OREANDA-NEWS. August 24, 2016. 21st Century Oncology Holdings, Inc. (21C or the Company), the leading global, physician-led provider of integrated cancer care services, announced today its financial results for the fourth quarter and full year ended December 31, 2015 and announced the completion of the restatement of financial results for the years ended December 31, 2012, 2013 and 2014, the unaudited condensed consolidated financial statements as of and for each of the interim periods within the years ended December 31, 2012, 2013 and 2014 and for the interim periods ended March 31, June 30, and September 30, 2015.

Fourth Quarter 2015 and Full Year 2015 Results

Total revenues for the fourth quarter of 2015 were \\$263.1 million, down 1.3% as compared to total revenues of \\$266.6 million in the same quarter of 2014. Revenue growth from acquired and new operations was offset by approximately \\$3.3 million relative to the effect of simulation code bundling. Net income for the fourth quarter was \\$7.0 million versus a net loss of \\$28.3 million for the same period in the prior year. The improvement in net income resulted from a fair market value adjustment for embedded derivatives.
Pro-forma adjusted EBITDA in the fourth quarter of 2015 was \\$38.8 million, or 14.7% of total pro-forma revenues, as compared to \\$30.7 million, or 11.5% of total pro-forma revenues, in the fourth quarter of 2014. The primary contributor to the pro-forma adjusted EBITDA improvement was a \\$6.2 million reduction in compensation expense and \\$5.1 million improvement in bad debt offset by the \\$3.5 million decrease in total revenues.

Total radiation oncology treatments per day during the fourth quarter increased 1.8% over the same period in the prior year and same market radiation oncology treatments per day for the quarter declined 2.0% compared to the same period in the prior year. As previously disclosed, the Company has experienced a decrease in treatments per case for breast and lung diagnoses, as a result of technological innovations.

Net patient service revenue per radiation oncology treatment declined 1.1% in the fourth quarter of 2015 relative to the same period last year. This was largely driven by the simulation code for IMRT cases being bundled with the planning code. The impact of the bundling code change in the fourth quarter of 2015 was \\$3.3 million.    

Total revenues for full year 2015 were \\$1,079.2 million as compared to \\$1,018.2 million in 2014. The net loss for 2015 was \\$126.8 million as compared to a net loss of \\$352.7 million in 2014. The improvement in the net loss was due to recording a \\$229.5 million impairment loss in 2014.

Total pro-forma revenues for full year 2015 were \\$1,080.3 million, an increase of 5.2% year over year. Pro-forma adjusted EBITDA was \\$159.1 million for 2015, an increase of 12.9% as compared to \\$141.0 million in 2014. The increase in pro-forma adjusted EBITDA was primarily driven by a \\$53.3 million increase in total pro-forma revenues offset by a \\$34.5 million increase in salaries and benefits. Pro-forma adjusted EBITDA margin for 2015 increased 1.0% as compared to 2014.

Total radiation oncology treatments per day for 2015 increased 4.2% year over year, reflecting the impact of strategic acquisitions made earlier in 2015. Same market radiation oncology treatments per day decreased 1.6% year over year due to the reduction in treatments per case, particularly breast and lung diagnoses. For 2015, net patient service revenue per radiation oncology treatment declined 1.9% and same market net patient service revenue per radiation oncology treatment declined 0.6%, each as compared to 2014, due to the impact of the simulation code change.

Dr. Daniel Dosoretz, Founder, President and Chief Executive Officer, commented, We finished the fourth quarter and full year 2015 with positive momentum in our business. We are pleased with our performance against the backdrop of headwinds from simulation code bundling and a reduction in treatments per day due to advances in hypo-fractionated external beam radiotherapy and stereotactic radiosurgery.

Restatement of Financial Results

On March 24, 2016, the Board of Directors of 21C (the Board) determined that the financial statements for all interim periods and years ended December 31, 2012, 2013 and 2014 as well as the first three periods of 2015, should be restated. The restatement was primarily related to revenue recognition matters, accounts receivable reconciliation issues and income and non-income tax matters with respect to operations in Latin America as well as to give effect to refunds and payment adjustments that the Company recorded in connection with electronic health records incentive payments received under the Health Information Technology for Economic and Clinical Health Act (HITECH).

