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CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($)
$ in Thousands
 9 Months Ended
Sep. 30, 2021
Sep. 30, 2020
CASH FLOWS FROM OPERATING ACTIVITIES    
Net (loss) income $ 43,005 $ (12,734)
Adjustments to reconcile net income (loss) to net cash provided by operating activities:    
Depreciation and amortization 71,272 64,536
Amortization of operating lease right-of-use assets 55,880 50,769
Equity in earnings of joint ventures, net of dividends (8,259) 530
Amortization of deferred financing costs and loan discount 2,608 3,266
(Gain) loss on sale and disposal of equipment and other (279) 543
Loss on extinguishment of debt 1,496 0
Amortization of cash flow hedge, net of taxes 2,765 2,204
Non-cash change in fair value of interest rate hedge (14,149) 4,523
Stock-based compensation 21,566 10,144
Change in fair value of contingent consideration 891 (145)
Changes in operating assets and liabilities, net of assets acquired and liabilities assumed in purchase transactions:    
Accounts receivable (23,237) 17,380
Other current assets 3,358 13,522
Other assets (4,998) (700)
Deferred taxes 10,124 (7,640)
Operating lease liability (55,035) (43,351)
Deferred revenue (19,438) 44,530
Accounts payable, accrued expenses and other 12,725 22,966
Net cash provided by operating activities 100,295 170,343
CASH FLOWS FROM INVESTING ACTIVITIES    
Purchase of imaging facilities and other acquisitions (70,108) (10,125)
Purchase of property and equipment (88,478) (77,303)
Proceeds from sale of equipment 521 779
Equity contributions in existing and purchase of interest in joint ventures (1,441) (1,631)
Net cash used in investing activities (159,506) (88,280)
CASH FLOWS FROM FINANCING ACTIVITIES    
Principal payments on notes and leases payable (3,302) (2,704)
Payments on term loan debt (616,217) (33,472)
Additional deferred finance costs on revolving loan amendment 0 (741)
Proceeds from debt refinancing, net of issuing costs 716,369 0
Proceeds from sale of economic interest in majority owned subsidiary, net of taxes 11,602 0
Distributions paid to noncontrolling interests 0 (601)
Proceeds from paycheck protection program loans 0 4,023
Proceeds from revolving credit facility 128,300 250,900
Payments on revolving credit facility (128,300) (250,900)
Proceeds from issuance of common stock upon exercise of options 26 0
Net cash provided by (used in) financing activities 108,478 (33,495)
EFFECT OF EXCHANGE RATE CHANGES ON CASH (32) 6
NET INCREASE IN CASH AND CASH EQUIVALENTS 49,235 48,574
CASH AND CASH EQUIVALENTS, beginning of period 102,018 40,165
CASH AND CASH EQUIVALENTS, end of period 151,253 88,739
SUPPLEMENTAL DISCLOSURE OF CASH FLOW INFORMATION    
Cash paid during the period for interest 21,408 31,210
Cash paid during the period for income taxes $ 1,913 $ 5,036