA includes equity earnings in unconsolidated operations and subtracts allocations of earnings to non-controlling interests in subsidiaries, and is adjusted for non-cash and extraordinary events which took place during the period.
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Adjusted EBITDA is reconciled to its nearest comparable GAAP financial measure. Adjusted EBITDA is a non-GAAP financial measure used as analytical indicator by RadNet management and the healthcare industry to assess business performance, and is a measure of leverage capacity and ability to service debt. Adjusted EBITDA should not be considered a measure of financial performance under GAAP, and the items excluded from Adjusted EBITDA should not be considered in isolation or as alternatives to net income, cash flows generated by operating, investing or financing activities or other financial statement data presented in the consolidated financial statements as an indicator of financial performance or liquidity. As Adjusted EBITDA is not a measurement determined in accordance with GAAP and is therefore susceptible to varying methods of calculation, this metric, as presented, may not be comparable to other similarly titled measures of other companies.
^(2)^ As noted above, the Company defines Free Cash Flow as Adjusted EBITDA less total Capital Expenditures (whether completed with cash or financed) and Cash Interest paid. Free Cash Flow is a non-GAAP financial measure. The Company uses Free Cash Flow because the Company believes it provides useful information for investors and management because it measures our capacity to generate cash from our operating activities. Free Cash Flow does not represent total cash flow since it does not include the cash flows generated by or used in financing activities. In addition, our definition of Free Cash Flow may differ from definitions used by other companies.
Free Cash Flow should not be considered a measure of financial performance under GAAP, and the items excluded from Adjusted EBITDA should not be considered in isolation or as alternatives to net income, cash flows generated by operating, investing or financing activities or other financial statement data presented in the consolidated financial statements as an indicator of financial performance or liquidity. As Adjusted EBITDA is not a measurement determined in accordance with GAAP and is therefore susceptible to varying methods of calculation, this metric, as presented, may not be comparable to other similarly titled measures of other companies.
^(3)^ The Company defines Adjusted Earnings Per Share as net income or loss attributable to RadNet, Inc. common stockholders and excludes losses or gains on the disposal of equipment, loss on debt extinguishments, bargain purchase gains, severance costs, loss on impairment, loss or gain on swap valuation, gain on extinguishment of debt, unusual or non-recurring entries that impact the Company’s tax provision and any other non-recurring or unusual transactions recorded during the period.
Adjusted Earnings Per Share is reconciled to its nearest comparable GAAP financial measure. Adjusted Earnings Per Share is a non-GAAP financial measure used as analytical indicator by RadNet management and the healthcare industry to assess business performance. Adjusted Earnings Per Share should not be considered a measure of financial performance under GAAP, and the items excluded from Adjusted Earnings Per Share should not be considered in isolation or as alternatives to net income, cash flows generated by operating, investing or financing activities or other financial statement data presented in the consolidated financial statements as an indicator of financial performance or liquidity. As Adjusted Earnings Per Share is not a measurement determined in accordance with GAAP and is therefore susceptible to varying methods of calculation, this metric, as presented, may not be comparable to other similarly titled measures of other companies.
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Exhibit 99.2
C O R P O R A T E PA R T I C I P A N T S
Mark Stolper, Executive VicePresident and Chief Financial Officer
Dr. Howard Berger, Chairman,President and Chief Executive Officer
C O N F E R E N C EC A L L P A R T I C I P A N T S
Brian Tanquilut, Jefferies
Mitra Ramgopal, Sidoti &Co. LLC
Jonathan Ransom, Raymond James
P R E S E N T A T IO N
Operator
Good day, and welcome to the RadNet Inc. Q4 and Full-Year 2020 Financial Results Call.
Today’s conference is being recorded.
At this time, I would like to turn the conference over to Mr. Mark Stolper, Executive Vice President and Chief Financial Officer of RadNet, Inc. Please go ahead, sir.
Mark Stolper
Thank you.
Good morning, ladies and gentlemen, and thank you for joining Dr. Howard Berger and me today to discuss RadNet’s Fourth Quarter and Full-Year 2020 Financial Results.
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Before we begin today, we’d like to remind everyone of the Safe Harbor statement under the Private Securities Litigation Reform Act of 1995. This presentation contains forward-looking statements within the meaning of the U.S. Private Securities Litigation Reform Act of 1995. Specifically, statements concerning anticipated future financial and operating performance; RadNet’s ability to continue to grow the business by generating patient referrals and contracts with radiology practices; recruiting and retaining technologists; receiving third-party reimbursement for diagnostic imaging services; successfully integrating acquired operations; generating revenue and Adjusted EBITDA for the acquired operations as estimated, among others, are forward-looking statements within the meaning of the Safe Harbor.
Forward-looking statements are based on Management’s current preliminary expectations and are subject to risks and uncertainties which may cause RadNet’s actual results to differ materially from the statements contained herein. These risks and uncertainties, including those risks set forth in RadNet’s reports filed with the SEC from time to time, including RadNet’s Annual Report on Form 10-K for the year ended December 31, 2020, to be filed shortly.
Undue reliance should not be placed on forward-looking statements, especially guidance on future financial performance which speaks only as of the date it is made. RadNet undertakes no obligation to update publicly any forward-looking statements to reflect new information, events or circumstances after the date they were made, or to reflect the occurrence of unanticipated events.
With that, I’d like to turn the call over to Dr. Berger.