Management remains committed to remediating the material weaknesses identified in its internal controls over financial reporting as well as other areas of risk that led to the restatement of financial results. Several specific remediation initiatives have already been implemented and we believe on-going efforts will continue to improve the effectiveness of our internal control environment.

Robert L. Rosner, Chairman of the Board of Directors and Chair of The Executive Committee, said, While the last nine months have included some unique challenges for 21C, the Board and management believe we will emerge from this process a stronger and more focused organization. After a diligent and comprehensive review, we have identified areas in our financial and compliance procedures in need of remediation and have constructed a robust plan to address those issues. The Company is thoroughly committed to executing that plan and maintaining the highest levels of compliance going forward. The importance of these initiatives has been and will continue to be communicated to every 21C employee.

Debt Agreements

On August 15, 2016, 21C entered into amendment and waiver agreements with certain creditors. The agreements, among other things, waive the event of default for failure to file financial statements for the year ended December 31, 2015 until September 10, 2016, and waive the event of default for failure to file financial statements for the quarters ended March 31, and June 30, 2016 until September 30, 2016. The amendment agreements require 21C to complete three separate capital events to receive the lessor of, 1) net cash proceeds from the issuance or sale of 21Cs capital stock or from other equity investments and/or sales of assets for a total aggregate amount of \\$125.0 million, or 2) an amount such that following the third capital event 21Cs cash and cash equivalents plus unused revolving loan commitments equals at least \\$120.0 million and 21Cs consolidated leverage ratio is not greater than 6.4 to 1.0. The amendment agreements also require the Company to maintain minimum liquidity of \\$40.0 million. 


The United States Congress unanimously passed the Patient Access and Medicare Protection Act (S. 2425) which freezes radiation oncology freestanding payment rates for treatment delivery and image guidance codes in 2017 and 2018 at levels set for 2016. The bill was signed into law by President Obama on December 28, 2015. In 2019, CMS will transition to a new episodic alternative payment model. The legislation requires the Secretary of Health and Human Services to submit to Congress a report on the development of an episodic alternative payment model for reimbursement under the Medicare program within 18 months.

Dr. Dosoretz, concluded, We applaud Congress and President Obama for their dedication to working together with the industry to advance payment reform and achieve payment predictability while ensuring patient access to quality cancer care. This is an exceptional example of how bipartisan collaboration can deliver a meaningful benefit to patients in need of the most advanced technologies available in radiation therapy. We look forward to working with policymakers over the next few years on developing an alternative payment model which will provide continued access to sophisticated radiation therapy treatment for patients for years to come.

About 21st Century Oncology Holdings, Inc.

21st Century Oncology Holdings, Inc. is the largest global, physician led provider of integrated cancer care services. The Company offers a comprehensive range of cancer treatment services, focused on delivering academic quality, cost-effective patient care in personal and convenient settings. As of December 31, 2015, the Company operated 181 treatment centers, including 145 centers located in 17 U.S. states and 36 centers located in seven countries in Latin America.

Forward-Looking Statements
This press release contains forward-looking statements within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Act of 1934, as amended. Statements preceded by, followed by or that otherwise include the words believes, expects, anticipates, intends, projects, estimates, plans, may increase, forecast and similar expressions or future or conditional verbs such as will, should, would, may and could are generally forward-looking in nature and not historical facts. Forward-looking statements are based on managements current expectations or beliefs about the Companys future plans, expectations and objectives. These forward-looking statements are not historical facts and are subject to risks and uncertainties that could cause the actual results to differ materially from those projected in these forward-looking statements including, but not limited to reductions in Medicare reimbursement, healthcare reform, state and federal investigations, claims and litigation matters, decreases in payments by managed care organizations and other commercial payers  and other risk factors that may be described from time to time in the Companys filings with the Securities and Exchange Commission. Readers of this release are cautioned not to place undue reliance on forward-looking statements contained herein, which speak only as of the date stated, or if no date is stated, as of the date of this press release. The Company undertakes no obligation to publicly update or revise the forward-looking statements contained herein to reflect changed events or circumstances after the date of this release, unless required by law.

