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Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2018	Jun. 30, 2017
Cash flows from operating activities:
Net income	$ 142,840	$ 118,389
Adjustments to reconcile net income to net cash from operating activities:
Depreciation and amortization	52,681	51,349
Amortization of premiums, discounts and issuance costs	2,212	2,740
Stock-based compensation expense	20,399	14,781
Deferred income taxes	(21,211)	18,454
Other	(2,148)	(3,407)
Changes in assets and liabilities:
Accounts receivable	(23,998)	18,361
Prepaid expenses and other current assets	(1,178)	(666)
Other long term assets	(317)	(3,425)
Accounts payable and accrued expenses	(100,442)	(87,862)
Income taxes payable	(39,909)	(15,900)
Payments of contingent consideration liabilities	(65)	(299)
Long-term professional liabilities	(5,863)	1,016
Other liabilities	(1,397)	2,282
Net cash provided from operating activities	21,604	115,813
Cash flows from investing activities:
Acquisition payments, net of cash acquired	(25,575)	(113,746)
Purchases of investments	(15,884)	(15,324)
Proceeds from maturities of investments	5,995	7,290
Purchases of property and equipment	(26,274)	(21,909)
Proceeds from sale of controlling interest in assets	22,764
Other		3,868
Net cash used in investing activities	(38,974)	(139,821)
Cash flows from financing activities:
Borrowings on credit agreement	821,500	821,000
Payments on credit agreement	(782,500)	(754,000)
Payments of contingent consideration liabilities	(367)	(1,961)
Payments on capital lease obligations	(636)	(998)
Proceeds from issuance of common stock	9,389	13,990
Repurchases of common stock	(52,160)	(70,192)
Contribution from noncontrolling interests		894
Net cash (used in) provided from financing activities	(4,774)	8,733
Net decrease in cash and cash equivalents	(22,144)	(15,275)
Cash, cash equivalents and restricted cash at beginning of period	80,200	55,698
Cash, cash equivalents and restricted cash at end of period	$ 58,056	$ 40,423

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The cash inflow associated with the sale, maturity and collection of all investments such as debt, security and so forth during the period.

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Aggregate cash proceeds received from a combination of transactions in which noncurrent assets are sold, which may include the sale of a business, an investment in an affiliate (including an equity method investee), property, plant and equipment and intangible assets. Excludes sales of trading, available-for-sale, and held-to-maturity securities.

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Amount of cash outflow for payment of an obligation from a lender, including but not limited to, letter of credit, standby letter of credit and revolving credit arrangements.

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