Dr. Howard Berger
Thank you, Mark.
Good morning, everyone, and thank you for joining us today.
On today’s call, Mark and I plan to provide you with highlights from our fourth quarter and full-year 2020 results, give you more insight into the factors which affected this performance and discuss our future strategy. After our prepared remarks, we will open the call to your questions. I’d like to thank all of you for your interest in our Company and for dedicating a portion of your day to participate in our conference call this morning.
Before we start, I would like to say on behalf of myself and the entire team at RadNet, we hope all of you and your loved ones are healthy and staying safe. We are extremely grateful for all of our stakeholders, including our employees, business partners, lenders and shareholders, and wish you all well during this challenging time.
Let’s begin. I am very pleased with our performance in the fourth quarter. Continuing with the recovery of our procedural volumes that began in the third quarter, we recorded the highest quarterly revenue and Adjusted EBITDA in the Company’s history this fourth quarter. The turnaround of our business has been quite remarkable, from its low point in mid-April when our procedural volumes dropped by 72% from pre-COVID levels.
In the fourth quarter, our revenue grew by 2.5%, which was the result of several factors. First, during 2020, we significantly expanded our 3D mammography program on both coasts. As a result, our mammography volumes increased by 11.7% during the fourth quarter, relative to the same quarter in 2019. Much of the increase in mammography volumes brought an associated reimbursement premium for the tomosynthesis 3D technology. Second, the increased revenue was the result of reimbursement increases from private and capitated payers, as well as improved collections, particularly around patient co-payments.
In addition to the record revenue performance, our Adjusted EBITDA in the fourth quarter of 2020 was $50.7 million, as compared with $46 million in the fourth quarter of 2019, an increase of 8.1%. While the increase in revenue contributed to the growth in Adjusted EBITDA, the improved Adjusted EBITDA performance was also the result of cost saving measures we instituted during the COVID-19 period.
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Since the onset of COVID-19, we aggressively focused on reducing expenses, consolidating underperforming sites and changing key operational metrics, both at the center level and within our corporate support departments. The operational improvements we made will continue to benefit the business into the future and are reflected in the 2021 guidance ranges we announced earlier today in our financial results press release. From a margin perspective, our Adjusted EBITDA margin was 16.4% in the fourth quarter of 2020, as compared with 15.6% in the fourth quarter of 2019, an improvement of 0.8% or 80 basis points.
Our adjusted earnings were also very strong. Adjusted for one-time and extraordinary events during the quarter, our adjusted net income was $10.2 million or $0.20 per diluted share, as compared with $9.9 million or $0.19 per diluted share in the fourth quarter of 2019. Throughout the COVID-19 period, we have focused on strengthening our balance sheet by managing our liquidity and financial leverage.
At year-end 2020, we had a cash balance of $102 million and our net debt leverage ratio was reduced to under four times Adjusted EBITDA, a little similar to that of year-end 2019 prior to the onset of COVID-19. We believe that our strong balance sheet positions us to be aggressive in 2021 with respect to growth initiatives, and will include tuck-in acquisitions, de novo centers and continued capital spending to drive same-center performance.
While it is noteworthy to highlight the strong financial performance of our last three quarters as our business began to recover from the worst of COVID-19 impact throughout 2020, we made some significant progress in furthering our long-term operating plan. Here are some of the highlights.
In March of 2020, we completed our acquisition of DeepHealth, a leading artificial intelligence and machine learning company, initially focused on solutions for the medical interpretation of mammography exams. DeepHealth’s development has focused on screening mammography, specifically 3D breast imaging, where the large volume of cases and the difficult nature of their interpretation placed significant demand on radiologists. We are more certain today than ever before that artificial intelligence will transform the diagnostic imaging and radiology industry.
Machine learning, big data applications and automation algorithms will allow us to deliver our services more cost effectively, efficiently and accurately. We spend almost 20% of our globally billed net revenue to the radiologist’s interpretation of our images. We believe AI will create workflow efficiencies and can improve the accuracy of image interpretation in mammography and in other modalities we perform, which can materially benefit all of our RadNet stakeholders.
In the fourth quarter of 2020, we submitted for FDA approval of our first AI mammography product, which is a screening triage product for radiologists. We hope to receive approval sometime towards the middle of the year. By the end of the year, we anticipate submitting for FDA approval in a secondary product for more advanced mammography diagnostics, and look forward to keeping you informed with our progress on these fronts.
Related to our DeepHealth acquisition, in August of 2020, we announced a collaboration with Hologic to advance the development of artificial intelligence tools in breast health. The collaboration will enable new joint market opportunities and further efforts to build clinician confidence and develop and integrate new AI technologies. As part of the collaboration, RadNet has been upgrading its entire fleet of Hologic mammography systems to feature the Hologic Clarity HD and Quorum 3D imaging technologies, and we’ll share with Hologic certain data produced by RadNet’s suite of high-resolution mammography systems.
In 2020, we furthered the expansion of our health system joint venture businesses. In October, we established a partnership with Adventist Health to create an outpatient imaging joint venture in Simi Valley, California, to initially include three outpatient facilities. In addition, we assumed operational management of Adventist Health’s Nancy Reagan Breast Center. Also in October, RadNet announced its third joint venture, with Dignity Health, CommonSpirit in Phoenix, Arizona, initially established with eight acquired facilities. We plan to significantly expand our offerings in the Greater Phoenix Area in the coming years through a combination of new site development and the acquisition of existing radiology providers. The process of expansion has begun and we anticipate allocating significant focus and financial and management resources on this new market over the coming years.