 (in thousands, except share amounts)  
   December 31,   December 31,  
   2015   2014  
Current assets:     
Cash and cash equivalents \\$65,211  \\$99,082  
Restricted cash  195   7,283  
Marketable securities  1,078   -  
Accounts receivable, net  122,355   121,799  
Prepaid expenses  7,822   8,728  
Inventories  3,918   3,162  
Income taxes receivable  4,966   4,432  
Deferred income taxes  -   1,771  
Other    15,732     8,291  
Total current assets  221,277   254,548  
Equity investments in joint ventures  1,214   1,646  
Property and equipment, net  238,585   269,570  
Real estate subject to finance obligation  12,631   22,552  
Goodwill  498,680   476,559  
Intangible assets, net  70,115   81,385  
Embedded derivative & other financial instrument features of     
Series A convertible redeemable preferred stock  17,883   -  
Other assets  65,971   47,184  
Deferred income taxes    1,888     -   
Total assets \\$  1,128,244  \\$  1,153,444  
Current liabilities:     
Accounts payable \\$59,888  \\$62,507  
Accrued expenses  111,653   88,604  
Income taxes payable  2,501   1,326  
Current portion of long-term debt  1,048,260   26,350  
Current portion of finance obligation  283   433  
Other current liabilities    14,265     19,512  
Total current liabilities  1,236,850   198,732  
Long-term debt, less current portion  49,233   940,771  
Finance obligation, less current portion  13,318   23,610  
Embedded derivative & other financial instrument features of     
Series A convertible redeemable preferred stock  19,911   15,843  
Other long-term liabilities  70,928   71,985  
Deferred income taxes    3,887     4,834  
Total liabilities  1,394,127   1,255,775  
Series A convertible redeemable preferred stock, \\$0.001 par value, \\$1,000 stated    
value, 3,500,000 authorized, 385,000 issued and outstanding     
at December 31, 2015 and 2014  389,514   319,997  
Noncontrolling interests - redeemable  19,233   15,273  
Commitments and Contingencies     
Common stock, \\$0.01 par value, 1,000,000 shares authorized     
1,059 and 1,028 shares issued and outstanding at December 31, 2015     
and December 31, 2014, respectively  -   -  
Additional paid-in capital  579,920   634,930  
Retained deficit  (1,226,298)  (1,091,449) 
Accumulated other comprehensive loss, net of tax    (54,574)    (36,920) 
Total 21st Century Oncology Holdings, Inc. shareholder's deficit  (700,952)  (493,439) 
Noncontrolling interests - nonredeemable    26,322     55,838  
Total deficit    (674,630)    (437,601) 
Total liabilities and deficit \\$  1,128,244  \\$  1,153,444  
 (in thousands)
  Three Months Ended   Years Ended
  December 31,   December 31,
  2015  2014   2015  2014 
Net patient service revenue\\$244,249 \\$245,962  \\$1,000,126 \\$938,488 
Management fees 14,458  16,797   59,719  67,012 
Other revenue   4,417    3,828     19,382    12,682 
Total revenues 263,124  266,587   1,079,227  1,018,182 
Salaries and benefits 142,498  148,714   579,492  545,025 
Medical supplies 25,091  26,360   98,654  97,367 
Facility rent expenses 17,843  15,582   68,664  63,111 
Other operating expenses 17,753  15,749   64,750  61,784 
General and administrative expenses 33,450  33,550   174,791  135,819 
Depreciation and amortization 22,265  21,397   89,040  86,583 
Provision for doubtful accounts 843  5,908   14,526  19,253 
Interest expense, net 24,239  25,620   98,075  113,279 
(Gain) loss on the sale/disposal of property and equipment (548) (137)  (751) 119 
Electronic health records incentive income (39) (93)  (39) (93)
Gain on BP settlement (1,699) -   (7,495) - 
Gain on insurance recoveries (291) -   (1,655) - 
Impairment loss -  -   -  229,526 
Early extinguishment of debt -  -   37,390  8,558 
Equity initial public offering expenses -  -   -  4,905 
Loss on sale leaseback transaction -  -   -  135 
Fair value adjustment of earn-out liabilities (1,293) 1,015   (1,811) 1,627 
Fair value adjustment of embedded derivatives     
and other financial instruments (26,841) 837   (17,919) 837 
Loss on foreign currency transactions 367  384   904  678 
Gain on foreign currency derivative contracts   -    -     -    (4)
Total expenses   253,638    294,886     1,196,616    1,368,509 
Income (loss) before income taxes and equity interest in net     
income (loss) of joint ventures 9,486  (28,299)  (117,389) (350,327)
Income tax expense   2,456    78     9,654    2,319 
Net income (loss) before equity interest in net income (loss)     
of joint ventures 7,030  (28,377)  (127,043) (352,646)
Equity interest in net (loss) income of joint ventures, net of tax   (1)   111     201    (50)