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In August of 2020, we completed an amendment to our credit agreement to increase the amount of the revolving commitments thereunder by $57.5 million to a total of $195 million. While this was done out of an abundance of precaution and a concern for our liquidity position during the global pandemic, the expansion of our available credit position allows us to have funds at our disposal to grow the Company more aggressively in the coming years, and are available for accretive acquisitions.
At this time, I’d like to turn the call back over to Mark to discuss some of the highlights of our fourth quarter and full 2020 performance. When he is finished, I will make some closing remarks.
Mark Stolper
Thank you, Howard.
I’m now going to briefly review our fourth quarter and full-year 2020 performance, and intend to highlight what I believe to be some material items. I will also give some further explanation of certain items in our financial statements, as well as provide some insights into some of the metrics that drove our fourth quarter and full-year 2020 performance. I will also provide 2021 financial guidance levels, which were raised in this morning’s financial results press release.
In my discussion, I will use the term Adjusted EBITDA, which is a non-GAAP financial measure. The Company defines Adjusted EBITDA as earnings before interest, taxes, depreciation and amortization, and excludes losses or gains on the disposal of equipment, other income or loss, loss on debt extinguishments and non-cash equity compensation.
Adjusted EBITDA includes equity and earnings in unconsolidated operations and subtracts allocations of earnings to non-controlling interests in subsidiaries, and is adjusted for non-cash or extraordinary and one-time events taking place during the period. A full quantitative reconciliation of Adjusted EBITDA to net income or loss attributable to RadNet, Inc. common shareholders is included in our earnings release.
With that said, I’d now like to review our fourth quarter and full-year 2020 results. For the three months ended December 31, 2020, RadNet reported revenue of $308.5 million and Adjusted EBITDA of $50.7 million. Both were the highest quarterly levels in our Company’s history. Revenue increased $7.7 million or 2.5% over the prior-year same quarter, and Adjusted EBITDA increased $3.8 million or 8.1% over the prior-year same quarter. The increase in revenue and Adjusted EBITDA was the result of a combination of better reimbursement from the expansion of our 3D mammography offerings, improved reimbursement from private and capitated payers, enhanced cash collections and significant cost reductions, as detailed by Dr. Berger in his earlier remarks.
For the fourth quarter of 2020, as compared with the prior-year’s fourth quarter, aggregate MRI volume decreased 1.8%, CT volume increased 2.4% and PET CT volume decreased 2.8%. Overall volume, taking into account routine imaging exams, inclusive of x-ray, ultrasound, mammography and other exams, decreased 0.5% over the prior-year’s quarter.
In the fourth quarter of 2020, we performed 1,977,086 total procedures. The procedures were consistent with our multimodality approach, whereby 76.7% of all the work we did by volume was from routine imaging. Our procedures in the fourth quarter of 2020 were as follows. Note that the CT volumes for 2019 have been restated to account for a change we made as of January 1 of 2020 in how we account for one of our CT CPT codes. The comparative numbers that follow are on an apples to apples basis: 276,482 MRIs, as compared with 281,646 MRIs in the fourth quarter of 2019; 172,728 CTs, as compared with 168,706 CTs in the fourth quarter of 2019; 11,063 PET CTs, as compared with 11,381 PET CTs in the fourth quarter of 2019; and 1,516,813 routine imaging exams, compared with 1,524,608 of all these exams in the fourth quarter of 2019.
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Adjusted net income, which is net income adjusted in each period for one-time or extraordinary items, was $10.2 million for the fourth quarter of 2020 or $0.27 per diluted share, as compared with $9.9 million or $0.19 per diluted share for the same period in 2019. These per-share values are based upon weighted average number of diluted shares outstanding of 52.2 million shares in the fourth quarter of 2020, and 50.6 million shares outstanding in the fourth quarter of 2019.
Affecting net income in the fourth quarter of 2020 were certain noncash expenses and nonrecurring items, including the following: $2.3 million of noncash employee stock compensation expense; $2.7 million of severance paid in connection with headcount reductions related to cost savings initiatives; $657,000 loss on the disposal of certain capital equipment; $750,000 of noncash gain from interest rate hedges; $4.2 million loss on the impairment of intangible assets associated with trade names the Company has discontinued; $4 million gain on the extinguishment of certain debt; and $1.1 million of amortization of deferred financing costs and loan discounts related to our existing credit facilities.
With regards to some specific income statement accounts, overall GAAP interest expense for the fourth quarter of 2020 was $12.4 million. This compares with GAAP interest expense in the fourth quarter of 2019 of $11.5 million. Cash paid for interest during the period, which excludes noncash deferred financing expense and accrued interest, was $8.3 million, as compared with $10.2 million in the fourth quarter of last year. For the full-year of 2020, the Company reported $1,098,104,000 of revenue, which is inclusive of $26.2 million of provider relief funding we received under the CARES Act.
Adjusted EBITDA was $139.5 million and net loss was $14.8 million. Due to the impact of COVID-19, revenue decreased $56.1 million or 4.9%, and Adjusted EBITDA decreased $24.7 million or 15%, as compared with 2019.