Net income (loss) 7,029  (28,266)  (126,842) (352,696)
Net  income attributable to noncontrolling     
interests- redeemable and non-redeemable   (1,397)   (75)    (8,007)   (4,595)
Net income (loss) attributable to 21st Century     
Oncology Holdings, Inc. shareholder 5,632  (28,341)  (134,849) (357,291)
Other comprehensive loss, net of tax:     
Net periodic benefit cost of pension plan (366) (91)  (366) (91)
Unrealized loss on foreign currency translation   (13,269)   (552)    (19,683)   (12,098)
Other comprehensive loss   (13,635)   (643)    (20,049)   (12,189)
Comprehensive loss   (6,606)   (28,909)    (146,891)   (364,885)
Comprehensive (income) loss attributable to noncontrolling             
interests- redeemable and non-redeemable   (13)   59     (5,612)   (3,224)
Comprehensive loss attributable to 21st Century             
Oncology Holdings, Inc. shareholder\\$  (6,619)\\$  (28,850) \\$  (152,503)\\$  (368,109)
(in thousands) 
      Years Ended 
      December 31, 
       2015   2014  
Cash flows from operating activities         
Net loss  \\$(126,842) \\$(352,696) 
Adjustments to reconcile net loss to net cash provided by (used in)     
 operating activities:     
 Depreciation and amortization  89,040   86,583  
 Deferred rent expense  676   774  
 Deferred income taxes  (278)  (783) 
 Stock-based compensation  8   106  
 Provision for doubtful accounts  14,526   19,253  
 (Gain) loss on the sale/disposal of property and equipment  (751)  119  
 Gain on insurance recoveries  (291)  -  
 Loss on sale leaseback transaction  -   135  
 Gain on the sale of marketable securities  (3)  -  
 Impairment loss  -   229,526  
 Early extinguishment of debt  37,390   8,558  
 Equity initial public offering expenses  -   4,905  
 Loss on foreign currency transactions  450   348  
 Gain on foreign currency derivative contracts  -   (4) 
 Fair value adjustment of earn-out liabilities  (1,811)  1,627  
 Fair value adjustment of embedded derivatives and other financial instruments  (17,919)  837  
 Amortization of debt discount  1,706   2,483  
 Amortization of loan costs  4,708   6,277  
 Paid in kind interest on notes payable  757   -  
 Equity interest in net (earnings) loss of joint ventures  (201)  50  
 Distribution received from unconsolidated joint ventures  106   221  
 Pension plan contributions  (1,756)  (1,587) 
 Changes in operating assets and liabilities:     
    Accounts receivable and other current assets  (31,636)  (35,108) 
    Income taxes payable  972   (3,453) 
    Inventories  (1,680)  8  
    Prepaid expenses and other assets  5,331   3,677  
    Accounts payable  500   514  
    Accrued deferred compensation  1,444   1,522  
    Accrued expenses / other liabilities  33,998   11,321  
Net cash provided by (used in) operating activities  8,444   (14,787) 
Cash flows from investing activities     
Purchase of property and equipment  (40,936)  (56,659) 
Acquisition of medical practices  (34,205)  (50,245) 
Restricted cash associated with medical practice acquisitions  7,088   (3,181) 
Proceeds from the sale of property and equipment  1,680   96  
Proceeds from insurance recoveries  291   -  
Purchase of marketable securities  (5,687)  -  
Sale of marketable securities  4,612   -  
Repayments from (loans to) employees  186   (1,226) 
Contribution of capital to joint venture entities  -   (620) 
Distribution received from joint venture entities  496   -  
Proceeds from foreign currency derivative contracts  -   26  
Company owned life insurance policies  (1,302)  (1,265) 
Change in other assets and other liabilities  (340)  (765) 
Net cash used in investing activities  (68,117)  (113,839) 
Cash flows from financing activities     
Proceeds from issuance of debt  1,047,871   169,845  
Principal repayments of debt  (944,437)  (268,377) 
Repayments of finance obligation  (219)  (278) 
Proceeds from issuance of Series A convertible redeemable preferred stock  -   325,000  
Payments of issue costs related to the issuance of preferred stock  -   (6,137) 
Proceeds from issuance of noncontrolling interest  743   1,250  
Proceeds from noncontrolling interest holders - redeemable and non-redeemable  3,230   259  
Purchase of noncontrolling interest - non-redeemable  (16,233)  -  
Cash distributions to noncontrolling interest holders - redeemable     
 and non-redeemable  (5,174)  (3,599) 
Payments for contingent considerations  (8,537)  -  
Payments of costs for equity securities offering  -   (4,905) 
Payment of call premium on long-term debt  (24,877)  -  
Payments of loan costs  (26,481)  (2,436) 