For the year ended December 31, 2020, as compared with 2019, MRI volume decreased 11.9%, CT volume decreased 6.8% and PET CT volume decreased 4.1%. Overall volume, taking into account all routine imaging, decreased 12.9% for the 12 months of 2020, as compared with 2019.
In 2020, we performed 6,867,021 total procedures. The procedures were consistent with our multimodality approach, whereby 76.1% of all the work we did by volume was from routine imaging. Our procedures in 2020 were as follows. Again, like the assumption of the comparison of the fourth quarter procedural volume, the CT volumes for 2019 have been restated to account for a change we made as of January 1, 2020 in how we account for one of our CT CPT codes. The comparative numbers that follow are also on an apples to apples basis: 976,633 MRIs, compared with 1,108,496 MRIs in 2019; 620,547 CTs, as compared with 665,539 CTs in 2019; 41,567 PET CTs, as compared with 43,341 PET CTs in 2019; and 5,228,274 routine imaging exams, as compared with 6,068,928 of all these exams in 2019.
Net loss for 2020 was $14.8 million or negative $0.29 per diluted share. This compares to net income of $14.8 million or $0.29 per diluted share in 2019. These per-share volumes are based on weighted average number of diluted shares outstanding of 50.9 million shares in 2020 and 50.2 million shares in 2019.
Affecting net income in 2020 were certain noncash expenses and nonrecurring items, including the following: $12.4 million of noncash employee stock compensation expense; $4.4 million of severance paid in connection with headcount reductions related to cost savings initiatives; $1.2 million loss on the disposal of certain capital equipment; $6 million of noncash loss from interest rate hedges; $4.2 million loss on the impairment of intangible assets associated with trade names the Company has discontinued; $4 million of gain on the extinguishment of certain debt; and $4.4 million of amortization of deferred financing costs and loan discounts related to our existing credit facilities.
With regards to some specific income statement accounts, overall GAAP interest expense in 2020 was $45.9 million. Adjusting for the noncash impact from items such as amortization of financing fees and accrued interest, cash interest expense was $39.5 million in 2020. This compares with GAAP interest expense in 2019 of $48 million and cash paid for interest of $46.3 million in 2019.
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With regards to our balance sheet, as of December 31, 2020, unadjusted for bond and term loan discounts, we had $563.7 million of net debt, which is total debt at par value less our cash balance. Note that this debt balance includes New Jersey Imaging Network’s debt of approximately $53 million, for which RadNet is neither a borrower nor guarantor. This compares with $672.4 million of net debt at December 31, 2019. As of year-end 2020, we were undrawn on our $195 million revolving line of credit and had a cash balance of $102 million, which was substantially up from $40.2 million cash balance at year-end 2019.
At December 31, 2020, our accounts receivable balance was $129.6 million, a decrease of $25.2 million from year-end 2019. The decrease in accounts receivable is mainly from improved cash collections, including additional efforts and resources dedicated to patient collections at the time of service. Our DSO was 36.2 days at December 31, 2020, lower by 8.5 days when compared with 44.7 days as of that date one year earlier.
Throughout 2020, we had total capital expenditures net of asset dispositions and the Seattle Imaging Center assets and joint venture interests of $86 million. This amount excludes $7.4 million of capital expenditures of New Jersey Imaging Network. Approximately all of our capital expenditures were paid for in cash, and we recognized $828,000 in proceeds from the sale of equipment.
Capital expenditures in 2020 were higher than we originally budgeted as a result of additional investments we made in 3D mammography capacity, in conjunction with the Whiterabbit.ai rollout and some opportunities we saw to take market share away from some of our competitors in selected markets during the COVID-19 period.
At this time, I’d like to review our 2021 Fiscal Year guidance levels which we released this morning in our financial results press release. For total net revenue, our guidance range is $1.25 billion to $1.3 billion. For Adjusted EBITDA, our guidance range is $180 million to $190 million. For capital expenditures, our guidance range is $70 million to $75 million. For cash paid for interest, our guidance range is $39 million to $44 million. For free cash flow generation, which we define as our Adjusted EBITDA less capital expenditures, less cash paid for interest, our guidance range is $60 million to $70 million.
These guidance levels are built on a number of assumptions. First, we entered 2021 on the strength of a strong recovery from COVID-19, as indicative of our performance levels during the second half of 2020. For the second half of 2020, we exceeded $600 million of revenue and $96 million of Adjusted EBITDA. Our guidance ranges for 2021 are built with this run rate in mind, and the assumption that our business will continue to strengthen as COVID-19 restrictions are lifted in the states in which we operate.
We believe there is upside to our guidance ranges, which could result from accretive tuck-in acquisitions we expect to complete during the year, further benefit from the cost reduction measures implemented in 2020, increases in reimbursement from private and capitated payers and the expansion of our joint venture initiatives. Additionally, achieving growth in the Arizona marketplace through our Dignity Health joint venture will be a major focus throughout 2021, which could include both de novo centers as well as acquisitions.
In 2021, we will also complete our upgrade to 3D mammography and continued development of our AI solutions. Sometime around the middle of 2021, we hope to receive FDA approval for our initial mammography AI product submitted in the fourth quarter of 2021; and we anticipate filing with the FDA for its review, a second mammography AI offering by year-end.
I now would like to turn the call back over to Dr. Berger, who will make some closing remarks.
Dr. Howard Berger
Thank you, Mark.
In conclusion, the challenges encountered during the COVID-19 pandemic created a seminal event for RadNet. COVID-19 required us to re-evaluate every aspect of our business, a business that has grown primarily in the past through acquisitions. COVID-19 allowed us to pause and analyze all of our procedures and processes in order to achieve more optimal performance.
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The pandemic also gave us the opportunity to make decisions that would otherwise have proven more difficult in more normal times. We were able to consolidate some of our centers that were in close proximity to other centers in ways that preserve patient access, convenience and our procedural volume. The regional centralization of our scheduling departments and preauthorization teams afforded us the ability to more effectively manage our capacity without losing business or negatively impacting our customer service. In addition, we were able to exit noncore businesses and activities that were distracting our management teams from more core functions.
As we now approach the end of the first quarter of 2020, we are optimistic for the remainder of the year. In particular, we look to make substantial progress in deploying artificial intelligence in our business, especially with regards to screening mammography. These AI tools should improve our diagnostic accuracy and result in earlier disease detection and better compliance amongst patients.
We are also working diligently to expand a number of our health system joint ventures and seek to establish new ones. Our strong cash position at the end of 2020 leading into this year, along with the availability of our $195 million revolving credit facility, will provide us with financial capabilities to pursue accretive strategic acquisitions and execute on all of the facets of our operating plan.
Operator, we are now ready for the question-and-answer portion of the call.
Operator
Thank you. We’ll take our first question from Brian Tanquilut with Jefferies.
Brian Tanquilut
Hi, good morning, guys, congratulations on a good quarter and obviously a tough year, so congrats on navigating all that.
I guess my first question, for both of you guys, Howard and Mark, as I look at the numbers that you posted in the quarter, obviously it looks like you’ve seen a good bit of recovery already. Mark, I appreciate you mentioning the conservatism of guidance, but how are you thinking about the recovery that’s remaining, or the opportunity remaining to see volumes pick up through pent-up demand? What kind of cadence, over the course of the year, are you embedding in your guidance as it pertains to that?
Dr. Howard Berger
Good morning, Brian, and thank you.
I think there were a number of issues that occurred in 2020 that will continue to help drive volumes into our centers, along with normal efforts that we make from a marketing and contracting standpoint and just what has traditionally been a 2% to 3% annual organic growth in volumes. Notably, the pandemic has created an additional effort on the part of payors to further encourage and help direct business away from hospitals. A number of the major payors have either re-iterated or announced their reimbursement preferences for outpatient imaging centers, to the point where they may not pay for some of the routine imaging that are done in hospital systems, both at not only higher cost, but now with the pandemic still upon us, a less comfortable place for patients to go. We believe both of those issues will create additional volume directed to outpatient facilities in general, and in ours in particular.
In addition to that, it’s clear that some of our recovery to more normal volumes, and in fact having exceeded that so far in the early part of this year, is delayed treatment and doctor visits that were put upon everybody in 2020. Notably, during the last nine months of 2020, many health systems went to the extent of not performing elective procedures, which is one of the reasons why our MRI volume and others were affected so much. We expect those to be lifted. Most of the health systems have already done that, but we expect that that additional need for these essential services will be resurrected in 2020.
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Alongside of that, we believe that the additional volume that will come to us will be a result of people preferring to go to the outpatient and ambulatory centers, along with the fact that there are more articles appearing in the literature that delayed healthcare leads to greater cost and more bidding (phon) in the system. I think all of those factors will help drive our revenues and are somewhat factored into our guidance for 2021.
Brian Tanquilut
Yes, appreciate that. Then I guess, Howard, while I have you, obviously mammography is an area that you’ve been focused on and you’ve talked about AI a little bit in that space. Can you just walk me through what the strategy is there, and what sort of investments and expansion that we should be watching out for going forward?
Dr. Howard Berger
Okay. Well, I think the primary reason why we’re focused on mammography is that, depending upon whose articles you read or which statistics, the marketplace does not do a particularly good job at this time in the compliance for our patients to get their annual or biannual mammogram. We’ve begun, both through our Whiterabbit relationship, as well as some of our own internal measurements and analytics, to reach out to patients and improve that compliance.
In addition, there’s an estimate that anywhere from perhaps as much as 30% to maybe even 50% or 60% of all women who should be getting mammography are not. Therefore, since there’s about 40 million mammograms done annually, there’s a good argument to believe that, perhaps, 20 million to 30 million more mammograms should be done on an annual basis. We believe that, given the scale that we have and the analytics that we’re capable of using to drive better compliance and reach out to first-time women getting the mammograms after the age of 40, will help drive that business.
To that end, as I mentioned in my remarks, we have gone through a significant upgrading of our mammography systems through a relationship with Hologic, to not only get to the 3D tomosynthesis throughout our entire fleet, but to elevate to their newest technology with high-resolution detectors and faster and better management for reading the scans. We hope to couple that with the continued effort in our artificial intelligence through the DeepHealth division, which, in an article that we published back in November, demonstrated that artificial intelligence is able to detect breast cancer one to two years earlier than even some of the most qualified mammographers are capable of doing.
I think all of those give us a good reason to think that our mammography, which was up as we reported, even in the fourth quarter, up almost 12%, has that opportunity to continue in 2021. I also want to mention that, in most households, the mother or women are very much the determinant of where healthcare is accessed by the rest of their family, so encouraging more and more of that mammography business, we believe, will also help us with other downstream imaging and procedures that we can do in our centers.