Net cash provided by financing activities  25,886   210,622  
Effect of exchange rate changes on cash and cash equivalents  (84)  (42) 
Net (decrease) increase in cash and cash equivalents  (33,871)  81,954  
Cash and cash equivalents, beginning of period  99,082   17,128  
Cash and cash equivalents, end of period \\$65,211  \\$99,082  
Supplemental disclosure of noncash investing and financing activities     
Interest paid \\$99,253  \\$101,149  
Income taxes paid \\$11,467  \\$7,585  
Finance obligation related to real estate projects \\$1,898  \\$7,790  
Derecognition of finance obligation related to real estate projects \\$12,215  \\$4,119  
Capital lease obligations related to the purchase of equipment \\$2,408  \\$17,625  
Medical equipment and service contract component related to the acquisition     
 of medical equipment through accounts payable \\$2,865  \\$3,049  
Noncash vendor credits \\$1,500  \\$-  
Issuance of notes payable relating to the acquisition of medical practices \\$5,522  \\$2,000  
Liability relating to the escrow debt and purchase price of medical practices \\$-  \\$2,970  
Capital lease obligations related to the acquisition of medical practices \\$3,166  \\$47,796  
Change in earn-out accruals \\$13,572  \\$11,052  
Amounts payable to sellers in the purchase of a medical practice \\$150  \\$249  
Noncash dividend declared to noncontrolling interest \\$97  \\$194  
Noncash issuance of noncontrolling interest \\$56  \\$-  
Step up in basis of joint venture interests \\$688  \\$-  
Issuance of notes payable relating to the purchase of SFRO noncontrolling interest\\$14,560  \\$-  
Issuance of equity units relating to the purchase of SFRO noncontrolling interest \\$14,500  \\$-  
Accrued dividends on Series A convertible preferred stock, accrued at effective rate\\$55,074  \\$12,683  
Accretion of redemption value on Series A convertible preferred stock \\$17,447  \\$3,457  
Change in additional paid-in capital from sale/purchase of interest in subsidiaries \\$2,315  \\$-  
Noncash contribution of capital by noncontrolling interest holders \\$-  \\$37  
 Supplemental Financial Information (Unaudited)  
 Reconciliation of Total Pro-forma Revenue and Pro-forma Adjusted EBITDA to Net Loss Attributable   
 to 21st Century Oncology Holdings, Inc. Shareholder  
  Three Months Ended   Years Ended  
  December 31,   December 31,  
  2015  2014   2015  2014  
(in thousands):     
Total revenues\\$263,124 \\$266,587  \\$1,079,227 \\$1,018,182  
Pro-forma full period effect of acquisitions (a)   -    -     1,075    8,819  
Total pro-forma revenues\\$263,124 \\$266,587  \\$1,080,302 \\$1,027,001  
Net income (loss) attributable to 21st Century      
Oncology Holdings, Inc. shareholder\\$5,632 \\$(28,341) \\$(134,849)\\$(357,291) 
Income tax expense 2,456  78   9,654  2,319  
Interest expense, net 24,239  25,620   98,075  113,279  
Depreciation and amortization 22,265  21,397   89,040  86,583  
Gain on BP settlement (1,699) -   (7,495) -  
Impairment loss -  -     -   229,526  
Early extinguishment of debt -  -   37,390  8,558  
Equity initial public offering expenses -  -     -   4,905  
Loss on sale leaseback transaction -  -     -   135  
Fair value adjustment of noncontrolling interest      
Fair value adjustment of earn-out liabilities (1,293) 1,015   (1,811) 1,627  
Fair value adjustment of embedded derivatives      
and other financial instruments (26,841) 837   (17,919) 837  
Gain on foreign currency derivative contracts -  -     -   (4) 
Net income attributable to noncontrolling interests,      
net of cash distributions 295  (1,473)  2,833  996  
Other expenses (b) 8,153  4,036   14,298  15,324  
Non-cash expenses (c) 1,066  1,148   4,359  4,238  
Sale-lease back adjustments (d) (289) (441)  (1,049) (1,403) 
Acquisition-related costs (e) 3,205  2,261   6,712  12,216  
Litigation matters (f) 1,579  2,108   59,354  6,530  
Expenses associated with note-holder negotiations and      
management of liquidity (g) -  2,482     -   11,861  
Pro-Forma full period effect of acquisition EBITDA (a)   -    -     543    742  
Pro-Forma Adjusted EBITDA (1) \\$  38,768 \\$  30,727  \\$  159,135 \\$  140,978  
Pro-Forma Adjusted EBITDA as a percentage of      
total pro-forma revenues 14.7% 11.5%  14.7% 13.7% 
(1) Pro-Forma Adjusted EBITDA, as defined per the Credit Agreement dated as of April 30, 2015, calculated as  
income (loss) before interest expense (net of interest income), income taxes, depreciation and amortization, net income attributable 
to noncontrolling interests, net of cash distributions, gain on the sale of an interest in a joint venture, loss on sale leaseback 