Brian Tanquilut
Okay, that makes a lot of sense. Then I guess shifting gears, Howard, you obviously entered the Arizona market from the JV with Dignity. How should we be thinking about your expansion plans there? You expanded the credit facility, so should we be thinking that you’d be acquiring more in that market specifically, or are you open to further expansion from a geographic footprint perspective?
Dr. Howard Berger
I think we’ll be doing both, Brian. We already have designs on at least two new imaging facilities that’ll be on campuses of two of the largest Dignity Health systems. We are in conversation with other medical groups that are closely aligned with Dignity about helping to manage their imaging in a more effective way and driving business into the joint venture. We believe that there are acquisition opportunities that are available to us to expand our footprint and have similar kind of opportunities and results like we’ve experienced in other markets that we’ve entered. The best example of that being when we entered the New York metropolitan marketplace, believe it or not, it’s eight years ago at this point, we have become the largest operator of independent freestanding imaging facilities, and a lot of our growth opportunities and improved performance are based on those kind of metrics.
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Phoenix, which has, I think, a population of well over five million people, has some very attractive and unique situations for us. As I’ve mentioned in prior earnings calls and conferences, the opportunity for us to enter new markets will follow the pattern that we’ve demonstrated over the last couple of years of expanding it with joint venture partners with large health systems. I think the investment and involvement in Phoenix very much fits that profile.
Brian Tanquilut
Got it. Mark, last question for me. How are you thinking about the sustainability of the margins, because they were obviously very strong within the quarter? I know you’ve laid out your cost initiatives, but just your quick thoughts on that. Thank you.
Mark Stolper
Sure. With the initiatives that we completed in 2020 in evaluating, really, every aspect of how we do business, both at the regional levels, the center levels, as well as in all of the corporate support functions, we did pull significant amounts of cost out of our cost structure that will certainly impact margins positively here in 2021. Having over a 16% margin in the fourth quarter was a significant improvement, not only over the prior year but over prior quarters.
We expect, if you look at our guidance and look at the implied margin there, we expect to have somewhere around 15% blended margins for 2021. Why that’s a little bit lower than the fourth quarter here is there is some seasonality, as you’re well aware, Brian, in our business, with respect to first quarter. There’s always some seasonality related to weather conditions in the Northeast, as well as the issue with deductibles.
Having said that, we’ve had a robust start, other than some of these weather conditions here, in the first quarter of 2021. We do expect the margin enhancement here in 2021, I would even say versus 2019, because 2020 is not a good year to compare to because of COVID, where our margin was incredibly depressed.
I think there’s some real good opportunity for margin enhancement. Also, as we adopt AI technology, particularly around mammography, and then develop or license other AI technologies for other modalities into the future, we have the ability to make our radiologists more productive, potentially use fewer radiologists and lower the cost significantly of delivering the professional interpretation of our scans. That could be a real game changer into the future with respect to our margins.
Brian Tanquilut
Awesome. Thanks, guys.
Mark Stolper
Thanks, Brian.
Operator
We’ll go to our next question, from Mitra Ramgopal with Sidoti.
Mitra Ramgopal
Yes, good morning and thanks for taking the questions.
I just wanted to follow-up on the AI comments earlier. Obviously, it seems like you’re getting some nice traction on the mammography side and with the FDA approval likely and the upgrade to 3D. I was just wondering if the AI platform could be expanded to areas beyond mammography for you?
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Dr. Howard Berger
Good morning, Mitra.
Yes. There’s four core areas that we think, as an outpatient provider, that primarily, as we see a shift of population health, will be beneficial not just for the Company, but hopefully for the populace.
If you look at the various cancers that are most significant in volume, you deal with breast cancer, prostate cancer, lung cancer and colon cancer. Those account for about 80% of all the cancers. Each of those have screening tools that exist right now that, I believe, can be demonstrably improved through application of artificial intelligence. We’ve already demonstrated some of that and have indeed put our capital to work as regards to mammography. Once we get some good traction on that, we can and are already looking at some initiatives for at least prostate, along with colon and lung cancers down the road.
We think if anything, that can serve as a great tool for putting some definition behind what population health means. We believe that diagnostic imaging will be at the forefront of that, and that tools in these areas can have a very prominent effect on both diagnosing earlier as well as, and obviously leading to, lower costs and reduced mortality. We think it’s incumbent upon us as the leader in this industry, as well as just generally what’s good for the population, to focus our attention on these tools and provide programs for the health insurers as well as employers to give some real meaning and definition to population health.
Mitra Ramgopal
Okay, thanks, that’s very helpful.
Howard, I know you had talked earlier about the increasing preference of payors to shift some of these procedures to the outpatient setting. I’m just wondering if that’s also leading now to increased conversations or opportunities as it relates to more JVs.
Dr. Howard Berger
I think it is. These are slow to develop and take a long time. The health systems are large; to get their attention as well as deal with other local and geographic issues takes a lot of work. But we think that the marketplace is ready for this. I think in a very specific way, COVID has helped focus people’s attention on that, given that the general healthcare consumer is more reluctant to go into a hospital or health system today if they have the availability of comparable or even better access to outpatient imaging. I think more and more of the hospital systems are recognizing the need to make this shift, in addition to issues related to reimbursement, we can focus on a more strategic relationship and an approach to population health. I think we’re getting a lot of good conversation surrounding these opportunities.
Again, I think RadNet is unique in terms of the number of centers it has at our own joint ventures. As we’ve mentioned before, over 25% of our centers now are in joint ventures and we look eagerly to expand that number as we go forward, given that, I think, the joint venture arrangement affords a lot of opportunity for both long-term stability and growth initiatives with our healthcare systems. I’d be loathe if I didn’t mention here that during the COVID period one of the additional benefits from our joint ventures was that all of our health systems reached out to us and afforded RadNet employees the opportunities to get their vaccinations for COVID as part of the frontline essential healthcare workers. While that is not necessarily an easily monetized benefit, it was a significant benefit to the RadNet employees that gave them the comfort and the confidence to continue to provide these services, which clearly has now been identified as an essential service.
I think these initiatives and the benefits that they provide were more demonstrated during the COVID period than perhaps at any other time in our history.
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Mitra Ramgopal
Okay. Thanks for the additional color.
Then quickly on the capitation business, if you can offer in terms of—what are you thinking about that? Obviously, despite the pandemic, you saw a really nice growth there, and I’m just wondering if we should continue to expect elevated top line in that piece of the business going forward, near term?
Dr. Howard Berger
Yes, I believe that will be the case, Mitra. Particularly out here in California where we had the greatest penetration in capitation, I think more and more of our medical groups and related insurers are looking at not just capitation, but potentially new risk-sharing models that, given our geographic access and the breadth of services we offer, are exciting propositions. Hopefully you’ll be hearing more about that later this year, with initiatives that may not be conventional in terms of what we have traditionally been doing in the way of capitation, but expanding the potential reimbursement models that may move a little bit further away from the traditional fee-for-service. Again, I think RadNet’s in a unique position to do those, for a lot of the reasons that we’ve already talked about.
Mark Stolper
Yes. I’ll add that, during 2020, our capitation business was really a shining star. Unlike the other books of business that we had that were significantly impacted from COVID-19, i.e., the fee-for-service business, our capitated revenue was up over $14 million from 2019. That was really because the enrolment in these HMO programs was stable and even slightly increased in 2020, even despite COVID-19. Many of the workforce that lost their jobs during 2020, many of them were put on furlough but still had their health benefits, so the enrolment within HMO, as you’re aware, in California, most of these HMO patients are then managed by medical groups through these capitated contracts and we sub-capitate from these medical groups.
Our revenue dollars are associated with the number of enrollees in these programs, and because the number of enrollees was stable to slightly growing in 2020, our revenue was up, not only because of the enrollees, but also because of some price increases that we have built into many of these contracts on an annual basis.
Then furthermore, the incident of imaging, meaning the use of imaging under these contracts, the utilization was significantly lower in 2020 so that the profitability of our capitated contracts in 2020 was drastically up relative to prior years. It’s really a great book of business, one that we’re looking to expand. We continually have conversations with new medical groups here in California, as well as taking on and assuming the financial responsibility for more lives that might be part of other medical groups that we do contract with here in California that have other geographies that we could potentially capitate for.
It’s a business we like; we have no costs of billing and collecting, we have very little patient bad debt, and we get paid in the month that we render the services so that we have no cost of carrying receivables. It’s really a unique part of our business.
Mitra Ramgopal
Okay, no, that’s great. Then quickly, Mark, I don’t know if you can help, but what’s a good tax rate to use for 2021?
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Mark Stolper
Yes, 2020 was jumping all over, there were lots of ins and outs related to transactions, so it’s really hard to tell from 2020 what our effective tax rate is. If you assume, for your modeling purposes, a federal tax rate of about 21% and a blended state tax rate of about 5%, so you get into the 26% to 27%, that’s a good proxy for our tax provision. As you’re probably aware, we’re still burning off a pretty substantial net operating loss carry-forward, so at least the federal part of that tax provision isn’t paid in cash, but it still hits our income statement with respect to our earnings per share.
Mitra Ramgopal
Okay, thanks again for taking the questions.
Mark Stolper
You’re welcome. Thanks, Mitra.
Operator
We’ll go to our next question, from John Ransom with Raymond James.
Jonathan Ransom
I want to congratulate you guys on having the shortest prepared remarks of any Company I cover, so you get the succinct award.
Mark Stolper
Wait, say that again, John, we’re having a little trouble hearing you.
Jonathan Ransom
Oh. Sorry, is that better?
Mark Stolper
Yes, that’s better. Yes.
Jonathan Ransom
That’s better. Yes, sorry, that’s better. I just wanted to give you guys the award for being the most succinct management team I cover in terms of your prepared remarks, so congratulations.
Mark Stolper
Is that facetious or did we put you to sleep?
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Jonathan Ransom
No, no, it’s actually a compliment, you guys are succinct. It’s a sincere compliment. Just a few things, if we remember right, so DaVita Medical Group sold to United, and that’s a big, as you know, IPO group in California. Has having those practices in the hands of United, which is probably more aggressive with rationalism (inaudible)—has that been part of the better pricing that you’ve seen in California, on the IPA contracts, or is that just a coincidence?