transaction, early extinguishment of debt, fair value adjustment of earn-out liability, fair value adjustment of embedded derivative, 
impairment loss, foreign currency derivative contract loss (gain), management fees accrued to our sponsor, non-cash expenses 
including costs relating to stock compensation, amortization of straight-line rent and amortization of capital expenditures relating 
to repairs and maintenance, non-cash equipment rent, sale-lease back adjustments, acquisition-related costs, other expenses 
including loss on sale of assets, severance payments related to termination of employee staff reductions, tail premiums on termed 
physicians, franchise taxes, costs relating to consulting services on Medicare reimbursement, litigation settlements with physicians, 
costs associated with tradename and rebranding initiatives, expenses associated with idle / closed radiation therapy treatment 
facilities and pro-forma full period effect of acquisition EBITDA.      
(a) Pro-forma amounts related to adjustments to total revenues and Pro-forma Adjusted EBITDA to reflect the full period effect of 
our acquisitions and Value Added Services contracts completed during 2015 and 2014.  The adjustments reflect the impact to our 
total revenues and Pro-forma Adjusted EBITDA as if the acquisitions and Value Added Services contracts had occurred at the 
beginning of the year.      
(b) Other expenses include management fees accrued to our sponsor, Vestar Capital Partners, loss on sale of assets, 
severance payments related to termination of employee staff reductions, tail premiums paid on terminated physicians, 
franchise taxes and costs relating to consulting services on Medicare reimbursement. Expenses related to the costs associated 
with the Company's tradename and rebranding initiatives and expenses associated with idle / closed radiation therapy facilities, 
costs associated with the CMS Medicare freeze.      
(c) Non-cash expenses including costs relating to stock compensation, amortization of straight-line rent, amortization of capital 
expenditures relating to warranty arrangements amortized to repairs and maintenance and non-cash equipment rent.  
(d) Sale-lease back adjustments relates to the adjustment of benefit derived from the classification of operating leases as finance 
obligations reflecting a reclassification of interest expense and depreciation and amortization expense as rent expense. 
(e) Acquisition related costs associated with ASC 805, "Business Combinations," including professional fees, corporate 
development, integration and due diligence costs relating to the acquisition of medical practices.    
(f) Litigation matters relate to loss contingency reserves related to the Medicare investigative matters  
and costs associated with the termination of physicians.      
(g) Expenses associated with negotiating with note-holders, recapitalization support agreement and legal and consulting fees 
associated with management of liquidity.      
We believe the Pro-Forma Adjusted EBITDA provides useful information about our financial performance to investors, lenders, financial
analysts and rating agencies since these groups have historically used EBITDA-related measures in the healthcare industry, along 
with other measures, to estimate the value of a company, to make informed investment decisions, to evaluate a company's leverage 
capacity and its ability to meet its debt service requirements.  Pro-forma Adjusted EBITDA eliminates the uneven effect of non-cash 
depreciation of tangibles assets and amortization of intangible assets, much of which results from acquisitions accounted for under 
the purchase method of accounting.  Pro-forma Adjusted EBITDA is also used by us to measure individual performance for incentive 
compensation purposes and as an analytical indicator for purposes of allocating resources to our operating business and assessing 
their performance, both internally and relative to our peers, as well as to evaluate the performance of our operating management teams,
and for purposes in the calculation of debt covenants and related disclosures.     
Pro-Forma Adjusted EBITDA is not intended as a substitute for net income (loss) attributable to 21st Century Oncology Holdings, Inc.
shareholder, operating cash flows or other cash flow data determined in accordance with accounting principles generally accepted in the
United States. Due to varying methods of calculation, Pro-forma Adjusted EBITDA as presented may not be comparable to similarly 
titled measures of other companies.      