Dr. Howard Berger
I don’t think, at this point, John, that it has translated into any additional benefit or opportunities for us. The marketplace here in California is not so much controlled by United corporate, but really, here, the local Management and Officers here in California that we’ve known for quite some time. Even without United entering the picture, I think we had ongoing discussions with the various groups that have now been aggregated under United into opportunities to further expand capitation. Maybe at some point there might be more of a national opportunity that we would look at with United that could be—not only for capitation, but other fee-for-service businesses, particularly in terms of mammography, that could be exciting for us.
Jonathan Ransom
Okay. You guys obviously came through the awfulness with flying colors, and this is—I’m trying to find a glass half empty question, but don’t take it the wrong way. But being so exposed to California and New York, that were kind of extreme examples of lockdown states, did that cause you to maybe rethink some of your geographic concentration, or are you thinking, “Gosh, it couldn’t get worse than this, and look how well we did”?
Dr. Howard Berger
I get often asked the question, John, about why we’re only in five or six states, now actually a seventh with Arizona. But again, I make the analogy, for those of you who are old enough or who have read widely about history, that when they caught the famous bank robber William Sutton, they asked him why he robbed banks and he said, “Because that’s where the money is.”
To some extent I think our strategy follows along with that. While we can suffer through situations like we did here through the pandemic and the lockdowns, the fact of the matter is that, if you combine the population of the United States that is in New York and New Jersey and in California, we’re probably talking, I’m going to say, about a third of the population or somewhere in that area. I think we have to take the good with the bad. There’s seasonal issues that we get confronted with like we were in February with some inclement weather, but it’s where the people live, it’s where the lives are. We’re very much a volume-driven business and my preference would be to stay in those markets where we can become the major outpatient player and benefit from large volumes and access to our centers, which gives us some very unique contracting capabilities.
Jonathan Ransom
Fine, okay, fair enough. Then lastly, can you give an update, if any—we don’t see a lot of portfolios trade in this business, but where do you think the private equity/competitive strategic bid is for, let’s say, a substantial plateful (phon) of assets versus where RadNet would be? I mean, if the market can have a two to three times higher than you’re willing to pay for, say, some other KPU (phon) with a nice market and something like $20 million of EBITDA, are you going to be consistently outbid in those situations, just given your history?
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Dr. Howard Berger
I think we’re aware of all the transactions that go on in the imaging space, and we see the size of these transactions, not so much in terms of dollar amount, but in terms of the multiples that people are paying. I think we look at each one of these in a very specific way. I think if a set of assets were to come up that are very strategic for us, it would be worth taking a close look at those, even if they tended to be at higher multiples than we may have paid in the past for. I think while that aggressive PD (phon) approach for acquiring some of these imaging assets has been a bit of a head-scratcher for us, nonetheless, I think it helps define how valuable the RadNet strategy is, that should have some of that benefit nevertheless in terms of our attractiveness to the stock market and shareholders.
But I would say that we’re more optimistic about how we can continue to leverage our facilities, and that the consolidation—I know I’m rambling here a little bit, so I apologize, John. But consolidation is a major force inside of healthcare. I think there’s no better poster child for that than the imaging, particularly the outpatient imaging space. The leverage that we have with our platform gives us enormous opportunities, many of which that we’re working on this year to further create efficiencies and streamline our business. Scaling up under the right circumstances is certainly something that we would be very serious about.
Jonathan Ransom
Sorry, one more I just forgot to ask you. In your hospital JVs, I mean, your legacy was, gosh, unaffiliated freestanding centers are one-third, say, one-half the price of what it would cost to get it done in a hospital. Of course, you pointed rightly, all the payors that are now steering people away from hospital settings for routine scans. Will you do a joint venture with a hospital? I’m assuming there is some contracting work. Let’s say the rate is, just make up a number, $1,500 for an MRI at the hospital and it’s $400 at RadNet. Is the hospital affiliation price $600 or is it a little better, a lot better, or how does that work? Considering, obviously, they have more leverage with the payors that, say, RadNet would, in a given market.
Dr. Howard Berger
It varies from market to market. In some markets, the relationship with the health system has in fact allowed us to get better rates than we would’ve on a standalone basis. But I think the primary benefit of the relationship with the health systems is not so much for rate lift. It’s more having a seat at the table with the relationship of the health system on a shoulder-to-shoulder basis, and where the health system can actually drive volume into the outpatient centers, and that happens in two ways.
Number one, when the health insurers see that we are joint ventured with a health system, they know that there is less of a necessity for them, meaning the health insurers, on the pricing side of this, and that the health systems are shoulder-to-shoulder with us and helping drive the business away from the hospitals into the outpatient centers.
The other thing is that all of our health systems, bar none, are in the business of acquisition of practices, physician practices. Once they’re under the health system, it’s easier for them, particularly with the access that they get afforded with the RadNet locations, to direct that business into the outpatient marketplace. Both of those benefits have been, I think, a very important part of our strategy with health system joint ventures and have created benefits that we would not have enjoyed without them.
Jonathan Ransom
That’s it for me, thanks so much.
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Dr. Howard Berger
All right, thanks, John. Stay safe.
Jonathan Ransom
Yes sir.
Operator
There are no further questions at this time.
Dr. Howard Berger
Again, I would like to take this opportunity to thank all of our shareholders for their continued support, and the employees of RadNet for their dedication and hard work. Our Management will continue its endeavor to be a market leader that provides great services with an appropriate return on investment for all stakeholders. Thank you for your time today, and I look forward to our next call. Stay safe and healthy.
Operator
Thank you for your participation.
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