   Three Months Ended     Year Ended    
   December 31,   %   December 31,   %  
Operating Metrics 2015   2014  Change  2015   2014  Change 
 Number of operating days 64   64   0.0%  255   255   0.0% 
 Radiation oncology treatment plans (total) (1) 8,770   8,708   0.7%  36,251   34,190   6.0% 
 Radiation oncology treatments per day (total) 3,184   3,127   1.8%  3,245   3,114   4.2% 
 Net patient service revenue per radiation oncology\\$750  \\$759   -1.1% \\$750  \\$765   -1.9% 
 treatment (total)            
 Radiation oncology treatment plans (same market) (1,2) 8,386   8,696   -3.6%  33,854   33,823   0.1% 
 Radiation oncology treatments per day (same market) (2) 3,049   3,112   -2.0%  3,020   3,070   -1.6% 
 Net patient service revenue per radiation oncology            
 treatment (same market) (2)\\$753  \\$753   0.0% \\$756  \\$760   -0.6% 
 Total number of open cases 4,564   4,395   3.8%  18,598   17,756   4.7% 
 Revenue per radiation oncology case\\$6,676  \\$5,899   13.2% \\$6,340  \\$5,126   23.7% 
   Three Months Ended     Year Ended    
   December 31,     December 31,    
Revenue Details 2015   2014     2015   2014    
 Net patient service revenue per Consolidated Statements            
 of Operations and Comprehensive Loss\\$244,249  \\$245,962    \\$1,000,126  \\$938,488    
 Less net patient service revenue ICC (78,323)  (88,830)    (333,977)  (320,841)   
 Less net patient service revenue professional services (1,980)  (2,003)    (8,161)  (8,063)   
 Plus net patient service revenue unconsolidated MSAs (3) 19,344   22,590     80,795   88,925    
 Less international net patient service revenue (30,470)  (25,926)    (117,903)  (91,021)   
 Domestic freestanding net patient service revenue\\$   152,820   \\$   151,793    0.7% \\$   620,880   \\$   607,488    2.2% 
   December 31,          
Center Details 2015   2014          
 Radiation therapy centers - freestanding (domestic) 133   133          
 Radiation therapy centers - freestanding (international) 36   36          
 Radiation therapy centers - professional / other   12     11          
 Total radiation therapy centers   181      180           
 (1) Total radiation oncology treatment plans represents the number            
 of prescriptions issued by the physicians to start the treatment process.           
 (2) Same market is defined as markets that have been open in excess of 12 months.         
 This includes in market acquisitions and conversion of existing professional only relationships to freestanding.      
 (3) Medical services agreement